Autologous platelet gel in coronary artery bypass grafting: effects on surgical wound healing.

Stimulating the body's natural healing at the cellular level can be achieved through the application of growth factors located within platelets. Once combined with a mixture of calcium and thrombin, this substance, now referred to as autologous platelet gel (APG), can be applied to surgical wound sites for patients undergoing cardiac surgery. The purpose of this study was to examine the effects of APG on surgical site infection, post-operative pain, blood loss, and bruising. After 30 mL platelet-rich plasma (PRP) was processed, 10 mL PRP was distributed on the sternum after re-approximation and 7 mL PRP before skin closure. Ten milliliters PRP was used on the endoscopic leg harvest (EVH) site. The remaining 3 mL was sent to the laboratory for hematologic testing. Both the control (CTR) and treatment (TRT) groups were well matched, with the exception of ejection fraction and pre-operative platelet count, which was significantly higher in the TRT group. Average platelet count yield was 4.2 +/- 0.5 x 103/mcL, white blood count (WBC) yielded 1.9 +/- 0.7 x 103/mcL, and fibrinogen yielded 1.2 +/- 0.2 mg/dL above baseline. There were no deep or superficial sternal infections. However, one patient from each group did experience a leg infection at the EVH site, which occurred after hospital discharge. More patients in the TRT group experienced less pain on postoperative day (POD) 1 and at the post-operative office follow-up. Blood loss and bruising was less in the TRT group on POD 2; however, there was no statistical significance. The application of APG seems to confer beneficial effects on pain, blood loss, and bruising. However, further studies with a greater sample size are needed to power significant differences.

Clinical evaluation of poly(2-methoxyethylacrylate) in primary coronary artery bypass grafting.

In an attempt to make cardiopulmonary bypass (CPB) less traumatic for patients undergoing cardiac surgery, extracorporeal circuits (ECC) have been modified to achieve this goal. Poly(2-methoxyethylacrylate) (PMEA, X-coating) is a new polymer coating used in the ECC. PMEA studies have shown excellent biocompatibility with the components of blood. In this evaluation, PMEA-coated ECC were compared with control (CTR) circuits with emphasis on hematological parameters, peri-operative homologous blood product usage, and clinical outcomes. Patients undergoing elective coronary artery bypass grafting were randomized to either a PMEA group (n = 30) or a CTR group (n = 30). Extracorporeal circuit components in the PMEA group were coated except for the cardioplegia delivery device and cannulas. Patients in the CTR group had just the arterial line filter coated. The following hematological parameters were measured: platelet count (PLT), white blood cell count (WBC), red blood cell count (RBC), and hematocrit (Hct). Blood product usage was observed along with clinical outcomes for the following parameters: ventilation time, mediastinal tube output, intensive care unit (ICU) and hospital lengths of stay. The preoperative patient profiles were comparable between the two groups. The PMEA group had marginally higher CPB times (134+/-31.9 vs. 118+/-33.7 minutes) and cross clamp times (83.9+/-21.3 vs. 73.7+/-21.6 minutes), however no significant differences were reached. Platelet count, RBC, and Hct levels were also comparable between groups with no significant differences. However, there was a significant difference in WBC between groups (p = 0.041). Less platelets were administered both intraoperatively and 48 hours postoperatively in the PMEA group. The authors evaluated PMEA-coating by measuring clinical outcomes, such as ventilation time, ICU and hospital lengths of stay, and homologous blood utilization. PMEA patients trended towards less homologous blood transfusions, which helped save an average of $83.41 per patient. Further clinical studies are needed to evaluate the benefits of this new polymer coating.

Quantification of the effect of altering hematocrit and temperature on blood viscosity.

