Source of elastin-degrading enzymes in mycotic aortic aneurysms: bacteria or host inflammatory response?

Elastolytic matrix metalloproteinases play a central role in the development of chronic atherosclerotic aortic aneurysms, but mycotic aortic aneurysms are a distinct and unusual form of aneurysm disease caused by bacterial infection. Mycotic aortic aneurysms follow a more rapid and unpredictable course than chronic aneurysm disease and they exhibit a predilection for the suprarenal aorta, further implying unique pathophysiologic mechanisms. The purpose of this study was to examine the nature and source of elastin-degrading enzymes in mycotic aortic aneurysm. Bacterial isolates and aortic tissues were obtained from four consecutive patients undergoing surgical repair of suprarenal mycotic aortic aneurysm. Using an in vitro 3H-labeled elastin degradation assay, elastin-degrading enzyme activity was only observed in the bacteria-conditioned medium from an isolate of Pseudomonas aeruginosa. Elastin-degrading enzyme activity in the aortic tissue homogenate of this patient was abolished by the serine protease inhibitor, phenylmethylsulfonyl fluoride, but it was not suppressed by the metalloproteinase inhibitor, ethylenediamine tetraacetic acid (EDTA). In contrast, elastin-degrading enzyme activity in the bacterial-conditioned medium was decreased by about half by both phenylmethylsulfonyl fluoride and EDTA. Elastin substrate zymography revealed two phenylmethylsulfonyl fluoride-inhibitable elastin-degrading enzyme activities in the aortic tissue homogenate that corresponded to human neutrophil elastase (approximately 30 kDa) and its stable complex with alpha 1-proteinase inhibitor (approximately 80 kDa), but no activity attributable to Pseudomonas elastase, a 33-kDa metal-dependent enzyme. Human neutrophil elastase was readily detected throughout mycotic aortic aneurysm tissues by immunohistochemistry, but elastolytic metalloproteinases were only occasionally observed. The results of this study suggest that the elastin-degrading enzyme produced in mycotic aortic aneurysm are largely serine proteases of host neutrophil origin, rather than elastases produced by the infecting microorganisms or the macrophage-derived metalloproteinases typically observed in atherosclerotic aneurysm disease. Further studies will be needed to extend these findings to a larger number of patients with mycotic aortic aneurysm and those caused by additional microorganisms.

Pain management in the pediatric intensive care unit.

Control of pain in the pediatric intensive care unit has become increasingly important to intensivists. Improved understanding of the pharmacology of analgesics and the development of new techniques for analgesic administration have greatly enhanced the ability of intensivists to successfully manage patients in pain. The appropriate selection, use, and techniques for administration of analgesics in the treatment of pain in pediatric patients are discussed.

Intraabdominal hemorrhage during combined coronary artery bypass and carotid endarterectomy.

Intraabdominal complications during cardiopulmonary bypass are extremely rare, with an incidence of less than 1% in multiple retrospective studies. These complications are associated with a high mortality, and their rapid diagnosis is critical to the outcome of the patient. We present a case of spontaneous intraabdominal hemorrhage after combined carotid endarterectomy and four-vessel coronary artery bypass grafting, which was diagnosed through a diaphragmatic window.

Regulation of polyamine synthesis and transport by fibroblast growth factor in aortic smooth muscle cells.

Basic-FGF (FGF2) is implicated as a regulator of smooth muscle cell proliferation that develops after arterial injury. Polyamines are essential for cell growth and differentiation and may mediate some of the FGF2-elicited responses. To examine this possibility, the effect of FGF2 on polyamine synthesis and uptake was tested on rat arterial smooth muscle cells. Exposure of cells to FGF2 for 24 and 48 h resulted in increased intracellular polyamine content. Ornithine decarboxylase (ODC) activity increased in FGF2-treated cells after 6 h of treatment, whereas no increases were detected in ODC mRNA steady-state levels. Basic-FGF increased maximal polyamine transport rate without changes in Km. Treatment with actinomycin D decreased polyamine transport. The effect of cyclohexamide on polyamine uptake was dose dependent. These studies indicate that treatment of vascular smooth muscle cells with FGF2 results in increases in intracellular polyamine content, polyamine synthetic activity, and polyamine transport.

An angioscopic method for intraluminal aortic evaluation and stent placement.

PURPOSE: The purpose of this study was to develop an angioscopic technique to visualize the endoluminal surface of the aorta and to guide vascular stent placement. METHODS: A fiberoptic angioscope, fitted with a balloon at its tip, was passed via a carotid arteriotomy into the abdominal aorta of seven anesthetized pigs. Saline solution inflation of the balloon allowed for blood displacement and clear visualization of the endoluminal anatomy. After the left renal artery orifice had been identified with angioscopy, a catheter was inserted via a left femoral sheath to cannulate the orifice under direct visualization. The position of the catheter was verified angiographically. A vascular stent was loaded onto an angioplasty balloon, inserted through a right femoral arteriotomy, positioned by use of angioscopic visualization, and deployed immediately below the left renal artery orifice. RESULTS: The aortic trifurcation and the lumbar and renal artery orifices were clearly visualized in every animal. Vascular stents were placed in seven animals within an average of 3.14 +/- 1.14 mm (mean +/- SEM, range 0 to 8 mm) below the inferior rim of the left renal artery orifice. No stents were positioned above a renal artery orifice or obstructed blood flow. CONCLUSIONS: This angioscopic technique permitted detailed evaluation of aortic endoluminal anatomy and precise implantation of vascular stents. Direct endovascular visualization may facilitate other endovascular procedures, including endovascular grafting.

Further experience with transesophageal echocardiography in the evaluation of thoracic aortic injury.

