Dynamic optimization of CRT pacing using a novel algorithm improves survival in a real-world cohort of patients

Background

The AdaptivCRT (aCRT) algorithm continuously adjusts cardiac resynchronization therapy (CRT) according to intrinsic atrioventricular (AV) conduction status, providing synchronized left-ventricular pacing in patients (pts) with a normal PR interval and adaptive biventricular (BiV) pacing in pts with a prolonged PR interval. Prior secondary analyses of prospective trials demonstrated a reduction in mortality and atrial fibrillation incidence with aCRT.

Objective

To compare mortality in a large real-world population of pts with and without aCRT using electronic health record (EHR) data.

Methods

An Optum® de-identified EHR dataset and Medtronic CareLink device data were linked to identify pts (age>18 years) with a CRT implanted between 2014–2018 who survived ≥35 days post implant and with a documented baseline left ventricular ejection fraction (LVEF). Pts were grouped with aCRT set to either Adaptive BiV+LV (aCRT group) or standard CRT (control group). Two pt subgroups were identified: (i) pts with left bundle branch block (LBBB) and no AV block, (ii) pts with either no LBBB or with AV block.

Kaplan-Meier curves and log-rank were used to estimate and compare survival between treatment and control groups in both the full cohort and subgroups. Multivariate Cox regression was used to estimate the aCRT treatment effect while controlling for baseline characteristics.

Results

Among 8624 patients implanted with a CRT device with EHR data available for a median of 23.5 months post implant [IQR: 12.6, 37.3], 3994 patients had the aCRT feature activated. Pts in the aCRT group were younger (median 69 [IQR:60, 76] vs 73 [IQR: 65, 79] years), more frequently female (35% vs 26%), and more frequently had LBBB (72% vs 51%); p's<0.001. Median QRS duration was 150ms (IQR: 133, 164) for the aCRT group and 152ms (IQR: 134, 172) for the control group (p<0.001). Median LVEF was 22% (IQR: 18, 30) for the aCRT group and 25% (IQR: 20, 30) for the control group (p<0.001). Through 60 months post implant, the overall mortality rate was 23.6% (95% CI: 20.7%-26.3%) for the aCRT group and 37.6% for the control group (95% CI: 34.9%-40.1%), p<0.001. Subgroup analysis demonstrated a significant reduction in mortality with aCRT in both pts with LBBB without AV block (Figure, left panel) and pts without LBBB and with AV block (Figure, right panel). After accounting for baseline differences, the reduction in mortality remained significant in the LBBB/no AV block group (HR: 0.54, 95% CI: 0.39–0.76, p<0.001) and trended toward significance in the no LBBB/with AV block group (HR: 0.89, 95% CI: 0.79–1.01; p=0.08).

Conclusion

In a large, real-world population of pts implanted with CRT devices, the AdaptivCRT algorithm was associated with significantly reduced mortality, with a greater reduction observed among pts with LBBB and without AV block. These results are being tested prospectively in the ongoing AdaptResponse multi-national, randomized clinical trial.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic, Inc. Cumulative probability of death by group

Endothelial eNAMPT drives EndMT and preclinical PH: rescue by an eNAMPT-neutralizing mAb

Pharmacologic interventions to halt/reverse the vascular remodeling and right ventricular dysfunction in pulmonary arterial hypertension (PAH) remains an unmet need. We previously demonstrated extracellular nicotinamide phosphoribosyltransferase (eNAMPT) as a DAMP (damage-associated molecular pattern protein) contributing to PAH pathobiology via TLR4 ligation. We examined the role of endothelial cell (EC)-specific eNAMPT in experimental PH and an eNAMPT-neutralizing mAb as a therapeutic strategy to reverse established PH. Hemodynamic/echocardiographic measurements and tissue analyses were performed in Sprague Dawley rats exposed to 10% hypoxia/Sugen (three weeks) followed by return to normoxia and weekly intraperitoneal delivery of the eNAMPT mAb (1 mg/kg). WT C57BL/6J mice and conditional EC-cNAMPTec-/- mice were exposed to 10% hypoxia (three weeks). Biochemical and RNA sequencing studies were performed on rat PH lung tissues and human PAH PBMCs. Hypoxia/Sugen-exposed rats exhibited multiple indices of severe PH (right ventricular systolic pressure, Fulton index), including severe vascular remodeling, compared to control rats. PH severity indices and plasma levels of eNAMPT, IL-6, and TNF-α were all significantly attenuated by eNAMPT mAb neutralization. Compared to hypoxia-exposed WT mice, cNAMPTec-/- KO mice exhibited significantly reduced PH severity and evidence of EC to mesenchymal transition (EndMT). Finally, biochemical and RNAseq analyses revealed eNAMPT mAb-mediated rectification of dysregulated inflammatory signaling pathways (TLR/NF-κB, MAP kinase, Akt/mTOR) and EndMT in rat PH lung tissues and human PAH PBMCs. These studies underscore EC-derived eNAMPT as a key contributor to PAH pathobiology and support the eNAMPT/TLR4 inflammatory pathway as a highly druggable therapeutic target to reduce PH severity and reverse PAH.

