Cuneiform nucleus stimulation-induced sympathoexcitation: role of adrenoceptors, excitatory amino acid and serotonin receptors in rat spinal cord

Stimulation of the midbrain cuneiform nucleus has previously been shown to produce increases in arterial blood pressure and lumbar sympathetic nerve activity. While this sympathoexcitatory effect is, in part, due to excitation of premotor sympathoexcitatory neurons in the rostral ventrolateral medulla, the specific spinal neurotransmitter systems recruited by cuneiform nucleus stimulation remains to be elucidated. In this study, mean arterial pressure, resting and cuneiform nucleus stimulation-evoked lumbar sympathetic nerve activity were analysed following intrathecal injections of an excitatory amino acid antagonist (kynurenic acid), alpha1-adrenoceptor antagonist (prazosin) and a serotonin receptor antagonist (methiothepin) in anesthetized, paralysed male Sprague-Dawley rats. Mean arterial pressure and resting sympathetic nerve discharge were decreased by all treatments (n = 6/group) compared to the vehicle control group. Intermittent electrical stimulation of the cuneiform nucleus produced a bimodal sympathoexcitatory response, of which the short latency peak was significantly attenuated (43% reduction) by intrathecal kynurenate whereas the long latency peak was reduced by intrathecal prazosin (decrease of 21%) and methiothepin (38% attenuation). These results are consistent with the significant roles of excitatory amino acid, alpha1-adrenergic and serotonin receptors in modulating the activity of sympathetic vasomotor preganglionic neurons supplying the lumbar sympathetic nerve trunk, and suggest the existence of at least three neuronal groups and/or pathways associated with the sympathoexcitatory response to cuneiform nucleus stimulation.

Effects of dietary lipid modification on adrenoceptor-mediated cardiovascular responsiveness and baroreflex sensitivity in normotensive subjects

To examine the effects of short-term dietary lipid modification on alpha- and beta-adrenoceptor-mediated cardiovascular responsiveness, 19 normal volunteers consumed either a high-fat or a low-fat diet for 2 weeks in an open, randomized, crossover study of 6 weeks' duration. Diets were balanced for sodium and potassium content. Adrenoceptor-mediated cardiovascular responsiveness was assessed by measuring blood pressure and heart rate responses to incremental infusions of phenylephrine and isoprenaline. Baroreflexes were studied by examining heart rate responses to phenylephrine and to the Valsalva manoeuvre. Total plasma cholesterol and low-density lipoprotein cholesterol levels both fell significantly (by 22% and 26%, respectively), on the low-fat compared with the high-fat diet, as did resting supine blood pressures and heart rate (by 6 mmHg systolic and 3 mmHg diastolic, and 5 beats/min). These changes were accompanied by a significant reduction in the systolic blood pressure response to isoprenaline. Blood pressure responses to phenylephrine and baroreflex sensitivity did not change. These results suggest that dietary fat intake alters cardiac beta-adrenergic reactivity without significant effects on vascular alpha-adrenoceptor mediated responses or baroreflexes.

Partial synergism between dextran-conjugated doxorubicin and cancer drugs on the killing of multidrug resistant KB-V1 cells

One of the major problems in cancer chemotherapy is the development of tumor resistance to drug treatment. In in vitro experiments, the stepwise selection of cancer cells resistant to a single antineoplastic agent may lead to resistance to multiple agents (multidrug resistance). One of the well known mechanisms leading to multidrug resistance is the over-expression of the mdr1 gene product, the 170 kDa membrane P-glycoprotein which is an ATP-driven efflux pump of xenobiotics. We studied the effects of dextran-conjugated doxorubicin in combination with colchicine, vinblastine and free doxorubicin respectively on the killing of human KB 3-1 carcinoma cells and its multidrug resistant subclone KB-V-1 cells. Cell survival was quantified by the tetrazolium salt MTT assay Cytotoxicity studies were designed so that data could be analyzed by the medium-effect principle and the calculated Combination Indices at different cell survival levels. When added alone conjugated doxorubicin was not as effective as doxorubicin in cell killing. When conjugated doxorubicin was combined with free doxorubicin or colchicine at high (over 75%) killing rates, a significant degree of synergism was observed in the killing of multidrug resistant KB-V1 cells. This synergism was not observed in non-resistant KB-3-1 cells nor when conjugated doxorubicin was combined with vinblastine.

