Left ventricular functional improvement after transmyocardial laser revascularization

BACKGROUND

Transmyocardial laser revascularization has been used to treat patients with end-stage coronary artery disease that is not amenable to standard revascularization. Although there is evidence of angina relief and quality of life enhancement, there is little information concerning improvement in myocardial contractility. The purpose of this study was to determine whether transmyocardial laser revascularization improves myocardial function in chronically ischemic myocardium.

METHODS

In a model of chronic ischemia by Ameroid occlusion of the circumflex artery, domestic pigs (n = 8) were treated with transmyocardial laser revascularization. Before laser treatment, segmental contraction was assessed at rest and with dobutamine stress echocardiography. Myocardium subtended by the occlusion was compared with that remote from the occlusion. Six weeks after transmyocardial laser revascularization, the animals were restudied at rest and with stress, and then sacrificed. Sham-treated control animals (n = 4) underwent the same procedures but were not treated with transmyocardial laser revascularization. Control animals did not demonstrate significant recovery of function.

RESULTS

Transmyocardial laser revascularization improved resting function in chronically ischemic myocardium by 100%.

CONCLUSIONS

Transmyocardial laser revascularization significantly improves the function of chronically ischemic myocardium. These data may help explain the mechanisms by which transmyocardial laser revascularization is clinically effective.

Gas tensions in cardiac lymph as a reflection of the interstitial space of the heart

The purpose of this study was to determine the feasibility of measuring partial pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2), and pH in cardiac lymph and to evaluate the relationship of these parameters to comparable measurements in arterial and coronary sinus blood in the normal heart under various respiratory conditions. In four anesthetized open-chest dogs, the principal cardiac lymphatic as well as the femoral artery and coronary sinus were cannulated. Ventilation was varied by changing oxygen concentration, tidal volume, and respiratory rate. PO2, pCO2, and pH were measured in the cardiac lymph, arterial blood, and coronary sinus blood after each change in ventilation. For pH and pCO2, good correlations were observed between the arterial blood and cardiac lymph, arterial blood and coronary sinus blood, and coronary sinus blood and cardiac lymph. The correlation between the pO2 measured in the arterial blood and the pO2 measured in the cardiac lymph was not as strong, and this may have been related to difficulty achieving a steady state. Gas tensions (pO2, pCO2, and pH) can be measured in cardiac lymph and may provide a window to the interstitial compartment of the heart. This is an additional tool for the laboratory study of ischemia and other forms of heart disease.

Stress reduction for family caregivers: effects of adult day care use

OBJECTIVES

This study reports the findings of an evaluation of the psychological benefits of use of adult day care by family caregivers assisting a relative with dementia.

METHODS

The study used a quasi-experimental design in which caregivers in the treatment group used substantial amounts of services, whereas caregivers in a control group did not use day care at any point during the evaluation and only small amounts of other respite services. The evaluation was guided by the stress process model of caregiving which distinguishes between appraisals of primary stressors and well-being.

RESULTS

Results after 3 months of day care use showed that the treatment group had significantly lower scores than the control group on two of the three measures of primary appraisals (overload and strain) and two of the three measures of well-being (depression and anger). Findings at one year showed that the treatment group had significantly lower scores on overload and depression than the control group.

DISCUSSION

These results demonstrate that use of adult day care by caregivers of dementia patients results in lower levels of caregiving-related stress and better psychological well-being when compared to that of controls.

Septo-hippocampal cholinergic and neurotrophin markers in age-induced cognitive decline

Messenger RNA (mRNA) molecules encoding proteins related to the presynaptic cholinergic and neurotrophin systems were quantitated in the hippocampus and basal forebrain of Long-Evans rats with spatial learning ability assessed in the Morris water maze. The reverse transcriptase-polymerase chain reaction showed that the mRNAs for the low-affinity neurotrophin receptor (p75-NTR) and the growth-associated protein GAP-43 were decreased in level in the basal forebrain of aged-impaired rats. In the hippocampus of these aged-impaired rats, the mRNA for VGF, another neurotrophin-inducible gene, also was decreased. In situ hybridization histochemistry revealed that mRNAs for nerve growth factor (NGF) and brain-derived neurotrophic factor increased in level in the aged rat hippocampus; when age effects were removed, NGF mRNA level remained significantly correlated with maze performance. Enzyme-linked immunosorbent assay indicated that NGF protein was expressed at normal levels in the aged rat hippocampus. These mRNA and protein alterations may signify that a defect in neurotrophin signaling exists in the brains of aged Long-Evans rats, underlying reduced plasticity responses in the basal forebrain cholinergic system.

The lymphatic drainage of the left ventricle in the Yucatan minipig

The gross anatomy of the cardiac lymphatic system draining the left ventricle was studied in 15 Yucatan minipigs and 2 regular swine. The findings confirm that the drainage pathways are similar to those of man and dog. After a coloring marker is injected near the apex of the left ventricle, one or more lymphatics are seen to ascend towards the left atrial appendage. Where there is more than one ascending lymphatic, they typically join before or at the left atrial appendage. This principal lymphatic then passes beneath the appendage and travels behind (dorsal to) the pulmonary artery and aorta to the right side of the mediastinum. From here, the lymphatic passes cephalad along the left border of the superior vena cava to enter the cardiac lymph node between the superior vena cava and the trachea.

