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INTRODUCTION: A qualitative assessment of discharge resource needs is important for developing evidence-based care improvements in neurocritically ill patients. We hypothesized that standardized, open-ended assessments of patients or caregivers after neurocritical care would result in themes that reflect post-intensive care concerns. METHODS: We conducted a quality improvement initiative at an academic hospital and included all patients admitted to the Neurosciences Intensive Care Unit (NSICU) over an 18-month period. Telephone assessments were made at 3–6 months following admission. Patients or caregivers were asked if they had adequate resources upon discharge and if they had any unanswered questions. The content of responses was reviewed by a neurointensivist and neurocritical care nurse practitioner. A structured codebook was developed, organized into themes, and applied to the responses. RESULTS: 61 patients or caregivers responded regarding access to resources at discharge with 114 individual codable responses. Responses centered around five themes with 23 unique codes: satisfied, needs improvement, dissatisfied, poor post ICU care, and poor health. The most frequently coded responses were that caregivers believed their loved one had experienced an unclear discharge (n=11) or premature discharge (n=12). 204 patients or caregivers responded regarding unanswered questions or additional comments at follow-up, with 516 codable responses. These centered around six themes with 26 unique codes: positive experience, negative experience, neutral experience, medical questions, ongoing medical care or concern, or remembrance of time spent in the ICU. The most frequent response was that caregivers or patients stated that they received good care (n= 115). Multiple concerns were brought up, including lack of follow-up after hospitalization (n=15), and dissatisfaction with post-ICU care (n=15). CONCLUSIONS: Obtaining qualitative responses after discharge provided insight into the transition from critical care. This could form the basis for an intervention to provide a smoother transition from the ICU to the outpatient setting.

Background. Children under 3 years of age may benefit from a double-dose of inactivated quadrivalent influenza vaccine (IIV4) instead of the standard-dose. Methods. We compared the only United States-licensed standard-dose IIV4 (0.25 mL, 7.5 µg hemagglutinin per influenza strain) versus double-dose IIV4 manufactured by a different process (0.5 mL, 15 µg per strain) in a phase III, randomized, observer-blind trial in children 6–35 months of age (NCT02242643). The primary objective was to demonstrate immunogenic noninferiority of the double-dose for all vaccine strains 28 days after last vaccination. Immunogenic superiority of the double-dose was evaluated post hoc. Immunogenicity was assessed in the per-protocol cohort (N = 2041), and safety was assessed in the intent-to-treat cohort (N = 2424). Results. Immunogenic noninferiority of double-dose versus standard-dose IIV4 was demonstrated in terms of geometric mean titer (GMT) ratio and seroconversion rate difference. Superior immunogenicity against both vaccine B strains was observed with double-dose IIV4 in children 6–17 months of age (GMT ratio = 1.89, 95% confidence interval [CI] = 1.64–2.17, B/Yamagata; GMT ratio = 2.13, 95% CI = 1.82–2.50, B/Victoria) and in unprimed children of any age (GMT ratio = 1.85, 95% CI = 1.59–2.13, B/Yamagata; GMT ratio = 2.04, 95% CI = 1.79–2.33, B/Victoria). Safety and reactogenicity, including fever, were similar despite the higher antigen content and volume of the double-dose IIV4. There were no attributable serious adverse events. Conclusions. Double-dose IIV4 may improve protection against influenza B in some young children and simplifies annual influenza vaccination by allowing the same vaccine dose to be used for all eligible children and adults.

Addressing potential sex differences in pre-clinical studies is crucial for developing therapeutic interventions. Although sex differences have been reported in epidemiological studies and from clinical experience, most pre-clinical studies of neuroinflammation use male rodents; however, sexual dimorphisms in microglia might affect the CNS inflammatory response. Developmental changes are also important and, in rodents, there is a critical period of sexual brain differentiation in the first 3 weeks after birth. We compared rat microglia from sex-segregated neonates (P1) and at about the time of weaning (P21). To study transitions from a basal homeostatic state (untreated), microglia were subjected to a pro-inflammatory (IFNγ + TNFα) or anti-inflammatory (IL-4) stimulus. Responses were compared by quantifying changes in nitric oxide production, migration, and expression of nearly 70 genes, including inflammatory mediators and receptors, inflammasome molecules, immune modulators, and genes that regulate microglial physiological functions. No sex differences were seen in transcriptional responses in either age group but the IL-4-evoked migration increase was larger in male cells at both ages. Protein changes for the hallmark molecules, NOS2, COX-2, PYK2 and CD206 correlated with mRNA changes. P1 and P21 microglia showed substantial differences, including expression of genes related to developmental roles. That is, P21 microglia had a more mature phenotype, with higher basal and stimulated levels of many inflammatory genes, while P1 cells had higher expression of phagocytosis-related molecules. Nevertheless, cells of both ages responded to IL-4 and IFNγ + TNFα. We examined the Kv1.3 potassium channel (a potential target for modulating neuroinflammation) and the Kir2.1 channel, which regulate several microglia functions. Kv1.3 mRNA (Kcna3) was higher at P21 under all conditions and male P21 cells had higher mRNA and Kv currents in response to IFNγ + TNFα. Overall, numerous transcriptional and functional responses of microglia changed during the first 3 weeks after birth but few sex-dependent changes were seen.

Within hours after stroke, potentially cytotoxic pro-inflammatory mediators are elevated within the brain; thus, one potential therapeutic strategy is to reduce them and skew the brain toward an anti-inflammatory state. Because interleukin-4 (IL-4) treatment induces an anti-inflammatory, "alternative-activation" state in microglia and macrophages in vitro, we tested the hypothesis that early supplementation of the brain with IL-4 can shift it toward an anti-inflammatory state and reduce damage after transient focal ischemia. Adult male rat striata were injected with endothelin-1, with or without co-injection of IL-4. Inflammation, glial responses and damage to neurons and white matter were quantified from 1 to 7 days later. At 1 day, IL-4 treatment increased striatal expression of several anti-inflammatory markers (ARG1, CCL22, CD163, PPAR gamma), increased phagocytic (Iba1-positive, CD68-positive) microglia/macrophages, and increased VEGF-A-positive infiltrating neutrophils in the infarcts. At 7 days, there was evidence of sustained, propagating responses. IL-4 increased CD206, CD200R1, IL-4R alpha, STAT6, PPARc, CD11b, and TLR2 expression and increased microglia/macrophages in the infarct and astrogliosis outside the infarct. Neurodegeneration and myelin damage were not reduced, however. The sustained immune and glial responses when resolution and repair processes have begun warrant further studies of IL-4 treatment regimens and long-term outcomes.

