Accuracy of peak treadmill exercise echocardiography to detect multivessel coronary artery disease: comparison with post-exercise echocardiography

AIMS

Although peak exercise echocardiography has been reported for both bicycle and treadmill exercise and has shown higher sensitivity than post-exercise imaging, little is known about its utility for identifying multivessel involvement. We sought to compare feasibility and accuracy of peak treadmill exercise echocardiography vs post-exercise echocardiography for identification of multivessel coronary artery disease and to assess its incremental value when combined with clinical and exercise test variables.

METHODS AND RESULTS

The study group included 335 patients (228 men; mean (+/- SD) age 60 +/- 11 years). Two hundred and seventy-nine patients were included on the basis of having had an exercise echocardiography and a coronary angiography within 4 months of the exercise test. To avoid bias to coronary angiography, a subgroup of 56 consecutive non-diabetic patients referred for exercise echocardiography with pretest probability of coronary artery disease <10% and had atypical chest pain or were asymptomatic were also included and considered as having no coronary artery disease. Multivessel coronary artery disease (> or = 50% diameter stenosis in >1 vessel) was confirmed in 170 patients, whereas 165 patients were considered to have one-vessel coronary artery disease or no coronary lesions. Positive exercise echocardiography was defined as ischaemia or necrosis in at least two coronary territories. Post-exercise images were acquired within 125 s after exercise (49 +/- 15). Mean heart rate (bpm) was 139 +/- 19 at peak vs 117 +/- 22 at post-exercise imaging (P<0.001). Interpretable peak and post-exercise images were obtained for all patients. Sensitivity for predicting multivessel disease was higher with peak than with post-exercise imaging (79 vs 55%, P<0.001), with lower specificity (79 vs 88%, P<0.05). Predictive positive value was similar (80 vs 83%). Negative predictive value was again higher with peak imaging (78 vs 66%, P<0.01). Total accuracy was not different (79 vs 72%). A stepwise logistic regression analysis identified peak exercise echocardiography positivity for multivessel coronary artery disease as the strongest independent predictor of multivessel disease (odds ratio (OR): 7.36); also significant were male gender (OR: 4.22), diabetes mellitus (OR: 4.28), previous myocardial infarction (OR: 3.12) and increment of product heart rate x blood pressure (OR: 1.00).

CONCLUSIONS

Peak treadmill exercise echocardiography is technically feasible and has higher sensitivity and negative predictive value for predicting multivessel disease than post-treadmill exercise echocardiography. This method adds independent and incremental values to clinical and exercise variables for the diagnosis of multivessel coronary artery disease. Therefore, in the clinical setting, peak exercise echocardiography should be performed to diagnose multivessel coronary artery disease.

Epidermal growth factor-based cancer vaccine for non-small-cell lung cancer therapy

BACKGROUND

The role that growth factors and their receptors play in human cancer growth and progression makes them interesting targets for novel treatment modalities. Our approach consisted of active immunotherapy with the epidermal growth factor (EGF). Two pilot clinical trials were conducted to examine the safety and immunogenicity of a five-dose immunization protocol and to compare different adjuvants and treatment designs.

PATIENTS AND METHODS

Forty patients with advanced non-small-cell lung cancer were enrolled in both trials. They were randomized to be treated with aluminum hydroxide or montanide ISA 51 as adjuvants in the EGF vaccine preparation. The use of cyclophosphamide prevaccination treatment was evaluated in the second trial.

RESULTS

Pooled data from both trials showed that the use of montanide as adjuvant increased the percentage of good antibody responders (GAR). Cyclophosphamide prevaccination treatment did not provoke improvements in antibody response. GAR had a significant increase in survival as compared with poor antibody responders. Response duration was also related to a significant improvement in survival rates.

CONCLUSIONS

Vaccination with five doses of EGF vaccine is safe and immunogenic. Montanide ISA 51 increased the percentage of GAR. There is a direct relationship between anti-EGF antibody titers and immune response duration with survival time.

