Inactivation of Cryptosporidium parvum oocysts and faecal indicator bacteria in cattle slurry by addition of ammonia

AIMS

To determine inactivation of Cryptosporidium parvum oocysts and reduction of Escherichia coli and enterococci in cattle slurry added aqueous ammonia.

METHODS AND RESULTS

Escherichia coli, enterococci and nonviable C. parvum oocysts (DAPI+PI+) were enumerated every second day for 2 weeks in cattle slurry amended with 60 mmol l^-1 aq. ammonia and compared with untreated slurry at three temperatures. Regardless of temperature, the proportion of nonviable C. parvum oocysts increased significantly faster over time in slurry with added ammonia than raw slurry (P = 0·021) corresponding to 62·0% higher inactivation (P = 0·001) at day 14. Additionally, 91·8% fewer E. coli and 27·3% fewer enterococci were observed in slurry added ammonia at day 14 compared to raw slurry.

CONCLUSION

The addition of aqueous ammonia to raw slurry significantly reduced the viability of C. parvum oocysts and numbers of bacterial indicators. Hence, ammonia is usable at lower pathogen concentrations in slurry before application to agricultural land.

SIGNIFICANCE AND IMPACT OF THE STUDY

Livestock waste is a valuable source of plant nutrients and organic matter, but may contain high concentrations of pathogens like E. coli and Cryptosporidium sp. that can be spread in the environment, and cause disease outbreaks. However, die-off rates of pathogens in organic waste can increase following increasing ammonia concentrations.

Impact of device programming on the success of the first anti-tachycardia pacing therapy: An anonymized large-scale study

Background

Antitachycardia pacing (ATP) is an effective treatment for ventricular tachycardia (VT). We evaluated the efficacy of different ATP programs based on a large remote monitoring data set from patients with implantable cardioverter-defibrillators (ICDs).

Methods

A dataset from 18,679 ICD patients was used to evaluate the first delivered ATP treatment. We considered all device programs that were used for at least 50 patients, leaving us with 7 different programs and a total of 32,045 episodes. We used the two-proportions z-test (α = 0.01) to compare the probability of success and the probability for acceleration in each group with the corresponding values of the default setting.

Results

Overall, the first ATP treatment terminated in 78.4%–97.5% of episodes with slow VT and 81.5%–91.1% of episodes with fast VT. The default setting of the ATP programs with the number of sequences S = 3 was applied to treat 30.1% of the slow and 36.6% of the fast episodes. Reducing the maximum number of sequences to S = 2 decreased the success rate for slow VT (P < 0.0001, h = 0.38), while the setting S = 4 resulted in the highest success rate of 97.5% (P < 0.0001, h = 0.27).

Conclusion

While the default programs performed well, we found that increasing the number of sequences from 3 to 4 was a promising option to improve the overall ATP performance.

Predicting electrical storms by remote monitoring of implantable cardioverter-defibrillator patients using machine learning

Aims

Electrical storm (ES) is a serious arrhythmic syndrome that is characterized by recurrent episodes of ventricular arrhythmias. Electrical storm is associated with increased mortality and morbidity despite the use of implantable cardioverter-defibrillators (ICDs). Predicting ES could be essential; however, models for predicting this event have never been developed. The goal of this study was to construct and validate machine learning models to predict ES based on daily ICD remote monitoring summaries.

Methods and results

Daily ICD summaries from 19 935 patients were used to construct and evaluate two models [logistic regression (LR) and random forest (RF)] for predicting the short-term risk of ES. The models were evaluated on the parts of the data not used for model development. Random forest performed significantly better than LR (P < 0.01), achieving a test accuracy of 0.96 and an area under the curve (AUC) of 0.80 (vs. an accuracy of 0.96 and an AUC of 0.75). The percentage of ventricular pacing and the daytime activity were the most relevant variables in the RF model.

Conclusion

The use of large-scale machine learning showed that daily summaries of ICD measurements in the absence of clinical information can predict the short-term risk of ES.

Factor VIII with a 237 amino acid B-domain has an extended half-life in F8-knockout mice

Essentials Factor (F)VIII with an intermediate-length B-domain showed higher levels in murine gene therapy. FVIII with different B-domain lengths were analysed. FVIII variants with B-domains between 186 and 240 amino acids (aa) have extended half-life in mice. Reduced cell binding of FVIII with a 237aa B-domain may explain the extended half-life. SUMMARY: Background Factor VIII consists of the A1-domain, A2-domain, B-domain, A3-domain, C1-domain, and C2-domain. FVIII with an intermediate-length B-domain of 226 amino acids (aa) has previously been evaluated in murine gene therapy studies. Objective To characterize FVIII with intermediate-length B-domains in vitro and in vivo in F8-knockout (KO) mice. Methods and results FVIII molecules with B-domains of 186-240aa had longer half-lives in F8-KO mice than FVIII molecules with shorter or longer B-domains. FVIII with a B-domain containing the 225 N-terminal aa fused to the 12 C-terminal aa of the wild-type B-domain (FVIII-237) had a 1.6-fold extended half-life in F8-KO mice as compared with FVIII with a 21aa B-domain (FVIII-21). The in vitro and in vivo activity of FVIII-237 were comparable to those of FVIII-21, as was binding to von Willebrand factor. Cell binding to LDL receptor-related protein 1 (LRP-1)-expressing cells was markedly reduced for FVIII-237 as compared with FVIII-21, whereas the affinity for LRP-1 was not reduced in surface plasmon resonance (SPR) studies. FVIII-21 cell binding and internalization could be inhibited by a fragment consisting of the 226 N-terminal aa of the FVIII B-domain, and SPR analysis suggested that this B-domain fragment might bind with weak affinity to FVIII-21. Conclusion Reduced cell binding of FVIII-237 might explain the observed extended half-life in F8-KO mice. This may contribute to the increased FVIII levels measured in murine gene therapy studies using FVIII constructs with similar B-domain lengths.

Morphological and molecular characterisation of Eimeria vison-like oocysts (Apicomplexa:Eimeriidae) in farmed mink (Neovison vison) in Denmark

A survey was conducted on 30 Danish mink farms from April to October 2016 to determine the prevalence and species of Eimeria in Danish farmed mink. In total, 2.6% of mink faecal samples (108/4140) were positive for Eimeria vison-like oocysts by microscopy, with 24.8% (78/315) of mink being positive at least once during the study period. Morphological analysis of sporulated oocysts (n = 20) identified Eimeria vison-like oocysts measuring 21.0 × 13.8 μm with a length/width (L/W) ratio of 1.5. Phylogenetic analysis of 18S rRNA sequences (1221 bp) from three positive mink indicated that Eimeria vison-like shared the highest genetic similarity to Eimeria sp. ex Apodemus agrarius from a Striped field mouse (A. agrarius) from the Czech Republic (99.6%). Analysis of a shorter region of 18S (531 bp) revealed that the E. vison-like genotype sequences grouped in the same clade and shared 97.7% similarity with E. furonis. At the cytochrome c oxidase subunit I (COI) locus, mink-derived sequences were not available from GenBank and phylogenetic analysis placed the novel E. vison-like in a clade with E. cf. ictidea (99.4% similarity) from a black footed ferret (Mustela nigripes) from Canada.