Damage to myelinated axons contributes to neurological deficits after acute CNS injury, including ischemic and hemorrhagic stroke. Potential treatments to promote re-myelination will require fully differentiated oligodendrocytes, but almost nothing is known about their fate following intracerebral hemorrhage (ICH). Using a rat model of ICH in the striatum, we quantified survival, proliferation, and differentiation of oligodendrocyte precursor cells (OPCs) (at 1, 3, 7, 14, and 28 days) in the peri-hematoma region, surrounding striatum, and contralateral striatum. In the peri-hematoma, the density of Olig2(+) cells increased dramatically over the first 7 days, and this coincided with disorganization and fragmentation of myelinated axon bundles. Very little proliferation (Ki67(+)) of Olig2(+) cells was seen in the anterior subventricular zone from 1 to 28 days. However, by 3 days, many were proliferating in the peri-hematoma region, suggesting that local proliferation expands their population. By 14 days, the density of Olig2(+) cells declined in the peri-hematoma region, and, by 28 days, it reached the low level seen in the contralateral striatum. At these later times, many surviving axons were aligned into white-matter bundles, which appeared less swollen or fragmented. Oligodendrocyte cell maturation was prevalent over the 28-day period. Densities of immature OPCs (NG2(+)Olig2(+)) and mature (CC-1(+)Olig2(+)) oligodendrocytes in the peri-hematoma increased dramatically over the first week. Regardless of the maturation state, they increased preferentially inside the white-matter bundles. These results provide evidence that endogenous oligodendrocyte precursors proliferate and differentiate in the peri-hematoma region and have the potential to re-myelinate axon tracts after hemorrhagic stroke.

In the setting of technological advancements in imaging and intervention with concomitant rise in the use of non-operating room anesthesia (NORA) care, it has become even more critical for anesthesiologists to be aware of the needs and limitations of interventional procedures performed outside of the operating room. This article addresses the use of NORA services from the interventional radiologist's point of view and provides specific examples of preprocedural, intraprocedural, and postprocedural care patients may need for optimal outcome.

Plasticity of inhibitory transmission in the spinal dorsal horn (SDH) is believed to be a key mechanism responsible for pain hypersensitivity in neuropathic pain syndromes. We evaluated this plasticity by recording responses to mechanical stimuli in silent neurons (nonspontaneously active [NSA]) and neurons showing ongoing activity (spontaneously active [SA]) in the SDH of control and nerve-injured mice (cuff model). The SA and NSA neurons represented 59% and 41% of recorded neurons, respectively, and were predominantly wide dynamic range (WDR) in naive mice. Nerve-injured mice displayed a marked decrease in the mechanical threshold of the injured paw. After nerve injury, the proportion of SA neurons was increased to 78%, which suggests that some NSA neurons became SA. In addition, the response to touch (but not pinch) was dramatically increased in SA neurons, and high-threshold (nociceptive specific) neurons were no longer observed. Pharmacological blockade of spinal inhibition with a mixture of GABAA and glycine receptor antagonists significantly increased responses to innocuous mechanical stimuli in SA and NSA neurons from sham animals, but had no effect in sciatic nerve-injured animals, revealing a dramatic loss of spinal inhibitory tone in this situation. Moreover, in nerve-injured mice, local spinal administration of acetazolamide, a carbonic anhydrase inhibitor, restored responses to touch similar to those observed in naive or sham mice. These results suggest that a shift in the reversal potential for anions is an important component of the abnormal mechanical responses and of the loss of inhibitory tone recorded in a model of nerve injury-induced neuropathic pain.

Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.

Spinal cord injury (SCI) triggers inflammatory responses that involve neutrophils, macrophages/microglia and astrocytes and molecules that potentially cause secondary tissue damage and functional impairment. Here, we assessed the contribution of the calcium-dependent K+channelKCNN4(KCa3.1, IK1, SK4) to secondary damage after moderate contusion lesions in the lower thoracic spinal cord of adult mice. Changes inKCNN4mRNA levels (RT-PCR), KCa3.1 protein expression (Western blots), and cellular expression (immunofluorescence) in the mouse spinal cord were monitored between 1 and 28 d after SCI.KCNN4mRNA and KCa3.1 protein rapidly increased after SCI; double labeling identified astrocytes as the main cellular source accounting for this upregulation. Locomotor function after SCI, evaluated for 28 d in an open-field test using the Basso Mouse Scale, was improved in a dose-dependent manner by treating mice with a selective inhibitor of KCa3.1 channels, TRAM-34 (triarylmethane-34). Improved locomotor function was accompanied by reduced tissue loss at 28 d and increased neuron and axon sparing. The rescue of tissue by TRAM-34 treatment was preceded by reduced expression of the proinflammatory mediators, tumor necrosis factor-α and interleukin-1β in spinal cord tissue at 12 h after injury, and reduced expression of inducible nitric oxide synthase at 7 d after SCI. In astrocytesin vitro, TRAM-34 inhibited Ca2+signaling in response to metabotropic purinergic receptor stimulation. These results suggest that blocking the KCa3.1 channel could be a potential therapeutic approach for treating secondary damage after spinal cord injury.

SC1 is a member of the SPARC family of glycoproteins that regulate cell-matrix interactions in the developing brain. SC1 is expressed in astrocytes, but nothing is known about the expression in the aged or after stroke. We found that after focal striatal ischemic infarction in adult rats, SC1 increased in astrocytes surrounding the infarct and in the glial scar, but in aged rats, SC1 was lower at the lesion edge. Glial fibrillary acidic protein (GFAP) also increased, but it was less prominent in reactive astrocytes further from the lesion in the aged rats. On the basis of their differential expression of several molecules, 2 types of reactive astrocytes with differing spatiotemporal distributions were identified. On Days 3 and 7, SC1 was prevalent in cells expressing markers of classic reactive astrocytes (GFAP, vimentin, nestin, S100A), as well as apoliprotein E (ApoE), interleukin 1A, aggrecanase 1 (ADAMTS4), and heat shock protein 25 (Hsp25). Adjacent to the lesion on Days 1 and 3, astrocytes with low GFAP levels and a ‘‘starburst’’ SC1 pattern expressed S100A, ApoE, and Hsp32 but not vimentin, nestin, interleukin 1A, ADAMTS4, or Hsp25. Neither cell type was immunoreactive for NG2, CC-1, CD11b, or ionized calcium-binding adapter-1. Their differing expression of inflammation-related and putatively protective molecules suggests different roles for starburst and classic reactive astrocytes in the early glial responses to ischemia.