RV Pacing Percentage

Introduction

Chronic right ventricular pacing (RVP) has been associated with dyssynchrony, leading to increased mortality. However, there have been discrepancies in previous reports in the effect of RVP levels.

Objective

To sub-stratify mortality risk by age for different RVP level groups within a large real-world ICD cohort.

Methods

Optum® de-identified electronic health records were linked to the Medtronic Carelink data to identify dual chamber ICD recipients (2007–2017). RVP level was based on median daily pacing during the first 90 days post-implant and categorized either into groups with a cutoff of 40%, or with groups of 0–9%, 10–19%, 20–29%, 30–39%, 40–49%, and 50–100%. The endpoint was death more than 90 days post-implant. Kaplan-Meier survival curves, log-rank tests, and Cox regression were used to analyze the relationship between RVP and risk of death.

Results

Among 14,832 ICD patients (median age 67; 74.0% male), there were 2,602 deaths within 10 years after implant. In unadjusted comparisons, high RVP (>40%) increased the risk of death relative to low RVP (≤40%) (p<0.001). This effect remained significant in older cohort (≥67 years old at implant) (p<0.001), but not in younger cohort (<67 years old) (p=0.955) (Figure). After controlling for age, gender, pacing mode, MI, SCA, HF hospitalization, diabetes, and renal dysfunction, similar or increased risk was associated with higher pacing groups relative to the 0–9% pacing group in the older cohort, but not in the younger cohort.

Conclusions

Our data from a large contemporaneous real-world source suggests that older age or characteristics associated with age make patients more sensitive to chronic RVP effects. These results help reconcile differences observed in prior studies.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic, Inc.

Validation of the Roche AMPLICOR HIV DNA test version 1.5 for early infant diagnosis of HIV in Papua New Guinea

Human immunodeficiency virus (HIV) is a significant public health issue in Papua New Guinea (PNG). After heterosexual transmission (90%), the second most common route of transmission is vertically from mother to child (3.5%). Before the introduction of molecular methods of HIV testing in PNG, diagnosing exposed infants was problematic because there were no reliable assays available for accurate early infant HIV detection. This study aimed to validate and assess a global gold standard for virological early infant HIV diagnosis in PNG: the AMPLICOR HIV DNA v1.5 assay (Roche) using dried blood spot (DBS) specimens. The assay was validated in three ways: by testing well-characterized DBS and kit controls and by blinded retesting of 42 patient specimens. The assay was further investigated by comparison with a serological assay. The results indicated that the assay was robust and highly reproducible using DBS and kit controls, with 100% sensitivity and specificity. Of the 42 infant DBS specimens that were retested blindly, 100% of the test results were concordant with diagnostic results. Among the 42 infant specimens tested with the Amplicor HIV DNA v1.5 assay we found that 33% of infants (n = 14) were HIV PCR positive and 67% (n = 28) negative. The earliest point of HIV detection established for this study was three months of age. This pilot study indicates that HIV-infected infants in PNG can be effectively diagnosed using virological testing and can thus be started earlier on treatment than was previously possible with serological testing.

Surgical management of primary anorectal melanoma

BACKGROUND

This aim of this study was to analyse outcome after surgery for primary anorectal melanoma and to determine factors predictive of survival.

METHODS

Records of 40 patients treated between 1977 and 2002 were reviewed.