Echinococcus multilocularis in Denmark 2012-2015: high local prevalence in red foxes

In Western Europe, the Echinococcus multilocularis lifecycle is predominantly sylvatic, typically involving red foxes (Vulpes vulpes) as the main definitive hosts with Microtus spp. and Arvicola spp. as intermediate hosts. During a 4-year surveillance study (2012-2015), Danish red foxes and raccoon dogs (n = 1345) were examined for E. multilocularis. Moreover, 134 insectivores and rodents collected in South Jutland during spring and summer 2016 were examined for the presence of metacestodes. The sedimentation and counting technique and molecular typing were used to identify E. multilocularis infections in the carnivores, while the rodent livers were examined macro- and microscopically for parasite lesions. Following morphological identification of E. multilocularis adult worms, the identity was verified by sequence analysis of the 12S rRNA gene in most cases (n = 13). Echinococcus multilocularis infection was demonstrated in 19 red foxes (Vulpes vulpes) originating from only two specific areas of South Jutland, namely Højer and Grindsted, and in two raccoon dogs (Nyctereutes procyonoides), originating from Højer. In Højer, 28.5% (CI 95% 11.7-45.3) of the examined red foxes were E. multilocularis positive per year. Moreover, positive red foxes were identified each year from 2012 to 2015, while E. multilocularis positive red foxes were only identified in Grindsted in 2013 (4.0%) and 2014 (6.4%). In contrast, all collected rodents were negative for E. multilocularis. We conclude that E. multilocularis is locally endemic in South Jutland with a high local prevalence in Højer.

Factor Xa and VIIa inhibition by tissue factor pathway inhibitor is prevented by a monoclonal antibody to its Kunitz-1 domain

Essentials Activated FVII (FVIIa) and FX (FXa) are inhibited by tissue factor pathway inhibitor (TFPI). A monoclonal antibody, mAb2F22, was raised against the N-terminal fragment of TFPI (1-79). mAb2F22 bound exclusively to the K1 domain of TFPI (KD ∼1 nm) and not to the K2 domain. mAb2F22 interfered with inhibition of both FVIIa and FXa activities and restored clot formation.

SUMMARY

Background Initiation of coagulation is induced by binding of activated factor VII (FVIIa) to tissue factor (TF) and activation of factor X (FX) in a process regulated by tissue factor pathway inhibitor (TFPI). TFPI contains three Kunitz-type protease inhibitor domains (K1-K3), of which K1 and K2 block the active sites of FVIIa and FXa, respectively. Objective To produce a monoclonal antibody (mAb) directed towards K1, to characterize the binding epitope, and to study its effect on TFPI inhibition. Methods A monoclonal antibody, mAb2F22, was raised against the N-terminal TFPI(1-79) fragment. Binding data were obtained by surface plasmon resonance analysis. The Fab-fragment of mAb2F22, Fab2F22, was expressed and the structure of its complex with TFPI(1-79) determined by X-ray crystallography. Effects of mAb2F22 on TFPI inhibition were measured in buffer- and plasma-based systems. Results mAb2F22 bound exclusively to K1 of TFPI (KD ~1 nm) and not to K2. The crystal structure of Fab2F22/TFPI (1-79) mapped an epitope on K1 including seven residues upstream of the domain. TFPI inhibition of TF/FVIIa amidolytic activity was neutralized by mAb2F22, although the binding epitope on K1 did not include the P1 residue. Binding of mAb2F22 to K1 blocked TFPI inhibition of the FXa amidolytic activity and normalized hemostasis in hemophilia human A-like plasma and whole blood. Conclusion mAb2F22 blocked TFPI inhibition of both FVIIa and FXa activities and mapped a FXa exosite for binding to K1. It reversed TFPI feedback inhibition of TF/FVIIa-induced coagulation and restored clot formation in FVIII-neutralized human plasma and blood.

Safety of magnetic resonance scanning without monitoring of patients with pacemakers

Aims

The objective of this study was to investigate whether it is safe to perform 1.5-Tesla magnetic resonance imaging (MRI) scans in pacemaker (PM) patients without pulse oximetry or electrocardiogram monitoring and with no special specific absorption rate (SAR) or time limits, provided that the PMs are interrogated and programmed to asynchronous mode prior to the scan.

Methods and results

This study reports the outcome of 207 MRI scans on PM patients at Rigshospitalet, Copenhagen University Hospital from June 2010 to September 2013. All MRIs were performed with the PMs in asynchronous mode and without additional monitoring. There were no adverse events registered among the PM patients during the study period. The only statistically significant change after MRI scans was a small, but clinically insignificant increase in atrial sense. No occurrences of reprogramming to power-on-reset were registered.

Conclusion

It is possible to perform MRI scans relatively safely in PM patients without additional monitoring or change in the normal MRI protocol, given that the PM has been assessed and reprogrammed prior to MRI. This is especially important to remember in the acute setting where MRI scans may be delayed when monitoring facilities are unavailable.

The impact of co-morbidity burden on appropriate implantable cardioverter defibrillator therapy and all-cause mortality: insight from Danish nationwide clinical registers

AIMS

In a nationwide cohort of primary (PP-ICD) and secondary prevention (SP-ICD) implantable cardioverter defibrillator (ICD) patients, we aimed to investigate the association between co-morbidity burden and risk of appropriate ICD therapy and mortality.

