Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Preservation of vascular endothelial repair in mice with diet-induced obesity

INTRODUCTION

Preservation of structural integrity of the endothelial monolayer and maintenance of endothelial cell function are of critical importance in preventing arterial thrombosis, restenosis and atherosclerosis. Obesity has been intimately linked with endothelial dysfunction, and reports of reduced abundance and functional impairment of circulating progenitor cells in obesity have led to the suggestion that defective endothelial repair contributes to obesity-related cardiovascular disease.

METHODS

C57BL/6 mice were fed a high-fat diet for either 3 or 6 months to induce obesity; metabolic phenotyping was then carried out before femoral artery wire injury was performed. Endothelial regeneration was then quantified. Mononuclear cells and myeloid angiogenic cells were cultured and characterized for pro-angiogenic properties.

RESULTS

No impairment of endothelial regeneration following mechanical endothelial injury in diet-induced obese mice when compared with chow-fed controls was observed, despite the induction of an adverse metabolic phenotype characterized by glucose intolerance and insulin resistance. Dietary-obese mice had increased numbers of circulating myeloid angiogenic cells, which retained normal functional properties including intact paracrine angiogenic effects.

CONCLUSION

Preserved endothelial regeneration despite metabolic dysregulation in dietary obese mice suggests that compensatory mechanisms mitigate the deleterious influence of insulin resistance on endothelial repair in obesity.

Ischio-ilial Pinning for Stabilization of Coxo-femoral Luxations: An Anatomical Study

Bilateral cranio-dorsal coxo-femoral luxations were created in 20 canine cadavers. After reduction, ischio-ilial pins were placed bilaterally, at one of three insertion sites ventral or ventro-lateral to the ischiatic tuberosity. Stability of the reduction was assessed before and after pin placement. All (20) pins placed in the central position prevented the femoral head from luxating to the cranio-dorsal position, while cranio-dorsal luxations occurred in two of 10 cadavers after medial pin placement and two of 10 cadavers after lateral pin placement. The pelvic region was dissected to assess the relationship of the pin to the regional anatomy. Pins placed at the central position were often in contact with the ischiatic nerve, while pins placed in the medial and lateral positions were not. Pins placed in the central position afford the greatest stability; however, they also have the greatest potential of ischiatic nerve trauma.

The stability, resulting from ischio-ilial pinning, to prevent coxo-femoral luxation was studied in canine cadavers

Detection of Salmonella enterica Serovar Montevideo and Newport in Free-ranging Sea Turtles and Beach Sand in the Caribbean and Persistence in Sand and Seawater Microcosms

Salmonellae are Gram-negative zoonotic bacteria that are frequently part of the normal reptilian gastrointestinal flora. The main objective of this project was to estimate the prevalence of non-typhoidal Salmonella enterica in the nesting and foraging populations of sea turtles on St. Kitts and in sand from known nesting beaches. Results suggest a higher prevalence of Salmonella in nesting leatherback sea turtles compared with foraging green and hawksbill sea turtles. Salmonella was cultured from 2/9 and identified by molecular diagnostic methods in 3/9 leatherback sea turtle samples. Salmonella DNA was detected in one hawksbill turtle, but viable isolates were not recovered from any hawksbill sea turtles. No Salmonella was detected in green sea turtles. In samples collected from nesting beaches, Salmonella was only recovered from a single dry sand sample. All recovered isolates were positive for the wzx gene, consistent with the O:7 serogroup. Further serotyping characterized serovars Montevideo and Newport present in cloacal and sand samples. Repetitive-element palindromic PCR (rep-PCR) fingerprint analysis and pulsed-field gel electrophoresis of the 2014 isolates from turtles and sand as well as archived Salmonella isolates recovered from leatherback sea turtles in 2012 and 2013, identified two distinct genotypes and four different pulsotypes, respectively. The genotyping and serotyping were directly correlated. To determine the persistence of representative strains of each serotype/genotype in these environments, laboratory-controlled microcosm studies were performed in water and sand (dry and wet) incubated at 25 or 35°C. Isolates persisted for at least 32 days in most microcosms, although there were significant decreases in culturable bacteria in several microcosms, with the greatest reduction in dry sand incubated at 35°C. This information provides a better understanding of the epizootiology of Salmonella in free-ranging marine reptiles and the potential public health risks associated with human interactions with these animals in the Caribbean.

