Contribution of postnatally formed small beta cell aggregates to functional beta cell mass in adult rat pancreas.

AIMS/HYPOTHESIS: Neogenesis of beta cells and their clustering to small aggregates is a key process in prenatal development of beta cell mass. We investigated the contribution of postnatally formed small aggregates to functional beta cell mass in adult rats. METHODS: Conditions were defined for (1) counting total beta cell number in pancreases with relative error of <10% and (2) determining their distribution over aggregates of different size and over functionally different subpopulations. RESULTS: Pancreases of 10-week-old male Wistar rats contained 2.8 ± 0.2 × 106 beta cells, of which >90% was generated postnatally, involving: (1) neo-formation of 30,000 aggregates with diameter <50 µm including single cells; and (2) growth of 5,500 aggregates to larger sizes, accounting for 90% of the increase in cell number, with number of growing aggregates in the tail 50% greater than elsewhere. At 10 weeks, 86% of aggregates were <50 µm; compared with aggregates >200 µm, their beta cells exhibited a higher basal insulin content that was also resistant to glibenclamide-induced degranulation. The pool of Ki67-positive beta cells was sixfold larger than at birth and distributed over all aggregate sizes. CONCLUSIONS/INTERPRETATION: We describe a method for in situ counting of beta cell numbers and subpopulations with low relative error. In adult rats, >90% of beta cells and beta cell aggregates are formed after birth. Aggregates <50 µm are more than 100-fold more abundant than aggregates >200 µm, which are selected for isolated islet studies. Their topographic and functional properties contribute to the functional heterogeneity of the beta cell population; their growth to larger aggregates with characteristic beta cell functions may serve future metabolic needs.

Restoring a functional beta-cell mass in diabetes.

Type 1 and type 2 diabetes have often been presented as disease forms that profoundly differ in the presence and pathogenic significance of a reduced beta-cell mass. We review evidence indicating that the beta-cell mass in type 1 diabetes is usually not decreased by at least 90% at clinical onset, and remains often detectable for years after diagnosis at age above 15 years. Clinical and experimental evidence also exists for a reduced beta-cell mass in type 2 diabetes where it can be the cause for and/or the consequence of dysregulated beta-cell functions. With beta-cell mass defined as number of beta-cells, these views face the limitation of insufficient data and methods for human organs. Because beta-cells can occur under different phenotypes that vary with age and with environmental conditions, we propose to use the term functional beta-cell mass as an assessment of a beta-cell population by the number of beta-cells and their phenotype or functional state. Assays exist to measure functional beta-cell mass in isolated preparations. We selected a glucose-clamp test to evaluate functional beta-cell mass in type 1 patients at clinical onset and in type 1 recipients following intraportal islet cell transplantation. Comparison of the data with those in non-diabetic controls helps targeting and monitoring of therapeutic interventions.

A novel approach for BCR-ABL1 standardization to improve International Scale estimation.

INTRODUCTION: Standardization of BCR-ABL1 messenger RNA quantification by real-time PCR on the International Scale (IS) is critical for monitoring therapy response in chronic myelogenous leukaemia. Since 2006, BCR-ABL1 IS standardization is propagated along reference laboratories by calculating a laboratory-specific conversion factor (CF), co-ordinated in Europe through the European Treatment and Outcome Study project. Although this process has proven successful to some extent, it has not been achievable for all laboratories due to the complexity of the process and the stringent requirements in terms of numbers of samples to be exchanged. In addition, several BCR-ABL1 IS quantification methods and secondary reference materials became commercially available. However, it was observed that different IS methods generate consistently different results. METHODS: To overcome these difficulties, we have developed an alternative and simple approach of CF calculation, based on the retrospective analysis of existing external quality assessment (EQA) data. Our approach does not depend on the exchange of samples and is solely based on the mathematical CF calculation using EQA results. RESULTS AND CONCLUSION: We have demonstrated by thorough statistical validation that this approach performs well in converting BCR-ABL1 measurements to improve IS estimation. In expectation of a true golden standard method for BCR-ABL1 IS quantification, the proposed method is a valuable alternative.

Sensing and pacing with floating electrodes in the right atrium and right atrial appendage.