Increased nerve growth factor inducible-A gene and c-fos messenger RNA levels in the rat midbrain and hindbrain associated with the cardiovascular response to electrical stimulation of the mesencephalic cuneiform nucleus

Functional neuronal connections associated with the cardiovascular response to unilateral low-intensity electrical stimulation of the mesencephalic cuneiform nucleus were examined in the halothane-anaesthetized and paralysed rat by in situ hybridization histochemistry using specific 35S-labelled oligonucleotides for detection of nerve growth factor inducible-A gene (NGFI-A) and c-fos messenger RNAs. Stimulation of the cuneiform nucleus increased mean arterial pressure and heart rate by 20 +/- 0.5 mmHg and 35 +/- 3 b.p.m., respectively, while no significant cardiovascular response was observed in animals stimulated in the inferior colliculus or in sham-operated animals. Cuneiform nucleus stimulation produced increased NGFI-A and c-fos messenger RNA levels in the Kölliker-Fuse and parabrachial nuclei ipsilaterally, and the cuneiform nucleus, dorsal periaqueductal gray and caudal ventrolateral medulla bilaterally at levels significantly greater than those in inferior colliculus-stimulated, sham-operated and naive, unoperated animals. NGFI-A, but not c-fos, messenger RNA expression was increased bilaterally in the caudal portion of the nucleus of the solitary tract and inferior olive. These results are consistent with previous neuroanatomical tract-tracing studies of afferent and efferent pathways from the cuneiform nucleus and indicate that these midbrain and hindbrain structures may be involved in the pressor and tachycardic responses associated with stimulation of the cuneiform nucleus. The ipsilateral nature of responses in certain brain areas may be explained by the absence of decussating pathways and/or the presence of multisynaptic connections which attenuate bilateral signal transmission. Characterization of these activated neuronal structures using other compatible labelling techniques should further elucidate the mechanisms by which these central nervous system structures are integrated in the cardiovascular responses to stimulation of the cuneiform nucleus.

Environments of the four tryptophans in the extracellular domain of human tissue factor: comparison of results from absorption and fluorescence difference spectra of tryptophan replacement mutants with the crystal structure of the wild-type protein

The local environments of the four tryptophan residues of the extracellular domain of human tissue factor (sTF) were assessed from difference absorption and fluorescence spectra. The difference spectra were derived by subtracting spectra from single Trp-to-Phe or Trp-to-Tyr replacement mutants from the corresponding spectrum of the wild-type protein. Each of the mutants was capable of enhancing the proteolytic activity of factor VIIa showing that the mutations did not introduce major structural changes, although the mutants were more susceptible to denaturation by guanidinium chloride. The difference spectra indicate that the Trp residues are buried to different extents within the protein matrix. This evaluation was compared with the x-ray crystal structure of sTF. There is excellent agreement between predictions from the difference spectra and the environments of the Trp residues observed in the x-ray crystal structure, demonstrating that difference absorption and particularly fluorescence spectra derived from functional single-Trp replacement mutants can be used to obtain information about the local environments of individual Trp residues in multi-tryptophan proteins.

Effect of dorsal periaqueductal grey lesion on baroreflex and cardiovascular response to air-jet stress

Certain areas within the periaqueductal grey (PAG) have been implicated in cardiovascular regulation. The influence of excitotoxic lesions of the caudal dorsal periaqueductal grey on the baroreceptor-heart rate reflex and the cardiovascular response to air-jet stress was examined in awake Wistar-Kyoto rats. Pressor (11 +/- 2 mmHg) and tachycardic (25 +/- 4 beats/min) responses to air-jet were not influenced by the lesion. Similarly, the resting MAP and HR were unchanged. However, the gain of the baroreflex was reduced from -3.9 +/- 0.1 to -2.8 +/- 0.3 beats/min per mmHg and the upper threshold was increased from 120 +/- 5 to 135 +/- 7 mmHg in the lesioned group. These observations suggest that although the caudal dorsal PAG does not appear to exert a tonic influence on vasomotor tone or mediate the air-jet response, it may provide a facilitatory input to the baroreceptor-heart rate reflex.

Effects of pravastatin on cardiovascular reactivity to norepinephrine and angiotensin II in patients with hypercholesterolemia and systemic hypertension

This study was conducted to examine the effects of short-term cholesterol reduction on cardiovascular reactivity in mildly hypertensive patients. Seven male and 7 female patients, aged 34 to 68 years, received pravastatin (40 mg/day) or matched placebo for 3 weeks in a randomized, double-blind, crossover study. Cardiovascular reactivity was assessed by measurement of blood pressure (BP) responses to incremental infusions of angiotensin II and norepinephrine, by cold pressor testing and isometric exercise. Compared with placebo, pravastatin caused significant reductions in plasma total and low-density lipoprotein cholesterol levels, which averaged 20% and 31%, respectively (both p < 0.0001), and in diastolic BP responses (expressed as the infusion rate required to raise BP by 20 mm Hg) to both angiotensin II (7.3 +/- 3.0 vs 9.7 +/- 4.7 ng/kg/min, p = 0.05) and norepinephrine (0.15 +/- 0.13 vs 0.38 +/- 0.33 micrograms/kg/min, p = 0.03). Systolic BP responses were similar with both treatments. Body weight, resting BP, and maximal BP responses to physical stressors were similar with each treatment.

