Trial of heparin in viper bites

AIMS OF THE STUDY

Viper bites produce hematotoxicity and coagulopathy which may be either true disseminated intravascular coagulation (DIC) or DIC-like syndrome. Role of heparin is studied in the present study of viper bite cases as use of heparin provides a rational therapy for defibrination caused by viper envenomation.

METHODOLOGY

One hundred and twenty two patients with viper bite and incoagulable blood were randomised into test group and control group. Test group received heparin in addition to antisnake venom (ASV). Efficacy was assessed by monitoring bleeding time (BT), clotting time (CT), prothrombin time (PT), platelets, fibrinogen, blood urea (BU), serum creatinine, development of complications and overall outcome.

RESULTS

Heparin group showed favourable outcome in all parameters studied. But many of them were not statistically significant.

CONCLUSION

Heparin seems to be having a beneficial role which needs to be confirmed by larger trials and longer duration of heparin administration.

The effect of endocardial defibrillator shocks on basic atrial electrophysiology in man. Is post cardioversion atrial electrical 'remodelling' artefact?

AIMS

To determine the effect of an endocardial DC shock on the basic electrophysiology of the human atrium if delivered in sinus rhythm.

METHODS AND RESULTS

A 5J endocardial R wave synchronized DC shock was delivered in 10 patients in stable sinus rhythm during ICD implantation for ventricular arrhythmias. There was no prior history of atrial fibrillation. Monophasic action potential duration (APD) and atrial effective refractory periods (AERP) were evaluated before, 1 min post DC shock, and 15 min post shock. These parameters were assessed at basic cycle lengths and at atrial paced cycle lengths of 600 ms and 400 ms at two right atrial sites; mid lateral right atrial wall (MRLA) and the right atrial appendage (RAA). There were no significant differences in APD 90, AERP or atrial refractory dispersion at any site or drive cycle length before, immediately after or 15 min after shock delivery.

CONCLUSIONS

There are no significant changes in basic electrophysiological parameters following a DC shock delivered in sinus rhythm in patients with no prior history of atrial fibrillation. This suggests that atrial electrical remodelling occurs as a result of atrial fibrillation and is unrelated to shock artefact.

Evidence that nitric oxide production increases gamma-amino butyric acid permeability of blood-brain barrier

Blood-brain barrier permeability (BBB) to the inhibitory neurotransmitter gamma-amino butyric acid (GABA) was studied in rats following intraperitoneal (i.p) injections of GABA alone and in combination with L-Arginine (L-Arg). Administration of GABA (600 mg/kg body weight [b. wt.]) alone increased brain GABA concentration (33%, p < 0.01), when compared to untreated rats and administration of L-Arg (2000 mg/kg b. wt.) alone also increased GABA concentration (65%, p < 0.01) in the brain. Moreover, GABA + L-Arg treated brains showed a fourfold increase in GABA level (383.3%, p < 0.01) when compared to controls. Dose-dependent increase in nitric oxide production was observed 10 min after i.p injections of L-Arg (400, 800, 1000, and 2000 mg/kg b. wt.) and a peak nitric oxide (NO) production was observed at the dose level of 2000 mg/kg b. wt. On the other hand, administration of GABA failed to increase NO production in the brain. Rats pretreated (10 min) with a nonspecific nitric oxide synthase (NOS) inhibitor N(omega)-nitro-L-Arginine methyl ester (L-NAME, 50 mg/kg b. wt.) completely blocked the production of NO induced by L-Arg. In addition, L-NAME attenuated GABA entry into the brain after the administration of GABA alone or in combination with L-Arg. We conclude that high NO concentrations in the brain following L-Arg administration may increase the permeability of BBB to peripheral GABA.

