A double-blind ambulatory blood pressure monitoring study of the efficacy and tolerability of once-daily telmisartan 40 mg in comparison with losartan 50 mg in the treatment of mild-to-moderate hypertension in Taiwanese patients

Ambulatory blood pressure monitoring (ABPM) was used to compare the efficacy and tolerability of once-daily telmisartan 40 mg and once-daily losartan 50 mg in Taiwanese patients with mild-to-moderate essential hypertension in a randomised, double-blind, double-dummy, parallel-group study. The initial 2-week placebo run-in phase was followed by randomisation to treatment with telmisartan 40 mg (n = 31) or losartan 50 mg (n = 30) for 6 weeks. The reduction in 18- to 24-h mean (SE) ambulatory diastolic blood pressure (DBP) from baseline was significantly greater with telmisartan 40 mg (-12.1 +/- 1.6 mmHg, p = 0.036) than with losartan 50 mg (-7.0 +/- 1.8 mmHg). The reduction in 18- to 24-h mean (SE) ambulatory systolic blood pressure (SBP) from baseline was also greater with telmisartan 40 mg (-16.0 +/- 2.4 mmHg) than with losartan 50 mg (-11.8 +/- 2.7 mmHg), but did not achieve statistical significance. Telmisartan was well tolerated; no serious adverse events occurred.

Rutaecarpine-induced block of delayed rectifier K+ current in NG108-15 neuronal cells

The effects of rutaecarpine on ionic currents of NG108-15 neuronal cells were investigated in this study. Rutaecarpine (2-100 microM) suppressed the amplitude of delayed rectifier K+ current (I(K(DR))) in a concentration-dependent manner. The IC50 value for rutaecarpine-induced inhibition of I(K(DR)) was 11 microM. I(K(DR)) present in these cells is sensitive to the inhibition by quinidine and dendrotoxin, yet not by E-4031. The presence of rutaecarpine enhanced the rate and extent of I(K(DR)) inactivation, although it had no effect on the initial activation phase of I(K(DR)). Recovery from block by rutaecarpine (5 microM) was fitted by a single exponential with a value of 2.87 s. Crossover of tail currents in the presence of rutaecarpine was also observed. Cell-attached single-channel recordings revealed that rutaecarpine decreased channel activity, but it did not alter single-channel amplitude. With the aid of the binding scheme, a quantitative description of the rutaecarpine actions on I(K(DR)) was provided. However, rutaecarpine (20 microM) had no effect on L-type Ca2+ current. Under current-clamp configuration, rutaecarpine prolonged action potential duration in NG108-15 cells. These results show that rutaecarpine is a blocker of the K(DR) channel. The increase in action potential duration induced by rutaecarpine can be explained mainly by its blocking actions on I(K(DR)).

Fenamates stimulate BKCa channel osteoblast-like MG-63 cells activity in the human

BACKGROUND

The fenamates, a family of nonsteroidal anti-inflammatory drugs that are derivatives of N-phenylanthranilic acid, are the inhibitors of cyclo-oxygenase. The ionic mechanism of actions of these compounds in osteoblasts is not well understood.

METHODS

The effects of the fenamates on ionic currents were investigated in a human osteoblast-like cell line (MG-63) with the aid of the whole-cell and inside-out configurations of the patch-clamp technique.

RESULTS

In MG-63 cells, niflumic acid and meclofenamic acid increased K+ outward currents (IK). The niflumic acid-stimulated IK was reversed by subsequent application of iberiotoxin or paxilline, yet not by that of glibenclamide or apamin. In the inside-out configuration, niflumic acid (30 micromol/L) added to the bath did not modify single-channel conductance but increased the activity of large-conductance Ca2+-activated K+ (BKCa) channels. The EC50 values for niflumic acid- and meclofenamic acid-induced channel activity were 22 and 24 micromol/L, respectively. Niflumic acid (30 micromol/L) and meclofenamic acid (30 micromol/L) shifted the activation curve of BKCa channels to less positive membrane potentials. Membrane stretch potentiated niflumic acid-stimulated channel activity. The rank order of potency for the activation of BKCa channels in these cells was niflumic acid = meclofenamic acid > tolfenamic acid > flufenamic acid > nimesulide. Evans blue and nordihydroguaiaretic acid increased channel activity; however, indomethacin, piroxicam, and NS-398 had no effect on it.

CONCLUSIONS

The fenamates can stimulate BKCa channel activity in a manner that seems to be independent of the action of these drugs on the prostaglandin pathway. The activation of the BKCa channel may hyperpolarize the osteoblast, thereby modulating osteoblastic function.

Ceramide inhibits the inwardly rectifying potassium current in GH(3) lactotrophs

The effects of ceramide on ion currents in rat pituitary GH(3) cells were investigated. Hyperpolarization-elicited K(+) currents present in GH(3) cells were studied to determine the effect of ceramide and other related compounds on the inwardly rectifying K(+) current (I(K(IR))). Ceramide (C(2)-ceramide) suppressed the amplitude of I(K(IR)) in a concentration-dependent manner, with an IC(50) value of 5 microM. Ceramide caused a rightward shift in the midpoint for the activation curve of I(K(IR)). Pretreatment with PD-98059 (30 microM) or U-0126 (30 microM) did not prevent ceramide-mediated inhibition of I(K(IR)). However, the magnitude of ceramide-induced inhibition of I(K(IR)) was attenuated in GH(3) cells preincubated with dithiothreitol (10 microM). TNF alpha (100 ng/g) also suppressed I(K(IR)). In the inside-out configuration, application of ceramide (30 microM) to the bath slightly suppressed the activity of large conductance Ca(2+)-activated K(+) channels. Under the current clamp mode, ceramide (10 microM) increased the firing of action potentials. Cells that exhibited an irregular firing pattern were converted to those displaying a regular firing pattern after application of ceramide (10 microM). Ceramide also suppressed I(K(IR)) in neuroblastoma IMR-32 cells. Therefore, ceramide can produce a depressant effect on I(K(IR)). The blockade of this current by ceramide may affect cell function.

Real-time 3-dimensional echocardiographic evaluation of left ventricular volume: correlation with magnetic resonance imaging--a validation study

BACKGROUND

The purpose of our study was to validate the ability of real-time 3-dimensional echocardiography (RT3D) to measure cardiac volume.

METHODS

We studied 25 patients with various cardiac disorders who had a regular heart rhythm and a good precordial echocardiographic window. Each patient underwent complete transthoracic echocardiography (TTE), RT3D, and magnetic resonance imaging (MRI) studies. Left ventricular dimension was calculated from slices of the whole left ventricle obtained by 7 different equidistant azimuth tilts. Planimetry of the endocardial (for volume data) and epicardium (for mass data) surface was performed for each azimuth tilt. The left ventricular end-diastolic volume (LVEDV) and the left ventricular end-systolic volume (LVESV) were calculated. The cardiac mass data were derived with the formula (Epicardial volume - LVEDV) x 1.055. The parameters of LVEDV, LVESV, stroke volume, ejection fraction, and cardiac mass were compared with those derived from MRI.

RESULTS

No statistically significant differences were found between the data from RT3D and MRI (P > or =.05). Good correlations were found between these two methods for left ventricle volume and mass measurements (r from 0.92 to 0.99). However, a weaker correlation was found with larger chamber sizes because extrapolation was necessary for the volume of myocardial segments that were not covered by the small sector angle.

CONCLUSIONS

For data acquisition, RT3D is faster than either TTE or MRI. It is also better than MRI for measuring cardiac volume and mass. To improve results with larger cardiac chamber sizes, enlargement of the sector angle will be necessary.

Prediction of in-hospital mortality in patients with myocardial infarction using APACHE II system

BACKGROUND

The acute physiology and chronic health evaluation (APACHE) scoring system has been validated in many different patient populations, however, patients with myocardial infarction (MI) were not included in the original data base. To evaluate the ability of APACHE scoring system in predicting in-hospital mortality, 694 patients with MI were studied.

METHODS

Data had been collected prospectively in an ICU computer database in the past 3 years. Patients admitted in coronary care unit with acute MI or acute coronary syndrome who had previous history of MI were all included. Patients were divided into survivor and non-survivor data sets. Multiple logistic regression analysis was evaluated on the variables of APACHE II score to determine which variables could predict in-hospital mortality. A logistic regression model was used to study the mortality curves. The differences of APACHE II scores between survivors and non-survivors were compared. Correlation between observed and predicted mortality was also assessed.

RESULTS

According to the statistical analysis, the non-survivors tended to have significantly greater APACHE II scores than those of survivors. The APACHE II values of non-survivors and survivors were 23.64 +/- 9.41 versus 13.35 +/- 7.14 (p < 0.001), respectively. Using multiple logistic regression analysis, we found that age, creatinine, coma scale, sodium and APACHE II score were capable of predicting the in-hospital mortality (p < 0.05). With use of the logistic model, a good correlation of predicted mortality rate to observed mortality rate was found (r = 0.992). This study demonstrated that lower APACHE II scores predicted survival while high scores predicted mortality. Mortality rate increased significantly when APACHE II score was > 25. An APACHE II score greater than 28.25 predicted a more than 50% in-hospital mortality.

CONCLUSIONS

This study demonstrates that the APACHE II scoring system is capable of predicting mortality in patients with MI, which makes this modality more applicable in the busy intensive care unit.

