[Long-term follow-up of anti-tachycardia surgery in patients with ventricular tachycardia]

From March 1980 to May 1992 mapping guided surgery was performed in 132 patients with drug-refractory recurrent ventricular tachycardia. There were 121 patients (group I) with coronary disease and 11 patients (group II) had noncoronary ventricular tachycardia. Patients in group I underwent subendocardial resection and cryoablation was performed in group II patients. Perioperative mortality (< 30 days after surgery) was 8% (10/132 patients). During the mean follow-up of 41 +/- 24 months, 37/122 patients (30%) died, 35/111 patients in group I (32%) and 2/11 patients in group II (18%) (p = 0.29). In group I, sudden death occurred in 8/111 patients (7%) and cardiac death in 23/111 patients (21%); in group II, 1/11 patients (9%) died from sudden and 1/11 patients (9%) from cardiac death. Nonfatal recurrences occurred significantly more frequently in group II (6/11 patients, 55%) than in group I (16/111 patients, 14%) (p < 0.01). During the follow-up functional class of heart failure improved in 69 patients (57%), remained constant in 27 patients (22%) and decreased in the remaining 26 patients (21%). The surgical approach to control ventricular tachycardia has low rates of sudden death and nonfatal recurrences in patients with drug-refractory ischemic ventricular tachycardia. Patients with noncoronary disease had a high incidence of nonfatal ventricular tachycardia after surgery and should be considered for other therapeutic approaches in the future.

Insulin-mimetic actions of phorbol ester in cultured adult rat hepatocytes. Lack of phorbol-ester-elicited inhibition of the insulin signal

The actions of the phorbol ester phorbol 12-myristate 13-acetate (PMA) on glucose metabolism, amino acid transport and enzyme inductions were studied in primary cultures of adult-rat hepatocytes and compared with the effects of insulin. PMA and insulin stimulated glycolysis 5- and 7-fold respectively. The half-maximal effective dose of PMA was 60 nM. Stimulation of glycolysis was accompanied by an insulin- or PMA-dependent and okadaic acid-sensitive activation of 6-phosphofructo-2-kinase and pyruvate kinase, as well as by an increase in fructose 2,6-bisphosphate. Glucose production from glycogen was decreased to 50% by PMA and to 15% by insulin, whereas glycogen synthesis was stimulated 2- and 7-fold respectively. PMA also increased aminoisobutyrate uptake, induced ornithine decarboxylase and counteracted the glucagon-dependent induction of phosphoenolpyruvate carboxykinase. PMA strongly antagonized the hormonal activation of glycogen synthesis, but all other insulin actions assayed were not decreased by the phorbol ester. Whereas additive effects of PMA and insulin were not detected, PMA and a simultaneous increase in the glucose concentration had additive effects on glycolysis and glycogen metabolism. Cell exposure to insulin resulted in receptor autophosphorylation and a more than 10-fold activation of the receptor tyrosine kinase. PMA did not alter these effects, and also had no effect on the receptor phosphorylation status in the absence of insulin. Long-term (15 h) pretreatment of the cells with PMA abolished all PMA effects, but not the insulin effects. It is concluded that PMA does not generally antagonize the action of insulin in differentiated adult hepatocytes, and that insulin and PMA may use related signal-transduction pathways.

Treatment of chronic hepatitis B with interferon alpha-2b and interleukin-2

A total of 37 patients with histologically confirmed chronic viral hepatitis B and presence of HBV-DNA and HBsAg in the serum were treated in a randomized, prospectively controlled multicenter trial either with recombinant IFN alpha-2b alone or a combination of IFN alpha-2b and recombinant IL-2. Twenty-two patients from group A were treated with 3 MU of IFN alpha-2b s.c. thrice weekly for 5 months. Starting at month 2 IL-2 was added: priming doses of 1.5 million CU were given s.c. on the first 2 days of each of the remaining 3 months, followed by maintenance doses of 0.3 million CU daily for 5 days per week. Fifteen patients from group B received 5 MU of IFN alpha-2b s.c. thrice weekly for 5 months. Five patients from group A (24%) and 4 patients from group B (28%) cleared HBV-DNA and HBeAg from the serum, and normalized elevated serum aminotransferase activities. The response rate in both groups did not differ significantly. Since side effects were more pronounced during combination therapy than in IFN alpha-2b monotherapy, it is suggested that treatment with IFN alpha-2b alone is preferable to a regimen of IFN alpha-2b/IL-2 applied according to the above schedule.