Dynamics of piscine francisellosis differs amongst tilapia species (Oreochromis spp.) in a controlled challenge with Francisella noatunensis subsp. orientalis

A 25-week immersion challenge was conducted exposing Oreochromis mossambicus, Oreochromis aureus and Oreochromis urolepis hornorum to Francisella noatunensis subsp. orientalis (Fno). Two populations were compared for each fish species; 'resident fish' were defined as fish maintained in tanks since week 0 of challenge, whereas 'naïve fish' were defined as fish added to tanks once temperature in water reached <26 °C at 21 weeks post-challenge. Fno genome equivalents (GEs) in water were similar in all treatments 1 h post-challenge; however, significantly lower Fno GEs were detected 2 weeks post-challenge in all tanks, and the only treatment with detectable Fno GE after 4 weeks of challenge were the O. mossambicus tanks. Twenty-one weeks post-challenge, naïve fish were stocked with 'resident' cohorts. Over a 4-week period, mortalities occurred consistently only in O. mossambicus naïve cohorts. Overall presence of granulomas in spleen of survivors was similar (>55%) in all resident populations; however, in naïve populations, only O. mossambicus presented granulomas. Similarly, only O. mossambicus presented viable Fno in the spleen of survivors, and Fno GEs were only detected in O. mossambicus, and in resident O. aureus. In conclusion, the results of this study suggest different susceptibility of tilapia species to piscine francisellosis.

Prospective development and validation of a model to predict heart failure hospitalisation

Objective

Acute heart failure syndrome (AHFS) is a major cause of hospitalisation and imparts a substantial burden on patients and healthcare systems. Tools to define risk of AHFS hospitalisation are lacking.

Methods

A prospective cohort study (n=628) of patients with stable chronic heart failure (CHF) secondary to left ventricular systolic dysfunction was used to derive an AHFS prediction model which was then assessed in a prospectively recruited validation cohort (n=462).

Results

Within the derivation cohort, 44 (7%) patients were hospitalised as a result of AHFS during 1 year of follow-up. Predictors of AHFS hospitalisation included furosemide equivalent dose, the presence of type 2 diabetes mellitus, AHFS hospitalisation within the previous year and pulmonary congestion on chest radiograph, all assessed at baseline. A multivariable model containing these four variables exhibited good calibration (Hosmer–Lemeshow p=0.38) and discrimination (C-statistic 0.77; 95% CI 0.71 to 0.84). Using a 2.5% risk cut-off for predicted AHFS, the model defined 38.5% of patients as low risk, with negative predictive value of 99.1%; this low risk cohort exhibited <1% excess all-cause mortality per annum when compared with contemporaneous actuarial data. Within the validation cohort, an identically applied model derived comparable performance parameters (C-statistic 0.81 (95% CI 0.74 to 0.87), Hosmer–Lemeshow p=0.15, negative predictive value 100%).

Conclusions

A prospectively derived and validated model using simply obtained clinical data can identify patients with CHF at low risk of hospitalisation due to AHFS in the year following assessment. This may guide the design of future strategies allocating resources to the management of CHF.

Molecular and functional characterization of vacuolar-ATPase from the American dog tick Dermacentor variabilis