Neutrophils are thought to contribute to damage after intracerebral hemorrhage (ICH), but there is little direct evidence for this. We depleted circulating blood neutrophils with an anti-polymorphonuclear leukocyte antibody (anti-PMN) before inducing ICH in the rat striatum. Neutrophil infiltration, which was mainly at the edge of the hematoma, was decreased by more than 60% by anti-PMN mediated depletion. We then analyzed neutrophil contributions to BBB breakdown, white matter damage (axons and myelin), and glial and inflammatory responses, both spatially and temporally. Neutrophil depletion reduced BBB leakiness in the peri-hematoma region. Matrix metalloprotease 9, which is thought to contribute to BBB breakdown, was restricted to neutrophils after ICH and was thus reduced by neutrophil depletion. Early perihematomal axonal injury seen at 1 and 3 days after ICH was decreased by depleting neutrophils, and at later times (7 and 14 days), the astrocytic and microglia/macrophage responses were reduced in the perihematoma region and the surrounding striatum. Detailed spatial analysis showed that neutrophil depletion reduced infiltration of activated microglia/macrophages in the peri-hematoma white matter tracts and decreased myelin fragmentation and axon damage. These results show that, in experimental ICH, neutrophils produce matrix metalloprotease9and contribute to blood vessel disruption, BBB breakdown, axon damage, and astrocytic and microglial/macrophage responses that evolve after ICH.

The first atriopulmonary anastomosis (APA) with neither a valve in the inferior vena cava (IVC) nor an Glenn shunt was performed in 1971. A fenestration was intentionally left in the atrial septum. In a second patient, the APA incorporated the patient's own pulmonary valve, which had been removed from the outflow tract of the right ventricle. Since the early days, our rationale was that the right atrium would only function as a pathway, and the end diastolic pressure and the systole of the main ventricle would be the principal "pump" of this system. The late hemodynamic problems of the APA have decreased with newer and better surgical techniques, such as the lateral tunnel (LT) or the extracardiac conduit (EC). Although these procedures have improved the prognosis and quality of life of patients with a univentricular heart (UH), in the long run, deterioration frequently occurs because of chronic low cardiac output and high central venous pressure. Progressive increase in pulmonary vascular resistances and ventricular dysfunction are frequently the underlying reasons for this deterioration. However, such deterioration is not inevitable in every case, as shown in the longest survivor of the world after 34 years of follow-up. The Fontan Kreutzer (FK) palliation represents the best surgical option despite its uncertain late outcome. Certainly, it is one of the triumphs of cardiac surgery in congenital heart disease.

Experimental studies of intracerebral hemorrhage (ICH) have focused on neuron death, with little or no information on axonal and myelin damage outside the hematoma. Because development of effective therapies will require an understanding of white matter injury, we examined white matter injury and its spatial and temporal relationship with microglial/macrophage activation in a collagenase model of rat striatal ICH. The hematoma and parenchyma surrounding the hematoma were assessed in young and aged animals at 6 h, 1, 3 and 28 days after ICH onset. Demyelination occurred inside and at the edge of the hematoma; regions where we have shown substantial neuron death. In contrast, there was axonal damage without demyelination at the edge of the hematoma, and by 3 days this damage had spread to the surrounding parenchyma, a region where we have shown there is no neuron death. Because the axonal damage preceded infiltration of activated microglia into the white matter tracts (seen at 3 days), our results support the hypothesis that these cells respond to, rather than perpetrate the damage. Importantly, axonal damage was worse in aged animals, which provides a plausible explanation for the poorer functional recovery of older animals after ICH, despite a similar loss of grey matter. Our findings support strategies that target white matter injury to reduce neurological impairment after ICH.

A MRI of the lumbal spine was performed on a patient with lumbago. Besides the fact of no evidence for a myelopathy caused by a herniated disc a both-sided iliac vein thrombosis could be seen. In further examination the coincidence of a congenital absence of vena cava inferior with distinctive collateral vessel systems over lumbal and spinal veins and heterozygosis for Factor V Leiden abnormality could be identified as cause for thrombosis. It is very likely that symptoms developed as a result of spinal vein hyperplasia and consecutive myelon compression.

Using whole-cell patch-clamp recordings from spinal cord slices of young (10-15 days old) rats, we have characterized and compared the properties of inhibitory synaptic transmission in lamina II and laminae III-IV of the dorsal horn, which are involved in the processing of nociceptive and non-nociceptive sensory information, respectively. All (100%) of laminae III-IV neurons, but only 55% of lamina II neurons, received both gamma-aminobutyric acid (GABA)ergic and glycinergic inputs. The remaining 45% of lamina II neurons received only GABAergic synapses. Neurons receiving only glycinergic synapses were never observed. Among the 55% of lamina II neurons receiving both GABAergic and glycinergic inputs, all displayed a small proportion (approximately 10%) of mixed miniature inhibitory postsynaptic currents (mIPSCs), indicating the presence of a functional GABA/glycine co-transmission at a subset of synapses. Such a co-transmission was never observed in laminae III-IV neurons. The presence of mixed mIPSCs and the differences in decay kinetics of GABAA-type receptor mIPSCs between lamina II and laminae III-IV were due to the endogenous tonic production of 3alpha5alpha-reduced steroids (3alpha5alpha-RS) in lamina II. Stimulation of the local production of 3alpha5alpha-RS was possible in laminae III-IV after incubation of slices with progesterone, subcutaneous injection of progesterone or induction of a peripheral inflammation. This led to the prolongation of GABAergic mIPSCs, but failed to induce the appearance of mixed mIPSCs in laminae III-IV. Our results indicate that, compared with lamina II, inhibitory synaptic transmission in laminae III-IV is characterized by a dominant role of glycinergic inhibition and the absence of a functional GABA/glycine co-transmission.

The causes that lead to terminal renal failure in children and adolescents and subsequently require dialysis are different from those in adults. Moreover, children with a functioning kidney transplant evidence an approximately fourfold higher survival probability than children on dialysis. This contribution describes kidney transplantation in light of the specific features for this age group.

Objective Uterine hyperperistalsis and dysperistalsis are common phenomena in endometriosis and may be responsible for reduced fertility in cases of minimal or mild extent of disease. Since a high prevalence of adenomyosis uteri has been well documented in association with endometriosis, we designed a study to examine whether hyperperistalsis and dysperistalsis are caused by the endometriosis itself or by the adenomyotic component of the disease. Design A prospective observational study. Setting University hospital, Department of Obstetrics and Gynaecology, Division of Reproductive Medicine and Gynaecologic Endocrinology with 300 in vitro fertilisation/intracytoplasmatic sperm injection cycles and 350 intrauterine insemination cycles/year. Population Forty-one subjects with infertility and with laparoscopically proven endometriosis and patent fallopian tubes. Thirty-five subjects (85%) additionally showed signs of adenomyosis. Methods All subjects underwent T2-weighed magnetic resonance imaging (MRI) and hysterosalpingoscintigraphy (HSSG) during the subsequent menstrual cycle. MRI revealed the extent of the adenomyotic component of the disease and the integrity of uterotubal transport capacity was evaluated by HSSG. Main outcome measures Influence of adenomyosis on uterotubal transport capacity in endometriosis. Results In 35 of the 41 subjects (85%) with endometriosis, signs of adenomyosis were detected using T2-weighed MRI. Two of six (33%) subjects with no adenomyosis (group I) showed dysperistalsis and hyperperistalsis, compared with 14 of 24 (58%) women with focal adenomyosis (group II) and 10 of 11 (91%) women with diffuse adenomyosis (seven showed a failure in transport capacity and two contralateral transport). Conclusions Our data suggest that endometriosis is associated with impeded hyperperistaltic and dysperistaltic uterotubal transport capacity. However, adenomyosis is of even more importance, especially when diffuse adenomyosis is detected. Both forms of adenomyosis are commonly found in subjects with mild to moderate endometriosis. We suggest that the extent of the adenomyotic component in subjects with endometriosis explains much of the reduced fertility in subjects with intact tubo-ovarian anatomy.