The relationship between emotional state and alcohol consumption

Based on a November 1986 national probability sample of 1,069 American drinkers (i.e., people who drank at least one alcoholic beverage in the past 7 days) aged 21 and over, this study investigates the relationship between 10 emotional states (i.e., happy, sad, calm, tense, stimulated, bored, irritable, romantic, festive, and lonely) and the amount of beer, wine, distilled spirits, and/or wine cooler consumed during respondents' last drinking episode. The results indicate that: (1) Although all of the mediating variables studied affected the relationship between affect and alcohol consumption, age appears to be the most influential of these variables; and (2) For each alcoholic beverage type, at least one emotional state was significantly related to amount consumed.

Clinical efficacy and safety of the new cardioverter defibrillator systems

Clinical efficacy and safety of two new third-generation implantable cardioverter defibrillators (ICD) were studied in 38 patients with ventricular tachycardia (VT) or fibrillation (VF). There were 31 patients with coronary disease, three patients with right ventricular dysplasia, one patient with dilated cardiomyopathy, and three patients with valvular disease. Twenty-four patients (group I) received an ICD with monophasic (Ventak PRx 1700, CPI) and 14 patients (group II) with biphasic shocks (Cadence V 100, Ventritex). Intraoperatively, the mean defibrillation threshold was significantly lower in group II than in group I, both in patients with induced VT (group I 11.0 +/- 6.3 joules; group II 5.8 +/- 1.3 joules) (P < 0.01) and induced VF (group I 17.5 +/- 4.6 joules; group II 9.6 +/- 5.2 joules) (P < 0.01). During the mean follow-up of 12 +/- 7 months four patients (11%) died. 865 arrhythmia events (AE) occurred and were terminated by ATP (671 VTs, 78%). Acceleration of VTs was observed in 28 AE (3%) and ATP was unable to interrupt 58 AE (7%). ICD shocks were delivered as a first therapy in 108 AE (13%).

Initial experience with a new transvenous defibrillation system

The clinical efficacy and safety of a new bidirectional transvenous defibrillation endocardial lead system (ELS) was studied in 39 patients with ventricular tachycardia (VT) or fibrillation (VF). There were 28 patients with coronary disease and 11 patients with nonischemic VT/VF. Fourteen patients received the ELS combined with antitachycardia pacing devices (Ventak PRx 1700, CPI) and 25 patients with the Ventak P or P2 (CPI). Implantation of the ELS was attempted in 47 patients. Intraoperatively, the mean defibrillation threshold (DFT) was > 25 joules in five patients and no reliable ELS position was found in three other patients. These eight patients underwent thoracotomy and epicardial leads implantation. The mean DFT was < or = 20 joules in all 39 patients and the mean DFT was 18 joules. During the mean follow-up of 8 +/- 2 months two patients (5%) died suddenly. Complications occurred in two patients (5%).

Regional differences in alcohol consumption and drinkers' attitudes toward drinking

Based on a November 1986 national probability sample of American adults aged 21 and over (1,069 of whom were deemed "drinkers" on the basis of having consumed at least one alcoholic beverage in the 7 days prior to interview), this study examines whether region of residence influences drinkers' alcohol consumption and/or their perceptions of alcohol use. In addition to examining the main effects of the relationship between geographic region of residence and alcohol use, four measures of urbanization are also investigated for their influence on drinking. Results indicate that geographic region of residence makes little to no difference in people's alcohol use and has only a small impact on their drinking-related attitudes. By and large, urbanization and gender are not influential variables in these relationships.

Ventricular tachycardia surgery in 1992: did the automatic defibrillator change this approach?