METHODS AND RESULTS

We identified all patients >18 years, implanted with first-time PP-ICD (n = 1873) or SP-ICD (n = 2461) in Denmark from 2007 to 2012. Co-morbidity was identified in administrative registers of hospitalization and drug prescription from pharmacies. Co-morbidity burden was defined as the number of pre-existing non-ICD indication-related co-morbidities including atrial fibrillation, diabetes, chronic obstructive pulmonary disease, chronic renal disease, liver disease, cancer, chronic psychiatric disease, and peripheral and/or cerebrovascular disease, and divided into four groups (co-morbidity burden 0, 1, 2, and ≥3). Through Cox models, we assessed the impact of co-morbidity burden on appropriate ICD therapy and mortality. Increasing co-morbidity burden was not associated with increased risk of appropriate therapy, irrespective of implant indication [all hazard ratios (HRs) 1.0-1.4, P = NS]. Using no co-morbidities as reference, increasing co-morbidity burden was associated with increased mortality risk in PP-ICD patients (co-morbidity burden 1, HR 2.1; comorbidity burden 2, HR 3.7; co-morbidity burden ≥3, HR 6.6) (all P < 0.001) and SP-ICD patients (co-morbidity burden 1, HR 2.2; co-morbidity burden 2, HR 3.8; co-morbidity burden ≥3, HR 5.8). With increasing co-morbidity burden, an increasing frequency of patients died without having utilized their device, with 72% PP-ICD and 45% SP-ICD patients with co-morbidity burden ≥3 dying without prior appropriate ICD therapy.

CONCLUSION

Increasing co-morbidity burden was not associated with increased risk of appropriate ICD therapy. With increasing co-morbidity burden, mortality increased, and a higher proportion of patients died, without ever having utilized their device.

[Safety of magnetic resonance imaging in patients with pacemaker and implantable defibrillator]

INTRODUCTION

The presence of a cardiac implantable device is ICD considered an absolute contraindication to magnetic resonance imaging (MRI). The purpose of this study was to evaluate the safety of performing MRI in patients with cardiac pacemakers and ICDs that had a compelling clinical need for MRI examination.

MATERIAL AND METHODS

During a period of nine years we have included 65 patients with cardiac devices (60 pacemakers and five ICDs) who underwent a total of 73 MRI examinations at 1.5 T. All pacemakers were reprogrammed before MRI to asynchronous mode to avoid MRI-induced inhibition or to sense only mode to avoid MRI-induced competitive pacing and potential pro-arrhythmia. All devices were interrogated immediately before and after the MRI examination, which included measurement of sensitivity, pacing capture threshold (PCT) and lead impedance.

RESULTS

MRI examinations were completed safely in 63 patients. Inhibition of pacemaker output was observed in one patient and induction of ventricular fibrillation was observed in another with ICD. A significant increase in PCT was rare and only detected in 1% of all electrodes.

CONCLUSION

MRI can be performed safely in patients with pacemakers with an acceptable risk-benefit ratio, while MRI of patients with ICDs must still be considered an experimental procedure.

Prevalence of clinical signs of disease in Danish finisher pigs

Between December 1999 and February 2001, two visits, eight weeks apart, were made to 90 herds of Danish finisher pigs. The prevalence of clinical signs was recorded by three veterinary technicians from the Danish Bacon and Meat Council according to a standardised procedure; they had been trained and their observations were monitored and validated before and during the study. A total of 154,347 finisher pigs were examined and 22,136 clinical signs were recorded. Vices accounted for 43 per cent of the signs. The highest mean prevalence was observed for ear necrosis (4.44 per cent), followed by respiratory signs (2.17 per cent), lameness (1.92 per cent), other skin diseases (1.73 per cent), tail bites (1.26 per cent), umbilical hernia (0.78 per cent), flank bites (0.52 per cent), diarrhoea (0.27 per cent), respiratory distress (0.12 per cent), atrophic rhinitis (0.10 per cent), recumbency (0.09 per cent) and central nervous disease (0.05 per cent). The prevalence of atrophic rhinitis was higher in conventional herds than in specific pathogen-free herds. The prevalence of clinical signs of atrophic rhinitis was higher among finishers weighing 51 to 75 kg than among finishers weighing up to 50 kg, and the prevalence of respiratory signs was higher among finishers weighing 51 to 75 kg then among finishers weighing 76 to 100 kg.

Indication of the radiofrequency induced lesion size by pre-ablation measurements

BACKGROUND

During radiofrequency ablation of arrhythmias tissue heating and hence lesion size depend on electrode-tissue contact and cooling of the electrode tip caused by cavitary blood flow. These factors are unique and unknown for each catheter placement in the beating heart. A tool for assessing these factors prior to ablation may indicate the lesion size which will be obtained for any given catheter position.

METHODS AND RESULTS

Radiofrequency ablation was performed in vitro on strips of left ventricular porcine myocardium during two different levels of convective cooling (0 or 0.1 m/s), two different contact pressures (10 or 30 g) and parallel or perpendicular electrode-tissue orientation using 7F 4 mm tip catheters. Prior to ablation the impedance rise (DeltaIMP) caused by the obtained contact and the temperature rise with a 0.6 W 5 s test pulse (DeltaT) were measured. Subsequently, during unchanged conditions, radiofrequency ablation was performed as either temperature-controlled, power-controlled or irrigated tip ablation and lesion size was determined. DeltaIMP increased significantly (P < 0.05) by improved contact, whereas it was not affected by convective cooling. DeltaT was significantly increased by increasing contact pressure (P < 0.05) and significantly decreased by increased cooling (P < 0.001). DeltaT was not systematically affected by electrode orientation. The product of DeltaT and DeltaIMP showed a significant correlation between the obtained lesion size and power output for temperature-controlled and between lesion size and tip temperature for power-controlled ablation (P < 0.001).

CONCLUSIONS

Pre-ablation measurement of DeltaIMP and DeltaT can indicate the lesion size resulting after ablation in temperature-controlled, power-controlled and irrigated ablation in vitro, since DeltaT reflects cavitary cooling and to a smaller extent electrode-tissue contact, and DeltaIMP reflects only electrode-tissue contact.

Mechanisms for Enlarging Lesion Size During Irrigated Tip Radiofrequency Ablation:. Is There a Virtual Electrode Effect?

INTRODUCTION

Irrigated tip radiofrequency ablation of cardiac arrhythmias was developed to increase the size of the radiofrequency-induced lesion, since cooling of the electrode tip allows use of higher power settings. The purpose of this study was to determine if the increased lesion size during irrigated tip ablation is caused by the cooling effect solely or if increased electrical conductivity around the tip also contributes by increasing the "current-delivering size" of the tip: the so-called "virtual electrode effect."

METHODS AND RESULTS

In vitro strips of left ventricular porcine myocardium and in vivo canine left ventricles were ablated. In vitro closed loop tip and showerhead irrigated tip catheters were compared. In vitro and in vivo showerhead tip catheters irrigated with solutions having different ionic content were compared. We found no difference in lesion size for closed loop and showerhead-type catheters (998 +/- 345 vs. 811 +/- 313 mm(3) during power-controlled ablation and 227 +/- 76 vs 318 +/- 127 mm(3) during temperature-controlled ablation). For irrigation with liquids having increasing ionic strength we found a decrease in lesion volume in vitro (361 +/- 249 vs. 812 +/- 229 mm(3) (P < 0.001) for power-controlled and 156 +/- 78 vs. 318 +/- 127 mm(3) (P < 0.05) for temperature-controlled ablation and nonsignificant differences in vivo.

