Noninvasive Scale Measurement of Stroke Volume and Cardiac Output Compared With the Direct Fick Method: A Feasibility Study

Background Objective markers of cardiac function are limited in the outpatient setting and may be beneficial for monitoring patients with chronic cardiac conditions. We assess the accuracy of a scale, with the ability to capture ballistocardiography, electrocardiography, and impedance plethysmography signals from a patient's feet while standing on the scale, in measuring stroke volume and cardiac output compared with the gold-standard direct Fick method. Methods and Results Thirty-two patients with unexplained dyspnea undergoing level 3 invasive cardiopulmonary exercise test at a tertiary medical center were included in the final analysis. We obtained scale and direct Fick measurements of stroke volume and cardiac output before and immediately after invasive cardiopulmonary exercise test. Stroke volume and cardiac output from a cardiac scale and the direct Fick method correlated with r=0.81 and r=0.85, respectively (P<0.001 each). The mean absolute error of the scale estimated stroke volume was -1.58 mL, with a 95% limits of agreement of -21.97 to 18.81 mL. The mean error for the scale estimated cardiac output was -0.31 L/min, with a 95% limits of agreement of -2.62 to 2.00 L/min. The changes in stroke volume and cardiac output before and after exercise were 78.9% and 96.7% concordant, respectively, between the 2 measuring methods. Conclusions In a proof-of-concept study, this novel scale with cardiac monitoring abilities may allow for noninvasive, longitudinal measures of cardiac function. Using the widely accepted form factor of a bathroom scale, this method of monitoring can be easily integrated into a patient's lifestyle.

Protocol for exercise hemodynamic assessment: performing an invasive cardiopulmonary exercise test in clinical practice

Invasive cardiopulmonary exercise testing (iCPET) combines full central hemodynamic assessment with continuous measurements of pulmonary gas exchange and ventilation to help in understanding the pathophysiology underpinning unexplained exertional intolerance. There is increasing evidence to support the use of iCPET as a key methodology for diagnosing heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension as occult causes of exercise limitation, but there is little information available outlining the methodology to use this diagnostic test in clinical practice. To bridge this knowledge gap, the operational protocol for iCPET at our institution is discussed in detail. In turn, a standardized iCPET protocol may provide a common framework to describe the evolving understanding of mechanism(s) that limit exercise capacity and to facilitate research efforts to define novel treatments in these patients.

Age-related upper limits of normal for maximum upright exercise pulmonary haemodynamics

The exercise definition of pulmonary hypertension was eliminated from the pulmonary hypertension guidelines in part due to uncertainty of the upper limits of normal (ULNs) for exercise haemodynamics in subjects >50 years old.The present study, therefore, evaluated the pulmonary haemodynamic responses to maximum upright incremental cycling exercise in consecutive subjects who underwent an invasive cardiopulmonary exercise testing for unexplained exertional intolerance, deemed normal based on preserved exercise capacity and normal resting supine haemodynamics. Subjects aged >50 years old (n=41) were compared with subjects ≤50 years old (n=25). ULNs were calculated as mean + 2 sdPeak exercise mean pulmonary arterial pressure was not different for subjects >50 and ≤50 years old (23 ± 5 versus 22 ± 4 mmHg, p=0.22), with ULN of 33 and 30 mmHg, respectively. Peak cardiac output was lower in older subjects (median (interquartile range): 12.1 (9.4-14.2)versus16.2 (13.8-19.2) L·min(-1), p<0.001). Peak pulmonary vascular resistance was higher in older subjects compared with younger subjects (mean ± sd: 1.20 ± 0.45 versus 0.82 ± 0.26 Wood units, p<0.001), with ULN of 2.10 and 1.34 Wood units, respectively.We observed that subjects >50 and ≤ 50 years old have different pulmonary vascular responses to exercise. Older subjects have higher pulmonary vascular resistance at peak exercise, resulting in different exercise haemodynamics ULNs compared with the younger population.

Eyeblink conditioning deficits indicate timing and cerebellar abnormalities in schizophrenia

Accumulating evidence indicates that individuals with schizophrenia manifest abnormalities in structures (cerebellum and basal ganglia) and neurotransmitter systems (dopamine) linked to internal-timing processes. A single-cue tone delay eyeblink conditioning paradigm comprised of 100 learning and 50 extinction trials was used to examine cerebellar timing circuits in 13 medicated patients with schizophrenia and 13 age- and sex-matched controls. Patients with schizophrenia showed impaired learning of the conditioned response compared to controls and also greater within-subject variability in the timing of their responses. These findings are consistent with models of schizophrenia in which timing deficits underlie information-processing abnormalities and clinical features of the disorder.

