Proposal of leukotoxin, 9,10-epoxy-12-octadecenoate, as a burn toxin

It is postulated that toxic substances (burn toxin) synthesized in burned skin are transferred into general circulation and cause multiple organ failure. We found a highly cytotoxic substance, leukotoxin, a linoleate epoxide, exists in burned skin. Leukotoxin, as the name indicates, was synthesized by leukocytes from linoleate as a substrate. The aim of this study is to evaluate the possibility of leukotoxin as a burn toxin. We studied plasma leukotoxin level of four patients with extensive burns (over 50% of body surface area) and examined coagulation studies in these patients. We detected considerable amounts of leukotoxin (11.4 nmol/ml-37.0 nmol/ml) in all patients. Leukotoxin was not detected in the control subjects. Pulmonary edema, cardiac failure, and coagulation abnormalities were found in these patients. Exogeneously administered leukotoxin induced similar pathological conditions in experimental animals to those observed in patients with extensive burns. Hence, it is concluded that leukotoxin is a responsible substance as a burn toxin.     

Leukotoxin, 9, 10-epoxy-12-octadecenoate, causes cardiac failure in dogs

An epoxy derivative of linoleate, 9, 10-epoxy-12-octadecenoate, was demonstrated to be biosynthesized by leukocytes, thus nominated as leukotoxin. Its chemical structure was determined by gas-chromatography/mass spectrometry and nuclear magnetic resonance measurements. When it was injected intravenously, 15 mg/kg, canine heart showed signs of a typical cardiac failure; viz. Aortic flow started to drop immediately after the injection, and fell to 22% of the original at 40 min after the injection. At that point, systolic aortic pressure dropped to 35%, diastolic aortic pressure to 23%, and electronically differentiated maximal rate of left ventricular pressure rise (LV dp/dt) to 29%. All of experimental dogs died 40 to 50 min after the injection. On the contrary, administration of linoleic acid (15 mg/kg) did not affect these hemodynamical parameters. Therefore, leukotoxin seems to be an important factor to the genesis of heart failure.     

Possible role of platelet activating factor (PAF) in disseminated intravascular coagulation (DIC), evidenced by use of a PAF antagonist, CV-3988

The i.v. infusion of endotoxin (ET) (0.25 mg/kg/hr for 4 hr) induced disseminated intravascular coagulation (DIC) in rats; thrombocytopenia, prolongation of prothrombin time (PT) and partial thromboplastin time (PTT), hypofibrinogenemia and elevated levels of fibrinogen/fibrin degradation products (FDP) were observed. Platelet activating factor (PAF) (8 micrograms/kg/hr for 4 hr) also induced DIC-like changes, except in platelets. A specific PAF antagonist, CV-3988 (2 mg/kg bolus 5 min before ET + 1 or 2 mg/kg/hr for 4 hr of ET infusion) improved all the parameters that had been altered by both ET and PAF. CV-3988 (2 mg/kg bolus 2 hr after ET + 2 mg/kg/hr for 2 hr of ET infusion) also had beneficial effects on DIC. CV-3988 itself had no effects on the parameters of DIC. These results strongly suggest that PAF may play a role in the pathogenesis of DIC and CV-3988 may prove to be useful for the treatment of DIC.     

Neutrophil microsomes biosynthesize linoleate epoxide (9,10-epoxy-12-octadecenoate), a biological active substance

We demonstrated that linoleate epoxide (9,10-epoxy-12-octadecenoate) exists in human burned skin and in lung lavages in patients with adult respiratory distress syndrome. This epoxide shows a highly toxic effect on cellular function. Thus, it was given the name leukotoxin. In this communication, we reveal that neutrophils from various sources such as guinea-pig peritonea and canine or human blood biosynthesize linoleate epoxide from linoleate as a substrate. From the reaction mixture of neutrophils with linoleate, a leukotoxin isomer, 12,13-epoxy-9-octadecenoate, and a 'non-toxic' hydroxy derivative of linoleate, 9-hydroxy-12-octadecenoate, were detected. Biosynthesis of leukotoxin by neutrophils was substantially enhanced by osmotic activation or by a calcium-ionophore, A23187. Microsomes prepared from neutrophils could oxygenate linoleate to leukotoxin in the presence of NADPH. In liver or kidney microsomal reaction mixture, leukotoxin could be detected only in the presence of an epoxide hydrolase inhibitor, epoxytrichloropropane. As biosynthesis of leukotoxin was sensitive to carbon monooxide, it was concluded that cytochrome P-450 dependent monooxygenase is responsible for the biosynthesis. Elucidation of the biosynthesis pathway of leukotoxin might contribute to the treatment of diseases associated with neutrophil recruitment.     

