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Background: The EDAIC is a diploma of the European Society of Anaesthesiology and Intensive Care (ESAIC). which is obtained after passing two a written MCQ-based (Part1) and a structured oral (part2) examinationIn 2011, a formative On-Line Assessment (OLA) was introduced to help candidates to prepare for EDAIC Part1 examination (EDAIC-I). This retrospective observational study evaluated the results of the OLA and its impact on the EDAIC-1 between 2013 and 2019., Methods: After obtaining the authorisation from the ESAIC Examinations Committee, all the results of candidates registered to OLA and/or EDAIC-I between 2013 and 2019 were included. The total number of registrations and the results were analysed and compared for both., Results: Over 17,000 candidates (17,401) sat any of the written exams of the EDAIC. The overall pass-rate for the EDAIC-1 was 68.95%. The OLA score increased significantly with the number of attempts for Paper A (Basic Science) (p=0.006). Overall success of the EDAIC-I was higher in candidates who took the OLA before (72.9% versus 68.3%; OR: 1.25; 95% CI [1.12; 1.39]; p<0.001). Candidates who failed in their first attempt for EDAIC-I were more likely to sit the exam again if they had performed the OLA before (OR: 1.396, 95% CI [1.237; 1.574]; p<0.001)., Conclusion: The OLA was associated with an improvement of the results in basic science and success rate in the EDAIC-I., (Copyright © 2021 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. All rights reserved.)

Background: The European Diploma in Anaesthesiology and Intensive Care (EDAIC) has become a standard of quality among Spanish anaesthesiologists. The aim of this retrospective observational study was to assess the results of Spanish participants for the Part1 and Part2 exams over a recent five years period from 2012 to 2016 and 2013 to 2017, respectively., Material and Methods: After obtaining the authorization from the European Society of Anaesthesiology, the results of both parts of the EDAIC exams were anonymously analysed for five years. We analysed the number of registrations, the pass rates, the cause for failure and the mean scores for basic sciences (paperA of part1 exam and the two first vivas of part2 exam) and clinical anaesthesia and intensive care (paperB of part1 exam and the two last vivas of part2 exam). Quantitative variables were analysed using the one-way analysis of variance, and qualitative variables using the chi-square test for trends. The level of statistical significance was set at P<.05., Results: For the written part1 exam, 1,189 of a total of 10,954 candidates (10.85%) were registered in Spanish centres, reflecting the global growth of the exam (P=.29). The pass rate was 62.1%, with no significant differences from other countries (P=.38). Basic sciences were involved in 84.1% of failing candidates. Mean scores were 71.74±5.98% for basic science (paperA) and 74.48±4.29% for clinical anaesthesiology (paperB). Regarding the part2 exam, 72.4% of the candidates who had passed the part1 exam registered for the oral part2, with a pass rate of 62.7% versus 62.2% in the rest of the world (P=.91). Failing in the basic sciences sections of the part2 resulted in 93.8% of candidates failing the part2 exam. Bad fails were registered in 56 (31.5%) of failing candidates, of which 71.3% occurred in the basic sciences vivas. Isolated bad fails only occurred in 7 (3.9%) cases., Conclusions: The evolution of the EDAIC in Spain has been very similar to evolution of the EDAIC in the rest of the world. Further efforts to improve knowledge in basic sciences and better preparation in the technique of oral examination should improve the pass rate of the EDAIC examinations from an ever-increasing cohort of candidates., (Copyright © 2019 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. All rights reserved.)

Orofacial biofunction comprises muscular and physical effects, which may contribute to stabilization of the oropharyngeal airway. The tongue-repositioning manoeuvre (TRM) provides physical stabilization of the tongue and the soft palate together with, as a prerequisite, a nasal breathing mode. The aim of the present study was to evaluate the influence of a TRM treatment concept on primary snoring. The TRM was used to achieve a closed biofunctional rest position of the orofacial system and to re-educate the nasal breathing pattern. Pressure indicating oral shields were used for home exercises as a biofeedback instrument and to support nocturnal mouth closure. Treatment was undertaken on 125 consecutive primary snorers [101 males, mean age 52.4 years, range 34-75, mean body mass index (BMI) 28.1, range 18.9-38.5, and 24 females, mean age 55.2 years, range 36-70, mean BMI 26.8, range 22.7-31.9]. Bed partner ranking was performed, and snoring was judged using a 10-cm visual analogue scale (VAS). The VAS score was 8.4 (range 6-10) before treatment and decreased to 4.1 (range 0-10) after treatment [mean observation time 4.6 months (1-10)]. Analysis of variance showed a significant influence of treatment in subjects with a normal body weight (BMI 18.5-25). The data provide evidence that dynamic stabilization of the orofacial system with the TRM in conjunction with nocturnal wear of an oral shield is beneficial for reducing the symptoms in primary snorers with a normal BMI.

Objective: To determine whether the absence ofHPV1i6 LI capsid protein is a prognostic parameter for the histologic outcome of cervical intraepithelial neoplasia (CIN) 2+ in cytologically diagnosed cervical dysplasia., Study Design: Papanicolaou-stained microscopic slides of 95 HPV16-positive cervical samples that had a cytologic diagnosis of cervical dysplasia or borderline cytology were immunostained using an HPV16-specific anti-L1 viral capsid antibody. In parallel to the cytologic examination, HPV16 DNA and E6*I mRNA were quantitated using real-time polymerase chain reaction. Expression of L1 protein was correlated with relative levels of HPV16 DNA and E6*I mRNA as well as histologic diagnoses/cytologic follow-up., Results: Thirty-five cases with a histologic diagnosis of CIN 2+ (61%) were negative for HPV16 L1 protein; 22 (39%) were positive. Of the cases that either were CIN 1 or regressed to normal cytology, 10 cases (26%) were positive for HPV16 L1 protein, while 28 (74%) were negative. L1-negative and L1-positive cases showed no statistically significant difference (p = 0.22) in their histologic diagnosis/cytologic follow-up. The positive predictive value for CIN 2+ was 56% if L1 protein was absent; the negative predictivre value for CIN 1/regression to normal cytology was 31% if L1 protein was present. HPV16 Ll-positive cases had significantly higher HPV16 DNA concentrations than L1-negative cases (p < 0.001), while levels of HPV16 E6*I mRNA were comparable in both types of cases (p = 0.36)., Conclusion: The expression of HPV16 L1 capsid protein is correlated with viral DNA load but does not predict the histologic outcome of HPV16-positive cervical dysplasia.

