Minimally Invasive versus Full Sternotomy SAVR in the Era of TAVR: An Institutional Review

In the era of advancing transcatheter aortic valve replacement (TAVR) technology, traditional open surgery remains a valuable intervention for patients who are not TAVR candidates. We sought to compare perioperative variables and postoperative outcomes of minimally invasive and full sternotomy surgical aortic valve replacement (SAVR) at a single institution. A retrospective analysis of 113 patients who underwent isolated SAVR via full sternotomy or upper hemi-sternotomy between January 2015 and December 2019 at the University of Utah Hospital was performed. Preoperative comorbidities and demographic information were not different among groups, with the exception of diabetes, which was significantly more common in the full sternotomy group (p = 0.01). Median procedure length was numerically shorter in the minimally invasive group but was not significant following the Bonferroni correction (p = 0.047). Other perioperative variables were not significantly different. The two groups showed no difference in the incidence of postoperative adverse events (p = 0.879). As such, minimally invasive SAVR via hemi-sternotomy remains a safe and effective alternative to full sternotomy for patients who meet the criteria for aortic valve replacement.

The Developmental Chronnecto-Genomics (Dev-CoG) study: A multimodal study on the developing brain

Brain development has largely been studied through unimodal analysis of neuroimaging data, providing independent results for structural and functional data. However, structure clearly impacts function and vice versa, pointing to the need for performing multimodal data collection and analysis to improve our understanding of brain development, and to further inform models of typical and atypical brain development across the lifespan. Ultimately, such models should also incorporate genetic and epigenetic mechanisms underlying brain structure and function, although currently this area is poorly specified. To this end, we are reporting here a multi-site, multi-modal dataset that captures cognitive function, brain structure and function, and genetic and epigenetic measures to better quantify the factors that influence brain development in children originally aged 9-14 years. Data collection for the Developmental Chronnecto-Genomics (Dev-CoG) study (http://devcog.mrn.org/) includes cognitive, emotional, and social performance scales, structural and functional MRI, diffusion MRI, magnetoencephalography (MEG), and saliva collection for DNA analysis of single nucleotide polymorphisms (SNPs) and DNA methylation patterns. Across two sites (The Mind Research Network and the University of Nebraska Medical Center), data from over 200 participants were collected and these children were re-tested annually for at least 3 years. The data collection protocol, sample demographics, and data quality measures for the dataset are presented here. The sample will be made freely available through the collaborative informatics and neuroimaging suite (COINS) database at the conclusion of the study.

Rhodium-catalyzed enantioselective silylation of arene C-H bonds: desymmetrization of diarylmethanols

We report a Rh-catalyzed, enantioselective silylation of arene C-H bonds directed by a (hydrido)silyl group. (Hydrido)silyl ethers that are formed in situ by hydrosilylation of benzophenone or its derivatives undergo asymmetric C-H silylation in high yield with excellent enantioselectivity in the presence of [Rh(cod)Cl]2 and a chiral bisphosphine ligand. The stereoselectivity of this process also allows enantioenriched diarylmethanols to react with site selectivity at one aryl group over the other. Enantioenriched benzoxasiloles from the silylation process undergo a range of transformations to form C-C, C-O, C-I, or C-Br bonds.

Enantioselective construction of quaternary stereogenic carbon atoms by the Lewis base catalyzed additions of silyl ketene imines to aldehydes

Silyl ketene imines derived from a variety of α-branched nitriles have been developed as highly useful reagents for the construction of quaternary stereogenic centers via the aldol addition reaction. In the presence of SiCl4 and the catalytic action of a chiral phosphoramide, silyl ketene imines undergo extremely rapid and high yielding addition to a wide variety of aromatic aldehydes with excellent diastereo- and enantioselectivity. Of particular note are the high yields and selectivities obtained from electron-rich, electron-poor, and hindered aldehydes. Linear aliphatic aldehydes did react with good diastereo- and enantioselectivity in the presence of nBu4N(+)I(-), but branched aldehydes were much less reactive. Semiempirical calculations provided a rationalization of the observed diastereo- and enantioselectivity via open transitions states.

Silyl ketene imines: highly versatile nucleophiles for catalytic, asymmetric synthesis

This Minireview provides an overview on the development of silyl ketene imines and their recent applications in catalytic, enantioselective reactions. The unique structure of the ketene imine allows a diverse range of reactivity patterns and provides solutions to existing challenges in the enantioselective construction of quaternary stereogenic carbon centers and cross-benzoin adducts. A variety of reactions for which silyl ketene imines have been applied are presented with an overall goal of inspiring new uses for these underutilized nucleophiles.

AGT and RH blood group polymorphisms affect blood pressure and lipids in Afro-Caribbeans

Population blood pressure variation is most likely due to multiple genes. This is likely the reason why monogenic testing with the angiotensinogen (AGT) gene polymorphisms on chromosome 1 (1q42-43), especially M235T, has met with negative results, especially in those of African descent. The RH blood group system, also on chromosome 1 (1 p36.2-34), has likewise been associated with blood pressure variation in African-Americans and with the rise in blood pressure with age in whites. Using a random sample of the population, we investigated the combined effects of single and combined variation of the AGTN M235T and RH genotypes on blood pressure, lipids, and lipoprotein concentrations in Afro-Caribbeans aged 18-60 years from the island nation of Dominica. In monogenic analysis, AGT M235T was not associated with blood pressure. However, it was associated with HDL (MM 42+/-23, MT 44+/-12, TT 52+/-14 (P=0.002)). RH genotype was significantly associated with systolic blood pressure (P=0.006) and Apo-A (P=0.003). These effects remained after adjustment for age, gender, weight, and BMI. In the polygenetic analysis, AGT M235T and RH were significantly associated with systolic blood pressure (P=0.037; interaction effects, P=0.068). The association of the AGT M235T with blood pressure across RH blood group haplotypes was then tested. Of the five RH haplotypes available for analysis, the AGT M235T was significantly associated with blood pressure within the "D" haplotype (P=0.01). The RH blood group and gender were significantly associated with systolic blood pressure and Apo-A levels (P=0.005 and 0.012, respectively). All interactions were independent of age and weight. In conclusion, we demonstrate a significant association of AGT M235T with blood pressure and cholesterol metabolism in an Afro-Caribbean population in the "genetic context" of the RH blood group system. Further investigation of these interactions may help understand the effects of genetic factors on cardiovascular risk in African-derived and other populations.