Enantiomeric synthesis of D- and L-cyclopentenyl nucleosides and their antiviral activity against HIV and West Nile virus

Enantiomeric synthesis of D- and L-cyclopentenyl nucleosides and their antiviral activity against HIV and West Nile virus are described. The key intermediate (-)- and (+)-cyclopentenyl alcohols (7 and 15) were prepared from D-gamma-ribonolactone and D-ribose, respectively. Coupling of 7 with appropriately blocked purine and pyrimidine bases via the Mitsunobu reaction followed by deprotection afforded the target L-(+)-cyclopentenyl nucleosides (24-28, 31, 33, and 36). D-(-)-Cyclopentenyl nucleosides (1, 40, 43, and 52-56) were also prepared by a similar procedure for L-isomers from 15. The synthesized compounds were evaluated for their antiviral activity against two RNA viruses: HIV and West Nile virus. Among the synthesized D-(-)-nucleosides, adenine (1, neplanocin A), cytosine (55, CPE-C), and 5-fluorocytosine (56) analogues exhibited moderate to potent anti-HIV activity (EC(50) 0.1, 0.06, and 5.34 microM, respectively) with significant cytotoxicity in PBM, Vero, and CEM cells. Also, cytosine (55) and 5-fluorocytosine (56) analogues exhibited the most potent anti-West Nile virus activity (EC(50) 0.2-3.0 and 15-20 microM, respectively). Among L-(+)-nucleosides, only the cytosine (27) analogue exhibited weak anti-HIV activity (EC(50) 58.9 microM).

Calcium preventing locomotor behavioral and dental toxicities of fluoride by decreasing serum fluoride level in rats

Spontaneous motor activity, rota-rod performance (motor co-ordination), body weight gain, food intake, activities of total cholinesterase (blood) and acetylcholinesterase (brain), and dental structure were determined in adult female rats treated with a very high dose of sodium fluoride (500 ppm in drinking water) alone and in combination with calcium carbonate (50 mg/kg body weight by oral intubation) for 60 days. The concentration of fluoride and calcium were measured in the serum of these animals. Administration of sodium fluoride with drinking water produced both behavioural and dental toxicities and not lethality in the present study. A suppression of spontaneous motor activity, a shortening of rota-rod endurance time, a decreased body weight gain and food intake, a suppression of total cholinesterase and acetylcholinesterase activities and dental lesion were observed in test animals. Serum fluoride concentration was raised markedly and that of calcium was decreased in these animals. The effects of sodium fluoride were prevented significantly when animals received calcium carbonate along with sodium fluoride. Serum fluoride content was decreased and that of calcium was restored to control level in these animals. These results indicate that calcium prevents not only fluoride-induced hypocalcemia but also the locomotor behavioral and dental toxicities of fluoride by decreasing bioavailability of fluoride.

Pharmacological evidence for a role of gamma-aminobutyric acid A receptor mechanism in modulating nitric oxide synthase activity in rat brain

The role of gamma-aminobutyric acid (GABA) mechanism on the synthesis of nitric oxide (NO) has been investigated by measuring the activity of nitric oxide synthase (NOS) and the concentration of NO in rat brain 15 min after administration of anticonvulsant doses of diazepam (0.25 and 0.5 mg/kg) which is known to activate GABA A receptor for its anticonvulsant action. Diazepam enhanced both NOS activity and the concentration of NO in a dose-dependent manner. A reversal has been observed in animals treated with a convulsant dose of picrotoxin (5 mg/kg) which is known to produce convulsions by blocking GABA A receptor mechanism. These results suggest that a functional interaction occurs between GABA A receptor activity and NO synthesis in the brain.

Importance of rate control or rate regulation for improving exercise capacity and quality of life in patients with permanent atrial fibrillation and normal left ventricular function: a randomised controlled study

OBJECTIVE

To determine the importance of rhythm regulation or rate control in patients with permanent atrial fibrillation (AF) and normal left ventricular function.

PATIENTS AND INTERVENTIONS

Thirty six patients with a mixed fast and slow ventricular response rate to their AF were randomised to either His bundle ablation (HBA) and VVIR pacemaker (HBA group) or VVI pacemaker and atrioventricular modifying drugs (Med group). Outcomes assessed at one, three, six, and 12 months included exercise duration and quality of life.

RESULTS

Exercise duration significantly improved from baseline in both groups. There was no difference in outcome between the groups (Med +40% v HBA +20%, p = NS). The heart rate profile on exercise was similarly slowed in both groups compared to baseline. Quality of life significantly improved in both treatment arms for the modified Karolinska questionnaire (KQ) (Med +50% v HBA +50%, p = NS) and the Nottingham health profile (NHP) (Med +40% v HBA +20%, p = NS). However, for the individual symptom scores of each questionnaire more were improved in the Med group (KQ-Med 6 improved v HBA 4, NHP-Med 3 v HBA 1). Left ventricular function was equally preserved by both treatments during follow up.

