Long-Term Venovenous Connection for Extracorporeal Carbon Dioxide Removal (ECCO2R)-Numerical Investigation of the Connection to the Common Iliac Veins.

PURPOSE: Currently used cannulae for extracorporeal carbon dioxide removal (ECCO2R) are associated with complications such as thrombosis and distal limb ischemia, especially for long-term use. We hypothesize that the risk of these complications is reducible by attaching hemodynamically optimized grafts to the patient's vessels. In this study, as a first step towards a long-term stable ECCO2R connection, we investigated the feasibility of a venovenous connection to the common iliac veins. To ensure its applicability, the drainage of reinfused blood (recirculation) and high wall shear stress (WSS) must be avoided. METHODS: A reference model was selected for computational fluid dynamics, on the basis of the analysis of imaging data. Initially, a sensitivity analysis regarding recirculation was conducted using as variables: blood flow, the distance of drainage and return to the iliocaval junction, as well as the diameter and position of the grafts. Subsequently, the connection was optimized regarding recirculation and the WSS was evaluated. We validated the simulations in a silicone model traversed by dyed fluid. RESULTS: The simulations were in good agreement with the validation measurements (mean deviation 1.64%). The recirculation ranged from 32.1 to 0%. The maximum WSS did not exceed 5.57 Pa. The position and diameter of the return graft show the highest influence on recirculation. A correlation was ascertained between recirculation and WSS. Overall, an inflow jet directed at a vessel wall entails not only high WSS, but also a flow separation and thereby an increased recirculation. Therefore, return grafts aligned to the vena cava are crucial. CONCLUSION: In conclusion, a connection without recirculation could be feasible and therefore provides a promising option for a long-term ECCO2R connection.

In Vitro Calcification of Bioprosthetic Heart Valves: Investigation of Test Fluids.

Calcification is a major reason for the failure of bioprosthetic heart valves. Therefore, several attempts towards an accelerated in vitro model were undertaken in order to provide a cost- and time-saving method for the analysis of calcification processes. Due to the problem of superficial or spontaneous precipitation, which occurred in the fluids applied, we focused our study on the development of a near-physiological calcification fluid. The desired fluid should not precipitate spontaneously and should neither promote nor inhibit calcification. Eleven different fluid compositions were tested without contact to potentially calcifying materials. Crucial factors regarding the fluid properties were the ionic product, the ionic strength, and the degree of supersaturation concerning dicalciumphosphate-dihydrate, octacalciumphosphate, and hydroxyapatite. The fluids were kept in polyethylene bottles and exposed to a slight vibration within a durability tester at 37 °C. The precipitation propensity was monitored optically and colorimetrically. A structural analysis of the deposits was carried out by x-ray powder diffraction and IR-spectroscopy, which showed the development of the crystal phases that are relevant in vivo. Only two of the fluids did not precipitate. Resulting from the computations of the effective fluid contents, the saturation degree concerning dicalciumphosphate-dihydrate seems to be the key factor for spontaneous precipitation.

Reliability of left atrial pressure estimation from left ventricular filling measurement in a total artificial heart.

A physiological control of a total artificial heart (TAH) requires reliable information on left arterial pressure (LAP). When LAP is derived indirectly from intrinsic TAH parameters like end diastolic volume (EDV) and diastole duration (Td), the transfer function and associated uncertainties need to be well understood.We derived a computational equivalent to a hydraulic model consisting of the venous compliance, the heart valve and the pump chamber, and studied the filling phase in cases of different venous compliance. We calculated a family of curves of pump chamber volume as a function of time for different venous compliances and LAP. To visualize the LAP transfer function and uncertainties associated to EDV, Td measurement error and unknown venous compliance a family of similar curves in the vicinity of assumed measurement was found and visualised in the parameter space.Results were in a realistic absolute range and showed expected trends despite some simplifications in the simulation model. The venous compliance has no significant influence on LAP values extracted from EDV and Td, except at very low values. The uncertainty in the extracted LAP is particularly high for high EDV and short Td.A physiological regulation therefore does not have to be individually adapted to the patient's venous compliances, but has to deal with uncertainties in the input values like blood pressures extracted from intrinsic device parameters.

