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Background: The CCDC22 gene plays vital roles in regulating the NF-κB pathway, an essential pathway for neuroinflammation, neurodevelopment, and epileptogenesis. Previously, variants in CCDC22 were reported to be associated with intellectual disability. This study aimed to explore the association between CCDC22 and epilepsy., Methods: Trios-based whole-exome sequencing (WES) was performed in a cohort of patients with epilepsy of unknown cause recruited from the China Epilepsy Gene 1.0 Project. Damaging effects of variants were analysed using protein modelling., Results: Hemizygous missense CCDC22 variants were identified in three unrelated cases. These variants had no hemizygous frequencies in controls. All missense variants identified in this study were predicted to be "damaging" by multiple in silico tools and to alter the hydrogen bonds with surrounding residues and/or protein stability. The three patients presented with focal epilepsy of varying severity, including one with refractory seizures and focal cortical dysplasia (FCD) and two with seizures responding to antiseizure medicine. Notably, the variant associated with the severe phenotype was located in the coiled-coil domain and predicted to alter hydrogen bonding and protein stability, whereas the two variants associated with mild epilepsy were located outside functional domains and had moderate molecular alterations. Analysis of spatiotemporal expression indicated that CCDC22 was expressed in brain subregions with three peaks in the fetal stage, infancy, and early adulthood, especially in the fetal stage, explaining the occurrence of developmental abnormities., Significance: CCDC22 variants are potentially associated with X-linked focal epilepsy and FCD. The molecular subregional effects supported the occurrence of FCD., Competing Interests: Declaration of competing interest All the authors declare that there are no conflicts of interest., (Copyright © 2024 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

A comprehensive understanding of the molecular mechanisms underlying microbial catabolism of dibutyl phthalate (DBP) is still lacking. Here, we newly isolated a bacterial strain identified as Pseudomonas aeruginosa PS1 with high efficiency of DBP degradation. The degradation ratios of DBP at 100-1000 mg/L by this strain reached 80-99 % within 72 h without a lag phase. A rare DBP-degradation pathway containing two monobutyl phthalate-catabolism steps was proposed based on intermediates identified by HPLC-TOF-MS/MS. In combination with genomic and transcriptomic analyses, we identified 66 key genes involved in DBP biodegradation and revealed the genetic basis for a new complete catabolic pathway from DBP to Succinyl-CoA or Acetyl-CoA in the genus Pseudomonas for the first time. Notably, we found that a series of homologous genes in Pht and Pca clusters were simultaneously activated under DBP exposure and some key intermediate degradation related gene clusters including Pht, Pca, Xyl, Ben, and Cat exhibited a favorable coexisting pattern, which contributed the high-efficient DBP degradation ability and strong adaptability to this strain. Overall, these results broaden the knowledge of the catabolic diversity of DBP in microorganisms and enhance our understanding of the molecular mechanism underlying DBP biodegradation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reports in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Liver transplantation (LT) is the best treatment for patients with hepatocellular carcinoma (HCC). However, the surgical technique needs to be improved. The present study aimed to evaluate the "no-touch" technique in LT., Methods: From January 2018 to December 2019, we performed a prospective randomized controlled trial on HCC patients who underwent LT. The patients were randomized into two groups: a no-touch technique LT group (NT group, n = 38) and a conventional LT technique group (CT group, n = 46). Operative outcomes and survival in the two groups were analyzed., Results: The perioperative parameters were comparable between the two groups (P > 0.05). There was no significant difference between the two groups in disease-free survival (DFS) (P = 0.732) or overall survival (OS) (P = 0.891). Of 36 patients who were beyond the Hangzhou criteria for LT, the DFS of the patients in the NT group was significantly longer than that in the CT group (median 402 vs. 126 days, P = 0.025). In 31 patients who had portal vein tumor thrombosis (PVTT), DFS and OS in the NT group were significantly better than those in the CT group (median DFS 420 vs. 167 days, P = 0.022; 2-year OS rate 93.8% vs. 66.7%, P = 0.043). In 14 patients who had diffuse-type HCCs, DFS and OS were significantly better in the NT group than those in the CT group (median DFS 141 vs. 56 days, P = 0.008; 2-year OS rate 75.0% vs. 33.3%, P = 0.034). Multivariate analysis showed that for patients with PVTT and diffuse-type HCCs, the no-touch technique was an independent favorable factor for OS (PVTT: HR = 0.018, 95% CI: 0.001-0.408, P = 0.012; diffuse-type HCCs: HR = 0.034, 95% CI: 0.002-0.634, P = 0.024)., Conclusions: The no-touch technique improved the survival of patients with advanced HCC compared with the conventional technique. The no-touch technique may provide a new and effective LT technique for advanced HCCs., Competing Interests: Competing interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (Copyright © 2022. Published by Elsevier B.V.)