Rheological changes occurring with the conduct of cardiopulmonary bypass affect the distribution of blood throughout the cardiovascular system. The purpose of this study was to evaluate the effects of changing physical characteristics of fluid on the dynamics of blood flow in an in vitro model. An extracorporeal model simulating coronary vessel constriction was designed that consisted of tubing with varying internal diameters. Tubing sizes were selected as percentage reductions (11, 33, 56, and 78%) of a normal sized (3.6 mm) coronary artery. Flow rates were randomly varied between 150 and 300 mL min(-1) temperatures of 6 and 37 degrees C, and hematocrits of 0, 20, and 38%. Endpoints included viscosity, pressure drop, and volume distribution. As temperature fell from 37 to 6 degrees C, viscosity increased with hematocrit as follows: 192% at 0%, 225% at 20%, and 249% at 38%, p < .001. Pressure drop increased significantly across each tubing size ranging from 173-351%, p < .01, as fluid was cooled from 37 to 6 degrees C. However, intraconduit statistical differences in volumetric distribution of flow were not achieved. Although the induced hypothermia resulted in increases in resistance, statistical significance was only seen in the smallest lumen conduit. In conclusion, the effects of changing temperature has profound influence on fluid distribution secondary to changing blood viscosity in an in vitro model for fluid distribution. Knowledge of such flow alterations may aid in determining optimal perfusion strategies where vessel constrictions are encountered.

Nutrient-induced changes in the permeability of the rat jejunal mucosa.

We examined the site of action of nutrients that enhance mucosal permeability by use of D-glucose as an archetype of nutrients of this class. We tested the hypothesis that D-glucose enhances mucosal permeability by either acting outside the intestinal lumen after absorption or acting inside the intestinal lumen to cause mediator release from either endocrine or nerve tissue. The rate of absorption of L-[14C]glucose, a passively absorbed molecule, from the lumen was used as an index of the permeability of the mucosa of a perfused segment. L-Glucose was absorbed more rapidly in the presence of D-glucose than in the presence of an equimolar concentration of mannitol. However, the permeability of the jejunal mucosa was unaffected by elevated blood glucose levels during intravenous infusion of D-glucose. The mucosal permeability was also unaffected by exposure of an adjacent segment to D-glucose, a result suggesting that D-glucose does not alter mucosal permeability by inducing the release of a blood-borne mediator from enteroendocrine cells. Finally, the effect of D-glucose on mucosal permeability could not be blocked by hexamethonium or tetrodotoxin, a result suggesting that the intestinal nerves do not mediate this phenomenon. Lidocaine significantly increased the rate of L-glucose absorption when D-glucose was present in the lumen but had no effect on L-glucose absorption under basal conditions. Our findings indicate that D-glucose must be in contact with the apical membranes of enterocytes to alter mucosal permeability. This suggestion is consistent with the hypothesis that the modulation of mucosal permeability results from the activation of sodium-dependent cotransport systems.

Glucose-induced ion secretion in rat jejunum: a mucosal reflex that requires integration by the myenteric plexus.

We tested the hypothesis that the mucosa of rat jejunum is stimulated by intraluminal D-glucose, resulting in nerve-mediated ion secretion. We examined the D-glucose-induced secretory response in two ways. First, we measured the unidirectional fluxes of sodium and chloride ions, in vivo, during perfusion of segments of jejunum with solution that contained either D-glucose or mannitol. Second, we measured the net rate of absorption of D-glucose from sodium-free solution; this parameter is related to the rate of sodium ion secretion. We used the above two approaches in conjunction with techniques for destroying specific subsets of the intestinal nerves. Thus, we evaluated the subset of intestinal nerves that integrates the secretory response of the mucosa to D-glucose. Jejunal segments perfused with D-glucose solution exhibited significantly greater rates of sodium and chloride ion secretion than did segments perfused with mannitol. Intestinal segments in which the myenteric nerve plexus had been destroyed exhibited a significantly lower rate of sodium ion secretion in the presence of D-glucose than was seen in fully innervated segments. A role for the myenteric nerves in D-glucose-induced ion secretion was also indicated by experiments that involved absorption of D-glucose from sodium-free solution. It was concluded that exposure of the mucosa of rat jejunum to glucose increases the rate of secretion of both sodium and chloride ions. The myenteric nerve plexus is apparently involved in the integration of this mucosal reflex.

