Cohort survey of heart valve replacement patients: does the valve card scheme have room for improvement?
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Cohort Studies↗
Biomedical subjects
K M Taylor
Publications and source records attributed to K M Taylor.
Comparison of operative mortality after coronary artery bypass grafting in Indian subcontinent Asians versus Caucasians.
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Aged↗
The influence of incubation temperature and surfactant concentration on the interaction between dimyristoylphosphatidylcholine liposomes and poloxamer surfactants.
Differential scanning calorimetry and photon correlation spectroscopy have been used to study the interaction between poloxamers P338 and P407 and dimyristoylphosphatidylcholine (DMPC) liposomes. The extent of the interaction was found to be dependent on the incubation temperature in addition to the poloxamer concentration. At low poloxamer concentrations (0.1-1.0% w/v) an interaction with the phospholipid bilayer was detected by a reduction of the pre-transition enthalpy of DMPC. At higher concentrations (2.0-5.0% w/v), the main phase transition temperature of the liposomes decreased and the endotherm broadened with a shoulder on the high temperature side, indicative of phase separation. Maximum increases in the diameter of small freeze-thaw extruded liposomes were shown to occur at temperatures close to the poloxamer critical micelle temperatures. At higher temperatures and surfactant concentrations there was evidence of solubilization of phospholipid into mixed micelles.
Calorimetry, Differential Scanning↗
Conformational stability of collagen relies on a stereoelectronic effect.
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Animals↗
The measurement of beclomethasone dipropionate entrapment in liposomes: a comparison of a microscope and an HPLC method.
The purpose of this study was to examine the methodologies that may be used to estimate the maximum incorporation (<5 mole% drug) of beclomethasone dipropionate (BDP) in dipalmitoylphosphatidylcholine (DPPC) multilamellar liposomes. Two approaches are described. First, differential interference contrast (DIC) microscopy and cross-polarisation microscopy have been used to measure the concentration at which BDP crystals become apparent in BDP-containing liposome preparations, thereby allowing a semi-quantitative but simple estimation of entrapment. An alternative method is described whereby the unentrapped solid drug is separated from the liposomes via suspension in D2O, followed by centrifugation and HPLC analysis. The method resulted in an estimate of 1.5-2 mole% BDP, while the HPLC method yielded a value of 2.52 mole% BDP.
1,2-Dipalmitoylphosphatidylcholine↗
The antithrombotic and antiinflammatory mechanisms of action of aprotinin.
Aprotinin (Trasylol) is generally regarded to be an effective hemostatic agent that prevents blood loss and preserves platelet function during cardiac surgery procedures requiring cardiopulmonary bypass (CBP). However, its clinical use has been limited by the concern that such a potent hemostatic agent might be prothrombotic, particularly in relation to coronary vein graft occlusion. In this review we present a mechanism of action that challenges such a viewpoint and explains how aprotinin can be simultaneously hemostatic and antithrombotic. Aprotinin achieves these two apparently disparate properties by selectively blocking the proteolytically activated thrombin receptor on platelets, the protease-activated receptor 1 (PAR1), while leaving other mechanisms of platelet aggregation unaffected. We also review recent research leading to the discovery of novel antiinflammatory targets for aprotinin. A better understanding of its mechanisms of action has led to the conclusion that aprotinin is a remarkable drug with the capacity to correct many of the imbalances that develop in the coagulation system and the inflammatory system after CPB. Nonetheless, it has been clinically underused for fear of causing thrombotic complications, a fear that in light of recent evidence may be unfounded.
Animals↗
New antiinflammatory and platelet-preserving effects of aprotinin.
The clinical benefit of aprotinin with respect to improved hemostasis, platelet function, and inflammatory response to cardiopulmonary bypass (CPB) surgery has been well documented, but these benefits have been overshadowed by the concern that such a potently hemostatic agent might also be prothrombotic. In this article, we discuss recent advances in the understanding of the basic mechanism of aprotinin that have led to the identification of new antiinflammatory targets and the discovery that aprotinin is, in fact, antithrombotic with respect to platelets. Its antithrombotic action is mediated by the selective blocking of the major thrombin receptor, the protease-activated receptor 1 (PAR1), but not other receptors of platelet activation (ie, collagen, adenosine diphosphate [ADP], or epinephrine receptors). The selective targeting of PAR1 enables aprotinin to protect platelets from unwanted activation by thrombin generated during CPB surgery (consistent with a role in platelet-preservation), while permitting the participation of platelets in the formation of hemostatic plugs at wound and suture sites, where collagen, ADP, and epinephrine are most likely to be expressed. Aprotinin therefore exerts a subtle hemostatic yet antithrombotic mechanism of action, which, when allied with its multitiered antiinflammatory effect, makes this drug a valuable companion to cardiac surgery.