CONCLUSION

In these patients control of ventricular response rate with either HBA + VVIR pacemaker or atrioventricular modifying drugs + VVI pacemaker will lead to a significant improvement in exercise duration and quality of life. Rhythm regulation by HBA did not confer additional benefit, suggesting rate control alone is necessary for the successful symptomatic treatment of these patients in permanent AF.

No incremental benefit of multisite atrial pacing compared with right atrial pacing in patients with drug refractory paroxysmal atrial fibrillation

OBJECTIVE

To evaluate the incremental antifibrillatory effect of multisite atrial pacing compared with right atrial pacing in patients with drug refractory paroxysmal atrial fibrillation paced for arrhythmia prevention alone.

METHODS

In 20 of these patients (mean (SD) age 64 (8) years; 14 female, six male), a single blinded randomised crossover study was performed to investigate the incremental benefit of one month of multisite atrial pacing compared with one month of right atrial pacing. Outcomes included the number of episodes of paroxysmal atrial fibrillation, their total duration obtained from pacemaker Holter memory, and quality of life using a cardiac specific questionnaire (the modified Karolinska questionnaire).

RESULTS

Comparing right atrial with multisite atrial pacing, there was no significant change in either the number of paroxysmal atrial fibrillation episodes (mean (SD): right atrial pacing 77 (98) episodes v multisite pacing 52 (78) episodes, NS) or their total duration (right atrial, 4.8 (5.4) days v multisite, 6.3 (9.8) days, NS). Quality of life scores compared with baseline status were equally improved by either pacing strategy (mean percentage improvement: right atrial, 38%, p = 0.003; multisite, 44%, p = 0.003). There was no significant difference in life scores comparing the two pacing modes.

CONCLUSIONS

Multisite atrial pacing has no incremental antiarrhythmic effect compared with right atrial pacing in patients paced for drug refractory paroxysmal atrial fibrillation. Quality of life is equally improved with either pacing strategy, with no differences between them.

Effect of systemically administered nitric oxide donor, sodium nitroprusside on picrotoxin-induced convulsions in rats

Nitric oxide (NO), the gaseous neurotransmitter has been reported to have an endogenous anticonvulsant property. This has prompted proposals to develop NO donors as anticonvulsant drugs. In the present study, the effect of NO donor, sodium nitroprusside (SNP) on picrotoxin (PCT)-induced convulsions was investigated. A convulsant dose of PCT (5 mg/kg) was administered 5, 10, 15 and 30 min after intraperitoneal injection of graded doses (0.7, 1.25 and 2.5 mg/kg) of SNP. SNP at doses 0.7 and 1.25 mg/kg increased dose dependently the severity of PCT-induced convulsions. But, pretreatment with the higher dose (2.5 mg/kg) of SNP was protective against PCT-induced convulsions. However, post treatment (5 and 10 min) with the same dose exacerbated convulsions and caused death of the animals. These results indicate that the vasodilator effect of SNP and an increased perfusion of PCT into brain may be responsible for the proconvulsant action of SNP. A decreased entry of PCT because of marked vasodilation and hypotension has been speculated for an inhibition of convulsions in animals pretreated with a higher dose of SNP. In conclusion, the results reveal the non-suitability of SNP to be developed as an anticonvulsant.

Randomized controlled study investigating the effect of biatrial pacing in prevention of atrial fibrillation after coronary artery bypass grafting

BACKGROUND

Atrial fibrillation (AF) is a common problem after CABG. Prevention with prophylactic drug therapy has had limited success, therefore alternative approaches are required. This study investigated the role of biatrial pacing compared with no pacing on AF incidence after isolated first-time CABG.

