Prevention of relapse of histoplasmosis with fluconazole in patients with the acquired immunodeficiency syndrome

OBJECTIVE

To assess the effectiveness of fluconazole for suppression of relapse of histoplasmosis in patients with acquired immunodeficiency syndrome (AIDS).

DESIGN

Retrospective, nonrandomized, open trial.

SETTING

Multicenter at two university referral centers and in five private practices.

PATIENTS

Seventy-six patients with AIDS and disseminated histoplasmosis who completed induction treatment with amphotericin B, itraconazole, or fluconazole and maintained on treatment with fluconazole to prevent relapse.

INTERVENTIONS

Fluconazole was given at dosages of 100 to 400 mg per day. Patients were followed by their primary physicians, who completed questionnaires collecting information about treatment and relapse status. Blood and urine specimens were submitted periodically for Histoplasma capsulatum var. capsulatum antigen determination.

MEASUREMENTS AND MAIN RESULTS

Nine of the 76 patients relapsed during fluconazole therapy and another was removed from the study because of allergic rash. Survival after initiation of therapy for histoplasmosis was 94 weeks, ranging from 74 weeks for those who received less than 1 g of amphotericin B for induction and none for maintenance therapy to 156 weeks for those who received greater than 1 g for induction and additional amphotericin B for maintenance therapy before beginning fluconazole (P < 0.02). Antigen levels fell at rates of 0.05 units/week in urine and 0.02 units/week in serum in patients who were successfully maintained in remission and increased by > or = 2 units/week in 4 of 6 patients who relapsed.

CONCLUSIONS

Fluconazole > or = 200 mg daily is a reasonable choice for chronic suppressive therapy of histoplasmosis in patients who cannot take itraconazole because of drug interactions, malabsorption, or side effects.

Prediction of stroke volume from oxygen pulse measurements in untrained and trained men

This study examined the relationship of oxygen pulse (O2 pulse) to stroke volume (SV) and arterio-venous oxygen difference [(a-v)O2 diff] during submaximal cycle exercise in untrained (UG) and trained (TG) males. Fourteen volunteers in each group completed an incremental VO2 max test and a submaximal test at 60% VO2 max to determine cardiac output (Q) via CO2 rebreathing. VO2, Q, and heart rate (HR) were used to calculate SV and (a-v)O2 diff. There were no significant differences (p > .05) between the two groups for O2 pulse, SV, and (a-v)O2 diff during submaximal exercise. Stroke volume index (SVI) was significantly higher (p < .05) in the TG. O2 pulse was significantly related to SV and SVI (p < .05) but not to (a-v)O2 diff in both groups. Regression equations for predicting SV from O2 pulse for UG and TG were Y = 6.81X + 26.7, SE = 21.4, r = 0.84, and Y = 10.33X - 32.3, SE = 14.2, r = 0.71, respectively. These results suggest that O2 pulse can be used to predict SV during submaximal cycle exercise in untrained and trained men.

Effects of skin blood flow and temperature on bioelectric impedance after exercise

To examine the effects of increased skin blood flow (BFsk) and skin temperature (Tsk) on bioelectric impedance (BIA), 30 young males participated as subjects. All subjects underwent the following measurements: 1) BFsk and Tsk for the chest, biceps, thigh, and calf; 2) body composition using the BIA prediction equations and underwater weighting (UW); and 3) triceps skinfold (SFtri) thickness. After the baseline studies (M1) the subjects exercised for 30 min at approximately 83% of maximal heart rate. The above measurements were repeated immediately after exercise (M2), and at 1-h recovery from exercise (M3). Repeated measures ANOVA showed that mean Tsk and BFsk, and for the four measured sites were significantly increased from M1 to M2 (P < 0.05) and decreased from M2 to M3 (P < 0.05). These changes did not affect BIA measurement for resistance (R) and reactance between M1 and M2 (P > 0.05), and between M2 and M3 (P > 0.05). With regression analysis the following independent variables were identified as strong contributing factors for predicting fat-free mass (FFM): 1) SFtri and total body water for M1 and M3; and 2) WT, SFtri, and Tsk of the chest for M2. Two FFM equations have little multicolinearity (M1 and M2), e.g., they have low root mean square errors (< or = 2.6 kg), very high values for R2 (> or = 0.94), and relatively low values for coefficient of variations (< or = 5.65%). Differences (P < 0.05) were observed between the UW method and the Lukasi equation for estimating FFM for M1 and M3, but not for M2.(ABSTRACT TRUNCATED AT 250 WORDS)