The role of ventricular tachycardia (VT) surgery has been changed since the automatic implantable cardioverter defibrillator (ICD) is available. We studied the follow-up of 131 patients who underwent mapping guided surgery due to recurrent VT refractory to antiarrhythmic drug treatment. There were 65 patients operated upon between 1980-1985 (group I) and 66 patients between 1986-1991 (group II). Ten patients (8%) died perioperatively (< 3 weeks after surgery) [7/65 patients, 11%, in group I and 3/66 patients, 5%, in group II (P = 0.15)]. During a mean follow-up of 41 +/- 24 months, 38 of 121 patients died (31%), significantly more patients in group I (24/58 patients, 41%) than in group II (14/63 patients, 22%) (P < 0.05). In group I, there was a higher incidence of sudden (7/58 patients, 12%) or cardiac death (15/58 patients, 26%) than in group II (sudden death 4/63 patients, 6%, cardiac death 7/63 patients, 11%) (P < 0.05). There was a similar incidence of VT recurrences between group I (9/65 patients, 14%) and group II (9/66 patients, 14%). Our data show that the indication for VT surgery has changed since the ICD is available because of better patient selection.

Evidence of androgen receptivity in the pathway of testicular descent in humans. A postnatal study

The aim of this study was to detect androgen receptors in paratesticular tissue in an attempt to explain a possible mechanism of effect for hormone treatment in undescended testes. A total of 45 biopsies from the gubernaculum testis, musculus cremaster, processus vaginalis and subcutaneous fascia were taken from 13 patients aged 4 months-65 years. All biopsies were instantly frozen in liquid N2 in Norway and later transported to Hamburg for analysis. By using various procedures for stabilization and separation, cytosol was prepared which contained all primary intranuclear and extranuclear androgen receptors. R1881 was used as radioligand. The validity of the procedure was controlled with rat prostate. A full saturation analysis was obtained according to Scatchard. The musculus cremaster was the only structure examined which contained androgen receptors. The results indicate that endocrine treatment in undescended testes is effective in retractile testes only.

Low dose alpha interferon treatment in chronic hepatitis B virus infection

Fifty eight patients with chronic viral hepatitis B (HBV) were randomised in a prospectively controlled trial. Thirty patients were treated with 3 million units (MU) of interferon alfa-2b subcutaneously thrice weekly for four months. Twenty eight controls received no treatment. The follow up period after treatment was six months. Twenty eight treated patients and 27 controls completed the protocol. One woman in the treatment group showed a complete response, and eight other treated patients (32%) showed a partial response. Three patients in the control group (11%) lost hepatitis B e antigen and HBV-DNA spontaneously. This finding is statistically significant (p < 0.05). The elimination of HBV markers from the serum was associated with a return to normal of serum aminotransferase activities. Reactivation of hepatitis was not observed after seroconversion.

Pharmacokinetics of ANF and urodilatin during cANF receptor blockade and neutral endopeptidase inhibition

Urodilatin is a new member of the family of natriuretic peptides. It is of renal origin. Previous reports indicate that urodilatin is natriuretic in lower doses than atrial natriuretic factor (ANF)-(99-126) and that it might be more effective than ANF in the treatment of cardiovascular edema. The present study was designed to compare the pharmacokinetics of the hydrolysis and clearance of 125I-labeled urodilatin and 125I-ANF. In control rats, the volume of distribution (Vss), metabolic clearance rate (MCR), and distribution half-life (distribution t1/2) of urodilatin in plasma were not significantly different from those of ANF. Infusion of clearance (c)ANF-(4-23), a specific ligand for receptors that clear ANF in excess amounts (i.e., a bolus injection of 100 micrograms/kg followed by a continuous infusion of 10 micrograms.kg-1 x min-1), increased the amount of intact peptide in the plasma to the same extent for both urodilatin and ANF. In addition, cANF-(4-23) decreased the Vss and the MCR and increased the distribution t1/2 of both peptides to about the same degree. Prior treatment of rats with SQ-28,603, a specific neutral endopeptidase (NEP; EN 3.4.24.11) inhibitor, was without significant effect on the metabolic clearance of urodilatin, whereas it decreased the clearance of ANF by 65%. Furthermore, an infusion of SQ-28,603 suppressed the appearance of the hydrolytic products of ANF in blood but not of urodilatin. Moreover, the inhibitor increased the total amount of ANF recovered in the kidneys to five times the control values, whereas it did not alter the renal uptake of urodilatin.(ABSTRACT TRUNCATED AT 250 WORDS)

Early and long-term results of catheter ablation in patients with incessant ventricular tachycardia

