Quasi-Distributed Fiber Sensor-Based Approach for Pipeline Health Monitoring: Generating and Analyzing Physics-Based Simulation Datasets for Classification

This study presents a framework for detecting mechanical damage in pipelines, focusing on generating simulated data and sampling to emulate distributed acoustic sensing (DAS) system responses. The workflow transforms simulated ultrasonic guided wave (UGW) responses into DAS or quasi-DAS system responses to create a physically robust dataset for pipeline event classification, including welds, clips, and corrosion defects. This investigation examines the effects of sensing systems and noise on classification performance, emphasizing the importance of selecting the appropriate sensing system for a specific application. The framework shows the robustness of different sensor number deployments to experimentally relevant noise levels, demonstrating its applicability in real-world scenarios where noise is present. Overall, this study contributes to the development of a more reliable and effective method for detecting mechanical damage to pipelines by emphasizing the generation and utilization of simulated DAS system responses for pipeline classification efforts. The results on the effects of sensing systems and noise on classification performance further enhance the robustness and reliability of the framework.

Corrosion Sensors for Structural Health Monitoring of Oil and Natural Gas Infrastructure: A Review

Corrosion has been a great concern in the oil and natural gas industry costing billions of dollars annually in the U.S. The ability to monitor corrosion online before structural integrity is compromised can have a significant impact on preventing catastrophic events resulting from corrosion. This article critically reviews conventional corrosion sensors and emerging sensor technologies in terms of sensing principles, sensor designs, advantages, and limitations. Conventional corrosion sensors encompass corrosion coupons, electrical resistance probes, electrochemical sensors, ultrasonic testing sensors, magnetic flux leakage sensors, electromagnetic sensors, and in-line inspection tools. Emerging sensor technologies highlight optical fiber sensors (point, quasi-distributed, distributed) and passive wireless sensors such as passive radio-frequency identification sensors and surface acoustic wave sensors. Emerging sensors show great potential in continuous real-time in-situ monitoring of oil and natural gas infrastructure. Distributed chemical sensing is emphasized based on recent studies as a promising method to detect early corrosion onset and monitor corrosive environments for corrosion mitigation management. Additionally, challenges are discussed including durability and stability in extreme and harsh conditions such as high temperature high pressure in subsurface wellbores.

Modelling inorganic nitrogen in runoff: Seasonal dynamics at four European catchments as simulated by the MAGIC model

Nitrogen (N) deposition is globally considered as a major threat to ecosystem functioning with important consequences for biodiversity, carbon sequestration and N retention. Lowered N retention as manifested by elevated concentrations of inorganic N in surface waters indicates ecosystem N saturation. Nitrate (NO3) concentrations in runoff from semi-natural catchments typically show an annual cycle, with low concentrations during the summer and high concentrations during the winter. Process-oriented catchment-scale biogeochemical models provide tools for simulation and testing changes in surface water and soil chemistry in response to changes in sulphur (S) and N deposition and climate. Here we examine the ability of MAGIC to simulate the observed monthly as well as the long-term trends over 10-35 years of inorganic N concentrations in streamwaters from four monitored headwater catchments in Europe: Čertovo Lake in the Czech Republic, Afon Gwy at Plynlimon, UK, Storgama, Norway and G2 NITREX at Gårdsjön, Sweden. The balance between N inputs (mineralization+deposition) and microbial immobilization and plant uptake defined the seasonal pattern of NO3 leaching. N mineralization and N uptake were assumed to be governed by temperature, described by Q10 functions. Seasonality in NO3 concentration and fluxes were satisfactorily reproduced at three sites (R2 of predicted vs. modelled concentrations varied between 0.32 and 0.47 and for fluxes between 0.36 and 0.88). The model was less successful in reproducing the observed NO3 concentrations and fluxes at the experimental N addition site G2 NITREX (R2=0.01 and R2=0.19, respectively). In contrast to the three monitored sites, Gårdsjön is in a state of change from a N-limited to N-rich ecosystem due to 20 years of experimental N addition. At Gårdsjön the measured NO3 seasonal pattern did not follow typical annual cycle for reasons which are not well understood, and thus not simulated by the model.

CAPSULE

The MAGIC model is able to simulate NO3 leaching on a monthly as well as an annual basis, and thus to reproduce the seasonal and short-term variations in N dynamics.