Inhibition of large-conductance calcium-activated potassium channel by 2-methoxyestradiol in cultured vascular endothelial (HUV-EC-C) cells

2-Methoxyestradiol, an endogenous metabolite of 17beta-estradiol, is known to have antitumor and antiangiogenic actions. The effects of 2-methoxyestradiol on ionic currents were investigated in an endothelial cell line (HUV-EC-C) originally derived from human umbilical vein. In the whole-cell patch-clamp configuration, 2-methoxyestradiol (0.3-30 microm) reversibly suppressed the amplitude of K+ outward currents. The IC50 value of the 2-methoxyestradiol-induced decrease in outward current was 3 microm. Evans blue (30 microm) or niflumic acid (30 microm), but not diazoxide (30 microm), reversed the 2-methoxyestradiol-induced decrease in outward current. In the inside-out configuration, application of 2-methoxyestradiol (3 microm) to the bath did not modify the single-channel conductance of large-conductance Ca2+-activated K+ (BKCa) channels; however, it did suppress the channel activity. 2-Methoxyestradiol (3 microm) produced a shift in the activation curve of BKCa channels to more positive potentials. Kinetic studies showed that the 2-methoxyestradiol-induced inhibition of BKCa channels is primarily mediated by a decrease in the number of long-lived openings. 2-Methoxyestradiol-induced inhibition of the channel activity was potentiated by membrane stretch. In contrast, neither 17beta-estradiol (10 microm) nor estriol (10 microm) affected BKCa channel activity, whereas 2-hydroxyestradiol (10 microm) slightly suppressed it. Under current-clamp condition, 2-methoxyestradiol (10 microm) caused membrane depolarization and Evans blue (30 microm) reversed 2-methoxyestradiol-induced depolarization. The present study provides evidence that 2-methoxyestradiol can suppress the activity of BKCa channels in endothelial cells. These effects of 2-methoxyestradiol on ionic currents may contribute to its effects on functional activity of endothelial cells.

Transthoracic and transesophageal echocardiographic diagnosis of aneurysm of the sinus of Valsalva: a review of five year experience

BACKGROUND

Aneurysms of the sinus of Valsalva (SVA) are uncommon congenital lesions. The clinical presentations vary from asymptomatic to progressive heart failure following rupture of the aneurysm into an adjacent cardiac chamber. Retrograde aortogram is the diagnostic tool of choice preoperatively. Recent studies have demonstrated that the SVA can be accurately diagnosed using transthoracic two-dimensional, and color Doppler flow mapping, even for surgical preparation without cardiac catheterization. We report our 5-year experience of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in the evaluation of SVA.

METHODS

Eleven adult patients with SVA with or without rupture were studied using both TTE and TEE. All of the diagnoses were subsequently comfirmed by either cardiac catheterization or surgical findings.

RESULTS

Aneurysms originated in the right coronary sinus (n = 9) and noncoronary sinus (n = 2); they ruptured into the right ventricle in 5 patients and the right atrium in 5 patients. An unruptured right SVA was noted in 1 patient. Both TTE and TEE could identify the site of the aneurysm, rupture sites, and the receiving chamber equally well. Co-existent cardiac lesions included 11 cases of valvular aortic regurgitation (mild in 7, moderate in 2 and severe in 2). Two cases of perimembranous type ventricular septal defect (VSD) and 6 cases of supracristal type VSD (including 1 case of tetraology of Fallot, 3 supracristal, 1 muscular and 1 subaortic) were noted. Three cases were complicated with valvular vegetations (1 aortic valve, 1 aortic and tricuspid valve and 1 aortic and pulmonic valve). One patient had patent ductus arteriosus and 2 patients had pulmonic valvular stenosis.

CONCLUSIONS

TEE provides clearer definition for the detailed anatomy of the ruptured sac and co-existent cardiac lesions than TTE through high resolution and closer approach. We conclude that TEE is a powerful complementary diagnostic tool in the evaluation of patients with SVA. TEE also provides additionally useful information for guiding the surgical approach and for assessing the operative results even without cardiac catheterization.

Comparison of the APACHE II and APACHE III scoring systems in patients with respiratory failure in a medical intensive care unit

BACKGROUND AND PURPOSE

This retrospective study compared the capability of the Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scoring systems to predict outcome and determined the independent predictors of survival in these scoring systems for patients with respiratory failure in a medical intensive care unit (ICU).

MATERIALS AND METHODS

Seven hundred and eight patients with respiratory failure admitted to the medical ICU throughout a 9-year period were studied. Patients with an ICU stay of less than 24 hours, patients under 12 years of age, and burn and surgery patients were excluded. APACHE scores were calculated at 24 hours after admission. Student's t-test was used to compare the total APACHE scores of survivor and non-survivor groups. Multivariate logistic regression analysis was used to determine which variables were predictors of mortality. The discriminative power of APACHE scores to predict in-hospital mortality was studied by the area under the receiver operating characteristic curves of the APACHE II and APACHE III systems, respectively.

RESULTS

Both systems showed a significant association between higher scores and higher mortality. The APACHE II system under-predicted the actual hospital mortality rate. The APACHE III systems had a higher discriminative power (area 0.7462) than the APACHE II systems (area 0.6856; p < 0.05). The independent predictors of survival as assessed by APACHE II and III systems were respiratory rate, arterial oxygen pressure, oxygen gradient between alveoli and artery, serum creatinine concentration, and the presence of neurologic abnormalities.

CONCLUSIONS

The APACHE III systems has greater discriminative power than the APACHE II systems for predicting in-hospital mortality. The variables of oxygenation, mean artery pressure, respiratory rate, serum creatinine concentration, and Glasgow Coma Scale play important roles in predicting survival for patients with respiratory failure.

Characterization of action potential waveform-evoked L-type calcium currents in pituitary GH3 cells

The response of the L-type Ca2+ current (ICa,L) in pituitary GH3 cells to variations in the action potential (AP) waveform was examined using the whole-cell configuration of the patch-clamp technique. ICa,L evoked during an AP waveform exhibited an early and a late component. The early component occurred on the rising phase of the AP; the late component coincided with the falling phase. Prolonging the falling phase of the AP increased the Ca2+ charge carried by ICa,L, although the amplitude of the late ICa,L was reduced. Prolonging the peak voltage of the AP waveform, however, increased the amplitude of the late component. ICa,L inactivated during a train of AP waveforms. When Ba2+ was used as the charge carrier, current inactivation during a train of APs decreased. Likewise, ICa,L evoked by the AP templates with irregular bursting pattern was inactivated. When the repetitive firing of APs with depolarizing potentials was replayed to cells, Ca2+ entry was not only spread over the entire AP, but also occurred during the interspike voltage trajectory. After application of thyrotropin releasing hormone (TRH; 10 microM), ICa,L in response to rectangular pulses was increased and the current/voltage relation shifted slightly to more negative values. TRH (10 microM), thapsigargin (10 microM) or cyclopiazonic acid (30 microM) enhanced the late component of the AP-evoked ICa,L. TRH also attenuated the inactivation of ICa,L during a train of APs. These results indicate that in pituitary GH3 cells, the time course and kinetics of ICa,L during the AP waveforms is distinct from that evoked by rectangular voltage clamp. Changes in the shape and firing pattern of APs in GH3 cells can modulate Ca2+ influx through L-type Ca2+ channels. Ca2+ release from internal stores may affect the magnitude of AP-evoked ICa,L in these cells.

Significance of cardiac troponin I and creatine kinase release after coronary intervention

BACKGROUND

Cardiac troponin I is a highly sensitive and specific marker for early detection of myocardial injury. Whether it can be used to monitor myocardial injury after coronary intervention is uncertain. This study was designed to measure the cardiac troponin I and creatine kinase (CK) after coronary intervention and investigate their clinical significance.

METHODS

We measured cardiac troponin I and CK levels before intervention and 4 hours, 8 hours, 12 hours and 24 hours after apparently successful coronary intervention in 106 eligible patients. Nine patients were excluded due to missing data. We also followed up the clinical outcome to record major cardiac events (MACE).

RESULTS

The frequency of cardiac troponin I increase after coronary intervention was higher than that of CK increase (40.2% vs 8.2%). The frequency of cardiac troponin I increase in the stent group was significantly higher than that in the PTCA group (49.2% vs 21.9%, p < 0.001). The frequency of cardiac troponin I increase was also higher than that of CK increase in patients with in-hospital events (58.8% vs 14.7%).

CONCLUSIONS

Cardiac troponin I is more sensitive than creatine kinase in detecting myocardial injury after coronary intervention. The incidence of cardiac troponin I increase is significantly higher in patients undergoing stenting than in patients treated with balloon angioplasty only. The cardiac troponin I increase is more highly correlated with in-hospital events than is creatine kinase.

The effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial

BACKGROUND

Endoscopic treatment of esophageal varices may accentuate portal hypertensive gastropathy. The impact of the combination of band ligation and propranolol on this condition remains unknown.

METHODS

Patients with history of variceal bleeding were randomized to receive band ligation alone (control group, 40 patients) or a combination of band ligation and propranolol (propranolol group, 37 patients). Serial endoscopic evaluation of gastropathy was performed. Gastropathy was classified into 3 grades and scored as 0, 1, or 2.

RESULTS

Before endoscopic treatment, 17% of the control group and 22% of the propranolol group had gastropathy (p = 0.78). The occurrence of gastropathy after endoscopic treatment was significantly higher in the control group than in the propranolol group (p = 0.002). Serial endoscopic follow-up revealed that the mean gastropathy score was significantly higher in the control group than in the propranolol group (p < 0.05). In patients with gastropathy the gastropathy score reached a peak at 6 months after endoscopic treatment in both the control and propranolol groups (85% vs. 48%, respectively). After variceal obliteration, accentuation of gastropathy was significant in the control group (p < 0.01) but not in the propranolol group. Gastropathy was less likely to develop in patients who developed gastric varices. Esophageal variceal recurrence was not related to the development of gastropathy after variceal obliteration with banding. Only one patient in the control group bled from gastropathy.