Vacuolar (V)-ATPase is a proton-translocating enzyme that acidifies cellular compartments for various functions such as receptor-mediated endocytosis, intracellular trafficking and protein degradation. Previous studies in Dermacentor variabilis chronically infected with Rickettsia montanensis have identified V-ATPase as one of the tick-derived molecules transcribed in response to rickettsial infection. To examine the role of the tick V-ATPase in tick-Rickettsia interactions, a full-length 2887-bp cDNA (2532-bp open reading frame) clone corresponding to the transcript of the V0 domain subunit a of D. variabilis V-ATPase (DvVATPaseV0a) gene encoding an 843 amino acid protein with an estimated molecular weight of ~96 kDa was isolated from D. variabilis. Amino acid sequence analysis of DvVATPaseV0a showed the highest similarity to VATPaseV0a from Ixodes scapularis. A potential N-glycosylation site and eight putative transmembrane segments were identified in the sequence. Western blot analysis of tick tissues probed with polyclonal antibody raised against recombinant DvVATPaseV0a revealed the expression of V-ATPase in the tick ovary. Transcriptional profiles of DvVATPaseV0a demonstrated a greater mRNA expression in the tick ovary, compared with the midgut and salivary glands; however, the mRNA level in each of these tick tissues remained unchanged after infection with R. montanensis for 1 h. V-ATPase inhibition bioassays resulted in a significant decrease in the ability of R. montanensis to invade tick cells in vitro, suggesting a role of V-ATPase in rickettsial infection of tick cells. Characterization of tick-derived molecules involved in rickettsial infection is essential for a thorough understanding of rickettsial transmission within tick populations and the ecology of tick-borne rickettsial diseases.

Diabetes mellitus and the heart

Diabetes mellitus is a risk factor for the development of coronary artery disease and chronic heart failure. When carefully screened for, diabetes or prediabetic disorders, are present in the majority of patients with clinically manifest ischaemic heart disease, and confer a major adverse impact upon morbidity and mortality. Important therapeutic modifications are required in the management of coronary artery disease and chronic heart failure associated with diabetes, and vice versa. However, despite optimal management, aided by recent landmark trials solely recruiting patients with diabetes, outcomes for patients with diabetes and heart disease remain poor. This review outlines the epidemiology, pathogenesis and management of diabetic heart disease, along with highlighting the many gaps in the evidence-base and suggesting future research priorities.

A comparison of two integrated approaches of controlling nematode parasites in small ruminants

Control of gastrointestinal nematodes (GIN) in small ruminants in regions of the world where anthelmintic resistance is prevalent must rely on more than just chemical deworming strategies. The objective of this experiment was to compare two integrated treatment protocols for control of GIN (primarily Haemonchus contortus in this region) using anthelmintics, copper oxide wire particles (COWP) and FAMACHA(©), compared to traditional anthelmintic use only. Three separate trials were conducted on mature ewes, weaned goats, and weaned lambs in which three deworming management strategies were applied: 1) all animals were dewormed with levamisole at four week intervals (LEV), 2) individual animals were dewormed with moxidectin when scored≥4 (ewes) or ≥3 (kids and lambs) using FAMACHA(©) (FAM/MOX), 3) all animals were dewormed with moxidectin initially and again with COWP (2g) when group mean FEC exceeded 500 (ewes), 3000 (kids), or 1000 (lambs) eggs/g (MOX/COWP). In this final group, during periods between group treatments, individual animals were dewormed with albendazole and levamisole according to FAMACHA(©) score. Fecal egg counts (FEC) and blood packed cell volume (PCV) were determined every 7 days and body weight every 28 days for 30, 20, or 16 weeks in ewes, goats, and lambs, respectively. Efficacy of levamisole was 83.4-86.4%, efficacy of moxidectin was 93.5-100%, and efficacy of COWP was 10.8-98.1% among the three trials. The mean number of deworming treatments per animal that occurred for the LEV, FAM/MOX, and MOX/COWP groups, respectively, was 7.9, 0.6, and 2.5±0.4 (P<0.001) for ewes, 5.2, 1.6, and 3.4±0.3 (P<0.001) for goats, and 4.0, 1.7, and 3.6±0.2 (P<0.001) for lambs. Production (body weight of lambs weaned from ewes or final body weight of kids and lambs) was similar among management strategy groups for ewes and kids, but FAM/MOX lambs were lighter by the end of the trial (P<0.003). While more time and labor was required to use the FAMACHA(©) system, a more conservative use of anthelmintics occurred in the FAM/MOX group.

