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Markus Niemelä,1,2 Onni Niemelä,2 Risto Bloigu,3 Aini Bloigu,4 Päivikki Kangastupa,2 Tatu Juvonen1,5 1Department of Surgery, Oulu University Hospital, Oulu 90029, Finland; 2Department of Laboratory Medicine and Medical Research Unit, Seinäjoki Central Hospital and Tampere University, Seinäjoki 60220, Finland; 3Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu 90014, Finland; 4Center for Life Course Health Research, University of Oulu, Oulu 90014, Finland; 5Department of Cardiac Surgery, Helsinki University Hospital, Helsinki 00029, FinlandCorrespondence: Onni Niemelä Tel +358 50 474 4719Email onni.niemela@epshp.fiPurpose: While extreme physical exertion is known to induce changes in the status of inflammation comparisons of the responses for various mediators of inflammation after acute bouts of high-intensity exercise have been limited.Subjects and Methods: We examined the responses in serum levels of novel inflammatory proteins, calprotectin, suPAR, CD163, and pro- and anti-inflammatory cytokines in 12 physically active volunteers (10 men, 2 women, mean age 37± 14 years) before and after completing various types of extreme physical exertion (marathon run, half-marathon run or 24-h cross-country skiing). For comparisons, the levels of the biomarkers were also measured at rest in 30 healthy controls (25 men, 5 women, mean age 42 ± 12 years) with low or sedentary activity.Results: Extreme physical exertion induced significant increases in serum calprotectin (p < 0.0005), suPAR (p < 0.01), CD163 (p < 0.05), IL-6 (p < 0.0005), IL-8 (p < 0.01) and IL-10 (p < 0.0005) (pre- vs 3h-post-exercise). These responses were found to normalize within 48 hours. While the increases in blood leukocytes were of similar magnitude following the different types of exercise, markedly more pronounced responses occurred in serum TNF-α (p < 0.01), IL-8 (p < 0.01) and CD163 (p < 0.05) in those with more intense activity. In 3-h post-exercise samples significant correlations were observed between serum calprotectin and IL-6 (rs = 0.720, p < 0.01), IL-10 (rs = 0.615, p < 0.05), TNF-α (rs = 0.594, p < 0.05), suPAR (rs = 0.587, p < 0.05) and blood leukocytes (rs = 0.762, p < 0.01).Conclusion: The present results suggest distinct exercise-intensity dependent changes in mediators of inflammation (including calprotectin, suPAR and CD163) following extreme physical exertion. Our findings indicate that there is a major reversible impact of high-intensity physical exertion on the status of inflammation.Keywords: acute exercise, cytokine, immune status, leukocyte, oxidative stress

This article discusses the incidence and mortality rates of malperfusion syndrome in patients with acute Type A aortic dissection after surgical repair. The study, conducted across 18 European centers, included 3,902 patients. It found that 45.62% of patients presented with signs of preoperative malperfusion, with the most common type being cerebral malperfusion. The study also showed that rates of in-hospital mortality increased with the severity of malperfusion. The authors conclude that different levels of the Penn classification can be used as valid predictors of mortality. [Extracted from the article]

