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R Gerard

Publications and source records attributed to R Gerard.

At least 19 recordsLinked to original sources

Influence of plasminogen activator inhibitor type 1 on choroidal neovascularization.

High levels of the plasminogen activators, but also their inhibitor, plasminogen activator inhibitor 1 (PAI-1), have been documented in neovascularization of severe ocular pathologies such as diabetic retinopathy or age-related macular degeneration (AMD). AMD is the primary cause of irreversible photoreceptors loss, and current therapies are limited. PAI-1 has recently been shown to be essential for tumoral angiogenesis. We report here that deficient PAI-1 expression in mice prevented the development of subretinal choroidal angiogenesis induced by laser photocoagulation. When systemic and local PAI-1 expression was achieved by intravenous injection of a replication-defective adenoviral vector expressing human PAI-1 cDNA, the wild-type pattern of choroidal angiogenesis was restored. These observations demonstrate the proangiogenic activity of PAI-1 not only in tumoral models, but also in choroidal experimental neovascularization sharing similarities with human AMD. They identify therefore PAI-1 as a potential target for therapeutic ocular anti-angiogenic strategies.

Adenoviridae↗

Aerosol gene transfer with inducible nitric oxide synthase reduces hypoxic pulmonary hypertension and pulmonary vascular remodeling in rats.

BACKGROUND: Nitric oxide (NO) is a potent vasodilator with an important role in the regulation of pulmonary vascular tone. The effects of NO synthase (NOS) gene transfer on pulmonary vascular remodeling associated with hypoxic pulmonary hypertension are unknown. METHODS AND RESULTS: We aerosolized 3 x 10(9) pfu of an adenoviral vector containing inducible NOS gene (AdNOS2), constitutive NOS3 gene (AdNOS3), or no transgene (AdRR5) into rat lungs. Exhaled NO levels, monitored with chemiluminescence, were higher in AdNOS2-infected rats than in AdNOS3- and AdRR5-infected rats (at 3 days, 33+/-6 ppb, n=9, versus 17+/-4, n=9, and 6+/-2 ppb, n=3, P:<0.05 for both). Exposure to FIO(2) 0.10 for 7 days increased pulmonary artery pressure from 19+/-4 mm Hg (baseline) to 27+/-1 and 26+/-2 mm Hg in AdNOS3- and AdRR5-infected rats, respectively, but only to 21+/-1 mm Hg in AdNOS2-infected animals (P:<0.05). After 7 days of hypoxia, total pulmonary resistance in AdRR5- and AdNOS3-infected rats was significantly higher than in AdNOS2-infected animals (0.41+/-0.05 and 0.39+/-0.07 versus 0.35+/-0. 03 mm Hg. mL(-)(1). min(-)(1), respectively, P:<0.05). Right ventricular hypertrophy was reduced in AdNOS2-infected rats [right ventricular/(left ventricular+septal) weight, 0.19+/-0.10 versus 0. 28+/-0.10 and 0.32+/-0.10 in AdRR5- and AdNOS3-infected rats, respectively, P:<0.05]. The percentage of muscularized precapillary pulmonary resistance vessels was also significantly decreased (18+/-4% versus 25+/-8% and 30+/-5% in AdRR5- and AdNOS3-infected rats, P:<0.05). CONCLUSIONS: Aerosol NOS2 gene transfer increases pulmonary NO production and significantly reduces hypoxic pulmonary hypertension and pulmonary vascular remodeling. Aerosol NOS2 gene transfer may be a promising strategy to target pulmonary vascular disorders.

Aerosols↗

A reply

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Journal Article↗

Human endothelial nitric oxide synthase gene transfer inhibits vascular smooth muscle cell proliferation and neointima formation after balloon injury in rats.

