Transrenal fixation of aortic stent-grafts for the treatment of infrarenal aortic aneurysmal disease.

PURPOSE: We evaluated our early experience with the transrenal fixation of aortic stent-grafts to determine the efficacy of this procedure and its effects on renal artery patency and hemodynamics. METHODS: Twenty-eight patients (22 men) had endoluminally placed modular bifurcated stent-grafts with a bare spring structure at the proximal end crossing the origin of both renal arteries; no patient with infrarenal fixation was included for analysis. The mean age of the patients was 75 +/- 7 years (range, 58-86 years); the mean aneurysm size was 5.8 +/- 0.8 cm (range, 4.7-7.2 cm). Eight patients had preoperative or intraoperative angiographic evidence of renal artery atherosclerotic disease, but only four vessels had luminal narrowing of 50% or greater. No complications were noted during stent-graft placement, and all patients have returned for follow-up visits, ranging from 1 to 12 months (mean follow-up, 6 +/- 4 months). Follow-up evaluations included clinical assessment, duplex ultrasound scan of the renal arteries and kidneys, and computed tomographic angiography. RESULTS: No evidence of lobular or sublobular perfusion defects of the renal parenchyma was detected postoperatively. Two patients exhibited postoperative changes in renal artery hemodynamics-one progressing from a 30% diameter reduction to a greater than 60% diameter stenosis at the 12-month follow-up visit and one with a normal renal artery preoperatively having elevated flow velocities indicative of a greater than 60% stenosis at the 1-month visit. Of 19 patients with normal preoperative renal function, only one has had persistently elevated serum creatinine levels. CONCLUSION: We conclude from this experience that the transrenal placement of open stents is safe and effectively excludes the aneurysm, potentially expanding the availability of this technique to more patients with a short infrarenal aortic neck. Long-term follow-up is essential to determine the overall efficacy of this technique and to identify potential effects on renal artery hemodynamics or kidney function.

Relevance of carcinogenicity bioassays in mice in assessing potential health risks associated with exposure to methylene chloride.

Considerable research has been conducted to identify possible mechanisms of the carcinogenicity of methylene chloride in rodents, and to ascertain whether the observed increased incidences of liver and lung tumours in mice exposed to this substance, are relevant in assessing the potential hazards and risks to human health. On the basis of a study that purported to show qualitative differences between murine and human tissues, in the subcellular localization of the Theta-class glutathione S-transferase enzyme responsible for converting methylene chloride to a putative highly unstable, but reactive genotoxic metabolite, it was suggested that the mouse is an inappropriate model for human health risk assessment. However, other studies conducted in vitro with intact cells do not support the hypothesis that a putatively reactive metabolite of methylene chloride must be generated only within the nucleus in order to be able to interact with genomic DNA. Moreover, investigations employing semi-quantitative methods of mRNA hybridization are not convincing in identifying the subcellular localization of active Theta class glutathione S-transferase, and do not support the hypothesis of the differential subcellular localization of this enzyme within the nucleus of mouse, but not human cells. There is therefore, insufficient evidence to support the view that qualitative differences between humans and mice in the subcellular distribution of Theta-class glutathione S-transferase, renders carcinogenicity studies conducted with mice irrelevant in human hazard identification and risk assessment.

Prospective comparison of methods for the early prediction of treatment failure in patients with falciparum malaria.

The prompt identification of patients with falciparum malaria who are at risk of late therapeutic failure could help clinicians avoid the dangers of missed or delayed retreatment. Different methods for predicting late recrudescence were compared for 52 patients whose parasitemia initially cleared after treatment with either halofantrine or quinine. Parasites reappeared in the peripheral circulation of six individuals 17 to 28 days after the initiation of therapy. Transient rises in parasite counts on thick blood films were accurate (91% specific and 100% sensitive) and prompt indicators of eventual recrudescence. All six therapeutic failures had been predicted by the third day (mean time [+/- SEM], 51.5 +/- 3.6 hours) after initiation of treatment. Parasite clearance time, fever clearance time, rRNA probe, and the polymerase chain reaction had less practical prognostic value. Serial thick-film parasite counts are a simple, cheap, rapid, and reliable method for identifying patients at high risk of recrudescence.

