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Anupama Barua1, Vinay P Rao1, BC Ramesh2, Biplab Barua3, Hussain El-Shafei21Cardiothoracic Department, Nottingham City Hospital, Nottingham, UK; 2Cardiothoracic Department, Aberdeen Royal Infirmary, Aberdeen, UK; 3General Surgery Department, Glenfield Hospital, Glenfield, Leicester, UKBackground: Refractory post cardiopulmonary bypass (CPB) bleeding continues to cause concern for cardiac surgeons and intensivists. Massive postoperative hemorrhage following CPB is multifactorial and not fully understood, and it is also associated with increased mortality and morbidity. Activated recombinant factor VII (rFVIIa) has emerged as possible salvage medication in refractory post cardiac surgical bleeding. This observational study sought to identify the pattern of use of rFVIIa in cardiac surgery, its effectiveness, and risk.Methods: This study involved a retrospective case review of medical records of ten patients undergoing a variety of cardiac surgery procedures and who developed life-threatening bleeding during surgery or after surgery despite conventional medical therapy, including transfusion of blood and blood products, and received rFVIIa at a regional center between August 2007 and April 2009.Results: All ten patients received two consecutive doses of rFVIIa (average dose 65 µg/kg) at a 2-hour interval. Eight patients were re-explored due to massive postoperative bleeding or cardiac tamponade before receiving rFVIIa. Surgical sources of bleeding were not identified in any cases. A second re-exploration was carried out in two cases. Two patients (20%) died in ITU from problems not related to bleeding and thromboembolism. Blood loss was significantly reduced after administration of rFVIIa. Blood loss 6 hours prior to treatment was 1758.5 ± 163.9 mL and blood loss in the 6-hour period post treatment was 405.6 ± 50.5 mL (P < 0.05). Blood and blood products used in the 6-hour period before and after administration of rFVIIa were 19.6 ± 1.5U and 4.4 ± 0.6U, respectively (P < 0.05). No adverse reactions or thrombotic complications related to rFVIIa were noted.Conclusion: In our limited study, use of rFVIIa in refractory post surgical bleeding was significantly reduced blood loss and use of blood and blood products. We concluded that rFVIIa can be used satisfactorily and safely as a rescue therapy in the management of post cardiac surgical bleeding.Keywords: cardiopulmonary bypass, CPB, refractory bleeding, rFVIIa

Currently no reports are available from Egypt regarding occupational exposure to nickel and its effects on the liver. The aim of this study was to assess the liver function of workers occupationally exposed to nickel. Standard liver function tests were applied to blood samples from 25 nickel-plating workers in Damietta, Egypt and 30 administrative workers as a reference group. Levels of urine nickel, measured by inductively coupling plasma-emission spectroscopy, were significantly higher in nickel-exposed workers compared with the reference group. The levels of alanine aminotransferase and aspartate aminotransferase were significantly higher in nickel-exposed workers. The level of serum albumin was significantly negatively correlated and the levels of serum aminotransferases, and serum gamma-glutamyl-transpeptidase were significantly positively correlated with urine nickel levels. Liver function is compromised in nickel-plating workers compared with non-exposed administrative workers. [ABSTRACT FROM AUTHOR]

Objective: Because of increasing life expectancy, more patients require valve replacement for aortic stenosis. We aimed to determine perioperative and long-term outcomes, the factors associated with these and whether they have changed over time., Methods: We undertook a retrospective cohort study of all 4124 patients, who underwent isolated, primary aortic valve replacement in Scotland between April 1996 and March 2009 inclusive., Results: Annual operations increased by 68%, from 261 to 439. The overall risk of dying within 30 days, 5 years and 10 years was 3.4%, 19.9% and 38.5%, respectively. Over 10 years' follow-up, 4.4% underwent further valve surgery, 7.9% suffered a stroke and 5.3% a myocardial infarction. Age, renal impairment and urgency were predictors of both perioperative and long-term death. Perioperative death was associated with left-ventricular impairment and long-term death with respiratory disease, diabetes and deprivation. Over the 13 years, there was an increase in median age (from 66 to 69 years, p < 0.001), diabetes (from 1.9% to 12.6%, p < 0.001), hypertension (from 26.4% to 56.1%, p < 0.001), cerebrovascular disease (from 3.7% to 9.8%, p < 0.001), respiratory disease (from 6.6% to 9.7%, p = 0.020) and previous myocardial infarction (from 0.6% to 5.8%, p < 0.001), but the risk of perioperative death fell from 6.5% to 3.1% (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83, 0.92, p < 0.001) per year., Conclusions: Patients undergoing aortic valve replacement have a poor risk profile. Over time, their numbers, age and co-morbidity have increased. In spite of these, there has been a significant reduction in the risk of perioperative death., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu syndrome) is an autosomal dominant condition which usually presents with recurrent epistaxis, due to the presence of mucocutaneous telangiectasia, and circulatory arteriovenous malformations (pulmonary, hepatic, cerebral and spinal). We present a patient with HHT and coronary artery disease, who underwent coronary artery bypass grafting with a successful outcome.