CONCLUSION

Band ligation of esophageal varices may accentuate gastropathy, which in this study was partly relieved by propranolol.

A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices

Gastric variceal bleeding is a catastrophic event. Both cyanoacrylate injection and banding ligation have been proven to be effective in the management of bleeding gastric varices. This study was performed to compare the efficacy and complications of both the modalities. Cirrhotic patients with a history of gastric variceal bleeding were randomized to 2 groups. The group receiving endoscopic obturation (group A) comprised 31 patients and the group receiving band ligation (group B) comprised 29 patients. Butyl cyanoacrylate and pneumatic-driven ligator were applied, respectively. Treatment was repeated regularly until obliteration of gastric varices. Active bleeding occurred in 15 patients in group A and 11 patients in group B. Initial hemostatic rate (defined as no bleeding for 72 hours after treatment) was 87% in group A and 45% in group B (P = .03). The sessions required to achieve variceal obliteration and obliteration rates were similar in both the groups. However, rebleeding rates were significantly higher in group B (54%) than group A (31%) (P = .0005). Treatment-induced ulcer bleeding occurred in 2 patients (7%) in group A and 8 patients (28%) in group B (P = .03). The amount of blood transfusions required were also higher in group B than group A (4.2 +/- 1.3 vs. 2.6 +/- 0.9 units, respectively) (P < .01). Nine patients of group A and 14 patients of group B died (P = .05). In conclusion, endoscopic obturation using cyanoacrylate proved more effective and safer than band ligation in the management of bleeding gastric varices.

Vinpocetine-induced stimulation of calcium-activated potassium currents in rat pituitary GH3 cells

The effects of vinpocetine, an inhibitor of cyclic GMP phosphodiesterase, on ionic currents were examined in rat pituitary GH3 lactotrophs with the aid of the patch-clamp technique. In GH3 cells bathed in normal Tyrode's solution, vinpocetine (10 microM) reversibly increased the amplitude of Ca2+-activated K+ current (I(K)Ca) with an EC50 value of 4 microM. When the recording pipettes were filled with 10 mM EGTA, vinpocetine also stimulated I(K)Ca. In the cell-attached configuration, application of vinpocetine to the bath increased the activity of large-conductance Ca2+-activated K+ (BK(Ca)) channels. In excised membrane patches, application of vinpocetine (10 microM) to the bath did not change the single-channel conductance of BK(Ca) channels; however, it did increase channel activity. In the inside-out configuration, neither 8-bromo cyclic GMP nor YC-1 applied intracellularly affected BK(Ca) channel activity. The vinpocetine-induced change in the kinetic behavior of BK(Ca) channels was due to an increase in mean open time and a decrease in mean closed time. Vinpocetine (10 microM) caused a leftward shift in the midpoint for the voltage-dependent opening. Under the current-clamp mode, vinpocetine (10 microM) decreased the firing rate of spontaneous action potentials induced by thyrotropin-releasing hormone (10 microM) in GH3 cells. In pheochromocytoma PC12 cells, vinpocetine (10 microM) applied intracellularly also enhanced the activity of BK(Ca) channels without altering single-channel conductance. Thus, the present study suggests that vinpocetine-mediated stimulation of I(K)Ca may result from the direct activation of BK(Ca) channels and indirectly from elevated cytosolic Ca2+.

Characterization of ATP-sensitive potassium channels functionally expressed in pituitary GH3 cells

ATP-sensitive K+ (KATP) channels have been characterized in pituitary GH3 cells with the aid of the patch-clamp technique. In the cell-attached configuration, the presence of diazoxide (100 microM) revealed the presence of glibenclamide-sensitive KATP channel exhibiting a unitary conductance of 74 pS. Metabolic inhibition induced by 2,4-dinitrophenol (1 mM) or sodium cyanide (300 microM) increased KATP channel activity, while nicorandil (100 microM) had no effect on it. In the inside-out configuration, Mg-ATP applied intracellularly suppressed the activity of KATP channels in a concentration-dependent manner with an IC50 value of 30 microM. The activation of phospholipase A2 caused by mellitin (1 microM) was found to enhance KATP channel activity and further application of aristolochic acid (30 microM) reduced the mellitin-induced increase in channel activity. The challenging of cells with 4,4'-dithiodipyridine (100 microM) also induced KATP channel activity. Diazoxide, mellitin and 4,4'-dithiodipyridine activated the KATP channels that exhibited similar channel-opening kinetics. In addition, under current-clamp conditions, the application of diazoxide (100 microM) hyperpolarized the membrane potential and reduced the firing rate of spontaneous action potentials. The present study clearly indicates that KATP channels similar to those seen in pancreatic beta cells are functionally expressed in GH3 cells. In addition to the presence of Ca(2+)-activated K+ channels, KATP channels found in these cells could thus play an important role in controlling hormonal release by regulating the membrane potential.

Characterization of inhibition by risperidone of the inwardly rectifying K(+) current in pituitary GH(3) cells

The effects of risperidone on ionic currents in rat pituitary GH(3) cells were investigated with the aid of the patch-clamp technique. Hyperpolarization-activated K(+) currents in GH(3) cells bathed in high-K(+) Ca(2+)-free solution were studied to determine the effect of risperidone and other related compounds on the inwardly rectifying K(+) current (I(K(IR))). Risperidone (0.1-10 microM) suppressed the amplitude of I(K(IR)) in a concentration-dependent manner. The IC(50) value for the risperidone-induced inhibition of I(K(IR)) was 1 microM. Risperidone (3 microM) was found to slow the rate of activation. An increase in current deactivation by the presence of risperidone was also observed. Haloperidol (10 microM) and thioridazine (10 microM) inhibited the amplitude of I(K(IR)) effectively, and clozapine slightly suppressed it; however, metoclopramide (10 microM) had no effect on it. Risperidone (10 microM) had no effect on voltage-dependent K(+) and L-type Ca(2+) currents. However, in the inside-out configuration, risperidone (10 microM) did not alter the single-channel conductance, but reduced the activity of large-conductance Ca(2+)-activated K(+) (BK(Ca)) channels. Under the current-clamp mode, risperidone (3 microM) depolarized the membrane potential and increased the firing rate. With the aid of the spectral analysis, cells that exhibited an irregular firing pattern were also converted to those displaying a regular firing pattern after addition of risperidone (3 microM). The present study provides evidence that risperidone, in addition to the blockade of dopamine receptors, can produce a depressant effect on I(K(IR)) and BK(Ca) channels, and implies that the blockade of these ionic currents by risperidone may affect membrane excitability and prolactin secretion in GH(3) cells.

Computerized-tomography-guided percutaneous tumor ablation using acetic acid injection in an aldosterone-producing tumor--a novel therapy

We report the first case of an adrenocortical tumor that was successfully ablated using computerized tomography (CT)-guided percutaneous acetic acid injection. A 57-year-old woman presented with recurrent sudden onset of general weakness, polyuria, hypokalemia and low plasma renin activity with a high aldosterone level. The computerized tomogram and sonogram of the abdomen demonstrated a well-defined low-density tumor in the right adrenal gland. Under CT guidance, we successfully ablated the tumor using percutaneous acetic acid injection. This procedure took only 40 minutes and required only local anesthesia. The patient was up and walking the following day. During the next 2 years of clinical follow-up, there was no evidence of tumor recurrence.

Plasma endothelin levels are unaltered by thyroid hormone status in humans

Endothelin is a novel potent vasoconstrictor peptide produced by a wide variety of cell types and which has diverse biological activities. Previously we have reported that thyroid hormone status alters tissue levels of immunoreactive endothelin (irET) in rats. In order to study whether plasma irET levels in humans are affected by thyroid hormone status, we measured irET concentrations by means of radioimmunoassay in plasma samples from euthyroid controls as well as from patients with either hypothyroidism or hyperthyroidism. Plasma samples from the above-mentioned three groups of subjects were collected. After extraction with Sep-Pak C18 cartridges, plasma irET levels were measured by radioimmunoassay. The plasma irET levels in the three groups of subjects did not show any significant difference. Also, no correlations were found between plasma irET levels, thyroid hormones and the thyroid-stimulating hormone thyrotropin (TSH) in euthyroid, hypothyroid and hyperthyroid subjects. These results suggest that thyroid function per se is not a major determinant of plasma irET levels in humans.