Objective: As cervical dysplasia may regress to normal cytology or progress to cervical carcinoma, it would be valuable to have a diagnostic tool to help decide whether therapeutic conization should be performed., Methods: Cervical samples of 301 HPV16 positive women were collected in RNAlater reagent to prevent RNA degradation. Relative levels of HPV16 DNA and HPV16 E6*I mRNA in the samples were determined using real-time polymerase chain reaction. Findings were correlated with histological diagnoses and cytological follow-up., Results: HPV16 E6*I mRNA levels were significantly higher in women with cytologically diagnosed severe cervical dysplasia (mean normalized ratio = 0.25) than in those with mild-to-moderate dysplasia (mean norm. ratio = 0.12), atypical squamous cells of uncertain origin (mean norm. ratio = 0.071) or normal cytology (mean norm. ratio = 0.034). Viral DNA levels were not significantly different between severe and mild-to-moderate dysplasia (mean norm. ratios, 55.8 and 63.5, respectively). The PPV for a histological diagnosis of severe cervical dysplasia [cervical intraepithelial neoplasia (CIN) II+] increased with the amounts of E6*I mRNA to more than 90% whereas the sensitivity decreased. The absence of HPV16 E6*I transcripts as well as HPV16 DNA considerably increased the negative predictive value and the specificity. However, low concentrations (or complete absence) of E6*I mRNA did not preclude a CIN II+ diagnosis., Conclusions: Although the sensitivity is low, high levels of HPV16 E6*I mRNA are indicative of CIN II+ in cytologically diagnosed cervical dysplasia of individual patients. Thus, quantification of HPV16 E6*I mRNA could be helpful in managing follow-up and treatment in a subset of HPV16 positive women.

Human papillomaviruses (HPV) are known to cause cervical dysplasia and cervical carcinoma. We used a 3-step PCR protocol that allows rapid type-specific HPV testing in a routine laboratory setting: HPV-16-positive samples were determined using a specific LightCycler PCR; HPV-16-negative samples were amplified by nested PCR and typed by sequence analysis. During a period of 7 months, 1275 PCR-based HPV tests were performed. Of the 1275 samples, 829 samples tested negative for HPV and 446 tested positive, including 124 positives found in the initial HPV-16-specific LightCycler assay. Sequence analysis of 132 samples detected 18 HPV types that are not included in the widely used Hybrid Capture II assay. For comparison, the first 100 cervical specimens were tested in parallel using PCR and direct hybridisation (Hybrid Capture II assay). PCR detected HPV DNA in 23 samples that tested negative in the Hybrid Capture assay. Four out of 37 samples that tested positive for HPV in the Hybrid Capture test may be false positives, because sequence analysis detected HPV types not included in the probe mixtures. As rare and novel HPV types may also confer an oncogenic risk, highly sensitive and specific PCR assays will help in understanding cervical HPV infection and cervical cancer of unknown causes.

Diagnostic work-up of patients sent to the hospital for diagnosing of deep venous thrombosis (DVT) often combines the determination of D-dimer and the application of a clinical probability score. To fulfill diagnostic as well as economic needs, D-dimer assays should exhibit a high negative predictive value (NPV) as well as reasonable specificity. In this study, we evaluated both a latex-enhanced immunoassay for use on routine coagulation analyzers and a radial partition immunoassay (RPIA) for use on a point-of-care analyzer. Samples included were from 344 outpatients with suspected deep venous thrombosis. Among them, 100 had deep venous thrombosis. Results obtained for both assays show a good efficiency for exclusion of deep venous thrombosis with well-acceptable specificity.

Background: Failure of the systemic right ventricle after atrial switch operation can be treated by conversion into an arterial switch operation., Methods: Four patients, age 38 to 59 months, presented with right ventricular failure after Senning operation and ventricular septal defect closure. One patient had elevated left ventricular pressure; in the other three patients the left ventricle was retrained to a left ventricular/right ventricular pressure ratio of 0.8 or greater by pulmonary artery banding in 12 to 24 months., Results: Postoperative course after arterial switch operation was prolonged, but clinical condition was good at discharge. Fractional shortening ranged from 20% to 28%. Trace-to-moderate aortic regurgitation was present; only 1 patient had preserved sinus rhythm. After a mean follow-up of 43.5 months 1 patient had died due to left ventricular dysfunction. The survivors are in New York Heart Association functional class I to II. Fractional shortening has improved (29% to 37%); aortic regurgitation has not increased. No patient has undisturbed sinus rhythm., Conclusions: Conversion of an atrial into an arterial switch is an alternative to cardiac transplantation in childhood. However, the procedure is demanding. Long-term morbidity is caused by rhythm disturbances. Aortic valve performance and left ventricular function require close observation.

Interaction of the Tramtrack protein from Drosophila melanogaster with DNA was analyzed by a cross-linking method. Tramtrack residues cross-linkable to the partially depurinated DNA were identified by direct sequencing. The N-terminal alpha-amino group of the protein DNA-binding domain was found to be the major product of cross-linking. The location of the N terminus on the DNA was determined by identification of the DNA bases that were cross-linked to the protein alpha-amino group. We conclude that accessory N-terminal peptide preceding the first zinc finger of Tramtrack directly interacts with DNA, both in specific and nonspecific DNA-protein complexes. Our finding explains the role in the protein binding of the DNA bases outside of the direct interaction with the zinc fingers.

Background: The arterial switch operation (ASO) is the treatment of choice for transposition of the great arteries., Methods: Anatomical risk factors on mortality and morbidity were analyzed retrospectively in 312 patients who underwent ASO between 1982 and 1997., Results: Survival was 95%, 92%, and 92% after 30 days, 5, and 10 years, respectively. Operative survival improved after 1990 to 97% (p < 0.001). Risk factors for operative mortality were complex anatomy (p = 0.018), coronary anomalies (p = 0.008), and prolonged bypass time (p < 0.001). Determinants of late mortality were coronary distribution (p = 0.03), position of the great arteries (p = 0.0095), bypass time (p = 0.047), and aortic coarctation (p = 0.046). After a follow-up of 3.6 +/- 2.7 years (0.1 to 14.9 years), 98% had good left ventricle function, 94% were in sinus rhythm, 2.4% had moderate to severe pulmonary stenosis, 0.3% had significant aortic regurgitation, and 1% had coronary stenosis. Freedom from reoperation was 100%, 96%, and 94% after 1, 5, and 10 years, respectively. No preoperative anatomic parameter correlated with long-term morbidity., Conclusions: ASO can be performed with low operative mortality (< 5%) and long-term morbidity. Malformations associated with complex transposition of the great arteries influence early and late mortality.