Neutrophils biosynthesize leukotoxin, 9, 10-epoxy-12-octadecenoate

An epoxy derivative of linoleate, 9,10-epoxy-12-octadecenoate, was demonstrated to be biosynthesized by neutrophils from various sources such as canine and human blood, and guinea-pig peritonea. It was nominated as leukotoxin from its 'toxic' activity onto mitochondrial respiration. From the reaction mixture of leukocytes with linoleate, an isomer of leukotoxin, 12,13-epoxy-9-octadecenoate, and a 'non-toxic' hydroxy derivative of linoleate, 9-hydroxy-12-octadecenoate, were detected. Such a cascade reaction of linoleate by leukocytes was discussed. Biosynthesis of leukotoxin by neutrophils was substantially enhanced by the presence of calcium ion and calcium-ionophore, A23187. Neutrophils contained leukotoxin, ca. 7 f moles/cell, which was extractable by 60% ethanol, but little of the isomer.     

The effects of the calcium entry blockers, nilvadipine and nitrendipine, on endotoxin-induced disseminated intravascular coagulation

We previously reported that calcium entry blockers (CEBs) protected against endotoxin-induced mortality in rats. In this investigation, the i.v. injection of endotoxin (ETX) in control awake male Wistar rats was found to produce pathophysiological changes indicative of disseminated intravascular coagulation (DIC). The latter included increased serum fibrin (ogen) degradation products (FDP), decreased plasma fibrinogen, reduced blood platelet count as well as microscopic findings of fibrin microthrombi in small blood vessels of visceral organs. Gross pathological examination revealed pronounced hemorrhagic congestion of the gastrointestinal tract and petechial and ecchymotic hemorrhages in other visceral organs. Pretreatment with the CEBs, nilvadipine (FR 34235) and nitrendipine, inhibited the elevation in serum FDP and decrease in plasma fibrinogen but did not prevent the thrombocytopenia produced by ETX. The gross pathological manifestations of DIC were also inhibited by pretreatment with the CEBs. The results suggest that the protective effect of CEBs against endotoxin-induced mortality in rats may be related to inhibition of DIC caused by the lipopolysaccharide.     

Leukotoxin,a linoleate epoxide: Its implication in the late death of patients with extensive burns

Burn death based on circulatory shock is often encountered after recovery from primary shock in patients with deep and extensive burns,i.e., late death. Several toxic substances have been proposed, however, the responsible substance remains obscure. Since we have found leukotoxin, a highly cytotoxic linoleate epoxide biosynthesized by neutrophils, in the burned skin, in the present study we determined plasma leukotoxin concentrations in various degree of 30 burn patients. C-reactive protein and circulatory white blood cells were also measured. A significantly high mortality rate of patients with extensive burns (burn surface area over 70%) was observed compared with that in patients with burn surface area under 70%, and significantly high leukotoxin concentrations were observed within a week, and 3 weeks after the thermal injury in patients with extensive burns compared with those in patients with burn surface area under 70%. There were two peaks of plasma leukotoxin concentrations,i.e., the early phase (within 1 week) and the late phase (over 1 week) in patients with extensive burns. Plasma leukotoxin concentrations significantly correlated with burn surface area in the early phase, and similar correlations were observed in the late phase. A significantly high mortality rate (61%) of patients with peak leukotoxin concentrations over 30 nmol/ml was observed compared with 8% for those below 30 nmol/ml. Plasma leukotoxin concentration correlated significantly to C-reactive protein concentration, log (leukotoxin nmol/ml)=0.042×C-reactive protein (mg/dl)+0.74, (r=0.83,P<0.01) in the late phase. From these results, it is concluded that leukotoxin is produced in patients with burns particularly in the late phase of extensive burns, and leukotoxin might play an important role in the tissue destructive procedure associated with severe burns.     

