Effect of implantable cardioverter/defibrillator lead placement in the right ventricle on defibrillation energy requirements. A combined experimental and clinical study

OBJECTIVES

The effect of implantable cardioverter/defibrillator (ICD) lead placement in the right ventricle (RV) on defibrillation efficacy has not been thoroughly investigated. Therefore, the goal of this combined experimental and clinical study was to evaluate the effect of a septal and a non-septal position of the right ventricular endocardial spring lead on defibrillation energy.

METHODS

In 12 isoflurane-anaesthetized swine and subsequently in 8 patients who underwent ICD implantation, two different positions of the distal spring lead in the RV were investigated in randomized order: non-septal position (free wall of the RV) and septal position (interventricular septum). For each position, separate 50% probability determinations of energy (E50), peak voltage (V50) and peak current (A50) were calculated using the three reversal up/down defibrillation procedure. The E50, V50, A50 and impedance (I) were averaged and compared using the two-sided t-test for paired samples.

RESULTS

Both the experimental study and the clinical study demonstrated that placing the distal defibrillation lead near to the septum rather than near to the ventricular free wall resulted both in the swine and in the patients in significantly lower E50-31.6%/ - 37.1%, V50-16.1%/-20.9% and A50 -10.0%/ - 24.2%, respectively. Defibrillation impedances were significantly reduced only in the experimental study.

CONCLUSIONS

Defibrillation efficacy depends on the position of the distal spring electrode in the RV. A septal position significantly reduces the energy requirements compared to a non-septal position. The decrease in energy requirements might be explained by an increase in current flow through the septum and the posterolateral wall of the left ventricle. reserved

Significant changes in VLDL-triacylglycerol and glucose tolerance in obese subjects following ten days of training

We characterized the effect of ten days of training on lipid metabolism in 6 [age 37.2 (2.3) years] sedentary, obese [BMI 34.4 (3.0) kg x m(-2)] males with normal glucose tolerance. An oral glucose tolerance test was performed prior to and at the end of the 10 d of training period. The duration of each daily exercise session was 40 min at an intensity equivalent to approximately 75% of the age predicted maximum heart rate. Blood measurements were performed after an overnight fast, before and at the end of the 10 d period. Plasma triacylglycerol was significantly (p < 0.05) reduced following exercise training (2.15+/-0.29 vs. 1.55+/-0.28 mmol x l(-1)). Very low density lipoprotein-triacylglycerol was also significantly (p < 0.05) reduced (1.82+/-0.3 vs. 1.29+/-0.29 mmol x l(-1)). No significant changes in high density lipoprotein-cholesterol were observed as a result of training. Following training fasting plasma glucose and fasting plasma insulin were significantly reduced [Glucose: 5.9 (0.2) mmol x l(-1) vs. 5.3 (0.22) mmol x l(-1) (p < 0.05); Insulin 264.3 (53.8) rho x mol x l(-1) vs. 200.9 (30.1) rho x mol x l(-1), p=0.05]. The total area under the glucose curve during the OGTT decreased significantly (p < 0.05). These preliminary data suggest that short-term exercise, without concomitant loss of body mass, induces favorable changes in plasma triacylglycerol, and very low density lipoprotein-triacylglycerol and glucose tolerance but has no effect on high density lipoprotein-cholesterol.

Lactulose--a multifaceted substance

Lactulose is therapeutically used in hepatic encephalopathy, constipation, and salmonellosis. This semisynthetic disaccharide is neither metabolized nor absorbed in the normal small intestines. Comparable to plant-polysaccharides lactulose is bacterially fermented in the colon to short chain fatty acids and gases. Major consequences are a drop in pH and a change in composition and metabolic activity of the colonic flora. These and other potential effects suggest complex mechanisms of action of lactulose, with the potential for additional indications in diagnosis and therapy. The use of lactulose as substrate for the H2-breath-test is well known as a means for the measurement of oroeceal transit time and as test for small intestinal bacterial overgrowth. An extension of the diagnostic potential is given by the assessment of the permeability in diffuse intestinal disease with combined disaccharide/monosaccharide test solutions, especially in Crohn's disease. Explanations for positive effects in the prophylaxis of cholesterol-gallstones, in the therapy of hypercholesterolemia and in the prevention of colorectal adenoma and carcinoma can be found in changes in lipid- and bile acid metabolism found after lactulose ingestion. Lactulose may lead to an improved glucose-tolerance in parallel to fibre and acarbose effects which involve several mechanisms of carbohydrate metabolism. Lactulose presumably reduces pathogenic bacteria in favor of the health promoting bifidusflora; also, production and absorption of endotoxines may be reduced; this suggests that lactulose may have therapeutic effects on both infectious and idiopathic inflammatory bowel diseases. Numerous studies with interesting but not as yet convincingly documented clinical relevance suggest that the many effects of lactulose may be interesting subjects for future research.

Effects of lactulose and lactitol on colonic microflora and enzymatic activity

The effects of lactulose and lactitol (2 x 10 g/d) were studied in 36 healthy volunteers in comparison to placebo. All parameters studied were affected by both treatments, lactulose in general leading to more pronounced changes compared to lactitol. Probiotic bacteria were increased, and putrefactive bacteria and potential pathogens were significantly reduced. These variations in colonic flora had the following consequences: (i) a reduced activity of pro-carcinogenic enzymes: azoreductase, 7 alpha-dehydroxylase, beta-glucuronidase, nitroreductase and urease activity; (ii) a global increase of short-chain fatty acids in faeces; (iii) an effect on pH and moisture of faeces, and (iv) also on aromatic compounds such as phenol, cresol, indole and skatol. The findings suggest that lactulose and lactitol are not comparable in their effect on the colonic microflora, its metabolism, and the consequent probiotic effects on human health. The differences found may also be of clinical relevance suggesting that neither compound is equipotent.