Lower gastrointestinal hemorrhage often produces diagnostic difficulty in children. Endoscopy, radionuclide scans, computed tomography/magnetic resonance angiography, and conventional angiography have been the usual armamentarium for locating the site of bleeding. In recent times, laparoscopy has offered an effective tool for diagnosing various intra-abdominal, especially extraluminal, pathologies elusive to other modalities of diagnosis. In this paper, we present a case of massive hemorrhage from an ileal duplication cyst in a 10-year-old Saudi boy diagnosed and treated by laparoscopy. We believe this is the first such reported case from the Kingdom of Saudi Arabia.

The neutrophil/lymphocyte (N/L) ratio integrates information on the inflammatory milieu and physiologic stress. It is an emerging marker of prognosis in patients with cardiovascular disease. We investigated the relation between the N/L ratio and postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting. In a prospective cohort study, 275 patients undergoing nonemergency coronary artery bypass grafting were recruited. Patients with previous atrial arrhythmia or requiring concomitant valve surgery were excluded. The N/L ratio was determined preoperatively and on postoperative day 2. The study end point was AF lasting >30 seconds. Patients who developed AF (n = 107, 39%) had had a greater preoperative N/L ratio (median 3.0 vs 2.4, p = 0.001), but no differences were found in the other white blood cell parameters or C-reactive protein. The postoperative N/L ratio was greater in patients with AF (day 2, median 9.2 vs 7.2, p <0.001), and in multivariate models, a greater postoperative N/L ratio was independently associated with a greater incidence of AF (odds ratio 1.10 per unit increase, p = 0.003: odds ratio for N/L ratio >10.14 [optimal postoperative cutoff in our cohort], 2.83 per unit, p <0.001). Elevated pre- and postoperative N/L ratios were associated with an increased occurrence of AF after coronary artery bypass grafting. In conclusion, these results support an inflammatory etiology in postoperative AF but suggest that other factors are also important., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a powerful predictor of cardiovascular outcome in many circumstances. There are, however, limited data regarding the utility of NT-proBNP or BNP levels in patients undergoing cardiac surgery. The current study assesses the ability of NT-proBNP to predict early outcome in this setting., Methods: One thousand and ten patients undergoing non-emergent cardiac surgery were recruited prospectively. Baseline clinical details were obtained and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet score were calculated. Preoperative NT-proBNP levels were measured using the Roche Elecsys assay. The primary endpoint was 30 day mortality., Results: Median NT-proBNP levels were 624 ng litre(-1) among patients who died within 30 days of surgery (n=29), compared with 279 ng litre(-1) in survivors [odds ratio (OR) 1.03 per 250 ng litre(-1), 95% confidence interval 1.01-1.05, P=0.001). NT-proBNP levels remained predictors of 30 day mortality in models including either the additive EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.01), the logistic EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.004), or the Parsonnet score (OR 1.02 per 250 ng litre(-1), P=0.04). Levels of NT-proBNP were also predictors of prolonged (>1 day) stay in the intensive care unit (OR 1.03 per 250 ng litre(-1), P<0.001) and of a hospital stay >1 week (OR 1.07 per 250 ng litre(-1), P<0.001). They remained predictive of these outcomes in regression models that included either the EuroSCORE or the Parsonnet score and in a model that included all study variables., Conclusions: NT-proBNP levels predict early outcome after cardiac surgery. Their prognostic utility is modest-but is independent of traditional indicators and conventional risk prediction scores.

Background: Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG). We prospectively compared the ability of echocardiographic parameters and the cardiac neurohormones, brain natriuretic peptide (BNP), and N-terminal pro-brain natriuretic peptide (NT-proBNP) to predict AF in this setting., Methods: We recruited 275 patients undergoing nonemergency CABG. Patients undergoing valve surgery or with prior atrial dysrhythmia (based on clinical history and review of medical records) were excluded. Echocardiography was performed, and natriuretic peptide levels were measured, 24 hours before surgery. The primary end point was postoperative AF lasting >30 seconds., Results: The only significant echocardiographic predictors of postoperative AF (n = 107, 39%) were the transmitral E to A-wave ratio and the early mitral annulus velocity. Levels of BNP and NT-proBNP were higher in patients who developed AF. Both natriuretic peptides, but none of the echocardiographic parameters, remained independently predictive in multivariable analysis. The optimum cut points for predicting AF were 31 pg/mL for BNP (odds ratio [OR] 2.74, P = .001) and 74 pg/mL for NT-proBNP (OR 2.74, P = .003)., Conclusion: Levels of BNP and NT-proBNP are independent, though modestly effective, predictors of AF after isolated CABG. In contrast, none of the echocardiographic parameters assessed, including measures of LV systolic function and filling pressure, were independently predictive.