CONCLUSIONS

The mechanism for enlarging lesion size during radiofrequency irrigated-tip ablation is that higher power levels can be used. There is no virtual electrode effect caused by the highly conductive surroundings of the tip during irrigation. In vitro this effect is shown to be opposite: it decreases lesion size.

Can lesion size during radiofrequency ablation be predicted by the temperature rise to a low power test pulse in vitro?

During radiofrequency ablation sufficient power must be delivered to achieve a proper lesion, while tissue temperatures are kept below 100 degrees C. Tissue temperature and hence lesion size are determined by electrode to tissue contact and convective cooling, which vary with any obtained electrode position in the beating heart. A tool for evaluation of the combined effect of these parameters prior to ablation to predict the resulting lesion size for any actually obtained electrode position would be valuable. A low power pulse prior to ablation will cause a small increase in tip temperature, which will reflect tissue contact and convective cooling of the tip for that particular electrode position and may thereby predict lesion dimensions after subsequent ablation at that site. Ablation was performed in vitro on strips of left ventricular porcine myocardium during different levels of convective cooling, variable contact pressure, and two electrode orientations in temperature-controlled and power-controlled modes. A 4-mm tip catheter was used. Prior to ablation a 30-second, 0.6-W test pulse was delivered and the increase in tip temperature (DeltaT) registered. The study found that DeltaT and lesion size were mainly affected by the external cooling of the electrode tip and less by the electrode to tissue contact. Increased cooling caused a lower DeltaT (P < 0.001), and the effect on lesion dimensions depended on the ablation mode. For temperature-controlled ablation a larger lesion due to increased power output was obtained (P < 0.0001) for increased cooling, whereas for power-controlled ablation a smaller lesion was obtained for increased cooling (P < 0.05). DeltaT can predict lesion size, but the interpretation of DeltaT depends on the ablation mode. For temperature-controlled ablation a high DeltaT indicates a small lesion and for power-controlled ablation a high DeltaT indicates a large lesion.

Serum haptoglobin concentration as a marker of clinical signs in finishing pigs

A case-control study of 340 finishing pigs aged 10 to 25 weeks in 15 commercial Danish pig herds was carried out to investigate serum haptoglobin concentration as an objective marker of clinical signs of disease. Pigs with different clinical signs were matched to control pigs without clinical signs with respect to herd, pen, estimated weight and gender, and each pig was subjected to a standard clinical examination. In 86 of the case-control pairs, the rectal temperature was also recorded. There was a significantly higher mean haptoglobin concentration in the serum of lame pigs (P<0.0001), pigs with respiratory disease (P=0.0004), pigs with tail or ear bites (P=0.0004) and pigs with diarrhoea (P=0.02). Similarly, a higher mean rectal temperature was recorded in lame pigs (P<0.0001), pigs with respiratory disease (P=0.002) and pigs with tail or ear bites (P=0.0003). There was a significant but low correlation between rectal temperature and haptoglobin concentration in serum (P=0.003, r=0.20). The area under the receiver-operating-characteristic curve was between 0.67 and 0.78 for the different clinical signs. The maximum simultaneous levels of sensitivity (0.61 to 0.71) and specificity (0.61 to 0.77) of serum haptoglobin for the different clinical signs were obtained at a cut-off value of 1.1 mg/ml. At a cut-off value of 1.8 mg/ml, the sensitivity decreased to 0.31 to 0.60, and the specificity increased to 0.82 to 0.86. It was not possible to define a cut-off value which classified individual pigs according to their clinical signs.

Evaluation of an enzyme-linked immunosorbent assay for determination of porcine haptoglobin

An enzyme-linked immunosorbent assay for quantification of haptoglobin in porcine serum was evaluated. The detection limit when expressed as the estimated concentration of a blank sample was 0.0003 mg/ml. The precision of the assay was acceptable with intra-assay coefficients of variation below 4% and inter-assay coefficient of variation below 5% for serum concentrations ranging from 1.0 mg/ml and above. For samples with a concentration below 0.8 mg/ml, the inter-assay coefficient of variation was above 10% The assay maintained linearity under dilution. Recovery was proportional. Haemolysis significantly decreased the measured concentration of haptoglobin in paired serum samples (one-sided t-test, P < 0.0001, degrees of freedom = 29). No significant effect on the concentration due to repeated freezing and thawing of serum was observed. The biological variation in individual pigs with no clinical signs of disease was estimated by nested analysis of variance. Between-pig variation was 86.0% within-pig variation was 13.3% and analytical variation was 0.7%. The one-sided critical difference was 12.3% and the two-sided critical difference was 14.6%. The index of individuality was 0.2. The maximum allowable analytical imprecision was 2.6% and the maximum analytical inaccuracy was 9.9%. The number of samples required to determine the true haptoglobin value in an individual pig when accounting for the day-to-day fluctuation was 5. In conclusion, the haptoglobin assay was found to be suitable for quantification of haptoglobin in non-haemolysed porcine serum samples with a haptoglobin concentration above 1.0 mg/ml. The analytical variance was found to be low. The haptoglobin concentration in serum was found to characterize individual animals. A large inter-animal variation in haptoglobin level was found.

Localization of epitopes for monoclonal antibodies to urokinase-type plasminogen activator: relationship between epitope localization and effects of antibodies on molecular interactions of the enzyme

We localized the epitopes for several murine mAbs to human urokinase-type plasminogen activator (uPA) by Ala scanning mutagenesis and related the localization to the effects of the mAbs on the molecular interactions of uPA. Several antibodies against the serine proteinase domain (SPD) were found to have overlapping epitopes composed of variable combinations of Arg178, Arg179, His180, Arg181, Tyr209, Lys211, and Asp214 in the so-called 37-loop and 60-loop, located near the active site and taking part in the binding of uPA to plasminogen activator inhibitor-1 (PAI-1). Besides inhibiting uPA-catalysed plasminogen activation, all antibodies to SPD strongly delayed the binding of uPA to PAI-1, decreasing the second-order rate constant 15- to 6500-fold. There was no correlation between the relative effects of the 37-loop and 60-loop substitutions on the second-order rate constant and on the binding of the antibodies, indicating that the antibodies did not delay complex formation by blocking residues of specific importance for the uPA-PAI-1 reaction, but rather by steric hindrance of the access of PAI-1 to the active site. The affinity of the SPD antibodies for the uPA-PAI-1 complex was only slightly lower than that for free uPA, indicating that the 37-loop and 60-loop are exposed in the complex. The epitopes for two antibodies to the kringle included Arg108, Arg109, and Arg110. The ability of these antibodies to block the binding of uPA to polyanions correlated with a reduced uPA-polyanion affinity after substitution of the three Arg residues.