Retraining of the left ventricle in congenitally corrected TGA or after Senning or Mustard operation is necessary when right-ventricular failure is developing and an arterial switch operation is indicated. As these hearts have little tolerance of marginal overbanding, a long-term adjustable pulmonary artery banding device would lower stress and risk of training. Although the inserted device (Osypka) allowed convenient intraoperative pressure ratio adjustment, mid-term adjustment failed due to dysfunction of the system.

Pericardiocentesis is usually an easy and uncomplicated procedure when guided by cross-sectional echocardiography, but an abnormal intracardiac or extrapericardial position of the puncture system can occur, especially in children. Injection of echo contrast medium through the puncture needle is a very sensitive, quick, easy and harmless procedure which can be performed at the bedside in all cases in which doubt remains concerning the location of the needle. Prompt enhancement of signal intensity of the pericardial fluid validates the correct intrapericardial position, and permits visualization of the tip of the needle. Absence of echodense formations excludes an intrapericardial position. We recommend the use of echo contrast medium during pericardiocentesis whenever blood is aspirated through the needle, or if there is any doubt concerning its location.

The effect of Cd2+, Pb2+, Hg2+ and Cu2+ on the aggregation behaviour of monoclonal rat-IgG1-anti-mouse antibodies (kappa-light chain specific) and their antibody-antigen complexes with monoclonal mouse-IgG1 is reported. Investigations were done using the dynamic light scattering method. Cd2+ ions affected the hydrodynamic properties of the antibodies and the immune complex formation very little. More than 4 Cu2+ ions per antibody molecule led to large insoluble aggregates. Pb2+ ions also interacted with antibodies and immune complexes. Instead of "monomeric' antibodies (Ab) or immune complexes (Ab1Ag1), large soluble aggregates were detectable in the solution. Hg2+ ions induced complex formation with 3-4 antibodies per aggregate. Possible kinds of interaction are discussed. Additionally, we tested the antigen binding activity of metal-treated antibodies in ELISA-tests. The Sandwich ELISA technique was used to investigate the serological activity of the metal-treated antibodies, i.e., the reaction with the specific antigen. For these experiments we used the same monoclonal antibodies, mouse-IgG1 and rat-IgG1-anti-mouse. The influence of the above mentioned heavy metal ions was investigated up to a 10-fold molar excess over the antibody concentration. Even at these "unphysiological' high metal ion concentrations an inhibition of the antibody-antigen binding activity was not detectable.

Objective: Arterial switch operation (ASO) is the procedure of choice for the repair of simple d-transposition of the great arteries (TGA) during the neonatal period. Beyond this time such correction is performed in two stages. The first step incorporates banding of the pulmonary artery with or without a Blalock-Taussig shunt to train the left ventricle (LV). The second step consists of the ASO. To find out whether candidates for a two-stage procedure would tolerate a one-stage correction, a trial of pulmonary artery banding was performed., Material and Methods: Between February 1986 and December 1995, 224 patients less than 3 months of age with TGA, intact ventricular septum or a small restrictive ventricular septal defect, had an ASO. Seven patients were 4 weeks of age or older (28-70 days). Two of these had a pulmonary artery to systemic pressure ratio higher than 0.6 and underwent primary ASO without complications. The remaining five patients had low left ventricular pressure with a pulmonary to systemic pressure ratio of 0.2-0.5; echocardiography showed a banana-shaped LV with left ventricular wall thickness as low as 3 mm. They underwent a trial of pulmonary artery banding to systemic pressure for 15-30 min. As this increase in workload was tolerated well with an anticipated decrease of oxygen saturation but without hemodynamic disturbances anticipated, the ASO was performed immediately., Results: Postoperative course was uneventful in all five patients, although catecholamine dependence was prolonged and three patients received enoximone. There were no severe complications. Echocardiography showed an increase in posterior wall thickness from 3 to 6 mm after 19 days in one infant., Conclusion: Some of the children, assigned for a 'two-stage' ASO may tolerate a primary anatomic repair up to an age of at least three months. This subgroup can be selected by a trial of pulmonary artery banding.

Background: Cerebral injury can render meaningless an otherwise successful cardiac operation. As carbon dioxide management during hypothermic cardiopulmonary bypass has a major impact on cerebral blood flow during bypass, it may also influence postoperative cerebral function. The objective of this prospective, controlled, double-blind study was to compare the effect of pH-stat (temperature correction of blood gas analyses) or alpha-stat (no temperature correction) on brain function., Methods: Cerebral function was assessed non-invasively using neurological examination, a neuropsychological test battery, quantitative electroencephalogram and the cognitive evoked potential P300 preoperatively and on postoperative day 7 or 8. Forty-five patients undergoing elective aortocoronary bypass grafting in barbiturate/opiate anesthesia were randomised into a pH-stat-(n = 23) and an alpha-stat-group (n = 22). Membrane oxygenators with arterial line filtration and non-pulsatile flow at a perfussion pressure of 50-60 mmHg were used throughout., Results: One patient in each group developed a new paresis. Among 49 comparisons of cerebral function parameters, only 3 showed significant differences at the 5%-level, i.e. exactly what is expected purely by chance. These differences were too small to be clinically relevant and favored either pH-stat (theta-amplitude) or alpha-stat (subtest 3 of syndrome-short-test, number of mistakes in aiming)., Conclusion: Under the bypass conditions of this study there was no difference in early cerebral functional outcome between pH-or alpha-stat carbon dioxide management during hypothermic cardiopulmonary bypass.