METHODS AND RESULTS

During surgery, temporary pacing leads were placed in the lateral wall of the right atrium and at the roof of the left atrium in Bachmann's bundle to allow bipolar pacing and sensing at each site. After surgery, all patients were connected to an external pacemaker (Chorum ELA) that also acted as a Holter monitor. Patients were consecutively randomized to either 4 days of biatrial pacing at a base rate of 80 bpm or to no pacing (control group, base rate 30 bpm). End points included an episode of AF lasting >1 hour on pacemaker Holter, clinically detected AF, intensive care unit (ICU) and hospital stay, and postoperative complications. One hundred thirty patients were randomized. Biatrial pacing significantly reduced both monitored (13.8% versus 38.5%, P:=0.001) and clinical (10.8% versus 33.8%, P:=0.002) episodes of AF. Median ICU (19 versus 24 hours, P:=NS) and mean hospital stay (7.7+/-6.9 versus 9.7+/-10, P:=NS) did not significantly change. The number of postoperative complications was lower in the biatrial group (13 versus 35, P:=0. 001).

CONCLUSIONS

Biatrial pacing after CABG significantly decreases the incidence of AF. This is associated with reduced postoperative complications and a trend toward reduced ICU and hospital stay.

Ablate and pace for drug refractory paroxysmal atrial fibrillation. Is ablation necessary?

BACKGROUND

Atrio-ventricular junctional ablation with pacemaker insertion has been shown to improve quality of life in patients with drug refractory paroxysmal atrial fibrillation. It is unknown whether this improvement is secondary to the ablation procedure or to the pacemaker mode utilised. To investigate this we reviewed our experience of implanting a dual chamber rate responsive pacemaker with mode switching (DDDR/MS) alone on quality of life in this patient group.

METHODS AND RESULTS

Over a 1-year period, 19 patients (mean age 62+/-9 years, 13 female) with drug refractory paroxysmal atrial fibrillation (mean duration of symptoms 8.7+/-7 years, failed 3.1+/-0.9 anti-arrhythmic drugs, amiodarone in 15) were recruited. Quality of life was assessed at baseline and after 1 month using a cardiac specific questionnaire, the modified Karolinska questionnaire. The mean score for all patients significantly improved by 39% at follow up (baseline 59+/-24, 1 month 36+/-24, P=0.001). Individually 15 patients (79%) had an improvement in their score, whilst for 13 patients (68%) their symptoms were sufficiently improved after pacing that ablation was not required. The benefit was maintained to a mean follow up of 12+/-5 months (score 31+/-20, P<0.001). Six patients remained symptomatic after pacing and requested further treatment. Benefit was unrelated to symptoms at baseline or the number and total duration of paroxysmal atrial fibrillation episodes recorded on pacemaker Holter.

CONCLUSIONS

Patients with drug refractory paroxysmal atrial fibrillation, DDDR/MS pacing alone can improve quality of life without concurrent atrio-ventricular junctional ablation in a significant proportion of patients.

Does atrial overdrive pacing prevent paroxysmal atrial fibrillation in paced patients?

The role of atrial overdrive pacing for the suppression of paroxysmal atrial fibrillation remains unclear. To investigate this we have performed a randomised study evaluating the role of an increased atrial base rate in suppressing this arrhythmia in patients implanted with a permanent pacemaker (Chorum ELA) for sick sinus syndrome with previous documented paroxysmal atrial fibrillation. Twenty-seven patients (mean age, 69; 15 female) were randomised to two 3-month single-blinded crossover periods of DDDR pacing. The pacemaker was set with a base rate of 60 bpm (normal) during one period and at 10 bpm (overdrive) above the average heart rate during the other, mean (S.D.) 75+/-7 beats/min (range, 70-96). The fallback algorithm of the pacemaker was activated to record the number and duration of paroxysmal atrial fibrillation episodes. During the overdrive period there was a significant increase in the total duration of atrial pacing (normal 60+/-26% vs. overdrive 72+/-28%, P<0.001). However there was no significant difference in the number of paroxysmal atrial fibrillation episodes (normal 43+/-109 vs. overdrive 43+/-106, P=ns), or their total duration (normal 42+/-108 h vs. overdrive 99+/-254 h, P=ns). In conclusion, atrial overdrive pacing, achieved by increasing the atrial base rate, has no incremental benefit in the suppression of paroxysmal atrial fibrillation when compared to rate responsive pacing with a base rate of 60 bpm.

Initial United Kingdom experience with the use of permanent, biventricular pacemakers: implantation procedure and technical considerations

AIMS

To describe the institution of a biventricular pacing programme with particular reference to the implantation procedure and new technological considerations.