Polymerase chain reaction amplification from Plasmodium falciparum on dried blood spots.

We report a simple method for the polymerase chain reaction (PCR) amplification of whole blood samples collected on filter paper. The blood spot was used directly in the PCR after treatment with methanol. We evaluated this assay using clinical samples collected from subjects in a Plasmodium falciparum vaccine trial and from samples collected during a hospital-based study in Thailand. Specimens prepared from heparinized blood samples were successfully amplified following pretreatment with heparinase. Sensitivity was 100% when compared with thick blood film results in the vaccine trial (range = 4-60 parasites/microliters, median = 8/microliters) and 94.6% (range = 3-133,988 parasites/microliters, median = 616/microliters) in the hospital study.

QBC and Giemsa-stained thick blood films: diagnostic performance of laboratory technologists.

This study compared the proficiency of military medical technicians in the diagnosis of malaria using Giemsa-stained thick blood films (GSF) and the QBC system. Fourteen technicians, with no previous experience of the QBC and limited experience in interpreting GSF, were given training in the 2 techniques and then tested on their ability to make a malaria diagnosis when provided with previously prepared GSF and QBC specimens (9 positive and 10 negative). The students achieved a sensitivity of 75% and 84%, respectively, with the QBC and GSF; specificity was 84% and 76%. There was no difference in the concordance of the 2 techniques with the actual diagnosis (80% vs. 81%).

Acridine orange diagnosis of Plasmodium falciparum: evaluation after experimental infection.

The value and role of the acridine orange/microhematocrit tube method (quantitative buffy coat [QBC] analysis) in the diagnosis of malaria remains controversial. To establish the true sensitivity of this test in comparison with the thick blood film, we studied 49 subjects who were experimentally infected with Plasmodium falciparum in 10 malaria vaccine and infectivity trials. Diagnosis was made by the acridine orange staining method 1-3 days earlier than by the thick blood film in 23 subjects (47%) and at the same time as the thick blood film in 20. On the other hand, diagnosis was made by thick blood film earlier than by the acridine orange staining method in six individuals. There were no false positive results using acridine orange among 584 specimens studied. Diagnosis was made using acridine orange at a parasitemia of less than 11 parasites/microliters of blood in 65% of cases. Where available, the acridine orange assay is clearly preferable in terms of speed and accuracy to the thick blood film for diagnosis with parasitemias of less than 150/microliters of blood, and perhaps as important, for ruling out infection with P. falciparum in a symptomatic patient.

Diagnosis of malaria by detection of Plasmodium falciparum HRP-2 antigen with a rapid dipstick antigen-capture assay.

Two field studies in Kenya and an experimental challenge study in the USA were done to assess the accuracy of a dipstick antigen-capture assay based on qualitative detection of Plasmodium falciparum histidine-rich protein 2 (PfHRP-2) in peripheral blood for diagnosis of P falciparum infection. In these studies, the assay was 96.5-100% sensitive for detection of greater than 60 P falciparum asexual parasites/microL blood, 70-81% sensitive for 11-60 parasites/microL blood, and 11-67% sensitive for 10 parasites or less/microL blood. Specificity was 95% (95% CI 85-105%; n = 20) among naive American volunteers, 98% (96-101%; n = 112) among volunteers exposed to the bite of P falciparum-infected mosquitoes, and 88% (84-92%; n = 285) among Kenyans living in an area with holoendemic malaria. Our results also indicated that PfHRP-2 antigen was not detectable in blood 6 days after initiation of curative chemotherapy, and suggest that such circulating antigens rarely lead to false-positive tests. The dipstick assay's sensitivity, specificity, simplicity, and speed may make it an important tool in the battle against malaria.

