Isolation and Characterization of [DLeu1]microcystin-LY from Microcystis aeruginosa CPCC-464

[D-Leu¹]MC-LY (1) ([M + H]⁺m/z 1044.5673, Δ 2.0 ppm), a new microcystin, was isolated from Microcystis aeruginosa strain CPCC-464. The compound was characterized by ¹H and ¹³C NMR spectroscopy, liquid chromatography–high resolution tandem mass spectrometry (LC–HRMS/MS) and UV spectroscopy. A calibration reference material was produced after quantitation by ¹H NMR spectroscopy and LC with chemiluminescence nitrogen detection. The potency of 1 in a protein phosphatase 2A inhibition assay was essentially the same as for MC-LR (2). Related microcystins, [D-Leu¹]MC-LR (3) ([M + H]⁺m/z 1037.6041, Δ 1.0 ppm), [D-Leu¹]MC-M(O)R (6) ([M + H]⁺m/z 1071.5565, Δ 2.0 ppm) and [D-Leu¹]MC-MR (7) ([M + H]⁺m/z 1055.5617, Δ 2.2 ppm), were also identified in culture extracts, along with traces of [D-Leu¹]MC-M(O₂)R (8) ([M + H]⁺m/z 1087.5510, Δ 1.6 ppm), by a combination of chemical derivatization and LC–HRMS/MS experiments. The relative abundances of 1, 3, 6, 7 and 8 in a freshly extracted culture in the positive ionization mode LC–HRMS were ca. 84, 100, 3.0, 11 and 0.05, respectively. These and other results indicate that [D-Leu¹]-containing MCs may be more common in cyanobacterial blooms than is generally appreciated but are easily overlooked with standard targeted LC–MS/MS screening methods.

Effects of High-Intensity Interval Running Versus Cycling on Sclerostin, and Markers of Bone Turnover and Oxidative Stress in Young Men

This study compared sclerostin's response to impact versus no-impact high-intensity interval exercise in young men and examined the association between exercise-induced changes in sclerostin and markers of bone turnover and oxidative stress. Twenty healthy men (22.3 ± 2.3 years) performed two high-intensity interval exercise trials (crossover design); running on treadmill and cycling on cycle ergometer. Trials consisted of eight 1 min running or cycling intervals at ≥ 90% of maximal heart rate, separated by 1 min passive recovery intervals. Blood samples were collected at rest (pre-exercise), and 5 min, 1 h, 24 h, and 48 h following each trial. Serum levels of sclerostin, cross-linked telopeptide of type I collagen (CTXI), procollagen type I amino-terminal propeptide (PINP), thiobarbituric acid reactive substances (TBARS), and protein carbonyls (PC) were measured. There was no significant time or exercise mode effect for PINP and PC. A significant time effect was found for sclerostin, CTXI, and TBARS with no significant exercise mode effect and no significant time-by-mode interaction. Sclerostin increased from pre- to 5 min post-exercise (47%, p < 0.05) and returned to baseline within 1 h following the exercise. CTXI increased from pre- to 5 min post-exercise (28%, p < 0.05), then gradually returned to baseline by 48 h. TBARS did not increase significantly from pre- to 5 min post-exercise but significantly decreased from 5 min to 48 h post-exercise. There were no significant correlations between exercise-induced changes in sclerostin and any other marker. In young men, sclerostin's response to high-intensity interval exercise is independent of impact and is not related to changes in bone turnover and oxidative stress markers.

Sulfated diesters of okadaic acid and DTX-1: Self-protective precursors of diarrhetic shellfish poisoning (DSP) toxins

Many toxic secondary metabolites used for defense are also toxic to the producing organism. One important way to circumvent toxicity is to store the toxin as an inactive precursor. Several sulfated diesters of the diarrhetic shellfish poisoning (DSP) toxin okadaic acid have been reported from cultures of various dinoflagellate species belonging to the genus Prorocentrum. It has been proposed that these sulfated diesters are a means of toxin storage within the dinoflagellate cell, and that a putative enzyme mediated two-step hydrolysis of sulfated diesters such as DTX-4 and DTX-5 initially leads to the formation of diol esters and ultimately to the release of free okadaic acid. However, only one diol ester and no sulfated diesters of DTX-1, a closely related DSP toxin, have been isolated leading some to speculate that this toxin is not stored as a sulfated diester and is processed by some other means. DSP components in organic extracts of two large scale Prorocentrum lima laboratory cultures have been investigated. In addition to the usual suite of okadaic acid esters, as well as the free acids okadaic acid and DTX-1, a group of corresponding diol- and sulfated diesters of both okadaic acid and DTX-1 have now been isolated and structurally characterized, confirming that both okadaic acid and DTX-1 are initially formed in the dinoflagellate cell as the non-toxic sulfated diesters.

Development of Certified Reference Materials for Diarrhetic Shellfish Poisoning Toxins, Part 1: Calibration Solutions

Okadaic acid (OA) and its analogs dinophysistoxins-1 (DTX1) and -2 (DTX2) are lipophilic polyethers produced by marine dinoflagellates. These toxins accumulate in shellfish and cause diarrhetic shellfish poisoning (DSP) in humans. Regulatory testing of shellfish is essential to safeguard public health and for international trade. Certified reference materials (CRMs) play a key role in analytical monitoring programs. This paper presents an overview of the interdisciplinary work that went into the planning, production, and certification of calibration-solution CRMs for OA, DTX1, and DTX2. OA and DTX1 were isolated from large-scale algal cultures and DTX2 from naturally contaminated mussels. Toxins were isolated by a combination of extraction and chromatographic steps with processes adapted to suit the source and concentration of each toxin. New 19-epi-DSP toxin analogs were identified as minor impurities. Once OA, DTX1, and DTX2 were established to be of suitable purity, solutions were prepared and dispensed into flame-sealed glass ampoules. Certification measurements were carried out using quantitative NMR spectroscopy and LC-tandem MS. Traceability of measurements was established through certified external standards of established purity. Uncertainties were assigned following standards and guidelines from the International Organization for Standardization, with components from the measurement, stability, and homogeneity studies being propagated into final combined uncertainties.

Ethno-Cultural Considerations in Cardiac Patients’ Medication Adherence

We aimed to develop an in-depth understanding about factors that influence cardiac medication adherence among South Asian, Chinese, and European White cardiac patients. Sixty-four patients were purposively sampled from an ongoing study cohort. Interviews were audio-recorded and transcribed for analyses. Physicians’ culturally sensitive communication and patients’ motivation to live a symptom-free and longer life enhanced adherence. European Whites were motivated to enhance personal well-being and enjoy family life. South Asians’ medication adherence was influenced by the desire to fulfill the will of God and family responsibilities. The Chinese were motivated to avoid pain, illness, and death, and to obey a health care provider. The South Asians and Chinese wanted to ultimately reduce medication use. Previous positive experiences, family support, and establishing a routine also influenced medication adherence. Deterrents to adherence were essentially the reverse of the motivators/facilitators. This analysis represents an essential first step forward in developing ethno-culturally tailored interventions to optimize adherence.