Context: Atrial fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery. An exaggerated inflammatory response has been proposed to be one etiological factor.Objective: To test whether intravenous corticosteroid administration after cardiac surgery prevents AF after cardiac surgery.Design, Setting, and Patients: A double-blind, randomized multicenter trial (study enrollment August 2005-June 2006) in 3 university hospitals in Finland of 241 consecutive patients without prior AF or flutter and scheduled to undergo first on-pump coronary artery bypass graft (CABG) surgery, aortic valve replacement, or combined CABG surgery and aortic valve replacement.Intervention: Patients were randomized to receive either 100-mg hydrocortisone or matching placebo as follows: the first dose in the evening of the operative day, then 1 dose every 8 hours during the next 3 days. In addition, all patients received oral metoprolol (50-150 mg/d) titrated to heart rate.Main Outcome Measure: Occurrence of AF during the first 84 hours after cardiac surgery.Results: The incidence of postoperative AF was significantly lower in the hydrocortisone group (36/120 [30%]) than in the placebo group (58/121 [48%]; adjusted hazard ratio, 0.54; 95% confidence interval, 0.35-0.83; P = .004; number needed to treat, 5.6). Compared with placebo, patients receiving hydrocortisone did not have higher rates of superficial or deep wound infections, or other major complications.Conclusion: Intravenous hydrocortisone reduced the incidence of AF after cardiac surgery.Trial Registration: clinicaltrials.gov Identifier: NCT00442494. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether and which of the cerebral microdialysis parameters are predictive of postoperative outcome after an experimental 75-min period of hypothermic circulatory arrest (HCA) in a chronic porcine model.Design: Seventy-four juvenile female pigs underwent a 75-min period of HCA at 20 degrees C. A microdialysis catheter was placed into the cortex gray matter and brain extracellular concentrations of glucose, lactate, glycerol and glutamate were measured throughout the experiment by enzymatic methods using a microdialysis analyzer. Surviving animals were sacrificed on the 7th postoperative day and histopathological examination of the brain was performed.Results: Brain glucose concentrations were higher in animals that survived (p = 0.017), especially from the 90-min until the 7-h interval after the start of rewarming. The blood venous concentrations of glucose were also higher among survivors, and correlated significantly with the brain glucose levels at 2-h and 4-h intervals after the start of rewarming. Higher concentrations of brain lactate, glycerol and glutamate were observed throughout the study among animals that died postoperatively. Brain glutamate and glycerol concentrations were significantly, negatively correlated with brain glucose concentrations. The lactate/glucose ratio was significantly lower among survivors during the postoperative period (p=0.014). Furthermore, brain glucose concentrations were higher and brain glycerol concentrations lower among the animals that did not develop brain infarction, but such differences did not reach statistical significance.Conclusion: Cerebral microdialysis is a useful tool for cerebral monitoring during experimental HCA. Low brain glucose concentrations and high brain lactate/glucose ratios after HCA are strong predictors of postoperative death. Brain glucose concentrations are negatively correlated with brain glycerol and glutamate concentrations. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that nitric oxide is beneficial in acute right heart failure after right ventricle infarct. Right ventricle infarct results in a decrease in right heart function with a subsequent reduction in ejection fraction and cardiac index. The pulmonary circulation is compromised as the right ventricle weakens, and the resulting stasis and further weakening of the ventricle present clinically as an increase in right heart afterload. Pulmonary vasodilation should ease these hemodynamic symptoms of right heart infarct.Design: Ten 3-4-month-old pigs were chosen as experimental animals. All animals were cannulated, a sternotomy was performed and branches of the right main coronary were ligated to cause infarct of the right ventricle. After a 4-h stabilization period, all animals received fluid preload with a dextrose-based solution after which control hemodynamic measurements were recorded. Treatment with inhaled nitric oxide was begun at progressive concentrations and hemodynamic measurements recorded at 30-min intervals.Results: Nitric oxide treatment significantly reduced right heart afterload, which was also apparent as a reduction in left heart preload. A significant deterioration was observed in cardiac output as well as in left and right ventricle stroke work indices.Conclusion: The use of nitric oxide in this model of right heart infarct in previously healthy young swine effected a decrease in both right heart afterload and left heart preload, with an overall deterioration in global hemodynamics. [ABSTRACT FROM AUTHOR]

Objective: Serum S-100beta protein is suggested to be a neurobiochemical marker of brain injury after cardiac and aortic arch surgery. The aim of the present study was to investigate the predictive value of S-100beta protein with respect to histopathological analysis of the brain after a prolonged period of hypothermic circulatory arrest (HCA).Methods: Eighteen pigs (21 to 31 kg) underwent a 75 min period of HCA at 20 degrees C. Serum concentrations of S-100beta were assayed in mixed venous blood before and 2, 4, 7 and 20 h after HCA. A semiquantitative post-mortem histopathological analysis scoring all main regions of the brain was carried out in every animal.Results: All animals were stable during and after cardiopulmonary bypass (CPB) and survived at least to the first postoperative day. Ten of the 18 animals survived 7 days after surgery and were electively sacrificed. Animals with severe histopathological injury showed higher serum S-100beta protein levels at every time point after HCA. The strongest correlation between the total histopathologic score and serum S-100beta levels was found at 7 h after HCA (tau = 0.422 and p = 0.023).Conclusion: Serum S-100beta protein levels correlate with histopathological injury after a prolonged period of HCA in pigs. This finding supports the results of previous studies suggesting the potential accuracy of S-100beta in the prediction of brain injury after cardiac surgery. [ABSTRACT FROM AUTHOR]

Focuses on brain protection during aortic arch surgery in the United States. Mechanism of cerebral injury during aortic arch surgery; Concept of ischemic cerebral injury; Information regarding the cerebral metabolism; Methods of protection.