Chest pain admissions: characteristics of black, Latino, and white patients in low- and mid-socioeconomic strata

To assess the potential impact of socioeconomic status (SES) factors on health-care seeking behavior for suspected acute coronary artery disease symptoms, equal numbers of black, Latino, and white patients seeking care for chest pain at two large hospital emergency rooms were studied. Differences between low and middle SES groups with respect to pre-attack health, health history, ethnicity, gender, and modes of transportation to the hospital were explored. Highly significant self-reported differences between low SES and middle SES patients were found as follows: low SES subjects were more likely to describe themselves as being in fair to poor general health (68% versus 18%), had more frequent chest pain, reported other types of heart disease, were more often current smokers, more likely to be black or Latino, and to be younger. Members of the low SES group also were less [corrected] likely to have known cholesterol levels, to have used estrogen, to have had a prior ECG or cardiac surgery, to be nonsmokers, to have had a stress test, and to have typical angina. Middle SES subjects more often described typical angina, prior use of estrogen (females), congenital, rheumatic, or family history of heart disease, prior knowledge of high cholesterol, were more likely to be of the male gender, and to be older than the low SES cohort. The data reveal that low SES subjects, with markedly less health-care resources compared with middle SES subjects, have a worse general health and cardiac risk profile despite the fact that they were significantly younger (mean age 53.4 versus 60.7, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

A phase I trial of immunosuppression with anti-ICAM-1 (CD54) mAb in renal allograft recipients

Several adhesion molecules contribute to the interaction between T cells and antigen presenting cells or target cells. Leukocyte function-associated molecule-1 (LFA-1[CD11a/CD18]) and intercellular adhesion molecule-1 (ICAM-1 [CD54]) are one such critical adhesive receptor-counter-receptor combination. The importance of ICAM-1 dependent adhesion in the rejection response was initially demonstrated in cynomolgus renal allograft recipients treated with the anti-ICAM-1 murine monoclonal antibody BIRR1. BIRR1 also appeared to limit ischemic damage in these animals. A Phase I clinical trial has subsequently been completed in 18 patients who received cadaver donor renal allografts at high risk for delayed graft function (prolonged preservation time, highly-sensitized recipient). An adequate BIRR1 serum level was associated with significantly less delayed graft function (P < .01) and rejection (P < .01). In 1-hr biopsies, mouse IgG was detected along the endothelium of the vessels and glomeruli in the graft. There were no instances of primary non-function (PNF), and current allograft survival (followup: 16-30 months) in these "high-risk" mAb-treated patients is 78%. There were 3 instances of PNF and a graft survival rate of 56% in the recipients of the contralateral kidney allografts treated with conventional immunosuppression. No significant "first-dose" effect was associated with BIRR1 administration. These results establish a dosing schedule and the clinical safety of BIRR1. They also suggest that inhibition of leukocyte adhesion by mAb therapy may be useful in controlling allograft rejection and possibly in limiting reperfusion injury. Thus, these observations support the clinical importance of accessory molecules in T cell function. We hypothesize that anti-CD54 mAb acts by blocking leukocyte adhesion to the endothelium, thereby interfering with sensitization or target cell interaction.