This prospective study sought to further define the role of transesophageal echocardiography (TEE) in diagnosing thoracic aortic injury. We performed TEE, aortography, or both on 160 consecutive patients suspected of having blunt thoracic aortic injury: TEE correctly identified 14 aortic injuries, of which five were confirmed by aortography, seven at thoracotomy, and two at autopsy. The TEE results were suggestive of but not diagnostic for injury in two additional patients with proven aortic injury, and TEE was otherwise 100% sensitive and specific for aortic injury. Aortograms yielded one false positive result and four false negative results, for a sensitivity of 73% and a specificity of 99%. We conclude that TEE is a rapid, safe, and accurate bedside method for evaluating the heart and thoracic aorta for blunt trauma. Negative or positive TEE results obviate the need for aortography. We recommend that aortography be used when TEE results are equivocal, when TEE is not tolerated or contraindicated, or when other suspected vascular injuries require evaluation by arteriography.

Hepatocellular carcinoma embolus to the common hepatic duct with no detectable primary hepatic tumor.

Obstruction of the common bile duct (CBD) by direct extension of tumor is occasionally found in patients with hepatic neoplasms. Tumor embolus to the CBD is very rare, however, when no primary hepatic tumor is found. The patient described herein was a 74-year-old man who presented with a new onset of jaundice, nausea, anorexia, and epigastric pain. There was a history of dark urine and clay-colored stools, but no fever. Endoscopic retrograde cholangiopancreatography (ERCP) showed partial obstruction of the common hepatic duct and dilated intrahepatic bile ducts. A computed tomography (CT) scan of the upper abdomen showed no masses. Results of a mesenteric and selective hepatic arteriogram were normal. On abdominal exploration, no tumor was noted. There were no palpable stones in the gallbladder, but a firm mass was felt in the common hepatic duct. Exploration of the CBD produced light-colored debris organized into a cast of the common hepatic duct. Frozen section analysis was negative for tumor cells, but review of the permanent sections confirmed the presence of hepatocellular carcinoma. When non-calculous material is found to be obstructing the CBD, even in the absence of an obvious primary hepatic tumor, tumor embolus or metastasis from a distant site must be considered and the material sent for pathological evaluation.

Mucinous adenocarcinoma of the colon metastatic to the intestinal mucosa.

Autometastasis of colon cancer to the intestinal mucosa is a condition that has not been previously described. The 70-year-old man presented in this case report was seen for routine surveillance colonoscopy 14 months after low anterior resection, without anastomosis, of a Dukes' stage C mucinous adenocarcinoma of the rectosigmoid. The patient had received adjuvant chemotherapy according to Southwest Oncology Group protocol 8899. The routine colonoscopy revealed many new polypoid lesions in the remaining left and transverse colon, and the patient underwent completion total abdominal colectomy. Examination of the specimen revealed more than 100 polyps; the histologic examination identified these polyps as metastatic signet ring mucinous adenocarcinoma.

Fibroblasts maintain a complete endocytic pathway in the presence of lysosomotropic amines.

We have investigated the effects of the lysosomotropic amines, ammonium chloride and chloroquine, on the delivery of fluid-phase pinocytic tracers to lysosomes in Chinese hamster ovary (CHO) cells. In preliminary experiments, 15 mM ammonium chloride and 0.1 mM chloroquine were found to be sufficient to give maximal protection of endocytosed material from digestion in a lysosome. In the presence of either amine at these concentrations, the generation time of CHO cells was depressed by less than 30% even though selective depletion of lysosomal hydrolases was observed. For cells treated with either amine for 1 or 6 days the amount of horseradish peroxidase (HRP) internalized in a 1-h pulse was approximately 50-70% of that of control. By cell fractionation, cells treated with amine for 2 or 6 days were found to accumulate fluorescein-dextran or HRP in lysosomes. HRP accumulation in lysosomes in amine-treated cells was also observed by electron microscopy. Little exocytosis of lysosomal HRP into the media was observed under any condition. We conclude that in long-term amine-treated CHO cells endocytic vesicle traffic is maintained.

Effects of pH, detergent and salt on aggregation of Chinese-hamster-ovary-cell lysosomal enzymes.

Upon detergent or hypo-osmotic lysis of CHO-cell postnuclear supernatants or isolated lysosomes at pH 4.8, the lysosomal enzymes beta-hexosaminidase, beta-galactosidase, alpha-fucosidase and cathepsin C were readily pelleted, whereas the exogenous marker, long-term-internalized horseradish peroxidase, was not. Salt or pH elevation greatly decreased lysosomal-enzyme pelletability. The results suggest that, under native conditions, lysosomal hydrolases may be aggregated. Aggregation could promote enzyme retention within the organelle.

Retention of pinocytized solute by CHO cell lysosomes correlates with molecular weight.

We compared the exocytosis by Chinese hamster ovary (CHO) cells of a set of fluid-phase pinocytic tracers. The tracers were horseradish peroxidase (HRP), a glycoprotein of approximately 40 kDa, lucifer yellow (LuY), a 457 dalton, membrane-impermeant fluorescent dye, and glucose polymers ranging from sucrose through higher molecular weight, fluorescein isothiocyanate (FITC) dextrans. After a long term uptake (16-20 h), each of these tracers was localized to lysosomes. Exocytosis of the majority of the small molecule tracers, LuY and [14C] sucrose, was observed over a period of a few to several h. There was no significant exocytosis of 42 kDa FITC dextran or HRP during an 18-20 h chase, while lower molecular weight dextrans were exocytosed. After co-accumulation of LuY and HRP in lysosomes, only the low molecular weight marker was exocytosed. These observations suggest retention of endocytized solutes within lysosomes is dependent on molecular size and may be limited by the rate of diffusion of molecules into shuttle vesicles.