Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for evaluation of the left atrium and the left atrial appendage (LAA) for the presence of thrombi. Anticoagulation is conventionally used for patients with atrial fibrillation to prevent embolization of atrial thrombi. The mechanism of benefit and effectiveness of thrombi resolution with anticoagulation is not well defined. METHODS AND RESULTS: We used a TEE database of 9058 consecutive studies performed between January 1996 and November 1998 to identify all patients with thrombi reported in the left atrium and/or LAA. One hundred seventy-four patients with thrombi in the left atrial cavity (LAC) and LAA were identified (1.9% of transesophageal studies performed). The incidence of LAA thrombi was 6.6 times higher than LAC thrombi (151 vs 23, respectively). Almost all LAC thrombi were visualized on transthoracic echocardiography (90.5%). Mitral valve pathology was associated with LAC location of thrombi (P <.0001), whereas atrial fibrillation or flutter was present in most patients with LAA location of thrombi. Anticoagulation of 47 +/- 18 days was associated with thrombus resolution in 80.1% of the patients on follow-up TEE. Further anticoagulation resulted in limited additional benefit. CONCLUSIONS: LAC thrombi are rare and are usually associated with mitral valve pathology. Transthoracic echocardiography is effective in identifying these thrombi. LAA thrombi occur predominantly in patients with atrial fibrillation or flutter. Short-term anticoagulation achieves a high rate of resolution of LAA and LAC thrombi but does not obviate the need for follow-up TEE.     

Diagnostic chorionic biopsies in the first trimester. Report of experiences over a 2 year period

We report about 58 ultrasonographically guided transcervical chorionic villus biopsies from January 1985 to November 1987. Maternal age greater than 35 years (n = 28), followed by trisomy 21 or 18 (n = 10) were the mean indications. Biochemically evaluation of storage diseases (n = 6) and genomically DNA-analysis because of phenylketonuria (n = 2) were combined in each case with cytogenetic diagnosis. In the other cases certain indications were the reasons for biopsy. In 52 of 58 cases we were successful in biopsies and diagnoses. In the other 6 biopsy specimen we didn't found chorionic villi. 3 abortions we observed up to day 3 after operation (n = 3) and after 6 weeks (n = 1). Pathological findings were 1 trisomy 16, 1,47,XYY-karyotype and 1 embryo with phenylketonuria. Another reason for termination of pregnancy was male karyotype in a Morbus Duchenne-risk and 1 risk for Rett-syndrome. Meanwhile 30 healthy babies were born.     

A mouse model for Sorsby fundus dystrophy

PURPOSE: Sorsby fundus dystrophy (SFD) is a rare, late-onset macular dystrophy caused by mutations in the tissue inhibitor of metalloproteinases-3 (TIMP3) gene. The known mutations introduce potentially unpaired cysteine residues in the C terminus of the protein and result in the formation of higher-molecular-weight protein complexes of as yet unknown composition and functional consequences in the pathologic course of SFD. To facilitate in vivo investigation of mutant TIMP3, the authors generated a knock-in mouse carrying a disease-related Ser156Cys mutation in the orthologous murine Timp3 gene. METHODS: Site-directed mutagenesis and homologous recombination in embryonic stem (ES) cells was used to generate mutant ES cells carrying the Timp3(S156C) allele. Chimeric animals were obtained, of which two displayed germline transmission of the mutated allele. Molecular genetic, biochemical, electron microscopic, and electrodiagnostic techniques were used for characterization. RESULTS: At 8 months of age, knock-in mice showed abnormalities in the inner aspect of Bruch's membrane and in the organization of the adjacent basal microvilli of the retinal pigment epithelium (RPE). Changes resembling those in the mutant animals were also present to some extent in normal littermates, but only at an advanced age of 30 months. Long-term electrodiagnostic recordings indicated normal retinal function throughout life. The biochemical characteristics of the mutant protein appear similar in humans and knock-in mice, suggesting common molecular pathways in the two species. The localization of the mutant protein in the eye is normal, although there is evidence of increased Timp3 levels in Bruch's membrane of mutant animals. CONCLUSIONS: The knock-in mice display early features of age-related changes in Bruch's membrane and the RPE that may represent the primary clinical manifestations of SFD. In addition, our immunolabeling studies and biochemical data support a model proposing that site-specific excess rather than absence or deficiency of functional Timp3 may be the primary consequence of the known Timp3 mutations.     

Neurobiology of relapse to heroin and cocaine seeking: a review

The objective of this article is to review data from studies that used a reinstatement model in rats to elucidate the neural mechanisms underlying relapse to heroin and cocaine seeking induced by exposure to the self-administered drug (drug priming), conditioned drug cues, and stressors. These factors were reported to contribute to relapse to drug use in humans following prolonged abstinence periods. In the reinstatement model, the ability of acute exposure to drug or nondrug stimuli to reinstate drug seeking is determined following training for drug self-administration and subsequent extinction of the drug-reinforced behavior. We will review studies in which pharmacological agents were injected systemically or intracranially to block (or mimic) reinstatement by drug priming, drug cues, and stressors. We also will review studies in which brain lesions, in vivo microdialysis and electrochemistry, and gene expression methods were used to map brain sites involved in relapse to drug seeking. Subsequently, we will discuss theoretical issues related to the processes underlying relapse to drugs and address methodological issues in studies on reinstatement of drug seeking. Finally, the implications of the findings from the studies reviewed for addiction theories and treatment will be discussed. The main conclusion of this review is that the neuronal mechanisms involved in relapse to heroin and cocaine seeking induced by drug priming, drug cues, and stressors are to a large degree dissociable. The data reviewed also suggest that the neuronal events mediating drug-induced reinstatement are to some degree dissociable from those mediating drug reinforcement.     