Objective: Endoscopic extraperitoneal radical prostatectomy (EERPE) and robot-assisted laparoscopic prostatectomy (RALP) are minimally invasive surgical techniques to treat localized prostate cancer. We report the outcome and complications of these two techniques conducted by one individual surgeon. Patients and Methods: 86 patients underwent EERPE between January 2008 and June 2011, and 100 patients underwent RALP between August 2011 and October 2012. All surgeries were performed by one single surgeon. Results: The patients of the EERPE and RALP groups had similar clinical characteristics in PSA, prostate volume and D'Amico classification, and were significantly different in their age and BMI as well as in the number of prior surgeries. RALP surgeries were significantly slower (183 vs. 157 min) but also involved lower blood loss (147 vs. 245 ml). Pathological stages and positive surgical margins were similar in both groups. Complications were assessed by the Clavien-Dindo classification. 6 patients in the EERPE group and 3 patients of the RALP group suffered major complications (IIIb-IV). Conclusion: Altogether our results indicate that the learning curve for RALP was short after experience with EERPE. We hypothesize that this is more a result of the surgical experience of the surgeon with the EERPE than on the robotic technique.

We have studied the modulatory effect of dehydroepiandrosterone (DHEA), the most abundant neurosteroid produced by glial cells and neurones, on membrane currents induced by the activation of ionotropic ATP (P2X) receptors in neonatal rat dorsal root ganglion neurones. ATP (1 microM) induced three types of currents/responses termed F (fast and transient), S (slowly desensitizing) and M (mixed, sum of F- and S-type responses). DHEA (10 nM to 100 microM) concentration-dependently increased the amplitude of plateau-like currents of S- and M-type responses evoked by submaximal (1 microM) but not saturating (100 microM or 1 mM) concentrations of ATP. Alphabeta-methylene ATP (alphabetame-ATP, 5 microM) also evoked F-, S- and M-type responses, the plateau phases of which were potentiated by lowering external pH (6.3) and by ivermectin (IVM, 3 microM), indicating the presence heteromeric P2X2-containing receptors and possibly of functional native P2X4/6 receptors. There was a strict correlation between the potentiating effects of low pH and DHEA on alphabetame-ATP responses but not between that of IVM and DHEA, suggesting that DHEA selectively modulated P2X2-containing receptors. DHEA also potentiated putative homomeric P2X2 receptor responses recorded in the continuous presence of 1 microM 2'-(or 3')-O-(2,4,6-trinitrophenyl) adenosine 5'-triphosphate (TNP-ATP). Our results constitute the first demonstration of a fast potentiation of P2X receptors by a neurosteroid and suggest that DHEA could be an endogenous modulator of P2X2-containing receptors thereby contributing to the facilitation of the detection and/or the transmission of nociceptive messages, particularly under conditions of inflammatory pain where the P2X receptor signalling pathway appears to be upregulated.

Kv1.3 is a voltage-gated potassium channel with roles in human T cell activation/proliferation, cell-mediated cytotoxicity, and volume regulation and is thus a target for therapeutic control of T cell responses. Kv1.3 is also present in some mouse thymocyte subsets and splenocytes, but its role in the mouse is less well understood. We report the generation and characterization of Kv1.3-deficient (Kv1.3 –/–) mice. In contrast to wild-type cells, the majority of Kv1.3 –/– thymocytes had no detectable voltage-dependent potassium current, although RNA and protein for several potassium channel subunits were found in the thymocyte population. Surprisingly, the level of chloride current in the Kv1.3 –/– thymocytes was increased approximately 50-fold over that in wild-type cells. There were no abnormalities in lymphocyte types or absolute numbers in thymus, spleen, and lymph nodes and no obvious defect in thymocyte apoptosis or T cell proliferation in the Kv1.3 –/– animals. The compensatory effects of the enhanced chloride current may account for the apparent lack of immune system defects in Kv1.3 –/–mice.

OBJECTIVE To evaluate the role of intraoperative real-time transesophageal echocardiography (TEE) for the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension. METHODS Retrospective analysis of the intraoperative application of TEE in a series of 4 patients. RESULTS Real-time TEE with a multiplane probe allowed visualization of inferior vena cava tumor extensions, accurate assessment of the distal extent of vena cava invasion into hepatic veins and right atrium, monitoring of embolism and evaluation of cardiac preload and function in all patients. CONCLUSION Intraoperative TEE is a useful adjunct to the anesthetic and surgical management of patients with renal cell carcinoma and vena cava extension.

Objectives To evaluate the diagnostic potential of echo-enhanced ultrasonography (US) for depicting the vascularization pattern of renal cell carcinoma (RCC), and calculating the first-pass effect using harmonic imaging, against that obtained by triphasic helical computed tomography (CT). Patients and methods Sixty patients with surgically confirmed RCC underwent US using B-mode and power Doppler methods with or without an intravenous microbubble echo-enhancing agent. After depicting and defining the tumour extent by B-mode US, the first-pass effect/enhancement by the echo-enhancing agent within the lesion, and that of a reference area of unaffected renal cortex, were recorded on-line by calculating the mean pixel intensity. Time-intensity curves, i.e. the rise time and gradient of both the suspected tumour and reference areas, were constructed. Results Using B-mode US, the extent of all tumours was delineated (mean tumour size 3.8 cm, sd 0.6). After applying the microbubble agent all tumours were enhanced, whereas the perfusion was decreased (in 48%), increased (in 16%) or similar (in 36%) compared with the cortical reference area. Using the Hounsfield classification, these results correlated well with the hypo/hypervascularity shown on CT. Conclusion Ultrasonography has considerable potential in diagnosing RCC, if combined with echo-enhancing methods, harmonic imaging and computer-based calculation of tumour vascularization. Dynamic US studies should provide a diagnostic yield similar to that of CT.

We looked for an interaction between etifoxine and the neurosteroid allopregnanolone at central gamma-aminobutyric acid (GABA A ) receptors. Etifoxine (2 μM) did not affect the affinity of allopregnanolone (IC 50 =108 nM) for its site in preparations of Sprague–Dawley rat cerebral cortex membranes, as determined by the inhibition of [ 35 S] t-butylbicyclophosphorothionate binding, a specific ligand of the GABA A receptor chloride channel site. Etifoxine and allopregnanolone were anticonvulsants, blocking the clonic convulsions induced by bicuculline (an antagonist of the GABA A receptor) in CD1 mice. A combination of subactive doses of the two compounds showed additive anticonvulsant effects. These results suggest that etifoxine and allopregnanolone bind to distinct putative recognition sites at or near the chloride channel site. Functionally, their binding may have an additive effect by enhancing GABA A inhibitory transmission.