Anti-Inflammatory Agents↗
Oncologists' use of quality of life information: results of a survey of Eastern Cooperative Oncology Group physicians.
PURPOSE: Objectives of this study were to obtain data from Eastern Cooperative Oncology Group (ECOG) oncologists regarding their views on quality of life (QOL) information; perform psychometric testing on the MD-QOL questionnaire, develop a model to describe oncologists' willingness to use QOL information and propose data-based interventions to facilitate use of QOL information in clinical decision-making. METHODS: A self-administered questionnaire, MD-QOL, designed to assess physician perspective on QOL information was mailed to a random sample of 500 oncologists, members of ECOG; 271 responded. RESULTS: Oncologists' attitude, current behaviour, knowledge of QOL data, and reported willingness to use QOL can be measured using MD-QOL. The attitude, behaviour and willingness scales have high internal consistency. Physician attitude and behaviour account for 59% of the variance in the willingness to use QOL information. Demographic variables influencing physician responses were their primary income source and exposure to trials with a QOL component. CONCLUSIONS: This report of ECOG oncologists' views on QOL information suggests a model to describe relationship between physician willingness to use QOL information on the basis of their attitude and behaviour. Data-based interventions are proposed to influence the key variables and thus facilitate the incorporation of QOL data in clinical practice.
Analysis of Variance↗
Patterns of failure with increasing intensification of induction chemotherapy for acute myeloid leukaemia.
Patterns of failure were studied in two consecutive randomized trials of intensified induction therapy carried out by the Australian Leukaemia Study Group (ALSG) between 1984 and 1991 to determine the impact of dose intensification. Patients received standard dose cytarabine and daunorubicin (7-3), 7-3 plus etoposide (7-3-7) or 7-3 plus high-dose cytarabine (HIDAC-3-7) chemotherapy. Patients with FAB M3 morphology were excluded. Time to failure (TTF) was defined as the time from randomization to induction death or removal from study for non-responders, or to relapse or death in complete response (CR) for complete responders. An estimated 86% of 470 de novo patients with acute myeloid leukaemia failed within 10 years of randomization, as a result of death in induction in 17% of the randomized patients, failure to achieve CR in a further 17%, relapse in 44% and death in CR in 8% of patients. An estimated 66% of patients failed as a result of refractory disease or relapse within that period (disease-related failures). Multifactor analysis identified age and peripheral blast count as the most significant pretreatment factors associated with overall TTF. These factors, together with cytogenetics, were significantly associated with disease-related failures. High-dose cytarabine in induction significantly decreased the disease-related failure rate as did allogeneic transplantation in first CR. The impact of high-dose cytarabine did not depend on the cytogenetic risk group.
Acute Disease↗
The effect of circuit surface area on CD11b(mac-1) expression in a rat recirculation model.
The aim of the study was to assess the effect of exposed surface area of diethylhexylphthalate plasticized polyvinylchloride (PVC) on the expression of the adhesion molecule CD11b(mac-1) on neutrophils and to determine whether there is any apparent advantage in the current trend in reducing circuit surface area in terms of neutrophil activation. The study was carried out using a parallel plate rodent recirculation biomaterial testing model on 4 groups of 10 adult male Sprague Dawley rats weighing between 350 and 450 g. One group comprised the control group in which there was no biomaterial exposure. In the remaining 3 groups, the animals were subjected to either high (48 cm2), intermediate (24 cm2), or low (12 cm2) biomaterial surface area exposure. The parallel plate test cell was connected to the right femoral circulation and recirculation initiated at a flow rate of 1.5 ml/min for a period of 60 min. Blood samples were taken at 0, 30, and 60 min for the assessment of CD11b expression. Cd11b was assessed using flow cytometric analysis on neutrophils. The results demonstrated that there was a surface area related effect in the upregulation of CD11b. The difference at the terminal sample point between the highest surface area group (293.95 +/- 18.57%) and the low surface area group (133.80 +/- 49.31%) was highly statistically significant (p < 0.001). These results demonstrate that there may be some gain in terms of reduced inflammatory response from reducing the exposed surface area of PVC in extracorporeal perfusion circuits.