A new type of magnetic metal chelating carrier (PCMM-IDA-Cu 2+ ) was prepared for the immobilization of papain, using chitosan as raw material, nano Fe 3 O 4 as magnetic material, SiO 2 as porogen, iminodiacetic acid (IDA) as a chelating ligand, and binding with transition metal ion (Cu 2+ ). The resulting products were well characterized by optical microscopy, scanning electron microscopy (SEM), vibrating sample magnetometer (VSM), Fourier transform infrared spectroscopy (FTIR) and thermogravimetric analysis (TGA). The BBD (Box-Behnken Design) of RSM (Response Surface Methodology) was applied to analyze the optimum enzyme immobilization conditions. The results showed that the enzyme immobilization capacity was 94.18mg/g of PCMM-IDA-Cu 2+ , with 7.976U/mg of relative immobilized enzyme activity under the optimum conditions (pH6.73, 1.56mg enzyme/15.0mg carrier, 30.9°C), and the recovery of enzyme activity was reached 87.21%. Compared with the free papain, the immobilized papain displayed enhanced enzyme activity, superior enzymatic properties, good operational stability and reusability. It is worth mentioning that the novel carriers exhibited selectively biological adsorption capacity, and this technique is an alternative method for the immobilization of enzyme, making the process more efficient and economic., (Copyright © 2018 Elsevier B.V. All rights reserved.)

A variable-displacement pump controlled pitch system is proposed to mitigate generator power and flap-wise load fluctuations for wind turbines. The pitch system mainly consists of a variable-displacement hydraulic pump, a fixed-displacement hydraulic motor and a gear set. The hydraulic motor can be accurately regulated by controlling the pump displacement and fluid flows to change the pitch angle through the gear set. The detailed mathematical representation and dynamic characteristics of the proposed pitch system are thoroughly analyzed. An adaptive sliding mode pump displacement controller and a back-stepping stroke piston controller are designed for the proposed pitch system such that the resulting pitch angle tracks its desired value regardless of external disturbances and uncertainties. The effectiveness and control efficiency of the proposed pitch system and controllers have been verified by using realistic dataset of a 750 kW research wind turbine., (Copyright © 2015 ISA. Published by Elsevier Ltd. All rights reserved.)