Unipolar and bipolar floating atrial electrograms from 58 pacemaker patients were recorded and compared. Twenty-four floating unipolar electrodes and 29 floating bipolar electrodes were used at mid-right atrial level and five orthogonal atrial J leads within the right atrial appendage. Each signal was analyzed in the time domain: peak to peak deflection of P wave and QRS complex, duration of P wave and QRS complex and slew rate; and in the frequency domain: maximum of the energy spectrum and frequency at which a decrease of 3 dB from the maximal amplitude occurred. Atrial P (1.31 +/- 0.94 mV, mean +/- SD) and QRS (1.0 +/- 0.56 mV) waves from unipolar floating electrodes were comparable, whereas they were significantly different from bipolar floating electrodes (1.15 +/- 0.77 mV and 0.25 +/- 0.39 mV). Amplitudes of P waves from orthogonal J leads were largest (3.1 +/- 2.6 mV) and QRS complexes (0.21 +/- 0.13 mV) smallest. The P waves had the highest frequency content (17.1 +/- 19.4 Hz). It is concluded that atrial electrograms from orthogonal electrodes (bipolar or orthogonal J) offer superior sensing characteristics because of the large amplitude P wave and discriminating power between P and QRS waves (P/QRS voltage 15:1). An orthogonal J lead can thus be used for P synchronous pacing at the atrial level, whereas an orthogonal ventricular lead can be used for rate-response pacing systems.

Simultaneous right atrial appendage sensing with a target tip, a solid tip and J orthogonal electrodes.

To compare the sensing characteristics of a solid tip, target tip (Medtronic) and orthogonal electrodes within the right atrial appendage, atrial electrograms were simultaneously recorded from 2 pacing leads in 11 patients. No significant differences were noted between atrial electrograms derived from target tip or a solid tip electrode in contact with atrial myocardium. Mean values for P-wave amplitudes of 3.0 vs 3.1 mV and slew rates 0.4 V/s vs 0.6 V/s, and QRS amplitudes of 1.0 vs 1.2 mV and slew rates 0.4 vs 0.2 V/s were obtained. The frequency content was also similar, with spectral maxima at 8 vs 9 Hz (P wave) and 7 vs 6 Hz (QRS). In contrast, atrial electrocardiograms derived from the orthogonal electrodes were significantly different: P-wave amplitude of 6.1 mV (p less than 0.025) and slew rate of 1 V/s and QRS of 0.13 mV and slew rate of 0.04 V/s. Spectral analysis was also dissimilar with maxima at 34 Hz (P wave) and 3 Hz (QRS). Orthogonal noncontacting sensing electrodes positioned within the atrial appendage offer substantially better electrographic P-wave amplitude detection and QRS rejection than contacting tip electrodes. These leads yield a significant improvement when discriminate atrial sensing is required.

Predisposing risk factors and natural history of acute neurologic complications of left-sided cardiac catheterization.

The reported incidence of acute neurologic complications of left heart catheterization varies from 0.03% to 0.3%. The predisposing risk factors, clinical features, and natural history have not been well characterized. We retrospectively reviewed all cases of acute neurologic complications developing during or within 36 hours of diagnostic catheterization or angioplasty to determine the incidence, clinical features, and natural history, and (using a case-control methodology) the clinical variables associated with their development. During the 37-month study, 6,465 patients underwent diagnostic left-sided cardiac catheterization and balloon angioplasty or valvuloplasty, and 27 patients developed an acute neurologic complication (0.4%). The most common symptoms were visual disturbances (26%), hemiparesis (26%), and facial droop (26%). Deficits were localizable to the anterior or posterior circulation in 22 patients: posterior in 8 (36%), and anterior in 14 (64%). Long-term follow-up was available in all patients, with 17 of 27 (63%) having complete resolution with no residuum. With use of a case-control methodology and multiple logistic regression analysis, female gender, the presence of left ventricular hypertrophy, depressed ejection fraction, and the presence of > or = 2 coronary arteries with > 50% narrowing were independent predictors of a neurologic event.

Intramyocardial pressure in the canine heart. An experimental study.

