Niclosamide Enema for Active Distal Ulcerative Colitis: A Phase 1, Open-Label Study

BACKGROUND

Oral and rectal formulations of 5-aminosalicylic acid are the first-line therapy for mild-to-moderate, distal ulcerative colitis (UC), but such a treatment is not effective in one-third of patients. Niclosamide is a small molecule, developed and approved as an orally administered drug to treat helminthic infections, with an excellent safety profile. Preclinical work showed that niclosamide is an anti-inflammatory agent, thereby providing the rationale to explore its safety and efficacy in patients with UC. This phase 1, open-label trial was aimed at assessing the safety of niclosamide formulated as an enema in patients with mild-to-moderate, distal UC, who relapsed on maintenance therapy with oral and/or rectal 5-aminosalicylic acid.

METHODS

Seventeen patients with active UC received niclosamide enema (150 mg/60 mL) twice a day for 6 weeks. The primary endpoint was the safety of niclosamide treatment. Secondary endpoints included clinical remission and improvements in endoscopic Mayo/histologic scores. Endoscopic remission percentages exclude participants meeting criteria at baseline for endoscopic remission.

RESULTS

Niclosamide was well tolerated by all 17 patients that were enrolled and treated. No serious adverse event was registered. Fifteen mild adverse events were registered in 6 patients and considered to be unrelated to the treatment. Clinical remission was achieved in 10 (59%) of 17 patients. Improvements of endoscopic Mayo score and histologic Geboes score were seen in 7 (58%) of 12 and 7 (41.2%) of 17 patients, respectively.

CONCLUSIONS

Niclosamide enema treatment is safe and well tolerated. Niclosamide improves clinical symptoms and endoscopic/histologic signs of UC; however, appropriately designed placebo-controlled clinical trials are required to confirm efficacy.

Discovery of LYC-55716: A Potent, Selective, and Orally Bioavailable Retinoic Acid Receptor-Related Orphan Receptor-γ (RORγ) Agonist for Use in Treating Cancer

Retinoic acid receptor-related orphan receptor γ (RORc, RORγ, or NR1F3) is the nuclear receptor master transcription factor that drives the function and development of IL-17-producing T helper cells (Th17), cytotoxic T cells (Tc17), and subsets of innate lymphoid cells. Activation of RORγ+ T cells in the tumor microenvironment is hypothesized to render immune infiltrates more effective at countering tumor growth. To test this hypothesis, a family of benzoxazines was optimized to provide LYC-55716 (37c), a potent, selective, and orally bioavailable small-molecule RORγ agonist. LYC-55716 decreases tumor growth and enhances survival in preclinical tumor models and was nominated as a clinical development candidate for evaluation in patients with solid tumors.

Inhibition of RORγT Skews TCRα Gene Rearrangement and Limits T Cell Repertoire Diversity

Recent studies have elucidated the molecular mechanism of RORγT transcriptional regulation of Th17 differentiation and function. RORγT was initially identified as a transcription factor required for thymopoiesis by maintaining survival of CD4⁺CD8⁺ (DP) thymocytes. While RORγ antagonists are currently being developed to treat autoimmunity, it remains unclear how RORγT inhibition may impact thymocyte development. In this study, we show that in addition to regulating DP thymocytes survival, RORγT also controls genes that regulate thymocyte migration, proliferation, and T cell receptor (TCR)α selection. Strikingly, pharmacological inhibition of RORγ skews TCRα gene rearrangement, limits T cell repertoire diversity, and inhibits development of autoimmune encephalomyelitis. Thus, targeting RORγT not only inhibits Th17 cell development and function but also fundamentally alters thymic-emigrant recognition of self and foreign antigens. The analysis of RORγ inhibitors has allowed us to gain a broader perspective of the diverse function of RORγT and its impact on T cell biology.

Abstract 4273: RORγ agonists as a novel immunotherapy approach for cancer

Agents that enhance activation or release suppression of the immune system could form the basis of new treatments for cancer. RORγt is the key transcription factor controlling the development and function of CD4+ Th17, CD8+ Tc17 and IL-17+ innate immune cells. RORγγmodulates expression of genes involved in multiple anti-tumor mechanisms and in some cancers Th17/Tc17 cells are reported to mediate potent and durable anti-cancer efficacy. To further enhance these responses, we designed small molecule RORγ agonists and characterized their activities on immune cells and utility in murine tumor models.

Synthetic agonists activate an RORγ-dependent reporter construct and when present during activation of murine or human T cells in vitro, increase production of IL-17A, IL-17F, IL-22 and GM-CSF without negatively impacting IFNγ production. Th17 and Tc17 cells differentiated in the presence of RORγ agonists exhibit decreased expression of inhibitory molecules such as PD-1, TIGIT, CD160, CD73 and increased expression of costimulatory molecules including CD137 (4-1BB) and CD226 (DNAM-1). Stimulation of CD4+ T cells with cytokine cocktails including TGFβ in vitro can generate Th17 and Treg cells; addition of RORγ agonists improves the Teff/Treg ratio via decreased FOXP3 and increased IL-17 expression. Functionally, RORγ agonist treatment reprograms cells to resist PD-1:PD-L1 mediated inhibition of proliferation and cytokine production. In vitro activation of OT-1 Tc17 cells with RORγ agonists generates potent effector cells that control the growth of large EG7 tumors when transferred into non-irradiated mice. The tumor-infiltrating lymphocytes from this model have enhanced survival, increased IL-17 production and decreased PD-1 expression. Oral administration of RORγ agonists to C57BL/6 mice significantly inhibits the growth of established, subcutaneous MC38 colon carcinoma tumors. The anti-tumor activity of RORγ agonists is dependent on T cells, as growth of MC38 cells implanted into scid mice is not affected by agonist treatment. RORγ agonists also inhibit growth of established, subcutaneous 4T1 mammary carcinoma tumors in Balb/c mice. In the tumors from agonist-treated animals there is significantly elevated expression of RORγ and IL-17 as well as decreased CD73 expression with evidence of decreased metastases.