Dual effect of tamoxifen, an anti-breast-cancer drug, on intracellular Ca(2+) and cytotoxicity in intact cells

The effect of tamoxifen on Ca(2+) signaling and viability in Madin Darby canine kidney (MDCK) cells was investigated by using fura-2 as a Ca(2+) probe. Tamoxifen evoked a rise in cytosolic free Ca(2+) levels ([Ca(2+)](i)) concentration-dependently between 1 and 50 microM with an EC50 of 10 microM. The response was decreased by extracellular Ca(2+) removal. In Ca(2+)-free medium, pretreatment with 5 microM tamoxifen abolished the [Ca(2+)](i) increase induced by the endoplasmic reticulum Ca(2+) pump inhibitor thapsigargin (1 microM), but pretreatment with brefeldin A (50 microM; a Ca(2+) mobilizer of the Golgi complex), thapsigargin (an inhibitor of the endoplasmic reticulum Ca(2+) pump), and carbonylcyanide m-chlorophenylhydrazone (CCCP; a mitochondrial uncoupler), only partly inhibited tamoxifen-induced [Ca(2+)](i) increases. This suggests that tamoxifen released Ca(2+) from multiple pools. Addition of 3 mM Ca(2+) induced a [Ca(2+)](i) rise after pretreatment with 5 microM tamoxifen in Ca(2+)-free medium. Inhibiting inositol 1,4,5-trisphosphate formation with the phospholipase C inhibitor U73122 (2 microM) did not alter 5 microM tamoxifen-induced Ca(2+) release. The [Ca(2+)](i) increase induced by 5 microM tamoxifen was not altered by La(3+), nifedipine, verapamil, or diltiazem. Tamoxifen (1-10 microM) decreased cell viability in a concentration- and time-dependent manner. Tamoxifen (5 microM) also increased [Ca(2+)](i) in neutrophils, bladder cancer cells, and prostate cancer cells from humans and glioma cells from rats. Collectively, it was found that tamoxifen increased [Ca(2+)](i) in MDCK cells by releasing Ca(2+) from multiple Ca(2+) stores in a manner independent of the production of inositol 1,4, 5-trisphosphate and also by triggering Ca(2+) influx from extracellular space. The [Ca(2+)](i) increase was accompanied by cytotoxicity.

Actions of epoxyeicosatrienoic acid on large-conductance Ca(2+)-activated K(+) channels in pituitary GH(3) cells

Epoxyeicosatrienoic acids (EETs), a family of cytochrome P450 epoxygenase metabolites of arachidonic acid, are believed to have an autocrine or paracrine role in the regulation of neurons or neuroendocrine cells. The effects of 14,15-EET on ionic currents were investigated in rat pituitary GH(3) cells. In the whole-cell configuration, 14,15-EET (3 microM) reversibly increased the amplitude of the Ca(2+)-activated K(+) current (I(K(Ca))). The 14, 15-EET-induced increase in I(K(Ca)) was unaffected in the presence of 10 microM thyrotropin-releasing hormone externally or 10 microM inositol trisphosphate in the recording pipette. In cells preincubated with pertussis toxin or herbimycin A, the 14, 15-EET-induced increase in I(K(Ca)) was also not changed. In the inside-out configuration, 14,15-EET applied intracellularly did not change single-channel conductance, but did increase the opening probability of large-conductance Ca(2+)-activated K(+) (BK(Ca)) channels. 14,15-EET (3 microM) shifted the activation curve of BK(Ca) channels to less positive membrane potential by approximately 15 mV. The change in the kinetic behavior of BK(Ca) channels caused by 14,15-EET is explained by a lengthening of open and a shortening of closed times. 14,15-EET increased the activity of BK(Ca) channels in a concentration-dependent manner with an EC(50) value of 1 microM. However, 14,15-EET did not affect the Ca(2+) sensitivity of BK(Ca) channels. The present study indicates that 14,15-EET is an opener of BK(Ca) channels in GH(3) cells and that the stimulatory effect of 14, 15-EET on these channels may, at least in part, contribute to the underlying cellular mechanisms by which EETs affect neuronal or neuroendocrine function.

A left atrial thrombus is not an absolute limitation to balloon mitral commissurotomy for patients with mitral stenosis. a serial transesophageal echocardiographic study

Previous reports did not encourage balloon mitral commissurotomy (BMC) when left atrial (LA) thrombi were located beyond LA appendage. We hypothesize that LA thrombi may be resolved in some patients after anticoagulant therapy, and BMC can be performed subsequently. In the present study, we used transesophageal echocardiography (TEE) to evaluate the effects of anticoagulant on LA thrombi in patients with mitral stenosis, to compare the clinical differences between patients with (group A) and without (group B) resolution of LA thrombi, and to evaluate the safety of subsequent BMC in these patients. TEE was performed on 190 consecutive patients with mitral stenosis; 14 (7.4%) of them were found with LA thrombi. Serial TEE was performed and optimal anticoagulant therapy was achieved in all 14 patients. The thrombi were located within the LA appendage in 6 cases, attached to the LA posterior wall in 5, posterior wall and interatrial septum in 1, and LA appendage and posterior wall in 2. Based on the 6-month TEE follow-up, we found that the LA thrombi disappeared in 8 (57.2%) patients (group A) and persisted in 6 patients (group B). LA thrombi resolved within 3 months in 7 group A patients (87.5%). Furthermore, the resolution of LA thrombi was more frequently observed in patients either with a smaller LA dimension (51.9 +/- 3.4 vs. 57.8 +/- 4.8 mm, p = 0.02) or with their thrombi located inside their LA appendage (p = 0.03). No differences in other clinical and echocardiographic variables were noted between these two groups. Subsequently, group A patients underwent BMC without complications of systemic embolization. In conclusion, LA thrombi can be resolved after optimal anticoagulant therapy in a considerable proportion of patients with mitral stenosis. Serial TEE studies are helpful to observe LA thrombus resolution; they may also be useful in planning the treatment strategy.

Novel effects of clotrimazole on Ca2+ signaling in Madin Darby canine kidney cells

The effect of clotrimazole on Ca2+ signaling in Madin Darby canine kidney (MDCK) cells was investigated by using fura-2 as a Ca2+ indicator. Clotrimazole (1-30 microM) induced a concentration-dependent [Ca2+]i increase. The [Ca2+]i increase comprised an initial rise and a slow decay. External Ca2+ removal partly inhibited the Ca2+ signals by reducing both the initial rise and the decay phase, indicating that clotrimazole triggered both Ca2+ influx and Ca2+ release. Pretreatment with 30 microM clotrimazole in Ca2+-free medium abolished the Ca2+ release induced by thapsigargin (1 microM), an endoplasmic reticulum Ca2+ pump inhibitor, and conversely, pretreatment with thapsigargin prevented clotrimazole from releasing more Ca2+. This suggests that the thapsigargin-sensitive Ca2+ store is the source of clotrimazole-induced Ca2+ release. Clotrimazole (10 microM) triggered Mn2+ quench of fura-2 fluorescence which was partly inhibited by 1 mM La3+. Addition of 3 mM Ca2+ induced a [Ca2+]i increase after preincubation with 10 microM clotrimazole in Ca2+-free medium, indicating that clotrimazole activated capacitative Ca2+ entry. However, 10 and 30 microM clotrimazole inhibited 1 microM thapsigargin-induced capacitative Ca2+ entry by 21% and 74%, respectively. Pretreatment with 40 microM aristolochic acid to inhibit phospholipase A2 reduced 30 microM clotrimazole-induced Ca2+ release by 51%, but inhibiting phospholipase C with 2 microM U73122 had little effect. This implies that clotrimazole induces Ca2+ release in an IP3-independent manner, which could be modulated by phospholipase A2-coupled events.

Regulation of Ca(2+)-activated K+ currents by ciglitazone in rat pituitary GH3 cells

BACKGROUND

Ciglitazone, an antidiabetic agent of the thiazolidinedione family, is known to be an activator of the peroxisome-proliferator activator receptor (PPAR)-gamma. The underlying mechanism of ciglitazone actions on ionic currents in neuroendocrine cells remains unclear.

METHODS

The effects of ciglitazone on ionic currents were investigated in rat pituitary GH3 cells using the whole-cell and inside-out configurations of the patch-clamp technique.

RESULTS

In GH3 cells, ciglitazone at 3-300 mumol/L caused a reversible increase in the amplitude of the Ca(2+)-activated K+ current (IK(Ca)) with a half-maximal concentration of 16 mumol/L. Under the inside-out patch recording mode, ciglitazone applied intracellularly increased the activity of the large-conductance Ca(2+)-activated K+ (BKCa) channels, but did not affect their single-channel conductance. However, troglitazone (30 mumol/L) caused a reduction in the channel activity. The ciglitazone-induced change in the kinetic behavior of BKCa channels is due to an increase in mean open time and a decrease in mean closed time, whereas the troglitazone-induced decrease in the channel activity is related to a decrease in mean open time and an increase in mean closed time. Ciglitazone caused a left shift in the midpoint for voltage-dependent opening. The ciglitazone-stimulated activity of BKCa channels is independent of internal Ca2+. Under the current clamp mode, ciglitazone (30 mumol/L) hyperpolarized the membrane potential.

CONCLUSIONS

This study shows that in addition to its activation of PPAR-gamma, ciglitazone can stimulate the activity of BKCa channels expressed in GH3 cells. These effects may affect membrane potentials and contribute to the ciglitazone-induced change in the functional activity of neurons or neuroendocrine cells.

Modulatory effects of carbon monoxide on baroreflex activation in nucleus tractus solitarii of rats

Recent studies suggest that carbon monoxide (CO), which is produced in significant quantities in many brain regions, may function as a neurotransmitter. Heme oxygenase catalyzes the metabolism of heme to CO and biliverdin; however, the physiological role of CO in central cardiovascular regulation was not well understood. In the present study, we evaluated the baroreflex response of CO in the nucleus tractus solitarii (NTS) of rats. Male Sprague-Dawley rats were anesthetized with urethane, and blood pressure and heart rate were monitored intra-arterially. Unilateral microinjection (60 nL) of hematin, a heme molecule cleaved by heme oxygenase to yield CO, into the NTS produced prominent dose-related depressor and bradycardic effects. Baroreflex responses were elicited by increasing doses of phenylephrine (10 to 30 microg/kg IV) before and after intra-NTS administration of zinc deuteroporphyrin 2,4-bis-glycol (ZnDPBG) (1 nmol), an inhibitor of heme oxygenase activity, or vehicle alone. The reflex bradycardia elicited by phenylephrine was significantly inhibited by pretreatment with ZnDPBG. Furthermore, the inhibitory effect of ZnDPBG on baroreflex activation was dose dependent. These results suggest CO formed by brain heme oxygenase plays a significant role in central cardiovascular regulation and that inhibition of heme oxygenase attenuated baroreflex activation.