Background: Evidence of extensive cross-talk between calcium (Ca 2+ )- and cAMP-mediated signaling systems suggests that previously reported abnormalities in Ca 2+ homeostasis in bipolar I (BP-I) patients may be linked to disturbances in the function of G proteins that mediate cAMP signaling. Methods: To test this hypothesis, the β-adrenergic agonist, isoproterenol, and the G protein activator, sodium fluoride (NaF), were used to stimulate cAMP production in B lymphoblasts from healthy and BP-I subjects phenotyped on basal intracellular calcium concentration ([Ca 2+ ] B ). cAMP was measured by radioimmunoassay and [Ca 2+ ] B by ratiometric fluorometry with fura-2. Results: Isoproterenol- (10 μM) stimulated cAMP formation was lower in intact B lymphoblasts from BP-I patients with high [Ca 2+ ] B (≥ 2 SD above the mean concentration of healthy subjects) compared with patients having normal B lymphoblast [Ca 2+ ] B and with healthy subjects. Although basal and NaF-stimulated cAMP production was greater in B lymphoblast membranes from male BP-I patients with high versus normal [Ca 2+ ] B , there were no differences in the percent stimulation. This suggests the differences in NaF response resulted from higher basal adenylyl cyclase activity. Conclusions: These findings suggest that trait-dependent disturbances in processes regulating β-adrenergic receptor sensitivity and G protein–mediated cAMP signaling occur in conjunction with altered Ca 2+ homeostasis in those BP-I patients with high B lymphoblast [Ca 2+ ] B .

Objective: Evaluate long-term results of autologous pericardial valved conduits in the pulmonary outflow. Methods: Between June 1983 and October 1993, 82 conduits were placed in the outflow of the venous ventricle. Patients who received homografts (n = 2 patients), heterografts (n = 3 patients), and valveless conduits (n = 19 patients) and those patients who died within 90 days after the operation were excluded. Fifty-four survivors of pulmonary outflow reconstruction with fresh autologous pericardial valved conduits were followed up from 5 to 15 years (mean, 7.47 ± 2.8 years). Diagnosis include d -transposition of great arteries (n = 16 patients), L -transposition of great arteries (n = 14 patients), tetralogy of Fallot, pulmonary atresia with ventricular septal defect (n = 11 patients), truncus arteriosus (n = 10 patients), and double-outlet ventricle (n = 3 patients). Implantation age ranged from 0.25 to 24 years (mean, 5.2 ± 4.2 years). Median conduit diameter was 16 mm. Two-dimensional echocardiographic Doppler evaluations were made yearly; 9 patients underwent cardiac catheterization. Reintervention for stenosis was indicated when the pressure gradient exceeded 50 mm Hg. Results: Three late deaths were unrelated to the conduit. Thirty-five autologous pericardial valved conduits increased in diameter (1-7 mm), remained unchanged in 15 patients, and reduced 1 to 2 mm in 4 patients. The median diameter was 18 mm at the last evaluation ( P = .0001). Eight patients required conduit-related reoperation 3 to 8 years after the implantation. Two patients underwent balloon dilation of the autologous pericardial valved conduit. No conduit had to be replaced. Freedom from reintervention at 5 and 10 years was 92% and 76%, being 100% at 10 years for conduits larger than 16 mm at time of implantation. Conclusions: Autologous pericardial valved conduits show excellent long-term results and compare favorably with other conduits. (J Thorac Cardiovasc Surg 2000;119:869-79)

Genetic characterization of multifocal tumor growth in renal cell carcinoma. The primary cancer found in the kidney is renal cell carcinoma (RCC), which does not as yet have a delineation of the types of lesions that progress to tumor malignancy. We studied tissues from primary tumors and secondary lesions, and compared it with the surrounding normal kidney tissue using comparative genomic hybridization to determine their potential for malignancy. Although our sample size was small, we found that small multifocal tumors have the same potential as primary carcinoma to lead to RCC malignancy. Further genetic studies in a larger sample of patients is necessary before the risk of different lesions to remain benign or progress to RCC can be defined absolutely.

THIS study examined the nature of the interactions of etifoxine, an anxiolytic and anticonvulsant compound, with the GABA A receptor/chloride channel complex. In membrane preparations of Sprague-Dawley rat cerebral cortex, etifoxine competitively inhibited the binding of [ 35 S]t-butylbicyclophosphoro-thionate (TBPS), a specific ligand of the GABA A receptor chloride channel site. In vivo studies demonstrated an anticonvulsant effect of etifoxine (50 and 75 mg/kg, i.p.) against the clonic convulsions induced by TBPS in CD 1 mice. Flumazenil (10 and 40 mg/kg, i.p.), an antagonist of benzodiazepine sites at GABA A receptors, had no effect on the action of etifoxine. These findings suggest that etifoxine exerts its effect by interacting with the Cl - channel of GABA A receptors and probably by facilitating GABAergic inhibition.

The indication for elective organ-preserving surgery in renal cell carcinoma is under discussion. The statements about the maximum tumor size, which could be considered for this surgical procedure, differ in the literature. In a series of 281 consecutive radical tumor nephrectomies we compared the results of preoperative ultrasound and computerized tomography regarding to tumor size and multifocality with the results of the postoperative systematically section of the removed kidneys. Further we analysed the results of 14.793 autopsies regarding to tumor size and multifocality. Serial section of the 281 nephrectomy specimens revealed a total of 64 multifocal tumors in 48 kidneys ( = 17,1 %). The correlation between tumor size and multifocality showed only in tumors up to 20 mm no additional lesions, whereas in the higher tumor categories the incidence was up to 23 %. These clinical investigations were confirmed by the results of the autopsies. In summery of the results we conclude, that the elective organ-preserving surgery of renal cell carcinoma is only indicated in tumors with a maximum diameter of 20 mm.