During 11 acute open-chest experiments with dogs, intramyocardial pressure was measured in the anterior wall of the left ventricle with a miniature pressure transducer mounted on a 1.6 mm diameter needle. Pressures were measured at the subendocardium (+/- 10 mm), midwall (+/- 7.5 mm), and subepicardium (+/- 5 mm). Simultaneous recordings of left ventricular pressure and two measures of intramyocardial pressure were made during control, acute volume overload, and after administration of verapamil. Maximal amplitude of the subendocardial pressure was higher and the maximal amplitude of the subepicardial pressure was lower than maximal left ventricular pressure for all interventions (p less than 0.001 and p less than 0.01). During volume overload left ventricular pressure increased more than intramyocardial pressure (left ventricular pressure 34%, subendocardial pressure 6%, midwall pressure 14%, and subepicardial pressure 14%). After the administration of verapamil intramyocardial pressure decreased more than left ventricular pressure (left ventricular pressure 16%, subendocardial pressure 26%, midwall pressure 13%, subepicardial pressure 32%). Positive and negative first derivatives of subendocardial pressure were higher than those of left ventricular pressure during control and after verapamil (between p less than 0.01 and p less than 0.001). Positive and negative first derivatives of subepicardial pressure were lower than those of left ventricular pressure during all interventions (p less than 0.001). The timing of the C-point (onset of mechanical contraction) and the positive first derivative of all tracings was synchronous within 8 msec in all interventions. The 0-point (crosspoint of the tangent to the diastolic plateau and the tangent to the relaxation slope; early diastole) of intramyocardial pressure came later than the 0-point of left ventricular pressure, indicating longer relaxation times in the myocardium (subendocardial pressure: control, p less than 0.001, volume, p less than 0.05, verapamil, no significance; midwall pressure: between p less than 0.05 and p less than 0.001; subepicardial pressure: between p less than 0.01 and p less than 0.001).

Cardiac events after heart transplantation: incidence and predictive value of coronary arteriography.

Cardiac events from graft arteriopathy, including myocardial infarction, heart failure resulting from previous myocardial infarction, and sudden death, may limit long-term survival after heart transplantation. To determine the incidence of cardiac events and the use of coronary arteriography in predicting these events, the long-term results (mean follow-up, 3.5 years; standard deviation +/- 2.0) of heart transplantation in 427 patients were reviewed. Cardiac events included 19 cases of myocardial infarction, 13 cases of sudden death, and 10 cases of congestive heart failure. All these events occurred after the first year except for three cases of sudden death and one case of myocardial infarction. Cumulative incidence of cardiac events per patient year was 0.9% within the first year, increasing to 1.9% by 5 years. Cardiac events accounted for 3.8% of the deaths by the end of the first year, rising to 18% of total mortality by 7 years after heart transplantation. In patients dying after the first year of transplantation, deaths from sequelae of coronary artery disease occurred in 36% (20/55). The relative risk ("odds ratio") of any cardiac event was 3.44 (p less than 0.05) in patients with angiographic evidence of obstructive disease compared with those without evidence of disease, risk of cardiac death 4.6 (p less than 0.05) and risk of sudden death, 2.4 (not significant). Of the 13 patients who died suddenly, five seen at autopsy were found to have had a recent myocardial infarction. Of all patients who died of heart disease, recent myocardial infarction was detected in nine who were seen at autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Cationic concentrations and transmembrane fluxes in erythrocytes of humans during exercise.

The effect of exercise on the intraerythrocyte cationic concentrations and transmembrane fluxes such as the Na+-K+-adenosinetriphosphatase (ATPase) pump, the Na+-K+ cotransport, and the Na+-Li+ countertransport system was studied in 11 normal male volunteers. All subjects performed an uninterrupted incremental exercise test on a bicycle ergometer, starting at an initial work load of 20% of the subjects' maximal exercise capacity, as determined in a pretest. The work rate was increased with an additional 20% each 6 min up to a final work load of 80%. Blood samples were taken at rest, at 60 and 80% of maximal exercise capacity, and 1, 2, 3, 4, 5, and 30 min after cessation of exercise. At moderate exercise (60% of maximal exercise capacity) the intraerythrocyte potassium concentration was not changed, but at severe exercise (80% of maximal exercise capacity) it was decreased. After exercise the intraerythrocyte potassium concentration returned to base line within 2 min. Exercise did not affect the intraerythrocyte concentrations of sodium and magnesium. The activity of the Na+-K+-ATPase pump and the Na+-K+ cotransport in the erythrocytes during and after exercise was no different from the resting level. The activity of the Na+-Li+ countertransport system on the contrary tended to decrease during exercise. It is concluded that exercise is accompanied by a leakage of potassium out of the erythrocytes without major alterations in the active red cell cationic fluxes.

The acute effects of exercise intensity on HDL-C metabolism.