As a transcription modulator, RORγ agonists increase immune activation and decrease immune suppression. These activities translate into robust anti-tumor effects in syngeneic tumor models and represent a promising approach for the treatment of cancer.

Citation Format: Xiao Hu, Jacques Moisan, Charles Lesch, Yahong Wang, Xikui Liu, Rodney Morgan, David Mertz, Brian Sanchez, Dick Bousley, Clark Taylor, Chad Van Huis, Thomas Aicher, Peter Toogood, Weiping Zou, Gary Glick, Laura L. Carter. RORγ agonists as a novel immunotherapy approach for cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4273. doi:10.1158/1538-7445.AM2015-4273

Novel RORgamma agonists enhance anti-tumor activity of adoptive T cell therapy (TUM2P.1010)

Adoptive cell transfer (ACT) therapy using tumor infiltrating lymphocytes (TILs) or T cells modified to express chimeric antigen receptors is a promising anti-cancer approach. Evidence suggests that Th17 or Tc17 cells display superior anti-tumor activity over unpolarized T cells commonly used in ACT clinical trials. As an approach to improve the potency and persistence of ACT, synthetic RORɣ agonists were designed to bolster the generation of type 17 cells. In vitro stimulation in the presence of RORɣ agonists modulates expression of costimulatory and coinhibitory molecules and increases IL-17A, IL-22 and GM-CSF production while maintaining IFNɣ production. Additional investigation revealed that treating tumor-specific Th0, Th17, Tc0 or Tc17 T cells with a RORɣt agonist in vitro significantly enhanced their ability to regress large and established EG.7 lymphoma and B16F10 melanoma tumors in vivo. Animals receiving RORɣ agonist-treated T cells had increased frequency of transferred cells, elevated IL-17A levels and decreased PD-1 expression in tumors and spleen compared to control animals. Previous studies have also shown that systemic delivery of an RORɣ agonist can also enhance anti-tumor immune response in syngeneic pre-clinical tumor models. By enhancing cytokine/chemokine production, promoting survival as well as decreasing PD-1 expression, RORɣ agonist molecules provide an effective means to enhance the potency of adoptively transferred T cell products.

Maternity validation using sire-only BovineSNP50 BeadChip data

Based on pairwise identity-by-state (IBS) distances and whole-genome SNP data, kinship was investigated in the Israeli Holstein population. A total of 789 bulls, including most of the artificial insemination sires in service since 1987, were genotyped by the BovineSNP50 BeadChip. This sample included up to five generations. For each bull-by-bull combination, three states are possible for each marker: no match, a single match and both alleles match. Summing over all markers, the 932 598 IBS scores (three match frequencies*310 866 bull-by-bull combinations) were visualized using three-dimensional coordinates that corresponded to the frequencies of the three possible states. Results were reduced to two dimensions using the transformations x' = 0.7071(1 + freq1-freq2) and y' = 1.2247freq0. Bull-by-bull pairs were grouped according to their level of kinship, and canonical scores were calculated using discriminant analysis and the x' and y' features. Of the 474 pairs of recorded maternal grandsire-grandson with both individuals genotyped, the probability for 28 pairs to belong to this level of kinship was low (P < 0.05), suggesting an error rate of around 3% per generation in pedigree determination.

Follicular characteristics and luteal development after follicle-stimulating hormone induced multiple ovulations in heifers

A protocol based on small doses of FSH was examined for the induction of double or triple (multiple) ovulations in cattle. Ovulation rate, follicular characteristics, and luteal responses were determined. In Exp. 1, three groups of estrous-synchronized, cyclic Holstein heifers were treated once daily, on d 3 to 6 of the cycle, with a FSH product (Folltropin-V): large FSH dose (total of 150 mg; n=18), medium FSH dose (total of 130 mg, n=12), and small FSH dose (total of 80 mg; n=7). Controls received saline (n=6). Prostaglandin F(2α) was injected on d 6, ultrasound-guided aspiration of surplus follicles (if needed) was performed on d 7, and GnRH was injected on d 8 to induce ovulation. The large FSH dose induced growth of more (2.6±0.3, P<0.05) large follicles than controls on d 8; medium and small FSH doses insufficiently stimulated growth of <2 large follicles. Ovulation rates were determined in subgroups of heifers (n=10, 13, 4, and 6, respectively). The large FSH dose induced greater rates (P<0.01) of mostly double and triple ovulations (90% multiple ovulations, 70% double ovulations), most of which (89%) were bilateral, with only 2 out of 10 heifers requiring aspiration of surplus follicles. Medium and small FSH doses induced fewer multiple ovulations (38% and 25%, respectively). Estradiol concentrations on d 8 did not differ among treatments, but the concentration per large follicle in controls was greater (P<0.05) than in FSH treatments. Mean corpus luteum (CL) volume in single-ovulation controls was greater (P<0.05) than that of multiple ovulations in the large FSH group and total CL volume and progesterone concentrations were numerically greater in multiple ovulations. In Exp. 2, the characteristics of follicles aspirated on d 7 from large FSH (n=11) and control heifers (n=10) were compared. Based on estradiol-to-progesterone ratio, 57% of the large FSH-treated follicles were classified as codominant/healthy follicles and 43% as subordinate/early atretic. Although concentrations of estradiol and androstenedione in FSH-treated codominant follicles were less (P<0.05) than in controls, estradiol-to-progesterone ratio indicated that those follicles were steroidogenically active. Finely tuned small doses of FSH administered during the first follicular wave can induce a large incidence of double/triple, mainly bilateral, ovulations in cattle, which may serve as a basis for treatment aimed at promoting twinning in beef cattle.