Background: Cell-saving devices (CS) are frequently used in cardiac surgery to reduce transfusion requirements, but convincing evidence from randomized clinical trials is missing. Filtration of salvaged blood in combination with the CS is widely used to improve the quality of retransfused blood, but there are no data to justify this approach., Methods: To determine the contribution of CS and filters on transfusion requirements, we performed a multicenter factorial randomized clinical trial in two academic and four nonacademic hospitals. Patients undergoing elective coronary, valve, or combined surgical procedures were included. The primary end point was the number of allogeneic blood products transfused in each group during hospital admission., Results: From 738 included patients, 716 patients completed the study (CS+filter, 175; CS, 189; filter, 175; neither CS nor filter, 177). There was no significant effect of CS or filter on the total number of blood products (fraction [95% confidence interval]: CS, 0.96 [0.79, 1.18]; filter, 1.17 [0.96, 1.43]). Use of a CS significantly reduced red blood cell transfusions within 24 hours (0.75 [0.61,0.92]), but not during hospital stay (0.86 [0.71, 1.05]). Use of a CS was significantly associated with increased transfusions of fresh frozen plasma (1.39 [1.04, 1.86]), but not with platelets (1.25 [0.93, 1.68]). Use of a CS significantly reduced the percentage of patients who received any transfusion (odds ratio [95% confidence interval]: 0.67 [0.49, 0.91]), whereas filters did not (0.92 [0.68, 1.25])., Conclusions: Use of a CS, with or without a filter, does not reduce the total number of allogeneic blood products, but reduces the percentage of patients who need blood products during cardiac surgery., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background & Aims: To investigate diagnostic and prognostic values of sulfite oxidase (SUOX) in patients with hepatocellular carcinoma (HCC) who underwent curative resection., Methods: We investigated immunohistochemically the expression dynamics of SUOX, aldo-ketoreductase family 1 member B10 (AKR1B10) and CD34 at different stages of HCC. The differential diagnostic performance of three markers or their combinations in high-grade dysplastic nodules (HGDNs) and well-differentiated small HCC (WD-sHCC) were investigated by logistic regression models and validated in an independent testing set. Overall survival (OS) and time to recurrence (TTR) were evaluated in 300 patients with HCC as the testing cohort, and validated in 198 patients with HCC., Results: SUOX was decreased and AKR1B10 and CD34 were increased with the stepwise progression of hepatocarcinogenesis. For differential diagnosis of WD-sHCC from HGDNs, the sensitivity and specificity of the SUOX+AKR1B10+CD34 combination for WD-sHCC detection were 93.8% and 95.2%, respectively, and overall accuracy was much higher than any of the three individual markers and two marker combinations. In addition, SUOX, but not AKR1B10 and CD34, was an independent prognostic factor for OS and TTR, and showed better correlation with OS and TTR if combined with serum α-fetoprotein (AFP) for both the testing and validation cohorts., Conclusions: SUOX+AKR1B10+CD34 combination could make a substantial contribution to hepatic immunopathological diagnosis to distinguish WD-sHCC from HGDNs. Meanwhile, SUOX combined with serum AFP may predict postoperative outcome and tumor recurrence risk., (Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Multidrug resistance (MDR) is a major clinical obstacle to the success of cancer chemotherapy. Here we developed a gold-doxorubicin (DOX) nanoconjugates system to overcome MDR. Gold nanoparticles (AuNPs) were first PEGylated as Au-PEG-NH(2), and DOX was then grafted onto AuNPs via a cleavable disulfide linkage (Au-PEG-SS-DOX). Confocal images revealed that the extent of intracellular uptake of Au-PEG-SS-DOX was greater than that of free DOX in the MDR cells, and inductively coupled plasma mass spectroscopy analysis further confirmed that AuNPs significantly increased the level of drug accumulation in MDR cells at a nanoparticles dose greater than 15 μM. The cytotoxicity study demonstrated that the Au-PEG-SS-DOX nanoconjugates system efficiently released the anticancer drug DOX and enhanced its cytotoxicity against MDR cancer cells. This study highlights the potential of using AuNPs for overcoming of MDR in cancer chemotherapy., From the Clinical Editor: This study demonstrates that gold nanoparticles can be successfully applied to overcome MDR in cancer chemotherapy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Mechanical cell salvage is increasingly used during cardiac surgery. Although this procedure is considered safe, it is unknown whether it affects the red blood cell (RBC) function, especially the RBC aggregation, deformability, and the contents of 2,3-diphosphoglycerate (2,3-DPG). This study examines the following: (1) whether the cell salvage procedure influences RBC function; and (2) whether retransfusion of the salvaged blood affects RBC function in patients., Methods: Forty patients undergoing cardiac surgery with cardiopulmonary bypass were randomly allocated to a cell saver group (n = 20) or a control group (n = 20). In the cell saver group, the blood aspirated from the wound area and the residual blood from the heart-lung machine were processed with a continuous-flow cell saver before retransfusion. In the control group this blood was retransfused without processing. The RBC aggregation and deformability were measured with a laser-assisted optical rotational cell analyzer and 2,3,-DPG by conventional laboratory test., Results: The cell saver procedure did not influence the RBC aggregation but significantly reduced the RBC deformability (p = 0.007) and the content of RBC 2,3-DPG (p = 0.032). However, in patients receiving the processed blood, their intraoperative and postoperative RBC aggregation, deformability, and 2,3-DPG content did not differ from those of the control patients. Both groups of patients had a postoperative drop of RBC function as a result of hemodilution., Conclusions: The mechanical cell salvage procedure reduces the RBC deformability and the cell 2,3-DPG content. Retransfusion of the processed blood by cell saver does not further compromise the RBC function in patients undergoing cardiac surgery with cardiopulmonary bypass.