Hydroxyl radical and leukotoxin biosynthesis in neutrophil plasma membrane

We measured O2-, H2O2, .OH and leukotoxin biosynthesis in neutrophil plasma membrane. O2- was produced by respiratory burst oxidase in the membrane coupling with NADPH oxidation. Leukotoxin was biosynthesized in the system containing linoleate. Addition of SOD into the system doubled the amount of leukotoxin synthesized. Further addition of catalase into the system decreased leukotoxin formation. .OH and leukotoxin formation in the system was substantially increased by the presence of cytochrome c. In addition, leukotoxin was detected in the non-biological reaction mixture containing H2O2 and linoleate in the presence of heme iron. In this mixture, .OH and leukotoxin formation also showed a good correlation. From these results, it is evident that, in neutrophil cell membrane, leukotoxin is synthesized by .OH with linoleate.     

Mechanism for increase in tracheobronchial blood flow induced by hyperventilation of dry air in dogs

To test whether the consistent increase in tracheal and bronchial blood flow observed in dogs during hyperventilation of dry air might be the result of release of mediators such as vasodilatory prostaglandins or neuropeptides, we studied two groups of anesthetized mechanically ventilated dogs. Group 1 (n = 6) was hyperventilated for four 30-min periods with 1) warm humid air (38-40 degrees C, 100% relative humidity), 2) warm dry air (38-40 degrees C, 0% relative humidity), 3) warm humid air, and 4) warm dry air. After period 2, a loading dose of indomethacin (4 mg/kg iv) was given over 15 min followed by a constant infusion (4 mg.kg-1.h-1). Group 2 (n = 10) was hyperventilated for four 15- to 20-min periods by use of the protocol described above. After period 3 (group 2a) or period 2 (group 2b), topical 4% lidocaine hydrochloride solution was instilled into the trachea and main stem bronchi. Five minutes before the end of each period of hyperventilation, cardiac output and vascular pressures were measured. To determine airway blood flow, differently labeled radioactive microspheres were injected into the left atrium. After the last measurements, dogs were killed and the lungs excised. Blood flow to the trachea, main stem bronchi, and parenchyma (group 1 only) was calculated. Results showed that hyperventilation of dry air produced a significant increase in blood flow to the trachea and bronchi (period 2). In group 1, this increase was attenuated (P less than 0.02) after administration of indomethacin.(ABSTRACT TRUNCATED AT 250 WORDS)     

Model of disseminated intravascular coagulation

Vascular-thrombocytic and plasma hemostasis was studied in dogs after blood loss (40--50 ml/kg weight) and subsequent hypervolemic (60--65 ml/kg weight) transfusion of homologous (from 3 donors) platelet and leukocyte rich in plasma. After a short phase of hypercoagulation all the tested dogs displayed hypocoagulation accompanied by a decrease in the count of platelets and a fall of their aggregation function, prolongation of bleeding time, diminution of capillary wall resistance, a decrease of plasma fibrinogen concentration and factor XIII activity, and by a rise of blood fibrinolytic activity. The data obtained show the development of the acute disseminated intravascular coagulation syndrome (DIC). DIC model is porposed on the basis of the results obtained.     

弥漫性血管内凝血产妇围术期凝血与纤溶系统指标的检测及临床意义

目的:探讨弥漫性血管内凝血(DIC)产妇围术期凝血与纤溶系统指标检测的临床意义。方法:选择2017年1到2017年12月在我院接受治疗的DIC孕妇57例(DIC组)为研究对象,采取分层抽样的方法选择同期在我院进行产检的正常孕妇57例(健康孕妇组)及在我院体检的健康非孕妇57例(非孕妇组)作为对照,比较各组凝血酶原时间(PT)、凝血酶时间(TT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、D-二聚体(D-D)及血小板计数(PLT)变化,根据DIC组的治疗结果分为有效组和无效组,并比较两亚组治疗前PT、TT、APTT、FIB、D-D、PLT,采用Pearson相关分析法分析DIC组治疗前各检测指标间的相关性。结果:与健康孕妇组、非孕妇组比较,DIC组PT、TT、APTT延长(P0.05),D-D水平升高(P0.05),FIB、PLT水平降低(P0.05);与非孕妇组比较,健康孕妇组PT、TT、APTT缩短(P0.05),D-D水平降低(P0.05),FIB、PLT水平升高(P0.05)。DIC组患者治疗后有效组治疗前的PT、TT、APTT短于无效组(P0.05),D-D水平低于无效组(P0.05);FIB、PLT水平高于无效组(P0.05)。Pearson相关分析结果显示,除PT与APTT之间无明显相关性(P0.05)外,其他凝血、纤溶系统指标之间均存在一定的相关性(P0.05)。结论:DIC孕妇围术期凝血与纤溶系统指标异常改变,检测凝血与纤溶系统指标对DIC孕妇的诊疗具有重要意义。     