The objective of this study was to evaluate the early and late results of an autologous pericardial valved conduit in the pulmonary circulation. Between 1983 and 1997, 86 autologous pericardial valved conduits were used to achieve venous ventricle-pulmonary artery continuity. The mean patient age at the time of implantation was 4.16 +/- 4.10 years (15 days to 24 years). All patients had two-dimensional postoperative and yearly Doppler echocardiograms in which the valve function and the presence of distal, valvar, and proximal stenosis were evaluated. There were 13 early deaths (15%). Twenty-one patients (24.4%) showed trivial, 54 (62.8%) mild, nine (10.4%) moderate, and two (2.3%) severe pulmonary regurgitation in the early postoperative period. The 73 survivors were monitored from 1 to 15 years (mean, 6.5 years; median, 7.1 years). There were five late deaths. The mean conduit diameter at the time of implantation was 15.8 mm, increasing to 18.21 mm at last evaluation (P.0001). There were nine reoperations, with only one conduit replacement. Freedom from reintervention at 5 and 10 years was 89% and 80%, respectively. In conclusion, autologous pericardial valved conduits provide good early and excellent long-term results that compare favorably with those of other conduits. Copyright 1999 by W.B. Saunders Company

Cardiovascular neurons in the Rostro-Ventrolateral Medulla (RVLM) have been shown to display a regular action potential discharge activity in vitro which has been proposed to result either from pacemaker conductances or from the activity of an oscillating network. Using intracellularly recordings in vitro from regularly-discharging RVLM neurons, we observed in young adult rats (>19 days) that the regular discharge activity in RVLM is labile, as many neurons were or spontaneously became quiescent during the recording. A regular discharge could be induced or restored in quiescent neurons by superfusing an external concentration of K+ ions ([K+]ext) of 6 mM. In order to elucidate how neurotransmitters might influence this discharge activity, we studied the effects of a catecholamine, noradrenaline (present in this brain region). Noradrenaline depolarized or increased the spiking frequency of regularly-discharging neurons. This excitatory effect was sensitive to prazosin and propranolol. In the presence of these two blockers, noradrenaline induced a hyperpolarization sensitive to idazoxan and mimicked by α2-adrenergic agonists. These effects persisted in the presence of tetrodotoxin. In spontaneously active neurons, prazosin plus propranolol abolished the discharge activity. At hyperpolarized potentials, the adrenoceptor blockers reduced the baseline synaptic/oscillatory activity. Our results demonstrate that the regular discharge activity of RVLM neurons is labile and depends on external ionic conditions, such as [K+]ext. This discharge activity can be modulated by catecholamines, acting at the 3 subtypes of adrenoceptors which co-exist on the same neuron. We propose that an endogenous release of catecholamines may condition the discharge activity of RVLM neurons.

Although radical nephrectomy is the standard treatment for localized unilateral renal cell carcinoma with a normal contralateral kidney, there is ongoing interest in the use of nephron sparing surgery or partial nephrectomy in such cases. The extent of radical surgery in such cases has also been reconsidered in view of the uncertainty regarding the malignant or benign nature.Of 14,793 autopsies in Jena from 1985 until 1995 there were 260 renal cell carcinomas. Of the 260 renal cell carcinomas the diameter was 40 mm. or less in 104. These 104 tumors were divided into group 1-20 mm. or less (33 cases), group 2-21 to 30 mm. (28) and group 3-31 to 40 mm. (43).Grade 1 renal cell carcinomas decreased in frequency with increasing tumor diameter, while an opposite result was noted for grade 3. Lymph node and distant metastases were well correlated with tumor size. With an increase in tumor size the frequency of venous involvement increased as well. Significantly more multifocal malignant renal cell carcinomas were seen in tumors between 21 and 40 mm. compared to those 20 mm. or less in diameter.The metastatic potential and biology of these small nodules are not yet known. To lower the risk of local recurrence the results of our study suggest that nephron sparing surgery might be advisable in patients with renal cell carcinoma 20 mm. or less in diameter.

The functional characteristics of binding sites for the neuropeptide oxytocin (OT) detected by radioautography in laminae I and II of the dorsal horn (DH) and on cultured neonatal DH neurons were studied on the latter using perforated patch-clamp recordings. The neurons were identified by their spike discharge properties and on the basis of the presence of met-enkephalin-like and glutamate decarboxylase-like immunoreactivities. OT (100 nm) never induced any membrane current at a holding potential of −60 mV but increased the frequency of spontaneously occurring AMPA receptor-mediated EPSCs or the mean amplitude of electrically evoked EPSCs in a subset (35%) of neurons. The frequency of miniature EPSCs (m-EPSCs) recorded in the presence of 0.5 μmtetrodotoxin was also increased by OT (100 nm) without any change in their mean amplitude, indicating an action at a site close to the presynaptic terminal. The decay kinetics of any type of EPSC were never modified by OT. The effect of OT was reproduced by [Thr4,Gly7]-OT (100 nm), a selective OT receptor agonist, and blocked by d(CH2)5-[Tyr(Me)2,Thr4,Tyr-NH29]-ornithine vasotocin (100 nm), a specific OT receptor antagonist. Reducing the extracellular Ca2+concentration from 2.5 to 0.3 mmin the presence of Cd2+(100 μm) reversibly blocked the effect of OT on m-EPSCs. The OT receptors described here may represent the substrate for modulatory actions of descending hypothalamo-spinal OT-containing pathways on the nociceptive system.

Jo, Y. H., M. E. Stoeckel, and R. Schlichter. Electrophysiological properties of cultured neonatal rat dorsal horn neurons containing GABA and met-enkephalin-like immunoreactivity. J. Neurophysiol. 79: 1583–1586, 1998. We have developed a culture of neurons dissociated from the most superficial laminae of the neonatal rat spinal cord dorsal horn (DH). By using the perforated patch-clamp technique, we distinguished four types of neurons based on their firing properties in response to intracellular injection of 900 ms lasting current pulses. Type 1 neurons were characterized by a tonic firing. Type 2 neurons displayed marked spike accommodation and fired brief (