Arginine vasopressin inhibition of cytochrome P450c17 and testosterone production in mouse Leydig cells

The mechanism of arginine vasopressin (AVP) action in Leydig cells was investigated, and compared to the effects of phorbol-13-myristate-12-acetate (PMA) and interleukin-1 beta (IL-1 beta). Previous reports suggested that AVP inhibits Leydig cell testosterone production at the level of 17 alpha-hydroxylase/C17-lyase activity. The present study confirms and extends these observations, and contrasts the effects of AVP to IL-1. In all experiments, macrophage-depleted Leydig cells were isolated from mice and maintained in primary culture for 5 d prior to initiation of treatments. Leydig cells were treated with 8-Br-cAMP plus increasing concentrations of AVP or IL-1 beta. AVP caused a significant and dose-dependent inhibition of cAMP-stimulated testosterone production and P450c17 mRNA expression. IL-1 beta completely inhibited cAMP-stimulated testosterone production and P450c17 mRNA expression. PMA is a known activator of protein kinase C (PKC) and has been reported to inhibit Leydig cell steroidogenesis. Leydig cells express type V1 vasopressin receptors, which are coupled to PKC activation. The mechanism of IL-1 action in Leydig cells is not understood, but activation of the PKC pathway has been suggested for IL-1 action in other systems. Therefore, the effects of PMA on cAMP-stimulated steroidogenesis were compared to AVP and IL-1. Similar to the effects of AVP, PMA inhibited cAMP-stimulated testosterone production and P450c17 mRNA expression. To assess the possible involvement of PKC in AVP and IL-1 action in Leydig cells, the PKC inhibitor Calphostin C was tested. cAMP-stimulated testosterone production and P450c17 mRNA expression were significantly inhibited by 10 nM AVP (p < 0.05), and this inhibition was reversed by treatment with Calphostin C. Analogous experiments were performed to assess the role of PKC in IL-1 action. In contrast to the results for AVP, Calphostin C did not reverse the inhibitory effects of IL-1 on cAMP-stimulated P450c17 mRNA expression. To assess further PKC activation, myristoylated alanine-rich C kinase substrate (MARCKS) phosphorylation was analyzed. Only AVP and PMA, but not IL-1 beta, caused an increase in MARCKS phosphorylation. These results confirm that AVP and PMA activate PKC and indicate that IL-1 likely does not activate PKC in Leydig cells. The implications of AVP-mediated inhibition of steroidogenesis and potential role of MARCKS phosphorylation are discussed.

Cannulation of the aortic branches using ultrasound guidance. An animal study

Catheter placement by ultrasound may reduce radiation, improve positioning, and allow the use of echo contrast agents for diagnostic and therapeutic procedures. To evaluate its utility in the peripheral and coronary vascular beds, a preshaped 20 MHz Doppler catheter was inserted into the femoral artery for renal artery, or into the right carotid artery for left coronary artery cannulation in five dogs. Ultrasonic imaging of the vascular structure and catheter was provided by either transabdominal or transesophageal ultrasound. Using Doppler waveform polarity for retrograde guidance, the catheter was advanced to the region of the left renal or left coronary ostia. Ultrasonic emissions from the Doppler catheter were identified by color Doppler mode of the ultrasound machine and allowed the catheter tip to be identified within the beam width of the scanning transducer, providing the depth dimension. In the two animals in which left renal artery cannulation was attempted, the catheter was successfully manipulated into the ostium. In two of the three animals in which left coronary artery cannulation was attempted, the catheter was successfully manipulated into the ostium, followed by saline contrast injections revealing myocardial perfusion. In addition, in one animal, a Doppler flow wire was identified as it was advanced into the mid circumflex coronary. In conclusion, ultrasonically guided cannulation of aortic branches may be possible without x-ray, and this technique may lead to further use of ultrasound in diagnostic and therapeutic procedures.

Comparison of nested PCR with immunofluorescent-antibody assay for detection of Ehrlichia canis infection in dogs treated with doxycycline

A partial 16S rRNA gene was amplified in Ehrlichia canis-infected cells by nested PCR. The assay was specific and did not amplify the closely related Ehrlichia chaffeensis, Ehrlichia muris, Neorickettsia helminthoeca, and SF agent 16S rRNA genes. The assay was as sensitive as Southern hybridization, detecting as little as 0.2 pg of E. canis DNA. By this method, all blood samples from four dogs experimentally infected with E. canis were positive as early as day 4 postinoculation, which was before or at the time of seroconversion. One hundred five blood samples from dogs from Arizona and Texas (areas of E. canis endemicity) and 30 blood samples from dogs from Ohio (area of E. canis nonendemicity) were examined by nested PCR and immunofluorescent-antibody (IFA) test. Approximately 84% of dogs from Arizona and Texas had been treated with doxycycline before submission of blood specimens. Among Arizona and Texas specimens, 46 samples were PCR positive (44%) and 80 were IFA positive (76%). Forty-three of 80 IFA-positive samples (54%) were PCR positive, and 22 of 25 IFA-negative samples (88%) were negative in the nested PCR. None of the Ohio specimens were IFA positive, but 5 specimens were PCR positive (17%). Our results indicate that the nested PCR is highly sensitive and specific for detection of E. canis and may be more useful in assessing the clearance of the organisms after antibiotic therapy than IFA, especially in areas in which E. canis is endemic.

