[Value of Doppler color ultrasonography in diagnosis of arterial occlusive disease of the lower extremity. A direct comparison with percutaneous angiography]

A Direct Comparison with Percutaneous Angiography:

AIM

To compare colour-coded Doppler sonography (CCDS) with conventional angiography in severe occlusive vascular disease of the lower limb.

METHODS

In 55 patients 1141 vessel segments were evaluated, 700 of them with atheromatous plaques, 270 with stenoses, 208 with occlusions and 6 with aneurysms.

RESULTS

Deeper-seated vessels such as the abdominal aorta, the pelvic arteries, the superficial femoral artery at the level of the adductor canal and parts of the lower leg arteries are less accessible for direct CCDS. Many pathological changes however can be diagnosed indirectly by changes in the spectral wave form distal to the lesion. In superficial vascular segments (the common femoral artery, the profunda femoris artery, the superficial femoral artery above the adductor canal and the popliteal artery) image quality was excellent, more pathological changes were found, and the degree of stenosis was better estimated in comparison to angiography.

CONCLUSION

The value of CCDS in patients with intermittent claudication is limited to those who have been examined with angiography e.g. before angioplasty, to follow-up examinations after vascular dilatation or surgery and to supplementary visualisation after angiography especially in readily accessible (superficial) vascular segments.

Arterial oxygen partial pressures reduce the insulin-dependent induction of the perivenously located glucokinase in rat hepatocyte cultures: mimicry of arterial oxygen pressures by H2O2

Liver glucokinase (GK) is localized predominantly in the perivenous zone. GK mRNA was induced by insulin maximally under venous O2 partial pressure (pO2) and only half-maximally under arterial pO2. CoCl2 and desferrioxamine mimicked venous pO2 and enhanced the insulin-dependent induction of GK mRNA under arterial pO2. H2O2 mimicked arterial pO2 and reduced insulin-induced GK mRNA under venous pO2 to the lower arterial levels. Thus the zonal O2 gradient in liver seems to have a key role in the heterogenous expression of the GK gene.

Agonist responses of neuronal nicotinic acetylcholine receptors are potentiated by a novel class of allosterically acting ligands

Similar to the gamma-aminobutyric acidA receptor and the N-methyl-D-aspartate subtype of glutamate receptor, neuronal nicotinic acetylcholine receptors are subject to positive modulatory control by allosterically acting ligands. Exogenous ligands such as galanthamine and the neurotransmitter 5-hydroxytryptamine, when applied in submicromolar concentrations with nicotinic agonists, significantly increase the frequency of opening of nicotinic receptor channels and potentiate agonist-activated currents. Because these effects have been shown to be blocked by the monoclonal antibody FK1, they are mediated by binding sites that are located on alpha subunits of nicotinic receptors and distinct from those for acetylcholine and acetylcholine-competitive ligands. At higher concentrations, the potentiating effect of these ligands decreases and is eventually overcome by an inhibition of the agonist-induced response. The sensitizing actions of galanthamine, 5-hydroxytryptamine, and related compounds, at submicromolar concentrations, may reflect the existence of cross-talk between adjacent neuroreceptors and synapses in the central nervous system and thus suggests the formation of transiently active chemical networks in the vertebrate brain.

Membrane protein subunit fractionation by means of inverse pore gradient elution polyacrylamide gel electrophoresis

We report here the preparative scale isolation of the four subunits of the nicotinic acetylcholine receptor (nAChR) applying short inverse pore gradient SDS gels on an elution-PAGE apparatus. The nAChR subunits are of similar molecular weights (alpha, 50.2 kDa; beta, 53.7 kDa; gamma, 56.3 kDa; delta, 57.6 kDa) and isoelectric point (approx 5.5) and share the typical properties of amphiphatic membrane proteins that are difficult to separate by chromatographic procedures. Preparative PAGE, which has proved to be the method of choice for nAChR-subunit fractionation, however, is time-consuming and achieves only moderate resolutions yielding dilute fractions. We present here the fractionation of a membrane preparation of Torpedo electric organ (2 mg of total protein) on short gels (2 cm) with linear or concave inverse pore gradients. All of the four subunits are isolated in homogeneous fractions of approx 70 micrograms/ml within only 4 h. Compared to the standard method, this means a 50% reduction in separation times with threefold higher concentrated protein fractions. We also give the theoretical explanation and experimental validation of the improved features resulting from short inverse-gradient polyacrylamide gels.

[The value of color Doppler ultrasound in follow-up of percutaneous transluminal angioplasty of the thigh area]

The value of colour-coded Doppler sonography to evaluate results of percutaneous transluminal angioplasty of the superficial femoral artery was tested in 26 patients. Because of good accessibility, morphology may be demonstrated similar to intravenous DSA. However, accurate evaluation of dilatation success also requires haemodynamic measurements. Numerous parameters were determined one day before, one day after and one month after angioplasty at various points of the extremity (dilated segment, popliteal artery, lower leg arteries). Results were compared with those of normal individuals. Because of the large range of scatter and overlapping between normal and pathological values, only a few parameters can be used as valuable indicators for successful PTA. Spectral wave form becomes bi- or triphasic pattern and due to this the Pulsatility Index rises distal to the dilated area. An increasing systolic acceleration rate, peak systolic velocity and prestenotic Pulsatility Index have excellent predictive value. Using a Damping Factor, the later walking range may be predicted.