Understanding the influence of urban- or rural-living on cardiac patients' decisions about diet and physical activity: descriptive decision modeling

BACKGROUND

It is challenging to assist people to attend to risk factors for coronary artery disease (CAD). There is potential for cultural elements associated with place of residence (i.e., urban- or rural-living) to have an effect on peoples' decision-making about managing CAD risk.

AIM

To better understand patient's decision-making processes regarding having a heart-healthy diet and engaging in regular physical activity (major CAD risk factors), and the potential influence of urban- or rural-living.

METHODS

Based on a previous series of qualitative interviews with 42 cardiac patients (21 urban-living, 21 rural-living), hierarchical decision-models regarding eating a heart-healthy diet and engaging in regular physical activity were developed, and a survey based on the decision-models generated. The models were then tested for 'fit' with another group of 42 cardiac patients, and were revised to make them more parsimonious. The final models were tested with a novel group of 647 CAD patients from Alberta, Canada (327 urban-living, 320 rural-living). The primary analysis was focused on determining the extent to which patients completing the survey fell in the correct behavioral group. Thereafter individual nodes were examined to determine decision-making constructs that were different between urban- and rural-living patients.

RESULTS

When tested, the models had overall accuracy of 93.5% for diet and 97.5% for physical activity. The most salient model nodes that led to differing behavioral outcomes reflected these constructs: perception of control over health; time, effort, or competing priorities; receipt of appropriate information; and appeal of the activity.

CONCLUSIONS

This information is potentially useful to assist healthcare providers to: (1) understand patients' decisions regarding their cardiac risk factor modification behavior, and (2) better direct conversations about risk factor modification and educational activities.

Skeletal effects of zoledronic acid in an animal model of chronic kidney disease

Bisphosphonates reduce skeletal loss and fracture risk, but their use has been limited in patients with chronic kidney disease. This study shows skeletal benefits of zoledronic acid in an animal model of chronic kidney disease.

INTRODUCTION

Bisphosphonates are routinely used to reduce fractures but limited data exists concerning their efficacy in non-dialysis chronic kidney disease. The goal of this study was to test the hypothesis that zoledronic acid produces similar skeletal effects in normal animals and those with kidney disease.

METHODS

At 25 weeks of age, normal rats were treated with a single dose of saline vehicle or 100 μg/kg of zoledronic acid while animals with kidney disease (approximately 30% of normal kidney function) were treated with vehicle, low dose (20 μg/kg), or high dose (100 μg/kg) zoledronic acid, or calcium gluconate (3% in the drinking water). Skeletal properties were assessed 5 weeks later using micro-computed tomography, dynamic histomorphometry, and mechanical testing.

RESULTS

Animals with kidney disease had significantly higher trabecular bone remodeling compared to normal animals. Zoledronic acid significantly suppressed remodeling in both normal and diseased animals yet the remodeling response to zoledronic acid was no different in normal and animals with kidney disease. Animals with kidney disease had significantly lower cortical bone biomechanical properties; these were partially normalized by treatment.

CONCLUSIONS

Based on these results, we conclude that zoledronic acid produces similar amounts of remodeling suppression in animals with high turnover kidney disease as it does in normal animals, and has positive effects on select biomechanical properties that are similar in normal animals and those with chronic kidney disease.

Improved isolation procedure for azaspiracids from shellfish, structural elucidation of azaspiracid-6, and stability studies

Azaspiracids are a group of lipophilic polyether toxins produced by the small dinoflagellate Azadinium spinosum. They may accumulate in shellfish and can result in illnesses when consumed by humans. Research into analytical methods, chemistry, metabolism, and toxicology of azaspiracids has been severely constrained by the scarcity of high-purity azaspiracids. Consequently, since their discovery in 1995, considerable efforts have been made to develop methods for the isolation of azaspiracids in sufficient amounts and purities for toxicological studies, in addition to the preparation of standard reference materials. A seven-step procedure was improved for the isolation of azaspiracids-1-3 (1, 2, and 3) increasing recoveries 2-fold as compared to previous methods and leading to isolation of sufficiently purified azaspiracid-6 (6) for structural determination by NMR spectroscopy. The procedure, which involved a series of partitioning and column chromatography steps, was performed on 500 g of Mytilus edulis hepatopancreas tissue containing ~14 mg of 1. Overall yields of 1 (52%), 2 (43%), 3 (43%), and 6 (38%) were good, and purities were confirmed by NMR spectroscopy. The structure of 6 was determined by one- and two-dimensional NMR spectroscopy and mass spectrometry. The stability of 6 relative to 1 was also assessed in three solvents in a short-term study that demonstrated the greatest stability in aqueous acetonitrile.

Investigations into the toxicology of spirolides, a group of marine phycotoxins

Spirolides are marine phycotoxins produced by the dinoflagellates Alexandrium ostenfeldii and A. peruvianum. Here we report that 13-desmethyl spirolide C shows little cytotoxicity when incubated with various cultured mammalian cell lines. When administered to mice by intraperitoneal (ip) injection, however, this substance was highly toxic, with an LD₅₀ value of 6.9 µg/kg body weight (BW), showing that such in vitro cytotoxicity tests are not appropriate for predicting the in vivo toxicity of this toxin. Four other spirolides, A, B, C, and 20-methyl spirolide G, were also toxic to mice by ip injection, with LD₅₀ values of 37, 99, 8.0 and 8.0 µg/kg BW respectively. However, the acute toxicities of these compounds were lower by at least an order of magnitude when administration by gavage and their toxic effects were further diminished when administered with food. These results have implications for future studies of the toxicology of these marine toxins and the risk assessment of human exposure.

The preparation of certified calibration solutions for azaspiracid-1, -2, and -3, potent marine biotoxins found in shellfish

The production and certification of a series of azaspiracid (AZA) calibration solution reference materials is described. Azaspiracids were isolated from contaminated mussels, purified by preparative liquid chromatography and dried under vacuum to the anhydrous form. The purity was assessed by liquid chromatography-mass spectrometry and nuclear magnetic resonance spectroscopy. The final concentration of each AZA in a CD(3)OH stock solution was determined by quantitative NMR spectroscopy. This solution was then diluted very accurately in degassed, high purity methanol to a concentration of 1.47 ± 0.08 μmol/L for CRM-AZA1, 1.52 ± 0.05 μmol/L for CRM-AZA2, and 1.37 ± 0.13 μmol/L for CRM-AZA3. Aliquots were dispensed into argon-filled glass ampoules, which were immediately flame-sealed. The calibration solutions are suitable for method development, method validation, calibration of liquid chromatography or mass spectrometry instrumentation and quality control of shellfish monitoring programs.