RESULTS

Twelve men and 28 women of mean age 58.1 (range 37-83) years were included in the analysis. Overall and disease-free survival rates were 17 and 14 per cent at 5 years. Median overall survival was 17 months and disease-free survival was 10 months. The 5-year survival rate was 24 per cent for patients with stage I tumours, and zero for those with stage II or stage III disease. There was no significant difference in overall survival after wide local excision (49 and 16 per cent at 2 and 5 years respectively) and abdominoperineal resection (33 per cent at both time points). In patients with stage I and stage II disease, there was a significant association between poor survival and duration of symptoms (more than 3 months), inguinal lymph node involvement, tumour stage and presence of amelanotic melanoma.

CONCLUSION

Anorectal melanoma is a rare disease with a poor prognosis. Wide local excision is recommended as primary therapy if negative resection margins can be achieved.

Simultaneous bilateral laparoscopic adrenalectomy: a surgical option for multiple endocrine neoplasia (MEN 2) patients with bilateral pheochromocytomas

Multiple endocrine neoplasia (MEN 2) is a rare disorder. Of this group, 42% develop a pheochromocytoma of which 60% will have bilateral involvement. Although the benefits of unilateral laparoscopic adrenalectomy have been well documented, fewer cases of simultaneous bilateral laparoscopic adrenalectomy have been reported. We present the cases of three patients with MEN 2 who underwent successful simultaneous bilateral laparoscopic adrenalectomy after their initial presentation with bilateral pheochromocytoma. Although the management of bilateral pheochromocytomas has traditionally been approached via open laparotomy or bilateral posterior incisions, the bilateral laparoscopic approach should be considered a viable alternative for patients requiring surgical intervention. Clinical outcomes and complications are similar to open laparotomy. Simultaneous bilateral laparoscopic adrenalectomy is a safe and effective procedure that results in a more rapid recovery and a shorter hospital stay for patients with bilateral pheochromocytomas originating from MEN 2.

Reaction to frustration in high and low feather pecking laying hens

Reaction to frustration of high (HFP) and low feather pecking (LFP) laying hens was investigated. From a HFP- and a LFP-line five birds with a HFP- and five birds with a LFP-phenotype were selected. Birds from the HFP-line were expected to show more key pecking and covered feeder pecking during frustration than birds from the LFP-line. When a bunch of feathers was presented, birds with a HFP-phenotype were expected to redirect their pecks at the bunch. Birds were trained to peck a key for a food reward in an automated Skinnerbox and subjected to two sessions: a control session, where food was available, and a frustration session, where the feeder was covered with Perspex. These two sessions were repeated in the presence of a bunch of feathers. Unexpectedly, birds from the LFP-line had a stronger reaction to frustration than birds from the HFP-line, expressed in pecking behaviour. When a bunch of feathers was offered, birds with a HFP-phenotype did not show more bunch pecking during frustration than birds with a LFP-phenotype.

Genetic variability and linkage disequilibrium within the HLA-DP region: analysis of 15 different populations

In order to understand the forces governing the evolution of the genetic diversity in the HLA-DP molecule, polymerase chain reaction (PCR)-based methods were used to characterize genetic variation at the DPA1 and DPB1 loci encoding this heterodimer on 2,807 chromosomes from 15 different populations including individuals of African, Asian, Amerindian, Indian and European origin. These ethnically diverse samples represent a variety of population substructures and include small, isolated populations as well as larger, presumably admixed populations. Ten DPA1 and 39 DPB1 alleles were identified and observed on 87 distinct DP haplotypes, 34 of which were found to be in significant positive linkage disequilibrium in at least one population. Some haplotypes were found in all ethnic groups while others were confined to a single ethnic group or population. Strong positive global linkage disequilibrium (Wn) between DPA1 and DPB1 was present in all 15 populations. The African populations displayed the lowest values of Wn whereas the Amerindian populations displayed near absolute disequilibrium. Analysis of the distribution of haplotypes using the normalized deviate of the Ewens-Watterson homozygosity statistic, F, suggests that DP haplotypes encoding the functional heterodimer are subject to much lower degrees of balancing selection than other loci within the HLA region. Finally, neighbor joining tree analyses demonstrate the power of haplotype diversity for inferring the relationships between the different populations.