Recent studies demonstrated different contracture responses in muscle from malignant hyperthermia susceptible (MHS) compared to normal (MHN) individuals following exposure to the plant alkaloid ryanodine in-vitro. To confirm if ryanodine has a specific action in MHS muscle, the effect of a single concentration was investigated in skeletal muscle from MHS, MHN and control subjects using a new evaluation technique. In-vitro contracture test (IVCT) and MH diagnosis were performed according to the European Protocol in 86 patients sent to us for MH diagnostic testing and in 24 controls. Viable fresh muscle bundles were exposed to a single bolus of ryanodine 1.0 microM. Contracture onset time (OTp: defined as the time (min) from administration of ryanodine to the start of a contracture as measured by a contracture exceeding predrug baseline height), and the time to an increase of the baseline height to 10 mN above the predrug level (10Tp) were recorded. 29 patients were identified by IVCT to be MHS, 50 MHN, 7 MHE (equivocal) and 24 controls MHN. The indices from the ryanodine test separated all MHS (OTp: < 16 min; 10Tp < 27.4 min) from MHN (> 18 and > 27.7 min) and control subjects (> 17.4 and > 29 min). Values for MHE (equivocal) individuals ranged from 17.1 to 27.8 min for the OTp and from 32 to 49.2 min for the 10Tp. 5 patients with fulminant MH crises were included in the MHS group and showed the 95% confidence intervals (CI) of the median value < or = 8.05 min (OTp) and < or = 13.35 min (10TP) for MHS. In contrast, CI of the median value for the control group were found to be > or = 25.2 min (OTp) and 43.15 min (10Tp) for normal muscle. Thus the ryanodine test protocol showed markedly different contractures in MHS and MHN or control muscle. These results suggest that MHS muscle has a higher sensitivity to ryanodine. However, the protocol should be investigated for reproducibility and validation of thresholds by other laboratories. Ryanodine can help to improve MH diagnostic tests.

Complement activation and leukocyte stimulation were prospectively studied during and after cardiopulmonary bypass in 16 children receiving sodium nitroprusside--a nitrovasodilator releasing nitric oxide--for vasodilation during the cooling and rewarming periods of extracorporeal circulation. Results were compared with those in 29 patients who were not treated with sodium nitroprusside during the operation. Patients treated with sodium nitroprusside had significantly less C3 conversion during cardiopulmonary bypass as measured by the ratio C3d/C3 (p <0.05) and significantly less C5a liberation immediately after cardiopulmonary bypass (p < 0.005) than patients not treated with sodium nitroprusside. C4 was not overtly consumed in our series. Leukocyte count during the rewarming period of cardiopulmonary bypass, but not leukocyte elastase release during cardiopulmonary bypass, was significantly reduced in patients treated with sodium nitroprusside (p <0.05). In vitro experiments were conducted to analyze the effect of sodium nitroprusside on complement hemolytic activity initiated by the classic and the alternate pathways and on zymosan-induced C3 conversion by the activation of the alternate pathway. The in vitro experiments clearly demonstrate inhibition of complement hemolytic activity by sodium nitroprusside in the sera tested. The 50% inhibitory concentration of sodium nitroprusside on the available complement hemolytic activity was less through the alternate pathway than through the classic one (4.2 +/- 0.8 mmol/L and 14.0 +/- 2.88 mmol/L, respectively). The decrease of complement hemolytic activity measured was dose-dependent and was enhanced by the sodium nitroprusside preincubation of the sera tested. This effect was related to the duration of preincubation. Sodium nitroprusside photodegradation (enhancing nitric oxide release) increased the anticomplementary effect of the drug, reducing the 50% inhibitory concentration on complement hemolytic activity to 0.24 to 0.02 mmol/L for the alternate pathway and 2.74 o 0.3 mmol/L for the classic pathway. the zymosan-induced C3 conversion was inhibited by sodium nitroprusside. Nitroglycerin and isosorbide dinitrate (other nitric oxide donors) had in vitro effects on complement hemolytic activity similar to those of nonphotodegraded sodium nitroprusside at similar concentrations (1 mmol/L). Our results suggest that sodium nitroprusside, both in vitro and in vivo, has an inhibiting effect on complement activation initiated by both classic and alternate pathways and that this effect is mediated by nitric oxide release from sodium nitroprusside. This is the first report on the anticomplementary effect of sodium nitroprusside by nitric oxide release.

The aim of the study was to evaluate a new ELISA for detection of HIV-1, HIV-2 and HIV-1 subtype 0 (HIV-0) antibodies. The assay format is based on the antigen sandwich principle. To enable specific detection of HIV-0 antibodies, in addition to HIV-1 and HIV-2 antigens HIV-0 antigen is used for coating the solid phase and for the conjugate. The results show that all 12 HIV-0 samples tested were detected with a high degree of reactivity, as were all the 1,144 anti-HIV-1 and 424 anti-HIV-2 positive samples. The capacity of the test to enable early detection of seroconversions is equivalent to that of other sandwich ELISAs. The specificity of the assay was determined to be 99.89/99.94% (initial/after retest) using 58,366 samples, which is superior to the other ELISAs used for comparison. Even with difficult samples (i.e. samples of African origin, samples known to cause false-positive reactivity in different ELISAs, or samples containing potential interference factors) there were very few false-positive reactions. Therefore, the new assay is well suited for screening blood donations as well as for evaluating samples from patients of different geographic origin.

Receptors for IgG (Fc gamma R) are expressed by small subpopulations of peripheral blood T lymphocytes. Our studies demonstrate that T lymphocytes can be induced in vitro to express two different low-affinity Fc gamma R. Mitogen activation of peripheral blood T lymphocytes obtained from eight healthy individuals leads to considerable augmentation of the Fc gamma RIII+ (CD32) T cell subpopulation. The highest percentage of CD32 expressing T lymphocytes could be detected after three days of activation. The T cell subpopulation which transiently express the CD32 antigen, encompasses CD4+ and CD8+ cells. Molecular cloning of the CD32 antigen by reverse transcription and polymerase chain reaction demonstrates that activated human T lymphocytes express the Fc gamma RIIIb2 isoform. The percentage of the Fc gamma RIII+ (CD16) T cell subpopulation was significantly increased only in the lymphocyte populations obtained from three out of eight volunteers immediately after mitogen activation. However, during short-term cell culture the CD16 expressing CD8+ T cell subset increased in the T cell population from all individuals investigated. During this time, the IL-2 receptor alpha-chain (CD25) expression level decreased as a function of time. In contrast to the CD8+CD16+ T cells, the percentage of the non-MCH-restricted CD56+CD16+ T cells was not influenced by mitogen activation and time of cell cultivation. We could show that CD16 in T cells is able to mediate a stimulus leading to proliferation of the CD8+CD56-CD16+ T cells but not that of the CD56+CD16+ T cell subset. This discrepancy cannot be explained by the expression of different Fc gamma RIII isoforms, because both T cell subsets express Fc gamma RIIIA alpha, as we demonstrate in this report.