Interaction of spirochetes with the host

The success of an invading organism must depend on several cytoplasmic, surface-associated and secreted factors. The technical difficulties in handling pathogenic spirochetes like Treponema pallidum and Borrelia burgdorferi have made it difficult to define specific factors involved in entry and long-term survival. The problem of defining virulence factors has been attacked by several strategies: T. pallidum secretes a number of immunogenic low molecular mass proteins. The most predominant are of molecular weight 15.5 and 22 kDa. Preliminary data suggest that antibodies against these proteins induce protective immunity in rabbits experimentally infected with T. pallidum. Many potentially important surface-associated antigens of T. pallidum have now been cloned and characterized. Two of these, TpD and TpE, are lipoproteins which exhibit characteristic size heterogeneity. The apparent molecular weight of TpE from T. pallidum and T. pertenue are different. The clinical symptoms in syphilis and yaws are very different, but sequence analysis of TpE has shown that the TpE proteins are indeed very similar in the two strains. This observation makes it unlikely that heterogeneity of TpE can account for the different clinical symptoms of syphilis and yaws. Sequence data for another newly sequenced surface-associated antigen of T. pallidum (molecular weight 41 kDa) indicate that this protein is involved in glucose transport and chemotaxis/motility. Intracellular factors like the molecular chaperonin GroEL have been documented both in treponemes and borreliae. This stress protein is involved in cellular repair processes and folding/assembly of protein subunits. Indirect evidence suggests that GroEL affects the ability of spirochetes to survive in the stressful environment of the infected host. Several lines of evidence suggest that the Osp proteins of Borrelia are important for host/parasite interaction. Further support for this idea has come from studies of a series of monoclonal antibodies against OspA. A monoclonal antibody against OspA (9B3D) is able to block attachment of B. burgdorferi to a cell monolayer. Borrelia loses infectivity after several passages in vitro. The loss of pathogenicity is associated with loss of specific plasmids and proteins. One of the low-passage-associated proteins (Lap30) has been cloned and sequenced. Lap30 is a lipoprotein encoded by a 38-kb plasmid, not present in high passage B. burgdorferi. Aberrant immunological processes induced by the lipopolysaccharide component of Treponema hyodysenteriae could explain the dramatic intestinal lesions in swine dysenteriae. But analysis by TLC reveals that the LPS of this treponeme is different from classical Salmonella LPS.(ABSTRACT TRUNCATED AT 400 WORDS)

Pulmonary aspergillosis in the acquired immunodeficiency syndrome

BACKGROUND AND METHODS

Symptomatic pulmonary aspergillosis has rarely been reported in patients with the acquired immunodeficiency syndrome (AIDS). We describe the predisposing factors, the clinical and radiologic features, and the therapeutic outcomes in 13 patients with pulmonary aspergillosis, all of whom had human immunodeficiency virus (HIV) infection and 12 of whom had AIDS.

RESULTS

Pulmonary aspergillosis was detected a median of 25 months after the diagnosis of AIDS, usually following corticosteroid use, neutropenia, pneumonia due to other pathogens, marijuana smoking, or the use of broad-spectrum antibiotics. Two major patterns of disease were observed: invasive aspergillosis (in 10 patients) and obstructing bronchial aspergillosis (in 3). Cough and fever, the most common symptoms, tended to be insidious in onset in patients with invasive disease (median duration, 1.3 months before diagnosis). Breathlessness, cough, and chest pain predominated in the three patients with obstructing bronchial aspergillosis, who coughed up fungal casts. Radiologic patterns included upper-lobe cavitary disease (sometimes mistaken for tuberculosis), nodules, pleural-based lesions, and diffuse infiltrates, usually of the lower lobe. Transbronchial biopsies were usually negative, but positive cultures were obtained from bronchoalveolar-lavage fluid or percutaneous aspirates. Dissemination to other organs occurred in at least two patients, and direct invasion of extrapulmonary sites was seen in two others. The results of treatment with amphotericin B, itraconazole, or both were variable. Ten of the patients died a median of 3 months after the diagnosis (range, 0 to 12 months).

CONCLUSIONS

Pulmonary aspergillosis is a possible late complication of AIDS; if diagnosed early, it may be treated successfully.

