Electro-mechanical response of a 3D nerve bundle model to mechanical loads leading to axonal injury

Traumatic brain injuries and damage are major causes of death and disability. We propose a 3D fully coupled electro-mechanical model of a nerve bundle to investigate the electrophysiological impairments due to trauma at the cellular level. The coupling is based on a thermal analogy of the neural electrical activity by using the finite element software Abaqus CAE 6.13-3. The model includes a real-time coupling, modulated threshold for spiking activation, and independent alteration of the electrical properties for each 3-layer fibre within a nerve bundle as a function of strain. Results of the coupled electro-mechanical model are validated with previously published experimental results of damaged axons. Here, the cases of compression and tension are simulated to induce (mild, moderate, and severe) damage at the nerve membrane of a nerve bundle, made of 4 fibres. Changes in strain, stress distribution, and neural activity are investigated for myelinated and unmyelinated nerve fibres, by considering the cases of an intact and of a traumatised nerve membrane. A fully coupled electro-mechanical modelling approach is established to provide insights into crucial aspects of neural activity at the cellular level due to traumatic brain injury. One of the key findings is the 3D distribution of residual stresses and strains at the membrane of each fibre due to mechanically induced electrophysiological impairments, and its impact on signal transmission.

Electro-mechanical response of a 3D nerve bundle model to mechanical loads leading to axonal injury

Axonal damage is one of the most common pathological features of traumatic brain injury, leading to abnormalities in signal propagation for nervous systems. We present a 3D fully coupled electro-mechanical model of a nerve bundle, made with the finite element software Abaqus 6.13-3. The model includes a real-time coupling, modulated threshold for spiking activation and independent alteration of the electrical properties for each 3-layer fibre within the bundle. Compression and tension are simulated to induce damage at the nerve membrane. Changes in strain, stress distribution and neural activity are investigated for myelinated and unmyelinated nerve fibres, by considering the cases of an intact and of a traumatized nerve membrane. Results show greater changes in transmitting action potential in the myelinated fibre.

Nutrient patterns and brain biomarkers of Alzheimer's disease in cognitively normal individuals

OBJECTIVES

Epidemiological evidence linking diet, one of the most important modifiable lifestyle factors, and risk of Alzheimer's disease (AD) is rapidly increasing. However, there is little or no evidence for a direct association between dietary nutrients and brain biomarkers of AD. This study identifies nutrient patterns associated with major brain AD biomarkers in a cohort of clinically and cognitively normal (NL) individuals at risk for AD.

DESIGN

Cross-sectional study.

SETTING

Manhattan (broader area).

PARTICIPANTS

Fifty-two NL individuals (age 54+12 y, 70% women, Clinical Dementia Rating=0, MMSE>27, neuropsychological test performance within norms by age and education) with complete dietary information and cross-sectional, 3D T1-weighted Magnetic Resonance Imaging (MRI; gray matter volumes, GMV, a marker of brain atrophy), 11C-Pittsburgh compound-B (PiB; a marker of fibrillar amyloid-β, Aβ) and 18F-fluorodeoxyglucose (FDG; a marker of glucose metabolism, METglc) Positron Emission Tomography (PET) scans were examined.

MEASUREMENTS

Dietary intake of 35 nutrients associated with cognitive function and AD was assessed using the Harvard/Willet Food Frequency Questionnaire. Principal component analysis was used to generate nutrient patterns (NP) from the full nutrient panel. Statistical parametric mapping and voxel based morphometry were used to assess the associations of the identified NPs with AD biomarkers.

RESULTS

None of the participants were diabetics, smokers, or met criteria for obesity. Five NPs were identified: NP1 was characterized by most B-vitamins and several minerals [VitB and Minerals]; NP2 by monounsaturated and polyunsaturated fats, including ω-3 and ω-6 PUFA, and vitamin E [VitE and PUFA]; NP3 by vitamin A, vitamin C, carotenoids and dietary fibers [Anti-oxidants and Fibers]; NP4 by vitamin B12, vitamin D and zinc [VitB12 and D]; NP5 by saturated, trans-saturated fats, cholesterol and sodium [Fats]. Voxel-based analysis showed that NP4 scores [VitB12 and D] were positively associated with METglc and GMV, and negatively associated with PiB retention in AD-vulnerable regions (p<0.001). In addition, both METglc and GMV were positively associated with NP2 scores [VitE and PUFA], and negatively associated with NP5 scores [Fats] (p<0.001), and METglc was positively associated with higher NP3 scores [Anti-oxidants and Fibers] (p<0.001). Adjusting for age, gender, ethnicity, education, caloric intake, BMI, alcohol consumption, family history and Apolipoprotein E (APOE) status did not attenuate these relationships. The identified 'AD-protective' nutrient combination was associated with higher intake of fresh fruit and vegetables, whole grains, fish and low-fat dairies, and lower intake of sweets, fried potatoes, high-fat dairies, processed meat and butter.