Efficacy of pravastatin in combination with captopril in hypertensive patients

OBJECTIVE

To determine the efficacy of pravastatin in the treatment of primary hypercholesterolaemia in patients being treated with captopril for hypertension.

DESIGN

A double-blind parallel group study comparing 12 weeks of pravastatin therapy (20-40 mg/day) with placebo.

PARTICIPANTS

25 patients (age, 37-73 years) with mild-to-moderate hypertension and hypercholesterolaemia (total cholesterol level, 5.5-8.8 mmol/L).

RESULTS

Pravastatin reduced total cholesterol levels by 22% (from 7.1 +/- 0.29 [SEM] to 5.5 +/- 0.25 mmol/L; P < 0.001) and low-density-lipoprotein cholesterol levels by 32% (from 5.0 +/- 0.32 to 3.4 +/- 0.28 mmol/L; P < 0.001) in four weeks and these levels were maintained for the 12 weeks of therapy. Pre-pravastatin values returned three weeks after stopping therapy. Levels of total cholesterol, cholesterol fractions and triglycerides remained constant or deteriorated in the placebo group. Pravastatin therapy was well tolerated. An integrated coronary risk score showed a 40% reduction in risk.

CONCLUSION

This study indicates that pravastatin (combined with captopril) is an effective cholesterol-lowering drug, but that treatment needs to be maintained.

Short term effects of pravastatin on blood pressure in hypercholesterolaemic hypertensive patients

In this study, which was primarily designed to determine the lipid-lowering efficacy of pravastatin in the setting of background antihypertensive therapy with ACE inhibitors and calcium antagonists, we took the opportunity to examine whether pravastatin interacts with antihypertensive therapy to produce additional falls in blood pressure. This may help clarify the mechanism of action of pravastatin's rapid beneficial effects on cardiovascular morbidity. We treated 25 hypertensive hypercholesterolaemic patients with 12 weeks of either pravastatin or placebo in this double blind, placebo controlled parallel group study. Placebo treatment did not alter plasma lipids, whereas 12 weeks' treatment with pravastatin reduced total cholesterol by 27% (from 7.1 +/- 0.27 to 5.2 +/- 0.18, p < 0.001 compared with placebo) and low density lipoprotein cholesterol by 35% (from 4.9 +/- 0.36 to 3.2 +/- 0.17, p < 0.001). There were no changes in systolic or diastolic blood pressure either following 12 weeks' treatment or 3 weeks' withdrawal of pravastatin. Thus, pravastatin remains efficacious as a lipid lowering agent in the presence of antihypertensive therapy but does not enhance the blood pressure lowering action of these drugs. Therefore it is unlikely that blood pressure reduction is the mechanism by which pravastatin mediates its reported short term effects on cardiovascular morbidity.

Comparison of the pharmacokinetics and pharmacodynamics of perindopril, cilazapril and enalapril

1. The pharmacokinetic and pharmacodynamic responses to enalapril, perindopril and cilazapril have been studied in essential hypertensives (2, 4 and 8 mg perindopril and 2.5 mg cilazapril, single dose and steady state) and normotensive volunteers (10 mg enalapril, single dose). 2. Plasma levels of the active diacid compounds reached similar peaks after single dose administration of the drugs. However, perindoprilat levels persisted for 5 days whereas cilazaprilat levels were not detectable beyond 12 h. 3. The higher levels of perindoprilat were associated with a greater inhibition of plasma angiotensin-converting enzyme (ACE) activity in both acute and steady state studies. 4. The potency of the active diacids in inhibiting plasma ACE activity was perindoprilat greater than cilazaprilat greater than enalaprilat. 5. There was a close relationship between plasma concentration, ACE inhibition and blood pressure decrease. Although both cilazapril and perindopril administration reduced blood pressure in hypertensive subjects, only perindopril exerted 24 h blood pressure control at the doses used.

Cimetidine-associated adverse reaction

Cimetidine, a histamine2-receptor antagonist, is used in the treatment and prophylaxis of peptic ulcer disease. Its use is relatively free of serious adverse reactions and only a few accounts of hypersensitivity exist. We report a case of intravenous cimetidine-associated adverse reaction characterized by junctional rhythm, bradycardia, and hypotension apparently not secondary to rapid intravenous cimetidine infusion. The adverse reaction was reproduced upon rechallenge. No previous accounts of this reaction appear clearly defined in the literature nor have such reactions been confirmed by rechallenge.

The development of an expert computer system on medical consulation

In order to master fuzziness and uncertainty in solving human problems, an expert system shell SYSTEM Z-II which can handle both exact and inexact reasoning has been successfully developed. This paper describes how the Z-II system shell works in building a medical consultation expert system which accepts fuzzy human concepts and uncertain factors. This expert system ABVAB in the domain of "Abnormal Vaginal Bleeding" is described to demonstrate the power and flexibility of such system. The methods of approach in the development and testing of this system are presented together with the results.