The development of evidence-based clinical practice guidelines. Integrating medical science and practice.

Practice guidelines are rapidly becoming preferred decision-making resources in medicine, as advances in technology and pharmaceutics continue to expand. An evidence-based approach to the development of practice guidelines serves to anchor healthcare policy to scientific documentation, and in conjunction with practitioner opinion can provide a powerful and practical clinical tool. Three sources of information are essential to an evidence-based approach: a) an exhaustive literature synthesis; b) meta-analysis; and c) consensus opinion. The systematic merging of evidence from these sources offers healthcare providers a scientifically supportable document that is flexible enough to deal with clinically complex problems. Evidence-based practice guidelines, in conjunction with practice standards and practice advisories, are invaluable resources for clinical decision making. The judicious use of these documents by practitioners will serve to improve the efficiency and safety of health care well.

Mutations that extend the specificity of the endonuclease activity of lambda terminase.

Terminase, an enzyme encoded by the Nu1 and A genes of bacteriophage lambda, is crucial for packaging concatemeric DNA into virions. cosN, a 22-bp segment, is the site on the virus chromosome where terminase introduces staggered nicks to cut the concatemer to generate unit-length virion chromosomes. Although cosN is rotationally symmetric, mutations in cosN have asymmetric effects. The cosN G2C mutation (a G-to-C change at position 2) in the left half of cosN reduces the phage yield 10-fold, whereas the symmetric mutation cosN C11G, in the right half of cosN, does not affect the burst size. The reduction in phage yield caused by cosN G2C is correlated with a defect in cos cleavage. Three suppressors of the cosN G2C mutation, A-E515G, A-N509K, and A-R504C, have been isolated that restore the yield of lambda cosN G2C to the wild-type level. The suppressors are missense mutations that alter amino acids located near an ATPase domain of gpA. lambda A-E515G, A-N509K, and A-R504C phages, which are cosN+, also had wild-type burst sizes. In vitro cos cleavage experiments on cosN G2C C11G DNA showed that the rate of cleavage for A-E515G terminase is three- to fourfold higher than for wild-type terminase. The A-E515G mutation changes residue 515 of gpA from glutamic acid to glycine. Uncharged polar and hydrophobic residues at position 515 suppressed the growth defect of lambda cosN G2C C11G. In contrast, basic (K, R) and acidic (E, D) residues at position 515 failed to suppress the growth defect of lambda cosN G2C C11G. In a lambda cosN+ background, all amino acids tested at position 515 were functional. These results suggest that A-E515G plays an indirect role in extending the specificity of the endonuclease activity of lambda terminase.

Mechanism-based predictions of interactions.

Exposure to more than one toxic compound is common in real life. The resulting toxic effects are often more than the simple sum of the effects of the individual compounds. It is unlikely that it will ever be possible to test all combinations. It is therefore highly desirable to improve or develop means for reasonably approximating predictions of interactions. In order to be valid and extrapolatable, these predictions are most promising if they are mechanism-based. Examples will be given for possibilities of mechanism-based predictions of interactions which exceed trivialities of simple increases by enzyme induction of enzymatic rates of a given biotransformation pathway leading to a toxic metabolite. Instead, examples will be provided where competition between various enzymes for shunting the same substrate into divergent pathways can lead to predictable dramatic changes in toxicity by shifting the metabolic routes under conditions of no significant changes of overall metabolism. Further examples are given on predictable interactions between chemicals which need bioactivation for exerting their toxicity and chemicals which effect hormonal status and other endogenous factors which in turn modify enzymes involved in the control of toxic metabolites.

Pharmacological properties of excitatory amino acid induced changes in extracellular calcium concentration in rat hippocampal slices.