CONCLUSION

Specific dietary NPs are associated with brain biomarkers of AD in NL individuals, suggesting that dietary interventions may play a role in the prevention of AD by modulating AD-risk through its effects on Aβ and associated neuronal impairment.

Reduced glucose uptake and Aβ in brain regions with hyperintensities in connected white matter

Interstitial concentration of amyloid beta (Aß) is positively related to synaptic activity in animal experiments. In humans, Aß deposition in Alzheimer's disease overlaps with cortical regions highly active earlier in life. White matter lesions (WML) disrupt connections between gray matter (GM) regions which in turn changes their activation patterns. Here, we tested if WML are related to Aß accumulation (measured with PiB-PET) and glucose uptake (measured with FDG-PET) in connected GM. WML masks from 72 cognitively normal (age 61.7 ± 9.6 years, 71% women) individuals were obtained from T2-FLAIR. MRI and PET images were normalized into common space, segmented and parcellated into gray matter (GM) regions. The effects of WML on connected GM regions were assessed using the Change in Connectivity (ChaCo) score. Defined for each GM region, ChaCo is the percentage of WM tracts connecting to that region that pass through the WML mask. The regional relationship between ChaCo, glucose uptake and Aß was explored via linear regression. Subcortical regions of the bilateral caudate, putamen, calcarine, insula, thalamus and anterior cingulum had WM connections with the most lesions, followed by frontal, occipital, temporal, parietal and cerebellar regions. Regional analysis revealed that GM with more lesions in connecting WM and thus impaired connectivity had lower FDG-PET (r = 0.20, p<0.05 corrected) and lower PiB uptake (r = 0.28, p<0.05 corrected). Regional regression also revealed that both ChaCo (β = 0.045) and FDG-PET (β = 0.089) were significant predictors of PiB. In conclusion, brain regions with more lesions in connecting WM had lower glucose metabolism and lower Aß deposition.

Mediterranean Diet and Magnetic Resonance Imaging-Assessed Brain Atrophy in Cognitively Normal Individuals at Risk for Alzheimer's Disease

OBJECTIVES

Epidemiological evidence linking diet, one of the most important modifiable environmental factors, and risk of Alzheimer's disease (AD) is rapidly increasing. Several studies have shown that higher adherence to a Mediterranean diet (MeDi) is associated with reduced risk of AD. This study examines the associations between high vs. lower adherence to a MeDi and structural MRI-based brain atrophy in key regions for AD in cognitively normal (NL) individuals with and without risk factors for AD.

DESIGN

Cross-sectional study.

SETTING

Manhattan (broader area).

PARTICIPANTS

Fifty-two NL individuals (age 54+12 y, 70% women) with complete dietary information and cross-sectional, 3D T1-weighted MRI scans were examined.

MEASUREMENTS

Subjects were dichotomized into those showing higher vs. lower adherences to the MeDi using published protocols. Estimates of cortical thickness for entorhinal cortex (EC), inferior parietal lobe, middle temporal gyrus, orbitofrontal cortex (OFC) and posterior cingulate cortex (PCC) were obtained by use of automated segmentation tools (FreeSurfer). Multivariate general linear models and linear regressions assessed the associations of MeDi with MRI measures.

RESULTS

Of the 52 participants, 20 (39%) showed higher MeDi adherence (MeDi+) and 32 (61%) showed lower adherence (MeDi-). Groups were comparable for clinical, neuropsychological measures, presence of a family history of AD (FH), and frequency of Apolipoprotein E (APOE) ε4 genotype. With and without controlling for age and total intracranial volume, MeDi+ subjects showed greater thickness of AD-vulnerable ROIs as compared to MeDi- subjects (Wilk's Lambda p=0.026). Group differences were most pronounced in OFC (p=0.001), EC (p=0.03) and PCC (p=0.04) of the left hemisphere. Adjusting for gender, education, FH, APOE status, BMI, insulin resistance scores and presence of hypertension did not attenuate the relationship.