The neonate has a temporary conductive hearing loss due to fluid in the middle ear

Postnatal functional changes in the activity of the ear and auditory pathway in neonatal guinea pigs [from day of birth (postnatal day, PND = 0), PNDs 1-4, 7 and then weekly up to 7 weeks] were studied as a model of maturation of hearing in human neonates. On the day of birth there were signs of a conductive hearing loss: negative middle ear pressure, auditory nerve brainstem evoked response (ABR) threshold elevation, ABR wave 1 latency prolongation and low amplitude otoacoustic emissions. The conductive hearing loss is probably a result of the (amniotic) fluid found in the neonatal middle-ear cavity. Over the next PNDs, this conductive hearing loss was resolved. In order to confirm this neonatal conductive hearing loss and its resolution, saline was instilled into the middle ear of guinea pigs. This induced signs of a conductive hearing loss similar to those seen in the neonatal guinea pigs which disappeared with clearance of this fluid. Therefore it may be concluded that most of the changes in auditory function seen over the first PNDs are due to absorption of amniotic fluid from the middle-ear cavity.

Sequential treatment with bolus and continuous infusion of recombinant factor VIIa for hip arthroplasty in a patient with haemophilia A and inhibitor

We describe a total arthroplasty of the hip in a 40-year-old male patient with haemophilia A and a high-titre inhibitor to factor VIII, treated with rFVIIa. The patient received sequential therapy first as bolus in the early postoperative phase in order to obtain appropriate haemostasis and then as continuous infusion with lower doses to avoid frequent episodes of bleeding without a higher consumption of product. After an initial dose of 150 micro g kg-1 for the first five days after surgery, we used bolus doses of 120-90 micro g kg-1 every 2.5-3 h, achieving plasma FVII:C levels above 40 U mL-1. We then continued with continuous infusion at decreasing doses 15-7 micro g kg-1 h-1 for 12 days (FVII:C 19-7 U mL-1). There were no bleeding complications nor signs of clotting activity. The rehabilitation programme was continued without prophylactic treatment. The total consumption of rFVIIa was 6.3 mg kg-1, implying a saving of at least 30% of the product with respect to previous publications.

In vivo visualization of pyloric mucosal hypertrophy in infants with hypertrophic pyloric stenosis: is there an etiologic role?

OBJECTIVE

Infantile hypertrophic pyloric stenosis (IHPS) is a common condition which presents in infants at 2-12 weeks of postnatal life, and whose cause remains obscure. Multiple associated abnormalities have been recognized within the external hypertrophied pyloric muscle layer, but the internal component of the pyloric mucosa has received scant attention in the literature to date. Our purpose in this study was to show that pyloric mucosal redundancy is a constant finding in infants with IHPS, to discuss its possible cause, and to explore the hypothesis of a relationship between pyloric mucosal redundancy and the development of IHPS.

MATERIALS AND METHODS

We identified 102 consecutive infants with surgically confirmed IHPS and determined the thickness of the pyloric mucosa compared with the thickness of the surrounding hypertrophied muscle. Fifty-one infants who did not have pyloric stenosis served as controls.

RESULTS

Mean mucosal thickness in patients with IHPS approximated mean muscle thickness, with a ratio of 0.89. In infants with IHPS, the pyloric mucosa constitutes approximately one third of the cross-sectional diameter of the pyloric mass and fills and obstructs the pyloric canal.

CONCLUSION

Mucosal redundancy is a constant associated finding in IHPS. Although the origin of the redundancy and a cause-and-effect relationship are difficult to establish, our findings support the hypothesis that hypergastrinemia may be implicated in the pathogenesis of IHPS, and suggest that mucosal thickening could be implicated as one of the initiating factors in its development.

Teleophthalmology link between a primary health care centre and a reference hospital

We have evaluated a teleophthalmology service linking a primary health care centre and an eye clinic at a reference hospital. General practitioners at the primary care centre serving a population of 15,000 and ophthalmologists at the reference hospital participated in this study. Eye fundus digital images were taken from 278 eye fundi of 139 consecutive patients with clinical conditions that could potentially produce fundus alterations. Fundus images were obtained with a non-mydriatic fundus camera (Canon CR6-45M) and were electronically sent reference hospital where ophthalmologist inspected the images and returned the diagnosis. In 18 patients (13%) the images did not have good enough quality to exclude eye fundus lesions. In 24 patients (17%) clear eye fundus alterations were found in at least one eye. In 14 patients (10%) there were image features suggesting retinal alterations that could not be confirmed by image inspection. Media opacity (13 eyes, 5%, seven patients, 5%) was the most common cause of poor image quality. The most difficult assessment was the evaluation of optic nerve head cupping. Retinal oedema was not observable in the digital images. In our experience teleopthalmology services seem to be an effective alternative for eye fundus diagnosis and patient follow-up.