Analysis of a two-domain binding site for the urokinase-type plasminogen activator-plasminogen activator inhibitor-1 complex in low-density-lipoprotein-receptor-related protein

The low-density-lipoprotein-receptor (LDLR)-related protein (LRP) is composed of several classes of domains, including complement-type repeats (CR), which occur in clusters that contain binding sites for a multitude of different ligands. Each approximately 40-residue CR domain contains three conserved disulphide linkages and an octahedral Ca(2+) cage. LRP is a scavenging receptor for ligands from extracellular fluids, e.g. alpha(2)-macroglobulin (alpha(2)M)-proteinase complexes, lipoprotein-containing particles and serine proteinase-inhibitor complexes, like the complex between urokinase-type plasminogen activator (uPA) and the plasminogen activator inhibitor-1 (PAI-1). In the present study we analysed the interaction of the uPA-PAI-1 complex with an ensemble of fragments representing a complete overlapping set of two-domain fragments accounting for the ligand-binding cluster II (CR3-CR10) of LRP. By ligand blotting, solid-state competition analysis and surface-plasmon-resonance analysis, we demonstrate binding to multiple CR domains, but show a preferential interaction between the uPA-PAI-1 complex and a two-domain fragment comprising CR domains 5 and 6 of LRP. We demonstrate that surface-exposed aspartic acid and tryptophan residues at identical positions in the two homologous domains, CR5 and CR6 (Asp(958,CR5), Asp(999,CR6), Trp(953,CR5) and Trp(994,CR6)), are critical for the binding of the complex as well as for the binding of the receptor-associated protein (RAP) - the folding chaperone/escort protein required for transport of LRP to the cell surface. Accordingly, the present work provides (1) an identification of a preferred binding site within LRP CR cluster II; (2) evidence that the uPA-PAI-1 binding site involves residues from two adjacent protein domains; and (3) direct evidence identifying specific residues as important for the binding of uPA-PAI-1 as well as for the binding of RAP.

The plasminogen activation system in tumor growth, invasion, and metastasis

Generation of the serine proteinase plasmin from the extracellular zymogen plasminogen can be catalyzed by either of two other serine proteinases, the urokinase- and tissue-type plasminogen activators (uPA and tPA). The plasminogen activation system also includes the serpins PAI-1 and PAI-2, and the uPA receptor (uPAR). Many findings, gathered over several decades, strongly suggest an important and causal role for uPA-catalyzed plasmin generation in cancer cell invasion through the extracellular matrix. Recent evidence suggests that the uPA system is also involved in cancer cell-directed tissue remodeling. Moreover, the system also supports cell migration and invasion by plasmin-independent mechanisms, including multiple interactions between uPA, uPAR, PAI-1, extracellular matrix proteins, integrins, endocytosis receptors, and growth factors. These interactions seem to allow temporal and spatial reorganizations of the system during cell migration and a selective degradation of extracellular matrix proteins during invasion. The increased knowledge about the plasminogen activation system may allow utilization of its components as targets for anti-invasive therapy.

Tissue temperatures and lesion size during irrigated tip catheter radiofrequency ablation: an in vitro comparison of temperature-controlled irrigated tip ablation, power-controlled irrigated tip ablation, and standard temperature-controlled ablation

The limited success rate of radiofrequency catheter ablation in patients with ventricular tachycardias related to structural heart disease may be increased by enlarging the lesion size. Irrigated tip catheter ablation is a new method for enlarging the size of the lesion. It was introduced in the power-controlled mode with high power and high infusion rate, and is associated with an increased risk of crater formation, which is related to high tissue temperatures. The present study explored the tissue temperatures during temperature-controlled irrigated tip ablation, comparing it with standard temperature-controlled ablation and power-controlled irrigated tip ablation. In vitro strips of porcine left ventricular myocardium were ablated. Temperature-controlled irrigated tip ablation at target temperatures 60 degrees C, 70 degrees C, and 80 degrees C with infusion of 1 mL saline/min were compared with standard temperature-controlled ablation at 70 degrees C and power-controlled irrigated tip ablation at 40 W, and infusion of 20 mL/min. Lesion size and tissue temperatures were significantly higher during all modes of irrigated tip ablation compared with standard temperature-controlled ablation (P < 0.05). Lesion volume correlated positively with tissue temperature (r = 0.87). The maximum recorded tissue temperature was always 1 mm from the ablation electrode and was 67 +/- 4 degrees C for standard ablation and 93 +/- 6 degrees C, 99 +/- 6 degrees C, and 115 +/- 13 degrees C for temperature-controlled irrigated tip ablation at 60 degrees C, 70 degrees C, and 80 degrees C, respectively, and 112 +/- 12 degrees C for power-controlled irrigated tip ablation, which for irrigated tip ablation was significantly higher than tip temperature (P < 0.0001). Crater formation only occurred at tissue temperatures > 100 degrees C. We conclude that irrigated tip catheter ablation increases lesion size and tissue temperatures compared with standard ablation in the temperature-controlled mode at the same or higher target temperatures and in the power-controlled mode. Furthermore, tissue temperature and delivered power are the best indicators of lesion volume during temperature-controlled ablation.

Ovarian follicular fluid, progesterone and Ca2+ ion influences on sperm release from the fallopian tube reservoir

As a means of determining whether ovarian follicular fluid reaches the functional sperm reservoir in the caudal isthmus of the Fallopian tube shortly after ovulation, 0.01-0.02 ml aliquots of whole or steroid-free follicular fluid were introduced into the distal extremity of the isthmus within 1 hr before ovulation. Eggs were recovered during a second intervention 4 hr 45 min-6 hr 10 min after treatment and examined by phase-contrast microscopy for the normality of fertilisation. In a separate experiment, 0.01-0.02 ml aliquots of 10 microM calcium ionophore solution were introduced into the same site in comparable animals. Sixty-nine fertilised eggs were recovered from 12 fallopian tubes treated with whole follicular fluid, of which 24 (34.8%) were polyspermic. The 12 contralateral control tubes (PBS-treated) yielded 47 fertilised eggs, of which only one (2.1%) was polyspermic (P < 0.001). Steroid-free aliquots of the same follicular fluid introduced bilaterally into eight fallopian tubes (4 animals) resulted in recovery of 59 fertilised eggs, of which only one (1.7%) was polyspermic. Treatment with ionophore solution yielded a 41.6% incidence of polyspermy (10 of 24 eggs from four tubes) compared with 3.8% polyspermy (1 egg) from the control tubes (P < 0.01). Dispermy was the principal form of polyspermy. The numbers of accessory spermatozoa on/in the zona pellucida were increased by the experimental treatment. Follicular fluid passing down the fallopian tube ampulla at ovulation was therefore considered not to be the physiological stimulus for an initial, tightly-controlled release of spermatozoa from epithelial binding in the caudal isthmus. Indeed, because such sperm activation commences shortly before ovulation, a locally transmitted ovarian programming with relatively high concentrations of follicular hormones remains the favoured model. Although pre-ovulatory progesterone is considered to be the coordinating steroid of increasing influence in these pre-fertilisation events, its effects are proposed to be modulated in the endosalpinx by mobilisation of Ca2+ ions into a discrete population of bound spermatozoa. Results of the steroid-free follicular fluid and calcium ionophore treatments stand in support.