Lactational transfer of volatile chemicals in breast milk

Lactational transfer of chemicals to nursing infants is a concern for occupational physicians when women who are breast-feeding return to the workplace. Some work environments, such as paint shops, have atmospheric contamination from volatile organic chemicals (VOCs). Very little is known about the extent of exposure a nursing infant may receive from the mother's occupational exposure. A physiologically based pharmacokinetic model was developed for a lactating woman to estimate the amount of chemical that a nursing infant ingests for a given nursing schedule and maternal occupational exposure. Human blood/air and milk/air partition coefficients (PCs) were determined for 19 VOCs. Milk/blood PC values were above 3 for carbon tetrachloride, methylchloroform, perchloroethylene, and 1,4-dioxane, while the remaining 16 chemicals had milk/blood PC values of less than 3. Other model parameters, such as solid tissue PC values, metabolic rate constants, blood flow rates, and tissue volumes were taken from the literature and incorporated into the lactation model. In a simulated exposure of a lactating woman to a threshold limit value concentration of an individual chemical, only perchloroethylene, bromochloroethane, and 1,4-dioxane exceeded the U.S. Environmental Protection Agency non-cancer drinking water ingestion rates for children. Very little data exists on the pharmacokinetics of lactational transfer of volatile organics. More data are needed before the significance of the nursing exposure pathway can be adequately ascertained. Physiologically based pharmacokinetic models can play an important role in assessing lactational transfer of chemicals.

Visualization of the lymphatics of the heart and the mediastinal drainage pathways in the living cynomolgous (Macaca mulatta) monkey

Our interest in the effects of impaired cardiac lymph drainage on coronary atherosclerosis led us to study the cardiac lymphatic anatomy in the monkey, generally considered the ideal experimental animal for examining coronary artery disorders. Short-term and long-term studies to visualize the cardiac lymphatic system and its mediastinal drainage pathways in 14 living monkeys confirmed that the epicardial collecting lymphatic anatomy is comparable to that of man, dog, and pig. These lymphatics, and particular lymphatic drainage to the cardiac lymph node in the right mediastinum, are difficult to visualize, in good part, because lymph uptake of such tracers as India Ink and T1824 blue dye is extremely slow. By modifying our techniques and taking cognizance of the slow lymphatic uptake of the tracers, we have been more successful in visualizing the mediastinal cardiac lymph node. Though our studies confirm that the lymphatic drainage of the monkey heart is similar to that in other mammals, we conclude that the "monkey model" has several drawbacks to study the effects of impaired cardiac lymph flow because of the laborious requirements to visualize successfully the cardiac lymph node. Perhaps the development of new markers would make this lymphatic system more approachable for experimental investigation.

Autonomic regulation of heart rate and peripheral circulation: comparison of high altitude and sea level residents

1. To evaluate the activity of the autonomic nervous system on the heart and peripheral circulation in native high-altitude residents, during a Himalayan expedition we studied 12 men (age: 48 +/- 4, mean +/- SEM), life-long resident in a village at 4800 m (Sumdo village, Zanskar, India) and 7 healthy sea-level residents (age: 37 +/- 4) after 7 days of acclimatization (acclimatized lowlanders) at the same altitude. Furthermore 25 sea level residents (age: 46 +/- 2) underwent the same protocol at sea level. 2. R-R interval (RR), respiratory signal, non-invasive blood pressure, and skin arteriolar blood flow were evaluated in three different conditions: during free breathing in supine position and during controlled breathing (at 0.15 Hz), in supine and upright position, and analysed by autoregressive spectral analysis [low- (around 0.1 Hz) and high-frequency (respiratory) fluctuations, LF and HF, markers of sympathetic and vagal activity, respectively]. 3. High-altitude residents showed in supine position a higher RR than acclimatized lowlanders, similar to sea-level residents. RR variability was reduced in acclimatized lowlanders compared to both high-altitude residents and sea level residents. Systolic blood pressure (SBP) did not show significant differences between the three groups. High altitude residents showed in supine lower LF in RR signal compared to sea-level residents, and, compared to acclimatized lowlanders, higher HF and lower LF/HF ratio; high-altitude residents showed a reduction in skin microcirculation variability compared to sea-level residents, but this was eight fold greater than in acclimatized lowlander, thus indicating a much greater vasoconstriction in acclimatized lowlanders than in high-altitude residents. 4. In upright position, high-altitude residents showed the same behaviour as sea-level residents, with increase in LF-RR, and decrease in HF and LF-SBP. Acclimatized lowlanders showed similar directional trends though not significant changes for RR-LF. 5. After one week of acclimatization, lowlanders still manifested sympathetic activation and skin vasoconstriction; high-altitude residents did not show reduced vagal tone compared to sea-level residents, but a mild vasoconstriction appeared to be present. In conclusion, normal or enhanced vagal tone and preserved vasomotion are probably evidence of adaptation at high altitude hypoxia.