Objective parameters are needed to quantify cerebral dysfunction following cardiac surgery in outcome and comparative studies. In this investigation we assessed the value of the late auditory evoked potentials N100 and P300 to measure the neuropsychological deficit after coronary artery bypass grafting (CABG). N100, an exogenous potential is influenced by the stimulus pattern (frequency, intensity and stimulus presentation rate). P300, an endogenous potential, depends on the cognitive processing invoked by the stimulus. With approval of the Human Investigation Committee and the patients' consents, 52 subjects undergoing elective CABG were enrolled. Operation, extracorporal circulation, anesthesia and postoperative intensive care were standardized. Twenty-channel recordings of N100 and P300 were obtained for off-line analysis. P300 was elicited using an oddball paradigm with rare target tones interspersed among frequent non-target tones. Additionally, neuropsychological tests (syndrome short test SKT and letter cancellation test) were carried out. Neurological examination and all tests were compared preoperatively and one week postoperatively. A significant deterioration in cerebral function was documented by the SKT score (P = 0.04), an increase in P300 latency (P = 0.004) and an increase of mistake rate in counting the P300 target tone (P = 0.02). No differences between preoperative and postoperative testing were found for letter cancellation, P300 amplitude and any N100 parameter. No correlation was found between the preoperative/postoperative changes in SKT score and P300 latency. P300 was proved to be an objective neurophysiological parameter that allows for the quantification of cerebral function after CABG.

Objective: To assess the incidence, importance, and history of cardiac involvement in infants and children with tuberous sclerosis., Design: Prospective study; clinical examination, sector and Doppler echocardiography, standard and ambulatory electrocardiography., Setting: A tertiary referral centre., Patients: 21 patients with tuberous sclerosis aged 1 day to 16 years (mean 6.3 years); follow up investigations were available in 14 cases (10 retrospective, 4 prospective; mean follow up 4.3 years)., Results: Multiple cardiac rhabdomyomas in the right ventricle (11) and left ventricle (14) as well as in the right atrium (1) were present in 14/21 patients. Two of them had obstruction of the left ventricular inflow and outflow tract related to a tumour. In the remaining 7 patients, echocardiography was normal in 4 and equivocal in 3 cases. The standard electrocardiogram (n = 20) showed ventricular hypertrophy (2), ventricular pre-excitation (1), arrhythmias (2), and repolarisation disturbances (4) in 7/13 patients with rhabdomyomas but was normal in all patients with a normal or equivocal echocardiogram. The ambulatory electrocardiogram (n = 19) showed frequent premature atrial (2) and polymorphous ventricular (2) contractions. The polymorphous ventricular contractions coexisted with rhabdomyomas. No arrhythmias that needed medical treatment were found. Follow up investigations showed return to a normal standard electrocardiogram in 3 patients. Definite regression or complete disappearance of the tumour occurred in 6 infants., Conclusions: Cardiac rhabdomyomas, although often present in these patients with tuberous sclerosis, caused neither major arrhythmias nor haemodynamic obstruction except in the neonatal period. The indication for operation is limited to cases with life threatening obstruction or arrhythmias refractory to medical treatment.

Cerebrospinal fluid (CSF) and serum levels of interleukin-2 (IL-2), soluble IL-2 receptors (sIL-2R), neopterin, L-tryptophan (L-TRP) and beta 2-microglobulin (beta 2-M) were measured in 31 untreated multiple sclerosis patients in acute exacerbation and 27 normal controls. Twenty-six patients showed the relapsing-remitting type of disease (RRMS); 5 had a chronic-progressive course (CPMS). No changes in serum IL-2 and sIL-2R were found between RRMS patients and controls, whereas serum and CSF levels as well as the CSF/serum ratio of neopterin were significantly elevated in the RRMS group. IL-2 was not detectable in CSF of patients or controls and sIL-2R levels were at the level of the lower detection (LD) sensitivity of the ELISA method. Four of 23 RRMS patients versus 1 of 25 controls showed CSF sIL-2R levels above the LD sensitivity, indicating a trend towards elevation in acute relapse. No difference was found in serum and CSF L-TRP and beta 2-M of patients and controls. In CSF of RRMS patients neopterin and L-TRP correlated negatively, reflecting the interferon-gamma mediated activation of macrophages in acute relapse. A significant positive correlation (Spearman rank 0.57, P = 0.001) between serum IL-2 levels and duration of acute relapse (mean 30 days) warrants further evaluation.

OSF-1/HB-GAM is a member of developmentally regulated growth factors and cytokines. High expression levels of this factor are found in different tissues, e.g., in brain and in bone. We have analyzed the biological function and binding properties of natural OSF-1 to human osteoblasts. Using antibodies raised against the entire OSF-1 molecule or a synthetic carboxy-terminal peptide (amino acids (aa) 110-140) we have investigated the binding sites of rat OSF-1 on human osteoblast-like osteosarcoma cell lines: HOS(TE85) and MG-63. Immunofluorescence microscopic studies and flow cytometric data revealed that OSF-1 is specifically bound to the surface of these cells. Further characterization of the binding sites showed that both osteosarcoma cells express two different kinds of binding sites: Besides binding to a specific OSF-1 receptor, OSF-1 also significantly binds to cell surface heparan sulfates. Using the peptide specific polyclonal antibody we show that the carboxy-terminal domain, aa 110 to 140 of OSF-1, seems to be involved in ligand binding. Studies on the biological function of OSF-1 revealed a strong cell attachment promoting activity in vitro. This activity is not diminished after digestion of cell surface heparan sulfates by heparinase I and heparitinase I, demonstrating that the OSF-1 receptor mediates the cell attachment of osteoblasts. Our results indicate that one biological function of OSF-1 is the promotion of osteoblast attachment to the extracellular bone matrix.

