Effects of dipyridamole on left ventricular function

BACKGROUND

Changes induced by dipyridamole infusion on left ventricular function in healthy individuals have not been investigated by gated myocardial perfusion single photon emission computed tomographic (SPECT) imaging.

METHODS AND RESULTS

This study examined the amplitude and duration of changes induced by dipyridamole infusion on left ventricular function as assessed by technetium 99m sestamibi gated SPECT in 18 subjects with a low likelihood of coronary artery disease. Twenty mCi (740 MBq) of Tc-99m sestamibi were injected at rest. Three different consecutive gated SPECT images were performed 60 minutes later: baseline at rest, during the infusion of 0.76 mg/kg of dipyridamole, and 1 hour later. No patient received aminophylline. Left ventricular ejection fraction (LVEF), end-diastolic volume, and end-systolic volume were automically computed. Heart rate (HR) and blood pressure were regularly monitored. Mean LVEF was 63.2% +/- 8.0% baseline at rest, increased to 73.8% +/- 8.2% (P = .0001) during dipyridamole infusion, and returned to baseline values (63.0% +/- 7.5%) 1 hour later. End-diastolic volume did not vary significantly, and end-systolic volume decreased (from 32.2 +/- 19.5 to 26.6 +/- 17.9 u, P = .002) and returned to baseline values (32.7 +/- 15.6 u) 1 hour later. Dipyridamole induced moderate HR acceleration (from 80.2 +/- 15.0 to 96.5 +/- 9.6 beats/min, P < .001) and a slight decrease in diastolic blood pressure (from 80.6 +/- 8.1 to 70.1 +/- 9.0 mm Hg, P < .001). However, 1 hour later, HR and blood pressure had returned to baseline values.

CONCLUSIONS

Dipyridamole increases LVEF and HR and decreases diastolic blood pressure slightly in healthy individuals. Because dipyridamole gated SPECT imaging acquisition is usually started 60 minutes after dipyridamole infusion, LVEF is in fact estimated at rest.

A role for beta(2) integrins (CD11/CD18) in the regulation of cytokine gene expression of polymorphonuclear neutrophils during the inflammatory response

Growing evidence supports the idea that adhesion via beta(2) integrins not only allows cellular targeting, but also induces intracellular signaling, which in turn activates functional responses of adherent cells. This study investigates whether beta(2) integrin-mediated adhesion of human polymorphonuclear neutrophils (PMN) has a functional impact on cytokine production. Aggregation of the beta(2) integrin Mac-1 (CD11b/CD18) by antibody cross-linking was found to induce substantial de novo synthesis of IL-8 mRNA as measured by semiquantitative RT-PCR and Northern blotting technique, respectively. Induction of IL-8 mRNA was also observed upon adhesion of PMN to immobilized fibrinogen, a functional equivalent of its clotting product fibrin that serves as a native ligand of Mac-1. Results were confirmed using PMN derived from CD18-deficient mice, which were unable to produce MIP-2 mRNA, a homologue of human IL-8, in the presence of immobilized fibrinogen. In contrast, a substantial increase of MIP-2 mRNA was observed when wild-type PMN were incubated on immobilized fibrinogen. In human PMN, ELISA technique showed that the gene activation that required tyrosine kinase activity resulted in a substantial production and secretion of biologically active IL-8 and IL-1beta. In contrast, no TNF-alpha or IL-6 production was found, revealing that beta(2) integrins mediate differential expression of proinflammatory cytokines. The biological relevance of the present findings was confirmed in an in vivo model of acute inflammation. Altogether, the present findings provide evidence for a functional link between clotting and inflammatory responses that may contribute to the recruitment and/or activation of PMN and other cells at sites of lesion.

Metoclopramide has no effect on abdominal activity of sestamibi in myocardial SPET

It has been suggested that metoclopramide may reduce artefacts caused by intestinal activity super-imposed on myocardial uptake of MIBI SPET. This study compared the abdominal activity of MIBI in patients given metoclopramide versus a control group. Forty-seven patients with normal scintigrams or with completely normal inferior wall perfusion underwent rest 201T1 + stress MIBI testing. Twenty-four patients arbitrarily received 10 mg metoclopramide orally 45 min before the MIBI injection and 23 patients no metoclopramide. The patients were divided according to the stress performed: 23 patients had exercise and 24 patients dipyridamole infusion, and a comparison was done between patients with metoclopramide and those without. Myocardial and abdominal activity were assessed at 15 and 60 min on three separate projections and the mean myocardium-to-abdomen ratios were computed. The ratio was 1.30 +/- 0.19 and 1.57 +/- 0.23 in the patients with exercise and metoclopramide versus 1.36 +/- 0.18 and 1.64 +/- 0.23 in the patients with exercise alone at 15 and 60 min respectively. The ratio was 0.92 +/- 0.13 and 1.21 +/- 0.21 in the patients with dipyridamole infusion and metoclopramide versus 1.02 +/- 0.17 and 1.33 +/- 0.16 in the patients with dipyridamole alone at 15 and 60 min respectively. These differences were not statistically significant. In conclusion, metoclopramide has no effect on MIBI abdominal activity and is not recommended in routine practice.