The cause of slowed forearm median conduction velocity in carpal tunnel syndrome

OBJECTIVES

Attempting to answer a debate concerning the etiopathogenesis of the decreased forearm median motor conduction velocity (FMMCV), we tried to use proximal stimulation at the wrist, elbow, mid-arm and axillary regions to determine segmental median motor conduction velocity (MMCV). We also correlated the FMMCV with median motor distal latency (MMDL) and compound muscle action potential (CMAP) amplitudes of the abductor pollicis brevis (APB) muscle in order to assess whether the conduction block of large myelinating fibers or retrograde axonal atrophy was the major cause of the decreased FMMCV.

BACKGROUND

The cause of the decreased FMMCV resulting from either the conduction block of the large myelinating fibers at the wrist or distal compression with retrograde axonal atrophy remains an unresolved issue at the moment. Animal models have supported the hypothesis that the retrograde axonal atrophy might also occur in humans. Other authors believe the standard FMMCV is calculated by subtracting the distal latency which may not represent an exact assessment of FMMCV but rather the velocity of small fibers that persist through the carpal tunnel.

SUBJECTS AND METHODS

Patients with the clinical symptoms and signs of carpal tunnel syndrome (CTS) confirmed using standard electrodiagnosis were included. The patients were arbitrarily divided into two groups based on the FMMCV, one with reduced FMMCV (n = 20, FMMCV < 50 m/s) and the other with normal FMMCV (n = 35, FMMCV> or =50 m/s). Age-matched volunteers served as controls. We explored motor conduction proximally at wrist, elbow, mid-arm and axillary stimulation, and recorded at the APB muscles. Based on the latency differences, we calculated the FMMCV, distal arm MMCV (DAMMCV) and proximal arm MMCV (PAMMCV), and compared the conduction velocity (CV) differences of DAMMCV-FMMCV, PAMMCV-FMMCV and PAMMCV-DAMMCV in the two patient groups and the control. Furthermore, we correlated FMMCV with MMDL and CMAP amplitudes of APB muscle because MMDL and CMAP amplitudes might reflect the integrity of the large myelinating fibers.

RESULTS

CMAP amplitudes of APB muscle at wrist stimulation and MMDL were not correlated with FMMCV in either of the two patient groups; however, the CMAP amplitude was markedly decreased and MMDL was significantly prolonged when compared with normal controls. The significant increase of CV gradient of DAMMCV-FMMCV and PAMMCV-FMMCV without an equal increase of CV gradient of PAMMCV-DAMMCV only occurred in the reduced FMMCV patient group, suggesting that the conduction block is not the primary cause. The CV gradient of DAMMCV-FMMCV and PAMMCV-DAMMCV did not show any significant difference between patients with the normal FMMCV and the control group.

CONCLUSION

The retrograde axonal atrophy, not selective damage of the large fibers at the wrist, was the direct cause of the decreased FMMCV.

Stimulatory effects of delta-hexachlorocyclohexane on Ca(2+)-activated K(+) currents in GH(3) lactotrophs

delta-Hexachlorocyclohexane (delta-HCH), a lipophilic neurodepressant agent, has been shown to inhibit neurotransmitter release and stimulate ryanodine-sensitive Ca(2+) channels. However, the effect of delta-HCH on neuronal activity remains unclear, although it may enhance the gamma-aminobutyric acid-induced current. Its effects on ionic currents were investigated in rat pituitary GH(3) cells and human neuroblastoma IMR-32 cells. In GH(3) cells, delta-HCH increased the amplitude of Ca(2+)-activated K(+) current (I(K(Ca))). delta-HCH (100 microM) slightly inhibited the amplitude of voltage-dependent K(+) current. delta-HCH (30 microM) suppressed voltage-dependent L-type Ca(2+) current (I(Ca, L)), whereas gamma-HCH (30 microM) had no effect on I(Ca, L). In the inside-out configuration, delta-HCH applied intracellularly did not change the single channel conductance of large conductance Ca(2+)-activated K(+) (BK(Ca)) channels; however, it did increase the channel activity. The delta-HCH-mediated increase in the channel activity is mainly mediated by its increase in the number of long-lived openings. delta-HCH reversibly increased the activity of BK(Ca) channels in a concentration-dependent manner with an EC(50) value of 20 microM. delta-HCH also caused a left shift in the midpoint for the voltage-dependent opening. In contrast, gamma-HCH (30 microM) suppressed the activity of BK(Ca) channels. Under the current-clamp mode, delta-HCH (30 microM) reduced the firing rate of spontaneous action potentials; however, gamma-HCH (30 microM) increased it. In neuroblastoma IMR-32 cells, delta-HCH also increased the amplitude of I(K(Ca)) and stimulated the activity of intermediate-conductance K(Ca) channels. This study provides evidence that delta-HCH is an opener of K(Ca) channels. The effects of delta-HCH on these channels may partially, if not entirely, be responsible for the underlying cellular mechanisms by which delta-HCH affects neuronal or neuroendocrine function.

Novel effects of propranolol. Release of internal Ca(2+) followed by activation of capacitative Ca(2+) entry in Madin Darby canine kidney cells

The effect of propranolol on Ca(2+) signalling in Madin Darby canine kidney (MDCK) cells was investigated by using fura-2 as a Ca(2+) probe. Propranolol increased cytosolic free Ca(2+) levels ([Ca(2+)](i)) in a concentration-dependent manner between 0.1 and 1 mM. The response was partly inhibited by external Ca(2+) removal. In Ca(2+)-free medium pretreatment with 0.2 mM propranolol partly inhibited the [Ca(2+)](i) rise induced by 1 microM thapsigargin, an inhibitor of the endoplasmic reticulum Ca(2+) pump; but pretreatment with thapsigargin abolished propranolol-induced Ca(2+) release. Addition of 3 mM Ca(2+) induced a [Ca(2+)](i) rise after pretreatment with 0.2 mM propranolol in Ca(2+)-free medium. Propranolol (0.2 mM) inhibited 25% of thapsigargin-induced capacitative Ca(2+) entry. Suppression of 1,4,5-trisphosphate (IP(3)) formation by 2 microM U73122, a phospholipase C inhibitor, did not alter 0.2 mM propranolol-induced internal Ca(2+) release. Propranolol (1 mM) also increased [Ca(2+)](i) in human neutrophils. Collectively, we have found that 0.2 mM propranolol increased [Ca(2+)](i) in MDCK cells by releasing Ca(2+) from thapsigargin-sensitive Ca(2+) stores in an IP(3)-independent manner, followed by Ca(2+) influx from external space. Independently, propranolol was able to inhibit thapsigargin-induced capacitative Ca(2+) entry.

Multiplane transesophageal echocardiography for assessing cardiac abnormalities: comparison to biplane imaging

BACKGROUND

Transesophageal echocardiography (TEE) is useful for visualizing the spatial relationships of the cardiac anatomy. The purpose of this study was to compare the diagnostic yield of multiplane TEE with that of biplane TEE in assessing cardiac abnormalities.

METHODS

A total of 102 consecutive patients underwent an initial comprehensive diagnostic assessment using transverse (0 degree) and longitudinal (90 degrees +/- 2 degrees) planes in the biplane imaging technique. "Off-axis" tomographic sections through the full 0 degree to 180 degrees angle were obtained later by means of the gradual electrical rotation of the transducer. The echoscope can be manipulated to improve the quality of images. All data were recorded on high fidelity videotapes. Subsequently, one observer reviewed only biplane TEE images, while another reviewed only multiplane TEE images; both were blinded to the other's TEE data. The echocardiographic results obtained by these two observers were compared to determine whether multiplane TEE provides any additional information.

RESULTS

Multiplane TEE detected more cardiac lesions (275) compared to biplane TEE (235). Significantly more (70 cases) information affecting patient management was obtained using multiplane TEE. Among these patients, biplane TEE detected cardiac lesions in 48 (68.6%) patients. Additional diagnoses provided by multiplane TEE were found in 22 (31.4%) patients. These findings included ventricular septal defect in two patients, prosthetic valve dysfunction in three, cardiac tumor or clot in four, endocarditis in two, aortic dissection in one, valvular abnormality in nine and coronary arteriovenous fistula in one.

CONCLUSIONS

Multiplane TEE provides precise visualization of cardiac structures without undue probe manipulation, resulting in greater diagnostic assurance than does biplane TEE.

Prophylactic banding ligation of high-risk esophageal varices in patients with cirrhosis: a prospective, randomized trial

BACKGROUND/AIMS

Injection sclerotherapy has been used to prevent the first episode of variceal hemorrhage, but the results are controversial. The value of banding ligation in the prophylaxis of the first episode of variceal bleeding has not yet been completely evaluated. This study was conducted to determine whether prophylactic banding ligation is beneficial for cirrhotic patients with high-risk esophageal varices.

METHODS

A total of 127 cirrhotic patients with endoscopically-assessed high-risk esophageal varices but no history of bleeding were randomized to undergo banding ligation (64 patients) or to serve as controls (63 patients). Ligation was performed at 3-week intervals until variceal obliteration was obtained.