Effects of low-dose follicle-stimulating hormone administration on follicular dynamics and preovulatory follicle characteristics in dairy cows during the summer

The well-documented phenomenon of reduced conception rate in dairy cows during the hot season involves impaired functioning of the ovarian follicles and their enclosed oocytes. Three experiments were performed to examine the administration of low doses of follicle-stimulating hormone (FSH) to induce turnover of follicles that are damaged upon summer thermal stress and to examine whether this FSH administration has beneficial effects on preovulatory follicles. In experiment 1, synchronized heifers were treated with 100 mg of Folltropin-V (n = 7) or 4.4 mg of Ovagen (n = 6) on day 3 of the estrous cycle. Treatment with both FSH sources resulted in greater (P < 0.05) numbers of follicles than in control animals (n = 12) on day 6 of the estrous cycle, indicating that low doses of FSH can increase the number of emerging follicles in a follicular wave. In experiment 2, milking cows were assigned to a control group (n = 4) or treated with 2.2 mg (FSH-2.2; n = 6) or 4.4 mg (FSH-4.4; n = 5) Ovagen. Follicle-stimulating hormone was administrated on day 3 or 4 and day 10 or 11 of the estrous cycle, coinciding with emergence of the first and second follicular waves, respectively. The number of follicles emerging during the first wave tended to be higher (P < 0.1) in FSH-4.4-treated cows than in controls. The second-wave dominant follicles emerged 2 d later in the treated cows and were smaller in diameter (P < 0.05) than controls, 2 d before aspiration. Despite being younger, the preovulatory follicles of FSH-4.4 cows expressed a steroidogenic capacity that was similar to controls with a tendency toward greater insulin concentrations (P < 0.09). In experiment 3, milking cows were assigned to a control group (n = 6) or treated with 4.4 mg Ovagen (FSH-4.4; n = 6). Follicle-stimulating hormone was administrated on day 3 and day 12 or 13 of the estrous cycle. The number of emerging follicles was higher (P < 0.05) in the treated vs control cows. However, the features of the preovulatory follicle developed in the subsequent cycle did not differ between groups. In summary, low doses of FSH can efficiently induce follicular turnover accompanied by a modest effect on the preovulatory follicle of the treated cycle. It appears that the administration of low doses of FSH, precisely timed to synchronize with the emergence of follicular waves, might have a beneficial effect on the preovulatory follicle and its enclosed oocyte.

Abstract 4143: Bz-423, a novel benzodiazpine, inhibits PI3 kinase signaling in ovarian cancer cells

Objective: Bz-423 is a 1,4-benzodiazepine with immunomodulatory and cytotoxic properties. The effect of Bz-423 on survival signaling in lymphoid neoplasms predicts activity against similar pathways in ovarian cancer cells. Having previously established the cytotoxic activity of Bz-423 against ovarian cancer, we now characterize the mechanism of action.

Methods: Human ovarian cancer cell lines were maintained in culture. Cells were treated with Bz-423 or vehicle control. Cell survival and proliferation were evaluated, along with signaling mechanisms including the PI3-kinase-Akt-mTOR axis. DNA degradation (apoptotic fraction), mitochondrial function and caspase activation were evaluated by flow cytometry. Cytochrome c release and protein kinase activation were analyzed by immunoblotting. Apoptosome complex formation was monitored by gel filtration chromatography. Cellular ultrastructure was determined by electron microscopy (EM).

Results: Growth inhibition and apoptosis were observed in all ovarian cell lines following treatment with Bz-423. Caspase-9 and −3 cleavage, along with cytochrome c release were seen, consistent with activation of the intrinsic pathway of apoptosis. Early mitochondrial changes identified by ultrastructural evidence of mitochondrial swelling and the accumulation of superoxide within 1 hr of treatment were seen. Bz-423 induced cell death was associated with inhibition of Akt activation through a oxidant dependent mechanism. Antioxidants blocked Bz-423-induced signaling.

Conclusions: Bz-423 is a novel benzodiazepine being developed as a mitochondria targeted therapy, and displays anti-neoplastic activity against ovarian cancer cells in vitro. Results show that by acting on mitochondrial complex V, this compound inhibits PI3-kinase signaling, including the tumor survival factor Akt. PI3-kinase signaling is increasingly recognized as a survival and growth promoting mechanism in ovarian cancer. Since Akt inhibition by Bz-423 is dependent upon cellular bioenergetics and anti-oxidant balance, strategies employing this compound offer a selective new approach to target ovarian cancer cells.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4143.