BACKGROUND: Loss of endothelial NO production after arterial injury may contribute to restenosis, characterized by neointima formation and elastic recoil. Adenovirus-mediated transfer of the gene encoding NO synthase (NOS) in balloon-injured arteries may restore NO production and inhibit neointima formation. METHODS AND RESULTS: After balloon injury, rat carotid arteries were transduced with 3x10(10) pfu/mL recombinant adenovirus carrying the human endothelial constitutive NOS cDNA (AdCMVceNOS, n=8) or no cDNA (AdRR5, n=8). ceNOS expression was confirmed by immunoblot analysis of vascular extracts and was localized by immunostaining in 30% of medial smooth muscle cells (SMCs) and in the adventitia of AdCMVceNOS-transduced arteries. Vascular cGMP levels were reduced from 3.9 pmol/g wet wt in uninjured arteries to 0.7 pmol cGMP/g after AdRR5 but were restored after ceNOS gene transfer (3.8 pmol cGMP/g wet wt, P<.05 versus AdRR5). Intima-to-media ratio 2 weeks after injury was significantly reduced (0.19+/-0.02 in AdCMVceNOS-infected versus 0.69+/-0.07 in AdRR5-infected arteries, P<.05). In vitro, BrdU incorporation of AdCMVceNOS-infected SMCs was reduced by 28% compared with AdRR5-infected SMCs. Transduced cells from injured carotid arteries subjected to FACS sorting showed a significantly lower BrdU labeling index in ceNOS-infected rats (29+/-6% versus 43+/-5% and 45+/-4% in control, injured, and AdRR5-infected rats, respectively, P<.05). CONCLUSIONS: AdCMVceNOS gene transfer to balloon-injured rat carotid arteries restores vascular NO production and reduces neointima formation, at least in part because of an antiproliferative effect on medial SMCs. Adenovirus-mediated ceNOS gene transfer might reduce arterial restenosis after balloon angioplasty.

Adenoviridae↗

Insights in vessel development and vascular disorders using targeted inactivation and transfer of vascular endothelial growth factor, the tissue factor receptor, and the plasminogen system.

VEGF has been proposed to participate in normal and pathological vessel formation. Surprisingly, lack of only a single VEGF allele resulted in embryonic lethality due to abnormal formation of intra- and extra-embryonic vessels. Homozygous VEGF-deficient embryos, generated by tetraploid aggregation, revealed an even more severe defect in vessel formation. These results (1) suggest a tight regulation of early vessel development by VEGF and, indirectly, the presence of other VEGF-like molecules; (2) reveal an unprecedented lethal phenotype associated with heterozygous deficiency of an autosomal gene, and (3) demonstrate that tetraploid aggregation was a valid and the only method to study the phenotype of the homozyogous VEGF-deficient embryos. The dominant and strict dose-dependent role of VEGF in vivo renders this molecule a desirable therapeutic target for promoting or preventing angiogenesis. Tissue factor (TF) is the principal cellular initiator of coagulation and its deregulated expression has been related to thrombogenesis in sepsis, cancer, and inflammation. However, TF appears to be also involved in a variety of non-hemostatic functions including inflammation, cancer, brain function, immune response, and tumor-associated angiogenesis. Surprisingly, TF deficiency resulted in embryonic lethality due to abnormal extra-embryonic vessel development and defective vitelloembryonic circulation. The abnormal yolk sac vasculature is reminiscent of that observed in embryos lacking VEGF, possibly suggesting that both gene functions are interconnected. These targeting studies extend the recently documented role of TF in tumor-associated angiogenesis and warrant further study of its role in angiogenesis during other pathological disorders. The plasminogen system, via its triggers, tissue-type plasminogen activator (t-PA) and urokinase-type plasminogen activator (u-PA) and its inhibitor, plasminogen activator inhibitor-1 (PAI-1), has been implicated in thrombosis, arterial neointima formation, and atherosclerosis. Studies in mice with targeted gene inactivation of t-PA, u-PA, PAI-1, the urokinase receptor (u-PAR), and plasminogen (Plg) revealed (1) that deficiency of t-PA or u-PA increase the susceptibility to thrombosis associated with inflammation and that combined deficiency of t-PA:u-PA or deficiency of Plg induces severe spontaneous thrombosis; (2) that vascular injury-induced neointima formation is reduced in mice lacking u-PA-mediated plasmin proteolysis, unaltered in t-PA- or u-PAR-deficient mice and accelerated in PAI-1-deficient mice, but that it can be reverted by adenoviral PAI-1 gene transfer; and (3) that atherosclerosis in mice doubly deficient in apolipoprotein E (apoE) and PAI-1 is reduced after 10 weeks of cholesterol-rich diet. Thus, the plasminogen system significantly affects thrombosis, restenosis, and atherosclerosis.