蛇伤凉血合剂对竹叶青蛇咬伤致DIC患者凝血机制的影响

目的观察蛇伤凉血合剂对竹叶青蛇咬伤致DIC患者凝血机制的影响及临床疗效。方法将14例患者随机分为治疗组及对照组,均给予常规治疗,治疗组加服蛇伤凉血合剂180ml,每日2次;于就诊时、给药后72h检测血小板（PLT）、凝血酶原时间（PT）、部分活化凝血活酶时间（APTT）、纤维蛋白原（Fg）、纤维蛋白降解产物（FDP）及血浆鱼精蛋白副凝固试验（3P）、D-二聚体（D-Dimer）变化．同时观察患者出血情况。结果治疗72h后PLT、PT、APTT、Fg、FDP两组比较,差异有显著性或非常显著性意义（P〈0．05）;D-Dimer、3P试验．两组均转为阴性。结论蛇伤凉血合剂对竹叶青蛇咬伤致DIC患者疗效显著,且安全、可靠,对保护正常凝血机制有一定的作用。     

Pharmacological profile of a new peptidic gastrin antagonist

Boc-Trp-Met-Asp-NH2 was described as the smallest peptidic fragment which presented gastric antisecretory activity. Some pharmacological aspects of a peptide analogue, Boc-Trp-Leu-Asp-NH2 (Boc-WLD-NH2), were studied on the main biological functions of gastrin. This compound was found to inhibit the binding of gastrin to isolated gastric fundic mucosal cells (IC50 50 microM). On pentagastrin-induced gastric acid secretion in the rat, a dose-dependent inhibition was observed with an ID50 of 55 mumol/kg when pentagastrin (1 microgram/kg per h) was continuously infused and with an ID50 of 7.8 mumol/kg when pentagastrin (1 microgram/kg) was bolus i.v. injected. Similar inhibition was observed on acid secretion induced by pentagastrin in the isolated rat gastric mucosa (IC50 100 microM), whereas the tripeptide had no effect when acid output was triggered by histamine. A dose-dependent inhibition with the tripeptide was shown on pentagastrin induced guinea-pig ileum contractions (IC50 31 microM). The compound had no activity on histamine-stimulated guinea-pig atria (histamine H2-receptor). These results suggest some evidence for a selective antigastrin activity.     

Portal infusion of a selective serotonin reuptake inhibitor enhances hepatic glucose disposal in conscious dogs

Intraportal delivery of serotonin enhanced net hepatic glucose uptake (NHGU) during a hyperinsulinemic hyperglycemic clamp, but serotonin elevated catecholamines and can cause gastrointestinal distress. We hypothesized that the selective serotonin reuptake inhibitor (SSRI) fluvoxamine would enhance NHGU without side effects. Arteriovenous difference and tracer ([3-(3)H]glucose) techniques were used in conscious 42-h-fasted dogs. Experiments consisted of equilibration (-120 to -30 min), basal (-30 to 0 min), and experimental (EXP; 0-270 min) periods. During EXP, somatostatin, fourfold basal intraportal insulin, basal intraportal glucagon, and peripheral glucose (to double the hepatic glucose load) were infused. Saline (SAL) was infused intraportally during 0-90 min (P1), and fluvoxamine was infused intraportally at 0.5, 1, and 2 mug.kg(-1).min(-1) from 90 to 150 (P2), 150 to 210 (P3), and 210 to 270 (P4) min, respectively, in the FLUV group (n = 8). The SAL group (n = 9) received intraportal saline during 0-270 min. NHGU in SAL was 13.9 +/- 1.7 and 17.0 +/- 2.0 mumol.kg(-1).min(-1) in P3-P4, respectively, while NHGU in FLUV averaged 19.7 +/- 2.8 and 26.6 +/- 3.0 mumol.kg(-1).min(-1) (P < 0.05 vs. SAL). Net hepatic carbon retention was greater (P < 0.05) in FLUV than in SAL (17.6 +/- 2.6 vs. 13.9 +/- 2.7 and 23.8 +/- 3.0 vs. 14.4 +/- 3.3 mumol.kg(-1).min(-1) in P3-P4, respectively), and final hepatic glycogen concentrations were 50% greater in FLUV (P < 0.005). Nonhepatic glucose uptake was greater in SAL than in FLUV at 270 min (P < 0.05). Catecholamine concentrations remained basal, and the animals evidenced no distress. Thus fluvoxamine enhanced NHGU and hepatic carbon storage without raising circulating serotonin concentrations or causing stress, suggesting that hepatic-targeted SSRIs might be effective in reducing postprandial hyperglycemia in individuals with diabetes or impaired glucose tolerance.     