In vitro enhancing oxidative phosphorylation by rapamycin in proliferative CD8+ T cells during antigenic priming augments the generation of long-lived memory T cells in vivo (101.11)

Oxidative phosphorylation is critical to the transition of effectors to memory T cells. However, whether increasing oxidative phosphorylation in proliferative CD8+ T cells during antigenic priming can augment memory T cell generation remains unknown. Using T cell receptor transgenic CD8+ T cells, we found that rapamycin significantly increased the oxidative phosphorylation in antigen-primed naïve CD8+ T cells in vitro without inhibiting their activation and proliferation. Augmented oxidative phosphorylation endowed the rapamycin-treated T cells great ability to survive after IL-2 withdrawal, whereas all the untreated control cells rapidly diminished. Rapamycin-treated CD8+ T cells expressed high levels of CD62L and CD127 but low levels of KLRG-1, PD-1 and IFN-γ. When adoptively transferred in vivo, CD8+ T cells derived from rapamycin-treated cultures generated 5-fold more memory T cells over a period of 6 months than control cells. These long-lived memory T cells had potent ability to produce IFN-γ and proliferate when reexposed to the specific antigen both in vivo and in vitro. These data indicate that augmentation of oxidative phosphorylation in T cells by rapamycin in vitro during antigenic priming dramatically increases both the number and quality of memory precursors, thereby enhancing the generation of long-lived memory T cells. Our findings may have significant implications in optimizing T cell properties to improve the efficacy of adoptive immunotherapy.

Unusual echocardiographic appearances attributable to submitral calcification simulating left ventricular "masses"

Using M-mode and cross-sectional echocardiography, we visualized in five patients abnormal large echos attributable to anterior submitral calcification or sclerosis (on or near the ventricular aspect of the anterior mitral leaflet). Such abnormal echos on M-mode echocardiography could have been mistaken for a mass in the left ventricular chamber. Autopsy in two cases confirmed the presence of nonrheumatic anterior submitral calcification. Echocardiographic features of anterior submitral calcification which are helpful in differentiating it from neoplastic or thrombotic ventricular masses include (1) less diastolic mobility and more echo density; (2) continuity with the base of the anterior mitral leaflet and/or the posterior aortic root region, whereas tumors or thrombi are attached to the left ventricular wall; and (3) calcification in the region of posterior "mitral annulus." Cross-sectional long-axis views and M-mode scanning from the left ventricle to the aortic root were particularly helpful in making the differentiation.

Submitral calcification or sclerosis in elderly patients: M mode and two dimensional echocardiography in "mitral anulus calcification"

Submitral calcification or sclerosis was visualized with M mode echocardiography in 84 elderly patients, 35 of whom were also studied with two dimensional echocardiography. Posterior submitral calcification, commonly referred to as "mitral anulus calcification," was present in 82 patients and was located in the angle between the posterior mitral leaflet and left ventricular posterior wall, rather than in the mitral anulus proper. M mode scans from the left ventricle to the left atrium showed that posterior submitral calcification ended abruptly in 66 cases, and in these it became contiguous with the posterior atrioventricular junction (true mitral anulus) in only 14 instances, in 16 patients the posterior submitral calcification sloped anteriorly to merge with the posterior aortic root. Anterior submitral calcification was visualized in 12 patients, 10 of whom also had posterior submitral calcification. Anterior submitral calcification was usually located immediately anterior to the base of the anterior mitral cusp. In two cases, if appeared to arise in the region between the aortic and mitral rings; in one instance, it was located in the mid left ventricle, in the mitral chordal region. We suggest that the terms anterior and posterior submitral calcification are more appropriate than "mitral anulus calcification" because in most cases such calcific deposits do not appear to be located in or to arise from the true mitral anulus.

The superiority of mitral E point-ventricular septum separation to other echocardiographic indicators of left ventricular performance

M-mode echocardiography, angiocardiography, and coronary arteriography were done in 40 patients with coronary heart disease, 12 with congestive cardiomyopathy, and 14 with no detectable cardiac or coronary abnormality. We measured mitral E point-ventricular septum separation (EPSS) at the moment of the E peak; the previously described method measures EPSS as the vertical distance between the nadir of systolic septal motion and the subsequent mitral E peak. Angiocardiographic ejection fractions correlated better with EPSS (r = 0.83) than with left ventricular (LV) end-diastolic internal diameter (r = 0.62), LV internal diameter systolic shortening fraction (r = 0.64), LV echocardiographic ejection fraction (r = 0.70), and LV posterior wall systolic thickening (r = 0.58). Patients with angiocardiographic ejection fractions below 55% usually had EPSS values over 10 mm by our method. Six false negatives and one false positive occurred. Our observations in patients with impaired LV performance suggest that LV dilatation, and especially dilatation of the LV outflow tract, is relatively more important than reduction in the amplitude of diastolic anterior mitral excursion in the production of high EPSS values. Although the usual method for measuring EPSS and ours are equally satisfactory, ours has certain theoretical advantages.