Meta-analysis of randomised controlled trials of nicotine chewing-gum

A meta-analysis was made of fourteen randomised controlled trials that evaluated the efficacy of nicotine chewing-gum in stopping patients smoking. The combined success rates in specialised cessation clinics are significantly higher with nicotine gum (27%) than with placebo gum (18%) at 6 months (n = 734), and 23% and 13% at 12 months, respectively. In contrast, success rates in general medical practices are similar with nicotine gum (11.4%) and with placebo gum (11.7%) at 6 months (n = 1022). However, in general practices, the success rates are 17% for nicotine gum and 13% for the no gum control at 4-6 months, and 9% and 5% at 12 months, a significant difference between the treatments at each time (n = 2238). The data suggest that proper use of nicotine gum in specialised clinics will increase the rate of stopping patients smoking. The use of the gum in general medical practices is questionable.

Comparative angiographic right and left ventricular volumes

Comparative angiographic right and left ventricular volumes and right and left ventricular ejection fractions have been reported in the same normal infants and children. This relationship was assessed in adult patients to determine if these pediatric observations persist in later life. Seventeen adults, who had both right and left ventricular angiograms and who had no demonstrable organic heart disease, were studied. Right ventricular end-diastolic volume ranged from 54 to 98 (76 +/- 14, mean +/- SD) cc/m2 and left ventricular end-diastolic volume ranged from 48 to 90 (70 +/- 12) cc/m2; p less than 0.03. Right ventricular end-systolic volume ranged from 22 to 47 (33 +/- 8.0) cc/m2 and left ventricular end-systolic volume ranged from 13 to 34 (22 +/- 5.3) cc/m2; p less than 0.00005. Calculated right ventricular stroke volume ranged from 31 to 60 (43 +/- 8.3) cc/m2 and left ventricular stroke volume ranged from 29 to 70 (48 +/- 11) cc/m2; p = NS. Calculated right ventricular ejection fraction ranged from 0.48 to 0.62 (0.57 +/- 0.04) and the left ventricular ejection fraction ranged from 0.57 to 0.84 (0.68 +/- 0.07; p less than 0.00005. Both right ventricular end-systolic and end-diastolic volumes were greater than left ventricular end-systolic and end-diastolic volumes. This resulted in decreased right ventricular ejection fraction compared to left ventricular ejection fraction. The difference between the two ventricles may be due to compliance, muscle mass, and anatomic configuration with a net result of one chamber more completely emptying than the other. Thus it appears that the relationships between right and left ventricular volumes noted in infancy and childhood persist in adult life.

Detection and quantification of regional wall motion abnormalities using phase analysis of equilibrium gated cardiac studies

Phase images obtained from equilibrium gated cardiac studies were evaluated for qualitative and quantitative information and correlated with contrast angiography in 33 patients. The left ventricular region of interest was obtained by a semiautomatic procedure which avoided underestimation of size but also eliminated extraventricular pixels. Phase images and phase distribution histograms were arranged in three standard displays which included the whole heart, isolated left ventricle, isolated abnormal areas, and quantification of maximum phase shift in the whole free border and in the inferolateral and posterolateral segments. Only the free left ventricular border was evaluated. According to contrast angiography results, four categories were obtained: normal, hypokinetic, akinetic, and dyskinetic. The best correlation with contrast angiography was found with the results obtained by dividing the left ventricular free border in two segments (r = 0.91). Scheffe's test for multiple comparisons showed significant differences between each of the four categories. Expressed in phase shifts from the histogram mode, the lower limits for the three abnormal categories were established at 30 degrees, 78 degrees, and 156 degrees respectively for hypokinetic, akinetic, and dyskinetic segments. For distinguishing normal from abnormal segments, sensitivity = 83%, specificity = 94%, and accuracy = 89%. The main reasons for discrepant results appeared to be small hypokinetic areas in an otherwise normal ventricle, very large area of hypokinesia, segments adjacent to an area of marked abnormality, and ventricles with asynchrony (wave-like motion). The method described provides an image which characterizes myocardial synchrony, generates clear boundaries for abnormal areas, and lends itself to quantification.

Angiographic correlates of recurrent sustained ventricular tachycardia in chronic ischemic heart disease

We report the angiographic studies of 53 consecutive patients with angiographic coronary artery disease (CAD) and recurrent sustained ventricular tachycardia occurring at least 6 weeks remote from an acute myocardial infarction. Triple-vessel disease was present in 25 patients (47%), double-vessel disease in 19 patients (36%), and single-vessel disease in nine patients (17%). All patients with single-vessel disease had left anterior descending coronary artery obstruction. Patients under 50 years old had significantly fewer diseased vessels than those over 50 years old (1.4 vs 2.4 vessels diseased; p less than 0.025). Left ventricular ejection fraction ranged from 0.15 to 0.61 (mean 0.34 +/- 0.11) and was 0.25 or less in 14 patients (26%). All patients had regional wall motion abnormalities. There was akinesia and/or dyskinesia in 49 patients (92%). Akinesia or dyskinesia was inferior in 17 patients (32%), anteroapical in 14 patients (26%), inferoapical in 10 patients (19%), and anteroapicoinferior in 6 patients (11%). Involvement of the septum was noted in 19 patients (36%) and of basal segments in 26 patients (49%). An average of 2.7 (out of seven) segments per patient were dyskinetic or akinetic. Thus multivessel disease, markedly reduced ejection fraction, and severe and extensive regional wall motion abnormalities are generally present. These findings have pathophysiologic as well as clinical and therapeutic implications. The nautral history of these patients as well as the results of therapy should be related to the underlying coronary anatomy and left ventricular function.