Ceftazidime in the elderly: appropriateness of twice-daily dosing

The disposition of drugs in the elderly is particularly relevant with antiinfectives, because this population has an increased risk of infections. Renal function deteriorates with age, yet dosage guidelines for antibiotics that allow for this reduction remain to be established. Ceftazidime, a cephalosporin with enhanced antipseudomonal activity that is eliminated primarily by glomerular filtration, has been evaluated in the elderly. Herein, we review ceftazidime's pharmacokinetic profile and dosing considerations in this population. Several aspects of renal function deteriorate with the normal aging process, including a decreased glomerular filtration rate (GFR). Using serum creatinine concentrations as an estimate of the GFR in the elderly is unreliable; a more reliable way of estimating GFR is the use of inulin or 51Cr-editic acid clearance or calculation from formulas or nomograms based on age, weight, sex, and serum creatinine. From pharmacokinetic studies it was found that the elderly individual without renal disease generally has an increased elimination half-life and decreased clearance of ceftazidime compared with a young person. A positive correlation (r = 0.7-0.95) was shown between ceftazidime clearance and GFR, suggesting that estimates of GFR may be used to determine the ceftazidime dose. In several studies, the trough (after 12 hours) ceftazidime serum concentration exceeded by several fold its minimum inhibitory concentration required to inhibit 90% of organisms for most commonly encountered organisms; efficacy and safety were also confirmed with an every-12-hour regimen. A twice-daily dosage regimen for ceftazidime in elderly patients with normal renal function should be considered based on age-related decreases in renal function and drug elimination.

Sickle cell anemia: does myocardial ischemia occur during crisis?

The possibility that myocardial ischemia may be associated with chest pain during painful crises was evaluated prospectively in 20 patients (11 women and nine men) with sickle cell disease (19 SS, 1 S beta + thalassemia). Sixteen of 20 (80%) had abnormal ECGs, 7 (35%) had transient ST-T wave changes, and 3 (15%) had persistent ST-T wave changes, both consistent with ischemia; 6 (30%) had nonspecific ST-T changes, and 4 (20%) had normal tracings. Serum enzymes (CK, SGOT, LDH) were abnormal in 16 of 19 (84%); 1 had CK-MB detected, (5%) and 1 had LDH1 to LDH2 reversal. All 10 Tc-99m pyrophosphate scans performed were negative; 4 of 6 (66%) thallium-201 scans had focal defects, and 5 of 8 (63%) radionuclide angiograms (MUGAs) had focal wall motion abnormalities. Three of 8 (38%) MUGAs showed cardiac dilation, diffuse hypokinesis, and reduced ejection fractions. Thus, myocardial damage may be a potentially serious complication of patients with sickle cell anemia who present with chest pain during painful crises. Studies are indicated to define the significance and pathophysiology of these observations.

Pharmacokinetic and pharmacodynamic studies in man with an antianginal agent 'Visacor'

This randomized, double-blind, crossover study in 10 healthy male volunteers compared four single oral doses of ICI 141,292 ('Visacor'), i.e. 50, 100, 200, and 300 mg, with placebo. Venous blood samples were collected pre-dose and at various times after dosing and the concentrations of ICI 141,292 in the plasma were determined by radioimmunoassay. A standardized 4-min bicycle exercise test was also performed and before this the resting haemodynamic parameters were assessed. Peak plasma concentrations of ICI 141,292 and the area under the plasma concentration-time curve increased disproportionately with dose such that after scaling to a dose of 200 mg there remained a significant linear trend with dose. The time to peak plasma concentration displayed an increasing trend with dose and, once again, the linear component of this trend was statistically significant. The mean heart rates during exercise were all significantly reduced compared to placebo for 24 h by each of the doses (range 7.8 to 17.4 beats min-1 at 24 h, p less than 0.01). The increase in heart rate during exercise was inversely related to the logarithm of the ICI 141,292 plasma concentration with higher plasma concentrations being associated with lower heart rate increases. The mean supine resting heart rates were slightly but significantly reduced at 2 and 6 h after dosing by each treatment and by the 300 mg dose at 24 h. Each of the doses of ICI 141,292 was well tolerated.

Postischemic recovery rate of cerebral ATP, phosphocreatine, pH, and evoked potentials