Non-invasive assessment of saphenous vein graft patency in asymptomatic patients

The development and progression of atherosclerotic disease in saphenous vein grafts (SVGs) following coronary artery bypass surgery (CABG) are often without symptoms. Four-slice CT is a non-invasive imaging technique reliable for assessing SVG patency. This study utilised CT to assess temporal progression of patency in asymptomatic patients. A four-slice CT scanner was used employing standard techniques. Analysis of the reconstructed images was performed offline by two experienced operators blinded to patient details. The primary aim was vein graft patency. 130 asymptomatic subjects were studied. The mean time from CABG was 7.3 years (range, 15 days to 21 years 9 months; standard deviation (SD), 4.4 years). 294 of the 305 SVGs were suitable for assessment of patency. The overall occlusion rate for assessable grafts was 23.5%. Occlusion rates for grafts <1 year old was 12.5% (2/16), 20.7% (42/203) for grafts 1-10 years old, and 33.3% (25/75) for grafts >10 years old. In conclusion, significant occlusion of SVGs occurs early after CABG in asymptomatic patients. Four-slice CT has the potential for the non-invasive assessment of individuals after surgery.

Secondary prevention of cardiovascular disease in type 2 diabetes and prediabetes: a cardiologist's perspective

Patients with type 2 diabetes mellitus (T2DM) and prediabetes have a substantially greater risk of developing cardiovascular (CV) disease than the general population. This increased risk of CV disease is due to a complex cluster of risk factors including insulin resistance, hyperglycaemia, diabetic dyslipidaemia, hypertension and systemic inflammation. As a result of this cluster of risk factors, life expectancy is reduced by up to 10 years upon diagnosis of T2DM, principally because of fatal CV events. Patients with T2DM are not only more likely to sustain a CV event, but also have a higher risk of a fatal outcome from this event. Therefore, whilst primary prevention is critical in determining the prognosis of patients newly diagnosed with T2DM, many will go on to suffer CV events and represent a high-risk group requiring intensive secondary prevention techniques. Recent data demonstrate that contemporary prevention therapies do not afford equal benefits to T2DM sufferers after acute myocardial infarction compared with their non-diabetic counterparts. This finding highlights the need for more effective secondary preventative strategies to prevent recurrent CV events in patients with T2DM and prediabetes. The cardiologist's role in the multidisciplinary management of T2DM is to improve patient outcomes by optimising use of evidence-based strategies for the prevention of recurrent CV events.

Effect of sericea lespedeza (Lespedeza cuneata) fed as hay, on natural and experimental Haemonchus contortus infections in lambs

Parasitic infection is one of the leading economic constraints in small ruminant production. This problem is exacerbated as the resistance of nematode populations to chemical treatment (anthelmintics) becomes increasingly more common. Condensed tannin (CT) containing plants are being investigated as alternative solutions to address these problems. This investigation was conducted to evaluate the effect of the CT containing forage, Lespedeza cuneata (sericea lespedeza, SL) fed as hay, on Haemonchus contortus infection in sheep. Naturally and experimentally infected lambs were fed either SL or bermudagrass (BG, control) hay for 49 days. All lambs were fed BG hay for an additional 14 days. SL hay effectively reduced (67-98%) fecal egg count (FEC) during the time of feeding for both infection groups. FEC increased in both infection groups after SL feeding was stopped which indicated an effect on fecundity. SL hay feeding also reduced worm numbers, with more of an effect on reducing naturally infected worm burdens (67.2%) than on establishment of incoming larvae (26.1%). SL fed as hay may be more useful to remove existing worms than establishing worms. The decrease in FEC would have the benefit of reduced pasture contamination.

Effect of fat distribution on endothelial-dependent and endothelial-independent vasodilatation in healthy humans

AIM

The present study aims to explore the relationship between inflammatory cytokines, plasma lipids, insulin, blood pressure (BP), total adiposity/markers of fat distribution and endothelial function in healthy people across a wide range of body fatness.

METHODS

Seventy-three healthy people (44 women; age range: 24-64 years) with body mass index (BMI) range of 18.6-73.1 kg/m2 were recruited. All participants underwent assessment of conduit artery endothelial-dependent vasodilatation by using flow-mediated vasodilatation (FMD) of the brachial artery and endothelial-independent vasodilatation to sublingual GTN. They had blood taken for measurement of plasma markers of glucose homeostasis (fasting insulin and glucose), systemic inflammation (interleukin-6 (IL-6), C-reactive protein (CRP) and tumour necrosis factor-alpha receptor 2 (TNF-alpha R2)) and lipids (low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides). Morphometric assessment (waist circumference, BMI and waist-to-hip ratio (WHR)) and systolic and diastolic arterial pressure were also measured.