Temperature-controlled radiofrequency ablation of cardiac tissue: an in vitro study of the impact of electrode orientation, electrode tissue contact pressure and external convective cooling

BACKGROUND

A variety of basic factors such as electrode tip pressure, flow around the electrode and electrode orientation influence lesion size during radiofrequency ablation, but importantly is dependent on the chosen mode of ablation. However, only little information is available for the frequently used temperature-controlled mode. The purpose of the present experimental study was to evaluate the impact during temperature-controlled radiofrequency ablation of three basic factors regarding electrode-tissue contact and convective cooling on lesion size.

METHODS AND RESULTS

In vitro strips of porcine left ventricular myocardium were ablated in a tissue bath. Temperature-controlled ablation at 80 degrees C for 60 s was performed using a 7F 4 mm tip electrode in either perpendicular or parallel contact with the endocardium at a pressure of 10 or 20 g. Increased flow around the electrode was induced by circulating the saline in the tissue bath at a flow-velocity of 0.1 m/s. Lesion volume was determined by cutting lesions in 1 mm thick slices, staining with nitroblue tetrazolium and planimetering. A total of 107 lesions was created. Lesion size was significantly larger for perpendicular electrode orientation compared to parallel for both pressure-settings and both levels of flow around the electrode (p < 0.05). Increased flow around the electrode enlarged lesion size (p < 0.005). Electrode-tissue contact pressure had no significant impact on lesion size.

CONCLUSIONS

During temperature-controlled radiofrequency ablation increased external cooling of the electrode tip due to either flow of the surrounding liquid or poor electrode tissue contact, as exemplified by perpendicular versus parallel electrode orientation, increases lesion size significantly. This is in contrast to the impact of these factors during power-controlled ablation due to the lack of increased power-delivery in the latter situation.

Engineering of conformations of plasminogen activator inhibitor-1. A crucial role of beta-strand 5A residues in the transition of active form to latent and substrate forms

The serpin (serine proteinase inhibitor) family is of general protein chemical interest because of its ability to undergo large conformational changes, in which the surface-exposed reactive centre loop (RCL) is inserted as strand 4 in the large central beta-sheet A. Loop insertion is an integral part of the inhibitory mechanism and also takes place at conversion of serpins to the latent state, occurring spontaneously only in plasminogen activator inhibitor-1 (PAI-1). We have investigated the importance of beta-strand 5A residues for the activity and latency transition of PAI-1. An approximately fourfold increase in the rate of latency transition resulted from His-substitution of Gln324 (position 334 in the alpha(1)-proteinase inhibitor template numbering), which interacts with the underlying alpha-helix B. The side chains of Gln321 and Lys325 (template residues 331 and 335, respectively) form hydrogen bonds to the peptide backbone of a loop connecting alpha-helix F and beta-strand 3A. While substitution with Ala of Glu321 had only minor effects on the properties of PAI-1, substitution with Ala of Lys325 led to stabilization of the inhibitory activity at incubation conditions leading to conversion of wild-type PAI-1 to a substrate form, and to an anomalous reaction towards a monoclonal antibody, which induced a delay in the latency transition of the mutant, but not wild-type PAI-1. We conclude that the anchoring of beta-strand 5A plays a crucial role in loop insertion. These findings provide new information about the mechanism of an important example of protein conformational changes.

Ligand binding properties of the very low density lipoprotein receptor. Absence of the third complement-type repeat encoded by exon 4 is associated with reduced binding of Mr 40,000 receptor-associated protein

The very low density lipoprotein receptor (VLDLR) binds, among other ligands, the Mr 40,000 receptor-associated protein (RAP) and a variety of serine proteinase-serpin complexes, including complexes of the proteinase urokinase-type plasminogen activator (uPA) with the serpins plasminogen activator inhibitor-1 (PAI-1) and protease nexin-1 (PN-1). We have analyzed the binding of RAP, uPA.PAI-1, and uPA.PN-1 to two naturally occurring VLDLR variants, VLDLR-I, containing all eight complement-type repeats, and VLDLR-III, lacking the third complement-type repeat, encoded by exon 4. VLDLR-III displayed approximately 4-fold lower binding of RAP than VLDLR-I and approximately 10-fold lower binding of the most C-terminal one of the three domains of RAP. In contrast, the binding of uPA.PAI-1 and uPA.PN-1 to the two VLDLR variants was indistinguishable. Surprisingly, uPA.PN-1, but not uPA.PAI-1, competed RAP binding to both VLDLR variants. These observations show that the third complement-type repeat plays a crucial role in maintaining the contact sites needed for optimal recognition of RAP, but does not affect the proteinase-serpin complex contact sites, and that two ligands can show full cross-competition without sharing the same contacts with the receptor. These results elucidate the mechanisms of molecular recognition of ligands by receptors of the low density lipoprotein receptor family.

Temperature-controlled irrigated tip radiofrequency catheter ablation: comparison of in vivo and in vitro lesion dimensions for standard catheter and irrigated tip catheter with minimal infusion rate

INTRODUCTION

In patients with ventricular tachycardias due to structural heart disease, catheter ablation cures < 60% partly due to the limited lesion size after conventional radiofrequency ablation. Irrigated tip radiofrequency ablation using power control and high infusion rates enlarges lesion size, but has increased risk of cratering. The present study explores irrigated tip catheter ablation in temperature-controlled mode, target temperature 60 degrees C, using an irrigation rate of 1 mL/min, comparing this to conventional catheter technique, target temperature 80 degrees C.