Biosynthesis of 13-Desmethyl Spirolide C by the Dinoflagellate Alexandrium ostenfeldii

Biosynthetic origins of the cyclic imine toxin 13-desmethyl spirolide C were determined by supplementing cultures of the toxigenic dinoflagellate Alexandrium ostenfeldii with stable isotope-labeled precursors [1,2-13C2]acetate, [1-13C]acetate, [2-13CD3]acetate, and [1,2-13C2,15N]glycine and measuring the incorporation patterns by 13C NMR spectroscopy. Despite partial scrambling of the acetate labels, the results show that most carbons of the macrocycle are polyketide-derived and that glycine is incorporated as an intact unit into the cyclic imine moiety. This work represents the first conclusive evidence that such cyclic imine toxins are polyketides and provides support for biosynthetic pathways previously defined for other polyether dinoflagellate toxins.

Identification of pectenotoxin-11 as 34S-hydroxypectenotoxin-2, a new pectenotoxin analogue in the toxic dinoflagellate Dinophysis acuta from New Zealand

A new pectenotoxin, which has been named pectenotoxin-11 (PTX11), was isolated from the dinoflagellate Dinophysis acuta collected from the west coast of New Zealand. The structure of PTX11 was determined as 34S-hydroxypectenotoxin-2 by tandem mass spectrometry and UV and NMR spectroscopy. PTX11 appears to be only the third pectenotoxin identified as a natural biosynthetic product from algae after pectenotoxin-2 and pectenotoxin-12. The LD50 of PTX11 determined by mouse intraperitoneal injection was 244 microg/kg. The LD(min) of PTX11 in these experiments was 250 microg/kg. No signs of toxicity were recorded in mice following an oral dose of PTX11 at 5000 microg/kg. No diarrhea was observed in any of the animals administered with the test substance by either route of administration. Unlike pectenotoxin-2 (PTX2), PTX11 was not readily hydrolyzed to its corresponding seco acid by enzymes from homogenized green-lipped mussel (Perna canaliculus) hepatopancreas.

Detection and identification of spirolides in norwegian shellfish and plankton

Mussels sampled in the spring of 2002 and 2003 from Skjer, a location in Sognefjord, Norway, tested positive in the mouse bioassay for lipophilic toxins. The symptoms, which included cramps, jumping, and short survival times (as low as 4 min), were not characteristic of toxins previously observed in Norway. A survey of the algae present at the aquaculture sites showed that the toxicity correlated with blooms of Alexandrium ostenfeldii. Up to 2200 cells/L were found at the peak of one bloom. In Canadian waters, this alga is known to be a producer of the cyclic imine toxins, spirolides. Analysis of mussel extracts from Skjer in the spring of 2002 and 2003, using liquid chromatography tandem mass spectrometry, revealed the presence of several new spirolides. The same compounds were also found in algal samples dominated by A. ostenfeldii, which had been sampled from Skjer in February 2003. A large-scale extraction of mussel digestive glands and chromatographic fractionation of the extracts allowed the isolation and structure elucidation of the main spirolide, 20-methyl spirolide G, with a molecular weight of 705.5. This is the first confirmed occurrence of spirolides in mussels and plankton from Norway.

Hypoxaemia enhances peripheral muscle oxidative stress in chronic obstructive pulmonary disease

BACKGROUND

Because oxidative stress affects muscle function, the underlying mechanism to explain exercise induced peripheral muscle oxidative stress in patients with chronic obstructive pulmonary disease (COPD) is clinically relevant. This study investigated whether chronic hypoxaemia in COPD worsens peripheral muscle oxidative stress and whether an abnormal muscle inflammatory process is associated with it.

METHODS

Nine chronically hypoxaemic and nine non-hypoxaemic patients performed repeated knee extensions until exhaustion. Biopsy specimens were taken from the vastus lateralis muscle before and 48 hours after exercise. Muscle oxidative stress was evaluated by lipid peroxidation (lipofuscin and thiobarbituric acid reactive substances (TBARs)) and oxidised proteins. Inflammation was evaluated by quantifying muscle neutrophil and tumour necrosis factor (TNF)-alpha levels.

RESULTS

When both groups were taken together, arterial oxygen pressure was positively correlated with quadriceps endurance time (n = 18, r = 0.57; p < 0.05). At rest, quadriceps lipofuscin inclusions were significantly greater in hypoxaemic patients than in non-hypoxaemic patients (2.9 (0.2) v 2.0 (0.3) inclusions/fibre; p < 0.05). Exercise induced a greater increase in muscle TBARs and oxidised proteins in hypoxaemic patients than in non-hypoxaemic patients (40.6 (9.1)% v 10.1 (5.8)% and 51.2 (11.9)% v 3.7 (12.2)%, respectively, both p = 0.01). Neutrophil levels were significantly higher in hypoxaemic patients than in non-hypoxaemic patients (53.1 (11.6) v 21.5 (11.2) counts per fibre x 10(-3); p < 0.05). Exercise did not alter muscle neutrophil levels in either group. Muscle TNF-alpha was not detected at baseline or after exercise.

CONCLUSION

Chronic hypoxaemia was associated with lower quadriceps endurance time and worsened muscle oxidative stress at rest and after exercise. Increased muscle neutrophil levels could be a source of the increased baseline oxidative damage. The involvement of a muscle inflammatory process in the exercise induced oxidative stress of patients with COPD remains to be shown.

Peripheral muscle endurance and the oxidative profile of the quadriceps in patients with COPD

BACKGROUND

Based on previously reported changes in muscle metabolism that could increase susceptibility to fatigue, we speculated that patients with chronic obstructive pulmonary disease (COPD) have reduced quadriceps endurance and that this will be correlated with the proportion of type I muscle fibres and with the activity of oxidative enzymes.

METHODS

The endurance of the quadriceps was evaluated during an isometric contraction in 29 patients with COPD (mean (SE) age 65 (1) years; forced expiratory volume in 1 second 37 (3)% predicted) and 18 healthy subjects of similar age. The electrical activity of the quadriceps was recorded during muscle contraction as an objective index of fatigue. The time at which the isometric contraction at 60% of maximal voluntary capacity could no longer be sustained was used to define time to fatigue (Tf). Needle biopsies of the quadriceps were performed in 16 subjects in both groups to evaluate possible relationships between Tf and markers of muscle oxidative metabolism (type I fibre proportion and citrate synthase activity).

RESULTS

Tf was lower in patients with COPD than in controls (42 (3) v 80 (7) seconds; mean difference 38 seconds (95% CI 25 to 50), p<0.001). Subjects in both groups had evidence of electrical muscle fatigue at the end of the endurance test. In both groups significant correlations were found between Tf and the proportion of type I fibres and citrate synthase activity.

CONCLUSION

Isometric endurance of the quadriceps muscle is reduced in patients with COPD and the muscle oxidative profile is significantly correlated with muscle endurance.