Accuracy of the Dinamap 1846 XT automated blood pressure monitor

Accurate blood pressure (BP) measurement is important for the detection and treatment of hypertension. Despite widespread use of automated devices, there is limited published evidence for their reliability and accuracy. To determine the reliability and accuracy of the Dinamap 1846XT (Critikon Corporation, Tampa, FL, USA), a commonly used non-invasive oscillometric BP monitor The Dinamap was evaluated against the mercury manometer in 70 randomly selected adult hospitalised medical patients. Each individual underwent three sets of standardised BP measurement by automated method and three sets by mercury manometer by two independent observers. Reliability of BP measurement was assessed by repeated measures analysis. Dinamap accuracy was evaluated according to the American Association of Medical Instrumentation (AAMI) and British Hypertension Society (BHS) guidelines. Most patients were either normotensive or had stage I hypertension. The Dinamap tended to overestimate lower diastolic BP, and displayed poor reliability (P < 0.05). despite meeting aami guidelines, only 59% of systolic and 56% of diastolic dinamap readings were within 5 mm hg of the mercury manometer and 84% of systolic and 80% of diastolic readings were within 10 mm hg (bhs grade c). systolic and diastolic accuracy were worse with pressures >160/90 mm Hg (grade D) although these measures were based on a smaller sample of subjects. In conclusion the Dinamap yields inaccurate estimates of both systolic and diastolic BP even under standardised, and thus optimal conditions. This inaccuracy is exaggerated at higher BP (>160/90 mm Hg), although the number of measurements at higher pressures was small. We recommend that this device not be used when accurate BP measurement is needed for therapeutic decision-making.

Effect of zeranol or melengestrol acetate (MGA) on testicular and antler development and aggression in farmed fallow bucks

Fifteen yearling fallow bucks were randomly assigned by BW to one of three treatment groups: control (C; n = 5), melengestrol acetate (MGA; n = 5), and zeranol (Z; n = 5), to evaluate effects on testicular development, aggressive behavior, antler growth, sexual activity, ADG, and BW. Zeranol-treated bucks received zeranol ear implants (36 mg) at 90-d intervals, and MGA-treated bucks received MGA in the ration (100 microg x animal(-1) x d(-1)). Bucks grazed ryegrass/Coastal bermudagrass pasture and were supplemented with 3:1 corn/soybean meal at 0.45 kg x animal(-1) x d(-1). Body weights, body condition scores (BCS), blood samples, and testis measurements were obtained at d 0 and at 14-d intervals for 229 d. As bucks reached hard antler (7/15 to 8/25), antlers were harvested and weighed, and ejaculates were collected at 14-d intervals. Aggression was evaluated using 10-min video sessions scoring body blows, avoidance, head pushes, and head bunts. Scrotal circumference (SC) and paired testis volume were affected by a day x treatment interaction (P < 0.01); testes of zeranol-treated bucks were smaller than those of control or MGA-treated bucks. First sperm in the ejaculate tended to be delayed (P < 0.10) in zeranol-treated bucks compared with control and MGA-treated bucks. Melengestrol acetate-treated bucks had a maximum sperm concentration in the ejaculate that was three times (P < 0.05) that of control bucks and nine times (P < 0.05) that of zeranol-treated bucks. Antler weight was the least (P < 0.01) for bucks receiving zeranol and greatest (P < 0.10) for MGA-treated bucks; intermediate values were recorded for the control bucks. Aggressive behavior was delayed (P < 0.05) for zeranol-treated bucks until treatment effects were overcome. Melengestrol acetate-treated bucks had decreased (P < 0.01) aggressive behavior compared with control bucks. Melengestrol acetate-treated bucks had increased (P < 0.05) serum testosterone concentrations compared with control and zeranol-treated bucks. Human chorionic gonadotropin-stimulated peak serum testosterone concentrations for zeranol-treated bucks were delayed (P < 0.01) compared with control and MGA-treated bucks. Although zeranol-treated bucks overcame treatment effects, they were never able to reach testicular measurements or sperm concentrations equal to those of the control or MGA-treated bucks. Zeranol and MGA treatments may have both positive and negative effects that can be utilized when producing slaughter bucks.

Endothelin antagonist reduces hemodynamic responses to vasopressin in DOCA-salt hypertension

The contribution of endothelin to the changes in blood pressure, cardiac output, and total peripheral resistance evoked by arginine vasopressin and angiotensin II was investigated in deoxycorticosterone acetate (DOCA)-salt hypertensive rats by infusing the peptides intravenously before and after pretreatment with the endothelin receptor antagonist bosentan. Blood pressure was recorded with radiotelemetry devices and cardiac output was recorded with ultrasonic transit time flow probes in conscious unrestrained animals. The dose-related decreases in cardiac output induced by vasopressin and angiotensin II were unaffected by bosentan. In contrast, the dose-related increases in total peripheral resistance evoked by vasopressin were blunted in both DOCA-salt hypertensive and sham normotensive rats, but this effect of bosentan was greater in the DOCA-salt hypertensive group. In contrast with vasopressin, bosentan failed to change hemodynamic responses to angiotensin II. The exaggerated vascular responsiveness (total peripheral resistance) of the DOCA-salt hypertensive group to vasopressin was largely abolished by bosentan. These results suggest that endothelin contributes to the hemodynamic effects of vasopressin but not angiotensin II in the DOCA-salt model of hypertension.

The 2000 Canadian recommendations for the management of hypertension: part two--diagnosis and assessment of people with high blood pressure

OBJECTIVE

To provide updated, evidence-based recommendations for the diagnosis and assessment of high blood pressure in adults.

OPTIONS

For people with high blood pressure, the assignment of a diagnosis of hypertension depends on the appropriate measurement of blood pressure, the level of the blood pressure elevation, the duration of follow-up and the presence of concomitant vascular risk factors, target organ damage and established atherosclerotic diseases. For people diagnosed with hypertension, defining the overall risk of adverse cardiovascular outcomes requires laboratory testing, a search for target organ damage and an assessment of the modifiable causes of hypertension. Out-of-clinic blood pressure assessment and echocardiography are options for selected patients.

OUTCOMES

People at increased risk of adverse cardiovascular outcomes and were identified and quantified.

EVIDENCE

Medline searches were conducted from the period of the last revision of the Canadian recommendations for the management of hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.

VALUES

A high value was placed on the identification of people at increased risk of cardiovascular morbidity and mortality.

BENEFITS, HARMS AND COSTS

The identification of people at higher risk of cardiovascular disease will permit counselling for lifestyle manoeuvres and the introduction of antihypertensive drugs to reduce blood pressure for patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.

RECOMMENDATIONS

The present document contains detailed recommendations pertaining to aspects of the diagnosis and assessment of patients with hypertension, including the accurate measurement of blood pressure, criteria for the diagnosis of hypertension and recommendations for follow-up, routine and optional laboratory testing, assessment for renovascular hypertension, home and ambulatory blood pressure monitoring, and the role of echocardiography in hypertension.

VALIDATION

All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only the recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

ENDORSEMENT

These recommendations are endorsed by the Canadian Hypertension Society, The Canadian Coalition for High Blood Pressure Prevention and Control, The College of Family Physicians of Canada, The Heart and Stroke Foundation of Canada, The Adult Disease Division and Bureau of Cardio-Respiratory Diseases and Diabetes at the Centre for Chronic Disease Prevention and Control of Health Canada.

Binge drinking among undergraduate college students in the United States: implications for other substance use

The authors examined the relationship between binge drinking and other substance use among US college students, using nationally representative data from the 1995 National College Health Risk Behavior Survey implemented by the Centers for Disease Control and Prevention. Compared with nonbinge drinkers, current binge drinkers were significantly more likely to report "ever" using and current use of cigarettes, marijuana, cocaine, and other illegal drugs. The researchers also found that the more often students binge drank, the more likely they were to have ever used cigarettes, marijuana, cocaine, and other drugs, and the more likely they were to report current use of cigarettes and marijuana. Those who design programs to prevent binge drinking and use of other substances should take into account the reality that many students use more than one substance and that the more frequently students report binge drinking, the more likely they are to be using other substances as well.