CONCLUSION

NL individuals showing lower adherence to the MeDi had cortical thinning in the same brain regions as clinical AD patients compared to those showing higher adherence. These data indicate that the MeDi may have a protective effect against tissue loss, and suggest that dietary interventions may play a role in the prevention of AD.

MEDITERRANEAN DIET AND MAGNETIC RESONANCE IMAGING-ASSESSED BRAIN ATROPHY IN COGNITIVELY NORMAL INDIVIDUALS AT RISK FOR ALZHEIMER’S DISEASE

OBJECTIVES: Epidemiological evidence linking diet, one of the most important modifiable environmental factors, and risk of Alzheimer’s disease (AD) is rapidly increasing. Several studies have shown that higher adherence to a Mediterranean diet (MeDi) is associated with reduced risk of AD. This study examines the associations between high vs. lower adherence to a MeDi and structural MRI-based brain atrophy in key regions for AD in cognitively normal (NL) individuals with and without risk factors for AD. DESIGN: Cross-sectional study. SETTING: Manhattan (broader area). PARTICIPANTS: Fifty-two NL individuals (age 54+12 y, 70% women) with complete dietary information and cross-sectional, 3D T1-weighted MRI scans were examined. MEASUREMENTS: Subjects were dichotomized into those showing higher vs. lower adherences to the MeDi using published protocols. Estimates of cortical thickness for entorhinal cortex (EC), inferior parietal lobe, middle temporal gyrus, orbitofrontal cortex (OFC) and posterior cingulate cortex (PCC) were obtained by use of automated segmentation tools (FreeSurfer). Multivariate general linear models and linear regressions assessed the associations of MeDi with MRI measures. RESULTS: Of the 52 participants, 20 (39%) showed higher MeDi adherence (MeDi+) and 32 (61%) showed lower adherence (MeDi-). Groups were comparable for clinical, neuropsychological measures, presence of a family history of AD (FH), and frequency of Apolipoprotein E (APOE) ε4 genotype. With and without controlling for age and total intracranial volume, MeDi+ subjects showed greater thickness of AD-vulnerable ROIs as compared to MeDi- subjects (Wilk’s Lambda p=0.026). Group differences were most pronounced in OFC (p=0.001), EC (p=0.03) and PCC (p=0.04) of the left hemisphere. Adjusting for gender, education, FH, APOE status, BMI, insulin resistance scores and presence of hypertension did not attenuate the relationship. CONCLUSION: NL individuals showing lower adherence to the MeDi had cortical thinning in the same brain regions as clinical AD patients compared to those showing higher adherence. These data indicate that the MeDi may have a protective effect against tissue loss, and suggest that dietary interventions may play a role in the prevention of AD

Pharmacodynamic (PD) evaluation of LY2181308 in patients with metastatic malignancies

3507

Background: Survivin is an inhibitor of apoptosis and its overexpression in cancer has been associated with poor survival. LY2181308 (LY), a novel modified antisense oligonucleotide is a specific inhibitor of survivin. The safety and PK profile of LY from this first-in-human study was presented at ASCO 2008. We now present the PD data from this trial. Methods: Patients with advanced or metastatic malignancies who had failed previous anti-tumor treatments were enrolled. Three consecutive IV loading doses given over 3 hours were followed by weekly maintenance doses. Pre- and post-dosing biopsies were mandated to test for evidence of modification of the target at doses where a PD effect was expected. Biopsies were taken 48 hours after the last loading dose by CT-guided fine needle biopsy. Tumor tissue was paraffin-embedded for immunohistochemistry (IHC) and survivin gene expression. Given the finite amount of biopsy material, the quantification of survivin protein was prioritized. In addition, at one site, pre- and post-dosing endobronchial sampling was conducted in NSCLC patients, with the aim of quantifying levels of native survivin protein, and assessing changes in cell cycle profile in freshly isolated tumor cells using FACS analysis. Results: Out of the 34 patients enrolled, 22 patients had a pre- and posttreatment biopsy. Results from IHC indicated that survivin expression was reduced in the nucleus and cytoplasm in 11/17 and 5/14 evaluable pairs, respectively. LY was detected in neoplastic and non-neoplastic tumor cells in 5/16 and 15/16 evaluable pairs respectively. Gene expression analysis indicated a reduction in survivin expression by 20% to 50% in 11/15 evaluable pairs. Analysis of the fresh tumor material from endobronchial sampling revealed that 2 out of 3 patients with NSCLC had a near-complete elimination of survivin-positive cells accompanied by an increase in the fraction of cells with a sub-G1 DNA content, consistent with cell death. Conclusions: In this study, we were able to demonstrate the presence of the ASO in tumor tissue and confirm a reduction in survivin protein and gene expression. These findings demonstrate the proof of principle of antitumor activity of LY and provide the rationale for phase II studies.