[Ventral hyperostosis of the cervical spine--a rare differential diagnosis of dysphagia]

A case of dysphagia and hoarseness due to external compression by anterior hyperostosis between the third and fourth cervical vertebra is reported. Immediate relief of the symptoms was accomplished by surgical excision of the hyperostosis through an antero-lateral approach. The pathogenesis of the symptoms with reference to literature is discussed.

Potent photoaffinity labelled and iodinated antagonists of bradykinin

Continuing the studies on photoaffinity labelled analogues of the peptide hormone bradykinin (BK), several labelled antagonists were synthesized and characterized regarding their biological activities on rat uterus (RUT) and guinea pig ileum (GPI). The photoreactive amino acid p-benzoyl-phenylalanine (Bpa) was incorporated in potent, iodinated BK analogues at positions -2, -1, 0 and 7. The newly synthesized BK antagonists were derived from HOE 140 ([DArg0, Hyp3, Thi5, D-Tic7, Oic8]-BK) or [D-Phe7]-BK. Because the application of Bpa requires an additional group for the introduction of 125I, iodinated tyrosine was inserted at different positions as a model for radioiodination. Suitable positions for incorporation of tyrosine residues are -1, 0, 3 and 7, whereas the compound with 3-I-Tyr at position 4 had only a low biological activity. The antagonists obtained by modification of HOE 140 generally retained a high antagonistic potency. In this group [D-Bpa-2, 3-I-D-Tyr-1, D-Arg0, Hyp3, Thi5, D-Tic7, Oic8]-BK (pA2 values 8.06 on RUT and 8.15 on GPI) and [Bpa-1, D-Arg0, 3-I-Tyr3, Thi5, D-Tic7, Oic8]-BK (pA2 values 7.55 on RUT and 8.07 on GPI) belong to the most active compounds. The incorporation of D-Bpa at position 7 also resulted in potent analogues. The antagonists [3-I-Tyr-1, D-Arg0, D-Bpa7]-BK (pA2 on RUT 7.69) and [3-I-Tyr-1, D-Arg0, D-Bpa7, Oic8]-BK (pA2 on GPI 7.53) are an alternative to the N-terminal modified HOE 140 analogues. Compounds with D-Bpa7 act as pure competitive antagonists, whereas the HOE 140 derivatives show a mixed antagonism. The comparison of the results between photoaffinity labelled agonists and antagonists suggests that modifications in the series of BK antagonists were better tolerated.

New photoaffinity labelled agonists of bradykinin

Several photoaffinity labelled agonists of the peptide hormone bradykinin (BK) were synthesized by solid phase methods. Their biological activities and binding affinities were determined in both the isolated rat uterus (RUT) and guinea pig ileum (GPI). As photoreactive groups p-benzoyl-phenylalanine (Bpa) and the arylazides azidobenzoic acid (ABA) and azidosalicylic acid (ASA) were attached to the N-terminus of the BK agonists. In addition, Bpa was incorporated at different positions of the BK sequence. Three different types of BK agonists were used. Firstly, the photolabels ASA and ABA were attached to BK or to Lys-BK (kallidin). Secondly, tyrosine containing BK analogues, suitable for radioiodination, were labelled. This series is derived from the naturally occurring analogue phyllokinin [BK-Ile-Tyr(SO3H)] and from BK analogues with tyrosine at position 0 and 3. The third series includes several analogues with D-N-methyl-phenylalanine (D-NMe-Phe) at position 7, which selectively discriminate between the RUT and GPI bradykinin B2 receptors. Among the photoaffinity labelled BK agonists, the iodinatable Lys(ASA)-BK (50.8% on RUT, 73.0% on GPI), ASA-BK (26.3% on RUT), Bpa-BK-Ile-Tyr (13.6% on RUT, 14.0% on GPI) and the iodinated [D-Bpa-1, 3-I-Tyr0]-BK (15.5% on RUT, 19.0% on GPI) retained a relatively high biological activity compared with BK (100%). Thus, although BK agonists are known to allow only very restricted modifications without a strong reduction in biological activity, these compounds should be useful candidates for receptor labelling.

[Contraception the "morning after." A too little used opportunity]

With the constant high number of abortions, it seems that the propagation of the still little known post coital contraception--as an emergency "brake" the morning after--is urgently necessary. The three known hormonal methods, i.e. the oestrogen method, the gestagen method and the combination method as well as the intentional post coital insertion of an intra uterine device, are discussed as far as the application, advantages and disadvantages are concerned. The combination method, i.e. the application of 0,2 mg ethinylestradiol and 2,0 mg norgestrel seems to be the most recommendable, as it combines a high contraceptive assurance with good tolerance and use. The legal and moral considerations for post coital contraception are discussed.

Dependence of interfacial properties of normal and transformed 3T3 cell membranes on treatment with factors modifying proliferation

Interfacial properties of the outer cell membrane of normal and transformed in vitro cultures of mouse 3T3 cells have been investigated. The contact angles of sessile drops on dried cell preparations were measured and the interfacial tensions derived using the thermodynamic approach introduced by Neumann. Interfacial tensions were found to be within an order of magnitude of those determined for other cell and model membranes. Treatment of cells with calf serum, a stimulant to proliferation, resulted in a decrease in the interfacial tension of normal and transformed cells, whereas use of concanavalin A and its succinylated derivative lead to an increase of interfacial tensions of both cell types. These and further results show a detailed correlation between the growth-regulating effects and the effects on interfacial properties of these proliferation-modifying factors. An interpretation of the results of serum depression of the interfacial tension in terms of a binding equilibrium dependent on the concentration of humoral growth factors in the medium is attempted.