Modelling soil nitrogen: the MAGIC model with nitrogen retention linked to carbon turnover using decomposer dynamics

We present a new formulation of the acidification model MAGIC that uses decomposer dynamics to link nitrogen (N) cycling to carbon (C) turnover in soils. The new model is evaluated by application to 15-30 years of water chemistry data at three coniferous-forested sites in the Czech Republic where deposition of sulphur (S) and N have decreased by >80% and 40%, respectively. Sulphate concentrations in waters have declined commensurately with S deposition, but nitrate concentrations have shown much larger decreases relative to N deposition. This behaviour is inconsistent with most conceptual models of N saturation, and with earlier versions of MAGIC which assume N retention to be a first-order function of N deposition and/or controlled by the soil C/N ratio. In comparison with earlier versions, the new formulation more correctly simulates observed short-term changes in nitrate leaching, as well as long-term retention of N in soils. The model suggests that, despite recent deposition reductions and recovery, progressive N saturation will lead to increased future nitrate leaching, ecosystem eutrophication and re-acidification.

Increased nitrogen in runoff and soil following 13 years of experimentally increased nitrogen deposition to a coniferous-forested catchment at Gårdsjön, Sweden

Beginning in 1991, we have added nitrogen (N) to the 0.5-ha, N-poor, coniferous-forested catchment G2 NITREX at Gårdsjön, Sweden, to investigate the consequences of chronic elevated N deposition. We have added 40 kg N ha-1 yr-1 in fortnightly doses of NH4NO3 to the ambient 15 kg N ha-1 yr-1 by means of a sprinkling system. NO3 concentrations in runoff increased during 13 years from<1 to 70 microeq L-1, and in 2004 comprised about 10% of N input. Inhibition of NO3 immobilisation due to increased availability of NH4 might explain the increased leaching of NO3. C and N pools in the forest floor increased but C/N ratio has not changed. The increase in NO3 leaching thus occurred independently of change in C/N ratio. The results from Gårdsjön demonstrate that increased leaching of inorganic N and decrease in C/N ratio respond to increased N deposition at greatly different time scales.

Modelling the effect of climate change on recovery of acidified freshwaters: relative sensitivity of individual processes in the MAGIC model

The MAGIC model was used to evaluate the relative sensitivity of several possible climate-induced effects on the recovery of soil and surface water from acidification. A common protocol was used at 14 intensively studied sites in Europe and eastern North America. The results show that several of the factors are of only minor importance (increase in pCO(2) in soil air and runoff, for example), several are important at only a few sites (seasalts at near-coastal sites, for example) and several are important at nearly all sites (increased concentrations of organic acids in soil solution and runoff, for example). In addition changes in forest growth and decomposition of soil organic matter are important at forested sites and sites at risk of nitrogen saturation. The trials suggest that in future modelling of recovery from acidification should take into account possible concurrent climate changes and focus specially on the climate-induced changes in organic acids and nitrogen retention.

Linked models to assess the impacts of climate change on nitrogen in a Norwegian river basin and FJORD system

Dynamically downscaled data from two Atmosphere-Ocean General Circulation Models (AOGCMs), ECHAM4 from the Max-Planck Institute (MPI), Germany and HadAm3H from the Hadley Centre (HAD), UK, driven with two scenarios of greenhouse gas emissions (IS92a and A2, respectively) were used to make climate change projections. These projections were then used to drive four effect models linked to assess the effects on hydrology, and nitrogen (N) concentrations and fluxes, in the Bjerkreim river basin (685-km(2)) and its coastal fjord, southwestern Norway. The four effect models were the hydrological model HBV, the water quality models MAGIC, INCA-N and the NIVA FJORD model. The downscaled climate scenarios project a general temperature increase in the study region of approximately 1 degrees C by 2030-2049 (MPI IS92a) and approximately 3 degrees C by 2071-2100 (HAD A2). Both scenarios imply increased winter precipitation, whereas the projections of summer and autumn precipitation are quite different, with the MPI scenario projecting a slight increase and the HAD scenario a significant decrease. As a response to increased winter temperature, the HBV model simulates a dramatic reduction of snow accumulation in the upper parts of the catchment, which in turn lead to higher runoff during winter and lower runoff during snowmelt in the spring. With the HAD scenario, runoff in summer and early autumn is substantially reduced as a result of reduced precipitation, increased temperatures and thereby increased evapotranspiration. The water quality models, MAGIC and INCA-N project no major changes in nitrate (NO(3)(-)) concentrations and fluxes within the MPI scenario, but a significant increase in concentrations and a 40-50% increase in fluxes in the HAD scenario. As a consequence, the acidification of the river could increase, thus offsetting ongoing recovery from acidification due to reductions in acid deposition. Additionally, the increased N loading may stimulate growth of N-limited benthic algae and macrophytes along the river channels and lead to undesirable eutrophication effects in the estuarine area. Simulations made by the FJORD model and the HAD scenario indicate that primary production in the estuary might increase up to 15-20%, based on the climate-induced changes in river flow and nitrate concentrations alone.