Cysteinyl leukotrienes mediate enhanced vasoconstriction to angiotensin II but not endothelin-1 in SHR

We assessed whether cysteinyl leukotrienes mediate the vasoconstrictor responses to angiotensin II and endothelin-1 in the mesenteric vascular bed of Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR) perfused ex vivo at a constant flow rate of 5 ml/min with Krebs buffer. Maximal perfusion pressure response (E(max)) but not EC(50) values to angiotensin II (P < 0.001) and endothelin-1 (P < 0.01) were significantly higher in the SHR, whereas the responses to potassium chloride remained unchanged. Inclusion of the selective 5-lipoxygenase inhibitor AA-861 or the cysteinyl leukotriene receptor antagonist MK-571 significantly reduced the vasoconstrictor responses to angiotensin II but not to endothelin-1 and potassium chloride. The reduction in E(max) to angiotensin II was more pronounced in SHR (P < 0.001) than in WKY (P < 0.05) rats. Cysteinyl leukotrienes LTC(4)-, LTD(4)-, and LTE(4) (1 microM)-evoked vasoconstrictor responses were significantly higher in SHR (P < 0.05), whereas LTB(4) failed to evoke any response in either strain. These data suggest that 5-lipoxygenase metabolites, particularly cysteinyl leukotrienes, contribute to the exaggerated vasoconstrictor responses to angiotensin II but not to endothelin-1.

Insulin-Induced Biphasic Responses in Rat Mesenteric Vascular Bed

Abstract —The vasodilatory capacity of insulin has been widely reported, yet some investigators have not noted this effect. Because insulin has been shown to enhance endothelin release, we speculated that endothelin could be attenuating insulin-evoked vasodilation. We examined the effect of ex vivo insulin perfusion on vascular resistance by using the Sprague-Dawley rat mesenteric vascular bed. In methoxamine-preconstricted preparations, insulin (3.0 pmol/L to 10 nmol/L) evoked a concentration-dependent decrease in perfusion pressure (PP) with a maximal response of 42.0±9.2%, whereas continuous exposure to 10 nmol/L insulin induced a 51.8±3.5% relaxation. Further exposure to 10 nmol/L insulin resulted in the generation of endothelin and a subsequent loss of the vasodilatory response. Indomethacin had no effect on vascular responses. The vasodilatory response was significantly inhibited by nitric oxide synthase inhibition (20.5±4.2%; P <0.01) and calcium-activated potassium channel blockade (28.5±3.7%; P <0.05). Endothelial denudation attenuated the vasodilatory component (20.3±7.1%; P <0.01) and altered the biphasic pattern of the response. The decline in insulin-evoked vasodilation was significantly prevented by an endothelin-A antagonist (BQ123), an endothelin-B antagonist (BQ788), and nonselective endothelin blockade with both BQ123 and BQ788. These results demonstrate that the endothelium is intimately involved in regulating the vascular response to insulin. Insulin promotes the release of nitric oxide and endothelium-derived hyperpolarizing factor. During sustained exposure to higher concentrations, this vasodilatory effect is countered by the pathological generation of endothelin. Endothelin receptor blockade facilitates the maintenance of vasodilation despite high insulin concentrations.

Substance use on school property among students attending alternative high schools in the United States

We analyzed nationally representative data from the 1998 National Alternative High School Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, to determine the prevalence of substance use on school property among alternative high school students in the United States, to describe the characteristics of students who use substances on school property, and to examine the interrelationships of substance-use behaviors. During the 30 days preceding the survey, nearly 48 percent of students used at least one substance on school property and 17 percent used more than one substance on school property. Males were more likely than females and white students were more likely than black or Hispanic students to have used substances on school property. The results of this and other studies suggest that school administrators, public health practitioners, and policy makers should work to improve strategies for reducing substance use in this heterogeneous, hard-to-reach population.

Effect of losartan on angiotensin II-mediated endothelin and prostanoid excretion in humans

Angiotensin II (Ang II) stimulates renal prostanoid and vascular endothelin-1 (ET-1) release. Most known Ang II effects are mediated by AT1 receptors. Our aim was to determine whether AT1 receptor activation mediates Ang II-evoked renal prostanoid and ET-1 release. Eleven healthy men were randomized in a crossover, double-blind fashion to receive 100 mg/day of losartan or matching placebo, for 8 days. Blood and urine were sampled before and after a 2-h infusion of Ang II at a rate previously determined to increase mean arterial pressure (MAP) by 25 to 30 mm Hg in each subject. After a 14-day washout, subjects received the alternate treatment. Pretreatment with losartan had little effect on baseline MAP, but increased plasma renin activity, and virtually eliminated the pressor response to Ang II infusion. Angiotensin II significantly increased prostanoid excretion after placebo; the prostanoid response to Ang II was even greater after losartan. Plasma ET-1 was not altered by Ang II infusion, with or without losartan. In contrast, urine ET-1 excretion rate decreased to 40% of baseline after Ang II but not after losartan pretreatment; losartan alone had no effect. We conclude that Ang II decreases renal ET-1 synthesis and release through the AT1 receptor. In contrast, Angiotensin II-mediated renal prostanoid synthesis does not require activation of AT1 receptors. These findings indicate that AT1 receptor antagonists could provide renal protection through indirect mechanisms.

Fenofibrate lowers blood pressure in two genetic models of hypertension

Fenofibrate, a commonly used lipid lowering drug, induces the expression of the gene coding for cytochrome P450-4A, whose major product is 20-hydroxyeicosatetraenoic acid (20-HETE). 20-HETE, a potassium channel antagonist, could increase or decrease blood pressure (BP). We studied the effects of four weeks of oral fenofibrate on BP, urine output (UVol), plasma renin activity (PRA), and urine protein excretion in young (4-5 weeks) stroke prone spontaneously hypertensive rats (SHRSP), older (25 weeks) SHRSP, Dahl salt sensitive rats (Dahl S) on a high salt diet, Dahl S rats on a normal salt diet, and normotensive Sprague-Dawley (SD) rats. Fenofibrate prevented the increase in BP in 4-5 week old SHRSP, reduced BP in 25 week old SHRSP, but had no effect on BP in normotensive SD rats. Similarly, fenofibrate prevented the increase in BP in Dahl S rats on a high salt diet, but had no effect in Dahl S rats on a low salt diet. Fenofibrate increased UVol (and reduced weight gain) in young SHRSP and tended to increase it in other groups. It also increased PRA 2 to 5-fold in all groups except older SHRSP. Young SHRSP receiving fenofibrate excreted significantly less urine protein than control rats. The drug reduced proteinuria in Dahl S rats on high salt diet, but had no significant effect on proteinuria in other groups. In summary, fenofibrate reduced blood pressure and weight gain, increased UVol and PRA, and reduced urine protein excretion in young SHRSP. Other groups of animals showed these changes to a variable, but directionally similar extent. These findings are consistent with a natriuretic effect of fenofibrate.