Background: Neutrophil activation is implicated in postoperative complications in patients having cardiac surgery with cardiopulmonary bypass (CPB). This study was designed to determine the temporal fluctuations in the primability of neutrophils in the preoperative, intraoperative, and postoperative periods of CPB, and specifically whether CPB was a primary cause leading to increased neutrophil priming and elastase release., Methods: Twenty patients undergoing multiple coronary bypass grafting, valve replacement, or both of these procedures were included in this study. Blood samples were taken 1 day before the operation and at several time points during and after the operation. For each sample, blood was divided in vitro into four subgroups: control without priming, priming alone with cytochalasin B (CytoB), priming plus stimulation with platelet-activating factor (PAF), and priming plus stimulation with N-formyl-methionyl-leucyl-phenylalanine (fMLP). The elastase concentration of all these samples was determined using the enzyme immunoassay., Results: Compared with the controls, CytoB priming increased release of elastase more than 10-fold before CPB, 1.6-fold during CPB, and 1.5-fold at the end of CPB. Further stimulation with PAF or fMLP showed greater increase of elastase than priming alone, with peak values in both found before CPB. This increased neutrophil primability prior to CPB did not differ significantly among patients who had different preoperative disease profiles., Conclusions: Our data suggest that neutrophil priming occurs early before commencing CPB in cardiac surgical patients, and that CPB is not the primary primer. Anesthesia, surgical trauma, and other events may have been involved in neutrophil priming and sensitization before CPB, which warrants further investigation.

Background: Albumin in the priming solution precoats the surface of the cardiopulmonary bypass circuit, supposedly causing delayed adsorption of fibrinogen and reduced activation and adhesion of platelets. This action may result in lower transoxygenator resistance. Because our institution uses a colloidal prime solution (Gelofusine), questions were raised about the value of albumin in the prime solution. We decided to focus on the clinical effects of transoxygenator resistance., Methods: Sixty adults undergoing elective cardiac operations were randomly divided into three groups: a group with 20-g albumin (n = 20), a group with 2-g albumin (n = 20), and a group with no albumin (n = 20) in the 1,600-mL colloidal prime. Patients older than 75 years and patients with a preoperative serum albumin level of 30 g/L or less were excluded. The transoxygenator resistance was measured throughout cardiopulmonary bypass. Beta-thromboglobulin levels were used to study contact activation of platelets. Measures of prothrombin F1,2 fragments were used as a marker of thrombin generation. Body surface area, age, preoperative albumin, hematocrit, hemoglobin, fibrinogen, platelet count, and colloid osmotic pressure levels were compared between groups., Results: Base line characteristics and chosen control measurements were similar for all three populations. When comparing the observed transoxygenator resistance among the three different groups, no significant differences were noted. Prothrombin F1.2 fragments remained low for all the groups without significant differences. In the no-albumin group the level of beta-thromboglobulin appeared to be higher, but the difference was not statistically significant., Conclusions: Addition of albumin to prime solution in a cardiopulmonary bypass circuit that already contains colloids does not affect the transoxygenator resistance of the COBE Duo flat sheet oxygenator and does not affect prothrombin F1.2 and beta-thromboglobulin levels. Therefore additional costs for the albumin are not justified. Measurement of transoxygenator resistance is a reliable, simple method to determine the effects of a prime solution on the oxygenator surface in vivo.

Cardiopulmonary bypass surgery induces an inflammatory reaction among others by activation of granulocytes. Leukocyte filtration has been shown to reduce the postoperative morbidity mediated by activated granulocytes. However, little is known about the mechanism of filter-leukocyte interaction. This study examines whether a leukocyte filter removes activated granulocytes or a general leukocyte population. Eleven patients undergoing cardiopulmonary bypass surgery were included in this study. Leukocyte filtration was achieved before the reperfusion phase with a Pall non-woven polyester filter located at the venous side of the heart-lung machine. After filtration, the trapped granulocytes inside the filter were examined morphologically with light and scanning electron microscopy and immunologically by CD45RO antigen binding to the filter material. Furthermore, leukocyte release markers were measured to determine whether cells were activated during filtration. Microscopic evaluation revealed 84% granulocytes and 14% lymphocytes trapped in the filter, compared with 78% granulocytes and 22% lymphocytes in the blood before filtration. Granulocytes were trapped significantly more in the first blood contact layer of the filter material than in the middle layer and last layer, whereas lymphocytes trapped slightly more in the middle layer. The near maximum level of CD45RO expression was measured on granulocytes trapped inside the filter material, whereas CD2 and CD19 measured on lymphocytes were bound to a minor extent. Beta-glucuronidase concentration did not increase after filtration, suggesting the absence of activation of granulocytes by filtration. A leukocyte filter made of non-woven polyester material removes the activated granulocytes rather than leukocytes at random. This implies that this particular type of leukocyte removal filter is suitable for use in cardiopulmonary bypass patients whose granulocytes in the circulation are activated. Furthermore, measurement of activated granulocytes instead of total leukocyte count is likely preferable for functional assessment of leukocyte removal devices.