Newer molecular approaches to detect known viruses and previously unrecognized viruses in cell substrates

The theme of this brief presentation is that there are tremendous advances not only in PCR-based detection but in other novel ways of detecting viruses and other agents. Much of the research is now being driven by the bio-defence agenda. Somehow those with manufacturing and regulatory responsibilities have to keep abreast of these developments and incorporate them as they become available into defining the safety of cell substrates. I am concerned that these techniques are and may remain academic research tools without validation or standardization, and that individual academic laboratories will not develop the capacity and special skills necessary to satisfy regulatory requirements, but that there is a tremendous research incentive in this area that needs to be linked with the development of safe prophylactic and therapeutic biologicals. With that, I will finish what I would consider as a report rather than an original talk.

A radiation-shielding device for craniofacial implant placement

The use of radiation shields in the head and neck cancer patient receiving adjuvant radiation therapy is a treatment alternative for protecting anticipated prosthetic implant sites. Shields can be fabricated easily as part of an interdisciplinary treatment protocol. In this article, the methods used to fabricate an extraoral radiation shield are described, and a patient treatment that illustrates possible uses of the shield for both extraoral and intraoral sites is presented.

Modification of a Super-Sep bottle for paint-on application of a separating medium used in flasking dentures

Modifying a Super-Sep bottle by adding a brush to the lid for paint-on use allows for the precise application of the separating medium used when flasking dentures. Super-Sep offers many advantages over other commonly used separating mediums: It is virtually dimensionless, allowing for better accuracy; it dries quickly and functions best on moist stone; and it can be poured against immediately. The latter fact means less time is needed before the subsequent layers of stone can be applied when denture flasking.

Prosthodontic management of periodontally compromised patient

The fabrication and placement of a conventional immediate denture following extraction of periodontally compromised, non-restorable remaining teeth is a method that is frequently used to help restore form and function in an esthetically pleasing manner. This technique demands knowledge in applied basic sciences and prosthodontic principles. Accurate diagnosis and scrupulous treatment planning help the dentist address the patient's needs.

Effect of evaporation and mixing technique on die spacer thickness: a preliminary study

STATEMENT OF PROBLEM

Casting relief is required for proper seating of castings to allow for luting agent thickness. The application of die spacer to the die is the most common method of obtaining casting relief. Die spacer film thicknesses that are outside the ideal range of 25 to 40 microm can cause clinical problems. Thickness can be affected by the separation of die spacer constituents, which may not be reconstituted by mixing, in the bottle and by the evaporation of volatile components while the bottle is open.

PURPOSE

The purpose of this study was to determine the effects of component evaporation and die spacer mixing technique on applied die spacer thickness.

MATERIAL AND METHODS

Bottles of Gold Tru-fit die spacer were left open for 0, 1, 4, 8, and 24 hours at 22 degrees C. Spacer solutions were shaken either by hand per the manufacturer's directions or on a dental vibrator for 1 minute. One even brush stroke of spacer was applied to clean glass slides. Three die spacer films were made for each combination of time and mixing technique. Eighteen thickness measurements per sample at various sites were recorded with profilometer tracings. Statistical differences were determined with a 2-way ANOVA.

RESULTS

Handshaking provided greater die spacer thickness, which increased with the time that the bottle was open. Vibration provided lower thickness with no statistical increase with time.

CONCLUSION

Insufficient agitation caused lower film thickness. Excessive evaporation caused higher film thickness.