Psammomys obesus and the albino rat--two different models of nutritional insulin resistance, representing two different types of human populations

Animal models for insulin resistance and type 2 diabetes are required for the study of the mechanism of these phenomena and for a better understanding of diabetes complications in human populations. Type 2 diabetes is a syndrome that affects 5-10% of the adult population. Hyperinsulinaemia, hypertriglyceridaemia, decreased high-density lipoprotein (HDL) cholesterol levels, obesity and hypertension, all form a cluster of risk factors that increase the risk of coronary artery disease, and are known as insulin resistance syndrome or syndrome X. The gerbil, Psammomys obesus is characterized by primary insulin resistance and is a well-defined model for dietary induced type 2 diabetes. Weanling Psammomys and Albino rats were held individually for several weeks on high energy (HE) and low energy (LE) diets in order to determine the development of metabolic changes leading to diabetes. Feeding Psammomys on HE diet resulted in hyperglycaemia (303 +/- 40 mg/dl), hyperinsulinaemia (194 +/- 31 microU/ml) and a moderate elevation in body weight, obesity and plasma triglycerides. Albino rats on HE diet demonstrated an elevation in plasma insulin (30 +/- 4 microU/ml), hypertriglyceridaemia (170 +/- 11 mg/dl), an elevation in body weight and obesity, but maintained normoglycaemia (98 +/- 6 mg/dl). Psammomys represent a model that is similar to human populations, with primary insulin resistance expressed in young age, which leads to a high percentage of adult type 2 diabetes. Examples for such populations are the Pima Indians, Australian Aborigines and many other Third World populations. The results indicate that the metabolism of Psammomys is well adapted towards life in a low energy environment, where Psammomys takes advantage of its capacity for a constant accumulation of adipose tissue that will serve for maintenance and breeding in periods of scarcity. This metabolism known as 'thrifty metabolism', is compromised at a high nutrient intake.

Heterogeneous nuclear ribonucleoprotein complexes from Xenopus laevis oocytes and somatic cells

HnRNP proteins have been implicated in most stages of cellular mRNA metabolism, including processing, nucleocytoplasmic transport, stability, and localization. Several hnRNP proteins are also known to participate in key early developmental decisions. In order to facilitate functional studies of these pre-mRNA- and mRNA-binding proteins in a vertebrate organism amenable to developmental studies and experimental manipulation, we identified and purified the major hnRNP proteins and isolated the hnRNP complex from Xenopus laevis oocytes and somatic cells. Using affinity chromatography and immunological methods, we isolated a family of >15 abundant single-stranded nucleic acid-binding proteins, which range in apparent molecular weight from approximately 20 kDa to >150 kDa, and with isoelectric points from <5 to >8. Monoclonal antibodies revealed that a subset of these proteins are major hnRNP proteins in both oocytes and somatic cells in culture, and include proteins related to human hnRNP A2/B1/B2 and hnRNP K. UV crosslinking in living cells demonstrated that these proteins bind poly(A)+ RNA in vivo. Immunopurification using a monoclonal antibodyto X. aevishnRNPA2 resulted in the isolation of RNP complexes that contain a specific subset of single-stranded nucleic acid-binding proteins. The protein composition of complexes isolated from somatic cells and from oocyte germinal vesicles was similar, suggesting that the overall properties and functions of hnRNP proteins in these two cell types are comparable. These findings, together with the novel probes generated here, will also facilitate studies of the function of vertebrate RNA-binding proteins using the well characterized X. laevis oocyte and early embryo as experimental systems.

Appendicitis and alternate diagnoses in children: findings on unenhanced limited helical CT

The objective of this manuscript is to review and illustrate the findings of appendicitis, and of alternate diagnoses that may clinically or radiographically simulate appendicitis, on unenhanced limited CT in children. Potential pitfalls in unenhanced limited CT interpretation of pediatric patients will also be discussed.