Bcl-Xl- and Bax-alpha-mediated regulation of apoptosis of human neutrophils via caspase-3

In this study, a mechanism is reported which determines the lifetime of polymorphonuclear neutrophils (PMN). In human PMN freshly isolated from the circulation, expression of bcl-Xl, bax-alpha, and bak, members of the bcl-2 family of apoptosis-associated genes, was found using the reverse transcription-polymerase chain reaction technique. In contrast, no expression of bcl-2 was seen in PMN, whereas the myeloid cell line HL-60 was positive for bcl-2 mRNA. Two gene products, Bcl-Xl and Bax-alpha, which are known to function as the regulatory machinery of programmed cell death (apoptosis), were detected at the protein level in PMN. Moreover, differential expression of these proteins was found upon induction or prevention of apoptosis by cytokines: Whereas induction of apoptosis by tumor necrosis factor-alpha was associated with a reduction of expression of the anti-apoptotic Bcl-Xl protein, prevention of apoptosis by granulocyte-macrophage colony-stimulating factor led to a downregulation of expression of the death-promoting Bax-alpha protein. This shift of balance of anti- and pro-apoptotic proteins was found to control caspase-3 activity which, in turn, downregulated Bcl-Xl expression in PMN undergoing apoptosis. Thus, cytokines can affect the ratio of Bax-alpha/Bcl-Xl expression in human PMN and modulate the subsequent activity of caspase-3, which functions as executer of the programmed cell death and may promote apoptosis by a positive feed-forward mechanism that downregulates Bcl-Xl.

Enalapril plus frusemide MAG3 scintigraphy in hypertensive patients with atherosclerosis and moderate renal insufficiency

We performed a retrospective study on 26 patients with moderate renal failure (mean GFR = 51 +/- 21 ml min-1 1.73 m-2), hypertension and atherosclerosis. Apart from three patients who had completely normal renal Doppler ultrasonography, all patients underwent renal angiography. Three groups of kidneys with different atherosclerotic renal artery involvement were identified: Group 1, 24 kidneys with no renal artery stenosis (RAS); Group 2, 18 kidneys with mild (> 25% and < 50% diameter) RAS; and Group 3, 10 kidneys with moderate (> 50% diameter) RAS. We used a two-day protocol with frusemide plus enalapril 99Tcm-MAG3 scintigraphy. The mean parenchymal transit time (MPTT), time to the maximum activity (time to peak) of the renal curve (Tmax), residual activity and split renal uptake were evaluated. The measured parameters did not differ before and after enalapril in Group 1 or in Group 2. In Group 3, MPTT and residual activity differed significantly (P < 0.025) before and after enalapril. The Tmax before and after enalapril, MPTT before and after enalapril and residual activity after enalapril differed significantly (P < 0.05) between Groups 1 and 3 and between Groups 2 and 3. Threshold values were obtained to maximize diagnostic accuracy. The Tmax, MPTT and residual activity after enalapril gave satisfactory results, and MPTT performed best with a 75% positive predictive value and a 98% negative predictive value for the diagnosis of renal artery stenosis. We conclude that MPTT, measured after enalapril administration, is a useful parameter to detect renal artery stenosis in patients with hypertension, atherosclerosis and moderate renal insufficiency.

Quantitative analysis of cholesterol and cholesteryl esters in human atherosclerotic plaques using near-infrared Raman spectroscopy

Raman spectroscopy is a non-destructive analytical technique and previous results have shown that qualitative analysis of the lipid component of human atheromatous arteries is feasible. In this paper, we describe a quantitative analytical method for cholesterol and cholesteryl esters in human atherosclerotic plaques, combined with Raman spectroscopic results, using partial least-squares (PLS) regression, a statistical multivariate method based on factorial analysis. Twenty-nine human atherosclerotic pooled samples were studied and the results of Raman spectroscopy coupled with the PLS method were compared to biochemical results. The standard error of prediction was 16.1, 13.6, 1.9, 3.3 and 3.4 mg/g for total cholesterol, free cholesterol, palmitate cholesteryl, oleate cholesteryl and linoleate cholesteryl, respectively. The repeatability of Raman spectroscopy was found to be excellent. Our results show that Raman spectroscopy is a promising technique to obtain a consistent and non-destructive quantitative analysis of cholesterol and cholesteryl esters in human atherosclerotic lesions. In situ and in vivo analysis is a possibility in the near future.