Study Objectives: Complement activation is a trigger in inducing inflammation in patients who undergo coronary artery bypass grafting (CABG) and is usually thought to be induced by the use of cardiopulmonary bypass (CPB). In this study, we examined whether tissue injury caused by chest surgical incision per se contributes to complement activation in CABG patients., Design: Prospective study., Setting: Thorax center in university hospital., Patients: Twenty-two patients undergoing CABG without CPB were prospectively divided into two groups: a small chest incision via an anterolateral thoracotomy representing a minimized tissue injury (lateral group, n = 8), and a conventional median sternotomy representing a large tissue injury (median group, n = 14). Biochemical markers indicating complement activation as well as systemic inflammatory response were determined before, during, and after the operation., Measurements and Results: Plasma concentrations of complement 3a increased in both the lateral and median groups right after chest incision (p < 0.01 and p < 0.05, respectively) and by the end of operation increased only in the median group (p < 0.01). The terminal complement complex 5b-9 did not increase in the lateral group, but it did increase in the median group both after incision and by the end of the operation (p < 0.05 and p < 0.05, respectively). During surgery, complement 4a did not increase, suggesting that it is the alternative rather than the classic pathway that is involved in complement activation by tissue injury. Postoperatively, interleukin-6 production was greater in the median group (p < 0.01) than the lateral group (p < 0.05), suggesting a more pronounced inflammatory response to a larger chest incision., Conclusions: Tissue injury caused by surgical incision contributes to complement activation in CABG patients who are operated on without CPB. A small anterolateral thoracotomy is associated with reduced complement activation in comparison with a median sternotomy.

Background: Hemostasis is preserved after off-pump coronary operations compared with conventional coronary procedures. However, this preserved hemostasis may result in a procoagulant activity., Methods: We prospectively studied coagulation in 22 patients who underwent off-pump coronary operation either through a midline sternotomy (n = 14) or with minimally invasive anterolateral thoracotomy (n = 8)., Results: Procoagulant activity, represented by prothrombin factor 1 and 2, remained at baseline levels during operation but increased significantly on postoperative day 1. Factor VII remained at baseline levels during the operation but decreased significantly on postoperative day 1. Fibrinolysis was increased as indicated by the fibrin degradation products on postoperative day 1. A promoted hemostasis attributable to endothelial activation was indicated by the increase in von Willebrand factor on postoperative day 1. Platelets counts and platelet activation (beta-thromboglobulin) remained at baseline levels after the operation. No adverse clinical events occurred., Conclusions: Patients undergoing off-pump coronary operation show an increased procoagulant activity in the first postoperative 24 hours regardless of the surgical approach (midline sternotomy or anterolateral thoracotomy). This procoagulant activity is not mediated by platelet-related factors. Therefore, a specific perioperative prophylactic pharmacologic regimen is advisable.

Background: Leukocyte depletion recently has been introduced for cardiac surgical patients to attenuate leukocyte-mediated inflammation and organ reperfusion injury. We evaluated the feasibility of a new leukocyte depletion method in which systemic leukocyte depletion is achieved through the venous side of the cardiopulmonary bypass circuit under low blood flow., Methods: Forty cardiac surgical patients undergoing cardiopulmonary bypass were allocated randomly to a leukocyte depletion group (n = 20) and a control group (n = 20). In the depletion group, leukocyte filtration was achieved with two filter sets located between the venous drainage and the venous reservoir. Leukocyte filtration was commenced after the start of rewarming but before the release of the aortic cross-clamp, and it was driven by a spare roller pump of the heart-lung machine., Results: All the episodes of filtration went smoothly within a period of 10 minutes and with a blood flow rate of 400 mL/min. The mean leukocyte removal rate calculated at the end of filtration was 69%. Circulating leukocytes were reduced by 38% in the depletion group compared with the control group at the moment of cross-clamp release (4.3x10(9)/L versus 6.8x10(9)/L, p<0.05). The postoperative inflammatory response also was reduced as indicated by less production of interleukin-8 (p<0.05). Clinically, there was no significant difference between the two groups in postoperative PaO2 or pulmonary hemodynamics., Conclusions: It is technically feasible to deplete circulating leukocytes through the venous side of the cardiopulmonary bypass circuit with a low blood flow rate. Future studies should focus on the duration and timing of leukocyte depletion to optimize the methodology of leukocyte depletion for cardiac surgical patients.