METHODS AND RESULTS

In vivo anesthetized pigs were ablated in the left ventricle. In vitro strips of porcine left ventricular myocardium were ablated in a tissue bath. Lesion volume was significantly larger after irrigated tip ablation both in vivo (544 +/- 218 vs 325 +/- 194 mm3, P < 0.01) and in vitro (286 +/- 113 vs 179 +/- 23 mm3, P < 0.001). The incidence of cratering was not significantly different between the two groups. In vivo, no coagulum formation on part of the catheter tip was seen after irrigated tip ablation as opposed to 52% of the applications with conventional ablation (P < 0.05).

CONCLUSION

We conclude that temperature-controlled radiofrequency ablation with irrigated tip catheters using low target temperature and low infusion rate enlarges lesion size without increasing the incidence of cratering and reduces coagulum formation of the tip.

Binding of urokinase-type plasminogen activator-plasminogen activator inhibitor-1 complex to the endocytosis receptors alpha2-macroglobulin receptor/low-density lipoprotein receptor-related protein and very-low-density lipoprotein receptor involves basic residues in the inhibitor

The complex of the type-1 plasminogen activator inhibitor (PAI-1) and its target proteinases, the urokinase and tissue-type plasminogen activators (uPA and tPA), but not the free components, bind with high affinity to the endocytosis receptors alpha2-macroglobulin receptor/low-density lipoprotein receptor-related protein (alpha2MR/LRP) and very-low-density lipoprotein receptor (VLDLR). To characterize the molecular interaction between the complexes and the receptors, alanine codons were introduced into the human PAI-1 cDNA to replace the four basic residues, Arg-78, Lys-82, Arg-120 and Lys-124, as double mutations. The purified recombinant mutant proteins, rPAI-1/R78A-K124A and rPAI-1/K82A-R120A, produced by the yeast Pichia pastoris, were indistinghuisable from wild-type recombinant and natural human PAI-1 with respect to inhibitory activity against uPA, stability of SDS-resistant complexes with uPA, and vitronectin binding. Radiolabelled mutant uPA.PAI-1 complexes bound with a 10- to 20-fold, and 3- to 7-fold reduced affinity to purified alpha2MR/LRP and VLDLR respectively. alpha2MR/LRP-mediated endocytosis of the mutant complexes by COS-1 cells was reduced to 48 and 38% of the level of endocytosis of wild-type PAI-1. Binding of the mutant complexes to the uPA receptor was not affected. These findings suggest that the binding mode of the uPA.PAI-1 complex to both alpha2MR/LRP and VLDLR is similar. The four residues are surface exposed in the region defined by alpha-helix D and beta-strand 1A in the serine protease inhibitor (serpin) structure. Our study represents the first identification of residues in a surface region implicated in molecular recognition of protease.serpin complexes by endocytosis receptors of the low-density lipoprotein receptor family.

Lesion size in relation to ablation site during radiofrequency ablation

This study was designed to investigate the effect of the convective cooling of the tip of the ablation electrode during temperature controlled radiofrequency ablation. In vivo two different application sites in the left ventricle of anaesthetised pigs were ablated and in vitro ablation was performed during two different flow-velocities in a tissue bath, while electrode contact pressure and position were unchanged. Target temperature was 80 degrees C. Obtained tip temperature, power consumption and lesion dimensions were measured. In vivo lesion volume, depth and width were found significantly larger for septal applications than apical applications (p < 0.01) and more power was used (p < 0.001). Obtained tip temperature was significantly lower in the septal applications (p < 0.001). In vitro increased convective cooling by induction of flow yielded larger lesion volume, depth and width (p < 0.01), and had higher power consumptions (p < 0.01). Obtained tip temperature did not differ significantly. For the given chosen target temperature power consumption was positively related to lesion volume (r = 0.66 in vivo and 0.65 in vitro), whereas obtained tip temperature was not (r = -0.49 in vivo and -0.61 in vitro). We conclude that during temperature controlled radiofrequency ablation lesion size differs for septal and apical left ventricular applications. Differences in convective cooling might play an important role in this respect. This is supported by our in vitro experiments, where increased convective cooling by induction of a flow around the electrode tip increases lesion dimensions and power consumptions. Furthermore we conclude that for the given target temperature the power consumption is positively correlated with lesion volume (p < 0.001), whereas the obtained tip temperature is not.

Breast carcinoma epithelial cells express a very low-density lipoprotein receptor variant lacking the O-linked glycosylation domain encoded by exon 16, but with full binding activity for serine proteinase/serpin complexes and Mr-40,000 receptor-associated protein

Very-low density lipoprotein receptor (VLDLR) belongs to the low-density lipoprotein receptor family of endocytosis receptors. It binds a variety of different ligands, including apolipoprotein E, Mr-40,000 receptor-associated-protein (RAP), and some serine proteinase/serpin complexes. We previously demonstrated the occurrence of two forms of VLDLR in SDS/PAGE, migrating with Mr 105,000 and Mr 130,000, respectively [Heegaard, C. W., Simonsen, A. C. W., Oka, K., Kjøller, L., Christensen, A., Madsen, B., Ellgaard, L., Chan, L. & Andreasen, P. A. (1995) J. Biol. Chem. 270, 20,855-20,869]. We now demonstrate that these two forms correspond to forms with the absence (type-II) and presence (type-I) of the O-linked glycosylation domain encoded by exon 16, respectively. We show that the two forms have the same binding affinity to RAP and serine proteinase/serpin complexes. Using reverse transcription and PCR, we demonstrate that the splice variation giving rise to the two forms is highly cell specific. In particular, we demonstrate that human breast carcinomas express predominantly or exclusively the variant lacking exon 16. By immunohistochemistry, we demonstrate that VLDLR is mainly expressed by the epithelial cancer cells in these carcinomas. The VLDLR variant expressed by epithelial cancer cells could function in the clearance of cell-surface-associated serine proteinase/serpin complexes in breast carcinomas.