RESULTS

Markers of total body fat/fat distribution (waist circumference, BMI and WHR), inflammation (IL-6, CRP and TNF-alpha R2), metabolism (fasting insulin, HDL, LDL and triglycerides) and BP (systolic and diastolic) correlated with FMD. Among these measurements, WHR was the only independent predictor of FMD (r2 = 0.30; p = 0.0001).

CONCLUSIONS

WHR is an important marker of endothelial dysfunction in healthy people across a wide range of body fatness.

Real-Time Three-Dimensional Echocardiography

Background— Left ventricular (LV) mechanical dyssynchrony (LVMD) has emerged as a therapeutic target using cardiac resynchronization therapy (CRT) in selected patients with chronic heart failure. Current methods used to evaluate LVMD are technically difficult and do not assess LVMD of the whole LV simultaneously. We developed and validated real-time 3D echocardiography (RT3DE) as a novel method to assess global LVMD.

Methods and Results— Eighty-nine healthy volunteers and 174 unselected patients referred for routine echocardiography underwent 2D echocardiography and RT3DE. RT3DE data sets provided time-volume analysis for global and segmental LV volumes. A systolic dyssynchrony index (SDI) was derived from the dispersion of time to minimum regional volume for all 16 LV segments. Healthy subjects and patients with normal LV systolic function had highly synchronized segmental function (SDI, 3.5±1.8% and 4.5±2.4%; P =0.7). SDI increased with worsening LV systolic function regardless of QRS duration (mild, 5.4±0.83%; moderate, 10.0±2%; severe LV dysfunction, 15.6±1%; P for trend <0.001). We found that 37% of patients with moderate to severe LV systolic dysfunction had significant dyssynchrony with normal QRS durations (SDI, 14.7±1.2%). Twenty-six patients underwent CRT. At long-term follow-up, responders demonstrated reverse remodeling after CRT with a significant reduction in SDI (16.9±1.1% to 6.9±1%; P <0.0001) and end-diastolic volume (196.6±17.3 to 132.1±13.5 mL; P <0.0001) associated with an increase in LV ejection fraction (17±2.2% to 31.6±2.9%; P <0.0001).

Conclusions— RT3DE can quantify global LVMD in patients with and without QRS prolongation. RT3DE represents a novel technique to identify chronic heart failure patients who may otherwise not be considered for CRT.

Predicting sudden death in patients with mild to moderate chronic heart failure

OBJECTIVES

To explore the relation between non-invasive measures of cardiac function and sudden cardiac death, as well as the development and utility of an index integrating these variables to identify patients at increased risk of this mode of death.

DESIGN

UK-HEART (United Kingdom-heart failure evaluation and assessment of risk trial) was a prospective study conducted between December 1993 and April 2000. The study was specifically designed to identify non-invasive markers of death and mode of death among patients with chronic heart failure.

SETTING

8 UK general hospitals.

MAIN OUTCOME MEASURES

Death and mode of death.

RESULTS

553 patients aged a mean (SD) of 63 (10) years, in New York Heart Association functional class 2.3 (0.02), recruited prospectively. After 2365 patient-years' follow up, 201 patients had died (67 suddenly). Predictors of sudden death were greater cardiothoracic ratio, QRS dispersion, QT dispersion corrected for rate (QTc) across leads V1-V6 on the 12 lead ECG, and the presence of non-sustained ventricular tachycardia. The hazard ratio and 95% confidence intervals (CI) of sudden death for a 10% increase in cardiothoracic ratio was 1.43 (95% CI 1.20 to 1.71), for a 10% increase in QRS dispersion 1.11 (95% CI 1.04 to 1.19), for the presence of non-sustained ventricular tachycardia 2.03 (95% CI 1.27 to 3.25), and for a 10% increase in QTc dispersion across leads V1-V6 1.03 (95% CI 1.00 to 1.07) (all p < 0.04). An index derived from these four factors performed well in identifying patients specifically at increased risk of sudden death.