Background: This study was designed to investigate whether clinical signs of the inflammatory response in pediatric cardiac patients are reduced by heparin-coated cardiopulmonary bypass circuits and how this could be explained by differences in the pathophysiologic mechanisms involved., Methods: In a randomized, prospective study 19 patients underwent cardiopulmonary bypass either with Carmeda BioActive Surface bypass circuits (n = 9) or with identical noncoated circuits (control, n = 10). Clinical parameters were recorded during the first 48 hours after the start of operation. Blood samples for determination of terminal complement complex, soluble form of E-selectin, and beta-thromboglobulin were obtained perioperatively up to 24 hours after operation., Results: All clinical and inflammatory mediators showed a tendency in favor of the group with heparin-coated circuits. When analyzed on a point-by-point basis there were significant differences in postoperative central body temperature, soluble E-selectin levels, and beta-thromboglobulin levels (all p < 0.05)., Conclusions: These data suggest that the use of heparin-coated cardiopulmonary bypass offers clinical benefit and tends to reduce the release of inflammatory mediators.

Background: The cardiopulmonary bypass (CPB) circuit induces blood activation and a systemic inflammatory response in cardiac surgical patients. The CPB circuit treated with surface-modifying additive (SMA) has been found to reduce blood activation by in vitro and ex vivo experiments. This study evaluates the surface thrombogenicity and complement activation of SMA circuits during clinical CPB., Methods: Twenty patients undergoing coronary artery bypass grafting were randomly divided into two groups. In the SMA group (n = 10), all blood-contacting surfaces in the CPB circuit were treated or coated with SMA, whereas in the control group (n = 10) patients were perfused with an identical circuit without treatment., Results: During CPB, platelet count and beta-thromboglobulin were found similar in both the SMA and the control groups. Prothrombin activation indicated by fragment F1 + 2 was found less in the SMA group (p < 0.05). After CPB, platelet deposition on the CPB circuit was significantly less (p < 0.05) in the SMA group than in the control group as assessed by the labeled monoclonal antibody against platelet glycoprotein IIIa. Complement activation identified by C3a and terminal complex C5b-9 did not differ between the two groups, but C4a generation was less in the SMA group (p < 0.05). Leukocyte activation identified by elastase and cytokine release indicated by interleukin-8 were found uniformly in both groups. Postoperatively, chest tube drainage, blood transfusion, duration of ventilatory support, as well as the intensive care unit and hospital stay were not significantly different between the two groups., Conclusions: These preliminary clinical results suggest that SMA inhibits platelet interaction with the biomaterial surface of the CPB circuit. Complement activation assessed by the terminal complement complex is not influenced by SMA. The clinical benefit of this surface-modifying technique has yet to be assessed in a larger population of patients undergoing cardiac operations.

Background: The aim of this prospective study was to determine whether the inflammation-associated clinical morbidity as well as the subclinical markers of the inflammatory response are reduced in patients who undergo minimally invasive coronary artery bypass grafting without cardiopulmonary bypass., Methods: From June 1995 to June 1996, 62 consecutive patients with isolated stenosis of the left anterior descending coronary artery were assigned randomly to two groups: 31 patients underwent minimally invasive coronary artery bypass grafting and 31 patients underwent conventional coronary artery bypass grafting with cardiopulmonary bypass. In a subgroup of 10 patients in each group, subclinical markers were measured to determine the level of the inflammatory response generated during the operation., Results: In the group that underwent minimally invasive coronary artery bypass grafting, leukocyte elastase, platelet beta-thromboglobulin, and complement C3a were unchanged at the end of the procedure compared with their baseline concentrations, whereas these inflammatory markers were increased significantly in the group that underwent conventional coronary artery bypass grafting with cardiopulmonary bypass. The patients who underwent minimally invasive coronary artery bypass grafting had a shorter duration of operation (104 +/- 28 versus 140 +/- 28 minutes; p < 0.01), less blood loss (312 +/- 167 versus 788 +/- 365 mL; p < 0.01), shorter ventilatory support (7.7 +/- 4.1 versus 12.9 +/- 3.4 hours; p < 0.01), and a shorter postoperative hospital stay (4.4 +/- 1.7 versus 7.7 +/- 2.6 days; p < 0.01) than the patients who underwent the conventional procedure., Conclusions: These data suggest that patients who undergo minimally invasive coronary artery bypass grafting have a significant reduction in the systemic inflammatory response, postoperative morbidity, and hospital stay compared with patients who undergo conventional coronary artery bypass grafting with cardiopulmonary bypass.