Chronic recurrent right ventricular tachycardia in patients without ischemic heart disease: clinical, hemodynamic, and angiographic findings

Surgical cure of right ventricular tachycardia (RVT) has been recently described in patients with "arrhythmogenic right ventricular dysplasia," a disease characterized by abnormal electrical activation of the right ventricle and localized or generalized angiographic right ventricular (RV) wall motion abnormalities (WMA). In search of a selective RV cardiomyopathy complicated by chronic recurrent RVT, 38 consecutive patients (mean age 30.5 +/- 12 years) with RVT and no ischemic heart disease were studied clinically, noninvasively, and by cardiac catheterization including left and right ventriculography. RV volumes were as follow: end-systolic volume ranged from 23 to 103 (mean +/- SD, 45.8 +/- 20) cc/m2 and was abnormal in 14 patients (37%); end-diastolic volume ranged from 57 to 138 (90.5 +/- 26) cc/m2 and was abnormal in 15 patients (39%); ejection fraction (EF) ranged from 0.18 to 0.64 and was decreased in five patients (13%). Seventeen patients (45%) had abnormal RV volume, EF, and/or pressures (RVD), five (13%) of whom had abnormal LV volume, EF, and/or pressures (LVD), and 12 (32%) patients with RVD had no LVD. Twenty-one patients (55%) had no RVD, two of whom had LVD. Only two of the 17 patients had RV regional WMA, one with and one without LVD. Most patients with LVD five of seven (71%) also had RVD while 12 of 31 patients (39%) with no LVD had RVD. In conclusion, less than one half of patients with RVT had selective RV cardiomyopathy and more than one half of patients with RVT had normal RV hemodynamics and angiography.

Equilibrium radionuclide gated angiography in patients with tricuspid regurgitation

Equilibrium gated radionuclide angiography was performed in 2 control groups (15 patients with no organic heart disease and 24 patients with organic heart disease but without right- or left-sided valvular regurgitation) and in 9 patients with clinical tricuspid regurgitation. The regurgitant index, or ratio of left to right ventricular stroke counts, was significantly lower in patients with tricuspid regurgitation than in either control group (range and mean +/- standard error of the mean 0.4 to 1.0, 0.7 +/- 0.1 versus 1.0 to 1.5, 1.3 +/- 0.1 and 1.0 to 2.9, 1.5 +/- 0.1, respectively, p less than 0.001). Time-activity variation over the liver was used to compute a hepatic expansion fraction which was significantly higher in patients with tricuspid regurgitation than in either control group (1.4 to 11.4, 5.8 +/- 1.0% versus 0.6 to 3.4, 1.9 +/- 0.3% and 1.0 to 5.1, 2.3 +/- 0.2%, respectively, p less than 0.001). Fourier analysis of time-activity variation in each pixel was used to generate amplitude and phase images. Only pixels with values for amplitude at least 7% of the maximum in the image were retained in the final display. All patients with tricuspid regurgitation had greater than 100 pixels over the liver automatically retained by the computer. These pixels were of phase comparable to that of the right atrium and approximately 180 degrees out of phase with the right ventricle. In contrast, no patient with no organic heart disease and only 1 of 24 patients with organic heart disease had any pixels retained by the computer. In conclusion, patients with tricuspid regurgitation were characterized on equilibrium gated angiography by an abnormally low regurgitant index (7 of 9 patients) reflecting increased right ventricular stroke volume, increased hepatic expansion fraction (7 of 9 patients), and increased amplitude of count variation over the liver in phase with the right atrium (9 of 9 patients).