The influence of lung volume reduction surgery on exercise in patients with COPD

Although the influence of lung volume reduction surgery (LVRS) on incremental- and constant-power exercise is important in the evaluation of this procedure for patients with chronic obstructive pulmonary disease (COPD), it is rarely reported even in large randomised controlled trials. This report describes 39 patients with severe COPD ((mean +/- SE) forced expiratory volume in one second 32 +/- 2% pred, functional residual capacity 195 +/- 6% pred) who participated in a randomised controlled trial of LVRS and who completed incremental exercise tests at 6 months as well as endurance tests (constant power of 25 +/- 1 W) at 3, 9 and 12 months. Peak oxygen uptake (V'O2,pk) was similar between the treatment (n = 19) and control groups (n = 20) at baseline. After LVRS, the treatment group had a significantly greater V'O2,pk (mean difference (95% CI) 1.28 (0.07-2.50) mL x kg x min(-1)) and power (13 (6-20) W). The treatment group achieved a significantly greater minute ventilation (7.1 (2.9-11.3) L x min(-1)) with a greater tidal volume (0.16 (0.04-0.28) L). Baseline endurance was similar between groups. After surgery, there were significant between-group differences in endurance time, which were maintained at 12 months (7.3 (3.9-10.8) min). Lung volume reduction surgery is associated with an increase in exercise capacity and endurance, as compared with conventional medical treatment.

Influence of lung volume reduction surgery (LVRS) on health related quality of life in patients with chronic obstructive pulmonary disease

BACKGROUND

The clinical value of LVRS has been questioned in the absence of trials comparing it with pulmonary rehabilitation, the prevailing standard of care in COPD. Patients with heterogeneous emphysema are more likely to benefit from volume reduction than those with homogeneous disease. Disease specific quality of life is a responsive interpretable outcome that enables health professionals to identify the magnitude of the effect of an intervention across several domains.

METHODS

Non-smoking patients aged <75 years with severe COPD (FEV(1) <40% predicted, FEV(1)/FVC <0.7), hyperinflation, and evidence of heterogeneity were randomised to surgical or control groups after pulmonary rehabilitation and monitored at 3 month intervals for 12 months with no crossover between the groups. The primary outcome was disease specific quality of life as measured by the Chronic Respiratory Questionnaire (CRQ). Treatment failure was defined as death or functional decline (fall of 1 unit in any two domains of the CRQ). Secondary outcomes included pulmonary function and exercise capacity.

RESULTS

LVRS resulted in significant between group differences in each domain of the CRQ at 12 months (change of 0.5 represents a small but important difference): dyspnoea 1.9 (95% confidence interval (CI) 1.3 to 2.6; p<0.0001); emotional function 1.5 (95% CI 0.9 to 2.1; p<0.0001); fatigue 2.0 (95% CI 1.4 to 2.6; p<0.0001); mastery 1.8 (95% CI 1.2 to 2.5; p<0.0001). In the control group one of 27 patients died and 16 experienced functional decline over 12 months. In the surgical group four of 28 patients died and three experienced functional decline (hazard ratio = 3.1 (95% CI 1.3 to 7.6; p=0.01). Between group improvements (p<0.05) in lung volumes, flow rates, and exercise were sustained at 12 months (RV -47% predicted (95% CI -71 to -23; p=0.0002); FEV(1) 0.3 l (95% CI 0.1 to 0. 5; p=0.0003); submaximal exercise 7.3 min (95% CI 3.9 to 10.8; p<0.0001); 6 minute walk 66 metres (95% CI 32 to 101; p=0.0002).

CONCLUSIONS

In COPD patients with heterogeneous emphysema, LVRS resulted in important benefits in disease specific quality of life compared with medical management, which were sustained at 12 months after treatment.

Studies of the biosynthesis of DTX-5a and DTX-5b by the dinoflagellate Prorocentrum maculosum: regiospecificity of the putative Baeyer-Villigerase and insertion of a single amino acid in a polyketide chain

The biosynthetic origins of the diarrhetic shellfish poisoning toxins DTX-5a and DTX-5b have been elucidated by supplementing cultures of the producing organism Prorocentrum maculosum with stable isotope labeled precursors and determining the incorporation patterns by 13C NMR spectroscopy. The amino acid residue in the sulfated side chain is found to originate from glycine, and oxygen insertion in the chain is shown to occur after polyketide formation.

In vitro and in vivo contractile properties of the vastus lateralis muscle in males with COPD

Peripheral muscle weakness is common in chronic obstructive pulmonary disease (COPD) but it is still under debate whether weakness is due to atrophy or contractile dysfunction. In vitro and in vivo contractile properties of the vastus lateralis muscle were studied in 16 patients with stable COPD (forced expiratory volume in one second 39 +/- 16% of predicted, age 67 +/- 4 yrs (mean +/- sD)) and nine sedentary control subjects. Isometric knee extensor strength was measured while mid-thigh muscle cross-sectional area (MTMCSA) was obtained using computed tomography. Muscle strips from the vastus lateralis obtained through open biopsy were rapidly suspended in an oxygenated Krebs-Ringer solution that was maintained at 35 degrees C with a pH of 7.40 to study their contractile properties. The isometric knee extensors strength/MTMCSA ratio was 0.50 +/- 0.08 versus 0.58 +/- 0.06 kg x cm(-2) for COPD and control subjects, respectively. The muscle bundle cross-sectional area (CSA) was 4.6 +/- 2.1 and 4.4 +/- 3.1 mm(-2), the length at which active tension was maximum was 15 +/- 4 and 15 +/- 3 mm, and maximal isometric peak forces normalised for CSA were 4.3 +/- 2.7 and 4.8 +/- 2.6 N x cm(-2) for COPD and control subjects, respectively. The force/frequency relationship tended to be shifted to the right in patients with COPD, meaning that a higher stimulation frequency was necessary to produce the same relative force. Patients with COPD had a lower proportion of type I fibre than controls (26 +/- 12% versus 39 +/- 11%) with reciprocal significant increase in type IIb fibre proportion (20+/-16% versus 8 +/- 4%). The proportion of type IIa fibres was similar between the two groups. These results suggest that the contractile properties of the vastus lateralis are preserved in patients with chronic obstructive pulmonary disease. Therefore, the reduction in the quadriceps strength in patients with chronic obstructive pulmonary disease cannot be explained on the basis of an alteration of the contractile apparatus.