Animals↗
Outlet strut fracture of Björk-Shiley convexo-concave valves: can valve-manufacturing characteristics explain the risk?
BACKGROUND: Björk-Shiley 60 degrees convexo-concave prosthetic heart valves (Shiley, Inc, Irvine, Calif, a subsidiary of Pfizer, Inc) continue to be a concern for approximately 35,000 nonexplanted patients worldwide, with approximately 600 events reported to the manufacturer to date. Fractures of the outlet struts of the valves began to appear in the early 1980s and have continued to the present, but their causes are only partially understood. METHODS: A matched case-control study was conducted evaluating manufacturing records for 52 valves with outlet strut fractures and 248 control subjects matched for age at implantation, valve size, and valve position. RESULTS: In addition to the risk factors recognized as determinants of outlet strut fracture, the United Kingdom case-control study has observed 7- to 9-fold increased risk with performance of multiple hook deflection tests. This test was performed more than once, usually after rework on the valve. Six valves in this study underwent multiple hook deflection tests, of which 4 experienced an outlet strut fracture. Cracks and further rework were noted for these valves. Significant associations were also observed between outlet strut fracture and disc-to-strut gap measurements taken before the attachment of the sewing ring. CONCLUSIONS: It is our view that a combination of factors related to valve design, manufacturing process, and patient characteristics are responsible for outlet strut fractures of Björk-Shiley convexo-concave valves. Multiple hook deflection tests have emerged as a potential new risk factor for outlet strut fracture in both The Netherlands and the United Kingdom. This factor appears to be correlated with the presence of other abnormalities. A further study is needed to investigate the factors correlated with multiple hook deflection tests. On confirmation of risk, the presence of multiple hook deflection tests may be added to equations, quantifying the risk of outlet strut fracture for comparison against risk of mortality and serious morbidity from explant operations.
Analysis of Variance↗
Effect of aprotinin on endothelial cell activation.
BACKGROUND: Cardiopulmonary bypass surgery is often accompanied by a systemic inflammatory response, which can lead to postoperative complications in high-risk patients. This is mediated in part through a systemic rise in inflammatory cytokine levels and the sequestration of leukocytes within organs. Aprotinin has previously been shown to exert an anti-inflammatory effect by preventing the capacity of leukocytes to transmigrate through vascular endothelium. Here we have focused on whether aprotinin has an effect on endothelial cell activation and adhesion molecule expression in response to tumor necrosis factor-alpha, particularly with reference to whether aprotinin inhibits tumor necrosis factor-stimulated neutrophil transendothelial migration. METHODS AND RESULTS: Intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin expression was studied in tumor necrosis factor-alpha-activated human umbilical vein endothelial cells in the presence of aprotinin at 200, 800, and 1600 kIU/mL. Aprotinin inhibited tumor necrosis factor-alpha-stimulated expression of intercellular adhesion molecule-1 (P =.019 at 1600 kIU/mL) and vascular cell adhesion molecule-1 (P =.003 at 1600 kIU/mL) but not E-selectin. Similar results were obtained in the dermal microvascular endothelial cell line, HMEC-1, which exhibited diminished intercellular adhesion molecule-1 expression in the presence of aprotinin (P =.040 at 800 kIU/mL and P <.001 at 1600 kIU/mL). Aprotinin also significantly inhibited neutrophil transmigration across tumor necrosis factor-alpha-activated human umbilical vein endothelial cells (P =.046 at 1600 kIU/mL). CONCLUSIONS: We have demonstrated that aprotinin inhibits intercellular adhesion molecule-1 and vascular cell adhesion molecule-1, but not E-selectin, expression on tumor necrosis factor-alpha-activated endothelial cells and that transendothelial migration by neutrophils is also specifically suppressed under these conditions. Our results indicate that endothelial cells can be specifically targeted by aprotinin, therefore adding to our understanding of the anti-inflammatory mechanism of action of aprotinin during cardiopulmonary bypass.
Aprotinin↗
Aprotinin administration in the pericardial cavity does not prevent platelet activation.