Neuro-ophthalmic complications of sarcoidosis

Sarcoidosis is a systemic disorder that is caused by granulomatous changes of uncertain etiology and commonly has multiorgan involvement. Ocular involvement may occur in up to 32% of persons afflicted by sarcoid. The neuro-ophthalmic manifestations of sarcoid, in particular, are varied and may affect any portion of the visual system, including neural structures. Diagnosis is often difficult due to the fact that the clinical presentation can mimic other disorders, such as Multiple Sclerosis, and therefore a systematic approach to testing must be used once the diagnosis has been considered. The importance of diagnosing neuro-ophthalmic sarcoid lies in the fact that it is a treatable disease. The mainstay of treatment is corticosteroids although other immunosuppressive agents may be used. The long-term prognosis of neuro-ophthalmic sarcoid has not been studied in large patient populations, but the data that is available suggests that remission may occur in up to 47%.

Characterization of high-risk HIV-1 seronegative hemophiliacs

Mechanisms that protect most high-risk HIV-1 seronegative (HRSN) persons are not well understood. Among hemophiliacs from the Multicenter Hemophilia Cohort Study who remained HIV-1 seronegative despite a high (94%) risk for acquisition of HIV-1 infection, only 7/43 were homozygous for the protective CCR5 Delta32 polymorphism. Among the remainder, neither CCR5 density nor beta-chemokine production, nor in vitro susceptibility to infection with the HIV-1 isolate JR-FL could distinguish HRSN hemophiliacs from healthy controls. When compared to lymphocytes of healthy controls not at risk for HIV-1 infection, diminished spontaneous lymphocyte proliferation was seen in lymphocytes of HRSN hemophiliacs as well as in lymphocytes of hemophiliacs not at risk for HIV-1 infection. Surprisingly sera/plasmas obtained from high-risk HIV-1 seropositve hemophiliacs prior to seroconversion more often contained alloreactive antibodies than date-matched sera/plasmas obtained from HRSN hemophiliacs. Thus alloreactivity may predispose to acquisition of HIV-1 infection after parenteral exposure.

Frequent umbilical cord-blood and maternal-blood infections with Plasmodium falciparum, P. malariae, and P. ovale in Kenya

The prevalence of malaria infection in 102 paired maternal-blood and umbilical cord-blood samples was assessed by microscopy and polymerase chain reaction (PCR) in a holoendemic area in Kenya. Plasmodium falciparum single-species infection was detected in maternal peripheral blood (3.4%), whereas microscopy indicated that no Plasmodium species were in cord blood. In contrast, maternal-blood samples showed a PCR prevalence of 48% for P. falciparum, 25% for P. malariae, and 24% for P. ovale, and cord-blood samples showed a PCR prevalence of 32%, 23%, and 21%, respectively. Although mothers with mixed-species infections were more likely to have offspring infected with mixed species, the specific malaria species were discordant in paired maternal- and cord-blood samples. Triple-species infections were observed in 11 cord- and maternal-blood samples at a 5.5-fold greater frequency than expected. These findings indicate that Plasmodium species infections in cord blood are common, occur at lower densities, and may be acquired before parturition.

Hepatic metastases from breast carcinoma: comparison of noncontrast, arterial-dominant, and portal-dominant phase spiral CT

PURPOSE

The purpose of this work was to determine the relative value of noncontrast (NC), arterial-dominant (AD), and portal-dominant (PD) phase images in spiral CT of the liver for breast cancer metastases.

METHOD

Forty-four spiral CT scans in 18 patients with hepatic metastases from breast cancer were retrospectively reviewed by three radiologists. Subjective evaluations of overall lesion conspicuity and margination were graded on a 5 point scale for NC, AD, and PD phase images, and the three phases were also ranked for demonstration of overall tumor volume. Those scans with hypervascular lesions were separately analyzed, resulting in three groups (all, hypervascular, hypovascular).

RESULTS

For lesion conspicuity and margination for the entire study group, AD phase images showed the lowest grades (1.97 and 1.83), whereas the PD phase showed the highest grade (3.34 and 3.14; p < 0.0001) followed by NC (2.36 and 2.42; p < 0.0001). For the hypervascular subgroup, the AD phase also showed the lowest grades (2.39 and 2.24). In no case did the AD phase show more lesions than the combination of NC and PD phases. For depiction of overall tumor volume, the AD phase had the lowest ranking (2.51) compared with the NC and PD phases (1.71 and 1.78; p < 0.001). For the hypervascular subgroup, the AD phase had the lowest ranking (2.33) compared with the NC and PD phases (1.39 and 2.27; p < 0.0001).

