Cardiac Surgery in Nonagenarians

A bstract Objectives and Background : The purpose of this study was to document our initial experience with patients 90 years of age and older and to determine whether cardiac surgery is justified in this age group. Cardiac surgery in octogenarians has proven to be a successful and worthwhile procedure. A small group of nonagenarians with severe coronary artery disease (CAD) and aortic valve disease refractory to medical therapy have been considered for surgery. Methods : Fourteen patients aged 90 or more underwent cardiac surgery for symptomatic CAD or aortic valvular disease refractory to medical therapy. Eight patients underwent isolated coronary artery bypass grafting (CABG) and six patients underwent aortic valve replacement (AVR). All patients were in NYHA Class IV preoperatively. Results : Hospital mortality occurred in one patient (7%). Hospital morbidity occurred in 10 patients (71%) and included 7 cardiac, 5 neurological, 1 gastrointestinal, 1 infectious, and 1 pulmonary event. All survivors left the hospital symptomatically improved. The mean length of stay was 26 days. Four CABG patients went on to die at a mean of 2 years and 2 months, and 3 remain alive at a mean of 2 years and 4 months. Three AVR patients expired at a mean of 3 years and 4 months, and 3 remain alive at 4 years and 1 month. Conclusions : Cardiac surgery in carefully selected nonagenarians is justified and can be performed with acceptable results.     

Immunolocalization of the Inducible Nitric Oxide Synthase Isoform in Human Fetal Membranes

PROBLEM: Nitric oxide (NO) synthesized by fetal membranes may protect the fetus from maternal infection or immune challenge or have a tocolytic effect on myometrium. The sites of synthesis and enzymes responsible for NO production in human fetal membranes remain unidentified. METHOD OF STUDY: Fetal membranes were obtained from four groups of patients: term (>37 weeks gestation) or preterm (<37 weeks gestation), both either in labor or not in labor. Frozen sections of membrane rolls were immunostained for inducible (iNOS) and endothelial (eNOS) nitric oxide synthase isoforms and the monocyte/macrophage marker CD14. RESULTS: Positive iNOS immunostaining was found in fibroblasts of amnionic and chorionic mesenchyme and in decidual macrophages identified by CD14 from all four groups of tissues. No iNOS immunostaining was seen in amnion epithelium or chorion trophoblast. Very intense iNOS staining was seen with evidence of monocyte/macrophage invasion of membranes. eNOS immunostaining was only found in decidual vascular endothelium. CONCLUSIONS: Constitutive expression of iNOS in decidual macrophages and fetal membrane fibroblasts may form an immune barrier against maternal insult. In chorioamnionitis, macrophage recruitment and NO expression may be part of the maternal immune response.     

Combination of ABO blood group incompatibility and glucose-6-phosphate dehydrogenase deficiency: effect on hemolysis and neonatal hyperbilirubinemia

The incidence (%) of hyperbilirubinemia (serum bilirubin ≥257 μmol/l) was similar in neonates with a combination of ABO incompatibility and glucose-6-phosphate dehydrogenase (G-6-PD) deficiency (45%), with ABO incompatibility (54%) or G-6-PD deficiency (37%), alone (ns). Carboxyhemoglobin values, corrected for inspired CO, were similarly elevated in all three groups (0.87 ± 0.32%, 0.82 ± 0.29%, 0.76 ± 0.18%, respectively, ns), but correlated with bilirubin only in those with ABO incompatibility alone. ABO-incompatible/G-6-PD-deficient neonates, compared with those with either condition alone, are not at increased risk for hemolysis or hyperbilirubinemia.     

Evolutionary variants of simian virus 40: characterization of cloned complementing variants.

Three evolutionary variants of simian virus 40 (SV40), cloned by complementation with temperature-sensitive SV40 mutants, have been mapped by restriction endonuclease analysis and by electron microscopic heteroduplex mapping. One of the variants contains a deletion of most of the “late” region of the genome, and the other two contain nonidentical deletions within the “early” region. Each of the variants has a distinctive duplication of a DNA segment which includes the initiation site for DNA replication. Based on the physical maps of these genomes, a recombinational mechanism is suggested for the generation of variants; once generated, encapsidatible molecules with duplications of the replication initiation site would have a selective growth advantage. One variant contains one of its two initiation sites close to the site where SV40-DNA replication normally terminates. In this variant, however, replication appears to terminate 180° from the initiation point. Therefore, unlike initiation, termination of SV40-DNA replication is probably not sequence specific.     

Evolutionary variants of simian virus 40: cloned substituted variants containing multiple initiation sites for DNA replication.

Two cloned evolutionary variants of simian virus 40 (SV40) containing substitutions of cellular DNA have been characterized by restriction endonuclease analysis, electron microscopic heteroduplex mapping, and DNA-DNA hybridization. Each variant genome is made up of a small, tandemly repeated segment of DNA consisting of cellular DNA and that portion of the SV40 genome containing the initiation signal for viral DNA replication. Cellular DNA sequences are different in the two variants, indicating that recombination between cell DNA and SV40-DNA can occur at more than one site. However, one end of the SV40 segment (0.68 SV40 map-units) is the same in each variant. The data suggest that substituted variants arise by integration of SV40-DNA into cellular DNA followed by excision of a small substituted genome which is subsequently amplified to a size compatible with encapsidation; the presence of multiple initiation signals in each molecule results in selective replication.