CONCLUSIONS

Results show that an index derived from three widely available non-invasive investigations has the potential to identify ambulant patients with chronic heart failure at increased risk of sudden death. This predictive tool could be used to target more sophisticated investigations or interventions aimed at preventing sudden death.

Inspiratory muscle load and capacity in chronic heart failure

BACKGROUND

Although breathlessness is common in chronic heart failure (CHF), the role of inspiratory muscle dysfunction remains unclear. We hypothesised that inspiratory muscle endurance, expressed as a function of endurance time (Tlim) adjusted for inspiratory muscle load and inspiratory muscle capacity, would be reduced in CHF.

METHODS

Endurance was measured in 10 healthy controls and 10 patients with CHF using threshold loading at 40% maximal oesophageal pressure (Poes(max)). Oesophageal pressure-time product (PTPoes per cycle) and Poes(max) were used as indices of inspiratory muscle load and capacity, respectively.

RESULTS

Although Poes(max) was slightly less in the CHF group (-117.7 (23.6) v -100.0 (18.3) cm H(2)O; 95% CI -37.5 to 2.2 cm H(2)O, p = 0.1), Tlim was greatly reduced (1800 v 306 (190) s; 95% CI 1368 to 1620 s, p<0.0001) and the observed PTPoes per cycle/Poes(max) was increased (0.13 (0.05) v 0.21 (0.04); 95% CI -0.11 to -0.03, p = 0.001). Most of this increased inspiratory muscle load was due to a maladaptive breathing pattern, with a reduction in expiratory time (3.0 (5.8) v 1.1 (0.3) s; 95% CI 0.3 to 3.5 s, p = 0.03) accompanied by an increased inspiratory time relative to total respiratory cycle (Ti/Ttot) (0.43 (0.14) v 0.62 (0.07); 95% CI -0.3 to -0.1, p = 0.001). However, log Tlim, which incorporates the higher inspiratory muscle load to capacity ratio caused by this altered breathing pattern, was >/=85% predicted in seven of 10 patients.

CONCLUSIONS

Although a marked reduction in endurance time was observed in CHF, much of this reduction was explained by the increased inspiratory muscle load to capacity ratio, suggesting that the major contributor to task failure was a maladaptive breathing pattern rather than impaired inspiratory muscle endurance.

Comparison of adhesion formation associated with Pro-Tack (US Surgical) versus a new mesh fixation device, Salute (ONUX Medical)

BACKGROUND

We evaluated efficacy and associated adhesion formation of an innovative mesh fixation device versus the helical tack device and analyzed two implantation techniques.

METHODS

Six purpose-bred female hounds were evaluated in this 90-day survival study. Six 4-cm round patches of 1-mm thick DualMesh were fixed to the abdominal wall with either 10 Pro-Tack or 10 Salute constructs in each patch. Zero to 4 additional patches were implanted with only Salute constructs.

RESULTS

Adhesion severity scores were significantly higher for middle left abdominal wall sites versus lower right and upper left sites. The adhesion dissection score was higher for group T (Pro-Tack) versus group S (Salute).

CONCLUSION

No significant effects occurred with adhesion extent scores, but group T developed denser adhesions. The second analysis determined that no significant differences existed relevant to secondary Salute placement, although the total score approached significance (p < 0.09). Salute equipment was easier to handle and allowed repositioning of the patch during operation.

Equine cyathostome populations: accuracy of species composition estimations

Historically, surveys of equine parasites either are not quantitative in regard to prevalence and intensities of cyathostome species, or if quantitative, are estimates based on the identification of a very small sample of the population. Commonly 100-200 worms are identified. In the current study cyathostomes from 10 ponies were counted and identified to species in subsets of approximately 200 worms each from 5% aliquots of the large intestine contents until all worms in the aliquot were examined. A mean of 10.9+/-4.3 species were identified by examining 200 cyathostomes from each animal. This number increased to 25.2+/-2.6 species when the 5% aliquots were totally examined, indicating that prevalence rates from species with low intensities are probably much greater than previous survey data indicate. A statistical model was used to determine how many worms need to be identified to give a 95% confidence level that all species present are identified.