Evidence for anti-Plasmodium falciparum antibodies that cross-react with human T-lymphotropic virus type I proteins in a population in Irian Jaya, Indonesia.

This study was performed to demonstrate the presence of anti-Plasmodium falciparum antibodies in a population living in Irian Jaya, Indonesia that cross-react with human T-lymphotropic virus type I (HTLV-I) proteins. Serum samples from 63 volunteers living in Oksibil, a secluded highland valley in Irian Jaya, were tested for anti-P. falciparum antibodies by an immunofluorescence assay and for anti-HTLV-I antibodies by an enzyme immunoassay (EIA). All samples were positive for anti-P. falciparum antibodies at titers of > or = 1:256. Twenty-four samples were reactive by EIA for HTLV-I, and of these, 23 were tested by western blotting (immunoblotting). Five of the 23 samples were classified as western blot positive and 18 were classified as western blot indeterminate. In competitive blocking assays with malaria proteins, western blot immunoreactivity to all HTLV-I Gag proteins was either reduced or eliminated. Significant reductions in the HTLV-I EIA optical density values of the Oksibil sera occurred when the sera were competitively blocked with the malaria antigens. The optical density values of HTLV-I-positive control sera showed no significant change. Competitive blocking with HTLV-I antigens produced reductions in the optical density values of both the Oksibil sera and the HTLV-I-positive control sera. These data suggest that in this population, anti-P. falciparum antibodies are cross-reactive with HTLV-I proteins in the western blot and EIA tests.

Exposure to lead in stained glass work. An environmental evaluation.

An environmental evaluation was conducted to determine lead exposure in a group of crafts people who produce stained glass and Tiffany glass. The environmental evaluation consisted of air sampling for potential lead emissions from solder and of work area dusts. In addition, the completion of a questionnaire, observation of work practices and noting of other details relevant to hazardous exposures were carried out. Lead concentrations in air were found to be well below the ACGIH TLV-TWA of 150 micrograms/m3. High lead concentrations were found in the work area dust samples. Exposure to high concentrations of lead could occur by ingestion as a result of neglect of basic hygiene precautions.

Cell washing versus immediate reinfusion of intraoperatively shed blood during abdominal aortic aneurysm repair.

Significant hematologic changes are known to occur following intraoperative autotransfusion of shed blood, but the clinical importance of cell washing prior to reinfusion has not been substantiated. To evaluate these changes and their relationship to the use of blood bank products and postoperative morbidity, 26 patients undergoing elective abdominal aortic aneurysm repair were prospectively randomized to reinfusion with washed shed blood or to the use of a collection system in which filtered, but unwashed, whole blood was reinfused intraoperatively. Each patient was evaluated with respect to standard metabolic and hematologic laboratory parameters preoperatively, immediately postoperatively, and 12 to 18 hours postoperatively. Patient demographic data were similar for both groups. Perioperative survival was 100% for both groups. Total blood loss and blood volume autotransfused were significantly greater in the unwashed cell group compared with the washed cell group (p = 0.00014 and p = 0.00011, respectively). Hemoglobin, fibrinogen, prothrombin time, and partial thromboplastin time levels were not significantly different between the two groups at any time perioperatively; fibrin split product and d-dimer levels were significantly higher in the unwashed cell group postoperatively (p = 0.016 and p < 0.001, respectively). Serum free hemoglobin levels were significantly higher in the immediate postoperative period in the unwashed cell group compared with the washed cell group (p = 0.0013); by 12 to 18 hours postoperatively, this difference was not significant. Haptoglobin levels were significantly lower in the unwashed cell group at both postoperative times (123 +/- 86 mg/dL versus 41 +/- 50 mg/dL, p = 0.0086; 102 +/- 66 mg/dL versus 24 +/- 36 mg/dL, p = 0.0001); however, there was no perioperative renal failure in either group. Furthermore, homologous blood product use was not significantly different between the two groups, with an average of 1.5 +/- 2.5 units of packed red blood cells given to patients in the unwashed cell group versus 0.8 +/- 1.7 units in the washed cell group (p = 0.419). Overall complications were higher and critical care and total hospital stays were longer in the unwashed cell group but did not result from autotransfusion of unwashed blood. We conclude that the intraoperative reinfusion of unwashed shed blood is safe and effective, causing transient hematologic abnormalities that normalize in the early postoperative period, and is not associated with increased mortality, or hematologic, cardiopulmonary, or renal complications.