The aim of the present investigation was to study if the benzodiazepine receptor antagonist flumazenil could reverse the effects on the brain electrical activity induced by the benzodiazepine receptor agonist midazolam. The method of FFT approximation was used for this purpose. It allows the calculation of center of gravity equivalent dipoles of spectral EEG data. The results are reference independent and allow therefore a more unambiguous interpretation compared to conventional FFT data reports. Twelve subjects were investigated before and after 0.1 mg/kg and 0.2 mg/kg midazolam respectively, directly and 4 h after administration of 1 mg flumazenil. Our results imply that the application of flumazenil after midazolam sedation leads to an almost complete restoration of the brain electrical activity. However, especially in the beta frequencies above 20 Hz differences in depth of equivalent dipoles were found directly after flumazenil application as well as 4 h later. This could suggest that neuronal generators in different brain structures were responsible for the electrical activity after flumazenil administration compared to before.

Isoflurane anaesthesia was proposed instead of electro-convulsive therapy (ECT) in patients with treatment-refractory depression. This open study compared burst-suppression-isoflurane-anaesthesia (BSIA) and ECT in 12 severely depressed patients. A series of 6 BSIA was administered in every patient. If improvement was insufficient or only temporary, a series of up to 12 ECT was given. A marked improvement of the depression was shown after both BSIA and ECT. Three patients were discharged from hospital after BSIA, nine patients were treated with BSIA and then ECT. The therapeutic effect of both regimens was equal as evidenced by the Hamilton-depression-rating-scale, a visual-analog-scale and the clinical global impression. BSIA requires more time and monitoring than ECT. Our exclusions of coronary, cerebral and peripheral vascular disease, untreated hypertension and focal neurological disease are strongly recommended. Due to the ease of application, ECT remains the standard treatment in depressed patients, but we consider BSIA a valuable alternative at least in patients who object to ECT.

Between January 1985 and March 1989 we retrospectively observed multiple system organ failure (MSOF) in 16 of 460 children (3.5%) who underwent cardiac surgery with cardiopulmonary bypass for congenital heart disease. MSOF was arbitrarily defined as a clinical entity with failure of two or more vital organ systems associated with high fever, thrombocytopenia, and cardiocirculatory insufficiency and occurring within the first postoperative week. In 13 children the first clinical manifestations of MSOF were evident on the first post-operative day and in the other 3 on the second or third post-operative day. All children showed acute renal failure, acute hepatic failure, high fever, and thrombocytopenia. Most of them showed respiratory insufficiency and neurological involvement. Seven of the 16 children died. Four of the 9 surviving patients had neurological sequelae still present 6 months after the operation, and the others recovered completely.

Twenty-one cases (13 male, eight female) of atrial automatic tachycardia (AAT) assessed by standard and Holter-ECG in otherwise healthy infants and children have been documented. AAT was incessant in 12 patients, repetitive in seven, and of undetermined type in the remaining two. The frontal P wave axis suggested an ectopic focus in the high right atrium or right atrial appendage in 13 patients, in the low right atrium in one patient, and in the left atrium in seven patients. Thirteen out of 14 patients with the incessant or undetermined type of AAT were symptomatic, in contrast to only two of seven patients with the repetitive type. All patients were treated with between one and eight (median three) antiarrhythmic drugs. The most effective drug was amiodarone, followed by the class I C antiarrhythmic drugs, propafenone and flecainide. At present, all patients are alive 4 months to 21 years (median 2.5 years) after diagnosis of AAT. Twelve patients are in sinus rhythm, five of them without any medication. Nine patients still have AAT, which, however, is repetitive or intermittent in all but one. In conclusion, AAT is an unusual, and in its incessant form often severely symptomatic arrhythmia, which is resistant to conventional antiarrhythmic medication. However, amiodarone and class I C antiarrhythmic drugs are frequently effective. Since medical treatment with these drugs is often successful, and AAT may resolve completely, a conservative approach is indicated in many cases.

The aim of present study was to characterize the topographical effect of thiopental on the EEG during induction of anesthesia. A multichannel (19 channels) digital EEG was recorded in 10 patients undergoing surgical treatment. The period during induction of anaesthesia before intubation was investigated in regard to peak frequency, amplitude, topography, and amplitude in conventional frequency bands. The main findings were a slowing of the EEG with a simultaneous increase of amplitude in the predominant EEG frequency (peak frequency) during induction. The topographical analysis showed a clear change of localization of the peak frequency in the occipito-frontal direction. Berger described the effect of thiopental on electrical cortical activity as early as 1933. Since then, many studies have investigated its influence on the EEG, but few have tried to characterize the effects of topographical changes in a quantitative way.

We have compared the EEG and auditory evoked wave P300 with psychometric tests in assessing vigilance after flumazenil antagonism of midazolam sedation in 12 healthy volunteers. Measurements were made before and after midazolam 0.1 and 0.2 mg kg-1 i.v., and immediately and 30, 60, 120 and 240 min after administration of flumazenil 1 mg. The sedative effects of midazolam and antagonism by flumazenil resulted in alterations in EEG, P300 and psychometric tests (syndrome short test, letter cancellation, choice reaction and recognition). However, 60 and 120 min after flumazenil a decrease in test performance indicating rebound sedation was seen only in P300 mapping. Thus P300 mapping was a sensitive method of detecting subtle differences in vigilance. Rebound sedation occurred even when midazolam 0.2 mg kg-1 was antagonized with an adequate dose of flumazenil. We suggest that it is advisable to supervise patients for at least 240 min after flumazenil antagonism of midazolam 0.2 mg kg-1.

In a 4-year period, 10 patients (mean age, 3.6 years) with a superior type sinus venosus atrial septal defect were investigated by two-dimensional echocardiography. The defects were easily visualized in all patients using a long axis vena cava superior-inferior plane with a subcostal approach, while the atrial septum seemed to be intact in the coronal plane conventionally used for atrial septal defects of the primum or secundum type. Additional colour flow mapping, performed in two patients, demonstrated shunting across the depicted defect. In our experience, the modified plane is of great diagnostic value in cases with a sinus venosus defect.

This paper gives a brief overview over the differences and similarities in the structure of aspartic proteinases presently available. Comparison of the three-dimentional structure of different aspartic proteinases by a common intramolecular coordinate system have been performed. The intramolecular movable subdomains have been localized and the role of motion in substrate binding and zymogen activation is discussed.

Myocardial ischaemia caused by perfusion impairment of translocated coronary arteries is the major cause of perioperative mortality after neonatal arterial switch operation for transposition of the great arteries. We report the successful use of the right internal mammary artery as a bypass graft to a dominant right coronary artery to treat insufficient perfusion of this artery in a newborn. Eight months later, coronary angiography showed a full blood supply of the right coronary artery across the internal mammary anastomosis. After a follow-up period of more than 30 months, somatic development, electrocardiogram and echocardiographically determined contractility of both ventricles are practically normal indicating regular function of the bypass graft.