CONCLUSION

The AD phase is not required for lesion detection in spiral CT for hepatic metastases from breast carcinoma. The NC phase depicts the maximal tumor volume.

Further evolution of a literature database: the international use of a common software structure and methodology for the establishment of national consultation/liaison databases

Every day there are 6000-7000 papers published in science. Since the C-L psychiatrist may be asked to consult on a patient with any medical illness, and who may be on any medical drug, methods need to be developed to review the recent literature and have an awareness of current findings. At the same time, teachers need to develop a current listing of seminal papers for trainees and practitioners of this subspecialty of psychiatry. Experts chosen because of their writings and acknowledged contributions to their subspecialty interests have sifted through thousands of articles to select the ones they regard as the most important for trainees in C-L psychiatry. In addition, certain countries--Spain, Portugal, Germany, Mexico, Australia and Brazil are developing national databases of C-L literature not only for their own use, but also to bring them to the attention of other parts of the world. This fifth iteration of the C-L literature database has especially targeted the period of 1996-1999--the millennium issue--in order to have easier access to contemporary essential studies on common problems. Part II of this issue describes the seminal cardiac drug-psychotropic drug interactions that the C-L psychiatrist may encounter in the most common medical disease in the United States--coronary heart disease--with advise to the practitioner as to their management. The use of the Internet and institutional Intranets is described.

Biogenic volatile organic compound emissions (BVOCs). I. Identifications from three continental sites in the U.S

Vegetation composition and biomass were surveyed for three specific sites in Atlanta, GA; near Rhinelander, WI; and near Hayden, CO. At each research site emissions of biogenic volatile organic compounds (BVOCs) from the dominant vegetation species were sampled by enclosing branches in bag enclosure systems and sampling the equilibrium head space onto multi-stage solid adsorbent cartridges. Analysis was performed using a thermal desorption technique with gas chromatography (GC) separation and mass spectrometry (MS) detection. Identification of BVOCs covering the GC retention index range (stationary phase DB-1) from approximately 400 to 1400 was achieved (volatilities C4-C14).

Doppler sonographic parameters for detection of carotid stenosis: is there an optimum method for their selection?

OBJECTIVE

A wide range of Doppler threshold values for carotid stenosis is found in the literature. We undertook this study to compare methods of derivation and to determine if an optimum strategy of threshold selection exists for a high-risk population.

MATERIALS AND METHODS

From the sonograms of all patent internal carotid arteries, peak systolic velocity in the internal carotid artery (ICA(PSV)) and the ratio of peak systolic velocity in the internal carotid artery to that of the common carotid artery (ICA(PSV)/ CCA(PSV)) were compared with the percentage of angiographically determined stenosis. Receiver operating characteristic curves were generated for levels of stenosis > or =60% and > or =70%. Doppler thresholds were chosen on the basis of maximum accuracy and on the basis of > or =90% sensitivity and specificity. Patients were then segregated into symptomatic and asymptomatic cohorts, and the above process was repeated. An effectiveness analysis was also conducted using various Doppler thresholds. Thresholds derived using these three methods were compared and optimal values chosen. RESULTS. Of 333 carotid arteries that fit inclusion criteria, 132 were found in asymptomatic patients and 201 in symptomatic patients. Maximum accuracy, > or =90% sensitivity and specificity, and effectiveness analysis each produced different ranges of thresholds. We chose final thresholds that maintained patient outcome profiles. For asymptomatic patients at the > or =60% stenosis level, thresholds were ICA(PSV) = 200 cm/sec and ICA(PSV)/CCA(PSV) = 3.0. For symptomatic patients with stenosis > or =70%, thresholds were ICA(PSV) = 175 cm/sec and ICA(PSV)/CCA(PSV) = 2.5.

CONCLUSION

Considerable latitude exists in the choice of carotid Doppler thresholds. We propose a rational strategy for threshold selection based on a combination of three commonly used methods. Our observations indicate that it appears advisable to consider symptomatic and asymptomatic patients separately and to apply appropriately derived thresholds.