[Table: see text]

A biomechanical study comparing the compressive forces generated by a conventional 4.5 AO/ASIF cortical lag screw with a differentially pitched cortical compression screw

The aim of this study was to compare the interfragmentary compression generated across a simulated femoral fracture model by a conventional 4.5 mm AO/ASIF cortical lag screw with a differentially pitched cortical compression screw. A 45-degree osteotomy was made in a whole bone composite femoral shaft, this was internally fixed with either a conventional 4.5 mm AO/ASIF cortical lag screw or the differentially pitched cortical screw and the compressive force generated at the fracture site measured on an Instron 8874 Axial/Torsion Servohydraulic Testing System. The mean interfragmentary compression generated by the differentially pitched screw was 81.4% of that generated by the 4.5 mm AO/ASIF cortical lag screw. The 4.5 mm AO/ASIF cortical screw produces a steep rise in compression per turn of the screw. The screw based on the differential pitch design creates a more gradual increase to peak compression. The resistance to torque was greater for the AO screw than for the differential pitch screw. Maximal interfragmentary compression is achieved within 4 180 degrees turns after the head engages the near cortex for the 4.5 mm AO/ASIF screw but required 5 180 degrees turns for the differentially pitched screw. Interfragmentary compression is achievable in cortical bone using differential pitch technology. A differentially pitched screw offers obvious advantages over a conventional screw allowing independent placement of lag screw and neutralisation plate, without needing additional exposure of the fracture site, limiting the insult to local fracture biology. It is proposed as an adjunct to osteosynthesis in long bone fractures.

Molecular analysis of polymerase gamma gene and mitochondrial polymorphism in fertile and subfertile men

CAG trinucleotide repeat length in the nuclear polymerase gamma gene (POLgamma) has been shown to be associated with men with reduced fertility. The present study investigated the frequency of CAG repeat length genotypes and three exonuclease motifs of the POLgamma in relation to the frequency of mitochondrial nucleotide substitutions. DNA from semen samples of 93 normozoospermic men and 192 non-normozoospermic men was isolated and the specific regions of the genes were amplified by polymerase chain reactions (PCR) and sequenced to identify mutations. The genotypic frequencies of pooled POLgamma CAG repeat lengths, =10/ not equal 10 heterozygotes and not equal 10/ not equal 10 homozygotes, were significantly different between normozoospermic and non-normozoospermic men (p < 0.05), with non-normozoospermic men having a slightly higher frequency of the =10/=10 genotypes. The allelic frequency for =10 is 0.79 and not equal10 is 0.21 for normozoospermic men and 0.85 and 0.15, respectively, for non-normozoospermic men (p < 0.025). There was no mutation detected in the exonuclease motifs in all the samples tested. Eighty normozoospermic and 124 non-normozoospermic semen samples were analysed for nucleotide substitutions in mitochondrial genes by PCR and sequencing. Heteroplasmic mutations were found in one azoospermic man, four asthenozoospermic men and two normozoospermic men. Only one asthenozoospermic man was heterozygous for the POLgamma genotype. Of the 17 men with non-synonymous nucleotide substitutions, 14 were homozygous for the POLgamma genotype. Non-normozoospermic men had twice as many nucleotide substitutions than normozoospermic men. However, there were no significant differences in the frequencies of nucleotide substitution and POLgamma genotypes in the two groups of men.

The random blood glucose level, a risk factor for mortality after acute myocardial infarction, in non-diabetic patients

The Correlation between blood glucose level and cardio-vascular events is well established in diabetic patients. In this study, fifty three non diabetic (M:30F:23), patients after acute myocardial infarction were studied for mortality in the following two years, retrospectively. Every patient had random venous glucose estimated on admission. This glucose level was correlated with all cause mortality. At the end of 2 years, 13 patients died and 40 remained alive. There was a significant difference of blood glucose between those who died and remained alive. The difference between the mean blood glucose level is between 0.6 mmol/L and 3.8 mmol/L higher for patients who died (mean = 8.62); compared with those that were still alive (mean = 6.69). This difference was particularly observed in the group of anterior wall infarction. The subgroup analysis also revealed that the difference between the mean blood glucose levels is 9 mmol/L for female patients with heart failure compared with those who did not suffer from heart failure (mean 6.8). The study concludes that, the higher glucose level is associated with increased all cause mortality in the following 2 years of first acute myocardial infarction.