Protective effects of enalaprilat against postischemic renal failure.

Prolonged intraoperative renal ischemia requires modalities to reduce the incidence of acute tubular necrosis, but there exists no definitive prophylactic regimen. We studied the effects of enalaprilat, an angiotensin-converting enzyme inhibitor, in an attempt to identify such a protective drug. Thirty-four mongrel dogs underwent 90 min of bilateral renal pedicle clamping. Group I was a control of 6 animals. Group II comprised 10 animals who received 12.5 g iv mannitol 15 min prior to clamping and 1 mg/kg iv furosemide immediately after clamp removal. Group III also comprised 10 animals who received enalaprilat 1 mg/kg iv enalaprilat each 15 min prior to clamp placement. Group IV consisted of 8 dogs, each of which received 12.5 g mannitol and 1 mg/kg iv enalaprilat 15 min prior to clamping and 1 mg/kg iv furosemide immediately upon removal of the clamps. Serum blood urea nitrogen (BUN) and creatinine levels were drawn preoperatively and at 12, 24, 48, and 72 hr postoperatively in each animal. The serum BUN levels in group III were significantly lower than those in group I at all times postoperatively (P < 0.05) and were not significantly different from those of group II at any time postoperatively. Similarly, the serum creatinine levels in group III were significantly lower than those of group I (P < 0.05) and were not significantly different from those in group II at any time postoperatively. Neither the serum BUN nor the serum creatinine levels in group IV were different from those of group I at any time postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of Francisella tularensis in blood by polymerase chain reaction.

We developed a polymerase chain reaction-based assay for Francisella tularensis which we evaluated by using spiked blood samples and experimentally infected mice. The assay detected both type A and type B F. tularensis at levels equivalent to one CFU/microliter of spiked blood. Results from polymerase chain reaction-based assay of limiting dilutions of blood from mice infected with the live vaccine strain agreed closely with results from blood culture.

Safety, immunogenicity, and efficacy of a Plasmodium falciparum vaccine comprising a circumsporozoite protein repeat region peptide conjugated to Pseudomonas aeruginosa toxin A.

Twenty-one malaria-naive volunteers were immunized with a vaccine consisting of a 22-kDa recombinant peptide (R32LR), derived from the repeat region of Plasmodium falciparum circumsporozoite (CS) protein, covalently coupled to detoxified Pseudomonas aeruginosa toxin A. Nineteen volunteers received a second dose of vaccine at 8 weeks, and eighteen received a third dose at 8 to 12 months. The vaccine was well tolerated, with only one volunteer developing local discomfort and induration at the site of injection which limited function for 48 h. The geometric mean anti-CS immunoglobulin G antibody concentration 2 weeks after the second dose of vaccine was 10.6 micrograms/ml (standard deviation = 3.0 micrograms/ml). Eleven volunteers (52%) developed anti-CS antibody levels of greater than 9.8 micrograms/ml, the level measured in the one volunteer protected against P. falciparum challenge after immunization with the alum-adjuvanted recombinant protein R32tet32 in a prior study. Three separate experimental challenges were conducted with 10 volunteers 2 to 4 weeks after the third dose of vaccine. The four best responders, on the basis of antibody levels (6 to 26 micrograms/ml), were challenged with two infected-mosquito bites, but only one of four immunized volunteers and one of three malaria-naive controls became parasitemic. In a second challenge study using five infected-mosquito bites as the challenge dose, three of three malaria-naive control volunteers and two of three immunized volunteers developed malaria. The third vaccine was apparently completely protected. In the third and last challenge, three of three controls and five of five vaccinees became infected. Sera obtained on the days of challenge inhibited sporozoite invasion of hepatocytes variably in vitro (range, 45 to 90% inhibition), but the degree of inhibition did not correlate with protection. Although antibody against the CS repeat region may protect some individuals against experimental challenge, this protection cannot be predicted from antibody levels by current in vitro assays. The functionality and fine specificity of anti-CS antibody are probably critical determinants.