Biogenic volatile organic compound emissions (BVOCs). II. Landscape flux potentials from three continental sites in the U.S

Landscape flux potentials for biogenic volatile organic compounds (BVOCs) were derived for three ecosystems in the continental U.S. (Fernbank Forest, Atlanta, GA; Willow Creek, Rhinelander, WI; Temple Ridge, CO). Analytical data from branch enclosure measurements were combined with ecological survey data for plant species composition and biomass. Other quantitative flux measurements at the leaf and landscape level were incorporated to scale the results from the enclosure measurements to the landscape level. Flux estimates were derived by using a one week ambient temperature and light record (30 min time resolution) and adjusting all emission rates to these conditions with temperature and light correction algorithms.

From war nursery to therapeutic milieu

The issue of violence in childhood and society is reviewed from the comparative perspective of the care of children by Anna Freud and her colleagues during the bombing of World War II and the plight of seriously troubled children and adolescents living in poverty and in violent families in contemporary society. Consistent with observations reported by Mahron, violence among these children is understood as a response to a world experience that is depleting and overwhelming; some sense of being alive is provided through aggressive behavior. Founded on the concept of the therapeutic milieu as described by Aichhorn, Bettelheim, and Redl and Wineman, the psychoanalytic intervention program described here fosters enhanced capacity for tension management and ego development via techniques of crisis management within the group living situation, incorporating the life-space or marginal interview, therapeutic education, and psychotherapy.

Mycobacterium tuberculosis infection as a zoonotic disease: transmission between humans and elephants

Between 1994 and 1996, three elephants from an exotic animal farm in Illinois died of pulmonary disease due to Mycobacterium tuberculosis. In October 1996, a fourth living elephant was culture-positive for M. tuberculosis. Twenty-two handlers at the farm were screened for tuberculosis (TB); eleven had positive reactions to intradermal injection with purified protein derivative. One had smear-negative, culture-positive active TB. DNA fingerprint comparison by IS6110 and TBN12 typing showed that the isolates from the four elephants and the handler with active TB were the same strain. This investigation indicates transmission of M. tuberculosis between humans and elephants.

Environmental controls over isoprene emission in deciduous oak canopies

In summer 1992, isoprene emission was measured on intact leaves and branches of Quercus alba (L.) at two heights in a forest canopy. Isoprene emission capacity (measured at 30 degrees C and a photosynthetic photon flux density of 1000 micro mol m(-2) s(-1)) was significantly higher in sun leaves than in shade leaves when expressed on a leaf area basis (51 versus 31 nmol m(-2) s(-1); P < 0.01). Because leaf mass per unit area (LMA, g m(-2)) was higher in sun leaves than in shade leaves, emissions of sun and shade leaves expressed on a dry mass basis did not differ significantly (99 versus 89 micro g C g(DW) (-1) h(-1); P = 0.05). Similar measurements in 1995 were consistent with the 1992 data, but data from leaves in more shaded locations demonstrated that isoprene emission capacity decreased with decreasing growth irradiance, irrespective of units of expression. Isoprene emission capacity in leaves of Q. coccinea Muenchh. and Q. velutina Lam. also declined steeply with canopy depth. Emission capacity, on a dry mass basis, showed no obvious pattern with canopy position in Q. prinus L. There was no difference in the temperature response of sun versus shade leaves of Q. alba, but shade leaves exhibited a greater quantum efficiency and saturated at lower irradiance than sun leaves. Rates of isoprene emission measured on branches of Q. alba were approximately 60% of those measured on individual leaves, as a result of self-shading within branch enclosures. It is recommended that within-canopy variation in isoprene emission capacity be incorporated into regional emission models.

Customer service: the new battlefield for market share

In a survey conducted by the authors of the following article, it was determined that more than 50 percent of employers and managed care companies dropped providers who failed customer service standards. Many employers stated that they changed health plans according to their employees' preferences. Managed care organizations reported that they use the data from customer service surveys to choose providers, facilitate contract negotiations, and determine provider bonuses. Healthcare financial professionals can gain competitive advantages and help secure their organizations' financial future by focusing their resources and attention toward customer service issues.

Visual significance of glistenings seen in the AcrySof intraocular lens

PURPOSE

To investigate the visual significance of "glistenings" in acrylic intraocular lenses (IOLS).