Automatic adjustment of pacemaker stimulation output correlated with continuously monitored capture thresholds: a multicenter study. European Microny Study Group

Pacing threshold is affected by many factors. A pacing system able to confirm capture at each beat and automatically adjust its output close to the actual pacing threshold is highly desirable. This study evaluates the safety and efficacy of the Autocapture function of the Pacesetter Microny SR+. One hundred thirteen patients were recruited from 16 centers in 7 European countries and followed up for 1 year. All pacemakers were implanted with Pacesetter's low polarization, bipolar leads. The key feature of Autocapture is the immediate delivery of a 4.5 V safety backup pulse 62.5 ms after any ineffective ongoing low output pulse. Holter recordings confirmed total reliability of this feature without any exit block. The measured evoked response (ER) signal was stable over time. Acute and chronic pacing thresholds measured by VARIO and Autocapture tests correlated (r > 0.79) over the period of the study. The incidence of backup pulses was 1.1% during pacing. With Autocapture programmed ON, the overall total current consumption was 4.1 microA for VVI and 5.0 microA for VVIR pacing. This study proved that the Autocapture safely and reliably regulates the pacemaker's output according to the prevailing threshold thus providing maximum patient safety and prolonging service life.

Overexpression of the death-promoting gene bax-alpha sensitizes human BL-41 Burkitt lymphoma cells for surface IgM-mediated apoptosis

Major regulators of programmed cell death, or apoptosis, are the members of the bcl-2 gene family. Recently, we reported that surface(s) IgM triggering of the human B lymphoma cell line BL-41 led to strong induction of bax-alpha, a death-promoting member of the bcl-2 family, and subsequently to induction of apoptosis, suggesting a potential regulatory role of bax-alpha in sIgM-mediated cell death. In contrast, apoptosis-resistant subclones of this cell line showed only weak bax-alpha expression, which was not inducible by sIgM cross-linking. In this study, we were able to demonstrate the functional significance of this observation. We stably transfected bax-alpha into a BL-41 subline resistant against sIgM-mediated apoptosis. Several bax-alpha overexpressing clones could be selected, which all showed enhanced sensitivity for sIgM-mediated apoptosis. In contrast, no sensitive clone could be identified in a large number of mock controls. This clearly indicates that induction of bax-alpha is a critical regulatory step, which sensitizes B cells for sIgM-mediated apoptosis.

Involvement of NAK-1, the human nur77 homologue, in surface IgM-mediated apoptosis in Burkitt lymphoma cell line BL41

The induction of apoptosis via surface IgM (sIgM) in immature B cells requires de novo transcription. To investigate the regulation of activation-induced cell death (AICD) in B cells we used a cell line model consisting of an Epstein-Barr virus-negative Burkitt lymphoma cell line (BL41), which is highly sensitive, and a subclone which is resistant to sIgM-mediated apoptosis (BL41/B5). Resistance in this cell line was not due to down-regulation of sIgM or functional impairment in signal transduction of the surface Ig complex. The zinc finger transcription factor nur77 has been implicated to play an important role in CD3-mediated apoptosis in murine T cells. We were able to demonstrate that surface IgM ligation and subsequent apoptosis in BL41 cells is associated with a concomitant induction of NAK-1, the human nur77 homologue. Induction of NAK-1 mRNA and DNA binding activity in the nucleus could be readily observed by means of Northern blot and electrophoretic mobility shift assay, respectively. In contrast, the resistant clone BL41/B5 did not show any NAK-1 expression upon stimulation. This suggests a role for NAK-1 in sIgM-mediated apoptosis of immature B cells.