Differential effects of physiological versus pathophysiological plasma concentrations of epinephrine and norepinephrine on ketone body metabolism and hepatic portal blood flow in man

Few studies that have examined the effects of catecholamines on ketogenesis have considered the effects of catecholamines on hepatic portal blood flow. Since hepatic blood flow is a major determinant of hepatic ketogenesis (via modification of free fatty acid availability), interpretation of these studies is difficult. To better define the relative contributions of these variables, we studied the effects of physiological and pathophysiological plasma concentrations of epinephrine and norepinephrine on plasma ketone body concentrations and hepatic portal blood flow in controlled paired studies in young healthy male volunteers. To assess the effects of physiological catecholamine concentrations, each of eight subjects received 60-minute sequential infusions of epinephrine (10 ng/kg/min) and norepinephrine (32.5 ng/kg/min) together with a control infusion of heparin (0.4 U/kg/min) separated by 60-minute washout periods. Similar increments in plasma nonesterified fatty acid ([NEFA] to approximately 1 mmol/L) were observed during each infusion. The ketotic ratios, calculated as the ratio of plasma ketone bodies to fatty acids integrated above baseline for 90 and 120 minutes, respectively, for epinephrine and norepinephrine infusions were both significantly greater (P < .005 for each) than for the heparin control infusion. To assess the effects of pathophysiological plasma catecholamine concentrations, each of eight subjects also received sequential 60-minute infusions of epinephrine 60 ng/kg/min, norepinephrine 80 ng/kg/min (plus heparin 0.1 U/kg/min), and a separate control infusion of heparin with or without Intralipid (KabiVitrum, Alameda, CA). Whereas integrated plasma fatty acid levels were approximately twofold greater than those observed in the physiological protocol, the absolute integrated ketone body response to the pathophysiological concentration of epinephrine was significantly lower than that observed for the physiological dose of the hormone (P < .05). In contrast, the ketotic ratio for norepinephrine was significantly greater (P < .005) than for both epinephrine and the control infusion of heparin with or without Intralipid. Significant (P < .01) increases above baseline fasting levels were observed in plasma glucose and immunoreactive insulin concentrations during infusion of pathophysiological concentrations of epinephrine. Because of the technical difficulties of simultaneously measuring portal blood and sampling blood frequently, studies were repeated in six additional subjects using noninvasive image-guided flowmetry to measure percentage changes in hepatic portal blood flow during catecholamine infusion. Norepinephrine reduced hepatic portal blood flow significantly at the low-physiological concentration by 12% (P < .05) and at the pathophysiological concentration by 18% (P < .05). In summary, (1) both epinephrine and norepinephrine were associated with significant ketotic effects at physiological plasma concentrations; and (2) when infused at pathophysiological concentrations, only norepinephrine exerted a significant additional ketotic effect. Since norepinephrine has a significant simultaneous effect of reducing hepatic portal blood flow, we conclude that previous studies may have underestimated the effect of norepinephrine on hepatic ketogenesis.

Computation of vascular flow dynamics from intravascular ultrasound images

Analysis of three-dimensional velocity profiles and wall shear stress distribution in a segment of an artery reconstructed from in vivo imaging data are presented in this study. Cross-sectional images of a segment of the abdominal aorta in dogs were obtained using intravascular ultrasound (IVUS) imaging employing a constant pull back technique. Simultaneous measurement of pressures distal and proximal to the vessel segment along with gated pulsed Doppler velocity measurements were also obtained. The three-dimensional geometry of the vascular segment was reconstructed from the IVUS images during peak forward flow phase, and a computational mesh was constructed from the data. A quasi-steady analysis of incompressible Newtonian fluid was performed with a finite difference general purpose computational analysis program FLOW3D. The velocity at the inlet and pressure at the outlet measured at the corresponding time (time referenced to ECG) were used to specify the boundary conditions for the computational flow model. The computed results compared favorably with previously reported results. The purpose of the present study was to analyze the hemodynamics in vascular segments from morphologically realistic three-dimensional reconstructions. The method can be potentially employed in analyzing the hemodynamics in the region of atherosclerotic plaques at various stages of development and the reactivity of the vessel in response to pharmacological and mechanical interventions.

Molecular indices of neuronal and glial plasticity in the hippocampal formation in a rodent model of age-induced spatial learning impairment

Spatial learning ability was quantitated in young and aged Long-Evans rats, and molecular markers were assessed in the striatum and hippocampal formation using immunocytochemical, immunoblotting, and in situ hybridization histochemical procedures. The mRNA for beta-amyloid precursor protein (beta APP), most likely the transcript encoding the 695-amino acid form of this protein, was elevated in pyramidal and granule cells in the hippocampus of aged rats exhibiting poorer spatial learning. In immunoblots of hippocampal protein extracts, however, the level of beta APP-like immunoreactivity was depressed in the more impaired subjects. Similarly, the level in hippocampus of the mRNA for manganese-dependent superoxide dismutase (Mn-SOD), a marker of oxidative stress, was positively correlated with the degree of behavioral impairment, but immunoblotting revealed that Mn-SOD protein was depressed in the aged hippocampus compared with young. The mRNAs for the neuronal form of nitric oxide synthase and for the astrocyte marker glial fibrillary acidic protein (GFAP) were elevated in the hippocampus in correlation with the extent of learning impairment. In the striatum, the levels of mRNA and protein for several candidate genes, including GFAP, were elevated in parallel with the learning index, but these were age effects. Several hippocampal proteins were unchanged (GFAP) or depressed (beta APP and Mn-SOD) in level, despite elevations in corresponding mRNAs. In the aged cohort, hippocampal GFAP mRNA, Mn-SOD mRNA, and beta APP emerged as predictors of behavioral impairment, suggesting the involvement of these hippocampal systems in age-related cognitive impairment.

Articular muscle of the knee: a muscle seldom recognized on MR imaging

OBJECTIVE

We studied the MR imaging characteristics of the articular muscle of the knee, an important but seldom recognized structure of the distal thigh and knee.

SUBJECTS AND METHODS

We used a 1.5-T system to prospectively evaluate the articular muscle of the knee in five healthy volunteers (10 knees); then we retrospectively studied the knee examinations of 24 patients (30 knees). One reader made duplicate readings to prospectively assess the sagittal proton density-weighted and axial T1-weighted images of the healthy volunteers. Three independent readers retrospectively evaluated the sagittal proton density-weighted images of the 24 patients.