M-mode echocardiography in left bundle branch block: significance of frontal plane QRS axis

M-mode echocardiograms were obtained in 48 patients with complete left bundle branch block (LBBB). Of these 48 patients, 28 had LBBB with normal frontal plane QRS axis (-20 degrees to +90 degrees, mean +/- SD 18 degrees +/- 34 degrees), and 20 had LBBB with a left axis deviation (LAD) (-30 degrees to -60 degrees, mean +/- SD -48 degrees +/- 11 degrees). In the group with LBBB and normal axis, 25 patients had typical early mean +/- SD -48 degrees +/- 11 degrees). In the group with LBBB and normal axis, 25 patients had typical early systolic posterior septal motion characteristic of LBBB. Septal motion following early posterior septal motion (through the ejection period) was posterior in 24 patients (86%), anterior (paradoxical) in 2 (7%), and flat in 2 (7%). In the group with LBBB and LAD, 16 patients had the typical early systolic posterior septal motion; subsequent septal motion was posterior in 3 (15%), anterior (paradoxical) in 13 (65%), and flat in 4 (20%). Patients with LBBB and normal axis had a higher frequency of posterior septal motion, and patients with LAD had a higher frequency of anterior septal motion (p less than 0.001). The correlation of abnormal axis and paradoxical septal motion may be explained by the activation pattern producing LAD or by a septal disease process producing both abnormalities of axis and abnormal septal motion.

Captopril as treatment for patients with pulmonary hypertension. Problem of variability in assessing chronic drug treatment

We gave captopril, an angiotensin converting-enzyme inhibitor, to four patients with unexplained pulmonary hypertension to see if it would lower pulmonary arterial pressure or pulmonary vascular resistance. The patients were studied at rest and during supine bicycle exercise, before and after 48 hours of captopril treatment (up to 450 mg/day). During the treatment, each patient was monitored, with systemic and pulmonary pressures measured hourly, and cardiac output every two to four hours. We found no significant effect of captopril, either at rest or with exercise, on the cardiac output, pulmonary artery pressure, or pulmonary vascular resistance, measured at the end of 48 hours treatment. We noted, however, that during the 48 hour period, all patients showed pronounced swings in their pulmonary and systemic artery pressures and cardiac outputs that had no relation to the administration of captopril or time of day. We conclude that captopril appears to be ineffective in causing a sustained reduction in the pulmonary artery pressure or pulmonary vascular resistance in patients with primary pulmonary hypertension. It appears, however, that these patients experience spontaneous variability in their pulmonary resistance from hour to hour which needs to be further studied before a reliable assessment of long-term drug treatment can be made.

Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography

It has been shown that the measured reduction in the cross-sectional area of the left ventricle (LV), as viewed in the short axis, closely approximates its ejection fraction (EF). We assessed the reliability of using two-dimensional echocardiography (2DE) to visually estimate the EF during real-time viewing, without the need of digitizers, planimetry, or calculations. Twenty-five adult hospitalized patients with either suspected or known cardiac disease were evaluated prospectively. Each patient also had gated nuclear angiography during the same admission, and 14 had cardiac catheterization with left ventriculography. The EF was determined by 2DE using a visual estimate of the percent area reduction of the LV cavity in the short-axis view at the level of the papillary muscles. All 2 DE studies were read by two or more blinded reviewers, with a value for the EF to the nearest 2.5% determined by consensus. These values correlated closely to the values determined in all 25 patients with gated nuclear angiography (r = 0.927) and the 14 patients who had left ventriculography (r = 0.935). We believe that this method of visually estimating the LVEF will enable echocardiographers to easily use 2 DE for a reliable and instantaneous assessment of ventricular function, without the need of sophisticated analytical equipment.

Symptomatic spontaneous paroxysmal AV nodal block due to localized hyperresponsiveness of the AV node to vagotonic reflexes

Two apparently healthy patients had recurrent syncope with documented paroxysmal AV block. In both patients the site of AV block was demonstrated to be in the AV node. Coronary angiography (in both patients) and sustained deep inspiration (one patient) reproducibly initiated episodes of paroxysmal AV nodal block (identical to spontaneous episodes). Atropine abolished further attempts of AV block induction. Vagal hyperresponsiveness was limited to the AV node, since the interventions provoking paroxysmal AV nodal block produced only appropriate sinus slowing. This syndrome reflects hyperresponsiveness of the AV node to vagotonic reflexes, and exists as a clinically significant entity producing recurrent syncope.

Sequential regional phase mapping of radionuclide gated biventriculograms in patients with sustained ventricular tachycardia: close correlation with electrophysiologic characteristics

Radionuclide (RNA) gated studies were performed during sinus rhythm and during spontaneous or induced sustained ventricular tachycardia (VT) in six patients with clinical VT. Fourier analysis of time-activity variation was used to calculate a RNA phase value for each pixel in the image. Color coding of each pixel according to its calculated phase resulted in a RNA phase map of the ventricles. The following results were considered to be consistent with the known electrophysiology of VT: (1) the phase map correlated with QRS morphology and axis in most but not all tachycardias; (2) earliest phase usually demonstrated the VT origin to be at the border of the ventricular wall motion abnormality; (3) endocardial mapping (available in one patient) showed close correlation with RNA phase mapping; (4) in three patients with ischemic heart disease, VT with left bundle branch block (LBBB) pattern had earliest LV phase along the septum; and (5) for one patient imaged during two different VT morphologies, the tachycardias had earliest phase at different borders of the same wall motion abnormality with differing progression of phase across the ventricles. RNA phase mapping of VT is feasible and appears to provide data consistent with the electrophysiology of this arrhythmia.