Specificity of serine proteinase/serpin complex binding to very-low-density lipoprotein receptor and alpha2-macroglobulin receptor/low-density-lipoprotein-receptor-related protein

Very-low-density lipoprotein receptor (VLDLR) and alpha2-macroglobulin receptor/low-density-lipoprotein-receptor-related protein (alpha2MR/LRP) are multifunctional endocytosis receptors of the low-density lipoprotein receptor family. Both have been shown to mediate endocytosis and degradation of complex between plasminogen activators and type-1 plasminogen-activator inhibitor (PAI-1) by cultured cells. We have now studied the specificity of binding and endocytosis by VLDLR and alpha2MR/LRP among a variety of serine proteinase/serpin complexes, including various combinations of the serine proteinases urokinase-type and tissue-type plasminogen activators, plasmin, thrombin, human leukocyte elastase, cathepsin G, and plasma kallikrein with the serpins PAI-1, horse leukocyte elastase inhibitor, protein C inhibitor, C1-inhibitor, alpha2-antiplasmin, alpha1-proteinase inhibitor, alpha1-antichymotrypsin, protease nexin-1, heparin cofactor II, and antithrombin III. Binding was estimated with radiolabelled ligands in ligand blotting analysis and microtiter well assays. Endocytosis was estimated by measuring receptor-associated protein (RAP)-sensitive degradation of radiolabelled complexes by Chinese hamster ovary cells transfected with VLDLR cDNA and by COS-1 cells, which have a high endogenous expression of alpha2MR/LRP. We found that the receptors bind with high affinity to some, but not all, combinations of plasminogen activators and thrombin with PAI-1, protease nexin-1, protein C inhibitor, and antithrombin III, while complexes of many serine proteinases with their primary inhibitor, i.e. plasmin/alpha2-antiplasmin complex, do not bind, or bind with a very low affinity. Both the serine proteinase and the serpin moieties contribute to the binding specificity. The binding specificities of VLDLR and alpha2MR/LRP are overlapping, but not identical. The results suggest that VLDLR and alpha2MR/LRP have different biological functions by having different binding specificities as well as by being expressed by different cell types.

[Sotalol and torsades de pointes ventricular tachycardia]

Sotalol is together with amiodarone the most effective antiarrhythmic. Compared to class I antiarrhythmics it has less mortality. However, sotalol can, like class IA antiarrhythmics, release life-threatening attacks of torsade de pointes ventricular tachycardia (TdP-VT), as proarrhythmia or by overdosing. TdP-VT appears in 2% of all patients treated with sotalol. In patients treated for ventricular tachycardias TdP-VT appears in 4%. Some factors increase the incidence of TdP-VT: reduced left ventricular function, hypokalaemia, hypomagnesiaemia, bradycardia, extended QT-interval and daily doses exceeding 320 mg. We recommend increased attention to these predisposing factors so as to prevent TdP-VT. Pharmacologically induced TdP-VT may be misdiagnosed as "genuine" ventricular tachycardia. This often results in increased doses of sotalol, which worsen the TdP-VT. Sotalol is renally excreted and TdP-VT can appear in patients with reduced renal function where normal doses are used. QTC prolongation above 550 ms. or severe bradycardia indicates risk of TdP-VT and should result in end of treatment or dose-reduction. Six case-stories are presented.

Relative role of low- and high pressure reflexes on sympathetic activity in humans during simulated gravitational stress

In order to determine the relative role of low- and high-pressure reflexes, respectively, on forearm sympathetic nerve activity (fSNA), 10 normal male subjects underwent a 4-step (5 min each) graded lower body negative pressure (LBNP) from -10 to -50 mmHg. Central venous pressure (CVP) and stroke volume gradually decreased (p<0.05), and arterial pulse pressure (PP) abruptly decreased at LBNP of -50 mmHg. Mean arterial pressure (MAP) remained unchanged. Forearm venous plasma norepinephrine concentration (fvNE) increased significantly at LBNP of -35 mmHg (p<0.05) and with a further sharp increase during LBNP of -50 mmHg (p<0.05). High degrees of intra-individual correlations were observed between changes in Log [fvNE] and CVP (r-values from -0.78 to -0.96, p<0.01). We conclude that low-pressure reflexes are the major determinants of fSNA during non-hypotensive gravitational stress (MAP and PP unchanged). When the gravitational stress is more pronounced, a decrease in PP further augments fSNA through inhibition of high-pressure arterial baroreflexes.

[Acute pancreatitis--induced by 5-aminosalicylic acid or an extraintestinal manifestation of ulcerative colitis?]

5-aminosalicylic acid has been reported to cause acute pancreatitis. We report the first Scandinavian case. A 27 year-old woman with a three month history of ulcerative colitis treated with Mesalazine developed acute abdominal pain. Serum and urine amylase were raised, and ultrasonographic and computed tomography scan showed oedema of the pancreas. Immediately following withdrawal of the drug, serum and urine amylase returned to normal. We discuss the possibility of acute pancreatitis as an extraintestinal manifestation of ulcerative colitis.

[The pacemaker syndrome]

The pacemaker syndrome is a complex of symptoms consisting of heart failure, near fainting, sensations of pulsation in the neck or abdomen or cough which develop or are aggravated after cardiac pacing. Objectively, a fall in systolic blood pressure is observed in the majority of cases and also canon waves in the neck veins, signs of heart failure, retrograde arterial activation and possibly canon-a-awaves in the central venous pressure. The syndrome occurs in approximately 15% of the patients with ventricular pacing. The condition is most probably caused by lack of atrioventricular synchrony with resultant distension of the atria which results in a reflex mediated decrease or defective increase in the total peripheral resistance and, thus, a fall in systolic blood pressure. Treatment consists of establishing normal atrioventricular synchrony either by implantation of an atrial or AV-sequential pacemaker or by re-programming so that the patient has, primarily, his own rhythm. Ensuring normal atrioventricular synchrony has also other advantages as several investigations have shown that 60-80% of the patients prefer this form of pacing rather than ventricular pacing. The working capacity improves and the patients feel subjectively better and the risk for development of chronic atrial fibrillation and heart failure decreases.

[The pacemaker syndrome: an overlooked complication?]

The pacemaker syndrome is a frequently occurring and frequently overlooked syndrome which can, as a rule, be treated. The diagnosis is often overlooked on account of the diffuse symptoms together with the frequency of symptoms in elderly patients. The temporal connection with VVI pacing is often, but not always, helpful in establishing the diagnosis. Three case histories with various manifestations of the syndrome are reviewed.

[Models for calculating risks as a tool in screening for cardiovascular diseases]

In connection with screening for risk factors for ischaemic heart disease in Bispebjerg Hospital, we have assessed three different models for calculation of the risk, employed on our own material. A total of 462 persons participated in the screening and 275 of these were under the age of 65 years. Out of these 275, 92 had plasma cholesterol values over or equal to 7.0 mmol/l and or smoked over 20 gram tobacco daily. On comparison between three models for calculation of the risk: one American, one British and one Swedish, moderate agreement was observed: the correlation coefficients varied between 0.75 and 0.89. The reason for this may be that the models for calculation of the risk are constructed on the basis of statistics already described from epidemiological investigations in which coincidence is demonstrated between selected observable factors and ischaemic heart disease. It is thus possible that the factors which we measure and possibly attempt to influence are not pathogenetic. We consider, therefore, that risk scoring should be employed with caution. As causal connection between ischaemic heart disease and cholesterol and smoking, respectively, have been demonstrated with reasonable certainty, we consider that it is reasonable to screen and intervene for these factors alone.