Strain on the human sciatic nerve in vivo during movement of the hip and knee

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function. We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR.

High incidence of single nucleotide substitutions in the mitochondrial genome is associated with poor semen parameters in men

Single nucleotide polymorphisms (SNPs) in 7000 bp of the mitochondrial genome, encompassing 15 coding regions from COI to ND5, were characterized by single strand polymorphism analysis and confirmed by DNA sequencing. About 2.4% of normozoospermic men and 8.4% of men with poor semen quality had at least one nucleotide substitution. Most of the substitutions occurred in the third codon and did not change the amino acid. Hydrophobicity plots of the proteins with changes in an amino acid as a result of a nucleotide substitution suggested that they did not affect the function of the protein. The two most common substitutions at nucleotide (nt) 9055 and 11719 had significantly higher frequencies in men with reduced sperm motility. Eleven percent of the men with poor semen parameters and 1.3% of normozoospermic men had a 9055 substitution, 12% of the men with poor semen parameters had a substitution at nt 11719, but none of the normozoospermic men had this substitution. All the patients with these substitutions had reduced sperm motility and/or low sperm count. These SNPs in the mitochondrial genome were in a homoplasmic state. Thus, we propose that possessing these mitochondrial mutations compromises the semen quality of these men.

Effect of stride length on symptoms of exercise-induced muscle damage during a repeated bout of downhill running

The purpose of this study was to assess the effects of changes in stride length on the symptoms of exercise-induced muscle damage (EIMD) during a repeated bout of downhill running in a group of 18 men and women. Muscle tenderness, plasma creatine kinase activity (CK) and maximal voluntary isometric force were measured before and after two downhill runs, with each run separated by 5 weeks. The first downhill run was at the preferred stride frequency (PSF). Participants were then randomly allocated to one of three sex-balanced groups with equal numbers of men and women: overstride (-8% PSF), understride (+8% PSF) and normal stride frequency for the second downhill run. Stride length had no effect (P>0.05) on muscle tenderness, CK or isometric peak force. Increases in muscle tenderness (P<0.001) and CK were lower (P<0.05) following the second downhill run, although there was no difference in the pattern and extent of the strength decrement between the two runs. There were also no differences (P>0.05) in muscle tenderness, CK or the relative strength loss between the men and the women. Results suggest that the symptoms of EIMD are unaffected by gender and small alterations to the normal stride pattern during constant velocity downhill running. The observation that muscle tenderness and CK were reduced following a repeated bout of similar eccentric exercise is consistent with the phenomenon known as the 'repeated bout effect' of muscle damage.

MRI volume of the amygdala: a reliable method allowing separation from the hippocampal formation

Studies of MRI-derived volume of the amygdala have been mostly performed on coronal sections where its boundaries with the hippocampus and the entorhinal cortex are indistinct. To date, all reports of in vivo amygdala volume have consistently overestimated the size of the structure. We have developed a method for the MRI-based in vivo measurement of the amygdala volume which allows a better separation of the amygdala from the adjoining hippocampal formation. In nine normal volunteers we obtained three-dimensional spoiled gradient recalled acquisition, 1.3-mm thick, T1 weighted sagittal MR images and created electronically linked reformatted images in the coronal and axial planes. On the original sagittal and the reformatted axial planes, where it is more readily apparent, we delineated the boundaries between the amygdala and the hippocampus and the amygdala and the hippocampo-amygdala transition area, respectively. We then projected those markings onto the coronal plane, where the other boundaries of the amygdala are more easily seen. Using these markings as a guide and utilizing extra-amygdalar coronal landmarks for the anterior end, we outlined the whole amygdala on the coronal plane and determined its volume. We observed that 45% of the coronal slices that contained amygdala also contained some hippocampus. The amygdala measurement had high test-retest reliability, with an intra-class correlation coefficient (rICC) of 0.99 for the total volume and an rICC of 0.93 for the measurement at the level of the individual slice. The average amygdala volume was 1.05 +/- 0.17 cm3 on the right and 1.14 +/- 0.15 cm3 on the left. Our amygdala volumes are in agreement with those reported in postmortem studies, which provides the reported method with face validity.