To determine whether exercise intensity influences acute HDL-C responses, 12 male recreational runners (24.8 +/- 4 yr) who ran 15-30 miles.wk-1 exercised on a motor driven treadmill at 60% (L) and 75% (H) VO2max. A counterbalanced experimental design was utilized and energy expenditure was 800 Kcal. Fasting blood samples were obtained 24 h before exercise (24 PRE), immediately post-(IPE), 1 h post- (1 h PE), 6 h post- (6 h PE), and 24 h post- (24 h PE) exercise and analyzed for HDL-C and HDL2&3-C. In addition, postheparin plasma samples, obtained 24 h PRE, 6 h PE, and 24 h PE were analyzed for lipolytic activity--LPLA and HTGLA. An exercise trial by time interaction was observed for HDL-C (P < 0.01). Post-hoc analysis revealed no change in HDL-C following the L trial. However, an increase in HDL-C was observed 24 h PE (P < 0.01) following the H trial. The increase in HDL-C was attributed to an elevated HDL3-C (P < 0.01), with no change in HDL2-C. Analysis of plasma lipolytic activity revealed an increase in LPLA 24 h PE (P < 0.05) which may be responsible for the postexercise alterations in HDL-C. However, HTGLA decreased 6 h PE (P < 0.01) and 24 h PE (P < 0.05). We conclude that increases in HDL-C levels following endurance activity are influenced, in part, by the exercise intensity.

The use of ionic and nonionic contrast agents and the effects of hydration in the post cardiac transplant patient with moderate renal insufficiency.

To determine the effects of ionic (diatrizoate) and nonionic (iopamidol) contrast and of hydration, 90 asymptomatic cyclosporine-treated cardiac transplant patients with moderate renal insufficiency (serum creatinine greater than or equal to 1.5 mg/dL) undergoing cardiac catheterization were evaluated. All patients were hydrated with intravenous fluid (5% dextrose and 0.5 normal saline) over a twelve-hour period prior to catheterization and with oral fluids thereafter. Thirty patients received iopamidol (Group I) and 60 were given diatrizoate (Group II). Renal function was determined the day before and after catheterization in all patients of Group I and in 30 patients of Group II (Group IIa). In the remaining 30 patients of Group II renal function was also determined before contrast administration (Group IIb). The dose of dye was similar in all groups (I: 139 +/- 55 mL, IIa: 140 +/- 58 mL, IIb: 128 +/- 38 mL). There was a significant decrease in BUN (I: 41 +/- 10 to 33 +/- 8 mg/dL [p less than 0.005], IIa: 42 +/- 9 to 33 +/- 8 mg/dL mg/dL [p less than 0.001], IIb: (44 +/- 12 to 34 +/- 10 mg/dL [p less than 0.005]) and a small decrease in serum cratinine after catheterization (I: 2.0 +/- 0.3 to 1.9 +/- 0.3 mg/dL, IId: 2.0 +/- 0.3 to 1.9 +/- 0.3 mg/dL, IIb: 2.1 +/- 0.4 to 1.8 +/- 0.4 mg/dL [p less than 0.005].(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of carbohydrate substrate availability on ratings of perceived exertion during prolonged exercise of moderate intensity.

This investigation examined the effect of carbohydrate substrate availability on ratings of perceived exertion (RPE) during cycling at moderate intensity to exhaustion and the relation between submaximal endurance performance and RPE obtained following 2 hr. of cycling at moderate intensity. Seven male cyclists performed two exercise trials at power output corresponding to 70% of their peak oxygen uptake until exhaustion. Subjects ingested either a 6% glucose/sucrose solution at the rate of 0.6 g.kg-1 (Body Weight).hr.-1 or an equal volume of artificially flavored placebo every 20 min. throughout the exercise trials. RPE for the legs, chest, and over-all body, and oxygen consumption, expired ventilation, carbohydrate oxidation rate, and blood concentrations of glucose, glycerol, and lactate were measured every 20 min. throughout exercise and at exercise termination. Statistical analysis of these dependent variables indicates that (1) an exercise-induced decrease in blood-borne carbohydrate substrate intensifies leg and over-all perceptions of exertion during the later stages of prolonged cycling at 70% VO2peak. (2) Factors other than availability of blood-borne carbohydrate substrate may influence perceptual intensity at exhaustion. (3) Ratings of perceived exertion for the legs and over-all body obtained after 2 hr. of cycling at moderate intensity may be useful in predicting submaximal endurance performance.

Improved flow cytometric detection of minimal residual disease in childhood acute lymphoblastic leukemia.