Two isotypes of the monocyte/macrophage as well as B cell Fc gamma receptor type II (FcRIIa and FcRIIb2, respectively) mainly differ in the length (76 vs. 44 amino acids) and amino acid sequence of their cytoplasmic domains. Only the eight amino acids just behind the putative transmembrane region are identical. Despite this marked difference, both FcRII mediate endocytosis of immune complexes. To determine the functional significance of the cytoplasmic domains, we expressed truncated FcRIIa and FcRIIb2 in FcR- BHK-21 cells. Mutants of both receptors containing only one amino acid (tail-minus) of the cytoplasmic domain failed to mediate immune complex uptake. The significance of the cytoplasmic domain of the receptors could be further demonstrated using a chimeric FcRIII-FcRIIa construct. Therefore we expressed an FcRIII lacking the hydrophobic carboxyl terminus (containing the putative phosphatidyl - inositol - glycan anchor site) fused inframe to the transmembrane and cytoplasmic domain of the FcRIIa in BHK-21 cells. In contrast to the wild type FcRIII, this chimeric receptor mediated immune complex uptake indistinguishable from that mediated by the FcRIIa. Receptor mutants with relatively short cytoplasmic domains (FcRIIb2: 13, and FcRIIa: 16 amino acids) revealed, that these short amino acid stretches are sufficient to allow reduced receptor-mediated endocytosis of bound ligand. Furthermore, using FcRIIa deletion mutants with a cytoplasmic domain consisting of 62, 46, and 28 amino acids, respectively, we found that the capability of these mutants to mediate immune complex uptake decreased gradually with the truncation of the cytoplasmic tails. Thus, only short amino acid sequences of the cytoplasmic domain are sufficient to enable an, albeit reduced, receptor-mediated endocytosis.

We have analyzed the mode of uptake of human beta FcRII molecules expressed in BHK cells (clone 2/14). When challenged with aggregated human IgG (ahIgG), these cells bind the ligand at 4 degrees C and endocytose the IgG: receptor complexes rapidly upon warming to 37 degrees C, as seen by fluorescence microscopy with antibodies directed against human IgG. Using 125I-labeled ahIgG, we found that 40% of the bound ligand was internalized within 15 min, and approximately 60% within 2 h. Surface replication and thin sectioning combined with immunogold labeling revealed that the ligand was taken up by coated vesicles and was transferred to the endosomal/lysosomal compartment. This was confirmed by confocal laser microscopy of cells double labeled for clathrin and ahIgG. After modulation of the coated vesicle pattern by hypertonic medium, ahIgG transport was impaired. These data show that a single isoform of human FcRII, expressed in an animal cell negative for Fc receptors, can use the coated vesicle based endocytic pathway of the host cell. Reincubation of cycloheximide-treated cells with a second batch of ligand showed that approximately 20% of the beta FcRII was recycled. This finding is in apparent contrast to the fate of the endogenous Fc receptors expressed on mouse macrophages.

Severe cyanosis resulting from postoperative atrial right-to-left shunt is a life-threatening complication. We present a technique of transient transcatheter balloon closure of a patent foramen ovale in a newborn operated on for critical pulmonary stenosis, where the foramen ovale had been left open intraoperatively. Cardiac catheterization was performed under echocardiographic control in the intensive care unit and the foramen ovale was occluded with a water-filled balloon-catheter. Significant improvement of arterial oxygen tension allowed delayed definitive surgical closure in a second step. Unfortunately, the child developed right-sided pneumothorax postoperatively and died of cardiopulmonary failure. Nevertheless, this procedure seems a suitable way to relieve atrial right-to-left shunt temporarily until definitive surgical closure can be performed.

Deletion mutants of loach oocyte 5S rRNA genes were injected and transcribed in vivo in the nuclei of loach (Misgurnus fossilis) and Xenopus laevis. A control region was found in the 5'-flanking sequence, the elimination of which greatly decreases in vivo transcription of 5S rRNA genes. This cis-acting element is located in the region between nt-18 and the transcription start point. We propose that the oocyte nucleus contains (a) specific transcriptional factor(s), NTFO, which interacts with the cis-acting element we described. We also propose that NTFO is inactivated in maturing oocytes when nucleoplasm interacts with oocyte cytoplasm after germinal vesicle breakdown. The residual activity of this factor(s) may be responsible for low-level synthesis of oocyte 5S rRNA at the beginning of embryogenesis. We consider the disappearance of NTFO during gastrulation to be responsible for the total inactivation of oocyte 5S rRNA genes in embryonic and somatic tissue.

A cDNA encoding the human beta Fc gamma receptor II (FcRII) was isolated from a placental cDNA library. Analysis of the predicted amino acid sequence indicates that this receptor is synthesized with a 42-amino acid leader sequence. The mature protein consists of 249 amino acids. The leader sequence and the cytoplasmic domain are strikingly different from the CDw32 antigen but show great homology to the mouse beta 2FcR. RNA blot analysis of human cells using CDw32 and beta FcRII-specific DNA fragments demonstrated one beta FcRII transcript (1.7 kb) in B cells and in HL-60 cells which were induced to differentiate along a monocyte-macrophage pathway by phorbol 12-myristate 13-acetate treatment. Under these conditions the CDw32 transcripts (2.5 and 1.7 kb) are induced to a minor extent in HL-60 cells. In contrast, the 2.5-kb CDw32 transcript is strongly induced in HL-60 cells which have been induced to differentiate into granulocytes by exposure to dimethylsulfoxide. To determine the biological properties of the beta FcRII, we expressed the antigen in FcR- hamster cells. Only immune complexes but not monomeric human IgG were bound significantly. Bound ligand was efficiently internalized within 15 min and it was then found in vesicular structures. Thus the low-affinity beta FcRII is able to internalize ligands without cooperation with any other FcR.

Genomic EMBL 3 DNA clones representing part of the human Fc gamma receptor II and the beta Fc gamma receptor II genes were characterized. One of them contains the first five exons including the 5' flanking region of the beta FcRII gene. The signal peptide, the extracellular domains, the putative membrane spanning region, and the first amino acids of the cytoplasmic region encoded by these five exons are spread over approximately 11 kb. Another genomic DNA clone comprises four exons encoding the second extracellular domain and the transmembrane and cytoplasmic regions of the FcRII. Alignment of the genomic DNA clones reveals that these FcR genes are identically organized. Comparison of the corresponding regions of these clones shows that not only the exons are strikingly homologous but also the splice junctions and parts of the intervening sequences are conserved. Furthermore, the genomic organization of FcRII and HLA-class I resemble each other.