Comparison of the effects of topical lignocaine spray applied before or after induction of anaesthesia on the pressor response to direct laryngoscopy and intubation

In an attempt to attenuate the cardiovascular pressor response to laryngoscopy and intubation, 30 patients presenting for routine ophthalmic surgery were studied and were randomly allocated into two groups: group A (n = 15) received direct laryngeal/tracheal lignocaine spray immediately before intubation; and group B (n = 15) received orolaryngeal lignocaine spray before the induction of anaesthesia. In both groups, general anaesthesia was induced with thiopentone 3-5 mg kg-1, followed by atracurium 0.6 mg kg-1 to facilitate tracheal intubation. Laryngoscopy and endotracheal intubation caused a significant increase in heart rate, by 28% in group A and 23% in group B (P < 0.05 in both), and in diastolic blood pressure, by 28% in group A and 24% in group B (P < 0.05 in both). In group A, the systolic blood pressure also increased significantly (by 18%) after intubation, but there was no significant change in group B. In addition, the plasma lignocaine concentrations remained well below the toxic range in both groups. It was concluded that topical lignocaine administration as an orolaryngeal spray before the induction of anaesthesia is effective in reducing but not abolishing the pressor response to laryngoscopy and endotracheal intubation.

Caffeine and schizophrenia

Although the database is small and not completely consistent, it appears that patients with schizophrenia have high caffeine intakes. The reasons are unclear. In nonhumans, caffeine enhances the effects of dopamine, which might be expected to worsen positive symptoms and improve negative symptoms of schizophrenia and worsen tardive dyskinesia. Eliminating caffeine among patients with schizophrenia does not appear to make them better or worse. Acute intake of large amounts of caffeine may increase psychoses and hostility. However, those who chronically use large amounts of caffeine may develop enough tolerance that these adverse effects do not occur, but whether this conjecture is true has not been tested. Interestingly, persons with schizophrenia do not develop anxiety at high doses of caffeine. Although there was initial concern that caffeine might inactivate liquid doses of neuroleptics, the clinical significance of this concern is unclear. On the other hand, caffeine might increase the level of clozapine, and more research in this area is needed.

Evaluation of a protocol to select patients of all ages for cardioversion from atrial fibrillation

OBJECTIVE

to audit the success of a decision protocol to select patients for cardioversion from atrial fibrillation or flutter by recording the success of cardioversion and the maintenance of sinus rhythm over a 2-year period.

DESIGN

retrospective case notes review.

SETTING

a teaching hospital coronary care unit and cardiology department.

PATIENTS

227 consecutive patients were considered for cardioversion from atrial fibrillation or flutter from 1989 to 1992; 128 fulfilled the selection criteria.

MAIN OUTCOME MEASURES

successful cardioversion and maintenance of sinus rhythm after cardioversion.

RESULTS

116 (91%) patients selected by application of the guidelines were successfully cardioverted. The probabilities of maintaining sinus rhythm at 6, 12 and 24 months were 0.92, 0.88 and 0.73 respectively.

CONCLUSION

careful selection of patients in atrial fibrillation identifies a group in whom cardioversion is likely to be safe and successful regardless of age.

Addison's disease and selective IgA deficiency in two coeliac patients

Coeliac disease is associated with selective IgA deficiency and various autoimmune disorders. An association between Addison's disease and coeliac disease has been documented previously in the literature but never heretofore in coeliac patients with selective IgA deficiency. From a coeliac registry of over 700 biopsy-proven coeliac patients, studied closely over a 25-year period at University College Hospital, Galway, we now report the finding of Addison's disease and selective IgA deficiency in two patients with established coeliac disease. Previous reports of Addison's disease in coeliac patients were sporadic, and it was felt that the association between the two conditions was fortuitous. We now believe that coeliac patients, especially those who are selectively deficient in serum IgA, should be followed up with increased vigilance, as the association between IgA-deficient coeliac patients and Addison's disease is greater than can be explained by chance. Furthermore, we suggest that patients with established Addison's disease may have subclinical coeliac disease and should be screened with anti-reticulin or anti-endomyseal antibodies.

