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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

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

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

Plasma endothelin levels are unaltered by thyroid hormone status in humans

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

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

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

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

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

OBJECTIVES

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

BACKGROUND

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Circadian and weekly variations in pain onset of acute myocardial infarction

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intrathoracic extramedullary haematopoiesis complicated by massive haemothorax in alpha-thalassaemia

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