Induction of Bax-alpha precedes apoptosis in a human B lymphoma cell line: potential role of the bcl-2 gene family in surface IgM-mediated apoptosis

The members of the bcl-2 gene family are major regulators of programmed cell death, but their role in sIg-triggered apoptosis remains unclear. Using sensitive and resistant variants of the human B cell line BL-41, we studied the expression of the bcl-2 gene family during surface IgM-mediated apoptosis. We found constitutive Bcl-2 and Bcl-x expression, which remained unaltered after sIg cross-linking, in both resistant and sensitive cells. This and other experiments suggest that constitutive expression of Bcl-2 or Bcl-x alone is not sufficient to protect from activation-induced cell death in B cells. We therefore investigated Bax-alpha, the death-promoting splice variant of Bax, and found strong induction of both mRNA and protein upon sIg stimulation in sensitive cells. However, resistant subclones showed only weak expression, which was not inducible by sIg cross-linking. We provide evidence that up-regulation of Bax-alpha and the resulting imbalance of Bcl-2/Bax might be a major regulator of sIg-mediated apoptosis. Additionally, we found strong constitutive expression of Bcl-xs, the death promoting variant of Bcl-x, in sensitive cells, whereas resistant cells showed only weak Bcl-xs expression. Thus, we observed a much stronger expression of the death-promoting proteins Bax-alpha (inducible) and Bcl-xs (constitutive) in sensitive cells than in resistant cells. We therefore propose a potential role of the novel bcl-2 gene family members bcl-x and bax in surface IgM-triggered apoptosis.

Myocardial sarcoidosis. Clinical value of technetium-99m sestamibi tomoscintigraphy

STUDY OBJECTIVE

The presence of defects on rest thallium 201 myocardial scintigraphy, reversible after dipyridamole infusion, was already demonstrated in myocardial localization of sarcoidosis. The present study compared the respective efficiency of a new tracer of myocardial blood flow, 99mTc sestamibi (sestamibi), vs thallium 201 (TI) for the diagnosis and follow-up of myocardial sarcoidosis.

METHODS

Quantitative single photon emission computed tomography (SPECT) was performed in 37 consecutive patients with confirmed sarcoidosis and clinical suspicion of myocardial localization. Three successive scans were performed in all patients within the same day: rest TI SPECT, rest sestamibi SPECT, and dipyridamole sestamibi SPECT. Thirteen patients were reinvestigated after 3 months of corticosteroid therapy. The size and intensity of the defects were compared using a computerized quantitative analysis of bull's eye.

RESULTS

At rest, sestamibi SPECT is more sensitive than TI, demonstrating significantly larger defects (28.1 +/- 13.2% vs 17.2 +/- 12.8% of bull's eye area, p < 0.001) and detecting abnormalities in seven more patients (24 vs 17). All patients with abnormal TI scans also had sestamibi abnormalities. After dipyridamole infusion, sestamibi defects decreased significantly (28.1 +/- 13.2% vs 15.2 +/- 12.3%, p < 0.001). This improvement correlated with the evolution of sestamibi SPECT performed in the 13 patients reinvestigated after corticosteroid therapy (r = 0.85, p < 0.001).

CONCLUSIONS

We conclude that sestamibi SPECT is suitable for the diagnosis of myocardial sarcoidosis and represents an objective tool for the follow-up. The improvement after vasodilatation supports the hypothesis of reversible abnormalities in most of these patients and accurately predicts corticosteroid efficiency.

Early and delayed brain SPECT with technetium-99m-ECD and iodine-123-IMP in subacute strokes

The brain distribution of 99mTc-ECD versus 123I-IMP was compared in patients with subacute stroke in order to compare diagnostic accuracy.

METHODS

A total of 25 patients with subacute stroke underwent early and delayed SPECT imaging with 99mTc-ECD and 123I-IMP. Washout of 99mTc-ECD was calculated and a differential percentage of activity (DPA) of ischemic versus normal zones was assessed. Images were analyzed twice by five independent observers.

RESULTS

Technetium-99m-ECD clearance was 12.5% from the whole brain during early imaging. Ischemic parietal zones had higher clearance than normal parietal zones. Technetium-99m-ECD images showed larger differences between abnormal and normal brain activity than 123I-IMP images. Detection accuracy was slightly, but not significantly, higher for 99mTc-ECD and 123I-IMP (sensitivity: 73.8% as 66.6%; specificity: 81.7% as 81.6%). Reproducibility among observers was similar for 99mTc-ECD and early 123I-IMP.

CONCLUSION

Technetium-99m-ECD demonstrates high diagnostic accuracy during subacute stroke, similar to 123I-IMP, but with more intense, better delineation of the perfusion defects.

A chimeric transactivator allows tetracycline-responsive gene expression in whole plants

The chimeric transcriptional activator tTA, a fusion between the Tn10 encoded Tet repressor and the activation domain of the Herpes simplex virion protein VP16, was stably expressed in transgenic tobacco plants. It stimulates transcription of the beta-glucuronidase (gus) gene from an artificial promoter consisting of 7 tet operators and a TATA-box. Tetracycline, which interferes with binding of tTA to operator DNA, reduces gus expression over several orders of magnitude. This stringency of regulation suggests that the system can be used to construct transgenic plants encoding a potentially lethal gene product. Furthermore, the specific and fast inactivation of tTA allows study of the stability of RNAs and proteins.