Effects of veratrine on the in situ dog heart: evidence for increased ventricular fibrillation threshold

The present work studied the effect of veratrine on electrical stability of the mammalian ventricles. In a group of anesthetized open-chest dogs we determined the effects of veratrine (0.001-0.3 mg/kg) on the threshold for ventricular fibrillation (VFT), both during sinus rhythm (SR) and during atrial drive (AD) at 166 +/- 7 beats/min. Veratrine (0.3 mg/kg) increased the VFT during SR from control levels of 33 +/- 5 mA to 56 +/- 4 mA (P less than .05) and during AD from 34 +/- 6 to 57 +/- 9 mA (P less than .05). VFTs after infusion of veratrine were higher than in a control group of dogs given the saline diluent in which VFT during SR was 26 +/- 3 mA (P less than .001) and during AD was 24 +/- 3 mA (P less than .005). The increase in VFT during SR was independent of the decrease in heart rate, which fell from 147 +/- 8 to 106 +/- 6 beats/min (P less than .001). It was associated, however, with an increase in the QT interval during SR from control values of 254 +/- 13 to 308 +/- 19 msec (P less than .02) and during AD from 238 +/- 8 to 267 +/- 8 msec (P less than .005). We conclude that small doses of veratrine increase the electrical stability of the ventricles in the normal dog heart.

A perfused canine right bundle branch-septal model for electrophysiological studies

As documented in the literature, isolated ventricular muscle preparations perfused with protein-free media become edematous and deteriorate. We hypothesized that the addition of colloid oncotic pressure to the perfusion medium might affect favorably the electrical characteristics and survival of an isolated right bundle branch-septal muscle preparation perfused via the anterior septal artery. Perfusion with protein-free Tyrode solution produced edema formation and a loss of transmembrane potential of Purkinje and muscle cells within 5.9 +/- 0.40 h. Addition of bovine albumin, 4 g/100 ml, to the Tyrode solution or perfusion with horse serum greatly reduced the formation of edema. Furthermore, intact electrical activity continued for more than 9 +/- 0.31 h (P less than 0.001). The preparations showed a greater diastolic potential and action potential amplitude during perfusion than during superfusion with Tyrode solution.

IN CONCLUSION

1) a viable, perfused septal muscle preparation was developed for electrophysiological studies, and 2) colloid oncotic pressure in the perfusion medium is essential to preserve the integrity of the capillary circulation and to eliminate edema formation and tissue death.

Aspirin inhibits development of coronary atherosclerosis in cynomolgus monkeys (Macaca fascicularis) fed an atherogenic diet

The effect of aspirin in the primary prevention of diet-induced atherogenesis in cynomolgus monkeys was studied. The diet consisted of 2% cholesterol and 10% butter by weight for 24 wk. Six monkeys received only the atherogenic diet and five monkeys received the diet plus aspirin, 81 mg/monkey per day. Aspirin did not affect plasma cholesterol levels or aortic atherosclerosis. Platelet aggregation to arachidonic acid was almost completely suppressed. Aspirin decreased significantly the number of coronary vessels with atherosclerotic involvement, and the number of coronary vessels narrowed by 20% or more. Thus, aspirin appears to exert a protective effect in the primary prevention of diet-induced coronary atherosclerosis in a primate model.

Effects of hypertonic mannitol on cardiac lymph in nonischemic myocardium

This investigation was designed to elucidate the effects of hypertonic mannitol on the nonischemic myocardium. In anesthetized open-chest dogs, we collected cardiac lymph for 2 h before and for 4 h during the infusion of hypertonic mannitol or normal saline. We studied the changes in the volume of lymph flow and the release of lysosomal enzyme acid phosphatase and protein into the cardiac lymph. In group 1 (n = 7) and group 3 (n = 8), the effects of 1-h and 4-h infusions of mannitol were studied, respectively. In these dogs, mannitol caused significant rises in lymph flow and release of total acid phosphatase into the cardiac lymph. In group 3, protein efflux increased significantly. In group 2 (n = 5) and group 4 (n = 4), infusion of normal saline for 1 and 4 h did not significantly change the release of total acid phosphatase and proteins into the cardiac lymph. Thus, infusion of hypertonic mannitol for 1--4 h in the nonischemic myocardium may have some deleterious effects because of its apparent ability to impair lysosomal membranes and to increase capillary permeability.

Echocardiographic diagnosis of dilatation of the ascending aorta using right parasternal scanning

With the ultrasound transducer positioned at the second or third right intercostal space, the ascending aorta was visualized in 8 patients in whom dilatation of the ascending aorta had been demonstrated radiographically. The diameter of the ascending aorta by right parasternal scan, with the transducer held perpendicular to the chest wall, measured 4.2-6 cm. The aortic root diameter (at aortic valve level) recorded by conventional left parasternal scan was normal or only slightly increased in 5 cases, but in 3 others it approached the value obtained by right parasternal scan. Aortography performed in 3 patients demonstrated marked dilatation of the ascending aorta.