Comparison of single unit responses to tone, light, and compound conditioned stimuli during rabbit classical eyeblink conditioning

Unit recordings and lesion studies have implicated the cerebellum as an essential site for the acquisition and maintenance of the conditioned eyeblink response. The current study looked at the neural characteristics of conditioned stimulus (CS) processing in the interpositus nucleus of the cerebellum after training New Zealand white rabbits (Oryctolagus cuniculus) in one of two conditioning paradigms: (a) compound conditioning (CMP), a compound CS consisting of light and tone paired with an air puff unconditioned stimulus (US); or (b) stimulus compounding (ALT), alternating blocks of tone CS and light CS trials paired with the air puff US. Single unit responses were recorded during five sessions after the animals had reached an asymptotic level of responding. Animals were tested for behavioral and neural responses to CS alone trials that included tone alone, light alone, and compound tone-light trials. For the CMP group, the compound CS elicited 80 to 90% conditioned eyeblink responses (CRs), whereas the individual tone and light CSs elicited only 40 to 50% CRs. For the ALT group, all three CSs (tone, light, and compound) elicited very high levels of responding of at least 80% CRs. For the CMP group, there were roughly equal numbers of cells responding to all of the CSs. This includes cells that responded exclusively to one, and only one, of the three stimuli and also those cells that responded to combinations of two or more. Cells from the ALT group were far more likely to respond exclusively to only one of the CSs. Both the behavioral and physiological results suggest that the compound tone-light stimulus was processed as a distinct stimulus, separate from the component tone and light. These results are discussed in the context of multisensory processing.

The diagnosis of lower extremity deep venous thrombosis

The diagnosis of lower extremity deep venous thrombosis (DVT) is critical to emergency physicians because of the risk of pulmonary embolism. This article reviews the diagnostic modalities available for patients with suspected lower extremity DVT. The use of compression ultrasonography and the recent advances in the D-dimer assays are emphasized. A clinical algorithm that utilizes a non invasive approach to this potentially life threatening disease is presented.

Classical eyeblink conditioning: clinical models and applications

In this paper, we argue that the main reason that classical eyeblink conditioning has proven so useful when applied to clinical situations, is that a great deal of information is known about the behavioral and neural correlates of this form of associative learning. Presented here is a summary of three lines of research that have used classical eyeblink conditioning to study three different clinical conditions; autism, fetal alcohol syndrome, and obsessive-compulsive disorder. While seemingly very different clinical conditions, classical eyeblink conditioning has proven very useful for advancing our understanding of these clinical pathologies and the neural conditions that may underlie them.

Rabbit classical eyeblink conditioning is altered by brief cerebellar cortical stimulation

A pair of studies examined how cortical intracerebellar stimulation (ICS) affects eyeblink conditioning in the rabbit. Rabbits were implanted with chronic bipolar stimulating electrodes in the cell body layers of cerebellar lobule H-VI. Brief (40 ms) trains of intracranial stimulation (100 Hz, 250 microA) were delivered during training trials [forward pairings of a tone-conditioned stimulus (CS) with an air puff unconditioned stimulus (US)]. In Experiment 1, the onset of ICS varied randomly within sessions. US-onset-coincident ICS proved detrimental to the maintenance of conditioning [measured as the percentage of trials on which conditioned responses (CRs) were made] compared to ICS that ended 60 ms before US onset. Based on these findings, a second experiment compared a group trained with ICS consistently delivered at US onset to groups trained with ICS consistently delivered either at CS onset or between the two stimuli, as well as to unstimulated control subjects. Animals receiving CS- or US-coincident ICS learned slowest, whereas animals receiving middle stimulation learned more quickly than all other groups. In both Experiments 1 and 2, highly trained animals produced blinks in direct response to the stimulation. These data are discussed in terms of a new hypothesis concerning interactions between cerebellar cortex and the deep cerebellar nuclei during eyeblink conditioning--a rebound from inhibition hypothesis.