SETTING

John Moran Eye Center, University of Utah, Salt Lake City.

METHODS

Seventeen patients who had phacoemulsification with implantation of the AcrySof acrylic IOL were evaluated by slitlamp examination and visual acuity, contrast sensitivity, and glare testing. Ten patients had a silicone posterior chamber IOL in the opposite eye and had testing with similar visual parameters for comparison. Glistenings noted in the acrylic IOLs were graded at the slitlamp. Laboratory analysis of five acrylic IOLs was also done to reproduce the glistenings noted clinically.

RESULTS

All 17 patients with the acrylic IOLs had some lenticular glistenings, ranging from trace to 2+. Statistical analysis of visual acuity, contrast sensitivity, and glare testing revealed a statistically significant difference between the acrylic and the silicone IOLs only in contrast sensitivity. Laboratory analysis of the acrylic IOLs showed similar glistenings from 48 to 72 hours after they were placed in balanced salt solution.

CONCLUSIONS

A patients who received AcrySof IOLs that came in the AcryPak had some degree of glistenings. There was also a significant decrease in contrast sensitivity compared with that of fellow eyes with silicone IOLs. The glistenings are likely caused by water vacuoles that form within the lens after hydration within the eyes. Further studies are necessary to assess the exact cause of these glistenings.

Leaf, branch, stand and landscape scale measurements of volatile organic compound fluxes from U.S. woodlands

Natural volatile organic compound (VOC) fluxes were measured in three U.S. woodlands in summer 1993. Fluxes from individual leaves and branches were estimated with enclosure techniques and used to initialize and evaluate VOC emission model estimates. Ambient measurements were used to estimate above canopy fluxes for entire stands and landscapes. The branch enclosure experiments revealed 78 VOCs. Hexenol derivatives were the most commonly observed oxygenated compounds. The branch measurements also revealed high rates of isoprene emission from three genera of plants (Albizia, Chusqua and Mahonia) and high rates of monoterpene emission from three genera (Atriplex, Chrysthamnus and Sorbus) for which VOC emission rates have not been reported. Measurements on an additional 34 species confirmed previous results. Leaf enclosure measurements of isoprene emission rates from Quercus were substantially higher than the rates used in existing emission models. Model predictions of diurnal variations in isoprene fluxes were generally within +/- 35% of observed flux variations. Measurements with a fast response analyzer demonstrated that 60 min is a reasonable time resolution for biogenic emission models. Average daytime stand scale (hundreds of m) flux measurements ranged from about 1.3 mg C m(-2) h(-1) for a shrub oak stand to 1.5-2.5 mg C m(-2) h(-1) for a mixed forest stand. Morning, evening and nighttime fluxes were less than 0.1 mg C m(-2) h(-1). Average daytime landscape scale (tens of km) flux measurements ranged from about 3 mg C m(-2) h(-1) for a shrub oak-aspen and rangeland landscape to about 7 mg C m(-2) h(-1) for a deciduous forest landscape. Fluxes predicted by recent versions (BEIS2, BEIS2.1) of a biogenic emission model were within 10 to 50% of observed fluxes and about 300% higher than those predicted by a previous version of the model (BEIS).

Effects of light, temperature and canopy position on net photosynthesis and isoprene emission from sweetgum (Liquidambar styraciflua) leaves

In June 1993, net photosynthetic rates, stomatal conductance and isoprene emission rates of sweetgum leaves (Liquidambar styraciflua L.) were measured at the top of the forest canopy (sun leaves) and within the canopy at a height of 8-10 m above ground level (shade leaves). Large differences in net photosynthetic rates and stomatal conductance were found between sun and shade leaves. Mean rates of isoprene emission, expressed on a leaf area basis, were significantly lower in shade leaves than in sun leaves (4.1 versus 17.1 nmol m(-2) s(-1)); however, because specific leaf area of sun leaves was lower than that of shade leaves (0.0121 versus 0.0334 m(2) g(-1)), the difference between sun and shade leaves was less, though still significant, when isoprene emissions were expressed on a dry mass basis (45.5 versus 29.0 micro g C g(-1) h(-1)). Saturation of both net photosynthesis and isoprene emission occurred at lower PPFDs in shade leaves than in sun leaves. The effect of leaf temperature on isoprene emissions also differed between sun and shade leaves. Sun leaves lost a significantly greater percentage of fixed carbon as isoprene than shade leaves. The leaf-level physiological measurements were used to derive parameters for a canopy-level isoprene flux model. The importance of incorporating differences between sun- and shade-leaf properties into existing models is discussed.