Bipolar pacemaker implantation was performed in three children, aged 5, 6 and 9 years. The two epimyocardial fishhook pacing electrodes were inserted through different incisions. After resection of the anterior part of the 5th and 6th rib, the generator was placed into a pocket with the posterior wall resulting from the remaining periostium/perichondrium and the anterior wall consisting of the isolated intercostal and pectoral muscle. The leads were brought in extrapleurally and connected to the generator. The operations were conducted without perioperative and late postoperative complications.

Gastric stress ulcers were produced by restraint in nonsecretory rats, and the response of the ulcer index to intraduodenal hydrochloric acid (HCl) or sodium chloride (NaCl) was studied in a three-step dose-response trial. Both substances lowered the ulcer index dose-dependently (Km HCl 0.038 +/- Km NaCl 0.089 +/- 0.009 mM/kg/h, respectively) reaching a nadir in rats receiving HCl. The improvement in ulcerations was associated with elevated plasma secretin, glucose, and lowered gastrin in this protocol. In both experimental procedures plasma vasoactive intestinal peptide (VIP) was higher with the low and intermediate doses as compared with the high dose when a slight venous hyperosmolality was present. Glucagon and insulin remained essentially stable. It is concluded that stress ulcers of the restraint type may be prevented by intraduodenal HCl, suggesting that the interplay of gastrointestinal hormones is deranged by stress and partly restored by acid instillation.

A monoclonal antibody, FR51, raised against the IgG Fc receptor (Fc gamma R) of the human monoblast cell line U937 was used to analyze the distribution of this antigen on various human cells. This antibody inhibited the binding of human IgG to the Fc gamma R on U937 cells, HL-60 cells and human peripheral blood monocytes. In contrast, the Fc gamma R on human granulocytes (neutrophil cells) and on an Epstein-Barr virus-transformed human lymphoblastoid cell line (Raji) were not recognized, indicated by the failure of blocking the binding of human IgG ligand to the Fc gamma R on these cells. By affinity chromatography of detergent-containing cell free lysates of surface-iodinated U937 cells, HL-60 cells and monocytes, a protein of 70-kDa was isolated. This protein was identified as the Fc gamma R by rebinding the isolated protein to immobilized human IgG. Removal of the carbohydrate moiety with endo-beta-N-acetylglucosaminidase F demonstrated that the receptors consist of a 40-kDa polypeptide. Analysis of the polypeptide patterns obtained by proteolytic digestion of either mature (70-kDa) or deglycosylated (40-kDa) receptors isolated from monocytes, U937 cells and HL-60 cells strongly suggests that the Fc gamma R are identical. The monoclonal antibody FR51 specifically reacts with Fc gamma R on human monocytes, a myeloblast and a monoblast cell line but not with the receptors on a B cell line and neutrophil cells.

In three groups--patients with recurrent calcium urolithiasis (RCU), patients with primary hyperparathyroidism (pHPT), and healthy controls--citrate was measured enzymatically in 24 and in 2-hr urine after an overnight fast. Citrate excretion per 24 hr was significantly lower in RCU than in age and sex matched controls, whereas there was no significant difference in citrate excretion in urines from the 2-hr morning collection. In pHPT citrate was also lower than in controls and fell within the range of RCU of comparable age. Both categories of urines (24 and 2hr) have in common the characteristic that the actual citrate concentration is lower by 50 per cent in RCU and pHPT than in controls, mainly as a result of the higher urine volume. Correction of citrate for creatinine does not disclose further differences among the populations studied but conversely hampers exact interpretation of urinary citrate in the absence of strict separation of individuals according to sex and age. From these data we conclude that (i) a low excretion and concentration of urinary citrate is detectable in calcium lithiasis and may contribute to a deficiency in inhibitory activity against nucleating processes in stone-forming urine; and (ii) the differences in urinary citrate elicited in samples of 24 and 2-hr morning urine are of unknown origin and merit further investigations.

In parathyroid-intact and parathyroidectomized rats we studied the influence of highly selective vagotomy (HSV) on net absorption and bidirectional (lumen-to-plasma, LP; plasma-to-lumen, PL) calcium (Ca) fluxes in the duodenum and ileum. In parathyroid-intact rats, Ca fluxes in the duodenum and ileum are not significantly altered by HSV. Nevertheless, net absorption is increased in the duodenum and decreased in the ileum. In parathyroidectomized rats duodenal LP flux is reduced and ileal PL flux is increased, by HSV, with the result that there is a decrease in the net absorption in both intestinal segments. It is suggested that (1) in intact rats, the influence of HSV on the net absorption of Ca is different in the duodenum and the ileum; (2) after prior parathyroidectomy, HSV is potentially harmful to the Ca balance of the body, and (3) the mineral metabolic effects of HSV have so far not been adequately studied.

In male Sprague-Dawley rats a microsurgical technique for highly selective vagotomy (HSV; syn. proximal gastric vagotomy) and for superselective vagotomy (SSV; cutting of proximal vagal fibers but sparing the blood vessels) has been developed. Basal acid secretion in both preparations was appr. 60% lower than in sham-operated controls. Acid response to 2-Deoxy-D-glucose (35 mg/kg/h over 4 h) was negative in HSV and SSV rats, whereas in sham rats acid output rose significantly. HSV, during mild stress (= control conditions), renders rats more susceptible to gastric stress ulcerations, whereas SSV with intact mucosal blood flow protects gastric mucosa almost completely. Although SSV, during severe restraint stress, cannot prevent the stress-induced breakdown of mucosal blood flow, gastric ulcerations are reduced to 40% of HSV and sham-operated control rats. SSV appears an elegant tool in stress ulcer research.

Surgical splanchnicectomy protects against stress ulcers in the presence of an intact adrenal medulla. The additional removal of adrenal medullary catecholamines results in an augmentation of gastric lesions. Inhibition of gastric acid secretion, improved gastric mucosal blood flow, enhanced gastric oxygen extraction, and increased energy supply to gastric tissue are discussed as possible protective mechanisms.