METHODS AND RESULTS

Analysis of outcomes of a consecutive series of 54 patients undergoing attempted biventricular pacemaker implantation between February 1998 and April 1999. Successful implantation was achieved in 49 of the 54 patients (91%). Five patients required lead repositioning after initial successful implantation. Left ventricular lead pacing thresholds were found to be satisfactory and stable in the long term, with pacing thresholds of 1.3 V, 1.9 V and 1.6 V at implantation, 1 and 3 months, respectively. Left-sided lead function was not dependent on lead position within the tributaries of the coronary sinus. The implantation procedure was found to be safe, although one patient died during long-term follow-up.

CONCLUSION

With appropriate previous experience in complex and coronary sinus pacing and with access to up-to-date pacemaker and lead technology, a biventricular pacemaker implantation service can be instituted with good medium-term results.

A comparison between passive and active fixation leads in the coronary sinus for biatrial pacing: initial experience

AIMS

It has been reported that biatrial pacing can prevent the recurrence of atrial fibrillation. This technique requires a stable coronary sinus (CS) lead position for left atrial pacing. We report our experience of CS pacing with a specifically designed lead [Medtronic 2188 (n= 19)] and active fixation leads [Pacesetter Tendril (n=3), Medtronic Capsurefix (n=6)] in 21 patients with paroxysmal atrial fibrillation and a normal mean left atrial size of 39 mm (range 33-54 mm).

METHODS AND RESULTS

Using the Medtronic 2188 lead, successful initial CS canulation and lead positioning was achieved in all 19 patients. One patient developed subclavian vein thrombosis 3 months after initial implant. Eight patients (42%) experienced subsequent lead displacement (12 displacements in total). Of these, seven had their lead replaced with active fixation leads. In addition, two patients underwent active fixation lead implantation at first implant. CS canulation and lead positioning was successful in all nine patients. No patient suffered displacement of an active fixation lead. There were no complications in this group. Twelve of the 19 (66%) Medtronic 2188 leads were functioning at long-term follow-up (11 +/- 4 months) with a biatrial pacing threshold of 2.4 +/- 1 V. Eight of the nine (89%) active fixation leads were functioning at long-term follow-up (6 +/- 3 months) with a biatrial pacing threshold of 2.9 +/- 1.1 V. Using a combined approach 95% of patients had a functioning CS lead at long-term follow-up.

CONCLUSION

Active fixation leads can safely be used for left atrial pacing via the CS with good long-term pacing thresholds and stability.

Initial results with left ventricular pacemaker lead implantation using a preformed "peel-away" guiding sheath and "side-wire" left ventricular pacing lead

We report our preliminary experience with the use of preformed "peel-away" guiding sheaths and "side-wire" pacing leads for permanent biventricular pacemaker insertion in 13 patients with heart failure. Three of these patients were undergoing an upgrade of a preexistent VVIR pacing system after prior His ablation for medically refractory atrial fibrillation. Six of the patients had undergone attempted biventricular pacemaker insertion, but required left ventricular lead repositioning after total implantation failure or late displacement of the lead. The remaining patients were undergoing new system implantation. Target vessel cannulation was achieved in all patients. However, in one patient, diaphragmatic pacing throughout the target vessel length prevented successful implantation. All other implants were ultimately successful (92% success rate). We conclude that device implantation using a preformed sheath and side-wire pacing lead is feasible and may offer significant benefits over implantation with currently available technology.

Does the mechanism of action of biatrial pacing for atrial fibrillation involve changes in cardiac haemodynamics? Assessment by Doppler echocardiography and natriuretic peptide measurements

AIMS

The antifibrillatory mechanism of biatrial (BI) pacing has not been fully elucidated. We investigated the role of a haemodynamic mechanism in eight patients implanted with a BI pacemaker (Chorus RM) by comparing changes in mitral Doppler flow and atrial and B-type natriuretic peptide levels (ANP, BNP) with BI pacing compared with sinus rhythm and right atrial (RA) pacing.