RESULTS

The articular muscle of the knee was identified in 100% of prospective studies (10/10) and in 83% of retrospective studies (25/30). For the prospective study group, measurements (mean +/- SEM) were as follows: number of bundles, 2.4 +/- 0.68 (range, 1-4); length of uppermost bundle, 47.2 +/- 4.06 mm; width of origin, 8.6 +/- 0.79 mm; angle of origin, 11.4 degree +/- 1.29 degree; and cross-sectional bundle width, 19.8 +/- 2.05 mm2.

CONCLUSION

The articular muscle of the knee can usually be identified by MR imaging as an independent entity, separate from the great (vastus) muscle group.

Discovery of a brain promoter from the human transferrin gene and its utilization for development of transgenic mice that express human apolipoprotein E alleles

Transgenic mice carrying heterologous genes directed by a 670-bp segment of the regulatory sequence from the human transferrin (TF) gene demonstrated high expression in brain. Mice carrying the chimeric 0.67kbTF-CAT gene expressed TF-CAT in neurons and glial cells of the nucleus basalis, the cerebrum, corpus callosum, cerebellum, and hippocampus. In brains from two independent TF-CAT transgenic founder lines, copy number of TF-CAT mRNA exceeded the number of mRNA transcripts encoding either mouse endogenous transferrin or mouse endogenous amyloid precursor protein. In two transgenic founder lines, the chloramphenicol acetyltransferase (CAT) protein synthesized from the TF-CAT mRNA was estimated to be 0.10-0.15% of the total soluble proteins of the brain. High expression observed in brain indicates that the 0.67kbTF promoter is a promising director of brain expression of heterologous genes. Therefore, the promoter has been used to express the three common human apolipoprotein E (apoE) alleles in transgenic mouse brains. The apoE alleles have been implicated in the expression of Alzheimer disease, and the human apoE isoforms are reported to interact with different affinities to the brain beta-amyloid and tau protein in vitro. Results of this study demonstrate high expression and production of human apoE proteins in transgenic mouse brains. The model may be used to characterize the interaction of human apoE isoforms with other brain proteins and provide information helpful in designing therapeutic strategies for Alzheimer disease.

Prevalence of Bartonella henselae antibodies in pet cats throughout regions of North America

Cat exposure has been directly associated with the development of human Bartonella henselae infections, resulting in cat-scratch disease, bacillary angiomatosis, or bacteremia. The prevalence of serum antibody titers to B. henselae was determined for selected pet cats from 33 geographic locations throughout the United States and several areas in western Canada. Seroprevalences paralleled increasing climatic warmth (P < .02) and annual precipitation (P < .03). These warm, humid areas with the highest seroprevalence would also have the highest number of potential arthropod vectors. The southeastern United States, Hawaii, coastal California, the Pacific Northwest, and the south central plains had the highest average prevalences (54.6%, 47.4%, 40.0%, 34.3%, and 36.7%, respectively). Alaska, the Rocky Mountain-Great Plains region, and the Midwest had low average prevalences (5.0%, 3.7%, and 6.7%, respectively). Overall, 27.9% (175/628) of the cats tested were seropositive. The seroprevalence of B. henselae in cats varies throughout the United States and appears to be influenced by climate.

The Effect of Magmatic Activity on Hydrothermal Venting Along the Superfast-Spreading East Pacific Rise

A survey of hydrothermal activity along the superfast-spreading (approximately 150 millimeters per year) East Pacific Rise shows that hydrothermal plumes overlay approximately 60 percent of the ridge crest between 13 degrees 50' and 18 degrees 40'S, a plume abundance nearly twice that known from any other rige portion of comparable length. Plumes were most abundant where the axial cross section is inflated and an axial magma chamber is present. Plumes with high ratios of volatile ((3)He, CH(4), and H(2)S) to nonvolatile (Mn and Fe) species marked where hydrothermal circulation has been perturbed by recent magmatic activity. The high proportion of volatile-rich plumes observed implies that such episodes are more frequent here than on slower spreading ridges.

Electrical activation during ventricular fibrillation in the subacute and chronic phases of healing canine myocardial infarction

BACKGROUND

Little information is available regarding the effects of myocardial infarction on the characteristics of ventricular fibrillation (VF). Epicardial activation during VF can be characterized by the cycle length and by the characteristics of activation wave fronts.