Background: Extreme dilution of clotting factors, as may occur during pediatric or neonatal cardiopulmonary bypass, often leads to inadequate monitoring of anticoagulation with activated clotting time (ACT). In this study we postulate that the high-dose thrombin time (HiTT) is less influenced by extreme dilution of clotting factors because it stimulates clotting through the common pathway., Methods: Heparinized prebypass blood was obtained from 30 adult cardiac surgical patients and was diluted in a laboratory setting with saline solution to mimic the clinical clear prime solution (group I; n = 10), with saline solution containing similar heparin as in the prebypass blood (group II; n = 10), and with fresh frozen plasma to substitute clotting factors in the diluted blood (group III; n = 10). Blood was diluted to four different degrees: a control without dilution, 25%, 50%, and 75% dilution. The ACT and HiTT were measured and compared., Results: In group I, significant prolongation of ACT was observed in blood diluted to 75% as compared with the nondiluted blood (p < 0.01). In contrast, HiTT was not prolonged at any degree of dilution but reduced proportionally to dilution up to 75%, reflecting the concomitant reduction of heparin. In group II, ACT increased at 25% dilution (p < 0.01) whereas HiTT increased at 50% dilution (p < 0.01). In group III, no prolongation of ACT or HiTT was found in any degree of dilution. Furthermore, adding fibrinogen to the diluted blood (n = 4) did not cause ACT to recover at 75% dilution, suggesting that dilution of other factors in the early clotting cascade rather than fibrinogen alone increases ACT., Conclusions: These results imply that when blood is extremely diluted during cardiopulmonary bypass with a clear prime without substituted clotting factors, HiTT is a better test than ACT for anticoagulation monitoring.

Cardiopulmonary bypass generates a systemic inflammatory response including the activation of the complement cascade and leukocytes contributing to postoperative morbidity. To evaluate whether the use of heparin-coated extracorporeal circuits could reduce these activation processes, we performed a study on 30 patients undergoing coronary artery bypass grafting who were randomly perfused with a heparin-coated circuit (Duraflo II, n = 15) or with a similar noncoated circuit (control, n = 15). Standardized systemic heparinization was applied for every patient before cardiopulmonary bypass. The use of heparin-coated circuits resulted in a reduction of systemic leukocyte activation during cardiopulmonary bypass reflected by reduced elastase release (p < 0.05) and tumor necrosis factor generation (p < 0.05) manifest after release of the aortic cross-clamp. In addition, blood samples taken from both the right and left atria after reperfusion revealed that the elastase release from the pulmonary microcirculation was absent in the Duraflo II group in contrast to the control group (p < 0.05). The pattern of complement activation, likely initiating this inflammatory reaction, was modified by heparin coating in two different aspects. There was a significant reduction of C3a generation after protamine administration in patients perfused with heparin-coated circuits, and there was a decrease of complement hemolytic capacity in pooled human serum incubated with heparin-coated tubing. These observations suggest that heparin coating might bind some of the complement components from the classic pathway, thereby reducing the inflammatory response to cardiopulmonary bypass.

Although beta-D-fucosidase (beta-D-fucohydrolase, EC 3.2.1.38) has been isolated from various sources, all those enzymes were associated with a high activity of beta-D-galactosidase and/or beta-D-glucosidase. We have purified a specific beta-D-fucosidase in electrophoretically homogeneous form from crude extracts of Aspergillus phoenicis by polyethyleneglycol 8000-phosphate buffer aqueous two-phase separation, and successive chromatography on DEAE-Sephadex A-50, hydroxyapatite, and Sephadex G-100 columns. The molecular weight of the enzyme was estimated to be 57,000 by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and 50,000 to 60,000 by gel filtration on Sephadex G-100. The enzyme showed optimum activity at pH 6.0 and 40 degrees C; it was stable in the pH range 5.5-6.5 and below 35 degrees C. The Km and the Vmax values for pNP-beta -D-fucoside were 2.4 mM, and 12.8 mumol.min-1.mg-1, respectively. The enzyme was strongly inhibited by sulfhydryl group reagents, p-chloromercuribenzoate, n-ethylmaleimide, and iodoacetate. It was also inhibited by 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide, diethyl pyrocarbonate, and N-bromosuccinimide. Thus, -SH and -COOH groups and histidyl and tryptophyl residues were essential for enzyme activity. The purified beta-D-fucosidase showed high specificity toward p-nitrophenyl-beta-D-fucoside. The enzyme was inhibited by D-fucose and D-fucono-gamma-lactone, but not by D-galactose, D-galactono-gamma-lactone, D-glucose, or D-glucono-gamma-lactone; the latter compounds are specific inhibitors of beta-D-galactosidase and beta-D-glucosidase, respectively. Thus, this enzyme is the most strictly specific beta-D-fucosidase when compared with those previously reported.