Altered paracrine effect of endothelin in blood vessels of the hyperinsulinemic, insulin resistant obese Zucker rat

OBJECTIVE

Earlier, we reported that high insulin incubation in vitro leads to increased ETA receptor expression in cultured rat aortic smooth muscle cells (Diabetes 1998, 47: 934-944). Our later observation of enhanced endothelin-1 evoked vasoconstriction in aorta from the hyperinsulinemic obese Zucker rat indicated that this interaction might also be relevant in vivo. To further examine the relationship between insulinemia and endothelin, we characterized endothelin receptor expression and endothelin-1 peptide levels in vascular tissues and plasma from young and old obese Zucker rats.

METHODS

12 and 40-week-old Zucker obese and lean rats were used. Plasma endothelin-1 levels and endothelin-1 peptide content in the mesenteric artery and in the thoracic aorta were examined by radioimmunoassay. Messenger RNA levels of endothelin-1 peptide and ETA and ETB receptors were examined in the aortic and mesenteric vessels using RT-PCR.

RESULTS

Obese rats from both age groups had significantly higher plasma levels of insulin (4-10 fold), total cholesterol (2-3 fold), triglycerides (10-fold), and glucose (approximately 1.5 fold) than their lean counterparts. There was a trend toward worsening lipoproteinemia and glycemia, but improved insulinemia with age in the obese rats. In association with these changes, obese rats exhibited attenuated endothelin-1 peptide and preproET-1 mRNA levels, but conversely elevated ETA and ETB receptor mRNA levels in both aortic and mesenteric vessels.

CONCLUSION

These data suggest that vascular tissue from the metabolically dysregulated obese Zucker rat exhibits attenuated endothelin-1 peptide production and elevated endothelin receptor levels. Since elevated insulin levels have been linked to increased endothelin receptor expression, it is plausible that hyperinsulinemia upregulates endothelin receptors contributing to elevated vasoconstrictor responses to endothelin-1 in this model of obesity and hypertension.

Prevalence and predictors of white-coat response in patients with treated hypertension

BACKGROUND

White-coat response, defined as higher office blood pressure readings than ambulatory readings, is common. Few studies have estimated its prevalence among subjects with treated hypertension, and almost none have defined its determinants. The objective of this study was to estimate the prevalence of white-coat response among subjects with treated hypertension and to determine whether the phenomenon could be predicted using clinical and psychometric data.

METHODS

A total of 103 treated patients (55 men and 48 women) with uncontrolled hypertension who attended a hypertension outpatient clinic in Saskatoon between September 1993 and December 1995 were entered into the study. Patients had at least 2 clinic blood pressure readings of 140/90 mm Hg or higher, had no target organ damage or left ventricular hypertrophy, and had been prescribed 2 or more classes of antihypertensive drugs. Patients had blood pressure measured in the supine position in the clinic, were placed on 24-hour ambulatory blood pressure monitoring and then completed questionnaires before returning to the clinic. Patients were classified as exhibiting a white-coat response if their mean daytime ambulatory systolic/diastolic blood pressure was 139/89 mm Hg (both) or less, or if the systolic/diastolic pressure was at least 20/15 mm Hg (both) lower than the clinic reading.

RESULTS

Eleven men (20%, 95% confidence interval [CI] 10%-33%) and 26 women (54%, 95% CI 39%-69%) showed white-coat response. Logistic regression modelling showed that determinants such as stress had significantly different effects among men and women. Separate models were therefore created for men and women. For women, perceived level of stress was the most important predictor of white-coat response (odds ratio [OR] per unit 7.0, 95% CI 1.3-36.0), followed by time since diagnosis. For men, depression was a weak predictor, with higher depression scores predicting sustained hypertension (OR per unit 1.2, 95% CI 1.01-1.5).

INTERPRETATION

Sex is an important factor in white-coat response. Attempts to predict white-coat response from psychometric variables should take sex differences into account. Clinical variables were not effective as predictors of white-coat response.

A cardiovascular risk factor reduction clinic

OBJECTIVE

To describe a cohort of patients referred to a cardiovascular risk factor reduction unit (CRFRU).

DESIGN

Prospective cohort study.

SETTING

Out-patients referred to a specialty clinic in a tertiary care hospital.

PATIENTS

Seven hundred and four consecutive male and female patients with one or more cardiovascular risk factors, of whom 388 were reassessed after one year.

INTERVENTIONS

Standard risk factors were measured in all participants. The probability of coronary artery disease (CAD) was assessed according to the Framingham equation and results were compared with data from the Saskatchewan Heart Health Survey for the general population of Saskatchewan. Patients received dietary and fitness advice, as well as drug therapy when indicated. For follow-up studies, the change in probability of CAD and selected variables after one year were measured.

MAIN RESULTS

Patients referred to the CRFRU were at considerably higher risk for CAD than the general population. One hundred and sixty-eight of 235 men and 77 of 153 women seen in follow-up had a reduced risk score. Those who improved had a favourable change in systolic blood pressure and in their lipid profile, as well as greater weight loss.

CONCLUSIONS

A CRFRU is feasible and appears to reduce risk in a considerable proportion of patients.

Burst testing of condoms. I. Basic features of the force-deformation curve of latex-rubber condoms

Inflation of a rubber condom involves biaxial deformation of the material which can be modeled by the use of an appropriate strain-energy function. Force versus deformation data for uniaxial extension of strips of condoms were used to determine the parameters for Ogden's form of a strain-energy function. These parameters were then used to fit experimentally obtained burst test data to a stress-strain equation formulated for inflation of condoms in a burst test. Experimental data on inflation of condoms agree well with theoretical curves verifying the applicability of the biaxial stress-strain equation to the particular strain-energy function on which it is based.

A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and gracilis tendon grafts

Biomechanical testing was done on 15 matched pairs of central-third bone-patellar tendon-bone and double-looped semitendinosus-gracilis grafts harvested from 15 cadaveric knees. Load to failure, composite graft stiffness, and the modulus of elasticity were calculated for each graft. Specimens were from 2 female and 13 male donors (average age, 40 years; range, 17 to 53). Average load to failure for the patellar tendon grafts was 1784 N (+/- 580), compared with 2422 N (+/- 538) for the hamstring tendon grafts (significantly different). There was no statistically significant difference in stiffness between grafts (patellar tendon, 210 N/mm; hamstring tendon, 238 N/mm). The elastic modulus was 225 MPa (+/- 129) for the patellar tendon grafts and 145 MPa (+/- 58) for the hamstring tendon grafts (significantly different). The average cross-sectional area for the hamstring tendon grafts was 57 mm2, compared with the 45 mm2 for the patellar tendon grafts. The hamstring tendon grafts were significantly stronger than the matched central-third patellar tendon grafts, but the two grafts were similar in stiffness. The patellar tendon grafts had a higher modulus than the hamstring tendon grafts.