Previous studies have shown that although retrograde cerebral perfusion (RCP) improves cerebral outcome during hypothermic circulatory arrest (HCA), RCP exposes the brain to subsequent edema. In this study, we have compared intermittent RCP (I-RCP) with continuous RCP (C-RCP) and HCA alone to determine whether the rate of fluid sequestration can be decreased without losing the beneficial effects of RCP. Eighteen pigs were randomly assigned to undergo 75 min of I-RCP, C-RCP or HCA at 20 degrees C. Hemodynamic and metabolic measurements were carried out for upto 20 h. Behavioral assessments were examined until day 7, when histopathologic analysis of the brain was performed. The median amount of fluid sequestered was 145 ml after C-RCP and -50 ml after I-RCP (p = 0.04). The mean brain weight of the animals that died within the first postoperative day was significantly higher than that in electively sacrificed animals in the C-RCP group (p = 0.04). These data suggest that if RCP is implemented intermittently, the rate of cerebral edema can be decreased, without compromising the benefits of this strategy. [ABSTRACT FROM AUTHOR]

Thymic carcinoid tumours constitute less than 1% of all carcinoids, and differ markedly from true thymomas in natural history, morphology, prognosis and therapeutic options. New clinical and diagnostic modalities are described in two brothers with thymic carcinoid associated with multiple endocrine neoplasia syndrome. Octreotide scintigraphy proved useful for diagnosis and follow-up, and somatostatin receptor positivity may provide new prospects for treatment of non-resectable or recurrent tumour. [ABSTRACT FROM AUTHOR]

The distribution of carbonic anhydrase isoenzymes I, II, and VI was studied in the human alimentary tract using specific antibodies to human isoenzymes in conjunction with the immunoperoxidase technique to elucidate the physiological role and possible functional interplay of carbonic anhydrases (CAs) in alimentary canal functions. From the isoenzymes studied, CA II was found to be the most widely distributed in the various epithelia throughout the alimentary canal. In addition to the acinar cells of the parotid and submandibular glands and the duodenal Brunner's glands, it was present in the mucosal epithelium of the oesophagus, stomach, duodenum, and colon. The epithelial cells of the hepatic bile ducts, gall bladder, and pancreatic ducts also contained CA II in abundance. In contrast, CA VI was present only in the serous acinar and ductal cells of the parotid and submandibular glands, and CA I in the mucosal epithelium of the colon and the A cells of the pancreatic Langerhans's islets. These results suggest that CA II as a widely distributed isoenzyme in the epithelia of the alimentary canal and CA VI as secreted into saliva, may form a mutually complementary system protecting oesophageal, gastric, and intestinal mucosa from acidity. [ABSTRACT FROM PUBLISHER]

Background: The cause of age-related degenerative (tricuspid) aortic valve calcification is largely unknown, but one typical characteristic is an active inflammatory process. The presence of Chlamydia pneumoniae in aortic valve stenosis was recently shown.Objective: To test the hypothesis that if persistent C. pneumoniae infection plays an active role in the development of aortic stenosis, the organism can be detected in the healthy aortic valves of young persons.Design: A cadaver study.Setting: Oulu University Hospital, Oulu, Finland.Subjects: 46 consecutive cadavers undergoing autopsy.Measurements: Macroscopic and histologic pathology of aortic valves was determined. The presence of C. pneumoniae was determined by immunohistochemistry.Results: 34 of 46 valves were macroscopically normal. Early lesions of aortic valve disease were found in 12 valves (no lesions in valves from persons 20 to 40 years of age [n = 15], 4 lesions in valves from persons 41 to 60 years of age [n = 16], and 8 lesions in valves from persons older than 60 years of age [n = 15]; P = 0.004). Fifteen of 34 normal valves (44%) and 10 of 12 valves with early lesions (83%) had positive results on staining for C. pneumoniae (P = 0.02). In persons older than 60 years of age, the chance of an early lesion was higher if the valve tested positive for C. pneumoniae (7 of 8 valves with C. pneumoniae infection compared with 1 of 7 valves without C. pneumoniae infection; P = 0.01).Conclusions: Chlamydia pneumoniae is frequently present in aortic valves and is associated with early lesions of aortic valve stenosis in elderly persons. [ABSTRACT FROM AUTHOR]