RESULTS

During a median follow-up of 29 months, 14 patients (21.8%) in the ligation group and 22 patients (34.9%) in the control group experienced upper gastrointestinal bleeding (p = 0.15). Variceal bleeding occurred in eight patients (12.5%) in the ligation group and 14 patients (22.2%) in the control group (p = 0.22). Blood transfusion requirements were fewer in the EVL group than in the control group (0.6+/-0.4 units vs. 1.2+/-0.8 units, p<0.001). Furthermore, variceal bleeding was significantly reduced in Child-Pugh class B patients treated with ligation compared with the control group (p<0.05). Sixteen patients (25%) in the ligation group and 23 patients (36.5%) in the control group died. Comparison of Kaplan-Meier estimates of time to death for the two groups did not show significant differences (p = 0.19). More patients died of uncontrollable variceal bleeding in the control group (7 patients, 11%) than in the ligation group (3 patients, 4.7%) (p = 0.15).

CONCLUSIONS

Although prophylactic ligation did not significantly reduce the first episode of bleeding from esophageal varices in cirrhotic patients with high-risk esophageal varices, a subgroup of patients (Child-Pugh class B) had a reduced frequency of the first episode of esophageal variceal bleeding after prophylactic banding ligation. Furthermore, there was a trend of reducing mortality from variceal bleeding in patients receiving prophylactic ligation. Prophylactic ligation is a promising treatment, but requires further investigation.

Circadian and weekly variations in pain onset of acute myocardial infarction

BACKGROUND

A seasonal variation with more myocardial infarctions in the winter months due to cold weather has been reported. Other reports have described excess numbers of acute myocardial infarction (AMI) in the summer in Southern USA due to hot temperatures. To determine whether circadian and seasonal variations affect the incidence of AMI in the subtropical area of Taiwan, 480 consecutive patients with AMI admitted to our coronary care units were analyzed.

METHODS

Six-hourly intervals over 24 hours (4 periods), daily intervals in a week (7 days) and monthly intervals in a year (12 months) were respectively studied. The distributions of the numbers of AMI occurring in the six-hour intervals were tested for differences among the four periods using the chi-squared test for goodness of fit.

RESULTS

We found that there was a circadian variation in the onset of AMI with a morning peak (6 am to noon) (35%, chi 2 = 28.52, df = 3, p < 0.01) but no secondary late evening peak. The incidence of AMI was significantly lower on Sundays (9%) than on the other weekdays (chi 2 = 16.37, df = 6, p = 0.012). However, no seasonal variation (no winter or summer peaks) occurred in the incidence of AMI in this study (chi 2 = 0.77, df = 3, p = 0.99).

CONCLUSION

Our results showed that there was a predominant morning peak in the onset of AMI. The low incidence of AMI cases on Sunday compared with other weekdays suggested that relief from tension or workload on Sundays might have an important role in this low percentage of AMI. Differing from other reports, there was no seasonal variation in the occurrence of AMI in our study, suggesting that the warm climate of a subtropical region does not provide an environment that is likely to increase the frequency of AMI.

Intrathoracic extramedullary haematopoiesis complicated by massive haemothorax in alpha-thalassaemia

Intrathoracic extramedullary haematopoiesis (EMH) is a rare entity that is usually asymptomatic. A 44 year old man with alpha-thalassaemia is described who developed dyspnoea and massive left sided haemothorax. The haemoglobin disorder was established by Hgb H staining and haemoglobin electrophoretic studies. The DNA analysis revealed it to be a case of double heterozygous terminal codon mutation with the genotype alphaalphaCS/alphaalphaT. Computed tomographic scanning and magnetic resonance imaging of the thorax showed multiple paravertebral masses which were found by thoracoscopic biopsy to be extramedullary haematopoiesis. Although no additional sclerosing pleurodesis or low dose radiation therapy was given, the lung expanded well and there has been no recurrence of haemothorax to date.

Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy

BACKGROUND

The impact of banding ligation and injection sclerotherapy on paraesophageal varices and gastric varices has received scarce attention. We conducted a study using endoscopic ultrasound (EUS) to visualize paraesophageal varices and gastric varices in patients who underwent sclerotherapy and banding ligation.

METHODS

Patients with esophageal variceal bleeding whose varices were obliterated by ligation (44 patients) and by sclerotherapy (35 patients) were enrolled. EUS was used to compare the prevalences of paraesophageal varices and gastric varices between the treatment groups. The correlation between paraesophageal varices and esophageal variceal recurrence and recurrent bleeding was assessed.

RESULTS

The prevalence of paraesophageal varices was 86% in the ligation group compared with 51% in the sclerotherapy group (p = 0.002). The prevalence of gastric varices was slightly higher in the ligation group than in the sclerotherapy group (43% vs. 26%, p = 0.18). Esophageal varices recurred in 70% of the ligation group and 43% of the sclerotherapy group (p = 0.04). Patients in both groups with more severe paraesophageal varices had a significantly higher rate of variceal recurrence (p = 0.002 in ligation group and p = 0.001 in sclerotherapy group). Bleeding recurred in 6 patients in the ligation group and 4 patients in the sclerotherapy group. All patients with recurrent bleeding had paraesophageal varices. The rate of recurrent bleeding was significantly higher in patients with paraesophageal varices (p < 0.0001).

CONCLUSIONS

EUS was helpful in the imaging of paraesophageal and gastric varices after sclerotherapy or banding ligation. Paraesophageal varices were more frequently noted in patients undergoing ligation. The presence of paraesophageal varices may predict the recurrence of esophageal varices and recurrent bleeding.

Follow-up study in patients with no stone retrieval from the bile duct after endoscopic sphincterotomy

BACKGROUND

No stones are retrieved from the bile duct in 10-20% of patients with suspected common bile duct (CBD) stones after endoscopic sphincterotomy (EST). The clinical outcome in these patients remains unclear. This study followed patients from whom no stones were retrieved, to discover their clinical outcome.

METHODS

From October, 1990, to October, 1996, 401 patients with suspected CBD stones received EST for stone removal. Only patients from whom no stones were retrieved from the bile duct were included in this study. All enrolled patients were regularly interviewed and received liver function tests. Sonography, computerized tomography, endoscopic retrograde cholangiopancreatography (ERCP), and/or intrapapillary biopsy were performed as indicated.

RESULTS

Forty-two patients were included in this study. The indications for EST included 34 cases with filling defects in the common bile duct on ERCP and eight cases with suspected impacted stones as seen by imaging studies. After a mean follow-up period of 28.6 months (range, 1-61 months), six patients developed biliary stones, four had carcinoma of the ampulla of Vater, one was found to have intrabiliary growth of hepatocellular carcinoma, and there was no pathologic change in 31 cases. Of the six patients with formation of biliary stones, two had an intact gallbladder and four had received previous cholecystectomy. Of the four patients with ampullary tumors, three were diagnosed by intrapapillary biopsy soon after EST, and one was diagnosed nine months later.

CONCLUSIONS

Biliary problems were found in 26% of patients soon after EST, although no stones were retrieved from the bile duct. Regular follow-up is warranted.

Serum endothelin and atrial natriuretic peptide in cirrhotic patients with ascites and hepatorenal syndrome

BACKGROUND

The pathogenesis of cirrhotic ascites and hepatorenal syndrome remains unresolved. The involvement of both endothelin-1 and atrial natriuretic peptide have recently been suggested. This study investigated the concentrations of serum endothelin and atrial natriuretic peptide in cirrhotic patients.

METHODS

Seven healthy subjects and 31 cirrhotic patients were studied. Cirrhotic patients were divided into three groups: Group I, 16 cirrhotic patients without ascites; Group II, 10 cirrhotic patients with ascites, but without hepatorenal syndrome; and Group III, five cirrhotic patients with hepatorenal syndrome and ascites. Their sera were analyzed for endothelin-1 and atrial natriuretic peptide concentrations.

RESULTS

Cirrhotic patients with ascites, Group II and Group III, had higher plasma endothelin-1 concentrations (15.9 +/- 2.3 pg/ml and 24 +/- 2.1 pg/ml, respectively) than normal subjects and compensated cirrhotics (3.8 +/- 0.7 pg/ml and 6.4 +/- 1.1 pg/ml, respectively); p < 0.001). Atrial natriuretic peptide concentrations were also significantly higher in cirrhotic patients than in normal subjects (p < 0.025). Plasma endothelin-1 concentration had a negative correlation with creatinine clearance (r = -0.65, p < 0.001), as did atrial natriuretic peptide concentrations (r = -0.44, p = 0.012). Plasma endothelin-1 correlated significantly with atrial natriuretic peptide concentrations (r = 0.38, p = 0.035).

CONCLUSIONS

Both endothelin-1 and atrial natriuretic peptide concentrations were elevated in cirrhotic patients with ascites and hepatorenal syndrome. Endothelin-1 may have a negative impact on renal function. Our data also suggested that impaired responsiveness rather than impaired secretion of atrial natriuretic peptide is responsible for sodium retention in cirrhotic patients with ascites.

Oral drug of choice in carpal tunnel syndrome

BACKGROUND

Conservative treatment of mild to moderate carpal tunnel syndrome (CTS) is variable.

OBJECTIVE

To evaluate the effectiveness of commonly used oral medications such as diuretics, nonsteroid anti-inflammatory drugs (NSAIDs), and steroids in the treatment of CTS.