METHODS AND RESULTS

Measurements were taken after 60 min in the supine position in each of two pairs of randomized pacing modes: (a) AAI40 beats x min(-1), (allows sinus rhythm mean rate 56 beats x min(-1), SR) vs AAI 40 beats x min(-1) with synchronized left atrial pacing (SRSync); (b) overdrive AAI RA pacing (89 beats x min(-1) (n = 6) or 70 beats x min(-1) (n = 2)) vs overdrive AAI BI pacing. Within each pair there was significant earlier activation of the left atrial Doppler signal in relation to the surface ECG P wave with BI pacing (SR 163 +/- 10 ms vs SRSync 144 +/- 21 ms (P = 0.02), and RA 232 +/- 14 ms vs BI 196 +/- 16 ms (P = 0.001)), and significant shortening of the P-R interval (SR 163 +/- 29 ms vs SRSync 148 +/- 20 (P = 0.007) and RA 261 +/- 27 ms vs BI 232 +/- 23 (P = 0.001)). The net observed effect was of no change in the atrioventricular timing sequence (delay of peak E or A to QRS/ mitral valve closure) and no change in other Doppler echo parameters. Levels of the cardiac peptides ANP and BNP were raised compared with healthy controls, but did not significantly change during the study.

CONCLUSION

Acute BI pacing shortens the P-R interval and causes earlier left atrial contraction in relation to the surface electrocardiogram P wave. It does not alter the atrioventricular timing cycle, any other Doppler measurements or change cardiac peptide levels. This suggests that BI pacing does not cause haemodynamic changes that could account for any antifibrillatory properties.

Preliminary results with the simultaneous use of implantable cardioverter defibrillators and permanent biventricular pacemakers: implications for device interaction and development

We report our preliminary experience with the combined use of implantable cardioverter defibrillators (ICD) and biventricular pacemakers in six patients with heart failure and malignant ventricular arrhythmia. Two patients underwent ICD implantation for malignant ventricular arrhythmia after previous biventricular pacemaker implantation. One patient underwent biventricular pacemaker insertion for NYHA Class III heart failure after previous ICD implantation. Two patients underwent single device implantation. In the sixth patient, a combined implantation failed due to an inability to obtain a satisfactory left ventricular pacemaker lead position. The potential for device interaction was explored during implantation. In two patients a potentially serious interaction was discovered. Subsequent alterations in device configuration and programming prevented these interactions with long-term use. No complication of combined device use has been demonstrated during a mean follow-up of 2 months (range 1-4 months). Satisfactory ICD and pacemaker function has also been demonstrated. We conclude that combined device implantation may be feasible with currently available pacing technology and that further prospective studies are required in this area.

A role of nitric oxide as an inhibitor of gamma-aminobutyric acid transaminase in rat brain

The present study has been aimed to investigate the effect of nitric oxide (NO) on the concentration of gamma-aminobutyric acid (GABA) in rat brain. The concentrations of GABA and glutamate and the activities of glutamic acid decarboxylase (GAD) and gamma-aminobutyric acid transaminase (GABA-T) were determined in groups of animals 5 and 30 min after intraperitoneal injection of a NO-increasing dose (1,000 mg/kg) of its precursor, L-arginine and a dose (50 mg/kg) of N-nitro-L-arginine methyl ester (L-NAME) that inhibits NO synthesis from L-arginine. L-arginine-induced elevation of NO concentration was accompanied by an increased concentration of GABA in the brain. GABA-T activity was inhibited in these animals. NO-decreasing action of L-NAME coincided with a reduction in the concentration of GABA and an enhancement of GABA-T activity. Both L-arginine and L-NAME did not alter the activity of GAD and the concentration of glutamate. An interpretation of these data suggests that NO has a GABA-T-inhibiting role in the brain.

[Simultaneous utilization of an implantable automatic defibrillator in a patient with previously implanted bi-ventricular pacemaker for end-stage heart failure]

We report a case of implantable cardioverter defibrillator (ICD) use after previous biventricular pacemaker insertion for end-stage heart failure. A 75-year-old man with inoperable three-vessel coronary artery disease, permanent atrial fibrillation and end-stage heart failure underwent bi-ventricular pacemaker insertion and His bundle ablation for symptomatic control. NYHA class decreased from class III to II after this procedure. Four months after implant the patient developed paroxysmal sustained, symptomatic ventricular tachycardia. ICD implantation was undertaken. No potentially serious ICD-pacemaker interaction was noted during subsequent follow-up. We conclude that ICD implantation is feasible after previous bi-ventricular pacemaker insertion, without the need to explant the bi-ventricular pacing device.