Objective: Elevated uric acid levels have been associated with an adverse cardiovascular outcome in several settings. Their utility in patients undergoing surgical revascularization has not, however, been assessed. We hypothesized that serum uric acid levels would predict the outcome of patients undergoing coronary artery bypass grafting., Methods: The study cohort consisted of 1140 consecutive patients undergoing nonemergency coronary artery bypass grafting. Clinical details were obtained prospectively, and serum uric acid was measured a median of 1 day before surgery. The primary end point was all-cause mortality., Results: During a median of 4.5 years, 126 patients (11%) died. Mean (+/- standard deviation) uric acid levels were 390 +/- 131 micromol/L in patients who died versus 353 +/- 86 micromol/L among survivors (hazard ratio 1.48 per 100 micromol/L; 95% confidence interval, 1.25-1.74; P < .001). The excess risk associated with an elevated uric acid was particularly evident among patients in the upper quartile (>or=410 micromol/L; hazard ratio vs all other quartiles combined 2.18; 95% confidence interval, 1.53-3.11; P < .001). After adjusting for other potential prognostic variables, including the European System for Cardiac Operative Risk Evaluation, uric acid remained predictive of outcome., Conclusion: Increasing levels of uric acid are associated with poorer survival after coronary artery bypass grafting. Their prognostic utility is independent of other recognized risk factors, including the European System for Cardiac Operative Risk Evaluation.

Background: The prognostic importance of renal function in patients undergoing surgery for valvular heart disease is poorly defined. The current study addresses this issue., Methods: Baseline demographic and clinical variables, including the European system for cardiac operative risk evaluation (EuroSCORE), were recorded prospectively from 514 consecutive patients undergoing heart valve surgery between April 2000 and March 2004. Patients with active infective endocarditis and/or requiring emergency surgery were excluded. The glomerular filtration rate was estimated (eGFR) using the Modification of Diet in Renal Disease equation. The primary outcome was all-cause mortality., Results: During a median follow-up of 2 years, 87 patients died. In univariable analysis, both eGFR (hazard ratio [HR] 0.69 per 10 mL/min per 1.73 m2, P<.001) and creatinine (HR 1.04 per 10 micromol/L, P<.001) predicted mortality. Estimated GFR was a stronger predictor and was used in subsequent multivariable models. It remained a powerful independent predictor of death in a multivariable model including all study variables (HR 0.70 per 10 mL/min per 1.73 m2 increase, P<.001) and in a model including EuroSCORE (HR 0.64 per 10 mL/min per 1.73 m2 increase, P<.001). After correction for preoperative EuroSCORE, an eGFR of <60 mL/min per 1.73 m2 was associated with an excess hazard of death of 2.31 (P=.001)., Conclusion: Renal function, particularly the eGFR, is a powerful predictor of outcome in patients undergoing heart valve surgery. This prognostic utility is independent of other recognized risk factors and the EuroSCORE.

Background: An elevated preoperative white blood cell count has been associated with a worse outcome after coronary artery bypass grafting (CABG). Leukocyte subtypes, and particularly the neutrophil-lymphocyte (N/L) ratio, may however, convey superior prognostic information. We hypothesized that the N/L ratio would predict the outcome of patients undergoing surgical revascularization., Methods: Baseline clinical details were obtained prospectively in 1938 patients undergoing CABG. The differential leukocyte was measured before surgery, and patients were followed-up 3.6 years later. The primary end point was all-cause mortality., Results: The preoperative N/L ratio was a powerful univariable predictor of mortality (hazard ratio [HR] 1.13 per unit, P < .001). In a backward conditional model, including all study variables, it remained a strong predictor (HR 1.09 per unit, P = .004). In a further model, including the European system for cardiac operative risk evaluation, the N/L ratio remained an independent predictor (HR 1.08 per unit, P = .008). Likewise, it was an independent predictor of cardiovascular mortality and predicted death in the subgroup of patients with a normal white blood cell count. This excess hazard was concentrated in patients with an N/L ratio in the upper quartile (>3.36)., Conclusion: An elevated N/L ratio is associated with a poorer survival after CABG. This prognostic utility is independent of other recognized risk factors.