Pathophysiological implications of insulin resistance on vascular endothelial function

BACKGROUND

Insulin resistance is a key component of the insulin resistance syndrome and is a crucially important metabolic abnormality in Type 2 diabetes. Insulin-resistant individuals are at significantly increased risk of cardiovascular disease, although the underlying mechanisms remain incompletely understood. The endothelium is thought to play a critical role in maintaining vascular homeostasis, a process dependent on the balance between the production of nitric oxide, superoxide and other vasoactive substances. Endothelial dysfunction has been demonstrated in insulin-resistant states in animals and humans and may represent an important early event in the development of atherosclerosis. Insulin resistance may be linked to endothelial dysfunction by a number of mechanisms, including disturbances of subcellular signalling pathways common to both insulin action and nitric oxide production. Other potential unifying links include the roles of oxidant stress, endothelin, the renin angiotensin system and the secretion of hormones and cytokines by adipose tissue. Lifestyle measures and drug therapies which improve insulin sensitivity and ameliorate endothelial dysfunction may be important in delaying the progression to overt cardiovascular disease in at risk individuals.

METHODS

We conducted a literature search using Medline, restricted to articles published in the English language between 1966 and the present, and reviewed bibliographies of relevant articles. An initial search strategy employing combinations of the MeSH terms: insulin resistance; endothelium, vascular; insulin; nitric oxide or hyperinsulinaemia produced over 300 references. Focused searches using keywords relevant to the molecular aspects of endothelial function and insulin signalling, and lifestyle or pharmacological interventions relevant to insulin resistance or endothelial function, produced over 300 further references. Abstracts of all references were screened before selecting those relevant to this review.

Nitric oxide and myocardial function in heart failure: friend or foe?

There is good evidence that nitric oxide has important autocrine/paracrine effects in the myocardium, serving to optimise and fine tune cardiac function

Obesity, atherosclerosis and the vascular endothelium: mechanisms of reduced nitric oxide bioavailability in obese humans

It is now well established that obesity is an independent risk factor for the development of coronary artery atherosclerosis. The maintenance of vascular homeostasis is critically dependent on the continued integrity of vascular endothelial cell function. A key early event in the development of atherosclerosis is thought to be endothelial cell dysfunction. A primary feature of endothelial cell dysfunction is the reduced bioavailability of the signalling molecule nitric oxide (NO), which has important anti atherogenic properties. Recent studies have produced persuasive evidence showing the presence of endothelial dysfunction in obese humans NO bioavailability is dependent on the balance between its production by a family of enzymes, the nitric oxide synthases, and its reaction with reactive oxygen species. The endothelial isoform (eNOS) is responsible for a significant amount of the NO produced in the vascular wall. NO production can be modulated in both physiological and pathophysiological settings, by regulation of the activity of eNOS at a transcriptional and post-transcriptional level, by substrate and co-factor provision and through calcium dependent and independent signalling pathways. The present review discusses general mechanisms of reduced NO bioavailability including factors determining production of both NO and reactive oxygen species. We then focus on the potential factors responsible for endothelial dysfunction in obesity and possible therapeutic interventions targetted at these abnormalities.

Effects of nitric oxide synthase inhibition on Basal function and the force-frequency relationship in the normal and failing human heart in vivo

BACKGROUND

Nitric oxide (NO) exerts autocrine/paracrine effects on cardiac function, including alterations of the inotropic state. In vitro studies suggest that NO modulates the myocardial force-frequency relationship. Basal left ventricular (LV) contractility is depressed and the force-frequency relationship is blunted in human heart failure, and it is speculated that an increase in NO production is involved.

METHODS AND RESULTS

We compared the effects of intracoronary NO synthase inhibition with N(G)-monomethyl-L-arginine (L-NMMA; 25 micromol/min) on basal LV function and the response to incremental atrial pacing in patients with dilated cardiomyopathy (n=11; mean age, 51 years) and in control subjects with atypical chest pain and normal cardiac function (n=7; mean age, 54 years). In controls, L-NMMA significantly reduced basal LV dP/dt(max) (from 1826 to 1578 mm Hg/s; P<0.002), but had no effect on heart rate, mean aortic pressure, or right atrial pressure. Pacing-induced increases in LV dP/dt(max) were unaltered by L-NMMA. In patients with dilated cardiomyopathy, L-NMMA had no effect on baseline LV dP/dt(max) (from 1313 to 1337 mm Hg/s; P=NS). The blunted pacing-induced rise in LV dP/dt(max) in these patients was unaltered by L-NMMA.