METHODS AND RESULTS

VF was induced by programmed stimulation in 6 dogs with subacute healing (1 week) myocardial infarction (MI), 5 dogs with chronic (8 week) healing MI, and 6 dogs without MI. Using a plaque electrode array with a 2.5-mm interelectrode distance, 112 electrograms were recorded and 91 vector loops were created for each cycle of VF from either the anterior (infarcted) or lateral (noninfarcted) wall. Direction of maximum epicardial activation was determined at each site for the first 10 cycles of VF (early) and for 10 cycles after 5 seconds of VF (late). Wave front size was determined based on a similarity in epicardial activation directions within a given area and by a statistical analysis that determined the degree of spatial linking at varying distances over the recording plaque. VF cycle length was defined as the mean interval of 10 consecutive local activation times. Differences among groups and differences between the anterior and posterolateral walls were determined by ANOVA. The mean wave front area was significantly larger in the presence of subacute MI (97 +/- 4 mm2, early; 78 +/- 3 mm2, late) or chronic MI (94 +/- 5 mm2, early; 78 +/- 5 mm2, late) than in noninfarcted animals (73 +/- 5 mm2, early; 61 +/- 3 mm2, late). The degree of linking of epicardial activation directions was similar in the three groups at distances of 2.5 and 5.0 mm but was lower at a distance of 7.5 mm among animals without infarction, confirming a smaller wave front size and suggesting less organization of activation. VF cycle length was significantly longer in the presence of infarction (98 +/- 5 ms, normal control animals; 121 +/- 13 ms, subacute MI; 127 +/- 13 ms, chronic MI). VF cycle length was significantly longer over the anterior than the lateral wall in the presence of subacute MI (131 +/- 8 ms, anterior; 109 +/- 5 ms, lateral) or chronic MI (136 +/- 9 ms, anterior; 119 +/- 6 ms, lateral) but not in noninfarcted animals (99 +/- ms, anterior; 97 +/- 5 ms, lateral). The prolongation of VF cycle length among animals with infarction was associated with slower estimated conduction velocities during VF.

CONCLUSIONS

During VF, in animals with subacute or chronic healing MI, (1) the size of activation wave fronts is larger, (2) the cycle length of VF is longer, (3) the conduction velocities are slower, and (4) the degree of organization is greater than in control animals. Thus, the characteristics of VF throughout the heart are altered by the presence of regional myocardial infarction. The implications of these findings for the initiation and maintenance of VF in the presence of different underlying myocardial substrates require further study.

In vivo assessment of nonlinear myocardial deformation using finite element analysis and three-dimensional echocardiographic reconstruction

In vitro data have shown that the myocardium exhibits nonlinear passive stress-strain relationship and a non-linear pressure-volume relationship. A finite element (FE) analysis and optimization algorithm was used on three-dimensional reconstructed left ventricular (LV) geometry using echocardiographic images, along with hemodynamic measurements, in seven closed-chest dogs to show a nonlinear stress-strain relationship in vivo. Our analysis included the computation of Poisson's ratio from the measured volumetric strain of the myocardium and a simulated pericardial pressure load ("equivalent pericardial pressure") applied to the epicardial surface of the reconstructed LV. LV geometry was reconstructed in three or four incremental time steps in diastasis and the myocardium was assumed to be homogeneous, isotropic, and linearly elastic during these short intervals in this initial study. Simultaneous LV chamber pressure and equivalent pericardial pressure were incorporated into the algorithm to predict actual LV expansion. Computations were performed iteratively at each interval to compute the optimized elastic modulus. By performing the FE analysis and optimization at each interval (a step-wise linear analysis approach), a linear relationship between the myocardial elastic modulus and LV chamber pressure was derived (r = .87 to .98). Such a linear relationship is equivalent to an exponential myocardial stress-strain relationship in vivo. Detailed measurement of nonhomogeneous regional deformation are becoming possible with the advent of sophisticated imaging techniques. The methodology described in this study, with appropriate modifications in the FE analysis and optimization algorithms, can be applied to assess the complex three-dimensional pressure-deformation characteristics in vivo.

Nuclear scanning with technetium-99m-sestamibi to evaluate ischemia in muscle flaps for cardiomyoplasty

Mobilization of the latissimus dorsi muscle from the chest wall for cardiomyoplasty interrupts part of its blood supply. The time required for adequate collaterals to develop from the thoracodorsal artery is unknown. In four dogs, the latissimus dorsi muscle was mobilized as for cardiomyoplasty and stimulating electrodes were implanted. The muscle was replaced on the chest wall over a sheet of Gore-Tex (W. L. Gore & Associates, Inc. Flagstaff, AZ) membrane to block growth of collateral vessels from the chest wall. The opposite latissimus dorsi muscle served as the control. After a delay of 2 weeks the latissimus dorsi was burst stimulated at a rate of 80 per min with two 100 msec bursts at 85 Hz and 25 Hz for 30 min. Technetium-99m-sestamibi scans were then done to detect ischemia. Serial studies were done during the next several weeks. Images at 4 weeks demonstrated maximum uptake in the mobilized muscle, which did not subsequently improve. The authors conclude that the mobilized latissimus dorsi muscle can be imaged with technetium-99m-sestamibi and evidence of ischemia resolves at 4 weeks. These findings suggest that collateral flow is adequate as early as 4 weeks after mobilization of the latissimus dorsi muscle for cardiomyoplasty.

Detection of pooled secretions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients

OBJECTIVE

Mechanical ventilation is thought to increase the risk of nosocomial pneumonia by permitting leakage of bacteria-laden gastro-oropharyngeal secretions into the upper airways. The goal of this study was (a) to validate radiographic signs of pooled secretions above endotracheal-tube cuffs (supracuff liquid) in an animal model and (b) to determine whether suctionable pooled supracuff liquid can be identified on bedside radiographs of intubated patients.

MATERIALS AND METHODS

Diagnostic criteria for supracuff liquid were initially validated by three radiologists interpreting 162 randomized radiographs made in an intubated sheep cadaver. The primary criteria included (a) replacement of the normal supracuff lucency with liquid opacity and (b) the formation of a sharp interface between the lucency of the upper edge of the cuff below and the liquid above. Graded infusions of 0, 3, 8, 13, and 23 ml of saline were made in triplicate into the space above the cuff, and radiographs were evaluated for the presence or absence of saline. The validated diagnostic criteria were used by two radiologists to estimate the frequency with which pooled liquid was seen on portable chest radiographs of 47 patients undergoing elective short-term postanesthetic mechanical ventilation.