Comparison of immediate seeding of endothelial cells with culture lining of small diameter ePTFE carotid interposition grafts.

This study is the first to compare chronic healing characteristics of immediately seeded grafts with those of grafts lined by autogenous venous endothelial cells in tissue culture prior to implantation. Ten mongrel dogs had a segment of external jugular vein excised for enzymatic harvest of endothelial cells. After approximately 21 days growth in tissue culture, 4 X 10(6) cells/ml were inoculated into a 6-cm length of 4 mm i.d. ePTFE for formation of a confluent lining in culture media. The remaining external jugular vein had its endothelial cells enzymatically harvested for immediate seeding of an identical length of preclotted ePTFE. Both grafts were implanted end-to-end in the carotid position and excised after 30 days. In 6 of the 10 dogs, grafts were patent bilaterally; all others were occluded. Planimetric measurements on patent grafts with immediate seeding showed a thrombus-free surface area of 56 +/- 39% compared to 86 +/- 15% for culture-lined grafts (P = 0.046). Endothelial coverage was 70 +/- 24% for immediately seeded grafts and 29 +/- 21% for culture-lined grafts (P = 0.016). We conclude that immediate seeding and culture lining of autogenous endothelial cells in small diameter ePTFE grafts produce equivalent short-term patency. While culture-lined grafts have an initially less thrombogenic luminal surface, subsequent development of a confluent endothelial lining is slower than that with an immediate seeding preparation, and thus would appear to offer no significant clinical benefit, especially in light of the complexity culture lining adds to the procedure.

Plasmodium berghei: quantitation of in vitro effects of antimalarial drugs on exoerythrocytic development by a ribosomal RNA probe.

A stage-specific ribosomal RNA probe has been used to quantitate exoerythrocytic development of Plasmodium berghei in primary cultures of mouse hepatocytes. Parasite rRNA could be detected as soon as 6 hr after sporozoite invasion and was increased during schizogony to a maximum at 48 hr, when mature schizonts were identified by microscopy. As few as 10 exoerythrocytic schizonts could be detected by filter blot hybridization, followed by autoradiography and liquid scintillation counting. By hybridizing the culture rRNA samples with either parasite-specific or universal rRNA probes, the in vitro tissue schizonticidal activity and hepatotoxicity of primaquine, two of its analogues, and pyrimethamine, could be assessed. After a 48-hr exposure of the culture to serial dilutions of each drug, a quantitative relationship was demonstrated between the decrease of the parasite rRNA and the increase of the drug concentrations. No significant parasite-specific rRNA could be detected at the concentration achieving complete inhibition of schizont formation but causing no cytotoxic effects on host hepatocytes. In contrast to microscopic-based assays, this molecular approach provides an objective and quantitative in vitro method for rapid screening and evaluation of tissue schizonticidal antimalarials.

Acridine orange detection of Plasmodium falciparum malaria: relationship between sensitivity and optical configuration.

Blood samples collected from five volunteers participating in a P. falciparum infectivity trial were examined to determine the efficacy of the acridine orange technique. Several lens configurations were tested for efficiency in the diagnosis of malaria using this system. There was no significant difference in the sensitivity for detecting positive specimens or number of parasites among three lens configurations: a 50x long working distance objective (0.34 mm) with either a 10x ocular (total magnification 500x) or a 12.5x ocular (625x) and a 750x configuration using a 50x objective with a shorter working distance (0.24 mm). All three lens configurations were significantly better than the 1,000x configuration using a commonly available 100x oil immersion objective. The results achieved using this lens still exceeded the sensitivity of the thick blood film.