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Aprotinin↗
Expression of messenger ribonucleic acids for fibroblast growth factors 7 and 10, hepatocyte growth factor, and insulin-like growth factors and their receptors in the neonatal ovine uterus.
In sheep, uterine development begins during fetal life but is only completed postnatally with proliferation and branching morphogenetic differentiation of the endometrial glandular epithelium (G) from the luminal epithelium (L) between birth or Postnatal Day (PND) 0 and PND 56. In other epithelial-mesenchymal organs, fibroblast growth factor (FGF)-7 and FGF-10, hepatocyte growth factor (HGF), and insulin-like growth factor (IGF)-I and IGF-II play essential roles in ductal branching morphogenesis. Semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) and in situ hybridization analyses were used to study temporal and spatial alterations in expression of mRNAs for growth factors (FGF-7, FGF-10, HGF, IGF-I, IGF-II) and their respective receptors (FGF receptor or FGFR2IIIb, c-met, and IGF-IR) in the developing neonatal ovine uterus. The RT-PCR analyses indicated that expression of FGF-10, HGF, IGF-I, and IGF-II mRNAs increased in the neonatal uterus between PND 1 and 56. In situ hybridization analyses indicated that FGFR2IIIb and c-met mRNAs were expressed solely in uterine L and developing G, whereas IGF-IR was expressed in all uterine cell types, with highest levels in L and developing G. Both IGF-I and IGF-II mRNAs were expressed in the endometrial stroma and myometrium, with IGF-I predominantly in the intercaruncular endometrial stroma. The highest levels of IGF-I and IGF-II mRNA expression were detected in the intercaruncular endometrial stroma surrounding the nascent and proliferating glands. Immunohistochemistry revealed that phosphorylated extracellular regulated kinases-1 and -2 were most abundantly expressed in the nascent and proliferating glands of the developing neonatal uterine wall. These results implicate FGF-7, FGF-10, HGF, IGF-I, IGF-II, and their epithelial receptors in epithelial-mesenchymal interactions regulating endometrial gland morphogenesis in the neonatal sheep uterus.
Animals↗
Endometrial glands are required for preimplantation conceptus elongation and survival.
Endometrial glands secrete molecules hypothesized to support conceptus growth and development. In sheep, endometrial gland morphogenesis occurs postnatally and can be epigenetically ablated by neonatal progestin exposure. The resulting stable adult uterine gland knockout (UGKO) phenotype was used here to test the hypothesis that endometrial glands are required for successful pregnancy. Mature UGKO ewes were bred repeatedly to fertile rams, but no pregnancies were detected by ultrasound on Day 25. Day 7 blastocysts from normal superovulated ewes were then transferred synchronously into Day 7 control or UGKO ewes. Ultrasonography on Days 25-65 postmating indicated that pregnancy was established in control, but not in UGKO ewes. To examine early uterine-embryo interactions, four control and eight UGKO ewes were bred to fertile rams. On Day 14, their uteri were flushed. The uterus of each control ewe contained two filamentous conceptuses of normal length. Uteri from four UGKO ewes contained no conceptus. Uteri of three UGKO ewes contained a single severely growth-retarded tubular conceptus, whereas the remaining ewe contained a single filamentous conceptus. Histological analyses of these uteri revealed that endometrial gland density was directly related to conceptus survival and developmental state. Day 14 UGKO uteri that were devoid of endometrial glands did not support normal conceptus development and contained either no conceptuses or growth-retarded tubular conceptuses. The Day 14 UGKO uterus with moderate gland development contained a filamentous conceptus. Collectively, these results demonstrate that endometrial glands and, by inference, their secretions are required for periimplantation conceptus survival and development.
Animals↗
Interferon regulatory factor-two restricts expression of interferon-stimulated genes to the endometrial stroma and glandular epithelium of the ovine uterus.