A method for identifying comparison counties: application to a rural telemedicine evaluation project

The evaluation of telemedicine activity in rural communities is complicated by the fact that most telemedicine sites are chosen because of their existing telecommunications infrastructure and institutional relationships, not by a random selection process. In addition, it is difficult to draw conclusions about the effects of telemedicine without a careful analysis of parallel changes in communities which do not have access to telemedicine services. We have developed a method of identifying comparable counties based on an aggregate measure of health status. A set of 66 variables was collected in a previous project to develop a model to evaluate the relative health status of the population in Missouri. A stepwise regression was used to identify a subset of 15 variables that had the highest predictive value for the health status of a county. Distance measures were then used to identify six counties which were most similar to three telemedicine counties. The method can be used with any study set chosen non-randomly, to identify similar objects that can be used for comparative purposes.

Purkinje cell responses to pontine stimulation CS during rabbit eyeblink conditioning

Previous studies have shown that stimuli typically used as CSs in eyeblink conditioning converge with US information in the cerebellum. Extracellular recordings of Purkinje cells have shown learning-related as well as stimulus-related discharge patterns. Stimulation of a portion of the auditory CS pathway, the pontine nucleus, also serves as a highly effective CS. Using a short-latency pontine stimulation CS and air puff US, single Purkinje cell responses were recorded and compared to those elicited with an auditory stimulus in previous work. Purkinje cell recordings in trained and untrained rabbits revealed patterns of responses very similar to those seen in rabbits trained to a tone CS or those given unpaired-tone/air-puff training. Similarities included the proportion of stimulus-related and behavior-related cell responses. However, fewer inhibitory responses were seen than in earlier studies and these differences are considered in light of the differences between an extracellular stimulation CS and a peripherally administered auditory CS.

Selective changes in AMPA receptors in rabbit cerebellum following classical conditioning of the eyelid-nictitating membrane response

alpha-Amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptors are critically involved in several forms of synaptic plasticity proposed to be neural substrates for learning and memory, e.g., long-term potentiation and long-term depression (LTD). The present study was designed to determine changes in cerebellar AMPA receptors following classical conditioning of the eyeblink-nictitating membrane response (NMR) in the rabbit. Quantitative autoradiography was used to assess changes in ligand binding properties of cerebellar AMPA receptors following NMR conditioning elicited by pairing electrical stimulation of the pontine nuclei with an airpuff to the eye. [3H]AMPA and [3H]-6-cyano-7-nitroquinoxaline-2,3-dion (CNQX) binding were determined following preincubation of frozen-thawed brain tissue sections at 0 or 35 degreesC. With 0 degreesC preincubation, no significant differences in [3H]AMPA binding to cerebellar AMPA receptors were seen between any of the experimental groups tested. In contrast, preincubation at 35 degreesC revealed significant decreases in [3H]AMPA binding to the trained side of the cerebellar cortex resulting from paired presentations of the conditioned and the unconditioned stimuli, while unpaired presentations of the stimuli resulted in no significant effect. With 35 degreesC preincubation, there were no significant differences in [3H]CNQX binding between any of the experimental groups and no significant differences in [3H]AMPA binding in the untrained side of the cerebellum. These results indicate that NMR conditioning is associated with a selective modification of AMPA-receptor properties in brain structures involved in the storage of the associative memory. Furthermore, they support the hypothesis that cerebellar LTD, resulting from decreased synaptic efficacy at parallel fiber-Purkinje cell synapses mediated by a change in AMPA-receptor properties, is a form of synaptic plasticity that supports this type of learning.

Evidence of plasticity in the pontocerebellar conditioned stimulus pathway during classical conditioning of the eyeblink response in the rabbit

Electrical stimulation thresholds required to elicit eyeblinks with either pontine or cerebellar interpositus stimulation were measured before and after classical eyeblink conditioning with paired pontine stimulation (conditioned stimulus, CS) and corneal airpuff (unconditioned stimulus, US). Pontine stimulation thresholds dropped dramatically after training and returned to baseline levels following extinction, whereas interpositus thresholds and input-output functions remained stable across training sessions. Learning rate, magnitude of threshold change, and electrode placements were correlated. Pontine projection patterns to the cerebellum were confirmed with retrograde labeling techniques. These results add to the body of literature suggesting that the pons relays CS information to the cerebellum and provide further evidence of synaptic plasticity in the cerebellar network.

