Influence of prenatal maternal corticosteroid therapy on clinical and metabolic features and pulmonary function of preterm newborn puppies.

Although the effects of antenatal corticosteroid therapy in clinical improvement and pulmonary maturation in preterm have been described, little is known on premature newborn puppies. This study aimed to evaluate the effect of maternal administration of a single dose of prenatal betamethasone on lung function of preterm newborn puppies in the first hours of life, especially from the clinical point of view and acid-base balance. A prospective study was conducted involving 21 puppies allocated into three experimental groups: Term Group (63 days post-ovulation), Preterm-Treated Group (57 days post-ovulation and maternal administration of a single dose of 0.5 mg/kg of betamethasone) and Preterm-Control Group (57 days post-ovulation). Puppies were analyzed clinically through the Apgar score, heart rate, respiratory rate and neurological tests (muscular tone and irritability reflex) and for oximetry and blood acid-base balance in distinct experimental moments. Premature puppies had marked degree of prematurity, reversed by maternal administration of betamethasone. Prenatal corticosteroid therapy promoted better pulmonary and metabolic condition, with more efficient compensatory response to acid-base imbalance and better pulmonary gas exchange capacity. Therefore, prenatal treatment with betamethasone can be adopted as clinical lung maturation protocol for pregnancies at risk in order to prevent low vitality and increase neonatal survival.

The oxidative stress, antioxidant profile and acid-base status in preterm and term canine neonates.

During the initiation of neonatal pulmonary respiration, there is an exponential increase in reactive oxygen species that must be scavenged by antioxidant defences. However, neonate and preterm newborns are known to possess immature antioxidant mechanisms to neutralize these toxic effects. The purposes of this study were to compare the development of antioxidant system between preterm and term canine neonates and to evaluate the magnitude of acid-base balance during the initial 4 h of life. A prospective study was conducted involving 18 neonatal puppies assigned to Term Group (63 days of gestation; n = 5), Preterm-57 Group (57 days of gestation; n = 8) and Preterm-55 Group (55 days of gestation; n = 5). Neonates were physically examined through Apgar score and venous haemogasometry within 5 min, 2 and 4 h after birth. No difference on amniotic fluid and serum superoxide dismutase (SOD), glutathione peroxidase (GPx) and the marker of oxidative stress (thiobarbituric acid reactive substances; TBARS) was verified. Irrespective of prematurity, all neonates presented low vitality, hypothermia, acidosis, hypoxaemia and hypercapnia at birth. However, term puppies clinically evolved more rapidly than preterm newborns. During the course of the study, premature neonates presented more severe complications, such as prolonged hypoxaemia and even death. In conclusion, premature puppies have no signs of immature enzymatic mechanisms for controlling oxidative stress, although SOD and GPx may participate in achieving acid-base balance. Aside from initial unremarkable symptoms, premature puppies should be carefully followed up, as they are at high risk of succumbing to odds of prematurity.

[Dor operation and quadruple coronary artery bypass grafting combined with endarterectomy].

For ischemic cardiomyopathy, both left ventricle (LV) reconstruction and coronary revascularization are necessary. A 58-year-old man with ischemic cardiomyopathy [end diastolic volume index (EDVI)/end systolic volume index (ESVI) = 214/157 ml/m2, ejection fraction (EF) 26%] underwent left ventricular reconstruction using endoventricular circulatory patch plasty (Dor operation) and quadruple coronary artery bypass grafting combined with endarterectomy, which was used for complete coronary revascularization. For the Dor operation, in order to minimize arrest time and to determine the purse-string suture line, palpation of contractility of the left ventricular muscle from inside under the beating heart was performed. And to avoid insufficient postoperative LV volume, a balloon was used. The surgery was performed without blood transfusion or intraaortic balloon pumping (IABP) support. Postoperative cardiac function was excellent (EDVI/ESVI = 128/68 ml/m2, EF 46%).

Alteration of V beta usage and cytokine production of CD4+ TCR beta beta homodimer T cells by elimination of Bacteroides vulgatus prevents colitis in TCR alpha-chain-deficient mice.