Limitation of lower limb VO(2) during cycling exercise in COPD patients

Patients with chronic obstructive pulmonary disease (COPD) usually stop exercise before reaching physiological limits in terms of O(2) delivery and extraction. A plateau in lower limb O(2) uptake (VO(2)) and blood flow occurs despite progression of the imposed workload during cycling in some patients with COPD, suggesting that maximal capacity to transport O(2) had been reached and that it had been extracted in the peripheral exercising muscles. This study addresses this observation. Symptom-limited incremental cycle exercise was performed by 14 men [62 +/- 11 (SD) yr] with severe COPD (forced expiratory volume in 1 s = 35 +/- 7% of predicted value). Leg blood flow was measured at each exercise step with a thermodilution catheter inserted in the femoral vein. This value was multiplied by two to account for both working legs (Q(LEGS)). Arterial and femoral venous blood was sampled at each exercise step to measure blood gases. Leg O(2) consumption (VO(2LEGS)) was calculated according to the Fick equation. Total body VO(2) (VO(2TOT)) was measured from expired gas analysis, and tidal volume (VT) and minute ventilation (VE) were derived from the flow signal. In eight patients, VO(2LEGS) kept increasing in parallel with VO(2TOT) as external work rate was increasing. In six subjects, a plateau in VO(2LEGS) and Q(LEGS) occurred during exercise (increment of <3% between 2 consecutive increasing workloads) despite the increase in workload and VO(2TOT) [corresponding mean was 110 +/- 38 ml (11 +/- 4%)]. These six patients also exhibited a plateau in O(2) extraction during exercise. Peak exercise work rate was higher in the eight patients without a plateau than in the six with a plateau (51 +/- 10 vs. 40 +/- 13 W, P = 0.043). VT, VE, and dyspnea were significantly greater at submaximal exercise in patients of the plateau group compared with those of the nonplateau group. These results show that, in some patients with COPD, blood flow directed to peripheral muscles and O(2) extraction during exercise may be limited. We speculate that redistribution of cardiac output and O(2) from the lower limb exercising muscles to the ventilatory muscles is a possible mechanism.

Peripheral muscle dysfunction in chronic obstructive pulmonary disease

Peripheral muscle dysfunction is a common systemic complication of moderate to severe COPD and may contribute to disability, handicap, and premature mortality. In contrast to the lung impairment, which is largely irreversible, peripheral muscle dysfunction is potentially remediable with exercise training, nutritional intervention, oxygen, and anabolic drugs. Therapeutic success is often incomplete, however, and a better understanding of the mechanisms involved in the development of peripheral muscle dysfunction in COPD is needed to help develop innovative and more effective therapeutic strategies.

Oxidative enzyme activities of the vastus lateralis muscle and the functional status in patients with COPD

BACKGROUND

Enzymatic and histochemical abnormalities of the peripheral muscle may play a role in exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). A study was undertaken to measure the mitochondrial enzyme activity of the vastus lateralis muscle in patients with COPD and to evaluate the relationship between enzyme activities and functional status.

METHODS

Fifty seven patients with COPD of mean (SD) age 66 (7) years with forced expiratory volume in one second (FEV(1)) 39 (15)% predicted and peak oxygen uptake (VO(2)) of 14 (4) ml/min/kg and 15 normal subjects of similar age were included in the study. Each subject performed a stepwise exercise test up to maximal capacity during which five-breath averages of VO(2) were measured. Muscle specimens were obtained by percutaneous needle biopsy of the vastus lateralis muscle and the activity of two mitochondrial enzymes (citrate synthase (CS) and 3-hydroxyacyl CoA dehydrogenase (HADH)) was measured. The functional status of the patients was classified according to peak VO(2).

RESULTS

CS and HADH activities were markedly reduced in patients with COPD compared with normal subjects (22.3 (2.7) versus 29.5 (7.3) micromol/min/g muscle (p<0.0001) and 5. 1 (2.0) versus 6.7 (1.9) micromol/min/g muscle (p<0.005), respectively). The activity of CS decreased progressively with the deterioration in the functional status while that of HADH was not related to functional status. Using a stepwise regression analysis, percentage predicted functional residual capacity (FRC), the activity of CS, oxygen desaturation during exercise, age, and inspiratory capacity (% pred) were found to be significant determinants of peak VO(2). The regression model explained 59% of the variance in peak VO(2) (p<0.0001).

CONCLUSIONS

The oxidative capacity of the vastus lateralis muscle is reduced in patients with moderate to severe COPD compared with normal subjects of similar age. In these individuals the activity of CS correlated significantly with peak exercise capacity and independently of lung function impairment.

Influence of work rate incremental rate on the exercise responses in patients with COPD

PURPOSE

The peak work rate (Wpeak) measured during a progressive stepwise exercise test is commonly used to select the target training intensity for an exercise training program. In healthy subjects, a greater Wpeak is achieved when a faster rate of increase in work rate is used, whereas VO2 peak is independent of the rate of increase in work rate. This effect might be even more pronounced in chronic obstructive pulmonary disease (COPD) patients, in whom the VO2 kinetics during exercise are slower compared with healthy subjects.

METHODS

To investigate this, we studied 10 COPD patients (9 M/1 F, age: 65+/-5 yr [mean +/- SD], FEV1: 33+/-8%). They underwent, on separate days, three stepwise exercise tests on an ergocycle. For each test, increments of 5, 10, or 20 W x min(-1) were used in random order; the investigator was blinded as to which increment was used. VO2, VCO2, heart rate (HR), minute ventilation (VE), breathlessness and leg fatigue at rest, at each work rate, and at maximal capacity were obtained.

RESULTS

Wpeak averaged 40+/-13, 53+/-14, and 66+/-19 W for the 5-, 10-, and 20-W protocol, respectively (P < 0.001), whereas VO2 peak was comparable at 0.96+/-0.16, 1.02+/-0.18, and 1.03+/-0.20 L x min(-1). As the rate of increase in work rate became faster, the VO2/work rate relationship shifted to the right. This is exemplified by the VO2 at 40 W, which averaged 0.98+/-0.06, 0.90+/-0.09, and 0.83+/-0.10 L x min(-1) for the 5-, 10-, and 20-W protocol, respectively (P < 0.05). Similar observations were made for the relationship between HR, VE, and symptom scores, and work rate. There was no significant differences in peak values for HR and VE, and symptoms scores.

CONCLUSIONS

We conclude that the work rate incremental rate influences the Wpeak achieved, whereas the peak values for VO2, HR, VE, and symptom scores remain comparable. These findings have practical implications for the exercise evaluation of patients with COPD.

Feasibility and efficacy of home exercise training before lung volume reduction

BACKGROUND

Exercise training is recommended before lung volume reduction surgery (LVRS) in patients with emphysema. Unfortunately, many of these patients are referred from remote areas where there is no available rehabilitation program. The authors evaluated the feasibility and efficacy of a minimally supervised home-based exercise training program.

METHODS

Twenty-three emphysematous patients (age 61 +/- 6, forced expiratory volume in 1 second = 29 +/- 7% predicted [mean +/- SD]) were recruited from our LVRS program. Measurements of pulmonary function, maximal and submaximal exercise capacity, 6-minute walking distance (6-MWD), muscle strength, and quality of life with the Chronic Respiratory Questionnaire were obtained before and after training. Home-based exercise training program included muscle exercises and aerobic training, and started with detailed teaching while the follow-up was ensured through weekly phone calls and a diary filled by each patient.

RESULTS

Significant increases in 6-MWD (P < 0.001), quality of life (P < 0.005), peak work rate (P < 0.05), peak oxygen consumption (P < 0.05), endurance time (P < 0.005), and muscle strength were observed in the home-based exercise training program.

CONCLUSIONS

Home-based exercise training for patients in preparation for LVRS was feasible, and induced significant improvement in exercise tolerance and quality of life.