METHODS

Prospective, randomized, double-blind and placebo-controlled study of patients with clinical symptoms and signs of CTS, confirmed by standard electrodiagnosis. Baseline assessments included a standardized symptom questionnaire, rating five categories of symptoms (pain, numbness, paresthesia, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (severe). The total score in each of the five categories was termed the global symptom score (GSS). After baseline assessment, patients were randomized to the following treatment arms: 1) 4 weeks of placebo (n = 16); 2) 4 weeks of diuretic (trichlormethiazide, 2 mg daily; n = 16); 3) 4 weeks of NSAID-slow release (SR) (tenoxicam-SR, 20 mg daily; n = 18); and 4) 2 weeks of prednisolone, 20 mg daily, followed by another 2-week dosage of 10 mg daily (n = 23). Results of follow-up assessments in the second and the fourth weeks were identical to baseline scores. The changes in GSS were analyzed to determine the statistical difference.

RESULTS

No significant reduction from baseline GSS was seen at second, and fourth weeks in the placebo, NSAID-SR, and diuretic groups. However, the mean score at 4 weeks in the steroid group decreased significantly from a baseline of 27.9 +/- 6.9 to 10 +/- 7.4.

CONCLUSION

For patients with mild to moderate CTS who opt for conservative treatment, corticosteroids are of greater benefit.

The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: a prospective, randomized trial

Endoscopic variceal ligation (EVL) is a new technique designed to manage esophageal varices. The effect of sclerotherapy following repeated banding ligation remains unknown. Seventy-two patients with a history of esophageal variceal bleeding received regular EVL until variceal disappearance or until left with residual small varices. Subsequently, patients were randomized to receive sclerotherapy (Group 1, 37 patients) or serve as a control (Group 2, 35 patients). Group 1 received one to two sessions of low-dose sclerotherapy to achieve complete variceal disappearance. After a mean follow-up of 2 years, 4 months, recurrent esophageal varices developed in 14% of Group 1 and 43% of Group 2 (P < .02). Rebleeding was encountered in 8% of Group 1 versus 31% of Group 2 (P = .01). One case of esophageal stricture (2.7%) was encountered in Group 1. One patient in Group 1, compared with 3 patients in Group 2, died of massive variceal bleeding (P > .05). The multivariate Cox model indicated that treatment was the only factor predictive of variceal recurrence, and both Child-Pugh class and treatment were factors predictive of variceal rebleeding. The addition of low-dose sclerotherapy following repeated banding ligations proved safe and effective in the prevention of recurrence of esophageal varices and rebleeding.

Effects of extracellular products of Vibrio vulnificus on Acanthopagrus schlegeli serum components in vitro and in vivo

A Vibrio strain Ls001, originally isolated from a body surface lesion of a moribund black porgy (Acanthopagrus schlegeli) in 1994 in Taiwan, was identified as Vibrio vulnificus. The extracellular products (ECP) of the strain were lethal to the fish, and its effects on fish serum in vitro and in vivo are described in the present study. Nine major precipitation arcs were visualized in normal fish serum in a crossed immunoelectrophoresis (CIE) gel using rabbit antiserum to the fish normal serum and staining with Coomassie brilliant blue. Only four and six of the nine major arcs could be tentatively identified by CIE following in vivo and in vitro ECP treatment, respectively. The same two major arcs were both missing following either in vivo or in vitro treatment with ECP. These complex events may significantly contribute to the pathogenesis of V. vulnificus in A. schlegeli.

Is captopril-induced improvement of insulin sensitivity mediated via endothelin?

Angiotensin-converting enzyme (ACE) inhibitors have been reported to improve insulin sensitivity during either short-term or long-term administration. Recent studies indicate that endothelin-1 (ET-1) has potent glycogenolytic effects in rat hepatocytes and may cause insulin resistance in rat adipocytes. In addition, ET may also have a role in stimulation of the hypothalamic-pituitary-adrenal axis. To test the hypothesis that part of the effect of captopril in enhancing insulin sensitivity may be mediated via ET and/or by glucocorticoids, we measured 24-h urinary excretion of ET and free cortisol before and after short-term treatment with captopril. The 24-h urinary immunoreactive endothelin (IR-ET) excretion decreased significantly (p < 0.05) from 65 +/- 4 ng at baseline to 42 +/- 3 ng after captopril treatment, whereas no significant change in the 24-h urinary free cortisol excretion was observed. Moreover, no significant change in the 24-h urinary IR-ET and free cortisol excretions was noted in the placebo-treated group. We speculate that ACE inhibitors may exert their effect on insulin sensitivity not only by blocking the renin-angiotensin and kinin systems but also by inhibiting production and/or release of ET.

Absence of a seasonal variation in myocardial infarction onset in a region without temperature extremes

To evaluate whether the incidence of acute myocardial infarction (AMI) attack would have circadian, weekly and monthly variations in a subtropical area, 540 consecutive patients with AMI who were admitted to our coronary care units were analyzed. Six-hour intervals over 24 h, daily intervals in a week (7 days) and monthly intervals in a year (12 months) were studied, respectively. Results showed that there was a circadian variation in the onset of AMI with a morning (6 a.m. to noon) peak (34%, p < 0.01) but no secondary late evening (18-24 p.m.) peak. The incidence of AMI was significantly lower on Sundays (9%) than on the other weekdays (Monday through Saturday; p < 0.05). However, no monthly and seasonal variations in the incidence of AMI (no winter or summer peaks) were observed in this series. This study demonstrated a circadian variation in the onset of AMI attack with a predominant morning peak. The fewer AMI cases on Sundays compared to the other weekdays suggested that freedom from 'stress' or 'work-load' on Sundays might have an important impact on this low incidence of AMI. Unlike the large ranges in cold or hot weather found in temperate regions, the warm climate of a subtropical region does not affect the frequency of AMI.

Spindle cell carcinoma of the lung: a clinicopathologic presentation of three cases

Three patients with spindle cell carcinoma located in the lower respiratory tract are presented, including cases of two monophasic and one biphasic tumor. On light microscopic examination, the spindle cell components of the tumors were histologically characterized by sheets of fusiform spindle cells that closely resembled a sarcoma. Keratin expression in the spindle cell components of these tumors, as shown by anti-cytokeratin antibody staining, demonstrated their epithelial nature. It is supposed that the spindle cell component displays a spectrum of phenotypes originating from epithelial cells with varying degrees of mesenchymal transformation. It is difficult to establish a diagnosis of this rare primary pulmonary malignancy prior to surgical intervention. A review of the literature allowed for a summary of the clinicopathologic characteristics of this tumor.

Characterization and quantification of organic anions with capillary zone electrophoresis using direct and indirect detection

A comparison of the separation and quantification capabilities of capillary zone electrophoresis (CZE) using direct and indirect detection of organic anions was conducted. A conventional CZE separation (normal polarity, electroosmotic flow toward the cathode) of phenol, benzoic acid, and 2,4-dihydroxybenzoic acid utilized direct UV absorption at 215 nM. A separation of myo-inositol 1,4,5-trisphosphate and myo-inositol hexakisphosphate utilizing a reversed polarity and an electroosmotic flow modifier (flow toward the anode) was monitored by indirect UV absorption at 250 nM. The separation buffers utilized in this study consisted of 50 mM borate buffer (pH 8.3) and IonPhor Anion PMA Electrolyte Buffer (pH 7.7) (Dionex Corp., Sunnyvale, CA, U.S.A.) for studies utilizing direct and indirect detection methods, respectively. The effect of separation voltage on the theoretical plate numbers observed for the separations was linear for both the direct and indirect systems. Sample introduction parameters investigated included electromigration injection voltage and duration, and gravity injection duration. The conventional CZE separation using direct detection gave superior precision and better agreement with theoretical predictions than the separation using indirect detection. Both systems were evaluated for quantitative accuracy using electromigration, pressure, and gravity sample introduction modes. The conventional CZE system showed superior performance with regard to sensitivity and limits of detection. Accuracy and precision in the quantitation of known standards was greatest for both systems when the gravity sample introduction mode was used.

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND

Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients.

AIMS

To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence.

METHODS

One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient.

RESULTS

During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy.

CONCLUSION

Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.

Putaminal petechial haemorrhage as the cause of chorea: a neuroimaging study

OBJECTIVES

A hyperintense putamen on either CT or MRI as a finding associated with chorea has occasionally been described and is almost always associated with non-ketotic hyperglycaemia. The cause of the hyperintensity of the striatum in these images is still controversial. Some reports have found that calcification was responsible whereas others have advocated petechial haemorrhage as the cause. The purpose of this study was to determine whether hyperintense striata are caused by petechial haemorrhage or calcification, with the sequential imaging changes.

SUBJECTS AND METHODS

Five patients presenting with an acute onset of either hemichorea or generalised chorea and showed either unilateral or bilateral hyperdense striatum on the initial CT were assessed. Neuroimaging studies including sequential CT and MRI examinations and detailed biochemical tests were performed.

RESULTS

Three patients had pronounced hyperglycaemia and the other two patients had no biochemical abnormalities. In all patients, the first CT scans, performed within two weeks of the onset of chorea, showed a high density over the striatum contralateral to the chorea, which diminished or disappeared two months later. T1 weighted imaging disclosed hypersignal intensities over the striatum contralateral to the chorea on admission which diminished two months later. T2 weighted imaging at two months showed hyposignal intensity changes corresponding to the area with hypersignal changes on T1 weighted images, implying haemosiderin deposition.