Effects of ridogrel, a thromboxane synthase inhibitor and receptor antagonist, on blood pressure in the spontaneously hypertensive rat

Ridogrel is a dual acting thromboxane synthase inhibitor/TP receptor antagonist. We examined the effects of single and multiple doses on systolic blood pressure in stroke-prone spontaneously hypertensive rats. Single doses of ridogrel (5 to 125 mg/kg) did not affect systolic blood pressure or furosemide-stimulated excretion rates of thromboxane B2 or 6-keto-prostaglandin F1alpha, although ex vivo serum thromboxane B2 was dose-dependently reduced up to 95%. In contrast, repeated dosing (7 days) with ridogrel (3 to 25 mg/kg/day), had an antihypertensive effect in 12-week-old stroke-prone spontaneously hypertensive rats. At 25 mg/kg/day, ridogrel reduced systolic blood pressure from 200+/-6.1 to 173+/-6.7 mmHg (n=12, P<0.01). Ridogrel dose-dependently reduced serum thromboxane B2 and increased plasma renin activity. Unlike single doses, repeated dosing reduced urinary thromboxane B2 excretion (from 103+/-7 ng/day to 49+/-10 ng/day, P<0.01) while preserving 6-keto-prostaglandin F1alpha excretion. Ketoprofen, a cyclo-oxygenase inhibitor, (10 mg/kg/day for 7 days), depressed urine 6-keto-prostaglandin F1alpha in addition to attenuating serum and urine thromboxane B2. Ketoprofen prevented the antihypertensive effects of ridogrel. Ridogrel did not lower systolic blood pressure in Sprague-Dawley rats. We conclude that the antihypertensive effect of ridogrel involves preserving renal prostaglandin synthesis during thromboxane attenuation.

Sudden death in a patient with chronic lymphocytic leukemia

The authors describe a 51-year-old man with chronic lymphocytic leukemia who presented with respiratory distress and then died suddenly while in hospital. Autopsy revealed pulmonary leukostasis and a large intracardiac mass containing mostly mature lymphocytes and fibrin. Although leukostasis and lymphocyte thrombi have been described (albeit rarely) in chronic lymphocytic leukemia, an intracardiac "clot" has not. It seems plausible that this intracardiac mass caused the patient's death.

Insulin and vanadate restore decreased plasma endothelin concentrations and exaggerated vascular responses to normal in the streptozotocin diabetic rat

Although insulin has been shown to raise plasma concentrations of endothelin (ET) and up regulate vascular smooth muscle ETA receptor expression, the interaction of vanadate, an insulinomimetic agent, with the vascular ET system has not been investigated. We compared the effects of oral vanadate treatment (0.5 mg/ml; p.o.) and insulin infusion (12 mU.kg-1.min-1 s.c.) for two weeks on plasma ET concentrations and vascular responses to endothelin-1 (ET-1) and the alpha-1 adrenoceptor agonist, methoxamine, in aortic ring preparations from streptozotocin (STZ) diabetic and non-diabetic adult male Sprague-Dawley rats. Plasma ET concentrations were lower (p < 0.01) in STZ diabetic rats compared with normal control rats. Insulin and vanadate treatment restored plasma ET to normal (p < 0.01) in STZ rats and increased ET concentrations in the control (p < 0.05) group. Higher maximal tension responses to both ET-1 (p < 0.01) and methoxamine (p < 0.05) were present in STZ rats in both endothelium intact and denuded aortic preparations compared with the control group. Both insulin and vanadate treatment returned these responses to normal. It is concluded that low plasma concentrations of insulin and high plasma glucose in STZ diabetic rats are accompanied by lower concentrations of plasma ET. Insulin and vanadate treatment restores diminished plasma ET to control concentrations and attenuates exaggerated agonist(s)-evoked vascular smooth muscle responses in STZ-induced diabetic rats. In addition to well known beneficial metabolic effects, insulin and vanadate may beneficially affect cardiovascular regulation in the STZ diabetic rat by correcting abnormal ET activity.

The antihypertensive efficacy of losartan and amlodipine assessed with office and ambulatory blood pressure monitoring. Canadian Cozaar Hyzaar Amlodipine Trial Study Group

BACKGROUND

Losartan potassium is a recently marketed angiotensin II receptor antagonist. Previous studies have suggested that its full antihypertensive efficacy may be delayed for up to 12 weeks. The authors compared the antihypertensive efficacy and tolerability of losartan at 6 and 12 weeks with those of amlodipine besylate, a commonly used calcium antagonist.

METHODS

This multicentre, randomized, double-blind clinical trial studied 302 patients with mild or moderate hypertension in 1995. Of the 302, 97 also underwent ambulatory blood pressure monitoring (ABPM). After a 4-week placebo run-in period, the patients were randomly assigned to group A, B or C for 12 weeks. Those in groups A and B began treatment with losartan at 50mg/d, and those in group C began with amlodipine at 5 mg/d. If the blood pressure remained uncontrolled after 6 weeks, subjects in group A had their losartan dose doubled (to 100 mg/d), those in group B were given hydrochlorothiazide (12.5 mg/d) in addition to the losartan, which remained at 50 mg/d, and patients in group C had their amlodipine dose doubled (to 10 mg/d).

RESULTS

At 12 weeks all 3 regimens reduced office-recorded diastolic blood pressure (DBP) with the patient sitting. The mean reduction in group A was 8.7 mm Hg (95% confidence interval [CI] 7.3 to 10.1) (p < 0.001), in group B 12.5 mm Hg (95% CI 11.0 to 14.0) (p < 0.001) and in group C 12.9 mm Hg (95% CI 11.4 to 14.5) (p < 0.001). Losartan alone lowered sitting DBP to a lesser degree than the other 2 treatments (p < 0.01). In contrast, ABPM readings, whether 24-hour, daytime or nighttime, were not different among the regimens. Comparison of the results at 6 weeks yielded similar findings. Adverse effects were uncommon and were not different among the groups, with the exception of ankle edema, which was more frequent in group C.

INTERPRETATION

Losartan alone reduces both office and ABPM readings. The observed changes in office-recorded sitting DBP suggest that losartan is less effective than amlodipine or the combination of losartan and hydrochlorothiazide, but ABPM did not confirm this difference. Perhaps changes in office readings measure different attributes of a drug than does ABPM.