Altered expression of myosin heavy chain in the vastus lateralis muscle in patients with COPD

This study was designed to further characterize peripheral skeletal muscle alterations in patients with chronic obstructive pulmonary disease (COPD) and to evaluate the possible relationship between myosin heavy chain (MyoHC) isoform expression and exercise tolerance in these individuals. MyoHC composition from biopsy of the vastus lateralis muscle was examined in 12 COPD patients (forced expiratory volume in one second (FEV1)=31+/-9% predicted, peak oxygen consumption (V'O2)=15+/-4 mL x kg(-1) x min(-1)) and 10 age-matched normal male subjects (peak V'O2=20+/-5 mL x kg(-1) x min(-1)). The proportion of MyoHC type I was smaller in COPD than in normals (27+/-17% versus 41+/-9%, p<0.05) with an increase in MyoHC type IIa (51+/-15% versus 39+/-9%, p<0.05) and the proportion of MyoHC type IIx being comparable between both groups. A significant relationship was found between peak V'Oo2 mL x kg(-1) x min(-1) and FEV1 % pred (r=0.91, p<0.0001) and the percentage of MyoHC type I (r=0.61, p=0.016). In stepwise multiple regression, only FEV1 % pred was found to be a significant determinant of peak V'O2 (p<0.0001). This variable explained 83% of the total variance of peak V'O2. In summary, this study showed considerable modifications in the phenotypic expression of the myosin heavy chain in the vastus lateralis muscle in patients with chronic obstructive pulmonary disease. An independent effect of myosin heavy chain expression on exercise capacity was not found. These results suggest that chronic inactivity and muscle deconditioning may not be the sole factors explaining peripheral muscle dysfunction in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease: capillarity and fiber-type characteristics of skeletal muscle

BACKGROUND

The purpose of this investigation was to compare capillarity and fiber type proportions of the vastus lateralis muscle between patients with chronic obstructive pulmonary disease (COPD) and healthy subjects.

METHODS

Fifteen male subjects were included in the study (8 COPD: 61.0 +/- 1.8 years [mean +/- SEM]; forced expiratory volume in 1 second 42.0 +/- 2.1% predicted; 7 N: age 54.0 +/- 1.1). Subjects were submitted to a symptom-limited maximal exercise test on ergocycle. After a transcutaneous biopsy of the vastus lateralis muscle, sections were cut 8 to 10 microns thick and stained with the Andersen method for capillarity and Stevens method for fiber typing.

RESULTS

Patients with COPD had a decrease in peak oxygen consumption compared with healthy subjects (1.2 +/- 0.1 versus 3.0 +/- 0.2 L/min). Number of capillaries per square millimeter was lower in patients with COPD versus healthy subjects (92.6 +/- 16.1 and 213.3 +/- 33.5, P < 0.001); percentages of fiber types were 43.5 +/- 5.5% type I, 56.5 +/- 5.5% type II in COPD, and 56.7 +/- 3.4% type I, 43.2 +/- 3.4% type II in healthy subjects (P < 0.05). In addition, capillaries/fiber ratio was 0.83 +/- 0.05 in COPD, and 1.56 +/- 0.10 in healthy subjects (P < 0.001).

CONCLUSION

As expected, patients with COPD showed a decrease in exercise capacity. The muscle analysis results indicate that patients with COPD have a greater proportion of type II fibers and a much lower capillaries/fiber ratio than normal subjects. We conclude that COPD adversely affects fiber type and capillarization of the lower limbs. This could be partly caused by deconditioning in these patients.

Peripheral muscle weakness in patients with chronic obstructive pulmonary disease

Peripheral muscle weakness is commonly found in patients with chronic obstructive pulmonary disease (COPD) and may play a role in reducing exercise capacity. The purposes of this study were to evaluate, in patients with COPD: (1) the relationship between muscle strength and cross-sectional area (CSA), (2) the distribution of peripheral muscle weakness, and (3) the relationship between muscle strength and the severity of lung disease. Thirty-four patients with COPD and 16 normal subjects of similar age and body mass index were evaluated. Compared with normal subjects, the strength of three muscle groups (p < 0.05) and the right thigh muscle CSA, evaluated by computed tomography (83.4 +/- 16.4 versus 109.6 +/- 15.6 cm2, p < 0.0001), were reduced in COPD. The quadriceps strength/thigh muscle CSA ratio was similar for the two groups. The reduction in quadriceps strength was proportionally greater than that of the shoulder girdle muscles (p < 0.05). Similar observations were made whether or not patients had been exposed to systemic corticosteroids in the 6-mo period preceding the study, although there was a tendency for the quadriceps strength/thigh muscle CSA ratio to be lower in patients who had received corticosteroids. In COPD, quadriceps strength and muscle CSA correlated positively with the FEV1 expressed in percentage of predicted value (r = 0.55 and r = 0. 66, respectively, p < 0.0005). In summary, the strength/muscle cross-sectional area ratio was not different between the two groups, suggesting that weakness in COPD is due to muscle atrophy. In COPD, the distribution of peripheral muscle weakness and the correlation between quadriceps strength and the degree of airflow obstruction suggests that chronic inactivity and muscle deconditioning are important factors in the loss in muscle mass and strength.

Reexamining the associate degree curriculum. Assessing the need for community concepts

Significant changes taking place in health care delivery in our community in Louisiana have led faculty to reexamine the associate degree nursing curriculum. We recognized the trend toward the decreased need for inpatient care and the greater need for outpatient care and home care in the community. In addition, we noted the need for nursing care to assist the elderly in the management of chronic illness and provide education on health promotion and disease prevention.

Metabolic and hemodynamic responses of lower limb during exercise in patients with COPD

Premature lactic acidosis during exercise in patients with chronic obstructive pulmonary disease (COPD) may play a role in exercise intolerance. In this study, we evaluated whether the early exercise-induced lactic acidosis in these individuals can be explained by changes in peripheral O2 delivery (O2). Measurements of leg blood flow by thermodilution and of arterial and femoral venous blood gases, pH, and lactate were obtained during a standard incremental exercise test to capacity in eight patients with severe COPD and in eight age-matched controls. No significant difference was found between the two groups in leg blood flow at rest or during exercise at the same power outputs. Blood lactate concentrations and lactate release from the lower limb were greater in COPD patients at all submaximal exercise levels (all P < 0.05). Leg D02 at a given power output was not significantly different between the two groups, and no significant correlation was found between this parameter and blood lactate concentrations. COPD patients had lower arterial and venous pH at submaximal exercise, and there was a significant positive correlation between venous pH at 40 W and the peak O2 uptake (r = 0.91, P < 0.0001). The correlation between venous pH and peak O2 uptake suggests that early muscle acidosis may be involved in early exercise termination in COPD patients. The early lactate release from the lower limb during exercise could not be accounted for by changes in peripheral O2. The present results point to skeletal muscle dysfunction as being responsible for the early onset of lactic acidosis in COPD.

Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease

The applicability of high-intensity training and the possibility of inducing physiologic adaptation to training are still uncertain in patients with severe chronic obstructive pulmonary disease (COPD). The purposes of this study were to evaluate the proportion of patients with moderate to severe COPD in whom high-intensity exercise training (30-min exercise session at 80% of baseline maximal power output [Wmax]) is feasible, and the response to training in these patients. We also sought to evaluate the possible influence of disease severity on the training intensity achieved and on the development of physiologic adaptation following endurance training. Forty-two patients with COPD (age = 66 +/- 7 yr, FEV1 = 38 +/- 13% predicted, [mean +/- SD]) were evaluated at baseline and after a 12-wk endurance training program. Each evaluation included a stepwise exercise test on an ergocycle up to the individual maximal capacity during which minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2), and arterial lactic acid concentrations were measured. The training consisted of 25 to 30-min exercise sessions on a calibrated ergocycle three times a week, with a target training intensity at 80% of Wmax. The training intensity was adjusted with the objective of reaching the target intensity, but also to ensure that the cycling exercise could be maintained for the specified duration. The training intensity sustained for the duration of each exercise session averaged 24.5 +/- 12.6, 51.7 +/- 17.4, 63.8 +/- 22.4, and 60.4 +/- 22.7% of Wmax at Weeks 2, 4, 10, and 12, respectively. High-intensity training was achieved in zero, three, five, and five patients at Weeks 2, 4, 10, and 12, respectively. A significant increase in VO2max and Wmax occurred with training (p < 0.0002). This improvement in exercise capacity was accompanied by a 6% and 17% reduction in VE and in arterial lactic acid concentration for a given work rate, respectively (p < 0.0001), suggesting that physiologic adaptation to training occurred. The intensity of training achieved, in % Wmax, was not influenced by the initial VO2max, age, or FEV1. The effects of training were compared in patients with an FEV1 > or = 40% or < 40% predicted. Percent changes in VO2max, Wmax, and VE, were significant and of similar magnitude for both groups, whereas the decrease in arterial lactic acid for a given work rate reached statistical significance only in those patients with an FEV1 > or = 40% predicted. We conclude that although most patients were unable to achieve high-intensity training as defined in this study, significant improvement in their exercise capacity was obtained and physiologic adaptation to endurance training occurred. The training intensity expressed as a percent of the individual maximum exercise capacity, and the relative effectiveness of training, were not influenced by the severity of airflow obstruction.

Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease

The purpose of this study was to evaluate the physiologic responses to endurance training in patients with moderate to severe airflow obstruction by specifically looking at changes in skeletal muscle enzymatic activities. Eleven patients (age = 65 +/- 7 yr, mean +/- SD, FEV1 = 36 +/- 11% of predicted value, range = 24 to 54%) were evaluated before and after an endurance training program. Each evaluation included a percutaneous biopsy of the vastus lateralis and a stepwise exercise test on an ergocycle up to his/her maximal capacity. VE, VO2, VcO2, and serial arterial lactic acid concentration were measured during the exercise test. The activity of two oxidative enzymes, citrate synthase (CS) and 3-hydroxyacyl-CoA dehydrogenase (HADH), and of three glycolytic enzymes, lactate dehydrogenase, hexokinase, and phosphofructokinase was determined. The training consisted of 30-min exercise sessions on a calibrated ergocycle, 3 times a week for 12 wk. The aerobic capacity was severely reduced at baseline (VO2max = 54 +/- 12% of predicted) and increased by 14% after training (p < 0.05). For an identical exercise workload, there was a significant reduction in VE (34.5 +/- 10.0 versus 31.9 +/- 9.0 L/min, p < 0.05) and in arterial lactic acid concentration (3.4 +/- 1.3 versus 2.8 +/- 0.9 mmol/L, p < 0.01) after training. The lactate threshold also increased after training (p < 0.01) while the activity of the three glycolytic enzymes was similar at the two evaluations. In contrast, the activity of CS and HADH increased significantly after training (22.3 +/- 3.5 versus 25.8 +/- 3.8 mumol/min/g muscle for CS, p < 0.05, and 5.5 +/- 2.9 versus 7.7 +/- 2.5 mumol/min/g for HADH, p < 0.01). A significant inverse relationship was found between the percent changes in the activity of CS and HADH, and the percent changes in arterial lactic acid during exercise (p = 0.01). We conclude that endurance training can reduce exercise-induced lactic acidosis and improve skeletal muscle oxidative capacity in patients with moderate to severe chronic obstructive pulmonary disease (COPD).

Oxidative capacity of the skeletal muscle and lactic acid kinetics during exercise in normal subjects and in patients with COPD

Early lactic acidosis during exercise and abnormal skeletal muscle function have been reported in chronic obstructive pulmonary disease (COPD) but a possible relationship between these two abnormalities has not been evaluated. The purpose of this study was to compare and correlate the increase in arterial lactic acid (La) during exercise and the oxidative capacity of the skeletal muscle in nine COPD patients (age = 62 +/- 5 yr, mean +/- SD, FEV1 40 +/- 9% of predicted) and in nine normal subjects of similar age (54 +/- 3 yr). Following a transcutaneous biopsy of the vastus laterialis, each subject performed a stepwise exercise test on an ergocycle up to his or her maximal capacity during which 5-breath averages of oxygen consumption (Vo2), and serial La concentration measurements were obtained. From the muscle biopsy specimen, the activity of two oxidative enzymes, citrate synthase (CS) and 3-hydroxyacyl CoA dehydrogenase (HADH), and of three glycolytic enzymes, lactate dehydrogenase, hexokinase, and phosphofructokinase were determined. The La/Vo2 relationship during exercise was fitted by an exponential function in the form La = a + bvo2, where be represents the shape of the relationship. The activity of the oxidative enzymes was significantly lower in COPD than in control subjects (22.8 +/- 3.3 versus 36.8 +/- 8.6 mumol/min/g muscle for CS, and 3.1 +/- 1.1 versus 5.5 +/- 1.4 mumol/min/g for HADH, p < 0.0005) and the increase in lactic acid was steeper in COPD (b = 4.3 +/- 2.0 versus 2.1 +/- 0.2 for normal subjects, p = 0.0005). A significant inverse relationship was found between CS, HADH, and b. No difference was found between the two groups for the glycolytic enzymes. We conclude that in COPD the increase in arterial La during exercise is excessive, the oxidative capacity of the skeletal muscle is reduced, and that these two results are interrelated.

Evaluation of the emphysematous patient

Most of the patients with emphysema complain of dyspnea and become limited in their activities during the course of the disease. Dyspnea is probably due to the change in the configuration of the thorax which is secondary to hyperinflation. The investigation should include the radiologic quantification of the structural abnormalities of the lungs and the functional consequences of these changes. When volume reduction of the lung is considered, the effects of hyperinflation on the mechanic of breathing and the ventilatory response to exercise has to be investigated rigorously.