Animals↗

Incidence of perforation and other mechanical complications during dual active fixation.

The intraoperative and early postoperative mechanical complications of a procedure combining an atrial screw-in lead and a ventricular screw-in lead insertion were prospectively evaluated. The procedure was performed in 119 consecutive patients (mean age 69 +/- 8 years), at first implant in 100 patients and at reoperation in 19. Nine patients had previously undergone cardiac surgery and three underwent transvenous ventricular defibrillator implantation. The double sets of leads were introduced through 2 separate veins in 5 cases, through a single venous route in 114 cases, using a percutaneous approach in 75 cases and a venous cutdown in 49, and a guidewire procedure following the venotomy in 19. The screw was mannitol coated in 102 cases, exposed in 111, and extendable/retractable in 25. The fixation of the ventricular lead was performed at the apex in 108 cases, at the outflow tract in 11, and was followed by the fixation of the atrial lead at the appendage in 112 cases and at the lateral wall in 7 cases. The lead positioning and fixation were successful at first attempt in 103 cases and after repeated lead manipulation in 19 cases. The rotational torque could be transferred to the helix in all cases except in one patient who required a second vein puncture. Unintentional fixation in the ventricular chamber with subsequent failure to remove the lead occurred in one patient. Reoperation for lead dislodgment was required in two patients. In one patient, symptomatic pericarditis with pericardial effusion was observed 1 day after the procedure and resolved spontaneously. Dual active fixation is feasible with a low incidence of mechanical complications.

Aged↗

[Fulminant or sub-fulminant hepatocellular failure caused by metastatic invasiveness of the liver: an other cause of hypoxic hepatitis?].

OBJECTIVES: The purpose of this retrospective study was to report a series of 9 new cases of fulminant hepatic failure due to metastatic liver disease and to identify signs to support a theory of hypoxia. METHODS: In these 9 cases and in 38 previously published cases of fulminant or subfulminant liver failure, we looked for clinical (shock, sepsis, and cutaneous signs of circulatory failure), laboratory (marked increase in serum aminotransferases levels) and histological (cell necrosis) parameters compatible with liver hypoxia. RESULTS: Cutaneous signs of circulatory failure or shock were observed in 3 of the 9 cases in this study, and were not due to cardiogenic or septic shock. A marked increase in serum aminotransferases levels, 10 times above the upper limit of normal, was observed in 8 of the 9 cases in the present study and in 23 of 37 cases of the literature. Liver cell necrosis was observed in 6 of the 7 autopsied patients in this series and in 20 of 34 cases in the literature. Generally, liver cell necrosis was more severe than tumor cell necrosis and was related to the degree of sinusoidal involvement by tumoral cells. In one case, hepatic blood flow was decreased despite a high level of cardiac blood flow suggesting impairment of circulation in the liver. CONCLUSIONS: These 9 cases and a review of the literature support the hypothesis of hypoxic liver cell necrosis leading to acute liver failure in cases of metastatic liver disease. However, liver hypoxia cannot explain all the reported cases and was never due to circulatory failure from cardiac or septic causes, but to the sinusoidal involvement by tumor cells.

Adult↗

Compensation in a patient focused environment. The past, present and future of reward systems.

What have you done with compensation? It's the question asked of every healthcare organization in the midst of restructuring and work redesign. The prescription at the outset of these dramatic change programs was often for a heavy dose of compensation overhaul. But the reality has often been far less dramatic. A group of PFCA Executive Members, led by executives Mike Speer and Roger Gerard from United Health Group of Appleton, Wisconsin, were not content that the best thinking had been applied to culling out successful compensation improvements and with finding breakthrough redesign options. The group has completed the first of its brainstorming sessions in search of new approaches and offers these initial thoughts to the PFCA REVIEW readership.

Guidelines as Topic↗

Compensation in a restructured environment. Part II: The past, present, and future of reward systems.

The participants in the HR Consortium walked away satisfied that they had left "no stones unturned" in their efforts to create new compensation approaches. The major takeaway was that there is no ready panacea. The creation of an effective compensation system will be the development of an approach that does not serve as an obstacle to staff and managers in their efforts to build a hospital system that services customers in a restructured setting; rather it shadows and supports these operational changes.

Employee Incentive Plans↗

[Intravenous and oral propafenone in the treatment and prevention of paroxysmal atrial fibrillation].