Reinnervation of villi of rat jejunum following severe mucosal damage.

We studied the time course of the regeneration of the jejunal mucosa of the rat after it was damaged by exposure to the surfactant, benzalkonium chloride. We placed particular emphasis on assessing the morphology of the nerve fibers within the villi during and after regeneration. The application of benzalkonium chloride resulted in virtually complete loss of villi within the treated segment; however, the crypts were only partially damaged. The mucosa began to regenerate within 6 hr of the insult. The villus lengths and crypt depths returned to pretreatment values within two to four days. The mucosal innervation was assessed through immunohistochemistry for vasoactive intestinal peptide (VIP), neuropeptide Y (NPY), and neuron-specific enolase (NSE). At all stages of regeneration, VIP, NPY, and NSE immunopositive fibers within the lamina propria extended to the tips of the villi. The density of the immunopositive fibers in the lamina propria at four days after mucosal insult was similar to that in control tissues regardless of the neuronal marker visualized. We conclude that the nerve fibers innervating the small intestinal mucosa grow at a rate of approximately 100 microns/day and that the entire length of each villus contains nerve fibers throughout the regeneration process. The innervation of the regenerated mucosa appears identical to that of control mucosa.

The myenteric plexus regulates cell growth in rat jejunum.

The roles of the myenteric and extrinsic nerves in the control of proliferation and cell growth in the rat jejunum were studied. The myenteric plexus and/or the extrinsic nerves in a segment of rat jejunum were ablated by serosal application of the surfactant benzyldimethyltetradecylammonium chloride or by crushing the nerves passing through the mesentery, respectively. Ablation of both myenteric and extrinsic nerves, but not the extrinsic nerves alone, resulted in a significant increase in the mitotic rate of the crypt-epithelial cells and in the size of VIP-immunoreactive neurons in the submucosal plexus. The increased mitotic rate was correlated with an increase in the weight of the mucosa per unit length of gut and in the villus length and crypt depth. Neither extrinsic denervation alone nor serosal application of saline had any effect on these parameters. Our results suggest that the myenteric plexus is able to influence the rate of cell proliferation and cell growth in the rat jejunum.

Submucosal plexus alone integrates motor activity and epithelial transport in rat jejunum.

It has been well established in several mammalian species, including humans, that contractions of jejunal smooth muscle correlate temporally with increases in mucosal ion transport. Furthermore, this correlation is abolished through local application of neurotoxins, suggesting interaction of enteric neurons. The purpose of this study was to determine whether the myenteric plexus is involved in this correlation. In the rat jejunum in vivo, we simultaneously measured phasic changes in intraluminal pressure and transmural potential difference (PD) as indicators of smooth muscle motor activity and epithelial ion transport, respectively. We compared the temporal association of these parameters in control animals with animals in which either the extrinsic nerves only or the extrinsic nerves and the myenteric plexus of a 5-cm jejunal segment had been ablated 30 days previously. A one-to-one coupling between muscle contractions and transmural PD fluctuations was observed in all animals; ablation of the extrinsic and/or myenteric neurons did not eliminate this correlation. We conclude that, in the rat jejunum, the submucosal plexus alone can integrate the reflex that couples ion secretion to muscle contraction.

Effects of substance P and vasoactive intestinal polypeptide on contractile activity and epithelial transport in the ferret jejunum.