1. We have used the whole-cell configuration of the patch-clamp technique to investigate the effects of neuroactive steroids on GABAA receptor-mediated synaptic transmission between rat hypothalamic neurones and pituitary intermediate lobe (IL) cells grown in coculture. In order to discriminate between possible pre- and postsynaptic sites of action, the effects of neurosteroids on GABAA receptor-mediated synaptic currents (IPSCs) were compared with those of GABAA currents (IGABA) triggered by local application of 50 or 500 microM GABA, which yielded approximately half-maximal and maximal responses, respectively. 2. In primary cultures of rat pituitary IL cells, allopregnanolone (5 alpha-pregnan-3 alpha-ol-20-one) reversibly potentiated IGABA in a dose-dependent manner with a threshold between 0.1 and 1 nM. At a concentration of 10 nM, allopregnanolone increased the response evoked by 50 microM GABA by +21.4 +/- 5.1% (n = 8), but had no effect on IGABA induced by 500 microM GABA. The beta-isomer of allopregnanolone, epipregnanolone (5 beta-pregnan-3 beta-ol-20-one, 10 nM), had no effect on IGABA at any concentration of GABA tested. 3. At concentrations lower than 10 microM, pregnenolone sulphate (5-pregnen-3 alpha-ol-20-one sulphate) did not significantly inhibit IGABA. However, at 10 microM, a systematic reduction of IGABA evoked by 50 and 500 microM GABA was observed, with mean values of -80 and -60%, respectively. This blocking effect was reversible and accompanied by a marked acceleration of decay of GABAA currents during the application of GABA. 4. In isolated pairs of synaptically connected hypothalamic neurones and IL cells, allopregnanolone (10 nM) augmented the mean amplitude of spontaneous IPSCs (sIPSCs) and electrically evoked IPSCs (eeIPSCs) by about 40% and increased the mean frequency of sIPSCs. Allopregnanolone (10 nM) also markedly increased the frequency of miniature IPSCs (mIPSCs) recorded in the presence of TTX (0.5 microM), but without modifying their mean amplitude. Epipregnanolone had no effect on the amplitude or frequency of sIPSCs. Neither epipregnanolone nor allopregnanolone modified the time to peak and decay time constants of GABAergic IPSCs. 5. Pentobarbitone (50 microM), a positive allosteric modulator of GABAA receptors, did not affect the amplitude of sIPSCs or eeIPSCs, but significantly increased the decay time constants of both types of IPSCs. Pentobarbitone had no effect on the frequency of sIPSCs. 6. Pregnenolone sulphate (10 microM) completely and reversibly blocked sIPSCs and eeIPSCs. Progressive block of IPSCs was correlated with a gradual decrease of the mean decay time constant. 7. Our results suggest that, under physiological conditions, allopregnanolone might be a potent modulator of GABAergic synaptic transmission, acting at both pre- and postsynaptic sites. The involvement of pregnenolone sulphate as a modulator of GABAergic IPSCs under physiological conditions is, however, more questionable. The mechanisms of action of both types of neurosteroids are discussed.

BACKGROUND Multifocal tumor areas occurred in 12-22% of patients with renal cell carcinoma. It is unknown whether these tumors have malignant potential and characterize a higher risk for metastases. The performance of nephron-sparing surgery in patients with low grade or low stage tumors is controversial. METHODS Primary and secondary tumors were analyzed by conventional cytogenetics and fluorescence in situ hybridization. Production of interleukin (IL)-6, IL-10, IL-11, and transforming growth factor (TGF)-β1 were determined using standard enzyme-linked immunosorbent assay and bioassays. RESULTS In 15.2% of the renal cell carcinoma cases evaluated, multifocal tumors were detected. Cytogenetics revealed a concordance of primary and secondary tumors in 9 of 14 cases (64%). In 11 of 12 multifocal tumors (94%), the same immunologic activity status was observed in both primary and secondary tumors. CONCLUSIONS Secondary tumors must be expected to have malignant potential similar to that of the primary tumors. This was underscored by the high concordance of cytogenetic, histopathologic, and immunologic data in this study. Cancer 1997; 79:975-81. © 1997 American Cancer Society.

Background. The aim of this study was to evaluate the long-term results of the use of an autologous pericardial valved conduit in the outflow tract of the venous ventricle in congenital heart malformations. Methods. Fifty-one patients were followed up for a period of 12 to 120 months; 30 for more than 36 months and 13 for more than 72 months. All were evaluated clinically and by two-dimensional and Doppler echocardiography. Eight patients were recatheterized. Postoperative evaluation included serial measurement of pressure gradients and the conduit's diameter at the proximal, valvular, and distal levels. Reoperation because of stenosis was indicated when the gradient across the right ventricular outflow was greater than 50 mm Hg. The reoperation rate in relation with postoperative time, diameter of the autologous pericardial valved conduit at the time of implantation, and malformation was statistically analyzed. Results. In 27 patients the conduit increased its diameter 1 to 7 mm. In 20 patients the diameter remained unchanged, whereas a reduction was noted in 4. Conduit survival free of reoperation for the whole group was 89.9% at 5 years. Conduit survival free of reoperation was 100% at 5 and 7 years for conduits larger than 16 mm at the time of implantation. It was 95% (standard deviation=4.8%) at 5 years and 72.3% at 7 years for those 16 mm or less. For patients operated after January 1, 1986 (technical modification), conduit survival free of reoperation was 95.4% at 7 years postoperatively. Conclusions. These results compare favorably with those of other available conduits.

A fenestrated extracardiac conduit Fontan operation was performed with a new method in 5 patients by means of a pericardial tube anastomosed end to end with the inferior inlet of the right atrium.

The progression of white matter damage after ischemic and hemorrhagic strokes can exacerbate the initial injury, but little is known about the processes involved. We show that the antiadhesive matricellular glycoprotein SC1 is a novel early marker of white matter damage in 3 models of acute injury in the rat striatum: transient focal ischemia, intracerebral hemorrhage, and a needle penetration wound. SC1 was restricted to the damaged portions of axon bundles that bordered stroke lesions in young-adult and aged rats. SC1 peaked at 1 and 3 days after intracerebral hemorrhage and at 7 days after ischemia. The SC1-positive bundles usually expressed degraded myelin basic protein and amyloid precursor protein, a marker of axonal injury. At the hematoma edge, SC1 was seen in a few axon bundles that retained myelin basic protein staining. In these bundles, punctate SC1 staining filled individual axons, extended beyond a core of pan-axonal neurofilament and NF200 and was inside or overlapped with myelin basic protein staining when it was present. Aged rats had less SC1 (and amyloid precursor protein) after both types of stroke, suggesting a reduced axonal response. SC1 also labeled amyloid precursor protein-positive axon bundles along the needle penetration tract of saline-injected rats; thus, SC1 appears to characterize damaged striatal white matter damage after multiple types of injury.

The properties of neuronal-type nicotinic acetylcholine receptors (nAChRs) present on the neuroendocrine cells of the porcine pars intermedia of the pituitary were studied in intact single cell using measurements of the free intracellular Ca2+ concentration ([Ca]i) with the calcium-sensitive dye fura 2. Local application of an extracellular solution containing 50 mM K+ or of the selective nAChR agonist, 1,1-dimethyl-4-phenylpiperazinium (DMPP) depolarised the cells and induced an elevation in [Ca]i. The effect of DMPP on [Ca]i was dose dependent (EC50 = 6 microM), reversibly blocked by d-tubocurarine and strictly dependent on the concentration of extracellular Ca2+. The calcium channel blocker Cd2+ (100 microM) reversibly blocked 80% of the response induced by 50 mM K+, whereas it reduced the DMPP response by only 50%. In the absence of extracellular Na+, DMPP no longer depolarised the cells but still increased [Ca]i. The rise in [Ca]i under these conditions represented 41% of the control response, i.e. in the presence of external Na+. Thus activation of nAChRs induced an elevation in [Ca]i which was in part independent of cell depolarisation. This was confirmed by recording simultaneously, under whole-cell voltage-clamp, a rise in [Ca]i associated with the inward nicotinic current. During prolonged application of the agonist (50 s), the amplitude of the nicotinic current decayed rapidly to a very low plateau level reflecting nAChR desensitisation. However, photometric experiments performed on intact non-dialysed cells revealed the presence of a slowly decaying phase in [Ca]i throughout the application of DMPP. This suggests the persistence of a substantial Ca2+ influx during prolonged exposure to the agonist. Taken together, our results show that stimulation of nAChRs induces an influx of Ca2+ which elevates [Ca]i. This phenomenon is due to activation of voltage-dependent Ca2+ channels and to Ca2+ entry through the nAChR.