Effect of tumor necrosis factor on enzymes of gluconeogenesis in the rat.

The effect of human recombinant tumor necrosis factor (TNF)-alpha on enzymes of gluconeogenesis in the rat was investigated by determining the activity of glucose 6-phosphatase, fructose 1,6-diphosphatase (FDP), and phosphoenolpyruvate carboxykinase in the liver and kidney of fed and fasted rats. The activity of transaldolase in the pentose phosphate pathway was also measured. Starvation of rats for 24 hr resulted in a 1.6- to 3.1-fold increase in liver and kidney glucose 6-phosphatase and phosphoenolpyruvate carboxykinase (P less than or equal to 0.05), a decrease in liver and kidney FDP (P less than 0.002), and an increase in liver and kidney transaldolase (P = 0.0001). Injection of 50 and 100 micrograms/kg/day of TNF for 5 days resulted in a significant (P less than or equal to 0.03) decrease in kidney FDP only. Injection of 100 micrograms/kg/day of TNF for 5 days with a 24-hr fast on Day 5 resulted in a significant (P = 0.04) increase in liver transaldolase, and a significant decrease in kidney FDP and phosphoenolpyruvate carboxykinase. Comparison of the enzyme activities of rats injected with 100 micrograms/kg/day of TNF for 5 days with those of their pair-fed control partners revealed additionally a significant decrease in glucose 6-phosphatase in the liver (P less than 0.001). It is concluded that TNF administration in the rat has different effects on the enzymes of gluconeogenesis in the liver and kidney, and these effects differ from those seen in starved or tumor-bearing rats.     

Biosynthesis of leukotoxin, 9,10-epoxy-12 octadecenoate, by leukocytes in lung lavages of rat after exposure to hyperoxia

In lung lavages of rat after pure oxygen breathing, a toxic linoleate peroxide, 9,10-epoxy-12-octadecenoate, and its isomer, 12,13-epoxy-9-octadecenoate were detected by HPLC analyses. The epoxide(s) was demonstrated to be biosynthesized by incubating linoleate with leukocytes collected from lung lavages, thus nominated to be leukotoxin. The chemical structures of leukotoxin and its isomer were determined by gas-chromatography/mass spectrometry and nuclear magnetic resonance measurements. Leukotoxin showed a potent uncoupling activity to rat liver mitochondrial respiration and a dose-dependent relaxation of rat stomach smooth muscle. These findings were discussed with 'oxygen toxicity' on the lung.     

Antibody response of dogs inoculated with a large number of cultured canine monocytes adsorbed with a calicivirus in advance

Five conventional Beagle dogs were intravenously injected with ten million canine monocyte cells (Cn/K99) cultured in vitro (Kadoi, 2000) adsorbed with a strain of calicivirus originally isolated from lions (Kadoi et al., 1997). Another two Beagle dogs were injected similarly with the virus suspension solely as control. Serum samples were collected from these dogs at intervals and specific seroneutralizing antibody production against the virus was measured in vitro. A significantly higher antibody production was demonstrated in the five dogs group. A clear booster effect was also proved in the sera of the dogs after the second virus inoculation made on day 100. A possibility of antigen presentation function of non-self monocytes is suggested.     