A major pathogenic factor for the development of inflammatory bowel disease (IBD) is the breakdown of the intestinal homeostasis between the host immune system and the luminal microenvironment. To assess the potential influence of luminal Ags on the development of IBD, we fed TCR alpha(-/-) mice an elemental diet (ED). ED-fed TCR alpha(-/-) mice showed no pathologic features of IBD, and their aberrant mucosal B cell responses were suppressed. Similar numbers of CD4(+), TCR betabeta homodimer T cells (betabeta T cells) were developed in the colonic mucosa of ED-fed mice; however, Th2-type cytokine productions were lower than those seen in diseased regular diet (RD)-fed mice. The higher cytokine production in diseased RD-fed mice could be attributed to the high incidence of Bacteroides vulgatus (recovered in 80% of these mice), which can induce Th2-type responses of colonic CD4(+), betabeta T cells. In contrast, ED-fed TCR alpha(-/-) mice exhibited a diversification of Vbeta usage of betabetaT cell populations from the dominant Vbeta8 one associated with B. vulgatus in cecal flora to Vbeta6, Vbeta11, and Vbeta14. Rectal administration of disease-free ED-fed mice with B. vulgatus resulted in the development of Th2-type CD4(+), betabeta T cell-induced colitis. These findings suggest that the ED-induced alteration of intestinal microenvironments such as the enteric flora prevented the development of IBD in TCR alpha(-/-) mice via the immunologic quiescence of CD4(+), betabeta T cells.

Laparoscopic-assisted surgery for Crohn's disease: reduced surgical stress following ileocolectomy.

Recent progress in laparoscopic techniques has enabled operations for various intestinal disorders to be performed under laparoscopic assistance. This study was conducted to assess the benefits of performing laparoscopic-assisted surgery (LAS) in patients with Crohn's disease. LAS was performed in 24 selected patients with Crohn's disease, most of whom underwent ileocolic resection for ileitis and/or colitis with stenosis. To determine the benefits of LAS, the postoperative inflammatory parameters of these patients were examined and compared with those of 17 patients who underwent conventional open surgery. Despite giving all patients total parenteral nutrition (TPN) for more than 2 weeks preoperatively, two patients with large inflammatory masses involving enteroenteric fistulas required conversion to laparotomy. No laparoscopic procedure was converted for adhesions after previous resection or intraoperative complications. The maximum C-reactive protein values and body temperatures were significantly lower, and the time taken to normalize body temperature and leukocyte counts was significantly shorter in the LAS group than in the laparotomy group. LAS should be performed for patients with Crohn's disease in the inactive phase after appropriate nutritional support. Patients with terminal ileitis without a fistula are considered to have the highest indication for this procedure.

Alteration of interleukin 4 production results in the inhibition of T helper type 2 cell-dominated inflammatory bowel disease in T cell receptor alpha chain-deficient mice.

T cell receptor alpha chain-deficient (TCR-alpha(-/-)) mice are known to spontaneously develop inflammatory bowel disease (IBD). The colitis that develops in these mice is associated with increased numbers of T helper cell (Th)2-type CD4(+)TCR-betabeta (CD4(+)betabeta) T cells producing predominantly interleukin (IL)-4. To investigate the role of these Th2-type CD4(+)betabeta T cells, we treated TCR-alpha(-/-) mice with anti-IL-4 monoclonal antibody (mAb). Approximately 60% of TCR-alpha(-/-) mice, including those treated with mock Ab and those left untreated, spontaneously developed IBD. However, anti-IL-4 mAb-treated mice exhibited no clinical or histological signs of IBD, and their levels of mucosal and systemic Ab responses were lower than those of mock Ab-treated mice. Although TCR-alpha(-/-) mice treated with either specific or mock Ab developed CD4(+)betabeta T cells, only those treated with anti-IL-4 mAb showed a decrease in Th2-type cytokine production at the level of mRNA and protein and an increase in interferon gamma-specific expression. These findings suggest that IL-4-producing Th2-type CD4(+)betabeta T cells play a major immunopathological role in the induction of IBD in TCR-alpha(-/-) mice, a role that anti-IL-4 mAb inhibits by causing Th2-type CD4(+)betabeta T cells to shift to the Th1 type.

Oligoclonal Th2-biased betabeta T cells induce murine inflammatory bowel disease.

A population of CD4+ T cells with TCR beta-chain without TCR alpha-chain (CD4+, betabeta T cells) producing Th2-type cytokines increased in the mucosal and peripheral tissues of TCR alpha-chain deficient mice with inflammatory bowel disease (IBD). Analysis of TCR-beta immunoprecipitates by two-dimensional electrophoresis and RT-PCR revealed TCR of the CD4+ T cells was a homodimer of TCR beta-chains. Polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) analyses of TCR Vbeta-chain transcripts of the betabeta T cells revealed monoclonal to oligoclonal accumulation of the cells in the colon, suggesting clonal expansion of the mucosal betabeta T cells upon the stimulation with gut-derived antigens. The homodimer of TCR beta-chains on the betabeta T cells was a biologically functional receptor that transduced activation signals provided by MHC-class II-associated peptidic antigens and superantigens. Treatments of the mutant mice with mAb against TCR beta or IL-4 suppressed the onset of IBD. These findings suggest that the generation of oligoclonal Th2-type betabeta T cells plays a critical role for the development of IBD.