Care of the neurosurgical patient by the anesthesiologist extends beyond the operating suite. Complications can occur in the postanesthesia care unit (PACU) that require intervention by the anesthesiologist. Common postoperative emergencies in the neurosurgical patient include depression of airway reflexes, hemodynamic instability, increased intracranial pressure (ICP), and bleeding complications. This section will focus on etiology, prevention, and treatment of three common postsurgical complications: (1) hemorrhage from the surgical site, (2) coagulopathy, and (3) hematoma formation.

After an ischemic stroke, there is a prolonged inflammatory response and secondary phase of injury that is more amenable to treatment than acute neurotoxicity. Surprisingly, little is known about temporal and spatial relationships between inflammation and white matter injury. Here, we quantified development of white matter damage, inflammation, and a glial limitans at 1, 3, and 7 days after transient ischemia in the rat striatum using immunohistochemistry. Quantitative analysis showed that decreased staining for myelin basic protein and increased staining for damaged myelin basic protein began in the core, coincided with neutrophil infiltration, and progressed outward over time. Axon damage (i.e. accumulation of amyloid precursor protein) began at the edge of the lesion, coinciding with substantial microglia/macrophage activation, and progressed into the core. During the 7 days, activated microglia/macrophages dramatically increased only in the core and edge of the lesion. Detailed spatial analyses revealed that activated microglia/macrophages that surrounded undamaged axon bundles did not express ED1, a marker of phagocytic cells, whereas those inside damaged bundles expressed ED1. These results imply different contributions of neutrophils and microglia/macrophages to white matter injury after ischemic stroke. The distinct localizations of activated microglia/macrophages imply complex signals that regulate their migration toward and infiltration of damaged white matter.

Aortopulmonary fistula has been documented in adult patients with acute aortic dissection, atherosclerotic disease, and other comorbidities. However, until now we believe this was not previously reported as a complication after the arterial switch operation in a patient with transposition of the great arteries. We report the case of a 3-month-old boy who underwent an arterial switch operation as a neonate. After balloon dilation to relieve a postoperative supravalvular pulmonary stenosis, he presented with severe congestive heart failure due to an undiagnosed but previously present fistula between the ascending aorta and the main pulmonary artery. He underwent successful surgical repair and recovered uneventfully.

1. The modulatory role of intracellular Ca2+ concentration ([Ca2+]i) on gamma-aminobutyric acid type A (GABAA) receptor-gated Cl- currents was investigated in dialysed and intact cells of cultured porcine pituitary intermediate lobe (IL) cells using the patch-clamp technique. In order to isolate Ca2+ and Cl- currents all other membrane currents were blocked pharmacologically. Isoguvacine, a specific GABAA receptor agonist, was used to activate selectively GABAA receptor-mediated whole-cell and single-channel Cl- currents. 2. In the whole-cell recording (WCR) configuration inward Ca2+ currents triggered before and/or during the application of isoguvacine (100 microM), did not inhibit the GABAA receptor-mediated response. This lack of effect of calcium currents was obtained in all situations tested, i.e. when the intracellular Ca2+ concentration was only weakly buffered (0.5 mM-EGTA in the pipette solution), not buffered at all (no EGTA added to the pipette solution) or when the resting [Ca2+]i was buffered at 10(-7) M (pCa 7) with internal EGTA. 3. At pCa 7, simultaneous application of isoguvacine (100 microM) and caffeine (10 mM) resulted in a 47 +/- 15% reduction of the whole-cell GABAA response. In the same conditions, a ten times lower concentration of caffeine (1 mM), induced a transient increase of the GABAA response which turned into a steady-state inhibition during the subsequent applications. 4. At pCa 7, when isoguvacine (100 microM) was applied together with 3Me-His2-TRH (50 nM), a potent analogue of the calcium-recruiting thyrotrophin-releasing hormone, the GABAA receptor-gated Cl- current was increased by 40 +/- 8%. In the absence of the Ca2+ chelator EGTA in the pipette solution, either potentiating or inhibitory effects of 3Me-His2-TRH on the GABAA response were observed. 5. If a high concentration (18 mM) of the calcium chelator EGTA was included in the pipette solution, caffeine and 3Me-His2-TRH had markedly lower effects on the GABAA response than those observed at pCa 7, suggesting that the effect of both substances was mediated by an increase in [Ca2+]i. 6. In the absence of extracellular Ca2+, the effects of caffeine and 3Me-His2-TRH were not significantly different from those obtained in the presence of Ca2+ (5 mM), suggesting that Ca2+ influx was not the major route for increasing [Ca2+]i. 7. In the cell-attached (CA) configuration, the presence of isoguvacine (3-5 microM) in the pipette solution triggered the opening of channels displaying multiple current levels.(ABSTRACT TRUNCATED AT 400 WORDS)

Determination of telomerase activity for differential analysis of multifocal renal cell carcinomas. Secondary tumors are found in approximately 12 to 22% of all renal cell carcinoma, and their origin is currently unknown. To determine their potential for malignancy, we examined the telomerase activity of primary tumors and secondary lesions, and found that 86% of the lesions had an identical telomerase status as the related primary tumors, and thus probably share their malignancy potential.

Intracerebral hemorrhage (ICH) usually affects older humans but almost no experimental studies have assessed aged animals. We address how aging alters inflammation, neuron death and lesion resolution after a hemorrhage in the rat striatum. In the normal aged brain, microglia displayed a 'dystrophic' phenotype, with shorter cellular processes and large gaps between adjacent cells, and there was more astrocyte reactivity. The ICH injury was monitored as hematoma volume and number of dying neurons at 1 and 3 days, and the volume of the residual lesion, ventricles and lost tissue at 28 days. Inflammation at 1 and 3 days was assessed from densities of microglia with resting vs. activated morphologies, or expressing the lysosomal marker ED1. Despite an initial delay in neuron death in aged animals, by 28 days, there was no difference in neuron density or volume of tissue lost. However, lesion resolution was impaired in aged animals and there was less compensatory ventricular expansion. At 1 day after ICH, there were fewer activated microglia/macrophages in the aged brain, but by 3 days there were more of these cells at the edge of the hematoma and in the surrounding parenchyma. In both age groups a glial limitans had developed by 3 days, but astrocyte reactivity and the spread of activated microglia/macrophages into the surrounding parenchyma was greater in the aged. These findings have important implications for efforts to reduce secondary injury after ICH and to develop anti-inflammatory therapies to treat ICH in aged humans.