Echocardiographic detection of cardiac involvement in patients with chronic renal failure

Echocardiography was performed in 50 patients in chronic renal failure with symptoms suggestive of possible cardiac involvement. Pericardial effusions were detected in 33 and pericardial thickening in 22. In five patients solid material, probably fibrinous, was seen adherent to the parietal or visceral pericardium. The left ventricle was dilated in 18 patients and showed definitely impaired contractility in 16. The left ventricular (LV) posterior wall was abnormally thick in 19 patients. In two, the ventricular septum was more than 1.3 times as thick as the LV posterior wall. Other echocardiographic findings included calcification in the mitral annulus region, mitral valve vegetations, and thickened chordae tendineae. Echocardiography has proved to be of great help in the assessment of symptomatic patients with chronic renal failure not only in diagnosing the presence and extent of pericardial effusion and thickening, but also in detecting impaired myocardial contractility, calcification in the posterior mitral annulus region, and vegetations of bacterial endocarditis.

Diet-induced atherosclerosis and experimental hypertension in stumptail macaques (Macaca arctoides). Effects of antihypertensive drugs and a non-atherogenic diet in the evolution of lesions

This study was carried out to determine the evolution of atherosclerotic lesions during a therapeutic period during which regression might be appreciated. We produced aortic and coronary atherosclerosis in 27 young adult stumptail macaques (Macaca arctoides) by feeding a diet supplemented with 2% cholesterol and 25% fat. Hypertension was produced by bilateral or unilateral narrowing of the renal artery. After six months of this regimen, four monkeys were killed (group 1) and 23 monkeys were divided into three groups: group 2 received unsupplemented diet; group 3 received the same diet as group 2 and drug treatment for hypertension; group 4 was continued on the atherogenic diet and received antihypertensive drug treatment. The results indicate that deleting the atherogenic diet leads to a decrease in the lipid content of the lesions and a transformation of the lipid laden atherosclerotic plaques into lipid-poor, fibro-collagenous lesions, with a decrease in the amount of coronary luminal narrowing. Partial control of systolic hypertension by antihypertensive drugs did not accelerate the involution of the atherosclerotic lesions over the relatively short period of this study. No statistically significant correlation by regression analysis was observed between the level of blood pressure elevation, the plasma renin activity, or the degree of the drug response, and the severity and extent of the atherosclerotic lesions. Furthermore, severe arterial hypertension without an atherogenic diet (group 5) produced arteriosclerosis of the aorta, and intensified branch cushions in the coronary arteries, without inducing lipid deposition in either vascular bed.

Successful treatment of drug-resistant atrial tachycardia and intractable congestive heart failure with permanent coupled atrial pacing

Temporary coupled atrial stimulation slowed the ventricular rate by nearly 50% in an adolescent patient with intractable congestive heart failure and focal repetitive atrial tachycardia that was resistant to drug treatment. Because of the success with the temporary pacemaker, a specially designed permanent pacemaker was implanted to provide coupled atrial stimulation. The necessary electrophysiologic conditions for ventricular slowing by coupled atrial pacing are: (1) an atrial effective refractory period shorter than that of the atrioventricular junction, and (2) depolarization of the ectopic atrial pacemaker by the responses to coupled atrial stimulation. During a 4 year follow-up period the treatment resulted in elimination of the tachycardia, followed by return of the heart size to normal and complete clinical recovery. Coupled atrial stimulation can provide effective treatment in selected patients with disabling drug-resistant atrial tachycardia in whom this mode of therapy is shown to be effective by careful electrophysiologic studies.

Echocardiographic features of second degree atrioventricular block

Echocardiographic studies demonstrated abnormalities of motion of the pulmonary valve, the aortic root and valve, the mitral and tricuspid valves, the left ventricle, and the left atrium in two patients with second-degree atrioventricular block. During Wenckebach 3:2 atrioventricular conduction, ventricular beats exhibited alternately long and short periods of systolic opening of the pulmonary and aortic valves and alternately large and small left ventricular stroke volumes. During 4:3 and 3:2 Wenckebach atrioventricular conduction, the left ventricular stroke volume was directly proportional to the preceding end-diastolic volume. During 2:1 atrioventricular conduction, the blocked atrial contractions may produce movements of the left atrial wall, thereby revealing the true atrial rate when the blocked P waves are obscured in the electrocardiogram by their superimposition on preceding T waves.

Effects of methylprednisolone on cardiac lymph in acute myocardial ischemia in dogs

It has been proposed that administration of pharmacologic doses of glucocorticoids may be beneficial in the setting of acute myocardial ischemia because of their ability to stabilize lysosomal membranes and thereby to prevent the leakage of proteolytic enzymes into the cytoplasm and interstitium. We collected cardiac lymph in anesthetized open-chest dogs in successive 2-h periods and used acid phosphatase as our marker lysosomal enzyme. In group 1 (n=5), we studied the effect of time alone. In these dogs, the total amount of acid phosphatase decreased (P less than 0.05). In group 2 (n=5), methylprednisolone, 30 mg/kg iv, was given. This drug did not change any variable we measured. Ligation of the circumflex coronary artery in group 3 (n=7), produced a significant increase (P less than 0.05) in the amount of acid phosphatase drained from the heart compared to group 1. In the dogs of group 4 (n=5), methylprednisolone did not reduce, and may have augmented, the total amount of acid phosphatase draining from the heart. Thus glucocorticoids do not appear to reduce the amount of acid phosphatase released by the ischemic myocardium into the cardiac lymph.

Effects of propranolol, minoxidil, and clofibrate on cholesterol-induced atherosclerosis in stumptail macaques (Macaca arctoides)

Propanolol, minoxidil, and clofibrate, three different classes of pharmacological agents used clinically in various conditions related to atherosclerosis, were shown not to have any intrinsic potentiating effects on the development of atherosclerosis in stumptail macaques fed an atherogenic diet. We did obtain, however, some results that suggest that clofibrate and propranolol may exert some beneficial actions.