Catheter ablation of sustained monomorphic ventricular tachycardia (VT) with high energy DC shock (360-400 J) was performed in 11 patients with incessant VT (duration greater than 24 hours), refractory to antiarrhythmic drugs, and DC cardioversion. There were ten patients with coronary disease and one patient had dilated cardiomyopathy. Direct current energy was delivered at the earliest endocardial activation in six patients (group I) or at the area of slow conduction in five patients (group II). Incessant VT was terminated by DC ablation in nine patients (82%). After the ablation procedure VT remained inducible in four patients in group I (67%) and in one patient (20%) in group II. Two patients in group II had to go to emergent surgery. During the mean follow-up of 31 +/- 26 (1-66) months nonfatal VT recurrences occurred in five patients in group I and in one patient in group II.

Regulation by prostaglandin E2 of cytokine-elicited nitric oxide synthesis in rat liver macrophages

Nitric oxide (NO), apart from its properties as a vasodilator, is a cytotoxic agent released from macrophages upon stimulation with immunomodulating agents such as interferon-gamma and endotoxin. In rat Kupffer cells endotoxin causes the release of NO as well as of tumor necrosis factor-alpha and prostaglandin E2 (PGE2). This eicosanoid and its second messenger, cyclic AMP, have been shown to increase nitric oxide formation in Kupffer cells treated with endotoxin (Gaillard et al. (1991) Pathobiology 59, 280-283). But not only added PGE2 but also the prostaglandin produced endogenously upon stimulation with endotoxin increases NO synthesis. Neither tumor necrosis factor-alpha nor interleukin-1 beta stimulate NO synthesis by themselves, but together with PGE2 they are as effective as lipopolysaccharide plus PGE2. To replace PGE2 in the combination with the cytokines, however, dibutyryl cAMP has to be present in higher concentrations than with LPS. Interleukin-6 alone or in combination with PGE2 or dibutyryl cAMP is without any effect. Anti-TNF-alpha as well as anti-PGE2 antibodies reduce the release of NO upon stimulation with LPS. Consequently, the effect of LPS on NO production seems to be in part due to the self-stimulating effect of PGE2 and some cytokines, both produced by Kupffer cells upon LPS stimulation.

Role of mapping-guided surgery in patients with recurrent ventricular tachycardia

To assess the value of ventricular tachycardia (VT) surgery 108 patients with recurrent episodes of VT were studied. There were 97 patients with coronary artery disease (group I) and 11 patients without coronary artery disease (group II). All patients in group I underwent subendocardial resection; 12 patients also underwent cryoablation. Cryoablation alone was performed in all patients in group II. During a mean follow-up period of 40 +/- 27 months, 29 patients (30%) in group I and two patients (18%) in group II died (p = 0.33). There were nine patients (9%) in group I and six patients (55%) in group II who had nonfatal recurrences of VT after surgery (p less than 0.01). In group I, there was a higher mortality rate among patients who had VT of posterolateral origin (14 of 31 patients; 45%) compared with 3 of 11 patients (28%) who had VT of anterolateral origin, 1 of 8 patients (12%) who had VT of inferoseptal, and 11 of 39 (29%) patients who had VT of anteroseptal origin. None of the eight patients with two distinct origins of VT died.

The bisphosphonate, alendronate, prevents bone loss in ovariectomized baboons

We examined the effect of the amino bisphosphonate alendronate, administered IV every 2 weeks at 0.05 and 0.25 mg/kg for 1 year, on bone loss and parameters related to bone metabolism in ovariectomized baboons. Relative to non-OVX animals, the OVX baboons experienced increased bone turnover, reflected in biochemical and histomorphometric measurements, and bone loss assessed by dual-beam absorptiometry in the lumbar spine, which was similar to changes observed in ovariectomized women. Alendronate treatment maintained all parameters of bone turnover at control (nonovariectomized) levels and prevented the bone loss in a dose-dependent manner. We concluded that ovariectomized baboons offer a suitable model for the bone changes observed in ovariectomized women and that these changes can be prevented by sustained administration of an appropriate dose of this aminobisphosphonate.