The efficacy of propafenone in the treatment of paroxysmal atrial fibrillation was investigated in 16 patients presenting with frequent and/or poorly tolerated paroxysmal atrial fibrillation despite prophylactic treatment in 13 patients. Prolonged atrial fibrillation (> 10 minutes) was triggered in 16 patients following a standard atrial stimulation protocol. Intravenous injection of propafenone (2 mg/kg over 5 minutes) restored sinus rhythm in 12 patients (75%) within 15 minutes after the end of the injection. In five of the 10 patients in whom this was possible, propafenone prevented the induction of atrial fibrillation in response to programmed stimulation by the same protocol. Oral propafenone (900 mg/24 hours) was indicated in 11 patients. The treatment was discontinued in 1 patient due to severe dizziness. Atrial fibrillation recurred in 4 patients 10 to 91 days after treatment began. With a mean follow-up time of 8 months, 4 patients had been brought under control and 2 had relapsed despite a generally beneficial effect. Three patients suffered side effects which did not make it necessary to stop treatment. This study suggests that intravenous propafenone is effective against persistent atrial fibrillation induced by stimulation. Oral propafenone may be useful for the prevention of attacks of recalcitrant paroxysmal atrial fibrillation.

Administration, Oral↗

Preparing a multi-skilled work force for the 21st century hospital.

The health care industry is facing the need to produce ever-improving quality at reduced cost to the consumer. One strategy is to re-train health care employees to have multiple competencies and skills. This article details the multi-competency effort at Northern Michigan Hospitals, and highlights some of the benefits and drawbacks of its approach.

Forecasting↗

[Post-traumatic fistula of the left anterior descending coronary artery and left ventricle. Apropos of a new case].

The authors report the case of a 23 year old man who presented with a continuous murmur five years after closed chest trauma. The electrocardiographic and echocardiographic findings indicated previous apical myocardial infarction. The underlying diagnosis was first suggested by continuous wave Doppler which showed systolo-diastolic flow in the septo-apical region directed towards the left ventricle (LV) in diastole. Color Doppler flow studies showed a mosaic pattern opposite a dilated left anterior descending (LAD) artery. These signs of LAD-LV fistula with a single orific were confirmed at coronary arteriography. The patient's previous history was in favour of a traumatic etiology. In the absence of left ventricular failure and myocardial ischaemia by coronary steal, surgery was deferred; Doppler echocardiography would seem to be a good method of following up the fistula and its consequences on left ventricular function. A traumatic left coronary to left ventricular fistula is an extremely rare condition and merits publication. The authors review the literature and describe the physiopathology, diagnosis and therapeutic indications of these fistulae.

Adult↗

[Wolff-Parkinson-White syndrome. Value of intravenous flecainide for detecting Kent's pathways with short refractory period].

The aim of this study was to assess the value of a non-invasive test in detecting accessory pathways with short anterograde effective refractory periods (AERP) (less than or equal to 270 ms) in patients with the Wolff-Parkinson-White syndrome. An intravenous injection of Flecainide acetate was administered to 19 consecutive patients referred for electrophysiological investigation of a WPW syndrome with permanent pre-excitation of the surface electrocardiogram. The first 8 patients (Group I) received a dose of 1.5 mg/kg over 5 minutes and the following 11 patients (Group II) were given 2 mg/kg in 5 minutes. In Group I, preexcitation disappeared in 3 patients (37.5%) who all had accessory pathways with AERP greater than 270 ms. It persisted in the other 5 patients (62.5%) of whom 4 had AERP less than or equal to 270 ms and 1 an AERP greater than 270 ms (false negative). In Group II, preexcitation disappeared in 8 patients (72.2%) of whom 4 had AERP greater than 270 ms and 4 had AERP less than 270 ms (false positives). Preexcitation persisted in the 3 other patients (27.3%); the AERP was less than or equal to 270 ms in 2 patients and greater than 270 ms in the other patients. These results suggest that intravenous Flecainide acetate at the dose of 1.5 mg/kg could be useful in differentiating WPW syndromes with long refractory periods (greater than 270 ms) from those with short refractory periods (less than or equal to 270 ms) with a satisfactory sensitivity and specificity, and that further studies on larger numbers of patients are required to confirm this hypothesis.