Insulin increases endothelin-1-evoked intracellular free calcium responses by increased ET(A) receptor expression in rat aortic smooth muscle cells

While insulin is known to promote vascular smooth muscle (VSM) relaxation, it also enhances endothelin-1 (ET-1) secretion and action in conditions such as NIDDM and hypertension. We examined the effect of insulin pretreatment on intracellular free calcium ([Ca2+]i) responses to ET-1 in cultured aortic smooth muscle cells (ASMCs) isolated from Sprague-Dawley (SD) rats and measured ET(A) receptor characteristics and ET-1-evoked tension responses in aorta obtained from insulin-resistant, hyperinsulinemic Zucker-obese (ZO) and control Zucker-lean (ZL) rats. Pretreatment of rat ASMCs with insulin (10 nmol/l for 24 h) failed to affect basal [Ca2+]i levels but led to a significant increase in peak [Ca2+]i response (1.7-fold; P < 0.01) to ET-1. The responses to IRL-1620 (an ET(B) selective agonist), ANG II, and vasopressin remained unaffected. ET-1-evoked peak [Ca2+]i responses were significantly attenuated by the inclusion of the ET(A) antagonist, BQ123, in both groups. The ET(B) antagonist, BQ788, abolished [Ca2+]i responses to IRL-1620 but failed to affect the exaggerated [Ca2+]i responses to ET-1. Saturation binding studies revealed a twofold increase (P < 0.01) in maximal number of binding sites labeled by 125I-labeled ET-1 in insulin-pretreated cells and no significant differences in sites labeled by 125I-labeled IRL-1620 between control and treatment groups. Northern blot analysis revealed an increase in ET(A) mRNA levels after insulin pretreatment for 20 h, an effect that was blocked by genistein, actinomycin D, and cycloheximide. Maximal tension development to ET-1 was significantly greater (P < 0.01), and microsomal binding studies using [3H]BQ-123 revealed a twofold higher number of ET(A) specific binding sites (P < 0.01) in aorta from ZO rats compared with that of ZL rats. These data suggest that insulin exaggerates ET-1-evoked peak [Ca2+]i responses via increased vascular ET(A) receptor expression, which may contribute to enhanced vasoconstriction observed in hyperinsulinemic states.

Transcutaneous delivery of prostaglandin E1: in vitro and laser doppler flowmetry study

The aim of this study was to assess the rate and extent of transcutaneous delivery of prostaglandin E1 (PGE1) from various formulations [liposomal, novel biphasic, and nonliposomal (oil/water cream) delivery systems] in vitro using diffusion cells and in vivo using laser doppler flowmetry, to aid in the development of a topically active preparation for the treatment of male sexual dysfunction. Percutaneous absorption through adult human foreskin was tested in flow-through diffusion cells using [3H]PGE1. Nine healthy volunteers participated in the crossover, randomized, double-blind, placebo-controlled study, where 0.1 g of each preparation was applied to a 4 cm2 area on the forearm. Laserflo BPM2 blood perfusion monitor with Model P-430 skin probe was used for evaluating skin blood perfusion. Encapsulation of PGE1 into novel biphasic delivery systems resulted in significantly increased skin blood perfusion relative to traditional liposomal, nonliposomal, and placebo formulations (6.25 +/- 1.58 vs 2.72 +/- 0.79, 0.53 +/- 0.64, and 0.58 +/- 0.06 mLLD/min/100 g, respectively, n = 9). The in vitro absorption of PGE1 through foreskin correlated well with the in vivo data (respective permeability coefficients 3.33, 1.57, and 1. 40 x 10(-4) cm/h). Formulation parameters greatly influence the absorption of PGE1 through skin as measured by laser doppler flowmetry, but by the application of a novel topical delivery technology, a significant enhancement of PGE1 delivery can be achieved.

Nuclear Ca2+ signaling to endothelin-1 in rat aortic smooth-muscle cells

Vascular smooth-muscle cells (VSMCs) isolated from genetically hypertensive animals show increased intracellular free calcium levels ([Ca2+]i) in response to endothelin-1 (ET-1). The differences in time course and distribution of Ca2+ increase after addition of ET-1 within the VSMCs are unknown. Therefore, ET-1-evoked changes in fluo-3 fluorescence were determined using a confocal laser scanning microscope in primary cultures of aortic smooth-muscle cells (ASMCs) from 12-week-old male Sprague-Dawley (SD) rats, Wistar-Kyoto (WKY) rats, and spontaneously hypertensive rats (SHR). Syto-11 staining enabled the assessment of intracellular free [Ca2+]i changes in the cytosolic ([Ca2+]c), perinuclear ([Ca2+]p), and nuclear ([Ca2+]n) regions. In the basal state, [Ca2+] was evenly distributed throughout the rat ASMCs. There were no significant differences in basal fluorescence values among the three strains. ET-1 evoked a concentration-dependent increase in fluo-3 intensity. The peak [Ca2+]i rise to ET-1 was much more rapid in ASMCs from SHR and WKY strains. The changes in [Ca2+]n were greater than in [Ca2+]c. Pretreatment of rat ASMCs with BQ-123 (an ETA antagonist) and BQ-788 (an ETB antagonist) abolished the rapid peak rise and the slow sustained elevation in [Ca2+]i, respectively. The nonselective antagonist bosentan attenuated both phases of the ET-1 response in all three strains. The ETB-selective agonist IRL 1620 evoked a significant elevation in [Ca2+]n values at 2 min in the ASMCs of SHR. These data suggest that ETA activation is linked to initial rapid increases in [Ca2+]c and [Ca2+]n, whereas ETB activation promotes slow [Ca2+]n signaling, particularly in ASMCs of SHR.

Differential regulation of endothelin-1 action by insulin and vanadate in vascular smooth muscle

The effects of insulin (10 nM) and sodium orthovanadate (SOV, 25 microM) pretreatment for 24 h on endothelin-1 (ET-1) and IRL-1620 (ETB agonist)-evoked increases in intra-cellular free calcium levels [Ca2+]i were determined by fura-2 fluorescence methodology using cultured rat aortic smooth-muscle cells (ASMCs). Whereas insulin preincubation led to an increase (p < 0.05) in [Ca2+]i responses to ET-1, SOV enhanced [Ca2+]i responses to both ET-1 (p < 0.05) and IRL-1620 (p < 0.01). Saturation binding studies revealed that insulin pretreatment led to a 2.2-fold (p < 0.01) increase in [125I]ET-1 binding sites, and SOV pretreatment led to a 2.4-fold (p < 0.01) and 6.6-fold (p < 0.01) increase in the maximal number of binding sites labeled by [125I]ET-1 and [125I]IRL-1620, respectively. Northern blot analysis revealed that insulin upregulated only ETA mRNA levels, and SOV enhanced both ETA and ETB mRNA levels. Pretreatment with the tyrosine kinase inhibitor genistein abolished these effects. These data suggest that insulin pretreatment of ASMCs selectively upregulates ETA receptor expression and ETA-mediated [Ca2+]i, signaling, and SOV upregulates both ETA and ETB receptor expression and exaggerates [Ca2+]i responses mediated by both ETA and ETB in rat ASMCs.