[Principles of quantitative color Doppler ultrasound of pelvic and leg arteries. Normal sample]

Statistical analysis of a group of 25 healthy individuals, examined via angiodynography, shows a large range of scatter for all measured parameters in pelvic and lower extremity arteries. Blood flow and velocity values, systolic acceleration and vessel diameter decrease whereas the pulsatility index rises from the centre towards the periphery. Problem areas for morphological and quantitative evaluation are the abdominal aorta, pelvic vessels, superficial femoral artery in the distal adductor canal and the fibular artery. Nearly all vessels showed tri- or multiphasic spectral patterns. Biphasic waveform, however, may be normal in lower extremity arteries. The data yielded by colour-coded Doppler sonography were comparable to results obtained with other procedures.

Identification of purine binding sites on Torpedo acetylcholine receptor

Electrophysiological studies from this and other laboratories have suggested a direct action of ATP on nicotinic acetylcholine receptors (nAChR). To determine the site of binding of this purine derivative, we have covalently modified the nAChR from Torpedo marmorata electrocytes employing 2-[3H]-8-azido-ATP as a photoactivable affinity label. Covalently attached radioactivity was predominantly found in the beta-polypeptide of the receptor. Based on the results of protection studies with several nAChR ligands whose target sites at the receptor are known, we conclude that the purine site(s) differ from those of acetylcholine and of physostigmine, galanthamine and related ligands, and those of local anesthetics.

Role of the oral calcium-loading test with measurement of intact parathyroid hormone in the diagnosis of symptomatic subtle primary hyperparathyroidism

BACKGROUND

This study was designed to assess the diagnostic value of the oral calcium tolerance test with measurement of intact parathyroid hormone by the immunoradiometric assay (IRMA PTH) in the diagnosis of primary hyperparathyroidism in patients with symptoms who have minimal, intermittent, or no elevation of the levels of total calcium and/or intact PTH.

METHODS

After baseline levels of IRMA PTH and total calcium were measured, an oral calcium load of 1000 mg elemental calcium was administered to 10 patients with hyperparathyroidism and 18 normal control subjects. Total calcium and IRMA PTH levels were measured at 30, 60, and 120 minutes after the oral calcium load was administered.

RESULTS

The mean suppression of the baseline level of IRMA PTH in the patients with hyperparathyroidism was 83.7% +/- 6.5% (mean +/- 1 SEM), but the levels of the normal control subjects fell significantly (p < 0.05) lower to 58.8% +/- 3.7% (mean +/- 1 SEM).

CONCLUSIONS

This study suggests that the oral calcium tolerance test may be a valuable adjunct in confirming the diagnosis of primary hyperparathyroidism in patients with symptoms who have minimal, intermittent, or no elevation of the levels of total calcium and/or IRMA PTH:

[Phantom studies using echo contrast media to improve the Doppler color sonographic imaging of the superficial femoral artery in the adductor canal]

The adductor canal was simulated using 2.6 cm muscular tissue and 2 fasciae to analyse the limits of colour-coded Doppler sonography (angiodynography) in this region. Defects in the spectral signal cause a significant underestimation of mean, peak systolic and peak diastolic (backflow) velocities and of calculated blood flow. Furthermore the pulsatility index is overestimated and the colour-coded visualisation of the arteries is almost lost. For the most part, these changes can be compensated by administration of a sonographic contrast agent (SH U 454). A minimum of 9 mg microbubbles/ml blood is required. Nevertheless, the adjustment of system controls (e.g. transducer power) becomes more difficult and an ideal setting impossible.

[Duplex sonography: accuracy, reproducibility and possibilities for error. Checking quantitative flow measurements against an in vitro model]

Using a pulsatile model of tubes, duplex-sonographic measurements of flow were compared with actual flow. The correlation coefficient between actual and duplex-sonographically obtained flow was 0.975, mean percentage deviation being -18.1% (P less than 0.0001). The obvious scatter (margin of error -69.2 to +50%) is to be explained by the simulation closely imitating a real situation: the transducer was hand-held and tubes were placed in muscle or fat tissue. Accuracy was increased by multiple measurements, especially when taking into account only the maximal value of any series of measurements. Vessel diameter was easy to measure accurately (mean error less than 0.01% [-18.7 to +9.4%]). Repeated measurements of flow velocity had only a small scatter (coefficient of variance 0.064). In muscle or fat the Doppler signal was attenuated and the error the greater the deeper the level at which measurements were made. Low flow (common in patients with obstructive vascular disease) can also cause faulty results.