Mechanical characteristics of dilated polytetraflouroethylene used for transluminally placed endovascular grafts

This study was conducted to assess the mechanical characteristics of dilated polytetraflouroethylene (PTFE) for use in transluminally placed endovascular grafts (TPEGs). Ten-centimeter lengths of 3- and 4-mm thinwalled PTFE were dilated to 8, 10, 12, and 15 mm diameters (3 mm) and 10-, 14-, 16-, and 20-mm diameters (4 mm), respectively (n = 6 for each size). The dilated PTFE segments were evaluated for leakage, further dilation, structural changes (with electron microscopy), and changes in wall thickness occurring after 24 hours of perfusion at pressures of 300-350 mmHg. Both 3- and 4-mm thinwalled PTFE could be dilated to five times their initial diameter before rupture occurred. Three-millimeter grafts dilated to 12- and 4-mm grafts dilated to 14 mm remained resistant to leakage at perfusion pressures up to 350 mmHg. When 3-mm grafts were dilated to 15 mm, the PTFE leaked saline at a rate of 20.3 +/- 9.3 cc per hour at 300 mmHg. pressure. Four-millimeter grafts dilated to 16- and 20-mm diameters leaked saline at 8.4 +/- 7.8 and 52.8 +/- 22 cc per minute, respectively, at the same pressure. No grafts were found to increase in diameter after 24 hours of pressure perfusion. Electron microscopy revealed that PTFE node size was significantly smaller in dilated grafts than in undilated grafts, but there was no significant change in internodal distance. This data suggests that thinwalled PTFE can be dilated to large diameters and retain sufficient strength to resist supraphysiologic pressures. Long-term studies are needed to determine the late structural integrity of dilated PTFE.

The efficacy of audiotapes in promoting psychological well-being in cancer patients: a randomised, controlled trial

Open or uncontrolled studies have suggested that providing cancer patients with audiotapes of their clinical interviews can improve information recall and reduce psychological distress. We tested these hypotheses in a 'clinician-blind', prospective, randomised controlled trial. A total of 117 patients newly referred to a medical oncology clinic who were to be given 'bad news' had their consultations audiotaped. Blind to the clinician, patients were randomly allocated to receive a copy of the tape to play at home or not (control group). At 6 months follow-up, tape group patients reported positive attitudes to the audiotape and were shown to recall significantly more information about their illness than did controls. Overall improvement in psychological distress at 1 and 6 months follow-up, as measured with the 30-item General Health Questionnaire and the Hospital Anxiety and Depression Scale was no different in the two groups. However, a second-order interaction suggested that poor-prognosis patients were disadvantaged specifically by access to the audiotape, with less improvement in psychological distress at 6 months follow-up than non-tape controls. Patient access to audiotapes of clinical interviews promotes factual retention but does not reliably reduce psychological distress and may be actively unhelpful in some subgroups of patients.

Effects of electrical stimulation on lymphatic flow and limb volume in the rat

BACKGROUND AND PURPOSE

The mechanism by which electrical stimulation affects edema has not been elucidated. The purpose of this study was to determine whether subcontraction high-voltage stimulation (SC-HVS) (ie, electrical stimulation that did not elicit a visible contraction) applied to the right hind limbs of rats would (1) alter the rate of lymphatic uptake of injected albumin labeled with Evans blue dye (AL-EBD) and (2) affect experimentally induced edema.

SUBJECTS AND METHODS

The paws of 28 anesthetized Sprague-Dawley rats (mean weight = 263 g, SD = 48 g) were injected with AL-EBD. The experimental group (n = 13) received 1 hour of SC-HVS, and the control group (n = 15) received sham treatment consisting of the same treatment administered to the experimental group but without the SC-HVS. Blood samples and volume measurements were obtained at intervals over a 7-hour period.

RESULTS

Analysis of variance and post hoc testing indicated that higher amounts of AL-EBD were taken up by the lymph of the experimental group animals as compared with the control group animals at each time period following the treatment. The experimental group's AL-EBD reached significance immediately after treatment, whereas the control group required an additional 4 hours. There was no significant reduction in limb volume in either group.

CONCLUSION AND DISCUSSION

The SC-HVS significantly increased the uptake of AL-EBD by lymphatic vessels, but it did not cause a significant decrease in the induced edema. The results of this study indicate that SC-HVS has the potential to reduce edema by increasing lymphatic uptake of proteins.