Dose-related antihypertensive effects of irbesartan in patients with mild-to-moderate hypertension

Two multicenter, double-blind, placebo-controlled, parallel group studies were conducted to evaluate the efficacy, safety, pharmacokinetics, and pharmacodynamics of the angiotensin II receptor (AT1 subtype) antagonist irbesartan. The effect of irbesartan withdrawal and the effect of adding hydrochlorothiazide (HCTZ) to irbesartan were also assessed. After a placebo lead-in phase, all patients were randomized to 8 weeks of double-blind therapy with either placebo (n = 158) or irbesartan at doses of 1, 5, 10, 25, 50, 100, 200, or 300 mg (n = 731 total) orally once daily. Irbesartan reduced blood pressure in a dose-related manner. Reductions from baseline in trough seated diastolic blood pressure ranged from 7.5 mm Hg for 50 mg irbesartan to 11.6 mm Hg for 300 mg irbesartan. At week 8, statistically significant reductions over placebo were observed in trough seated blood pressure with all irbesartan doses > or = 50 mg. These reductions reached statistical significance versus placebo within 2 weeks with 100, 200, and 300 mg irbesartan. Plasma irbesartan concentrations correlated with dose. Angiotensin II and aldosterone levels generally showed dose-related changes, consistent with AT1 receptor blockade. In patients not controlled at 8 weeks, the addition of 12.5 mg HCTZ resulted in further dose-related reductions in blood pressure. Irbesartan demonstrated a placebo-like safety profile and no dose-related toxicity. Irbesartan, administered alone or in combination with HCTZ, was well tolerated. Withdrawal of irbesartan did not result in rebound hypertension or adverse events. Thus, once-daily irbesartan is both an effective and safe antihypertensive agent for the treatment of mild-to-moderate hypertension.

Effects of lipid-lowering agents in the Dahl salt-sensitive rat

Inducing renal cytochrome P4504A (P4504A) activity with clofibrate prevents the development of hypertension in Dahl salt-sensitive (Dahl S) rats. To determine if this also occurs with other antilipidemic agents, we compared the effects of a related drug, fenofibrate, with those of an unrelated agent, pravastatin, on blood pressure, renal histology, and P4504A activity. Dahl S rats were pretreated with fenofibrate (95 mg/kg per day), pravastatin (70 mg/kg per day), or vehicle for 7 days before and after being switched from a low-salt (0.1% NaCl) to a high-salt (8.0% NaCl) diet. After 3 weeks on the high-salt diet, mean arterial pressures averaged 183+/-13 (n=9), 126+/-10 (n=9), and 148+/-11 mm Hg (n=8), respectively, in vehicle-, fenofibrate-, and pravastatin-treated animals. Both drugs reduced the degree of proteinuria and glomerular injury. P4504A protein levels and the synthesis of 20-hydroxyeicosa-5,8,11,14-tetraenoic acid (20-HETE) were increased in the liver and kidney of fenofibrate-treated, but not pravastatin-treated rats. We also administered these agents to Dahl S rats in which hypertension had previously been induced by a high-salt diet. Mean arterial pressures averaged 164+/-10, 113+/-23, and 160+/-15 mm Hg in rats treated with vehicle, fenofibrate, or pravastatin for 3 weeks. Fenofibrate-treated rats exhibited a natriuresis. Proteinuria and glomerular injury were reduced by pravastatin but not by fenofibrate. These results indicate that fenofibrate prevented the development of hypertension and reduced subsequent glomerular injury in Dahl S rats, probably secondary to increased renal production of 20-HETE. Although pravastatin did not induce renal P4504A activity in these animals, it reduced the severity of hypertension and renal damage through some other mechanism.

Patterns of compliance with once versus twice daily antihypertensive drug therapy in primary care: a randomized clinical trial using electronic monitoring

OBJECTIVE

To evaluate patterns of compliance with once versus twice daily administration of antihypertensive therapy (primary-outcome measure) and relevance of partial compliance for blood pressure control (secondary outcome measure).

DESIGN

Multicentre, nonblinded, parallel group randomized design.

SETTING

Nonacademic primary care practices across Canada.

STUDY POPULATION

Patients with mild essential hypertension (diastolic blood pressure 95 to 110 mmHg) of either sex (40% women), age 18 to 80 years (average 55 years). One hundred and ninety-eight patients were randomized to active treatment; 14 patients discontinued the study because of side effects.

INTERVENTIONS

After a four-week placebo run-in period, patients were randomized to amlodipine 5 mg once-a-day or diltiazem slow release formulation (SR) 90 mg twice daily. Doses were increased to 10 mg and 180 mg to achieve sitting diastolic blood pressure of 90 mmHg or less.

OUTCOME MEASURE

During 20 weeks on active treatment, compliance was assessed by pill counts and medication event monitoring system (MEMS), assessing percentage of prescribed doses taken, percentage days correct doses taken, percentage prescribed doses taken on time and blood pressure control as determined by office blood pressure measurement.

RESULTS

The percentage prescribed doses taken (by either pill count of MEMS) showed a high degree of compliance, similar for the two treatments. However, other parameters of compliance were significantly better with once versus twice daily therapy. Partial compliance (less than 80% by pill count) led to less blood pressure control with the short acting diltiazem, but did not affect blood pressure control for the long acting amlodipine. Side effects profiles did not differ between the two treatments.

CONCLUSIONS

Within the constraints of a clinical trial, hypertensive patients in primary care show a high degree of overall compliance with once or twice daily pill-taking, but patterns of pill-taking are more erratic with twice versus once daily medication, particularly in men. The results suggest that the negative consequences of partial compliance for blood pressure control can be offset by choosing agents with a duration of action well beyond the dosing interval.

Losartan: a new antihypertensive drug

Hypertension is a major risk factor for cardiovascular disease. It affects approximately one in five, or 20 per cent of Canadians. The consequences of untreated hypertension include myocardial infarction, stroke, congestive heart failure, peripheral vascular disease and renal disease. By lowering a person's diastolic blood pressure 5 to 6 mmHg, their chances of having a stroke are reduced by 35 to 40 per cent and 20 to 25 per cent for coronary heart disease. While the treatment for hypertension includes both nonpharmacological and pharmacological therapy, this article will explore losartan or Cozaar, which falls under the newest class of antihypertensive drugs, angiotensin II antagonists.

Renal P450 metabolites of arachidonic acid and the development of hypertension in Dahl salt-sensitive rats

Renal transplantation studies indicate that some form of renal dysfunction underlies the development of hypertension in Dahl salt-sensitive (S) rats; however, the factors responsible for altering kidney function remain to be determined. Previous studies have indicated that Dahl S rats require a higher renal perfusion pressure to excrete the same amount of sodium and water as normotensive rats and that this is due largely to an elevation in Cl- transport in the thick ascending limb of the loop of Henle. There are now five lines of evidence that suggest an abnormality in the renal metabolism of arachidonic acid by enzymes of the P4504A family may contribute to the increase in loop Cl- transport and the development of hypertension in Dahl S rats. In this regard, the formation of 20-HETE and the levels of P4504A protein are reduced in the outer medulla of Dahl S rats. Perfusion of the loop of Henle of Dahl S rats with exogenous 20-HETE normalizes the elevated loop Cl- transport. In addition, a genetic marker in the P4504A2 gene, which encodes for the enzyme that makes 20-HETE, cosegregates with the development of hypertension in an F2 cross of Dahl S and Lewis rats. Finally, induction of renal production of 20-HETE with clofibrate prevents the development of hypertension in Dahl S rats and inhibition of renal 20-HETE formation produces hypertension in Lewis rats fed a high salt diet. These results implicate the CYP4A2 locus as a candidate gene that contributes to the alterations in renal function and the development of hypertension in Dahl S rats.