Endotoxin, when released into the systemic circulation during cardiopulmonary bypass (CPB), might induce activation of plasmatic systems and blood cells during CPB, in addition to a material-dependent blood activation during CPB. However, the role of endotoxin in the development of this so-called whole-body inflammatory reaction in CPB is still unclear. We investigated the release of endotoxin into the systemic circulation in relation with the activation of the complement system and in particular the formation of tumor necrosis factor in 10 patients undergoing CPB. Immediately after the start of CPB the endotoxin concentrations increased significantly (p less than 0.01), accompanied by increases in C3a concentration (p less than 0.05). After release of the aortic cross-clamp, there was a second increase in endotoxin followed by a continuous increase in tumor necrosis factor, reaching a peak concentration 1 hour after the end of CPB (p less than 0.01). These observations demonstrate a release of endotoxin into the systemic circulation associated with tumor necrosis factor formation, which contributes to the whole-body inflammatory reaction associated with CPB.

The effects of cardiopulmonary bypass (CPB) on the expression of leukocyte adhesive receptors, ie, complement receptor type 3 (CR3), were studied in 16 patients. The CR3 expression on leukocytes was determined by time-resolved fluoroimmunoassay on a standardized number of cells isolated from blood samples taken during various times during CPB. The results demonstrated that CR3 expression on leukocytes increased immediately after the start of CPB (p less than 0.05), concomitant with an early sharp increase of plasma concentrations of C3a (p less than 0.01). After release of the aortic cross-clamp, a second peak of leukocyte CR3 expression was induced (p less than 0.05), paralleled by a significant increase of leukotriene B4 (p less than 0.05) and elastase (p less than 0.05) levels in the late period of CPB. In vitro studies with leukocytes isolated from healthy donors (n = 5) showed a dose-dependent increase of CR3 expression stimulated by zymosan-activated plasma, indicating that the rapid CR3 expression on leukocytes is likely mediated by complement activation. However, the mechanisms for the second peak of leukocyte CR3 expression during CPB remain to be further elucidated. In conclusion, CR3 expression on leukocytes increased immediately after the start of CPB and was followed by a second peak of expression in the late phase of CPB. Pharmacological blockage of these adhesive receptors might reduce the leukocyte-mediated deleterious effects of CPB.

The effect of blood activation on lung reperfusion injury during cardiopulmonary bypass was investigated in 20 dogs with the use of a bubble oxygenator (n = 10) or a membrane oxygenator (n = 10). In the bubble oxygenator group, significant leukocyte and platelet right to left atrium gradients were found 15 minutes after lung reperfusion (p less than 0.05, p less than 0.01) accompanied by a sharp increase in plasma malondialdehyde concentration 5 minutes after lung reperfusion, whereas no significant right to left atrium gradient of leukocytes or platelets nor significant increase in plasma malondialdehyde concentration was observed in the membrane oxygenator group. In both the bubble oxygenator and membrane oxygenator group, similar mild to moderate lung histological changes were found before lung reperfusion. After lung reperfusion, however, more endothelial cell swelling (p less than 0.05), leukocyte (p less than 0.01) and platelet (p less than 0.01) accumulation in lung capillaries, leakage of erythrocytes into the alveolar space (p less than 0.05), and type I cell damage (p less than 0.05) were found only in the bubble oxygenator group. Eventually, a significantly higher lung water content was found in the bubble oxygenator group than in the membrane oxygenator group (p less than 0.01) after cardiopulmonary bypass. This study indicated that lung injury during cardiopulmonary bypass starts mainly after lung reperfusion, which was correlated with lung leukocyte and platelet sequestration associated with different types of oxygenators.