The endodontic cube: a system designed for evaluation of root canal anatomy and canal preparation

An extensively redesigned muffle system is presented incorporating improved design features, such as rigid external fixation and machined internal indexing to enable a more accurate, clinically relevant, and reproducible evaluation of root canal anatomy before and after preparation. Given the ability to directly observe and quantify changes in the root canal system, the information obtained using this design is comprehensive. In each tooth pretreatment evaluation provides the ideal control, reinforcing the suitability of this technique.

Immunogenetic analysis of variable regions encoding AB1 and gamma-type AB2 antibodies from the NeuGc-containing ganglioside family

The variable regions from P3, a murine monoclonal antibody (MAb) against NeuGc-containing gangliosides, and two anti-idiotype MAbs directed to P3 MAb were cloned and sequenced. Comparisons with previously reported sequences showed that P3 is a germline antibody encoded by genes from the V(H)Q52 and V(kappa)19 families. Analysis of nucleotides at the heavy chain CDR3 (H-CDR3) showed the presence of an extensive 3' N region that contains almost 50% of the nucleotides of this CDR. In addition, amino acid sequence analysis of the H-CDRs of this MAb revealed the presence of three arginines, two of which are present in the H-CDR3, that could be involved in the interaction of P3 MAb with its electronegative epitope on gangliosides. Anti-idiotype 1E10, which seems to define a "regulatory" idiotope on P3 MAb (it induces Id+ Ab3), represents a germline Ab2 that belongs to the V(H)J558 and V(kappa)10 gene families. By contrary, the anti-idiotype 3B11 is an extensively mutated antibody that belongs to the V(H)3660 and V(kappa)4/5 gene families, defining a "private" idiotope on P3 MAb. Even when different V genes contribute to the variable regions of 1E10 and 3B11 MAbs, they share an acidic motif E/D-D-Y/D-Y-D in H-CDR3, suggesting that both Ab2s recognize paratope positive residues on the Ab1. Therefore, complementary electrostatic interactions involving H-CDR3 from both Ab1 and Ab2, might provide a clue to understand the molecular basis for the generation of gamma-type anti-idiotype antibodies to V regions recognizing glycolylated ganglioside antigens.

Crystallization and preliminary X-ray analysis of clade I catalases from Pseudomonas syringae and Listeria seeligeri

Haem-containing catalases are homotetrameric molecules that degrade hydrogen peroxide. Phylogenetically, the haem-containing catalases can be grouped into three main lines or clades. The crystal structures of seven catalases have been determined, all from clades II and III. In order to obtain a structure of an enzyme from clade I, which includes all plant, algae and some bacterial enzymes, two bacterial catalases, CatF from Pseudomonas syringae and Kat from Listeria seeligeri, have been crystallized by the hanging-drop vapour-diffusion technique, using PEG and ammonium sulfate as precipitants, respectively. Crystals of P. syringae CatF, with a plate-like morphology, belong to the monoclinic space group P2(1), with unit-cell parameters a = 60.6, b = 153.9, c = 109.2 A, beta = 102.8 degrees. From these crystals a diffraction data set to 1.8 A resolution with 98% completeness was collected using synchrotron radiation. Crystals of L. seeligeri Kat, with a well developed bipyramidal morphology, belong to space group I222 (or I2(1)2(1)2(1)), with unit-cell parameters a = 74.4, b = 121.3, c = 368.5 A. These crystals diffracted beyond 2.2 A resolution when using synchrotron radiation, but presented anisotropic diffraction, with the weakest direction perpendicular to the long c axis.

Receptive field organization of disparity-sensitive cells in Macaque medial superior temporal cortex

Binocular disparities are crucial for building an accurate three-dimensional representation of the peripersonal environment in a viewer-centred frame of reference. Previous studies have shown that visual cells of the medial superior temporal cortex (MST) have large receptive fields and that they are sensitive to disparities present in large surfaces. By using a reverse cross-correlation technique in this study we tested 175 disparity-sensitive units recorded from MST in the awake Macaca mulatta monkey to determine if these large receptive fields are homogeneous in terms of disparity sensitivity. We found that the receptive fields of 50 cells (50 out of 175, 29%) showed subregions with specific disparity sensitivity. These subregions presented eccentricities from 0.8 to 22.3 degrees and their sizes varied from 1.6 to 15.3 degrees 2. This particular receptive field organization represents a suitable mechanism for encoding the location of small objects within our peripersonal space.