Surface water acidification in the South Pennines I. Current status and spatial variability

The South Pennines, an area of acid-sensitive geology at the centre of a major industrial region, have undergone perhaps the most severe historic exposure to sulphur and nitrogen deposition in the UK. This study addresses a lack of existing research on the region by presenting the findings of a survey of 62 surface waters sampled during a 1-week period in April 1998. Results indicate that acidification in the region is acute; 27 of the sampled surface waters had a negative acid neutralising capacity (ANC) and 28 had a pH below 5.0. Minimum recorded pH values were below 4.0. Non-marine sulphate levels were extremely high (median 222 microeq/1), and widespread high nitrate concentrations (median 41 microeq/1) suggest that soils in the region as a whole may be at an advanced stage of nitrogen saturation. A consistent relationship was identified between site acidity and the balance between the major weathering-derived cations, calcium and magnesium, and sulphate. This could in turn be linked to catchment soil type and land use, with the most acidic conditions occurring in peat-dominated catchments, where weathering is minimal and the influence of atmospheric deposition most pronounced. Percentage of peat in each catchment was the single best predictor of surface water acidity. Nitrate concentrations, although not a dominant control on acidity, varied significantly according to land use. Elevated concentrations were observed in catchments containing forestry, due to enhanced deposition inputs, and in catchments containing improved land, linked to fertiliser use. Ammonium concentrations, although low at most catchments, were a significant component of the inorganic nitrogen total in a number of surface waters draining waterlogged peat catchments.

Clinical decision making in patients with congestive heart failure: the role of thoracic electrical bioimpedance

Optimizing appropriate pharmacologic therapy in patients with congestive heart failure has been difficult due to a lack of easily obtainable hemodynamic information to guide the approach to the patient. Recently, thoracic electrical bioimpedance has allowed reliable outpatient determination of these hemodynamic variables, potentially allowing tailored adjustment of therapy in patients with cardiac dysfunction. Case studies are presented in which bioimpedance data were important contributing factors in optimizing patient management. Utilization of this new technology to individualize patient therapy should lead to improved outcomes and more efficient use of health care resources. (c)2000 by CHF, Inc.

A technique to create appropriate abutment tooth contours for removable partial dentures

A technique is presented for using light-cured composite resin to create desirable contours on abutment teeth for the retention and support of removable partial dentures. The desired tooth shape is created on a diagnostic cast, captured in a clear temporary splint material, and formed in resin on the abutment teeth with the splint acting as a matrix.

Multidisciplinary treatment for an implant retained auricular prosthesis rehabilitation

Retention of a facial prosthesis is the most important factor in creating a useful prosthesis for the patient. This paper presents a detailed case study of an auricular defect that was rehabilitated using two types of prosthetic retention: adhesive and osseointegration. We present the patient selection criteria, the surgical considerations prior to implant placement, retention component selection, prosthetic fabrication techniques and patient management after prosthetic delivery. The osseointegrated prosthesis made a large improvement in the patient's quality of life.

Fabrication and use of a surgical template for placing implants to retain an auricular prosthesis

A procedure is described for the fabrication of a 3-dimensional surgical template to guide the placement of implants to retain an auricular prosthesis. This procedure requires a diagnostic wax pattern that is checked while on the patient to ensure it is positioned correctly and is also the correct size. The wax pattern is processed into a clear, methyl methacrylate resin, 3-dimensional surgical template. The most effective type of surgical template for planning implant placement is a 3-dimensional acrylic template that closely resembles the final prosthesis. This template will direct the implant placement where the retentive elements are most easily concealed, under the thickest areas of the prosthesis, which are the antihelix and antitragus. This location allows the best esthetic and functional results. An additional advantage of this technique is that it allows the retrieval of the diagnostic wax pattern of the auricle so that it can be used to fabricate the definitive prosthesis.

Craniofacial osseointegration of a large midfacial bone-anchored combination maxillofacial prosthesis: a clinical report

The combination of retentive clips and magnets has been used with favorable results for smaller facial prostheses. This patient's large midfacial defect created the need for an attachment design that would retain an intraoral obturator prosthesis and a large silicone facial prosthesis. The advantages of this design include having an obturator that is separately attached by clips to the framework. This allows the patient more ease in insertion and removal of the prosthesis. It also allows for better oral hygiene. The magnets aid the patient in the proper alignment of the facial prosthesis. The O-ring attachment was not a complicated technique in this patient's treatment. The patient can, without the use of a mirror, snap the rubber matrix O-ring attachment over the patrix attachment on the framework. This resulted in a retentive facial prosthesis, which helped the patient feel more secure. The silicone margins were well adapted to the patient's skin, which allows the use of thin translucent margins and the elimination of the inherent problems associated with the use of adhesives.