Evidence for possible involvement of an elastolytic serine protease in aspergillosis

A number of isolates of Aspergillus fumigatus obtained from the hospital environment produced extracellular elastolytic activity. This activity was found to be catalyzed by a single 33-kDa protein which was purified and characterized to be a serine protease. A. fumigatus, when grown on the insoluble structural material obtained from murine and bovine lung, produced the same extracellular 33-kDa elastolytic protease, indicating that this enzyme is likely to be produced when the organism infects the lung. Polymerase chain reaction with an oligonucleotide primer based on the N-terminal amino acid sequence of the elastolytic enzyme yielded a cDNA which was cloned and sequenced. The active serine motif showed more similarity to subtilisin than to mammalian elastase. The amino acid sequence showed 80% identity to the alkaline protease from Aspergillus oryzae. Screening of hospital isolates of Aspergillus flavus showed great variation in the production of elastolytic activity and a much lower level of activity than that produced by A. fumigatus. The elastolytic protease from A. flavus was shown to be a serine protease susceptible to modification and inactivation by active serine and histidine-directed reagents. This protease cross-reacted with the antibodies prepared against the elastolytic protease from A. fumigatus. Immunogold localization of the elastolytic enzyme showed that A. fumigatus germinating and penetrating into the lungs of neutropenic mice secreted the elastolytic protease. An elastase-deficient mutant generated from a highly virulent isolate of A. fumigatus caused drastically reduced mortality when nasally introduced into the lung of neutropenic mice. All of the evidence suggests that extracellular elastolytic protease is a significant virulence factor in invasive aspergillosis.

Monitoring asthma

The authors outline the management of asthma once the 'best lung function' is determined and answer some questions that may arise in general practice during the long-term monitoring of asthmatic patients. The answers represent the opinion of the authors, but are referenced where applicable.

Lesions of the suprachiasmatic nucleus disrupt circadian locomotor rhythms in the mouse

Entrained and free-running rhythms of wheel-running activity were recorded in male BALB/cByJ mice with electrolytic lesions of the suprachiasmatic nucleus (SCN), site of a circadian pacemaker in mammals. Complete ablation of the nucleus abolished the circadian locomotor rhythm; in some cases, wheel-running was synchronized by a light-dark cycle, but the phase relationship of this activity to the cycle was often aberrant. Unilateral lesions or those missing the SCN did not eliminate rhythmicity.

Circadian timekeeping in BALB/c and C57BL/6 inbred mouse strains

Circadian rhythms of locomotion (wheel-running activity) in 12 inbred mouse strains were recorded for interstrain differences in tau DD, the endogenous (free-running) period of the circadian pacemaker measured in constant environmental darkness. The results indicate that 1 or more genetic loci influence the value of tau DD, and a large (50 min) difference in mean tau DD between 2 of the strains, BALB/cByJ and C57BL/6J, allowed further characterization of the origins and inheritance of the polymorphic expression of this circadian pacemaker property. The interstrain difference in mean tau DD was associated with an interstrain difference in light-induced shifts of the phase of the free-running locomotor rhythm; the BALB/c strain (with the shorter mean tau DD) displayed relatively fewer advance phase shifts. Neither the history of previous light exposure, albinism, nor elevated circulating testosterone levels could account for the interstrain difference in mean tau DD. The value of tau DD based on the circadian rhythm of drinking activity (with the running wheel removed) was longer than that based on locomotion; this discrepancy was significantly greater and more variable in BALB/c than in C57BL/6 mice, though the interstrain difference in mean tau DD could not be attributed entirely to this effect. Reciprocal F1 hybrids of BALB/c x C57BL/6 matings revealed dominance of the C57BL/6 genotype, no sex linkage, and a significant (but small) maternal effect. Examination of CXB recombinant inbred strains provided no support for the hypothesis of monogenic inheritance. Further study of inherited differences in the BALB/c and C57BL/6 strains may be a useful noninvasive experimental approach for investigation of the neurobiological substrates of circadian rhythmicity.