A retrograde ventriculosinus (RVS) shunt is a watertight connection that delivers excess cerebrospinal fluid (CSF) to the superior sagittal sinus (SSS) against the direction of blood flow. This method of CSF shunting utilizes the impact pressure (IP) of the bloodstream in the SSS to maintain the intraventricular pressure (IVP) more than the sinus pressure (SP) regardless of changes in posture or intrathoracic pressure (ITP) and discourages stagnation and clotting of blood at the venous end of the connection. It also utilizes collapse of the internal jugular vein (IJV) in the erect posture to prevent siphonage. During the past 8 years, 50 RVS shunts were successfully implanted using valveless shunting catheters. There were no problems related to incorrect CSF drainage or sinus thrombosis. The results indicated arrest of the hydrocephalic process, normalization of the IVP and proper shunt function.

100 lactic acid bacterial strains isolated from traditional fermented foods (yoghurt, milk cream, sour dough and milk) were screened for bacteriocin production. Twenty six strains producing a nisin-like bacteriocin were selected. Most of these isolates gave only a narrow inhibitory spectrum, although one showed a broad inhibitory spectrum against the indicator strains tested, this strain was determined as Lactococcus lactis. The influence of several parameters on the fermentative production of nisin by Lactococcus lactis was studied. Production of nisin was optimal at 30 degrees C and in the pH range 5.5-6.3. The effect of different sulphur and nitrogen sources on Lactococcus lactis growth and nisin production was studied. Magnesium sulfate and manganese sulfate were found to be the best sulphur sources while triammonium citrate was the best inorganic nitrogen source and meat extract, peptone and yeast extract were the best organic nitrogen source for nisin production.

The lipolytic activities in the supernatant fractions of Bacillus cereus and Bacillus coagulans cultures were investigated. Aeration, agitation, different media, emulsified oils, inoculum size and phase of growth affected lipase production. Aeration was essential for lipase production (air: medium ration 4:1) and produced the highest activity. The lipolytic activity reached a maximum level after incubation for two days with continuous agitation. It was also elevated by the presence of either olive oil or tributyrin and with lesser extent in the presence of castor oil. The enzyme levels were drastically reduced in the presence of animal fat, cotton seed oil, margarine or glycerol. The extracellular lipase enzyme from Bacillus cereus was purified with 46.2% overall recovery thought too steps, an acetone precipitation of the whole supernatant and purification by gel filtration on sephadex G-100. The efficiency of the purification process was evaluated through the polyacrylamide gel electrophoresis. The enzyme has an optimum pH 7.5 at the optimum incubation temperature of 40 degrees C. It is stable and retains its full activity after heating at 40-50 degrees C for 30 min. The activity is lost completely at 80 degrees C.

Three new 5-[(1-benzoylamino)styren-1-yl]-1,3,4-oxadiazoline-2- thiones and nine of their Mannich bases with some primary and secondary amines and three N-hydroxymethyl derivatives are synthesized. Some of the new derivatives were active against the bacteria Escherichia coli.

Some novel sulfonate ester-containing mono-, bi- and tricyclic fused ring systems (IV, Xa,b, XIa,b, XIV and XV) together with their precursors I, II and III were synthesized with a view to evaluating their efficacy as new sulfur-containing fungitoxic agents. The structures of the named compounds were established from elemental and spectral analyses.

The intracellular peptide hydrolase activities of Leuconostoc species were determined using various aminopeptidase, dipeptidase, carboxypeptidase substrates, and casein. The activities were separated by disc gel electrophoresis. All strains had aminopeptidase activity as determined with amino acid ß-napthylamides and dipeptidase. All strains also showed bands or true dipeptidase activities on a large number of dipeptidase.

The cell-wall crude extract from Lactobacillus casei NCDO 151 was partially purified by DEAE-Sephacel chromatography. Three active fractions were eluted. Two major peaks (eluted with 0.05 M and 0.27 M phosphate buffer) were further investigated. Peak I represented enzymatic activity with an optimum temperature of 40 degrees C, an optimum pH of 7.0 and was strongly inhibited by the serine proteinase inhibitor phenylmethylsulfonylfluoride. Peak II represented an enzymatic activity with an optimum temperature of 45 degrees C, an optimum pH of 7.5 and was totally inhibited by p-hydroxymercuribenzoate. None of the enzymes was affected by the metal chelator ethylenediaminetetraacetic acid at a concentration up to 1 x 10(-2).