New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft.

BACKGROUND: To alleviate the invasiveness of surgical treatment for thoracic aortic aneurysm or dissection involving the distal arch, we developed a new method of implanting a graft in the distal anastomotic portion that does not require dissection, suture, or lateral thoracotomy. METHODS AND RESULTS: The tight circumferential attachment between the graft and the aortic inner wall, produced by the hoop strength of a self-expanding (Gianturco) stent that is anchored into the woven polyester graft, takes the place of the conventional anastomotic suture at the distal end of the graft. This new surgical method requires only a median sternotomy and relatively short circulatory arrest time to repair a thoracic aneurysm or dissection involving the distal arch. In a 12-month period in 1994 and 1995, we applied this new method in 10 cases (seven true aneurysms and three dissections). Complete thrombosis of the aneurysms or false lumens surrounding the grafts resulted in all 10. There were no surgical deaths, and the major complications were two cerebral infarctions due to inappropriate protection of the brain and dissecting procedure of an aortic arch, respectively. CONCLUSIONS: These preliminary results indicate that this new graft-implanting method with the stented graft should be considered one of the less-invasive surgical treatments for thoracic aneurysm and dissection involving the distal arch.

Drug-related illness in emergency department patients.

Drug-related illnesses (DRIs) associated with visits to a hospital emergency department (ED) were identified and classified, and the cost of these DRIs was analyzed. A pharmacist reviewed all available ED log forms on file at a 560-bed teaching hospital for October 1994. The following information was collected from these forms and, for patients with documented or suspected DRI, the medical record: medication and allergy history, drug involved in and cause of DRI, diagnosis, patient compliance, serum drug concentrations, and length of hospital stay. A patients was identified as having had a DRI if he or she was taking a drug before the ED visit and if a DRI was documented on the ED log form or suspected by the pharmacist. DRIs were classified as having been caused by inappropriate prescribing, patient noncompliance, an adverse drug reaction (ADR), or a drug interaction. DRIs were considered preventable if they could have been avoided through appropriate prescribing, outpatient monitoring, or compliance. A cost analysis was performed. Of 1260 ED log forms reviewed, 565 (45%) described patients receiving drugs before the ED visit. A total of 50 DRIs were discernible in 49 log forms (3.9% of all 1260 forms, and 8.6% of the 565 forms describing patients taking medication before the visit). Noncompliance, inappropriate prescribing, and ADRs accounted for 58%, 32%, and 10% of the DRIs, respectively. The drugs most frequently involved were albuterol, insulin, and warfarin. Thirty-three (66%) of the DRIs were considered to have been preventable; these DRIs accounted for an estimated $391,342 in annual ED and hospital costs. Many DRIs seen in the ED patients were preventable, and these preventable illnesses contributed substantially to ED and hospital costs.

Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase.

BACKGROUND: In patients with Stanford type B dissection who have been treated successfully with medical hypotensive therapy during the acute phase, a large number have incurred the risk of surgery during their chronic phases because of enlargement of the dissected aorta. The purpose of this study was to determine the indications for surgical treatment of acute type B dissection by studying chronic-phase enlargements of aortic dissections in patients treated successfully with medical hypotensive therapy during the acute phase. METHODS AND RESULTS: In 41 patients with type B dissection who had been treated medically during the acute phase, univariate and multivariate factor analyses were made to determine the predominant predictors for chronic-phase enlargement (> or = 60 mm) of the dissected aorta. Computed tomography was performed every 4 to 14 months to observe whether there was enlargement of the maximum aortic diameter. The predominant predictors for aortic enlargement in the chronic phase were the existence of a maximum aortic diameter of > or = 40 mm during the acute phase (P < .001) and a patent primary entry site in the thoracic aorta (P = .001). The values of actuarial freedom from aortic enlargement for the patients with a large aortic diameter (> or = 40 mm) during the acute phase and a patent primary entry site in the thorax at 1, 3, and 5 years were 70%, 29%, and 22%, respectively. No aortic enlargement was observed in the other patients throughout the entire follow-up period. CONCLUSIONS: These data suggest that patients with acute type B dissection who have a large aortic diameter (> or = 40 mm) and a patent primary entry site in the thorax should be treated surgically during the acute phase on the condition that the surgical risk in this phase is limited.