Eicosanoid-mediated contractility of hepatic stellate cells

To approach experimentally the problem of contractility, stellate cells from rats were isolated and grown on a flexible silicone rubber substrate. Increases or decreases in the number of wrinkles of the silicone membrane beneath the cells that were easily observable by microscopy was employed as semi-quantitative measure of stellate cell motility. Contraction of stellate cells accompanied by diminution of cell body size was induced by U46619 (a thromboxane A2 analogue) and prostaglandin (PG) F2 alpha. Wrinkle formation became detectable 1.5 min after addition of 2 microM-U46619 and reached its maximum 10-15 min later. The effect of PGF2 alpha was not so striking, but lasted for a longer period of time. On the other hand, dibutyryl cyclic AMP, Iloprost (a PGI2 analogue) and PGE2 led to the disappearance or decrease in the number of wrinkles, indicating relaxation of contracted stellate cells. For instance, after addition of 2 microM-Iloprost, 47, 75 and 82% of contracted stellate cells had relaxed within 5, 10 and 20 min respectively. Moreover, dibutyryl cyclic AMP induced disappearance of alpha-smooth muscle actin stress fibres. This response became recognizable 10 min after addition of dibutyryl cyclic AMP; 40 min later, 97% of stellate cells were devoid of stress fibres. Thus stellate cells are able to undergo reversible contraction in primary culture, and the contraction of these cells may be mediated by eicosanoids that can be produced within the liver.

Rectal prolapse after oral cathartics

Complete rectal prolapse or procidentia is an uncommon condition long recognized but of uncertain pathogenesis. We report two patients, seen a decade apart, both of whom developed complete rectal prolapse after ingestion of oral cathartics in preparation for diagnostic studies. To our knowledge, cathartic-induced complete rectal prolapse has not been reported previously in the current medical literature, despite the thousands of bowel preparations performed annually. These two cases address the implications of such an occurrence, and we discuss the pertinent management issues.

[Implantable defibrillators]

Automatic implantable defibrillator therapy has changed the approach to life-threatening ventricular tachycardia completely and essentially improved survival after aborted sudden cardiac death. Since the first implantation of a defibrillator in 1980, 20,000 patients have received such a device. Nonetheless, in Germany still too many patients die of sudden cardiac death because defibrillator therapy fails to be known enough and keeps not being made use of (no more than 1,000 implants to date). In this group of patients characterized by poor ventricular function, antiarrhythmic drug therapy proved to be unreliable or even dangerous in many cases, while electrophysiologically-guided surgical interventions use to be impossible. The introduction of the implantable defibrillator enabled the incidence of sudden cardiac death to be reduced to about 2% during the first year after implant, and to 5% in the third year, respectively. In most centers with more extensive experience in defibrillator implantations, operative mortality is about 2-3%. Long-term results with defibrillator patients are controlled by the course of the underlying disease, which is coronary artery disease with large scars due to infarction in some 75% of cases. In a large group of about 10,000 patients, total mortality has been calculated to be 15% after three years. Defibrillator systems of the latest generation offer multiple programmability of tachycardia identification parameters and permit differentiated modification of therapeutic intervention. Defibrillator therapy has now been improved essentially by the introduction of endocardial lead systems and, in addition, by the defibrillator being combined with an antitachycardia pacing system.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term follow-up of patients after interruption of the atrioventricular conduction by electrode catheter and DC shock: experiences with 100 patients]

Long-term follow-up (44 +/- 21 months) was studied in 100 patients (pts) (mean age 56 +/- 12 years) who underwent direct current ablation because of drug-resistant supraventricular arrhythmias. In 85 pts (85%) complete atrioventricular (AV) block was initially achieved. During the follow-up period, AV conduction resumed in 15 pts (15%). Thirteen pts underwent another ablation session and complete AV block was achieved in 11/13 pts (85%). After catheter ablation complete AV-block was achieved in 96 pts and the remaining four pts had second-degree AV-block. Complications like pericardial effusion, arterial hypotension or ventricular arrhythmias occurred in 18 pts. Total mortality was 13% (13 pts): one patient died suddenly, and seven pts died from cardiac causes (heart failure in six pts, reinfarction in one patient). Transcatheter direct-current ablation is an effective method to interrupt AV conduction and to treat patients with drug-resistant supraventricular arrhythmias. Although there is a small risk of severe complications, this procedure should be reserved for pts with supraventricular arrhythmias who do not respond to conventional drug treatment.