Adolescent↗

The single-chain form of tissue-type plasminogen activator has catalytic activity: studies with a mutant enzyme that lacks the cleavage site.

Tissue-type plasminogen activator (t-PA), the serine protease responsible for catalyzing the production of plasmin from plasminogen at the site of blood clots, is synthesized as a single-chain polypeptide precursor. Proteolytic cleavage at the C-terminal side of Arg275 generates a two-chain form of the enzyme whose subunits are held together by a single disulfide bond. We have measured the activities of both forms of the wild-type enzyme, as well as that of a mutant enzyme (Arg275----Gly), created by oligonucleotide-directed mutagenesis, that cannot be cleaved into a two-chain form. Both types of single-chain t-PAs are enzymatically active and exhibit identical Vmax and Km values when assayed with synthetic peptide substrates, indicating that the single amino acid change had no effect on the amidolytic activity of the enzyme. However, cleavage of wild-type t-PA into the two-chain form results in increased activity both on a peptide substrate and on the natural substrates Lys- and Glu-plasminogen in the absence or presence of stimulation by soluble fibrin. The enhanced activity is due to a 3-5-fold increase in the Vmax of the cleaved enzyme, rather than to any change in the Km values for the various substrates. During incubation with plasminogen, the single-chain form of wild-type t-PA is converted to the two-chain form by plasmin generated during the reaction. This conversion, from the less active form of the enzyme, results in a reaction that displays biphasic kinetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Amino Acid Sequence↗

[Atrioventricular block, a complication of radiotherapy of the mediastinum].

Cardiac complications of mediastinal irradiation usually concern the pericardium, the ventricular myocardium and the coronary arteries. We report the case of a 42-year old woman who experienced a syncopal atrioventricular (AV) block 12 years after irradiation of a mediastinal Hodgkin's lymphoma. Electrophysiological recordings showed infranodal conduction disturbances. A review of the literature yielded only 12 cases of syncopal radiation-induced AV block. This case highlights the risk of syncopal AV blocks occurring a long time after mediastinal irradiation and leading to severe damage of the His bundle and its branches. The presence, as in our patient, of an associated right ventricular outflow tract stenosis confirms the importance and severity of radiation-induced cardiac lesions.

Adult↗

[Cardioversion by internal electric shock of permanent atrial fibrillation].

A new technique for cardioversion of chronic atrial fibrillation was used in 17 patients whose arrhythmia had resisted all attempts at electrical and pharmacologycal cardioversion. Atrial fibrillation was badly tolerated by all patients despite digitalis administered alone (8 patients) or combined with amiodarone (9 patients). Twelve patients had left atrial dilatation at echocardiography. The 200, 300 or 400 joule electrical shock was delivered between the proximal pole of a quadripolar catheter (cathode) and a back plate (anode). The catheter was positioned at the His bundle recording site then withdrawn into the right atrium. The internal shock restored sinus rhythm in 15 patients (88 p. 100). Transient atrioventricular block (3-315 sec) was observed in 8 patients. Eleven patients were discharged in sinus rhythm. In 4 patients, the atrial fibrillation recurred on day 8 and after 2, 4 and 9 months. A second shock was attempted in two patients and succeeded in one. After a mean follow-up period of 14.8 +/- 8 months (range 2 to 25 months), 8 of the 11 patients successfully cardioverted (72 p. 100) or of the attempted reductions (47 p. 100) were in sinus rhythm. The remaining 9 patients were treated with antiarrhythmic drugs (n = 5) or by his bundle catheter ablation (n = 4). High energy internal shock therefore seems to be an interesting treatment in patients with permanent atrial fibrillation after failure of external electric shock. It enabled 13 of the 17 patients in this series to avoid His bundle catheter ablation indicated by the quasi-impossibility to control the atrial rate and associated symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Asymptomatic form of left pulmonary artery sling.

Eight patients with left pulmonary artery sling, which were asymptomatic at the time of the last consultation, are described: 2 adults and 1 child with no history of symptoms, 3 children with mild forms of airways obstruction and 2 patients with typical severe symptoms of airways obstruction in infancy. The mean follow-up of these 8 patients was 10 years (range 4 to 23), and in 1986, all were in good health and free of respiratory symptoms. The long-term prognosis is usually good.

Airway Obstruction↗