Ecosystem Experiments

Experimental manipulations of entire ecosystems have been conducted in lakes, catchments, streams, and open terrestrial and marine environments. Experiments have addressed applied problems of ecosystem management and complex responses of communities and ecosystems to perturbations. In the course of some experiments, environmental indicators and models have been developed and tested. Surprising results with implications for ecological understanding and management are common.

Management of heart failure. IV. Anticoagulation for patients with heart failure due to left ventricular systolic dysfunction

OBJECTIVE

This article reviews the incidence of arterial thromboembolism in patients with heart failure who are not receiving anticoagulants. We also examine whether more severe ventricular dysfunction increases this incidence and the efficacy and risks of anticoagulation for patients in sinus rhythm.

DATA SOURCES

English-language studies referenced in MEDLINE or EMBASE (January 1966 to September 1993) were reviewed. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms anticoagulation, cerebrovascular disorders, stroke, and thromboembolism.

STUDY SELECTION

All studies with separate data for patients with chronic heart failure not receiving anticoagulants were included. Articles addressing valvular heart disease or heart failure secondary to acute myocardial infarction or Chagas' disease were excluded. Studies of the occurrence of left ventricular mural thrombi were also reviewed.

DATA EXTRACTION AND SYNTHESIS

Inclusion and exclusion criteria, prevalence of atrial fibrillation, mean follow-up, and the occurrence of arterial thromboembolic events were extracted. If the incidence was not given, this was estimated using the proportion of patients with events divided by the mean follow-up.

CONCLUSION

The incidence of arterial thromboembolism ranged from 0.9 to 5.5 events per 100 patient-years, with the largest studies reporting incidence of 2.0% and 2.4%. Findings regarding the relationship between ventricular function and thromboembolic events are contradictory. No controlled trial has assessed the efficacy or risks of anticoagulation for patients with heart failure and sinus rhythm, and reported efficacy in case series ranged from 0% to 100%. Until adequate studies are performed, anticoagulation should be discouraged for patients with heart failure who are in sinus rhythm.

Nitrogen saturation induced during winter by experimental NH4NO3 addition to a forested catchment

To investigate the potential risk of 'nitrogen saturation' in Scandinavian boreal forests, the authors are experimentally adding 30-50 kg N ha(-1) year(-1) as NH4NO3 in precipitation to an entire 0.52-ha 80-year-old spruce forested catchment at Gårdsjön, near Gothenburg on the Swedish west coast. NO3 concentrations in runoff increased from 0 to about 7 microeq liter(-1) (maximum pulse of 43 microeq liter(-1)). The increase occurred in winter; during the April-October growing season, NO3 concentrations were very low. The speed of the response suggests that these forests are already close to saturation.

The MAGIC simulation of surface water acidification at, and first year results from, the Bear Brook Watershed Manipulation, Maine, USA

The catchments of East and West Bear Brooks, Maine, USA, have been hydrologically and chemically monitored for 3.5 years. Stream chemistries and hydrographs are similar. These clear water streams are low in ANC (0-70 microeq litre(-1)), with variations caused by changing concentrations of base cations, SO4, NO3 and Cl. The latter range between 90-120, 0-40 and 65-75 microeq litre(-1), respectively. The West Bear catchment is being treated with six applications per year of dry (NH4)2SO4 at 1800 eq ha(-1) year(-1). After one year of treatment, the response of the stream chemistry and the response modelled by MAGIC are similar. Retentions of NH4 and SO4 are nearly 100% and greater than 80%, respectively. The additional flux of SO4 is compensated principally by an increased Ca concentration. Episodes of high discharge in the treated catchment are now characterized by lower ANC and pH, and higher Al than prior to the manipulation. Concentrations of NO3 have increased about 10 microeq litre(-1) during the dormant season, presumably due to additional nitrification of N from NH4. Discharge-chemistry relationships indicate that changes in stream chemistry, except for NO3, are dominated by ion exchange reactions in the upper part of the soil profile.

State level expert review committees--are they protected?