A comparison of the natural survival of beagle dogs injected intravenously with low levels of 239Pu, 226Ra, 228Ra, 228Th, or 90Sr

The natural survival, relative to properly chosen controls, of 26 beagle dogs injected once intravenously with an average of 0.58 +/- 0.04 kBq 239Pu/kg, 23 dogs injected with 2.31 +/- 0.43 kBq 226Ra/kg, 13 dogs injected with 1.84 +/- 0.26 kBq 228Ra/kg, 12 dogs injected with 0.56 +/- 0.030 kBq 228Th/kg, and 12 dogs injected with 21.13 +/- 1.74 kBq 90Sr/kg was evaluated statistically. The amounts of these radionuclides are related directly to the estimated maximum permissible body burdens for humans suggested in ICRP II (1959). They constitute a level of exposure that initially was assumed to cause no deleterious effects in dogs. This study had two objectives: (1) identification of homogeneous control groups against which to evaluate the survival of the irradiated groups and (2) comparison of the survival characteristics and estimation of mortality or hazard rate ratios for control dogs vs dogs injected with the baseline dosages given above. It was shown, by goodness-of-fit plots, that the Cox proportional hazards model was an appropriate method of analysis. Therefore, covariates that possibly could influence survival were tested for significance. Only the effects of grand mal seizure, which is caused in epileptic dogs by an external stimulus and can be fatal if untreated, were significant (P less than 0.0001). Consequently, in the final model, death from grand mal seizure was considered as accidental. After censoring the dogs dying from grand mal seizure, it was established that the data for the control groups from previous and contemporary experiments could be pooled. The change in hazard rates relative to controls resulting from exposure to the baseline radionuclide level was modest, 1.6 times for 239Pu (P = 0.033), 1.0(4) for 226Ra (P = 0.86), 1.9 for 228Ra (P = 0.035), 2.5 for 228Th (P less than 0.001), and 0.52 for 90Sr (P = 0.041). Bone tumor induction was clearly elevated in dogs injected with 239Pu and 228Th. When the effect of these bone tumors on survival was removed by censoring, the dogs injected with 239Pu were indistinguishable from the controls. In contrast, the effects of bone tumor on group survival of the 228Ra and 228Th dogs were not significant. Thus, no additional life-shortening effects beyond those attributable to bone tumor were suggested by these data for 239Pu, but other, as yet unspecified, confounders are suggested for 228Ra and 228Th.     

Beta-oxidation of long-chain fatty acids by human fibroblasts: evidence for a novel long-chain acyl-coenzyme A dehydrogenase.

Fibroblasts from patients with long-chain acyl-CoA dehydrogenase deficiency were found to oxidize [1-14C]linoleate at an average rate of 60% of normal but [9,10(n)-3H]myristate at an average rate of only 37% of normal, a relationship reverse from that predicted by the chain-length specificities of the three known straight-chain mitochondrial acyl-CoA dehydrogenases. The residual long-chain beta-oxidative activity was found to be mitochondrial and associated with the accumulation of tetradecadienoate (C14:2w6) when the mutant fibroblasts were incubated with 100 mumol/L linoleate (C18:2w6) or eicosadienoate (C20:2w6). The results suggest the presence in human fibroblasts of a novel acyl-CoA dehydrogenase with activity toward 15 to 20 carbon-length fatty acids.     

Digital defects induced by vasodilating agents: relationship to reduction in uteroplacental blood flow

The effects of nifedipine (40-100 mumol/kg), nitrendipine (40 and 80 mumol/kg), hydralazine (381 and 763 mumol/kg), felodipine (12 mumol/kg), and the pharmacologically inactive first-step metabolite of felodipine, H152/37 (80 mumol/kg) were studied in rabbits (New Zeeland White) after oral administration on day 16 of gestation. The vasodilating drugs--nifedipine, nitrendipine, felodipine, and hydralazine--all induced digital defects in the fetuses. The defects consisted of a reduction, absence, or abnormal structure of the distal phalanx of especially the fourth digit on the hind paw(s). Histologically, a disturbed differentiation of the cartilage, and secondarily also of the ossification centre and joint structure of the distal phalanx, was observed. In contrast, no digital abnormalities were observed after administration of vehicle or H152/37. The findings that vasodilators with different structures, like dihydropyridines and hydralazine, induced the same type of digital defects strongly suggest that the observed phalangeal defects are secondary to pharmacological action, and not related to chemical structure. A decrease in uteroplacental blood flow, caused by excessive hypotension, is discussed as the most probable mechanism underlying the observed defects.