We tested the hypotheses that after complete cerebral ischemia, first, rate of recovery of ATP, phosphocreatine (PCr), and intracellular pH (pHi) varies with ischemic duration and second, rate of metabolic recovery is a more sensitive predictor of consequent electrophysiological deficit than steady-state metabolic recovery. With the use of transient intracranial hypertension in anesthetized dogs, ischemic duration was set for either 3, 12, or 30 min, which depressed somatosensory-evoked potential (SEP) recovery amplitude by 30, 59, and 88%, respectively. In contrast, ATP, PCr, and pHi, measured by 31P magnetic resonance spectroscopy, fully recovered. When ischemic duration was increased from 3 to 12 min, mean recovery time of ATP (6 min) remained rapid but that of pHi (12-28 min) was prolonged. After 30 min of ischemia, pHi recovery was not slowed further (25 min) but that of ATP was now markedly prolonged (36 min). PCr recovery time increased progressively with ischemic duration (5, 11, and 21 min, respectively) and correlated best with SEP recovery (r = 0.74). We conclude that the brain's ability to rapidly normalize pH is a sensitive predictor of electrophysiological recovery after short ischemia but that ATP regeneration becomes important with prolonged ischemia. PCr recovery rate was the best overall predictor, probably because it depends on both pHi and the ratio of ATP to ADP by the creatine kinase reaction.

Comparison of computer and non-computer-assisted technologies in noninvasive cardiac imaging

We compared gated magnetic resonance imaging (MRI) and dynamic computed tomography (DCT) with two-dimensional cardiac ultrasound (ECHO) to assess differences in diagnostic information. Magnetic resonance imaging was performed in 41 patients; ECHO in 36, and DCT in 28 patients with various pathologic conditions. We measured the left and right ventricular (LV, RV) long and short axes (LA, SA), LV free wall and septal thickness (WT, ST) at end systole (ES) and end diastole (ED) on the apical four-chamber view (ECHO) or appropriate transaxial slice (MRI, DCT) on a subset of 14 patients. Paired-sample analysis of these three techniques, in this preliminary data, yields statistically different results as follows: LV SA: MRI versus ECHO at ED and ES (P less than 0.001 and 0.005); WT: MR versus ECHO at ES (P less than 0.002); CT versus ECHO at ED and ES (P less than 0.05 and 0.01); ST: MRI versus ECHO at ED and ES (P less than 0.001), and CT versus ECHO at ES (P less than 0.05). Thus, CT and MRI yield similar quantitative data, but both differ in varying degree from ECHO measurements. Differential accuracies and utilities of these techniques warrant further careful investigation.

Histamine induced elevation of cyclic AMP phosphodiesterase activity in human monocytes

We have previously reported histamine desensitization of human blood mononuclear leukocytes resulting in reduced cAMP responses to beta-adrenergic agonists, histamine and prostaglandin E1. This heterologous desensitization occurred at low, micromolar histamine concentrations and was accompanied by elevation of cAMP-phosphodiesterase (PDE) activity in these cells. We have now investigated the activity of PDE in the lymphocyte and monocyte fractions of mononuclear leukocytes to determine the site of histamine effect. PDE activity per cell was higher in monocytes (0.075 +/- 0.070 units) than lymphocytes (0.026 +/- 0.08) units). Monocytes responded to 10(-6) M histamine stimulation with a much greater increase in PDE activity (0.354 +/- 0.1 units) than did lymphocytes (0.047 +/- 0.015 units). Histamine receptor studies, using thiazolylethylamine and chlorpheniramine as H1-agonist and antagonist respectively and dimaprit and cimetidine as H2-agonists and antagonists respectively, indicated that the histamine stimulation of PDE activity is mediated predominantly through H1 histamine receptor in the monocytes and the H1 receptor in the lymphocytes. Previously histamine had been thought to increase cyclic AMP by acting on H2 receptors to activate adenylate cyclase. Our studies show that stimulation of H1 or H2 receptors by low histamine concentration can cause the opposite effect i.e. increased catabolism and a net reduction in cAMP levels. The localization of this effect predominantly to monocytes indicates a potentially important mechanism for histamine action on immune regulation.