Recently, the functioning of State-level expert review committees, operating under the auspices of professional medical societies, has become problematic. In particular, an increased number of State maternal mortality review committees have become inactive or disbanded primarily because of concern over liability of committee members and committee proceedings being used in litigation. A study was conducted of legal protection of the expert review process at the State level. The relevant immunity and privilege statutes of each State and the protection afforded by State law were analyzed. Findings show that, in all but a few States, the legal risk of participating in expert review is negligible. Most States have statutes that protect information involved in the review process from disclosure or use in subsequent litigation. Laws in most States also protect participants in the review process (both members of committees and providers of information) from civil liability.

Role of reflex sympathetic withdrawal in the hemodynamic response to an increased inotropic state in patients with severe heart failure

Newer positive inotropic agents used in the treatment of severe heart failure not only increase cardiac contractility, but also cause peripheral vasodilation. It is not known to what extent this vasodilation is due to a direct peripheral action of the drug, as opposed to reflex withdrawal of sympathetic tone secondary to an augmented inotropic state. In 16 patients with severe heart failure, a 48 hour intravenous infusion of milrinone, a positive inotropic vasodilator drug, resulted in an increase in stroke volume index from 26 +/- 2 to 34 +/- 3 ml/m2 (p less than 0.001), a reduction in forearm vascular resistance measured by venous plethysmography from 43 +/- 5 to 27 +/- 3 U (p less than 0.003) and an increase in forearm venous capacitance from 2.1 +/- 0.2 to 2.9 +/- 0.2 ml/100 ml (p less than 0.001). To determine whether a withdrawal of sympathetic tone contributed to this vasodilation, milrinone was infused directly into the left main coronary artery in eight of the patients, thereby eliminating any direct vascular effects of the drug. Intracoronary milrinone (50 micrograms/min) caused an increase in peak positive first derivative of pressure (658 +/- 49 to 784 +/- 68 mm Hg/s; p less than 0.01) and stroke volume index (20 +/- 2 to 25 +/- 3 ml/m2; p less than 0.0001), which was associated with a reduction in plasma norepinephrine from 540 +/- 101 to 423 +/- 90 pg/ml (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Milrinone and dobutamine in severe heart failure: differing hemodynamic effects and individual patient responsiveness

Milrinone and dobutamine were compared in 15 patients with New York Heart Association functional class III and IV congestive heart failure. Dobutamine and milrinone were administered intravenously according a graded titration schedule up to maximum doses (14 micrograms/kg/min and 75 micrograms/kg, respectively) or until increased ventricular ectopy or a reduction in left ventricular end-diastolic pressure to 10 mm Hg or less occurred. Although both agents markedly increased cardiac index, milrinone caused a significantly greater reduction in left and right heart filling pressures and mean arterial pressure than did dobutamine, and for any given increase in dP/dt, milrinone caused a greater reduction in systemic vascular resistance than did dobutamine. Thus, the hemodynamic effects of milrinone are best represented by a combination of the actions of dobutamine, a positive inotropic agent, and a vasodilator such as nitroprusside, which causes both arterial and venous dilation. The positive inotropic responses of individual patients to dobutamine (5 micrograms/kg/min) and milrinone (25 micrograms/kg) were compared. The increases in dP/dt with both agents were variable, and correlated poorly (r = .50; p = .059). Patients were divided into two groups: Group I consisted of eight patients in whom the ratio of the increase in dP/dt with dobutamine vs milrinone was greater than 1.0 (good dobutamine responders); group II consisted of seven patients in whom this ratio was less than 1.0 (poor dobutamine responders).(ABSTRACT TRUNCATED AT 250 WORDS)

Survival of patients with severe congestive heart failure treated with oral milrinone

The safety and efficacy of long-term oral milrinone therapy were evaluated over a 2 1/2 year period in 100 patients who had severe congestive heart failure despite conventional therapy. Long-term oral milrinone therapy (27 +/- 8 mg/day initial dose) was well tolerated; drug-related side effects occurred in only 11% of patients and led to drug withdrawal in only 4% of patients. Of 94 patients evaluated after 1 month of therapy, 51% had improved by at least one New York Heart Association functional class. Despite hemodynamic and clinical improvements, life table analysis showed a 39% mortality rate at 6 months and a 63% mortality rate at 1 year of therapy. Characteristics at study entry that predicted death within 6 months included more advanced functional class, impaired renal function, lower right ventricular ejection fraction, presence of nonsustained ventricular tachycardia on 24 hour ambulatory electrocardiography, more impaired baseline hemodynamic function and absence of clinical improvement after 1 month of milrinone therapy. Multivariate analysis selected lower baseline cardiac index and aortic systolic pressure as the most significant variables in predicting death; patients who died of progressive heart failure had less frequent use of antiarrhythmic drugs and greater increases in furosemide and milrinone doses during long-term follow-up than did those who died suddenly. Thus, although milrinone is well tolerated and produces early symptomatic benefits in approximately half of patients with congestive heart failure refractory to conventional therapy, there is no evidence that it improves the high baseline mortality in this disorder.