Uniformity of myocardial protection during retrograde blood cardioplegia is still a controversial area. We conducted a study on electron microscopic changes in the myocardium during mild hypothermic retrograde cardioplegia (31-32 degrees C) in 12 patients undergoing coronary artery bypass grafting. Biopsies for electron microscopy were taken from the right and left ventricular myocardium before and at the end of aortic cross-clamping and after 15 min reperfusion. The intercellular junctions, intracellular and extracellular oedema, mitochondria, capillaries, nuclei and myofibrils were analysed separately in each specimen, using a semiquantative method with scoring from 0 (unchanged) to 3 (severe changes), and the total scores were correlated with the severity of right and left coronary artery disease and with ischaemia time during aortic cross-clamping. Mild to moderate ultrastructural changes occurred in the myocardium during the cardiopolegia, most typically myofibrillar injury and oedema. These changes increased during aortic cross-clamping and reperfusion, especially in the right ventricle. The total ultrastructural score for the right ventricle correlated negatively with the severity of right coronary artery disease at the end of cross-clamping. No such correlation was found in the left ventricle. Apart from one case of perioperative myocardial infarction, the clinical outcome was unproblematic. Myocardial structure thus was by and large well preserved during mild hypothermic retrograde blood cardioplegia, with the right ventricle seemingly somewhat less protected than the left. [ABSTRACT FROM AUTHOR]

The management of 27 consecutive deep sternotomy wound infections is reviewed. In 22 cases the initial treatment was debridement, sternal refixation and dilute antibiotic irrigation via multiple irrigation-suction catheters. In the nine cases (41%) in which these measures failed, more extensive sternal and costal cartilage debridement and closure with a muscle flap were performed. Five cases were initially managed with major reconstructive surgery. For reconstruction, a bilateral pectoralis major myocutaneous flap was used alone in eight cases, while in six the flap was insufficient to obliterate the whole poststernectomy space, and was supplemented with rectus abdominis muscle. Early mediastinitis can be effectively treated with thorough wound debridement and mediastinal irrigation, but if there is a two-week delay from the initial sternotomy to manifestation of infection, radical debridement with muscle flap closure should be seriously considered. [ABSTRACT FROM AUTHOR]

Objective: It has been shown that apoptosis contributes to neuronal cell death after ischemia, and we evaluated the degree of apoptotic activity occurring in brain cortex of pigs after hypothermic circulatory arrest (HCA). Design: Thirty-one pigs underwent 75 min of HCA at 20°C. Histological examination of the brain was performed, and slides of brain cortex were evaluated for apoptotic activity by the TUNEL method. Results: Ten animals died during the first postoperative day and 21 survived until the seventh postoperative day. Brain cortex infarcts were found in animals that survived 7 days and these were included in this study. The median histopathological score among animals that died on the first postoperative day was 3.0 (range, 2-4), whereas it was 4.0 (range, 2-4) among survivors (p = 0.019). The apoptotic index was particularly high in the area of the infarct, whereas only a few TUNEL-stained cells were observed in noninfarcted areas. The apoptotic index was nil in all pigs that died in the first postoperative period, whereas it was 2.0 (range, 0-6) among the animals that survived until the seventh postoperative day (p < 0.0001). Conclusion: The apoptotic index was significantly increased in brain cortex infarcts of animals that survived 7 days after HCA, whereas only a few apoptotic cells were observed in noninfarcted areas of these animals as well as in animals that died on the first postoperative day. Further studies are required to elucidate the timing of development of brain infarction after HCA and whether neuroprotective strategies targeting the apoptotic process may mitigate brain damage. [ABSTRACT FROM AUTHOR]

An abstract of the study "Distinct Down-Regulation of C-Type Natriuretic Peptide System in Human Aortic Valve Stenosis," by J. Rysa and colleagues is presented.