[Phantom studies of the value of color-coded Doppler sonography in arterial occlusive disease of the lower extremities]

A new practically orientated phantom for evaluating Doppler Duplex equipment was developed and used to determine the possibilities and limits of color coded Doppler Sonography (Angiodynography) in the diagnosis of arterial occlusive disease of the lower extremity. The problems that may occur in quantifying flow in these arteries are analyzed. The influence of superimposed slices of various soft-tissues on flow quantification, on the spectral waves and on color coded visualisation of the arteries and the possibility to compensate those changes by the use of sonographic contrast agents are discussed.

Strategy for the characterization of autoantigens in autoimmune diseases. Investigation of the target antigens of antimitochondrial antibodies by radioimmunoassay, immunoblotting, monoclonal antibodies and affinity chromatography

We present a strategy to characterize specific antigen/autoantibody systems using polyclonal sera from patients as a probe and crude antigenic preparations such as mitoplasts. Sera from patients with primary biliary cirrhosis (PBC) are characterized by at least one of two specific subtypes of antimitochondrial antibodies (AMA), anti-p48 or anti-p62. Immunoblotting of such sera with mitoplast preparations derived from human, rat and rabbit livers revealed three proteins of approximately 27, 48 and 68 kDa as target antigens. On the basis of the molecular weight of these antigens we were able to purify them by elution from preparative SDS gels. Immunization of NZB mice with the high molecular weight component (the 68 kDa antigen from human liver mitoplasts) elicited a monoclonal antibody. The 68 kDa protein was then isolated by affinity chromatography and may well represent the prime target antigen of anti-p62 antimitochondrial antibodies. This experimental approach could be applied to protein target antigens of other autoantibodies.

Left heart function in chronic obstructive lung disease

In patients with varying degrees of chronic obstructive pulmonary disease (COPD), simultaneous measurements of central hemodynamics and left ventricular radionuclide ventriculograms at rest and during exercise were made. In 21 of these patients, satisfactory echocardiograms could be performed. In seven of the patients, arterial blood pressure at rest was increased. Decreased compliance of the left ventricle was thought to be present in patients with COPD and additional arterial hypertension. The left ventricular ejection fraction (LVEF) at rest was in the high normal range in all patients. During exercise, no further increase was observed. This pattern of LVEF response seems to be typical in patients with COPD. Because the highest values were observed in the more severe COPD and right ventricular hypertrophy, it is unlikely that an impairment of left ventricular function is caused by COPD. In five of 27 patients, an abnormal decrease of LVEF and regional hypokinesis occurred during exercise, thus suggesting additional coronary heart disease. The fact that at least 30% of the patients with COPD suffered from arterial hypertension and 20% of the patients exhibited unexpected ischemia detected by regional hypokinesis in RNV during exercise, but not in the ECG, may be of practical relevance. Coronary angiography was not indicated because most of these patients were over 65 and the factor limiting the working capacity was ventilatory impairment and not angina pectoris, in all patients. For this reason, a diagnostic uncertainty remains with regard to additional coronary heart disease in the older patients with advanced chronic obstructive pulmonary disease.

Pulmonary gas exchange and central hemodynamics at rest and during exercise in patients with chronic obstructive pulmonary disease

Right-heart catheterization and ergometry with arterial and mixed venous blood gas analysis were performed in 27 patients with a wide range of chronic obstructive pulmonary diseases. The purpose of the examination was to evaluate the risk in patients for lung surgery or to detect additional heart diseases. Patients who developed exertional hypoxia (group 1) were compared with others who did not (group 2). In all patients the steady-state maximal workload was determined by ventilatory dysfunction. Both groups had normal values for mixed venous pO2 and normal increase of the circulatory parameters during exercise. The patients with exertional hypoxia differed from the others in that they showed no decrease of venous admixture and alveolar-arterial oxygen gradient. In addition, these patients had increasing pCO2 values at rest compared with exercise, indicating alveolar hypoventilation and ventilation-perfusion mismatching. Because of the good correlation of the absolute values of FEV1 (forced expiratory volume in 1 s) with pulmonary artery pressures, parameters of gas exchange and working capacity, this lung function parameter seems to have a central role in predicting the functional state of patients with chronic obstructive disease. Ergometry and blood gas analysis should be performed in addition because these values cannot be predicted with the calculated postoperative FEV1.

[Leo-insulins in the treatment of diabetes. Experiences from an internal medicine practice]

An account is given on the long-term control of 27 unselected diabetics treated with Leo insulins in private internal medical practice. Both primary adjustments in recently manifested juvenile diabetes and change-over from other insulins or oral antidiabetics were carried out as outpatient treatment. Thorough training of the patient, which is a prerequisite to successful cooperation between the diabetic and his physician, is just as important as regular metabolic check-ups. The therapeutic results was considerably improved using Leo insulins. While 26 out of 27 patients were inadequately compensated before the beginning of therapy, the subsequent observation revealed very good adjustment in 11, good adjustment in 3 and satisfactory adjustment in 4 patients.