A purified GM3 ganglioside conjugated vaccine induces specific, adjuvant-dependent and non-transient antitumour activity against B16 mouse melanoma in vitro and in vivo

The presence of substantial amounts of GM3 ganglioside on human melanomas and other tumours, together with its peculiar biological properties, makes this glycolipid a unique target for cancer immunotherapy. B16 mouse melanoma expresses GM3 and constitutes an appropriate model for the development of novel GM3-based vaccines. Recently, we hydrophobically incorporated purified GM3 into the outer membrane protein complex from Neisseria meningitidis to form very small size proteoliposomes (GM3/VSSP). We have examined the antitumour properties of GM3/VSSP vaccine and compared it with GM3 incorporated in very low density serum lipoproteins (GM3/VLDL). Immunization with four doses of GM3/VSSP vaccine (120 microg of ganglioside) plus Freund's adjuvant or Montanide ISA 51 significantly increased the overall survival of mice inoculated in the subcutis with 103 B16-F1 cells, whereas the GM3/VLDL immunogen was ineffective. The non-transient character of tumour protection was confirmed in animals surviving the first challenge and re-inoculated with 5 x 103 cells. GM3/VSSP vaccine also reduced the subcutaneous growth of highly aggressive B16-F10 cells. The importance of ganglioside structure in the tumour-protective effect of GM3/VSSP vaccine was confirmed using GM3 containing N-glycolylneuraminic acid, a ganglioside absent in melanoma cells. Immunostaining and enzyme-linked immunosorbent assay (ELISA) experiments showed a high specificity of immune sera against GM3 and the presence of all four IgG subclasses, with a preponderance of IgG2b and IgG3. In addition, a strong anti-B16 complement-mediated cytotoxicity was induced by vaccination with GM3/VSSP. The present data indicate the molecular specificity of GM3/VSSP vaccine as well as the adjuvant-dependent and non-transient character of tumour protection in the B16 mouse model. These findings suggest that an appropriate GM3 vaccine may be capable of inducing prolonged tumour protection in melanoma patients.

The pathway enabling external sounds to reach and excite the fetal inner ear

The human fetus in utero is able to respond to sounds in the amniotic fluid enveloping the fetus after about 20 weeks gestation. The pathway by which sound reaches and activates the fetal inner ear is not entirely known. It has been suggested that in this total fluid environment, the tympanic membrane and the round window membrane become 'transparent' to the sound field, enabling the sounds to reach the inner ear directly through the tympanic membrane and the round window membrane. It is also possible that sounds reach the inner ear by means of tympanic membrane--ossicular chain--stapes footplate conduction (as in normal air conduction). There is also evidence that sounds reach the fetal inner ear by bone conduction. Several animal and human models of the fetus in utero were studied here in order to investigate the pathway enabling sounds to reach and activate the fetal inner ear. This included studying the auditory responses to sound stimuli of animals and humans under water. It was clearly shown in all the models that the dominant mechanism was bone conduction, with little if any contribution from the external and middle ears. Based on earlier experiments on the mechanism and pathway of bone conduction, the results of this study lead to the suggestion that the skull bone vibrations induced by the sound field in the amniotic fluid enveloping the fetus probably give rise to a sound field within the fetal cranial cavity (brain and CSF) which reaches the fetal inner ear through fluid communication channels connecting the cranial cavity and the inner ear.

Binocular interaction and sensitivity to horizontal disparity in visual cortex in the awake monkey

We evaluated the binocular interaction and horizontal disparity sensitivity in neurons recorded from macaque visual cortex. Neurons from V1 of three awake Macaca mulatta monkeys were isolated by means of extracellular recording and tested for disparity sensitivity with dynamic random dot stereograms. Neurons sensitive to horizontal disparities were stimulated both monocularly and binocularly with flashing bars and their responses quantified. ANOVA and regression tests were used for data analysis. Sixty-six cells out of 185 (66/185, 36%) showed sensitivity to horizontal disparity. Disparity sensitive cells were grouped into near (25/66, 38%), tuned inhibitory (16/66, 24%), far (13/66, 20%) and tuned excitatory (12/66, 18%). Receptive fields of tuned cells were located more centrally in the visual field than those of near and far cells. The binocular interaction in tuned inhibitory cells increased linearly along with ocular unbalance. Most of tuned excitatory cells (10/12, 83%) showed facilitatory binocular interaction, characterized by a stronger response to binocular stimulation than to the stimulation of the dominant eye. On the contrary, most of tuned inhibitory cells (14/16, 88%) showed suppressory binocular interaction, characterized by a weaker response to binocular stimulation than to the stimulation of the dominant eye. Near and far cells showed both types of interaction in similar percentages. The binocular response showed a linear relationship with the sum of both monocular responses in tuned excitatory, tuned inhibitory and near cells, but not in far cells. Sensitivity to horizontal disparity may be a result of facilitatory and suppressive interactions between left and right inputs.