Characterization of a protein that regulates the DNA-binding activity of NF-AT, the nuclear factor of activated T cells

NF-AT is a T-cell-restricted activity that regulates interleukin 2 expression by binding to positions -285 to -254 of the interleukin 2 gene. Prior studies have shown that NF-AT is found only in T cells that are appropriately stimulated with "two signals" and is sensitive to the immunosuppressive drugs cyclosporin A and FK506. However, NF-AT has yet to be characterized biochemically. Here we show that the activity of NF-AT in electrophoretic gel mobility-shift assays is greatly enhanced by a distinct protein with an apparent molecular mass of 28 kDa. This modulator has been enriched from the flow-through of NF-AT affinity columns and enhances by severalfold the activity of the factor that elutes from these columns. The modulator has a predominantly nuclear location, but unlike NF-AT, the modulator is found in nuclear extracts of many cell types, even unstimulated T cells and T cells immunosuppressed with cyclosporin A or FK506. This modulator protein may regulate NF-AT binding activity posttranscriptionally, and it should prove useful in the isolation and biochemical characterization of NF-AT.

Effect of cisapride on morphine absorption after oral administration of sustained-release morphine

We investigated the effect of cisapride 20 mg given orally with MST 20 mg on the absorption of morphine in a double-blind, placebo-controlled study. Cisapride increased significantly both plasma concentrations of morphine after 1 h and peak concentrations. There was no significant change in time to peak concentrations, sedation scores or percentage decrease in pupil diameters. Plasma concentrations of amylase were increased in three patients in the MST-placebo group and three in the MST-cisapride group. One patient in the MST-cisapride group developed acute pancreatitis.

Effect of single doses of cisapride and ranitidine administered simultaneously on plasma concentrations of cisapride and ranitidine

We have studied in 12 volunteers the effect of single doses of cisapride and ranitidine, administered simultaneously, on plasma concentrations of cisapride and ranitidine. Median maximum plasma concentration of ranitidine was achieved 1 h earlier when ranitidine was taken with cisapride compared with ranitidine alone (P = 0.012). There was a 24% decrease in plasma ranitidine AUC8h when ranitidine was taken with cisapride compared with ranitidine alone (P less than 0.005). Ranitidine had no effect on absorption of cisapride.

Continuous ambulatory ECG monitoring in the perioperative period: relationship of preoperative status and outcome

We have used continuous ambulatory electrocardiography in the perioperative period to monitor 108 patients with known cardiovascular disease undergoing non-cardiac surgery. There was a high incidence of ischaemic ST segment changes and ventricular arrhythmias. For the group as a whole, anaesthesia and surgery were followed by increased ventricular ectopic activity, but did not worsen myocardial ischaemia. However, the mean duration of ischaemic ST segment changes was increased significantly in those patients with treated hypertension. Of the risk factors considered, preoperative ischaemia and peroperative systolic arterial pressure were significant correlates with postoperative myocardial ischaemia.

Real-time ultrasound in the diagnosis of congenital dislocation and dysplasia of the hip

A technique of examining the infant hip joint with real-time ultrasound is described. Since the cartilaginous femoral head is clearly imaged by ultrasound, anatomical structures and their relationships can be accurately determined. Dislocated hips are easily detected and subluxations also can be visualized. We report our experience with 131 examinations in 104 patients, comprising 259 single hip studies. Of 83 patients who were previously untreated, there were 178 hip studies with three false-negative and four false-positive ultrasound results. No dislocations were missed. Twenty-seven patients who were already being treated were examined to assess hip location, comprising a total of 81 hip studies. In some cases the patients were examined while in an abduction device, cast, or Pavlik harness. In one case a dislocation was not detected. The method of examination using real-time ultrasound is considered to be reliable, accurate, and a useful adjunct to radiography. The advantages are that it is non-invasive, portable, and involves no exposure to radiation.

Arsine toxicity aboard the Asiafreighter

Eight sailors on board the Asiafreighter were exposed to arsine that had escaped from a cylinder in the cargo hold. Four suffered severe toxicity and within a few hours had developed fever, weakness, nausea, vomiting, diarrhoea, abdominal pain, and haemoglobinuria. These patients had pronounced intravascular haemolysis, which in one patient was complete. This patient was also stuporose and anoxic, a condition attributed to failure of oxygen transport and sludging of red cell debris in the cerebral and pulmonary circulations, but he regained a normal level of consciousness after exchange transfusion. Evidence of marrow depression was present: the reticulocyte response to the haemolysis was poor and there was a thrombocytopenia. All four patients developed renal failure, one being totally anuric for five weeks. Two patients developed peripheral neuropathy, and one was still severely disabled six months after the incident. The other four patients had a similar, though less severe, illness.

Pneumomediastinum and diabetic hyperpnoea

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