Evidence of plasticity in the pontocerebellar conditioned stimulus pathway during classical conditioning of the eyeblink response in the rabbit

Electrical stimulation thresholds required to elicit eyeblinks with either pontine or cerebellar interpositus stimulation were measured before and after classical eyeblink conditioning with paired pontine stimulation (conditioned stimulus, CS) and corneal airpuff (unconditioned stimulus, US). Pontine stimulation thresholds dropped dramatically after training and returned to baseline levels following extinction, whereas interpositus thresholds and input-output functions remained stable across training sessions. Learning rate, magnitude of threshold change, and electrode placements were correlated. Pontine projection patterns to the cerebellum were confirmed with retrograde labeling techniques. These results add to the body of literature suggesting that the pons relays CS information to the cerebellum and provide further evidence of synaptic plasticity in the cerebellar network.

Associative learning

This chapter reviews evidence demonstrating the essential role of the cerebellum and its associated circuitry in the learning and memory of classical conditioning of discrete behavioral responses (e.g., eyeblink, limb flexion, head turn). It now seems conclusive that the memory traces for this basic category of associative learning are formed and stored in the cerebellum. Lesion, neuronal recording, electrical microstimulation, and anatomical procedures have been used to identify the essential conditioned stimulus (CS) circuit, including the pontine mossy fiber projections to the cerebellum; the essential unconditioned stimulus (US) reinforcing or teaching circuit, including neurons in the inferior olive (dorsal accessory olive) projecting to the cerebellum as climbing fibers; and the essential conditioned response (CR) circuit, including the interpositus nucleus, its projection via the superior cerebellar peduncle to the magnocellular red nucleus, and rubral projections to premotor and motor nuclei. Each major component of the eyeblink CR circuit was reversibly inactivated both in trained animals and over the course of training. In all cases in trained animals, inactivation abolished the CR (and the UR as well when motor nuclei were inactivated). When animals were trained during inactivation (and not exhibiting CRs) and then tested without inactivation, animals with inactivation of the motor nuclei, red nucleus, and superior peduncle had fully learned, whereas animals with inactivation of a very localized region of the cerebellum (anterior interpositus and overlying cortex) had not learned at all. Consequently, the memory traces are formed and stored in the cerebellum. Several alternative possibilities are considered and ruled out. Both the cerebellar cortex and the interpositus nucleus are involved in the memory storage process, suggesting that a phenomenon-like long-term depression (LTD) is involved in the cerebellar cortex and long-term potentiation (LTP) is involved in the interpositus. The experimental findings reviewed in this chapter provide perhaps the first conclusive evidence for the localization of a basic form of memory storage to a particular brain region, namely the cerebellum, and indicate that the cerebellum is indeed a cognitive machine.

Lifestyle, education, and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Blacks

Lifestyle Incongruity has been shown to be associated with elevated blood pressure in various developing societies. We sought to test this model in an international collaborative study of hypertension in populations of African origin. Data were available for 4770 men and women, aged 25-74, from Africa, the Caribbean, and the United States. The main effects of lifestyle score (LSS) and education on hypertension prevalence were explored, as well as interactions predicted by the Lifestyle Incongruity model. Significant interactions were observed, but only the U.S. men conformed to the pattern predicted. For this group, adjusted ORs for LSS were 4.45 among low-education and 0.71 among high-education subgroups (risk OR = 0.16, 0.03-0.84 95% CI). The Lifestyle Incongruity model therefore received limited support. The model was designed to describe processes in societies experiencing modernization and opportunities for lifestyle differentiation, conditions that may not have been met in some sites.

Lifestyle, education, and prevalence of hypertension in populations of African origin. Results from the International Collaborative Study on Hypertension in Blacks

Lifestyle Incongruity has been shown to be associated with elevated blood pressure in various developing societies. We sought to test this model in an international collaborative study of hypertension in populations of African origin. Data were available for 4770 men and women, aged 25-74, from Africa, the Caribbean, and the United States. The main effects of lifestyle score (LSS) and education on hypertension prevalence were explored, as well as interactions predicted by the Lifestyle Incongruity model. Significant interactions were observed, but only the U.S. men conformed to the pattern predicted. For this group, adjusted ORs for LSS were 4.45 among low-education and 0.71 among high-education subgroups (risk OR = 0.16, 0.03-0.84 95% CI). The Lifestyle Incongruity model therefore received limited support. The model was designed to describe processes in societies experiencing modernization and opportunities for lifestyle differentiation, conditions that may not have been met in some sites.