Previous studies in the ferret demonstrated that vagal nerve stimulation induced an atropine-resistant water secretion. Substance P and vasoactive intestinal polypeptide are possible mediators of this secretory response. The objectives of this study were to investigate the in vivo effects of substance P and vasoactive intestinal polypeptide on the jejunal musculature and epithelium. Substance P caused an increase in jejunal motility, water secretion, and transmural potential difference. Cholinergic blockade did not affect the substance P-induced contractions, but did reduce the increase in transmural potential difference, suggesting an inhibition of water secretion. Vasoactive intestinal polypeptide abolished motor activity; however, it induced an increase in transmural potential difference that was atropine and tetrodotoxin resistant. By immunohistochemical methods, immunoreactive vasoactive intestinal polypeptide and immunoreactive substance P were localized to both nerve cell bodies and nerve fibers in the ferret intestine. Determination of intestinal concentrations of vasoactive intestinal polypeptide and substance P in the ferret showed concentrations of these two neuropeptides that were similar to those in human intestine and demonstrated much higher concentrations of these substances in the muscular layer than in the epithelial layer. Our data demonstrate that in the ferret substance P excites and vasoactive intestinal polypeptide inhibits jejunal motor activity. However, both peptides increase water secretion. Our results suggest that in response to vagal stimulation, neuronally released substance P or vasoactive intestinal polypeptide may participate in the atropine-resistant water secretion.

Hyperplasia of jejunal smooth muscle in the myenterically denervated rat.

Application of a cationic surfactant, benzalkonium chloride, to the serosa of rat jejunum results in an increase in thickness of both longitudinal and circular smooth muscle layers. The increase in thickness is due primarily to an increase in the number of smooth muscle cells (hyperplasia). Little cellular hypertrophy was observed. The time sequence of surfactant-induced effects on the muscle layers was determined. Within 24 h, total destruction of the longitudinal muscle and partial destruction of the circular muscle was evident. The myenteric plexus was also necrotic; however, the submucosal plexus remained intact. By 48 h after surfactant treatment, the smooth muscle cells remaining in the circular muscle layer had begun to divide, as indicated by the presence of mitotic figures and incorporation of 3H-thymidine. A repopulation of the longitudinal muscle layer began at this time, apparently the result of migration of cells arising in the circular muscle layer. By 5 days post-treatment, both muscle layers had regenerated to their original states. The myenteric plexus was totally absent. The denervated smooth muscle cells proceeded to divide until approximately day 15, resulting in hyperplasia of both muscle layers. Between 15 and 105 days, the number of muscle cells in the circular layer progressively declined, eventually returned to the value seen in control tissue. In contrast, the number of smooth muscle cells in the longitudinal layer remained elevated through the period of study (165 days). We hypothesize that the smooth muscle hyperplasia observed after serosal benzalkonium chloride application results from loss of the myenteric nerves.

Adsorption of inorganic and organic ions to polycarbophil as a means of sustained-release dosage formulation.

The adsorption and desorption of drugs and inorganic ions to and from polycarbophil (PC), a polymer, were investigated to determine if PC would be a suitable carrier for sustained-release dosage formulations. Both in vitro and in vivo experiments with a polycarbophil-atropine sulfate complex demonstrated the gradual-release properties of this system. Adsorbed Cr3+ ions, like atropine, are released slowly. In contrast, 51CrO4(2-) ions are predominantly bound in an irreversible manner. A third group of drugs minimally adsorbed to PC under the conditions studied. We conclude that PC under both in vitro and in vivo conditions is able to bind certain ions and drugs and then release them over a period of time in a predictable and repeatable manner.

Relative value of oestrogen receptor assay, lactoferrin content, and glucose-6-phosphate dehydrogenase activity as prognostic indicators in primary breast cancer.

Oestrogen receptor content, lactoferrin, hexokinase, and glucose-6-phosphate dehydrogenase levels were measured in cytosol from 25 primary breast cancers and 3 fibroadenomas. Both hexokinase and glucose-6-phosphate dehydrogenase activity were higher in malignant tissue as compared to benign breast lesions. Oestrogen receptor concentration and lactoferrin content failed to predict the development of metastatic disease, while glucose-6-phosphate dehydrogenase activity was significantly higher in cytosol from those tumours which subsequently metastasized compared to those which remained localized.