Potential pitfalls in quantification of pericardial effusions by echocardiography

In the echocardiographic assessment of patients with pericardial effusions, the apparent width of the echo-free space between the left ventricular posterior wall and the parietal pericardium is commonly used to estimate the amount of pericardial fluid present. In 4 patients with pericardial effusions, we showed a distinct disparity between the widths of the posterior pericardial space at different levels of the left ventricular posterior wall. In 2 of them, a 'swinging heart' appearance was recorded when the ultrasoound beam was directed caudally, but not when its direction was cephalad or less caudad. It is suggested that the left ventricle should be scanned at all possible sites to minimise potential errors in estimating the amount of a pericardial effusion.

Attenuation of cardiac sympathetic drive in experimental myocardial ischemia in dogs

Sympathetic discharges to the heart were recorded from the left inferior cardiac nerve of 16 dogs. Inferior cardiac nerve activity (ICNA) under normal conditions consisted of grouped discharges, synchronous with the cardiac cycle and modulated by respiration. After ligation of the circumflex branch of the left coronary artery, ICNA declined concomitant with a decline in heart rate and mean aortic pressure. After 30 minutes, when arterial pressure tended to recover toward control values (six dogs), ICNA remained low; in contrast, when arterial pressure dropped to shock levels (three dogs), ICNA increaed. When aortic pressure fell precipitously as a result of ventricular fibrillation, even during the first 30 minutes of ischemia (seven dogs), ICNA immediately increased greatly. The results of this study suggest that acute coronary occlusion produces a cardiocardiac depressor reflex with attenuation of sympathetic discharge to the heart. This reflex, under the experimental conditions studied, gives way to the baroreceptor reflex when aortic pressure drops to critically low levels.

Flutter of left ventricular structures in patients with aortic regurgitation, with special reference to patients with associated mitral stenosis

Echocardiography was performed in 45 patients with aortic regurgitation. Forty showed a high frequency diastolic flutter of the mitral valve, which was holodiastolic in all but the patients with associated mitral stenosis. Of four patients with coexisting mitral stenosis, mitral flutter was absent in two; in the other two, in atrial fibrillation, mitral flutter occurred, but only during a fixed interval after mitral valve opening, irrespective of cycle length. A fine flutter of similar frequency was observed on the left ventricular aspect of the ventricular septum in 12 patients. In six of these it was of slight degree and restricted to early diastole and the high septum; in four others (three of whom had associated mitral stenosis), the septal flutter was more marked, holodiastolic, and present over all parts of the septum scanned; in two, it was holodiastolic over the high septum but early diastolic at lower septal levels. Aortography performed in 19 patients showed that septal flutter was present in seven of 12 patients in whom the regurgitant aortic jet was directed forward to the ventricular septum, whereas in the other seven patients with no septal flutter, the jet was directed away from the septum. Septal flutter is useful as an echocardiographic sign of aortic regurgitation, especially in the presence of mitral stenosis when mitral flutter may be absent or exceeded by septal flutter in both amplitude and duration, and when the mitral valve has been replaced by a prosthetic valve. Vibration of the septum appears to be attributable to the regurgitant aortic jet impinging on it and may contribute to the production and radiation of the characteristic diastolic murmur of aortic regurgitation.

Echocardiography in mechanical alternans. With a note on the findings in discordant alternans within the left ventricle

We described the echocardiographic manifestations of mechanical alternation of left ventricular (LV) contraction during regular sinus rhythm. Chronic LV dilatation and failure existed in all our four cases. Alternation was observed with respect to the following echocardiographic variables: amplitude and rate of increase of amplitude of systolic excursions of the LV posterior wall and ventricular septum (VS); reciprocal changes in the duration of LV ejection and pre-ejection periods (on the aortic valve echo) such that the total duration of LV electromechanical systole remained constant; reciprocal changes in the duration of RV ejection and pre-ejection periods (on the pulmonic valve echo) such that the total duration of RV electromechanical systole remained constant; systolic anterior excursion of the aortic root as a whole; steepness of the mitral EF slope; septal and LV posterior wall diastolic position; and end-systolic LV diameter. In two patients, discordant alternans of the motion of the LV posterior wall and the VS was observed.

Direct effects of various catecholamines on liver circulation in dogs

As measured by electromagnetic blood flow transducers, direct infusion of epinephrine, norepinephrine, and dopamine into the portal vein (PV) produced a 40-50% decrease in hepatic arterial (HA) blood flow; isoproterenol increased HA flow by about 69%. No changes in PV flow or pressure were observed. Direct HA infusion of the vasoconstrictors decreased HA flow by amounts comparable to those occurring after PV infusion. However, HA infusion of isoproterenol increased HA flow only 15% suggesting a difference in beta-receptor population in the two vessels. When infused directly into the superior mesenteric artery (SMA), epinephrine and norepinephrine reduced SMA flow by about 45% and PV flow by 20-25%; HA flow increased 6-8%. Infusion of isoproterenol and dopamine into SMA increased SMA flow by 115% and 206% and PV flow by 60% and 70%, respectively, whereas HA flow decreased by 25% and 50%. Portal vein pressure increased less than 3 mmHg. Alpha- and beta-receptor blockade of the liver did not change significantly the alterations in hepatic arterial blood flow that were secondary to changes in portal venous blood flow. It is likely that regulation of hepatic arterial flow resides in mechanisms located within the liver sinusoids.