Functional outcome of patients with chronic obstructive pulmonary disease and exercise hypercapnia

Chronic hypercapnia is associated with a poor prognosis in chronic obstructive pulmonary disease (COPD). Some patients are normocapnic at rest but retain CO2 during exercise. The significance of this abnormality on the course of the disease is unknown. Sixteen stable COPD patients (13 males and 3 females, aged 60 +/- 5 yrs, mean +/- SD) who had previously undergone pulmonary function tests and progressive exercise testing with arterial blood sampling at rest and maximal capacity, entered the study. At first evaluation (E1), subjects were normocapnic at rest (arterial carbon dioxide tension (Pa,CO2): 4.9-5.7 kPa, (37-43 mmHg)) and all presented exercise-induced hypercapnia (end-exercise Pa,CO2 > 5.7 kPa (43 mmHg) with a minimal 0.5 kPa (4 mmHg) increase from resting value). The subjects were re-evaluated 24-54 months later (34 +/- 8 months) (second evaluation (E2)). At E2, forced expiratory volume in one second (FEV1) had decreased from 42 +/- 13 to 38 +/- 15% of predicted values, and mean resting Pa,CO2 had increased from 5.2 +/- 0.3 to 5.7 + 0.4 kPa. Maximal exercise capacity (Wmax) decreased between E1 and E2 from 76 +/- 30 to 56 +/- 22 W. Even if Wmax was lower at E2, end-exercise, Pa,CO2 was higher than at E1 (6.6 +/- 0.8 vs 6.4 +/- 0.5 kPa). At E2, eight subjects presented resting hypercapnia (group H), whilst the others remained normocapnic (Group N). Group H subjects had higher Pa,CO2, at Wmax than Group N and lower Wmax than Group N at E2.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy: an effective treatment of cerebral involvement by lymphomatoid granulomatosis

We report the case of a 40-year-old woman who presented with neurologic complications of lymphomatoid granulomatosis after an initial pulmonary presentation. After treatment failure with immunosuppressive therapy, she responded dramatically to cranial radiation therapy without prior surgery.

Effects of lung resection on pulmonary function and exercise capacity

The effects of lung resection on exercise capacity and perception of symptoms were studied in 47 patients aged 39-73 (mean 58.3) years. Twenty had a pneumonectomy and 27 a lobectomy, all for lung cancer. Forced expiratory volume, maximal inspiratory and expiratory pressures, and progressive maximal one minute incremental cycle ergometer exercise performance were measured before and after surgery. Breathlessness and leg discomfort were assessed with a modified Borg scale (0-10). Mean FEV1 decreased from 79% (SD 22%) to 53% (11%) of the predicted value after pneumonectomy and from 89% (22%) to 74% (18%) after lobectomy. Exercise capacity, measured as the highest work load completed, Wmax, decreased from 78% (25%) to 58% (28%) predicted in the pneumonectomy group and from 77% (21%) to 67% (20%) in the lobectomy group. There was only a weak relation between changes in FEV1 and changes in Wmax (r = 0.54, r2 = 0.30). The slope of the relation between the intensity of dyspnoea and work load or the intensity of dyspnoea and ventilation increased significantly after pneumonectomy, but not after lobectomy. Leg discomfort increased more rapidly when related to work load after both pneumonectomy and lobectomy. After resection dyspnoea was rarely the only limiting factor at maximal exercise. It is concluded that (1) change in FEV1 is a poor predictor of change in exercise capacity after lung resection; (2) pneumonectomy results in a 25% decrease in Wmax and in an appreciable increase in dyspnoea during exercise; (3) lobectomy has little or no effect on Wmax or the intensity of postoperative dyspnoea; (4) after both pneumonectomy and lobectomy leg discomfort makes an important contribution to exercise limitation.

In situ right ventricular thrombus secondary to heparin induced thrombocytopenia

Heparin induced thrombocytopenia (HIT) is a relatively common complication of heparin therapy, occurring in approximately 5% of patients treated with this drug. HIT may be associated with diffuse arterial and venous thrombosis. The case of a patient without underlying heart disease who developed a right ventricular thrombus and recurrent pulmonary emboli in association with and possibly as a complication of HIT is reported. Ancrod was used as an alternative to heparin for the time required to obtain an effective oral anticoagulant effect. The patient recovered completely and has no residual right ventricular thrombus.

[The usefulness of an exercise test on a treadmill shortly after a myocardial infarction]

A program of reconditioning through walking was prescribed for 130 patients following an exercise test on a treadmill 3 weeks after a myocardial infarction. At 8 and at 12 weeks the patients again underwent an exercise test. The protocol is safe and permits the detection of angina, arrhythmias and dyspnea during the exercise, thus avoiding delays in treatment. The heart rate and the systolic blood pressure were measured at the end of each stage of the test and after 3 minutes of recuperation. About 75% of the patients attained the target energy output of the two submaximal tests (4 and 7 mets at 3 and 8 weeks respectively); an output of 7 mets permits a patient to resume his or her usual daily activities. The results of the tests at 3 and 12 weeks (the latter a maximal test) showed that the probability of an aerobic capacity of 7 mets or greater at 12 weeks is 86% if the 3-week test is completed. Clinical observations alone did not have the same prognostic value 3 weeks after the infarction.

In vitro and in vivo effects of ethanol on the formation of endoperoxide metabolites in rat platelets

Preincubation of rat platelet-rich plasma (PRP) with ethanol resulted in dose-dependent inhibition of the formation of endoperoxide metabolites (EPM) when the PRP was aggregated by collagen suspension. The inhibition was manifested at concentrations normally attainable in blood of rats or humans by tolerable amounts of ethanol ingestion. Paradoxically, chronic ingestion of ethanol caused enhanced synthesis of EPM in platelets, indicating that the inhibitory effect of ethanol would be temporary, and that it can be reversed as soon as ethanol is eliminated. The level of arachidonic acid in platelet phospholipids of rats fed the ethanol diet was not different from that of the control, indicating that availability of immediate precursor acid would not be a factor for the enhanced synthesis of EPM in the ethanol group. This result suggested that platelets from rats subjected to chronic ethanol ingestion become hyperactive in synthesizing EPM through an unknown mechanism. When citrated whole blood was incubated in the presence of collagen suspension, amounts of EPM synthesized in the ethanol group were not different from those of the control group, but this was due to significant reduction of platelet counts in the ethanol group. Whether the effect of ethanol on other tissues would be similar to that on platelets is unknown. It is tempting to speculate that some of the pathological changes resulting from alcoholism might be mediated through the effect of ethanol on EPM formation.

Heparin inhibits the formation of endoperoxide metabolites in rat platelets: aspirin-like activity

Amounts of thromboxane A2 (TXA2) synthesized during the collagen-induced aggregation was much higher in citrated PRP than in heaprinized PRP implying that heparin might inhibit the synthesis of endoperoxide metabolites besides its anticoagulant action. Preincubation of citrated PRP with heparin resulted in dose dependent inhibition of the formation of TXA2 and PGE2. At the high concentration, heparin also inhibited the aggregation of citrated platelets induced by collagen indicating that heparin possesses aspirin-like activity. The significance of this finding is that the antithrombotic effect of heparin is probably due to not only its anticoagulant effect but also inhibition of the formation of arachidonic acid metabolites by platelets.