Diagnosis of acute cardiac rejection with antimyosin monoclonal antibody, phosphorous nuclear magnetic resonance imaging, two-dimensional echocardiography, and endocardial biopsy

A cervical heterotopic cardiac allograft model was used to compare noninvasive techniques with endocardial biopsy diagnosis of rejection. The transplant procedure was performed in eight dogs (12 to 16 kg), with a mean ischemic time of 83 minutes. Beginning on the day of the operation each allograft was evaluated daily by palpation, two-dimensional echocardiography, phosphorous nuclear magnetic resonance spectroscopy, and septal endocardial biopsy. At specific intervals after the operation, antimyosin monoclonal antibody (Fab fragment) with an indium-111 label was administered for subsequent gamma camera imaging. Rejection was clinically evident by 2 to 8 days with a mean of 3.5 days. Endocardial biopsy demonstrated moderate to severe rejection by 2 to 4 days. Two-dimensional echocardiography demonstrated early loss of wall thickening dynamics in all allografts. Although subtle changes were evident early in some transplants, these findings were not consistent. After recovery from hypothermic ischemia, evaluation of high energy phosphate metabolites with phosphorous nuclear magnetic resonance spectroscopy showed a progressive decrease in phosphocreatine during mild to moderate rejection, dropping to 30% to 40% of baseline levels with severe rejection. Antimyosin antibody uptake directly correlated with endocardial biopsy rejection scores (R2 = 0.97). With mild to moderate rejection, mean total counts and corrected counts were 222,704 and 112,648, respectively, and were significantly different (p less than 0.05) from baseline counts (135,537 and 58,530) without rejection. As a preliminary finding in untreated acute rejection, both antimyosin antibody and phosphorous nuclear magnetic spectroscopy detected changes consistent with mild to moderate rejection, which usually preceded echocardiographic evidence for injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of varied cardioplegic perfusion pressure on myocardial preservation with critical coronary stenosis

Inadequate delivery of cardioplegic solution distal to coronary artery stenosis may result in increased injury during ischemic arrest. This study was performed to determine the effects of cardioplegic perfusion pressure on cardioplegia delivery and myocardial preservation in hearts with critical coronary artery stenosis. Twenty dogs underwent 90 minutes of cold potassium cardioplegic arrest with partial occlusion of the circumflex coronary artery. Group 1 received cardioplegia at 50 mm Hg pressure, Group 2 at 90 mm Hg pressure, and Group 3 at 130 mm Hg pressure. It was found that cooling rates were 5.4 degrees, 9.1 degrees, and 18.2 degrees C per minute in the nonischemic area (p = 0.004) and 2.0 degrees, 4.5 degrees, and 7.9 degrees C in the ischemic area (p = 0.008) in Groups 1, 2, and 3, respectively. Total of cardioplegic solution flows were 86, 188, and 262 ml per minute per 100 gm in Groups 1, 2, and 3, respectively (p = 0.001). However, flow did not differ significantly between groups in the ischemic area. Rate of rise of left ventricular (LV) pressure decreased significantly in Groups 1 and 2 but not in Group 3 (p = 0.002). Other measured variables did not differ significantly between groups, although LV function curves showed less deterioration in the high-pressure groups. It is concluded that higher cardioplegic perfusion pressure resulted in more rapid cooling in normal and ischemic areas and slightly better preservation of ventricular function as measured by some indexes. However, preservation was generally good for each of the pressures for up to 90 minutes of ischemia when the septum was consistently cooled to 10 degrees C.

Nimodipine and chronic vasospasm in monkeys: Part 1. Clinical and radiological findings

The efficacy of the calcium channel blocker nimodipine in the prevention of chronic cerebral vasospasm (VSP) and delayed ischemia after subarachnoid hemorrhage (SAH) in monkeys was examined in a blind, randomized, placebo-controlled trial. The primate model developed in this laboratory reliably induces chronic cerebral vasospasm and can induce pathologically proven delayed ischemic neurological deficits (DINDs). With standard microsurgical procedures, an average 6.4-ml autologous hematoma was placed directly against the major anterior cerebral vessels in the right basal subarachnoid spaces of 24 monkeys. The monkeys were randomized to one of four groups and were treated orally q8h for 7 days with nimodipine (3, 6, or 12mg/kg)or placebo. An additional 2 monkeys underwent the surgical procedure without clot placement. Drug administration began between 14 and 20 hours after clot placement. Indices monitored before and after SAH included neurological status, angiographic cerebral vessel caliber, and cerebral blood flow. Significant VSP (25 to 100% reduction in vessel caliber) was present on Day 7 on the clot side in 83% of the animals (P less than or equal to 0.001). There was no significant difference (P greater than 0.05) in the incidence of VSP among the four groups. Similarly, there was no significant difference (P greater than 0.05) in the mean vessel caliber reduction after SAH among the four treatment groups. There was no VSP present on Day 7 in the sham-operated animals. One animal receiving high dose nimodipine (12 mg/kg p.o. q8h) developed a DIND on Day 5 after SAH. A second animal in the 12-mg/kg group developed a transient neurological deficit between Days 4 and 7.