RESULTS

In the sheep-cadaver model, the diagnostic criteria for supracuff liquid allowed successful differentiation between no liquid, a small amount of liquid (3-8 ml), and a large amount of liquid (13-23 ml; c2, p < .0001). In a clinical study, radiographic signs of supracuff liquid were identified in 57% of 47 patients. In a small subset of patients (n = 18), the estimated liquid volume (mean +/- SEM) was calculated to be 7.8 +/- 1.1 ml (range = 2.1-18.4 ml).

CONCLUSIONS

Radiography is a sensitive means of identifying small volumes of supracuff liquid above the inflated cuffs of endotracheal tubes. Potentially contaminating liquid pooled above the cuff of an endotracheal tube can be identified in about half of patients undergoing short-term mechanical ventilation. Our results suggest the suction of the supracuff space may be a reasonable prophylactic maneuver against nosocomial pneumonia. A much larger study is suggested to investigate the actual relation between pooled supracuff liquid and the development of nosocomial pneumonia.

Methodological challenges and innovations in patient outcomes research

Between 1989 and 1992, the Agency for Health Care Policy and Research (AHCPR) awarded funding to 14 special projects known as Patient Outcomes Research Teams (PORTs). These large, complex projects form the centerpiece of the first generation of research under the Medical Treatment Effectiveness Program. In carrying out their individual 5-year research plans, and through collaborative work of six Inter-PORT Work Groups, PORTs have contributed to methodological advances related to their specific clinical focus and to outcomes research in general. Each of the PORTs has followed a standard research model, involving the application of: systematic literature review, measurement of outcomes, analysis of cost and claims data, decision analysis, and strategies for disseminating findings. This article reports what has been learned by individual PORTs, and by AHCPR, regarding the usefulness of each of these methodologies, both for the ongoing projects and for the next generation of effectiveness research. Example from individual PORTs and work groups illustrate some of the methodological gains that have been made in effectiveness research and provide a glimpse of the work that remains to be done.

The national medical effectiveness research initiative. The search for what really works in treating common clinical conditions

In 1989, Congress established the Agency for Health Care Policy and Research within the U.S. Public Health Service and gave it the lead in a national effort to produce reliable evidence of which medical treatments are effective and which are not. The research program addresses the effectiveness of different available strategies for diagnosis, prevention, treatment, and management of common conditions, including diabetes, and emphasizes outcomes that matter to patients. The modest size of this program and the eagerness for its results have led to the development and use of innovative research methods. Illustrations of these methods and early findings are provided.

Doppler catheter tip localization using color enhancement

The objective of this research was to determine if the ultrasound emissions of the Doppler catheter can be used to locate its position in 3 dimensions by conventional echocardiography. A Doppler catheter has previously been shown to permit nonfluoroscopic retrograde catheterization of the aortic root and left ventricular chamber by using velocity waveform polarity for directional guidance. A significant difficulty in providing ultrasound catheter guidance, however, has been the inability to recognize the Doppler catheter tip, because each point at which a flexible catheter crosses the image plane can be misinterpreted as the catheter tip. Initial in vitro water bath trials were performed using the Doppler catheter attached to a standard velocimeter. Using a 5 MHz imaging transducer and color Doppler methods, the presence or absence of a banded color pattern which could demarcate the Doppler catheter tip was recorded at various angles in and out of the scanning plane. Using Doppler retrograde guidance and transesophageal echocardiography, color Doppler banded patterns, which could identify the Doppler catheter tip, were investigated in the dog aorta. In order to understand the physical mechanisms involved, a series of water bath trials were then conducted using the Doppler catheter attached to a velocimeter which was synchronized to the echo machine. Initial nonsynchronized water bath trials revealed distinct banded color patterns demarcating the Doppler catheter tip when it pointed in any direction within the beam width, except for a 40 degrees blind cone directly away from the imaging transducer.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute electrical stimulation increases extramyocardial collateral blood flow after a cardiomyoplasty

We hypothesized that acute electrical stimulation of a latissimus dorsi cardiomyoplasty would augment the collateral blood flow delivered by the skeletal muscle to the heart. This hypothesis was tested in an animal model (13 goats) of coronary artery disease. Six weeks after a cardiomyoplasty was performed, myocardial collateral blood flow derived from the latissimus dorsi muscle was measured with colored microspheres when the muscle was at rest and during electrical stimulation of the thoracodorsal nerve at 1.25 Hz. The area at risk for ischemia averaged 13.37 +/- 2.08 g (mean +/- standard error), or 18.4% of left ventricular mass (n = 13). At rest, significant skeletal muscle-derived collaterals developed in 9 animals, and formed predominantly to chronic ischemic myocardium (mean +/- standard error, 0.07 +/- 0.02 mL.g-1 x min-1; n = 9), rather than infarct (0.03 +/- 0.02 mL.g-1 x min-1; n = 5), or normal myocardium (0.0005 +/- 0.0001 mL.g-1 x min-1; n = 9). Stimulation increased skeletal muscle-derived collateral blood flow to chronic ischemic areas to 0.38 +/- 0.09 mL.g-1 x min-1 (n = 9) (p < 0.05). During stimulation, the collateral flow was greater in the epicardium (0.46 +/- 0.11 mL.g-1 x min-1) than in endocardium (0.14 +/- 0.09 mL.g-1.min-1) (p < 0.05). This study demonstrates that electrical stimulation of a latissimus dorsi cardiomyoplasty increases extramyocardial collateral blood flow to chronic ischemic myocardium.