Interferon tau (IFNtau) is the signal for maternal recognition of pregnancy in ruminants. The positive effects of IFNtau on IFN-stimulated gene (ISG) expression are mediated by ISG factor 3 (ISGF3), which is composed of signal transducer and activator of transcription (Stat) 1, Stat 2, and IFN regulatory factor-9 (IRF-9), and by gamma-activated factor (GAF), which is a Stat 1 homodimer. Induction of ISGs, such as ISG17 and 2',5'-oligoadenylate synthetase, by IFNtau during pregnancy is limited to the endometrial stroma (S) and glandular epithelium (GE) of the ovine uterus. The IRF-2, a potent transcriptional repressor of ISG expression, is expressed in the luminal epithelium (LE). This study determined effects of the estrous cycle, pregnancy, and IFNtau on expression of Stat 1, Stat 2, IRF-9, IRF-1, and IRF-2 genes in the ovine endometrium. In cyclic ewes, Stat 1, Stat 2, IRF-1, and IRF-9 mRNA and protein were detected at low levels in the S and GE. During pregnancy, expression of these genes increased only in the S and GE. Expression of IRF-2 was detected only in the LE and superficial GE (sGE) of both cyclic and pregnant ewes. In cyclic ewes, intrauterine administration of IFNtau stimulated Stat 1, Stat 2, IRF-9, and IRF-1 expression in the endometrium. Ovine IRF-2 repressed transcriptional activity driven by IFN-stimulated response elements that bind ISGF3, but not by gamma-activation sequences that bind GAF. These results suggest that IRF-2 in the LE and sGE restricts IFNtau induction of ISGs to the S and GE. In the S and GE, IFNtau hyperactivation of ISG expression likely involves formation and actions of the transcription factors ISGF3 and, perhaps, IRF-1.
Animals↗
Outlet strut fracture of Björk-Shiley convexo concave heart valves: the UK cohort study.
OBJECTIVE: To investigate the risk of outlet strut fracture (OSF) in Björk-Shiley convexo concave (BSCC) valves in relation to patients' clinical and valve characteristics. DESIGN: A cohort of 2977 patients with 3325 valves with a follow up of 18 years. SETTING: 38 cardiac implantation centres in the UK. RESULTS: 56 OSF events were reported with 43 occurring in mitral and 13 in aortic valves. The overall OSF rate was 0.17%/year. No dominant clinical factor of risk was found, but multiple regression analysis identified age, body surface area, valve size, shop order fracture rate, and manufacturing period as risk factors for OSF. A 4% (95% confidence interval (CI) 2% to 6%) decrease in the risk of OSF was observed for each advancing year of age and a fivefold (95% CI 2 to 13) increase in risk for a 0.5 m(2) increase in body surface area. The association between the risk of OSF and valve size was not constant over time. Excess risks among 31 mm and 33 mm sizes (mainly mitral valves) decreased over time while that for 23 mm (almost all aortic valves) increased. The risk of OSF increased by 40% (95% CI 20% to 50%) for a unit increase in the fracture rate of other valves in the same batch. For valves manufactured during 1981 to 1984 the risk of OSF was 4 (95% CI 2 to 12) times greater than for valves manufactured before 1981. CONCLUSIONS: The OSF rates for 60 degrees BSCC valves observed in the UK are the highest among all monitored populations. The changing patterns of mitral and aortic valve OSF rates over time observed in this study have not been identified previously and highlight the need for continued monitoring of patients with the BSCC valve.
Adult↗
Leucodepletion during cardiopulmonary bypass reduces blood transfusion and crystalloid requirements.
Cardiopulmonary bypass (CPB) is associated with the production of inflammatory responses, which can have significant influence on prognosis. We studied the effects of leucocyte-depletion filters on inflammatory parameters and early postoperative prognosis during coronary revascularization. Twenty patients undergoing elective coronary revascularization were randomly divided into two groups. Ten patients had leucocyte-depletion filters added to the CPB circuit (treatment group) and 10 were used as control cases (control group). Expression of CD11b on neutrophils, and production of myeloperoxidase and lactoferrin, were measured in arterial samples between induction and 3 h postbypass. In addition, clinical parameters were measured during inpatient recovery. CD11b neutrophil expression, and myeloperoxidase and lactoferrin production, were found to be upregulated during CPB and then to decline to preoperative levels by the third postoperative hour. Blood transfusion requirements were reduced in the treatment group, equalling 1.5 +/- 1.2 units, compared to 2.7 +/- 1.1 units for the control group (p value = 0.034) and so were the volumes of crystalloid infused during the first 24 h postoperatively, equalling 3.9 +/- 1.21 in the treatment group and 3.3 +/- 0.71 in the control group (p value = 0.021). Overall, the application of leucocyte depletion produced an early clinical advantage, underlining the need for an improved understanding and manipulation of the inflammatory response to CPB.
Biomarkers↗