Effects of veratrine on repolarization in the canine right bundle branch

Superfusion of Purkinje fibers in the canine right bundle branch with Tyrode solution containing veratrine, less than or equal to 1 mug/ml, prolonged repolarization phases 2 and 3 and induced a long-lasting negative after-potential that ended in some experiments with a slightly hyperpolarized resting transmembrane potential. The alterations in repolarization time were reversed by washout with veratrine-free Tyrode solution or by adding tetrodotoxin to the veratrine-containing Tyrode solution to a concentration of 0.1 and 1 mug/ml. The effect of veratrine on the repolarization time was more prominent at slower driving rates. Its effect on repolarization of ventricular muscle cells was smaller than that on the repolarization of Purkinje fibers. In the concentrations used, veratrine did not induce multiple responses.

Diagnosis of cardiac tamponade by echocardiography: changes in mitral valve motion and ventricular dimensions, with special reference to paradoxical pulse

The echocardiographic findings in three patients who presented with pericardial effusion and cardiac tamponade are described. Cyclic respiratory changes affected the diastolic movement of the anterior mitral leaflet, viz., during inspiration its anterior excursion decreased in amplitude and the E-F slope diminished. This inspiratory alteration in mitral valve motion was accompanied by an increase in right ventricular dimensions and a reciprocal decrease in left ventricular dimensions. Pericardial paracentesis confirmed the presence of effusion and relieved cardiac tamponade in all the patients. Repeat echocardiography, performed in two of the patients immediately after the pericardial tap, showed that the E-F slope had become steeper and that phasic respiratory variations in the diastolic motion of the anterior mitral leaflet were no longer present. The compatibility of our observations with the theories which endeavor to explain the mechanism of the paradoxical pulse in pericardial effusion with cardiac tamponade is discussed. We suggest that the abnormalities in anterior mitral leaflet motion defined by echocardiography constitute a useful addition to the study of patients with suspected cardiac tamponade resulting from pericardial effusion.

Cardiac lymph flow and composition in acute myocardial ischemia in dogs

Cardiac lymph was obtained from 12 normal dogs (group 1) for two consecutive 2-h control periods and from 7 dogs (group 2) for 2 h before and 2 h after occlusion of the circumflex branch of the left coronary artery. Lymph composition was studied with reference to pH, red blood cell (RBC) concentration, total protein content, potassium and sodium ion concentrations, and creatine phosphokinase (CPK) and acid phosphatase enzyme activities. No significant difference was noted in any variable between the two groups during the firts 2-h period. In group 1, no significant changes occurred in any variable as a result of the passage of time alone. In group 2, 2 h of myocardial ischemia produced increases of 53.3 plus or minus 5.1% in lymph flow, 67 plus or minus 5% in protein content, and 418 plus or minus 27% in the RBC concentration, suggesting increased blood capillary permeability. Lactate rose 120.5 plus or minus 27%, potassium concentration increased 16.9 plus or minus 2.4%, acid phosphatase increased 30 plus or minus 3%, and CPK rose 61.6 pluse or minus 10.9%, suggesting ischemic injury of myocardial cells. These changes in lymph were statistically significant (P LESS THAN 0.05) and reflect both capillary and myocardial cell abnormalities.

Electrocardiographic studies in the stumptail macaque (Macaca arctoides)

Our study has defined normal electrocardiographic standards for Macaca arctoides. It appears that certain species differences exist in the electrocardiogram (ECG) in monkeys and that different criteria for normality may be necessary. Thus, in apparently normal Macaca arctoides a high frequency of Q waves and ST segment elevations of the J point type are present compared to Macaca mulatta. It is suggested that normal ECG criteria be established for each species of monkeys to allow accurate interpretation.

Deleterious effects of hypertension on the development of aortic and coronary atherosclerosis in stumptail macaques (Macaca speciosa) on an atherogenic diet

Utilizing the stumptail macaque, we studied the atherosclerotic lesions produced in the aorta and coronary arteries by an atherogenic diet alone and by the diet coupled with hypertension produced by a modified Goldblatt technique. One group of monkeys was subjected concomitantly to the diet and hypertension for 10-12 months; a second group was on the diet for 29-32 months, but hypertension was induced for only the last 7-9 months of this period. In both of these groups, hypertension led to more severe lesions in the aorta. When an index of coronary involvement was plotted as a function of either arterial systolic or diastolic blood pressure, a significant correlation was found in both groups of monkeys. Additionally, in the monkeys with hypertension, morphologic criteria indicated that increased amounts of elastic fibers were present in the plaques in a disorganized, fragmented manner; in the monkeys on the diet alone, the elastic fibers were disposed in well-formed, reduplicated lamellas. Fat deposition was also different between these two groups: fat was located in the depths and at the periphery of the lesions in the hypertensive monkeys, whereas it was evenly dispersed throughout the plaques in the monkeys on the atherogenic diet alone. Thus, hypertension coupled with an atherogenic diet increases the extent of aortic and coronary lesions in proportion to the elevation in arterial blood pressure and, furthermore, may modify the morphologic characteristics of the lesions.