Tricuspid insufficiency detected by equilibrium gated radionuclide study

The results of a gated radionuclide cardiac study are reported in a patient with biventricular failure and tricuspid insufficiency demonstrated by clinical evaluation, M-mode and 2-D sector echocardiography, and cardia catheterization. The processed gated radionuclide cardiac study showed a left ventricular/right ventricular stroke volume ratio of 0.5; expansion of the hepatic blood pool demonstrated by hepatic time activity curve and calculation of an "'expansion fraction"; and synchronous changes of count rate of the atrial and hepatic regions detected by phase analysis (similar phase shifts).

Procainamide-induced polymorphous ventricular tachycardia

Seven cases of procainamide-induced polymorphous ventricular tachycardia are presented. In four patients, polymorphous ventricular tachycardia appeared after intravenous administration of 200 to 400 mg of procainamide for the treatment of sustained ventricular tachycardia. In the remaining three patients, procainamide was administered orally for treatment of chronic premature ventricular contractions or atrial flutter. These patients had Q-T prolongation and recurrent syncope due to polymorphous ventricular tachycardia. In four patients, the arrhythmia was rapidly diagnosed and treated with disappearance of further episodes of the arrhythmia. In two patients, the arrhythmia degenerated into irreversible ventricular fibrillation and both patients died. In the seventh patient, a permanent ventricular pacemaker was inserted and, despite continuation of procainamide therapy, polymorphous ventricular tachycardia did not reoccur. These seven cases demonstrate that procainamide can produce an acquired prolonged Q-T syndrome with polymorphous ventricular tachycardia.

Left-to-right shunt via left superior vena cava communication with left atrium

The findings in a 22-year-old man with Ebstein's anomaly of the tricuspid valve, Wolff-Parkinson-White syndrome, and a persistent left superior vena cava are reported. This is the first reported case of this combination of anomalies in which the atrial septum was intact and the left superior vena cava communicated with the left atrium. Uniquely, blood was shunted left to right via the left superior vena cava from the left atrium. Only one previous case of left-to-right shunting via a left superior vena cava (in the absence of mitral valvular disease or cor triatriatum) has been reported (associated with aortic coarctation). Angiograms demonstrated the left atrial connection of the left superior vena cava to be at the entrance of the right superior pulmonary vein into the left atrium. In the absence of demonstrable left-sided heart disease, this anatomic juxtaposition is suggested as a possible explanation for the direction of shunting.

Paroxysmal atrial fibrillation in the Wolff-Parkinson-White syndrome

Eighty-eight patients with preexcitation were studied to determine how 30 patients with documented spontaneous paroxysmal atrial fibrillation differed from 58 patients without this arrhythmia. Inducible reentrant tachycardia was present in 23 (77 percent) of the 30 patients with, versus 28 (48 percent) of the 58 patients without, atrial fibrillation (p less than 0.025). Heart disease was present in 13 (43 percent) of the 30 patients with, versus 15 (26 percent) of the 58 patients without, atrial fibrillation (not significant). Inducible reentrant tachycardia or heart disease, or both, were significant). Inducible reentrant tachycardia or heart disease, or both, were present in 29 (97 percent) of the 30 patients with, versus 34 (59 percent) of the 58 patients without, atrial fibrillation (p less than 0.0005). Of 51 patients with inducible reentrant tachycardia, 23 patients with atrial fibrillation did not differ from 28 patients without this arrhythmia with respect to clinical features and atrial, sinus nodal, or anomalous pathway properties, or cycle length of induced reentrant tachycardia. Spontaneous degeneration of induced reentrant tachycardia to atrial fibrillation was observed in 6 (26 percent) of 23 patients with, versus none of 28 patients without, atrial fibrillation (p less than 0.025). In summary, patients with preexcitation and documented spontaneous paroxysmal atrial fibrillation almost always have inducible reentrant tachycardia or heart disease, or both. It is likely that in many patients with inducible reentrant tachycardia, spontaneously occurring reentrant tachycardia relates to induction of atrial fibrillation. However, it is unclear why some patients with inducible reentrant tachycardia have atrial fibrillation and others do not. In many patients with organic heart disease, atrial fibrillation could relate to hemodynamic changes.