Low doses of 2,3,7,8-tetrachlorodibenzo- p-dioxin increase transforming growth factor beta and cause myocardial fibrosis in marmosets ( Callithrix jacchus)

Epidemiological studies have suggested an association between exposure to dioxins and cardiovascular morbidity and mortality. However, cardiotoxic effects of low doses of 2,3,7,8-tetrachlorodibenzo- p-dioxin (TCDD) in animals have not been reported so far. We studied the hearts of male marmosets ( Callithrix jacchus)after treatment with single subcutaneous doses of 1, 10 or 100 ng TCDD/kg body weight or vehicle (toluene/DMSO 1+2 v/v, 100 microl/kg body weight). The animals were killed 2 or 4 weeks after treatment. Tissue samples of left ventricular myocardium were stained with picrosirius red and examined histologically along with quantitative image analysis. Extracellular matrix proteins were additionally analysed by western blotting. Monkeys showed no overt signs of toxicity nor did their relative heart weights differ significantly depending on treatment. Histology revealed an increase of picrosirius red-positive area above control values in 2 of 4 (1 ng TCDD/kg body weight), 6 of 12 (10 ng/kg) and 6 of 10 (100 ng/kg) marmosets. Western blotting confirmed these histological findings showing an increase of collagen, fibronectin and laminin in the hearts of TCDD-treated animals. Western blotting additionally showed an increased concentration of transforming growth factor beta1 (TGF-beta1) as well as TGF-beta receptor type I which could be a functional link to the effects on extracellular matrix. Our findings might explain the association of TCDD exposure with increased cardiovascular mortality observed in epidemiological studies and should stimulate further research on the role of changes in the extracellular matrix in the toxic effects of dioxins and related substances on other organs.     

Intrapulmonary shunt after cardiopulmonary bypass: the use of vital capacity maneuvers versus off-pump coronary artery bypass grafting

OBJECTIVES: It has been proved in human subjects and animals that atelectasis is a major cause of intrapulmonary shunting and hypoxemia after cardiopulmonary bypass. Animal studies suggest that shunting can be prevented entirely by a total vital capacity maneuver performed before termination of bypass. This study aimed to test this theory in human subjects and to evaluate possible advantages of off-pump coronary artery bypass grafting. METHODS: Twenty-four patients scheduled for coronary artery bypass grafting were randomly assigned to receive no total vital capacity maneuver (control group, n = 12) or standard total vital capacity maneuvers (TVCM group, n = 12). Additionally, 12 consecutive patients undergoing off-pump coronary artery bypass grafting (off-pump group) were studied. Systemic and central hemodynamics, the pattern of breathing, and ventilatory mechanics were evaluated after induction of anesthesia, after sternotomy, after cardiopulmonary bypass and skin closure, and 4 hours after extubation. RESULTS: The use of total vital capacity maneuvers reduced (P <.05) intrapulmonary shunting after termination of cardiopulmonary bypass. However, shunting increased (P <.05) in all groups (control group, 8.2% +/- 3.3% vs 25.6% +/- 8.1%; TVCM group, 8.7% +/- 3.4% vs 24.4% +/- 8.5%; and off-pump group, 7.8% +/- 2.8% vs 14.0% +/- 5.3%) after extubation, but the increase was significantly (P <.05) less pronounced in the off-pump group. Furthermore, pulmonary compliance decreased (P <.05) in all groups except the off-pump group after extubation. Duration of hospital and intensive care unit stay was significantly shorter (P <.05) in the off-pump group than in the other groups. CONCLUSION: The development of intrapulmonary shunting and hypoxemia after coronary artery bypass grafting can be substantially reduced by performance of total vital capacity maneuvers while patients are mechanically ventilated. However, off-pump coronary artery bypass surgery is superior in preventing shunting and hypoxemia after bypass grafting in the immediate and early postoperative periods, probably leading to substantially shorter intensive care unit and hospital stays.     

Treatment of Hypertension with Alternative Therapies (THAT) Study: a randomized clinical trial

OBJECTIVES: To examine the effect of spinal manipulation on blood pressure. DESIGN: This randomized clinical trial compared the effects of chiropractic spinal manipulation and diet with diet alone for lowering blood pressure in participants with high-normal blood pressure or stage I hypertension. Blood pressure observers were blinded to treatment group. SETTING: The study was conducted at the Berman Center for Clinical and Outcomes Research in Minnesota. Chiropractic treatments were administered by chiropractic physicians within private practice settings.PARTICIPANTS One hundred and forty men and women, aged 25-60 years, with high-normal blood pressure or stage I hypertension, were enrolled. One hundred and twenty-eight participants completed the study. INTERVENTIONS: (i) A dietary intervention program administered by a dietitian or (ii) a dietary intervention program administered by a doctor of chiropractic in conjunction with chiropractic spinal manipulation. The frequency of treatment for both groups was three times per week for 4 weeks, for a total of 12 visits. MAIN OUTCOME MEASURES: The primary outcomes for this study were change from baseline in diastolic and systolic blood pressure. RESULTS: Study groups were comparable at baseline. Changes in potentially confounding covariates did not differ between groups. Average decreases in systolic/diastolic blood pressure were -4.9/5.6 mmHg for diet group and -3.5/4.0 mmHg for the chiropractic group. Between group changes were not statistically significant. CONCLUSIONS: For patients with high normal blood pressure or stage I hypertension, chiropractic spinal manipulation in conjunction with a dietary modification program offered no advantage in lowering either diastolic or systolic blood pressure compared to diet alone.