[Computed tomography in the diagnosis of transitional cell carcinoma of the renal pelvis].

CT scans were carried out on 25 patients with transitional cell carcinoma of the renal pelvis. Of the 25 patients, tumors were identified in 24 patients (96%) and not in one patient on CT scan. Of the 24 patients the tumor was delineated as a solid mass in the renal pelvis and/or calyx in 15 and as an infiltrating mass in the renal parenchyma in 8 on CT scan. The depth of invasion was correctly estimated by CT in 18 of the 25 patients (72%). Whereas the tunica muscularis of the renal pelvis or the renal parenchyma was found involved in 3 of 10 patients (30%) in whom the diagnosis was made that the tumor was limited to the renal pelvic mucosa, the correct diagnosis was possible in 22 of 25 patients (88%) in whom the tumor was confined to the renal pelvic wall (pTa-pT2) or more invasive (pT3-pT4). In 6 of 7 patients with lymph nodes matastases enlarged lymph nodes were seen on the CT scan. In all 7 cases the primary tumor was classified as a pT3 or pT4 invasive disease. Based on the results presented above, it may be concluded that CT scan is valuable in making the diagnosis of transitional cell carcinoma of the renal pelvis and also in determining whether the tumor has invaded beyond the renal pelvic wall, thereby providing guidelines for the adequate treatment.

[Partial colpocleisis for vesicovaginal fistulas].

Four patients with a vesicovaginal fistula were operated upon transvaginally using the Latzko technique of partial colpocleisis. In 3 of the 4 patients, the fistulas had been formed after total hysterectomy for myoma uteri or endometriosis. The periods from fistulization-to-surgery intervals in these 3 patients were 4 months, 12 months, and 4 years and 4 months, respectively. The fistulas in the remaining one patient had been formed after forceps delivery. The patient underwent surgery 8 days after delivery. An indwelling catheter was retained for 3 to 14 days after surgery. The 4 patients were all cured of vesicovaginal fistulas after a single operation. This paper describes our partial colpocleisis technique and discusses its clinical utility. The partial colpocleisis has the advantages of dispensing with such procedures as fistula excision, fistula opening suture, and suturation of the bladder musculature, and of closing the fistulas using a demucosated vaginal wall. Having minimal surgical invasiveness and being easy to perform and reliable, the technique appears to be excellent for coping with vesicovaginal fistulas.

Pharmacist-managed drug therapy in California hospitals.

To assess the effect of state legislation expanding the scope of pharmacy practice in health-care institutions, California hospitals were surveyed in 1982 and 1986 about pharmacists' regulation of drug therapy. Questionnaires were mailed to pharmacy directors at all hospitals in the state. The survey form explained that in pharmacist-regulated drug therapy, the pharmacist, under order or authorization of the prescriber, requests laboratory tests and initiates or adjusts drug dosage to obtain the desired therapeutic response; the questions were based on this definition. The response rates were 51.4% (292 of 568) in 1982 and 56.2% (329 of 585) in 1986. For the responding hospitals of most sizes and types, the percentage having pharmacist regulation of drug therapy increased; the largest increase was in the for-profit chain hospitals. In 1986, pharmacists were involved in regulating maintenance dosages in more than half of the responding hospitals (from 52% of hospitals with 50 or fewer beds to 86% of hospitals with 400-499 beds). The responses indicated that at least 50% of patients receiving aminoglycoside or warfarin therapy or total parenteral nutrition had their maintenance dosages regulated by pharmacists. The two surveys indicate that between 1982 and 1986 pharmacists became more involved in regulating drug therapy in California hospitals.

Impact of clinical pharmacy services on prescribing on a cardiothoracic/vascular surgical unit.

A multi-faceted approach was used to study the impact of clinical pharmacy services on the cost of drug therapy on a cardiothoracic and vascular surgical service. Physician and nursing attitudes about the usefulness and likely effect of clinical pharmacist recommendations were also assessed. A cross-sectional design with a temporal factor was used to study physician prescribing of all pharmacologic classes, and particularly of antibiotics. Measurements were taken for nine months before the institution of clinical pharmacy services, 12 months during a clinical pharmacy service period, and for six months after the cessation of the services. A trend toward reduction in drug costs per patient day was observed on both services. This was observed for all pharmacologic classes, and when antibiotics were analyzed alone. The difference was significant when antibiotics were specifically analyzed on the vascular surgical service. The pharmacist's log and a survey of physicians' and nurses' attitudes toward clinical pharmacy services supported the above results.