Computer-assisted coregistration of multislice SPECT and MR brain images by fixed external fiducials

We have developed and validated in a phantom a method of computer-assisted coregistration using multislice SPECT and MR images. Reusable fiducial markers were fabricated from nylon-based plastic and consist of two parts: a base that remains fixed to the skin with adhesive between scans and a removable, spherical cavity insert that can be filled with contrast agents appropriate for multiple imaging modalities. Markers external and internal to a three-dimensional brain phantom provided a means of quantifying the method's accuracy. A computer algorithm was used to derive transformation matrices for image sets by minimizing the root mean squared deviations obtained for multiple permutations (n = 10) of increasing numbers (range 3-11) of external SPECT/MRI point pairs. As defined by the average +/- SEM mean residual deviations of noncoregistered internal fiducials, the minimal accuracy was 2.4 +/- 0.3 mm (no marker > 3.6 mm) for three coregistration points and did not improve beyond seven to eight fiducials (2.2 +/- 0.1 mm; no marker > 3.2 mm). The method's true accuracy is likely to be better than estimates of minimal accuracy, however, since such measures reflect surmountable random errors in fiducial location. With use of identical MRI (or SPECT) data sets, measures of intraoperator (0.5 +/- 0.1 and 0.5 +/- 0.1 mm, respectively) and interoperator (0.5 +/- 0.3 and 0.8 +/- 0.1 mm) reliability were also obtained, establishing the method as highly reproducible and objective. Preliminary results in a human subject suggest its feasibility for clinical studies.

Application of finite-element analysis with optimisation to assess the in vivo non-linear myocardial material properties using echocardiographic imaging

An application of finite-element analysis with an optimisation technique to assess the myocardial material properties in diastasis in vivo is described. Using the data collected from an animal model, the three-dimensional geometry of the left ventricular chamber, at several times in diastole, was reconstructed. From the measurement of the ventricular chamber pressure during image acquisition, finite-element analysis was performed to predict the expansion during diastasis. Initially, by restricting the motion of the epicardial nodes and computing the reaction forces, an 'equivalent pericardial pressure' was determined and applied in subsequent analysis. The duration of diastasis was divided into three or four intervals and the analysis was performed at each interval to assess the material properties of the myocardium. Using such a step-wise linear approach, the non-linear material properties of the myocardium during passive expansion was determined. Our results demonstrated that the computed 'equivalent pericardial pressure' increased with and was smaller than the corresponding left ventricular chamber pressure. The passive myocardium exhibited a linear tangent modulus against chamber pressure relationship which is equivalent to an exponential stress/strain relationship, similar to those suggested by in vitro studies.

Optimal pleurodesis: a comparison study

With the resurgence of thoracoscopy, there is renewed interest in less invasive methods of pleurodesis. We wished to compare in an animal model a variety of methods suggested in reports. The purpose of the study was to rank the effectiveness of each procedure against the standard mechanical pleurodesis. Twenty-five mongrel dogs (weight, 25 to 35 kg) underwent bilateral thoracotomy. Each animal was randomly assigned to receive two of the following methods of pleurodesis: tetracycline, talc, mechanical abrasion, neodymium: yttrium-aluminum garnet (Nd:YAG) laser (Hereus Inc, E. Rutherford, NJ) photocoagulation, and argon beam coagulator (ABC) (Beacon Lab, Bloomfield, CO) electrocoagulation of the parietal pleura. At evaluation at 30 +/- 2 days, the efficacy of pleurodesis was graded on a scale of 0 to 4, with 0 representing a complete absence of pleural symphysis and 4 the adhesion of more than one lobe to both the chest wall and mediastinum. Mean grade and standard deviation of each method were: talc, 3.0 +/- 0.67; mechanical, 3.0 +/- 0.82; tetracycline, 2.3 +/- 1.4; ABC, 1.5 +/- 0.97; and Nd:YAG laser, 0.7 +/- 0.95. Both the talc and mechanical methods were superior to either the Nd:YAG laser or the ABC (p < 0.01). In this study, neither the Nd:YAG laser nor the ABC proved efficacious in producing pleurodesis. Talc poudrage is the only method of pleural symphysis comparable with mechanical abrasion.

Chest "gestalt" and detectability of lung lesions

Image perception in chest radiography is thought to occur on two levels, (a) a fast global response based on learned templates ("gestalt") and, (b) a slower systematic scan process. The relative importance of "gestalt" on the detection of nodular lung cancers was studied by disturbing the "gestalt" through rotation of the radiograph but not actually diminishing the image content available for viewing. Sixty chest radiographs (20 normals, 21 with subtle lung cancers, 19 with obvious lung cancers) were presented to three readers in normal and abnormal (rotated randomly in 90 degree increments) orientation for varying durations (0.25 s, 1 s, 4 s and unlimited viewing time). The results indicate that the detectability of obvious and subtle lung lesions was degraded by the disturbed "gestalt" for both short and long viewing times. The readers did not significantly increase their unlimited viewing time when faced with rotated images (4.4 +/- 3.4 s) as opposed to non-rotated images (4.0 +/- 3.2 s). We conclude that the detection of lung lesions relies heavily on the chest "gestalt" and that systematic scanning cannot fully compensate for an impaired global response due to a disturbed "gestalt."