CONCLUSION

Endogenous NO has a small baseline positive inotropic effect in the normal human heart, which is lost in heart failure patients. NO does not significantly influence the force-frequency relationship in either the normal or failing human heart in vivo. Because this study was performed in patients with moderate heart failure, whether the findings apply to subjects with more severe heart failure requires further investigation.

Viral myocarditis and dilated cardiomyopathy: mechanisms, manifestations, and management

Viral infection of the heart is relatively common and usually of little consequence. It can, however, lead to substantial cardiac damage and severe acute heart failure. It can also evolve into the progressive syndrome of chronic heart failure. Recent studies have gone some way towards unravelling the complex mechanisms underlying the heart muscle damage that occurs after viral infection. These studies have lent support to both immune and viral mediated (independent of an immune response) cardiac damage. Acute myocarditis can present in various ways, and it may be a cause of sudden death in an otherwise healthy young adult. New treatments for viral heart disease are awaited. In the meanwhile, the haemodynamic support of patients with acute left ventricular failure caused by myocarditis should be aggressive, to allow for the possibility of spontaneous recovery. Contemporary trials of treatment in chronic heart failure secondary to dilated cardiomyopathy support the use of angiotensin converting enzyme inhibitors, beta adrenoceptor blockers, and spironolactone in such patients.

Differences in susceptibility to gastrointestinal nematode infection between Angus and Brangus cattle in south Louisiana

Breed susceptibility to nematode infection was evaluated in Angus (Bos taurus) and Brangus (B. indicus crossbreed) cattle. A cow-calf herd and a yearling replacement heifer herd were monitored during one grazing season. Calves were born in March and were weaned in October. Individual rectal fecal samples were collected monthly from the two herds and processed for fecal egg counts (FEC) and coprocultures. Cow and calf FEC increased from April, reaching maximum values during the summer. Angus cows and calves had significantly (p<0.05) greater FEC than Brangus cows and calves, and Haemonchus and Cooperia were the predominant genera. Replacement heifer FEC showed a similar pattern with maximum levels during late summer/fall, and Haemonchus was the predominant genus. No significant differences were seen between breeds, however, infection levels were consistently lower in Brangus heifers. Ostertagia was present in cows and heifers only in fall/winter, which is consistent with summer inhibition. The data suggested that cows were an important source of pasture contamination for their susceptible calves and that the Brangus breed was relatively more resistant to infection. The use of B. indicus crossbreeds may help in alleviating reliance on chemical control by reducing the rate of pasture contamination and subsequent infection losses.

An experimental evaluation of methods used to enumerate mucosal cyathostome larvae in ponies

With the increased interest in equine cyathostomes it has become apparent that some evaluations of methods currently used to count the various larval stages which occur in the mucosa would be beneficial. Experiments were conducted to investigate the effects of fixation and storage of mucosal tissues at -20 C on the accuracy of counting these larvae. The accuracy of counting developing larvae within the mucosa by transmural illumination (TMI) and by artificial digestion (DIG) of the mucosa was also compared. The data indicate that fixation of digested mucosa in PBS-buffered 5% or 10% formalin did not effect the enumeration of either early hypobiotic L3 or larger developing L3 or L4. Although not optimal, counting these larvae by either TMI of DIG after freezing did not significantly differ from counts made on fresh tissues. Significant differences were also not seen between counts of developing larvae made by TMI or DIG. Because DIG must be used to count EL3 and small developing L3, it is possible that TMI is not necessary in heavily infected equids.

Digoxin and mortality in chronic heart failure. UK Heart Investigation

Data from recent clinical trials suggest digoxin is now widely used in patients with chronic heart failure in sinus rhythm. We present data from a heart failure registry that reiterates concerns about the safety of digoxin in this population.