Effects of L-arginine on picrotoxin-induced increase in brain ammonia concentrations and convulsions in rats

The effect of L-arginine (840 mg/kg) pre- (30 min before challenge) and post-treatment (5 min after challenge) period was tested on picrotoxin-induced increase in ammonia concentrations in brain regions (cerebral cortex, brain stem and cerebellum) and the accompanying convulsive responses in adult male rats. The combined effect of L-arginine and diazepam was also tested against picrotoxin-induced convulsions. Picrotoxin-induced increase in ammonia was reverted partially by L-arginine pretreatment. However, L-arginine pretreatment did not show anticonvulsant effect independently or concurrently with diazepam. On the other hand, L-arginine post-treatment reverted ammonia to control level in all brain regions. A partial but significant inhibition of convulsion responses was found in these animals. The combined effect of diazepam and L-arginine post-treatment was much greater than that produced by these agents independently. These findings suggest that ammonia has a partial but significant participation in the convulsant action of picrotoxin. L-arginine has a potential to revert brain ammonia to control level in picrotoxin-treated animals and thereby it has produced a partial protection. The data further indicate that the duration of action of L-arginine is considerably short and has an additive anticonvulsant action with diazepam.

Evaluation of biatrial pacing, right atrial pacing, and no pacing in patients with drug refractory atrial fibrillation

It has been suggested biatrial pacing may prevent the recurrence of atrial fibrillation (AF). To further evaluate this hypothesis, we performed a randomized, single-blinded study in 19 patients with drug refractory AF. The study compared biatrial pacing with conventional right atrial (RA) pacing and a control period of inhibited pacing. The pacing modes utilized were DDD with a base rate of 70 beats/min for biatrial and RA pace (with and without biatrial resynchronization, respectively) and 40 beats/min for the control period. The duration of each pacing mode was 3 months. The number of AF episodes and their duration were obtained from pacemaker Holter memory (Chorus RM ELA Medical). Comparison of the control period (n = 11) with either pacing strategy showed a significant decrease in the total duration of AF (control 27 +/- 35 days, biatrial 8 +/- 15 days p = 0.02, RA 11 +/- 27 days p = 0.04). However, there was no effect on the number of AF episodes (control 79 +/- 108, biatrial 36 +/- 75 p = 0.32, RA 41 +/- 80 p = 0.11). The total percentage of atrial pacing also significantly increased when the control period (6 +/- 9%) was compared with both RA pace (62 +/- 33%, p = 0.008) and biatrial pace (63 +/- 31, p = 0.003). When biatrial pacing was compared with RA pace (n = 19), there was no significant difference in either the duration of AF (biatrial 16 +/- 26 days vs RA 19 +/- 31 days, p = 0.7) or the number of AF episodes (biatrial 56 +/- 91 vs RA 87 +/- 106, p = 0.34). In conclusion, pacing (either type) at a base rate of 70 beats/min has an antifibrillatory effect when compared with inhibited pacing at 40 beats/min. No additional benefit of biatrial pacing over right atrial pacing was demonstrated in this study.

Role of nitric oxide on GABA, glutamic acid, activities of GABA-T and GAD in rat brain cerebral cortex

The results of the present study clearly shows that a correlation exists between nitric oxide (NO) and gamma-aminobutyric acid transaminase (GABAT-T) activity as well as gamma-aminobutyric acid (GABA), glutamic acid and the activity of glutamic acid decarboxylase (GAD). Supporting of this 10 min after the administration of L-Arginine (L-Arg) increased GABA concentration and diminished the activity of GABA-T. There was no change in GAD activity and glutamic acid level. Administration of convulsion inducing agent Picrotoxin (PCT) decreased the NO concentration in the brain and enhanced the activity of GABA-T, and the fact that the NOS inhibitor (N(G)-nitro-L-Arg methyl ester (L-NAME) diminished the activity of NOS and increased the activity of GABA-T provide another support for the involvement of NO on GABA-T activity. The present study clearly showed that high concentrations of NO in the brain suppresses the activity of GABA-T.