Dual-isotope myocardial imaging: feasibility, advantages and limitations. Preliminary report on 231 consecutive patients

Two hundred and thirty-one patients underwent dual-isotope myocardial imaging (rest thallium-201 followed by stress technetium-99m sestamibi). The feasibility of the procedure was excellent: camera scheduling flexibility was improved and the duration of the procedure was less than that of a classical stress-redistribution procedure. Interpretation of defects due to image attenuation was facilitated by the different attenuation properties of 201Tl and 99mTc-sestamibi in 11 of 19 patients. 201Tl cross-over on 99mTc was found to be 15% +/- 3% with doses of 201Tl and 99mTc-sestamibi of 3 and 10 mCi, respectively, and 7% +/- 2% with doses of 3 and 20 mCi. This protocol should preferentially be reserved for patients with a history of myocardial infarction and/or a basal left ventricular dysfunction, in whom assessment of myocardial viability is of major interest. Extensive clinical validation of the dual-isotope procedure is required and optimal acquisition and reconstruction parameters should be established.

Non-matched images with 123I-IMP and 99mTc-bicisate single-photon emission tomography in the demonstration of focal hyperaemia during the subacute phase of an ischaemic stroke

Focal hyperaemia is a fairly common phenomenon in the subacute phase of an ischaemic stroke. This has rarely been reported with iodine-123 iodoamphetamine (IMP) and has never been identified using technetium-99m bicisate (99mTc-ECD). In this report, we present the case of a patient suffering from a left cerebral posterior stroke. 123I-IMP single-photon emission tomography (SPET) images showed a large area of significantly increased IMP activity located in the left occipital region whereas 99mTc-bicisate SPET displayed hypoactivity in the same area.

Comparison of brain SPECT using 99mTc-bicisate (L,L-ECD) and [123I]IMP in cortical and subcortical strokes

Single photon emission computed tomography (SPECT) using 99mTc-bicisate and N-isopropyl-p-[123I]iodoamphetamine ([123I]IMP) was compared in 25 patients suffering cerebral ischemia during the subacute phase (7-14 days) of stroke. Patients were classified as cortical strokes (15) and subcortical strokes (10) according to clinical and CT data. Images were analyzed by five independent blinded observers. Then, using a cross-matching method between normal and abnormal brain areas, we evaluated the sensitivity and specificity for 99mTc-bicisate and [123I]IMP and inter- and intraobserver reproducibility. A semiquantitative analysis was performed to compare abnormal hypoactive areas versus the corresponding contralateral areas for 99mTc-bicisate and [123I]IMP in the two patient groups. There was no significant difference for sensitivity and specificity between 99mTc-bicisate and [123I]IMP. Matching was approximately 90% in the two groups. The kappa-concordance index was satisfactory and slightly better for 99mTc-bicisate (0.485) than for [123I]IMP (0.435). Level of hypoactivity in the abnormal areas was significantly higher for 99mTc-bicisate (p < 0.03, n = 25) than for [123I]IMP, especially for cortical strokes. This comparative study demonstrates that 99mTc-bicisate is a very useful tracer for the detection of focal cerebral ischemia by SPECT during the subacute phase of stroke.

Coronary spasm induced by dipyridamole during a myocardial scintigraphy

A 59-year-old male underwent a dipyridamole myocardial scintigraphy. During dipyridamole infusion, a marked ST-segment elevation was observed in the inferior leads. After aminophylline injection, a short burst of ventricular tachycardia occurred, then the ST-segment elevation disappeared. The myocardial scintigraphy was consistent with myocardial ischemia of the inferior wall. The coronary angiography revealed no significant coronary lesion. Coronary spasm induced by dipyridamole remained the most probable mechanism for this complication.

99mTc-MAG3 and 99mTc-DMSA in the detection and assessment of pyelonephritis

In this report, we present the case of a patient suffering from recurrent acute pyelonephritis and who had a hypertrophic right kidney following left nephrectomy. 99mTc-dimercaptosuccinic acid (DMSA) scan is known to be of value in the diagnosis of pyelonephritis, based on the detection of parenchymal abnormalities. The kidney accumulation of 99mTc-mercaptoacetyl-glycylglycylglycine (MAG3) at 2-3 minutes also proves to supply useful information on cortical function. This case illustrates that 99mTc-MAG3 study may be an efficient complementary examination to 99mTc-DMSA scan in the detection and assessment of pyelonephritis.