Radionuclide regurgitant index: value and limitations

The radionuclide regurgitant index, defined as left ventricular/right ventricular stroke counts obtained from gated equilibrium studies, has been reported to predict the presence and severity of left-sided valve regurgitation. This study evaluated the radionuclide regurgitant index in 100 patients in whom left-sided valve regurgitation was angiographically graded (0 to 4+) with regard to most severe mitral or aortic regurgitation. Regurgitation was graded 0 in 44 of the 100 patients, 1+ in 22, 2+ in 8, 3+ in 6 and 4+ in 20. The radionuclide regurgitant index was 0.9 to 1.5 in 51 patients, 1.6 to 2.4 in 23 and 2.5 to 12.0 in 26. The mean radionuclide regurgitant index was 1.34 in the group with no regurgitation and 1.60 in those with 1+, 2.01 in those with 2+, 2.80 in those with 3+ and 3.85 in those with 4+ regurgitation. There was a significant difference (p less than 0.05) in the radionuclide regurgitant index between patients with no regurgitation and each group with regurgitation and between groups with regurgitation separated by two or more grades of angiographic regurgitation. Twelve patients had a discordant radionuclide regurgitant index; their index either predicted clinically significant or severe regurgitation when they had no or trivial regurgitation, or predicted no or trivial regurgitation when they had clinically significant regurgitation. Eight of 10 patients with a left ventricular ejection fraction of less than 0.30 had a discordant index (p less than 0.0005). All three patients with mitral valve prolapse associated with frequent ventricular extrasystoles had a discordant index (p less than 0.0005).

Oroantral fistula: broad-contact closure

1. A modified Rehrmann's buccal advancement flap technique is described for the treatment of medium-sized oroantral fistulae. 2. Its advantages are listed. 3. Disadvantages are: a slightly longer operating time, and because of the longer movement of the buccal flap the buccal sulcus temporarily is shallower than the traditional buccal flap technique. 4. The buccal sulcus however, is reconstituted after a period of two months.

Coronary hemodynamic and myocardial metabolic alterations accompanying coronary spasm

Arterial pressure, coronary sinus blood flow with the thermodilution technique and calculated coronary vascular resistance were measured and coronary arteriography performed at rest and after the administration of ergonovine in 14 patients with atypical chest pain (group 1) and 6 patients with variant angina (group II). Mild diffuse narrowing of the left coronary bed in group I was not accompanied by S-T segment shifts, and coronary vascular resistance did not change significantly. In contrast, severe focal spasm (greater than 90 percent narrowing) of the left anterior descending coronary artery in group II patients was accompanied by S-T elevation and a marked overall increase in coronary vascular resistance (from 0.65 +/- 0.07 to 1.14 +/- 0.10 mm Hg/ml per min) (P less than 0.005). In addition, the myocardial arteriovenous oxygen difference increased and net lactate extraction changed to lactate production in the two patients in group II in whom these measurements were made. Thus, thermodilution coronary sinus blood flow measurement may be a sensitive method for detecting primary increases in coronary vascular resistance due to a high grade focal spasm in the left anterior descending coronary artery.

Surgical access: the access-line concept

Adequacy of surgical access is determined by the position of the access line and not by the size of the flap as commonly believed. The case for small flaps in surgery is strongly argued for.

Apex sector echocardiography in evaluation of the right atrium in patients with mitral stenosis and atrial septal defect

Cross-sectional echocardiography utilizing the four chamber apical view was used to evaluate right atrial dimensions as a means of detecting abnormal right heart hemodynamics in 20 patients with mitral stenosis, 5 patients with an atrial septal defect and 10 patients without heart disease. Right and left atrial dimensions on apex echocardiography were 40 mm or less in control subjects. There was a good correlation (r = 0.81) between left atrial size assessed with apex sector and M mode echocardiography. In patients with an atrial septal defect, the left atrium was of normal size on apex sector echocardiography; in patients with mitral stenosis, it was larger on apex echocardiography (59 +/- 9 mm) than on M mode echocardiography (51 +/- 8 mm). The right atrium was enlarged (54 +/- 5 mm) on apex echocardiography in all five patients with an atrial septal defect, but the right ventricle was enlarged in only four. Seventeen of 20 patients with mitral stenosis had an enlarged right atrium (53 +/- 7 mm) on apex echocardiography, whereas 15 had normal right ventricular dimensions (21 +/- 9 mm) on M mode echocardiography. Right atrial size on apex echocardiography was enlarged (54 +/- 6 mm) in 10 of 11 patients with mitral stenosis and pulmonary arterial hypertension. Thus, evaluation of the right atrial dimension with apex echocardiography may be more sensitive than M mode echocardiography in detecting early right heart involvement in specific cardiac conditions.

Evaluation of a microscopy method for rapid detection and identification of Mycoplasma pneumoniae

A microscopy test that used the typical shape of Mycoplasma pneumoniae cells growing on glass was investigated for its value for diagnostic purposes. Suspensions from 108 throat swabs were infected artificially with 102, 103, and 104 colony-forming units of three M. pneumoniae strains per ml. Agar medium, a diphasic medium, and the microscopy method with liquid medium in cover slip chambers were compared for isolation of the mycoplasmas. The mycoplasms were detected first by the microscopy method in nearly all concentrations tested. Typical M. pneumoniae cells could often be detected after 48 h. No differences were found between a laboratory strain and two low-passage strains. The experimental results suggest that under special circumstances the microscopy method could be a useful tool for isolation and identification of M. pneumoniae.