We have studied extracellular ionic changes induced by iontophoretic application of excitatory amino acids in rat hippocampal slices. In contrast to kinetics of changes in [Ca2+]o, kinetics of changes in [K+]o, [Na+]o, [Cl-]o as well as in extracellular space size were comparable for different glutamate receptor agonists. Thus, alpha-amino-3-hydroxy-5-methylisoxazolepropionic acid (AMPA), quisqualate (quis), and kainate caused reductions in [Ca2+]o followed by an increase of [Ca2+]o above baseline, whereas glutamate, aspartate, N-methyl-D-aspartate (NMDA), and DL-homocysteic acid caused only reductions in [Ca2+]o. After blocking the NMDA receptors with ketamine and 2-amino-5- phosphonovaleric acid (2-APV), glutamate-induced decreases in [Ca2+]o were followed by an overshoot. Reduction of the transmembrane Na+ gradient by lowering [Na+]o, blocking of the Na(+)-K+ ATPase by lowering [K+]o, and application of ouabain blocked the overshoots after quis application, whereas vanadate, a blocker of the Ca(2+)-Mg2+ ATPase, had no effects. Lithium enhanced the reductions in [Ca2+]o and blocked the overshoots. Amiloride also reduced the overshoots. All organic Ca2+ entry blockers diminished reductions of [Ca2+]o but increased the overshoots. Inorganic Ca2+ antagonists had variable effects. Ni2+ had similar effects as the organic Ca2+ entry blockers while Cd2+ reduced both the [Ca2+]o decreases as well as the subsequent overshoots. Co2+ had initially a similar action as Ni2+. With prolonged application, [Ca2+]o decreases became augmented and, during wash, overshoots could no longer be elicited. We suggest that the overshoots in [Ca2+]o are due to a combined effect of extracellular space shrinkage and activation of the Na+/Ca2+ exchangers. This would imply that NMDA receptor activation blocks extrusion of Ca2+ from the cells. We tested the hypothesis that quis-induced intracellular Ca2+ release and extrusion of Ca2+ from the cells contributed to the overshoots. Dantrolene was without effect on the quis-induced signals, while ryanodine reduced the overshoots. Caffeine on the other hand diminished the [Ca2+]o decreases with no effects on the overshoots. To test for possible second messenger routes by which NMDA receptor activation might slow Ca2+ extrusion from cells, we investigated the effects of arachidonic acid and N-monomethyl-D- arginine on the quis-induced signals. While these agents reduced decreases in [Ca2+]o, they had no clear effects on the overshoots. Thus a possible route by which NMDA receptor activation may affect Ca2+ extrusion from cells has still to be elucidated.

Slow depolarizing afterpotentials in neocortical neurons are sodium and calcium dependent.

Depolarizing afterpotentials (DAPs) were studied in intracellular recordings from neocortical slices bathed in tetrodotoxin (TTX) (1 microM) and tetraethylammonium chloride (TEA) (24 mM), to block voltage-dependent Na+ currents and most K+ currents. The DAP was Ca(2+)-dependent, in that its magnitude varied as a function of the duration of the preceding Ca2+ plateau. It had an apparent reversal potential of between -40 and -5 mV. The DAP was blocked when choline replaced all extracellular Na+; there was a hyperpolarizing shift in apparent reversal potential when extracellular Na+ was lowered. The DAP was blocked by amiloride (1 mM), which also decreased the preceding Ca2+ plateau. The data are consistent with the hypothesis that the DAP is due to electrogenic Na+/Ca2+ exchange.

Effects of lowering [Na+]o and [K+]o and of ouabain on quisqualate-induced ionic changes in area CA1 of rat hippocampal slices.

Changes in extracellular ([Na+]o) and calcium ([Ca2+]o) concentration evoked by quisqualate (Quis), applied iontophoretically, were measured in rat hippocampal slices. Following an initial decrease in [Ca2+]o, Quis causes a post-application overshoot, which may reflect Ca2+ extrusion from cells by the Na+/Ca2+ exchanger. To test this hypothesis, the effects of directly and indirectly reduced transmembrane Na+ gradients on these Quis-induced Ca2+ overshoots were investigated. In all cases the post-application overshoots were reduced. This suggests that the Na+/Ca2+ exchanger is involved in the production of these Quis-induced Ca2+ overshoots which may have important implications for understanding how various types of glutamate receptors differ in their capability to trigger Ca2(+)-activated processes.