Separation of the direct myocardial and vasodilator actions of milrinone administered by an intracoronary infusion technique

To determine the relative contributions of milrinone's positive inotropic and vasodilator actions in patients with severe congestive heart failure, the drug was administered by constant infusion directly into the left main coronary artery of 11 patients with New York Heart Association functional class III or IV heart failure. Intracoronary infusion of milrinone at rates up to 50 micrograms/min had no effect on mean arterial pressure or systemic vascular resistance but resulted in dose-related increases in peak positive dP/dt (+21%), stroke volume index (+18%), and stroke work index (+21%) and decreases in heart rate (-3%), mean right atrial pressure (-25%), and left ventricular end-diastolic pressure (-17%). In eight patients, intravenous administration (75 micrograms/kg) after the intracoronary infusion resulted in significant decreases in mean arterial pressure (-14%) and systemic vascular resistance (-40%), further increase in stroke volume index compared with intracoronary administration, and further decreases in mean right atrial and left ventricular end-diastolic pressures compared with intracoronary administration. These data indicate that milrinone exerts both positive inotropic and vasodilator actions that contribute significantly to the drug's overall hemodynamic effect.

Positive inotropic and vasodilator actions of milrinone in patients with severe congestive heart failure. Dose-response relationships and comparison to nitroprusside

Milrinone is a potent positive inotropic and vascular smooth muscle-relaxing agent in vitro, and therefore, it is not known to what extent each of these actions contributes to the drug's hemodynamic effects in patients with heart failure. In 11 patients with New York Heart Association class III or IV congestive heart failure, incremental intravenous doses of milrinone were administered to determine the dose-response relationships for heart rate, systemic vascular resistance, and inotropic state, the latter measured by peak positive left ventricular derivative of pressure with respect to time (dP/dt). To clarify further the role of a positive inotropic action, the relative effects of milrinone and nitroprusside on left ventricular stroke work and dP/dt were compared in each patient at doses matched to cause equivalent reductions in mean arterial pressure or systemic vascular resistance, indices of left ventricular afterload. Milrinone caused heart rate, stroke volume, and dP/dt to increase, and systemic vascular resistance to decrease in a concentration-related manner. At the two lowest milrinone doses resulting in serum concentrations of 63 +/- 4 and 156 +/- 5 ng/ml, respectively, milrinone caused significant increases in stroke volume and dP/dt, but no changes in systemic vascular resistance or heart rate. At the maximum milrinone dose administered (mean serum concentration, 427 +/- 11 ng/ml), heart rate increased from 92 +/- 4 to 99 +/- 4 bpm (P less than 0.01), mean aortic pressure fell from 82 +/- 3 to 71 +/- 3 mmHg (P less than 0.01), right atrial pressure fell from 15 +/- 2 to 7 +/- 1 mmHg (P less than 0.005), left ventricular end-diastolic pressure fell from 26 +/- 3 to 18 +/- 3 (P less than 0.005), stroke volume index increased from 20 +/- 2 to 30 +/- 2 ml/m2 (P less than 0.005), stroke work index increased from 14 +/- 2 to 21 +/- 2 g X m/m2 (P less than 0.01), and dP/dt increased from 858 +/- 54 to 1,130 +/- 108 mmHg/s (P less than 0.005). When compared with nitroprusside for a matched reduction in mean aortic pressure or systemic vascular resistance, milrinone caused a significantly greater increase in stroke work index at the same or lower left ventricular end-diastolic pressure. Milrinone caused a concentration-related increase in dP/dt (32% increase at maximum milrinone dose), whereas nitroprusside had no effect. These data in patients with severe heart failure indicate that in addition to a vasodilating effect, milrinone exerts a concentration-related positive inotropic action that contributes significantly to the drug's overall hemodynamic effects. The positive inotropic action occurs at drug levels that do not exert significant chronotropic or vasodilator effects.