Abstract-Our study aimed to characterize the mechanisms underlying the attenuated cardiovascular responsiveness toward the renin-angiotensin system during sepsis. For this purpose, we determined the effects of experimental Gram-negative and Gram-positive sepsis in rats. We found that sepsis led to a ubiquitous upregulation of NO synthase isoform II expression and to pronounced hypotension. Despite increased plasma renin activity and plasma angiotensin (Ang) II levels, plasma aldosterone concentrations were normal, and the blood pressure response to exogenous Ang II was markedly diminished in septic rats. Mimicking the fall of blood pressure during sepsis by short-term infusion of the NO donor sodium nitroprusside in normal rats did not alter their blood pressure response to exogenous Ang II. Therefore, we considered the possibility of an altered expression of Ang II receptors during sepsis. It turned out that Ang II type 1 receptor expression was markedly downregulated in all organs of septic rats. Further in vitro studies with rat renal mesangial cells showed that NO and a combination of proinflammatory cytokines (interleukin-1␤, tumor necrosis factor-␣, and interferon-␥) downregulated Ang II type 1 receptor expression in a synergistic fashion. In summary, our data suggest that sepsis causes a systemic downregulation of Ang II type 1 receptors that is likely mediated by proinflammatory cytokines and NO. We suggest that this downregulation of Ang II type 1 receptors is the main reason for the attenuated responsiveness of blood pressure and of aldosterone formation to Ang II and, therefore, contributes to the characteristic septic shock. (Hypertension. 2001;38:177-182.)

BackgroundTranscranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination.MethodsFollowing a ‘911 stroke code’ call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care.ResultsWe enrolled ‘232 stroke code’ patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as ‘stroke mimics’. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis ‘any stroke’ showed a sensitivity of 94% and a specificity of 48%. ‘Major MCA or ICA stroke’ diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%.ConclusionsThe study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.

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Allylation of 1‐methyl‐5‐(1′‐methylpent‐2′‐ynyl)barbituric acid (MBS) with allyl acetate using in situ catalysts of palladium(II) acetylacetonate and chiral phosphane imine ligands resulted in the enantioselective formation of 5‐allyl‐1‐methyl‐5‐(1′‐methylpent‐2′‐ynyl)barbituric acid (Methohexital), an important anesthetic drug. Both, MBS and Methohexital contain two stereogenic carbon atoms. In MBS, the asymmetric centre in the barbiturate system is labile due to enolization. The asymmetric centre in the hexyne side chain is stable and racemic. The two asymmetric centres of Methohexital are stable and give rise to four stereoisomers, two diastereomeric racemates. An analysis of the isomers of MBS and Methohexital was established on the basis of 1H NMR and, in particular, GC including a base‐line separation of the four stereoisomers of Methohexital. The stereoselectivity of the allylation is difficult to control, because the new quaternary asymmetric centre in the barbiturate ring of Methohexital is formed within the nucleophile, attacking the η3‐allyl ligand of the catalyst from the side opposite to the palladium atom. Classical optically active ligands, such as diop or norphos, give only 2–6 % ee. Chiral phosphane imine ligands are a successful class of compounds, synthesized by Schiff base condensation of (2‐formylphenyl)diphenylphosphane with optically active primary amines. The most efficient ligands have a hydroxymethyl and a bulky alkyl substituent at the asymmetric centre in the imine part, e.g. the L‐iso‐leucinol and the L‐tert‐leucinol derivatives 5 and 7. In the Pd‐catalyzed allylation of MBS a kinetic resolution and the effect of the enantioselective catalyst interplay, the contributions of which are separated. For MBS the best stereoselectivity factor of the kinetic resolution s = kR/kS was 2.6 and 83 % “ee” were achieved. The corresponding values for Methohexital were s = 3.5 and 80 % ee in the α‐dl pair. For 10 mixtures of Methohexital stereoisomers the anesthetic doses for rats were determined. With 9.1 mg/kg body weight of the animal the sample obtained from the catalysis with the D‐α‐phenylglycinol derivative 8 gave a much lower anesthetic dose than the widely used narcotic Brevimytal®Natrium, the sodium salt of the α‐dl racemate of Methohexital, with 13.0 mg/kg body weight.

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