CONCLUSION

Based on the evolution of clinical manifestations and the findings of neuroimaging, putaminal petechial haemorrhage might be a new entity causing either hemichorea or generalised chorea.

The relation between thickened aortic valve and coronary artery disease

BACKGROUND

The relationship between the site of aortic valve thickening and ipsilateral coronary artery stenosis has not been reported previously. This study was undertaken to test the hypothesis that left-sided coronary cusp thickening may be associated with a left-sided coronary artery stenosis, and also as would be in the right-sided relationship.

METHODS

Two-dimensional echocardiography and cardiac catheterization were used to evaluate 420 consecutive patients. One hundred and six patients who had echocardiographic evidence of a single aortic valve thickening were studied to determine whether there was a relation between the coronary artery stenosis and the aortic valve thickening at the same side. Thickened aortic valve was defined as an aortic valve thickness to aortic wall thickness ratio > or = 1.0. Coronary artery disease (CAD) was defined as a > 50% luminal diameter narrowing of the left main coronary artery or a > 70% luminal diameter narrowing of the coronary artery other than the left main coronary artery.

RESULTS

Patients with a thickened aortic valve had a greater incidence of CAD (89/132, 67.4%) than those without (141/288, 49.0%) (p < 0.05). In patients with thickened aortic valves, the incidence of CAD was 45.5% in the fifth decade, 60% in the sixth decade, 69.6% in the seventh decade and 74.1% in the eighth decade. Progressive increase of the incidence of CAD was not found in patients without a thickened aortic valve. In the 106 cases with a single aortic valve thickening, 30 patients (28.3%) had a left coronary cusp thickening; 12 of them (40%) had a left-sided coronary artery stenosis, 3 patients (10%) had right coronary artery stenosis and 7 patients (23.3%) had no coronary artery stenosis. In the 34 patients with right coronary cusp thickening, the stenosis occurred at the left coronary artery in 13 patients (38.2%), at the right coronary artery in 3 patients (8.8%) and with normal coronary artery in 5 patients (14.7%). This finding did not support the relationship between thickened aortic valve and coronary artery disease at the same side (chi 2 = 0.06, p = 0.96).

CONCLUSIONS

There was a significantly greater incidence of CAD in patients with a thickened aortic valve than in those without. The incidence of CAD in patients with thickened aortic valves increased with age. There was no direct relationship observed between the site of aortic valve thickening and ipsilateral coronary artery stenosis.

Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices

Active bleeding varices are a great challenge to endoscopists. In this study, we compared the short-term efficacy and safety of banding ligation with injection sclerotherapy in the arresting of active bleeding from esophageal varices. Seventy-one cirrhotic patients with active variceal bleeding were randomized to receive banding ligation (37 patients) or sclerotherapy (34 patients) immediately after endoscopic examinations. Primary success rate (bleeding stopped for 72 hours) was 97% in the ligation group and 76% in the sclerotherapy group (P = .009). The efficacy of ligation was similar to sclerotherapy in the control of oozing varices (100% vs. 89%, P = .23), whereas ligation was superior to sclerotherapy in the control of spurting varices (94% vs. 62%, P = .012). The requirement of vasoconstrictors after emergency endoscopic treatment was lower in the ligation group than in the sclerotherapy group (11% vs. 41%, P = .007). Treatment failure within 1 month was 8% in the ligation group vs. 30% in the sclerotherapy group (P = .02). Blood transfusion requirements were significantly lower in the ligation group than in the sclerotherapy group (3.2 +/- 1.2 vs. 4.5 +/- 1.8 units, P < .01). Rebleeding rate within 1 month was 17% in the ligation group and 33% in the sclerotherapy group (P = .19). Significant complications were encountered in 5% of the ligation group and 29% of the sclerotherapy group (P = .007). Mortality rates within 1 month were 19% in the ligation group and 35% in the sclerotherapy group (P = .19). Banding ligation and sclerotherapy were comparable in the arresting of oozing varices, whereas ligation was superior to sclerotherapy in the control of spurting varices. Patients treated with ligation required fewer vasoconstrictors and fewer transfusion units than patients treated with sclerotherapy. Furthermore, banding ligation was associated with a lower complication rate than sclerotherapy.

Comparisons of long-term effects of lisinopril vs nifedipine vs conventional therapy in the treatment of mild-to-moderate hypertension in patients with chronic obstructive pulmonary disease

BACKGROUND

Any hypertensive patient may be found to have associated lung disease. The response of high blood pressure to specific antihypertensive agents in this category is still unknown. Thus, a group of 76 consecutive patients with mild-to-moderate hypertension and chronic obstructive pulmonary disease (COPD) were selected to participate in a clinical antihypertensive trial to define the roles of lisinopril, nifedipine and conventional therapy, and their impact on the renin-antiotensin system (RAS).

METHODS

After a two-week placebo period, patients were randomly assigned to a regimen of one of three main treatment strategies: (A) lisinopril with or without diuretics; (B) nifedipine with or without diuretics; or (C) diuretics with or without conventional vasodilators (sorbitrate and hydralazine) or selective beta-blockers. The drug doses were titrated to a goal of less than 90 mmHg for maximal diastolic pressure, and the patients continued to receive therapy for at least one year.

RESULTS

After one year of follow-up, only 66 patients had completed the study. All high blood pressure was significantly reduced by the three regimens (p < 0.005), but no significant difference in blood pressure control by any individual regimen was noted. Double product also showed the similar trend. Therapy A achieved the best reduction of double product among three regimens, but statis tieally insignificant. Furthermore therapy A suppressed the RAS, whereas therapies B and C might activate this system. Concomitantly, therapy A also had significant favorable effects on metabolic responses in contrast to therapy C. Therapy B revealed a neutral effect on such responses.

CONCLUSIONS

These data indicated that these three main strategies could provide significant antihypertensive efficacy for blood pressure control in patients with hypertension and COPD. For preventive strategy, therapy A may provide more advantageous effects than therapy C. A long-term double-blind trial including more subjects is warranted to identify the true advantages of therapy A in reduction or major cardiovascular and respiratory events.

The impact of endoscopic variceal ligation on the pressure of the portal venous system

BACKGROUND/AIMS

Endoscopic variceal ligation is a viable substitute for injection sclerotherapy. It is still not known how endoscopic variceal ligation may influence the portal venous system. To clarify this issue we investigated the impact of endoscopic variceal ligation on the pressure of the portal venous system.

METHODS

Twenty-nine patients with a history of esophageal variceal bleeding but without ascites were enrolled. All had cirrhosis; 63% of them were post-hepatitic. Ligation was performed at intervals of 2-3 weeks until all the varices were obliterated. Portal venograms were performed before institution of ligation and after variceal obliteration to assess venographic findings and pressure changes. The pressures of the main portal vein, splenic vein and superior mesenteric vein were recorded.

RESULTS

Twenty-five patients completed the study. A mean of 4.4 sessions (range: 2-7) of ligation over a period of 2 months was needed. Seventeen (68%) patients experienced elevated pressure and eight (32%) patients reduced pressure after ligation. Mean (median) pressure changes were as follows: portal venous pressure, 26.5 +/- 4.7 (25.0) mmHg vs. 28.2 +/- 7.2 (28.0) mmHg (p > 0.05); splenic venous pressure, 28.2 +/- 4.9 (26.0) mmHg vs. 29.0 +/- 6.8 (29.0) mmHg (p > 0.05); superior mesenteric venous pressure, 28.4 +/- 6.0 (27.0) mmHg vs. 29.5 +/- 7.0 (29.0) mmHg (p > 0.05). Five patients (20%) experienced rebleeding before variceal obliteration; all of them presented elevated portal pressures after variceal obliteration. Among the eight patients with decreased portal pressure, seven (87%) had other major collaterals apart from esophageal varices, compared to three out of the 17 (18%) patients with elevated portal pressure who had other major collaterals (p < 0.01).

CONCLUSIONS

Among patients receiving endoscopic variceal ligation, 68% experienced elevated portal pressure, while 32% had decreased portal pressure. Elevation of portal pressure after variceal ligation may be an important factor in variceal rebleeding. The presence of other major collaterals apart from esophageal varices may be responsible for the decrease in portal pressure after obliteration of esophagel varices.

Upright postures and isoproterenol infusion for provocation of neurocardiogenic syncope: a comparison of standing and head-up tilting

Head-up tilt testing has proved to be useful in provocation of neurocardiogenic syncope. The purpose of this study was to examine whether simply assuming an upright posture by standing can be an alternative to the head-up tilt testing for diagnosis of neurocardiogenic syncope. Eighty-four patients with recurrent unexplained syncope and 22 normal volunteers were recruited into the study. Forty-seven patients with syncope and all normal volunteers received the standing test. Thirty-seven of the patients with syncope received head-up tilt testing (90 degrees). All subjects lay down for 5 minutes and then assumed an upright posture until syncope or presyncope occurred or until a maximum of 10 minutes was reached in each stage of the test. The tests included four stages: baseline and infusion of 1, 2, or 3 micrograms/min isoproterenol in each of the successive stages. Five subjects could not tolerate the procedure, and further testing was terminated. Overall, the standing test was positive in 83% of the patients with syncope, and its specificity was 74%. The head-up tilt testing was positive in 75% of the patients with syncope. The duration of assuming an upright posture before occurrence of syncope or presyncope was significantly longer in the syncope-tilting group in the third stage (p < 0.01) and the fourth stage (p < 0.05) compared with the syncope-standing group. However, the curves of the time course for cumulative positive rates were not significantly different (p = 0.0739) in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)