Effect of an endothelin antagonist on hemodynamic responses to angiotensin II

We determined changes in blood pressure, cardiac output, and total peripheral conductance evoked by intravenous infusions of angiotensin II (Ang II) in conscious, unrestrained normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) before and after pretreatment with bosentan, a nonselective endothelin antagonist. Blood pressure was recorded by radiotelemetry and cardiac output by ultrasonic transit-time flow probes. Bosentan per se failed to affect basal blood pressure and evoked only small changes in cardiac output and total peripheral conductance in both strains. The pressor effects of Ang II were exaggerated in SHR compared with WKY. Strikingly, bosentan pretreatment blunted the increases in blood pressure, the fall in cardiac output, and the decreases in conductance evoked by lower doses of Ang II but not higher doses of the peptide. This effect was observed in both rat strains but was more pronounced in SHR. These data suggest that endothelin contributes to the hemodynamic effects of Ang II in both SHR and WKY and that endothelin may contribute to the exaggerated pressor responsiveness of SHR to Ang II.

Angle closure glaucoma complicating systemic atropine use in the cardiac catheterization laboratory

Atropine may precipitate angle closure glaucoma in those predisposed to the disorder. Previously reported cases demonstrate the frequent misdiagnosis of acute glaucoma as conjunctivitis. Resultant delays in treatment can lead to vision loss. The present case describes a 66-yr-old man who developed acute angle closure glaucoma after receiving atropine during a coronary angioplasty produce. Clinicians who utilize atropine should be aware of the possibility of precipitating angle closure glaucoma and the predisposing factors, signs, and symptoms to facilitate prompt diagnosis and treatment of this disorder.

Penetration of chemotherapy into vitreous is increased by cryotherapy and cyclosporine in rabbits

OBJECTIVE

To investigate whether cryotherapy, which induces a serous effusion in retina, might increase access of systemic chemotherapy into the vitreous.

METHODS

The right eyes of 18 rabbits were treated with triple or single freeze-thaw cryotherapy at 1 or 2 locations, 1 day before administering intravenous carboplatin with or without cyclosporine. Control left eyes received no cryotherapy. The rabbits were killed 2 or 24 hours after chemotherapy, and carboplatin concentrations were measured in the vitreous of each eye and in blood.

RESULTS

A significant increase was found in intravitreal carboplatin concentrations when cryotherapy was applied (P < .001) or high-dose cyclosporine was administered (P < .001) and if 2 locations were frozen compared with 1 location frozen (P = .02). Intravitreal carboplatin concentrations were always significantly greater after cryotherapy, either when the corresponding blood carboplatin concentrations were high (2 hours after completing treatment) or when they had dropped to much lower levels (at 24 hours). The triple freeze-thaw technique did not yield significantly better results than a single freeze-thaw technique.

CONCLUSION

Cryotherapy administered 24 hours before chemotherapy significantly increased the intravitreal penetration of carboplatin, and this strategy may enhance the capacity of chemotherapy to cure intraocular retinoblastoma, particularly avascular tumors such as vitreous seeds.

Pharmacoeconomics of hypertension control: basic principles of economic evaluation

Pharmacoeconomics, the science of assigning costs and outcomes of drug therapy can be applied to antihypertensive drug therapy. There are five principle tools: cost identification, cost minimization, cost benefit, cost effectiveness and cost utility. If only drug aquisition costs are considered, there are marked differences among antihypertensive drug classes. These differences become less marked when the costs per quality adjusted life year are calculated. Often, differences among patients rather than differences among drug prices account for the bulk of variation.

Heterogeneity in vascular smooth muscle responsiveness to angiotensin II. Role of endothelin

We compared the role of endothelium and of endothelin in mediating the vasoconstrictor responses to angiotensin II (Ang II) in three vascular smooth muscle preparations--aorta, mesenteric artery, and tail artery--isolated from adult male Sprague-Dawley rats. The vasoconstrictor potency for Ang II in blood vessels with endothelium varied in the following rank order: aorta > mesenteric artery > tail artery. Although the maximal tension responses to Ang II were similar for mesenteric and tail arteries, it was significantly lower in aorta. Endothelium removal led to a leftward shift in the concentration-response curves to Ang II in the aorta but a rightward shift in the mesenteric artery. Strikingly, Ang II failed to evoke tension responses in tail artery in the absence of endothelium. The endothelin-A (ETA)-selective antagonist BQ-123 blocked the responses to Ang II in a noncompetitive manner, with partial and complete attenuation of responses in the endothelium-intact mesenteric and tail artery preparations, respectively. In contrast, BQ-123 did not affect the responses to Ang II in the aorta. BQ-123 also failed to affect the responses to Ang II in endothelium-denuded mesenteric artery rings. The Ang II type 1 (AT1) receptor-selective antagonist losartan competitively blocked the responses to Ang II in the three tissues (pA2, 8.3 to 8.7) when endothelium was present. These data suggest that there are endothelium-dependent regional variations in vascular tissue sensitivity to Ang II.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential effects of phosphoramidon on contractile responses to angiotensin II in rat blood vessels

1. Cumulative concentration-tension response (C-R) curves to angiotensin II (AII), big endothelin-1 (big ET-1), ET-1 and arginine vasopressin (AVP) were determined in endothelium intact-ring preparations of aorta, mesenteric artery and tail artery isolated from adult male Sprague-Dawley rats in the presence or absence of the neutral metalloprotease inhibitor, phosphoramidon. 2. The order of sensitivity of the three rat vascular smooth muscle preparations to AII, big ET-1 and ET-1 was aorta > mesenteric artery > tail artery whereas that for AVP was reversed, namely, tail artery > mesenteric artery > aorta. 3. Phosphoramidon blocked the responses to AII in a concentration-dependent manner, whereas even very high concentrations of phosphoramidon (100 microM) failed to affect the tension responses evoked by ET-1 and AVP in all three preparations. Low concentrations of phosphoramidon (10 microM) produced significant increases in EC50 values for AII in tail artery (P < 0.01) and mesenteric artery (P < 0.05) but not in aorta. The rank order of sensitivity to the inhibition by phosphoramidon was tail artery > mesenteric artery > aorta. Phosphoramidon-evoked rightward shifts in the C-R curves to AII were much higher than those to big ET-1 in both mesenteric artery and tail artery. 4. In endothelium-denuded preparations, AII failed to evoke any increases in tension in tail artery while the responsiveness of the mesenteric artery to AII was reduced significantly relative to endothelium-intact tissues with a rightward shift in the C-R curve and a decrease in the maximal response. On the other hand, the C-R curve to AII was shifted to the left in aorta following removal of the endothelium.Importantly, ET-1 and AVP evoked vasoconstrictor responses were unaffected by the inclusion of a high concentration of phosphoramidon (100 microM) in endothelium-denuded aorta and mesenteric artery.5. The results suggest that AII-evoked tension responses of blood vessels such as tail artery are completely endothelium-dependent; in relatively larger blood vessels such as mesenteric artery they are partially endothelium-dependent while in much bigger conduit type blood vessel such as aorta, they are endothelium-independent. It is concluded that the vasoconstrictor responses to AII in mesenteric artery and tail artery may be mediated by the release of endothelins from the endothelium by increased formation from big ET, an effect that is blocked by phosphoramidon.