Nimodipine and chronic vasospasm in monkeys: Part 2. Pharmacological studies of vessels in spasm

The effect of nimodipine on the in vitro reactivity of cerebral vessels after subarachnoid hemorrhage (SAH) was studied. With the use of a primate model of chronic cerebral vasospasm, 12 female cynomolgous monkeys underwent the induction of a SAH by the direct placement of an average 6.4-ml autologous hematoma against the major anterior cerebral vessels in the right basal subarachnoid spaces (Day 0). The animals were then randomized to one of four groups and within 14 to 20 hours after clot placement were started on oral q8h therapy with nimodipine (3, 6, or 12 mg/kg) or placebo. On Day 7, the animals were killed and the right and left middle cerebral arteries (MCAs) were immediately resected and placed in oxygenated Krebs' solution. Ring preparations from the arteries were suspended in organ baths, and dose-effect curves to varying concentrations of norepinephrine, 5-hydroxytryptamine, and potassium chloride were obtained. There was a highly significant reduction in the response of the MCA on the clot side (right) relative to the nonclot side (left) to all three agonists. The clot side contractility was not influenced by nimodipine treatment at any of the four doses tested. The nonclot side arteries of the 12-mg/kg treatment group demonstrated significantly enhanced reactivity for all three agonists. Oral treatment with high dose nimodipine enhances the reactivity of normal cerebral vessels to the agonists tested, but it does not seem to affect the reactivity of arteries in chronic spasm at any of the four doses tested.

Digital intravenous ventriculography. Comparison of volumes from mask-mode and nonsubtracted images with thermodilution and sonocardiometric measurements

Left ventricular volumes calculated from mask-mode (MM) images obtained by digital intravenous ventriculography (DIV) were compared with volumes determined from direct contrast images (CV), thermodilution and sonomicrometer measurements in six anesthetized dogs in which volumes were varied by isoproterenol and phenylephrine infusions. Short and long axis sonomicrometer crystals allowed continuous measurement of cardiac size and function. The MM and CV ejection fractions and volumes correlated well with each other (r greater than or equal to 0.96) through the MM volumes consistently underestimated the CV volumes by 12 +/- 3%. Analyzing each dog individually, both CV and MM volumes and ejection fractions correlated well with sonomicrometer results. In addition CV and MM estimates of stroke volume correlated well (r greater than or equal to 0.91) with the thermodilution values, although the CV values exceeded the thermodilution value by 17 +/- 4%. We conclude that MM analysis of left ventricular function correlates well with standard measures of cardiac dimensional changes and agrees with, though underestimates, the simultaneous nonsubtracted contrast ventriculographic images.

Nursing procedures and alterations in transcutaneous oxygen tension in premature infants

This study evaluated the effects of three routine nursing procedures--suctioning, repositioning, and performing a heelstick--on blood oxygen levels in premature infants, using a transcutaneous oxygen (Tcp02) monitor. Twenty-five infants with respiratory distress syndrome were monitored for three hours during which all three procedures were performed. Continuous Tcp02 records were used for measurement of baseline Tcp02 degree and duration of Tcp02 changes, length of procedural time, and rest time prior to procedures. Data were analyzed to determine if Tcp02 was altered during routine procedures, and if the degree of change was affected by length of procedure or length of rest prior to a procedure. Degree of Tcp02 change was analyzed in relation to length of time taken to recover from procedures. Tcp02 was decreased significantly during suctioning and repositioning but not during heelstick. The three procedures resulted in different degrees of change in Tcp02. Suctioning elicited the greatest decrease, followed by respositioning then heelstick. Recovery time was related to the degree of change in Tcp02 only after the repositioning procedure. Length of procedure and rest time did not relate to the degree of change in Tcp02, suggesting that it was the type of procedure that determined infant response.