Use of evoked potentials to objectively differentiate between selective vulnerability of cochlear and vestibular end organ function

Auditory nerve brainstem evoked responses (ABR) have been used for several decades to investigate cochlear function. Recently techniques have been developed to elicit similar recordings from the vestibular end organs - short latency vestibular evoked potentials (VsEPs). Both ABR and VsEP reflect appropriate end organ function and may therefore be used to investigate the vulnerability of these end organs to various experimental insults, such as noise exposure and ototoxic drugs.

Laser myringotomy in different age groups

OBJECTIVE

To study the qualities of laser myringotomy (LM) as a treatment for middle ear ventilation problems.

DESIGN

Prospective study and follow-up of consecutive cases of adults, children, and infants. Patients were observed for up to 2 years.

SETTING

Children underwent LM, with or without adenoidectomy, under general anesthesia in the operating room. Adults and infants underwent LM under topical anesthesia, as an outpatient procedure.

PATIENTS

All consecutive patients with either secretory otitis media (SOM) (adults and children) or acute otitis media (AOM) (infants) who agreed to participate were included without selection.

INTERVENTION

Myringotomy was performed using new laser equipment, enabling a 0.1-second ablation with changeable diameter.

OUTCOME MEASURES

Close follow-up, with microscopic examination of all ears. Findings were noted on the medical charts.

RESULTS

Among all age groups, 136 ears were followed up. Perforation lasted a mean 22 days in adults, 17 days in children, and 11 days in infants. Patient age was found to be a significant determining factor for duration of perforation (P =.002). Laser myringotomy in the anterior and inferior areas lasted longer than posterior LM (P<.001). In patients with SOM, during the time the LM was patent, all ears were ventilated. In children, 38% of SOM cases resolved after a single LM treatment. All infants with AOM recovered promptly without antibiotic treatment.

CONCLUSIONS

Laser myringotomy is a convenient, quick procedure that can be performed in the medical office with the use of topical anesthesia and is suitable for patients with AOM or for those who need short-term ventilation for SOM. It was found to be a safe alternative to ventilation tubes in these patients. In AOM, it was used instead of antibiotics and gave prompt relief from symptoms and cure of the AOM.

Sylvatic population of Triatoma infestans from the Bolivian Chaco: from field collection to characterization

A sylvatic Triatoma infestans DM (dark morph) population detected in the Bolivian Chaco was characterized and compared with various domestic ones. The degree of differentiation of DM was clearly within the T. infestans intra-specific level. Nevertheless marked chromatic and morphometric differences as well as differences in antennal pattern, chromosome banding and randomly amplified polymorphic DNA support the hypothesis of a distinct population. Continuous exchange of insects between wild and domestic habitats seems unlikely in the Chaco.

Response latencies to visual stimulation and disparity sensitivity in single cells of the awake Macaca mulatta visual cortex

The onset response latencies to dynamic random dot figures (solid figures) and dynamic random dot stereograms were measured in single units recorded from areas V1 and V2 of two awake Macaca mulatta monkeys. We studied 56 cells, 39 from V1 and 17 from V2. In 14 disparity sensitive and 13 disparity unsensitive cells from V1 the median latencies to solid figures were 59.8 and 73.6 ms, respectively, which were statistically different. In 26 disparity sensitive cells from V1 and 17 from V2 the median latencies to stereofigures were 85.6 and 97.9 ms, respectively, which were statistically different. These results indicate that V1 disparity sensitive cells may have shorter integration time than disparity unsensitive cells and that there is a transferring delay for disparity information between areas V1 and V2.