Most current treatment protocols for acute lymphoblastic leukemia (ALL) include minimal residual disease (MRD) diagnostics, generally based on PCR analysis of rearranged antigen receptor genes. Although flow cytometry (FCM) can be used for MRD detection as well, discordant FCM and PCR results are obtained in 5-20% of samples. We evaluated whether 6-color FCM, including additional markers and new marker combinations, improved the results. Bone marrow samples were obtained from 363 ALL patients at day 15, 33 and 78 and MRD was analyzed using 6-color (218 patients) or 4-color (145 patients) FCM in parallel to routine PCR-based MRD diagnostics. Compared with 4-color FCM, 6-color FCM significantly improved the concordance with PCR-based MRD data (88% versus 96%); particularly the specificity of the MRD analysis improved. However, PCR remained more sensitive at levels <0.01%. MRD-based risk groups were similar between 6-color FCM and PCR in 68% of patients, most discrepancies being medium risk by PCR and standard risk by FCM. Alternative interpretation of the PCR data, aimed at prevention of false-positive MRD results, changed the risk group to standard risk in half (52%) of these discordant cases. In conclusion, 6-color FCM significantly improves MRD analysis in ALL but remains less sensitive than PCR-based MRD-diagnostics.

Anatomical variations of internal jugular vein location: impact on central venous access.

OBJECTIVE: To evaluate whether underlying anatomical variations in the position of the internal jugular vein may account for difficulty in obtaining central venous access in individual patients. DESIGN: Consecutive series. SETTING: Cardiac catheterization laboratory, coronary care unit, and ICU. PATIENTS: Two hundred patients (52 +/- 7 yrs, 147 males) who were undergoing internal jugular vein cannulation for hemodynamic monitoring or endomyocardial biopsy. INTERVENTION: The internal jugular vein and carotid artery were visualized with two-dimensional ultrasound and their position was compared with their projected location from external landmarks. RESULTS: In 183 (92%) patients, the position of the internal jugular vein was lateral and anterior to the carotid artery and increased in diameter during a Valsalva maneuver. In five (2.5%) patients, the internal jugular vein was not visualized and was probably thrombosed, as the internal jugular vein was normal on the other side. In six (3%) patients, the internal jugular vein was unusually small and did not increase in diameter during the Valsalva maneuver. In two (1%) patients, the internal jugular vein was positioned greater than 1 cm lateral to the carotid artery. Four (2%) patients had a medially positioned internal jugular vein overlying the carotid artery. In 5.5% of the patients, the position of the internal jugular vein was outside the path that had been predicted by the external landmarks. CONCLUSIONS: These findings suggest that anatomical variation may partly account for the inability to cannulate the internal jugular vein in certain patients. In these cases, ultrasound examination quickly establishes the position of the internal jugular vein and may allow for easy and rapid access.

Relaxation within the left ventricular myocardial wall.

To evaluate relaxation mechanics in the wall of the left ventricle needle mounted miniature pressure transducers were inserted at the subendocardial (ENDO) and subepicardial (EPI) level of the anterior wall of the left ventricle during acute open-chest experiments in 10 mongrel dogs. Pressures were recorded during control, volume load and after verapamil administration. The relaxation time constant (tau) was determined by fitting a monoexponential with offset to the isovolumic relaxation period of the ENDO, EPI and left ventricular pressure (LVP) tracings: p = p0e-t/tau + p1. Mean tau-values for LVP, ENDO and EPI during control were (mean +/- 1 SD, ms): 38 +/- 5, 60 +/- 12, 83 +/- 5; during volume overload: 55 +/- 10, 72 +/- 20, 85 +/- 31 and after verapamil administration: 58 +/- 13, 60 +/- 17 and 73 +/- 15, respectively. Relaxation time constants of ENDO and EPI were significantly longer than those of LVP during control and volume loading but not after verapamil when only EPI was significantly different from LVP. These results demonstrate that relaxation indices obtained from LVP may not always reflect intramyocardial mechanics.

Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique.

BACKGROUND: Central venous access is an essential part of patient management in many clinical settings and is usually achieved with a blinded, external landmark-guided technique. The purpose of this study is to evaluate whether an ultrasound technique can improve on the traditional method. METHODS AND RESULTS: We prospectively evaluated an ultrasound-guided method in 302 patients undergoing internal jugular venous cannulation and compared the results with 302 patients in whom an external landmark-guided technique was used. Ultrasound was used exclusively in an additional 626 patients. Cannulation of the internal jugular vein was achieved in all patients (100%) using ultrasound and in 266 patients (88.1%) using the landmark-guided technique (p < 0.001). The vein was entered on the first attempt in 78% of patients using ultrasound and in 38% using the landmark technique (p < 0.001). Average access time (skin to vein) was 9.8 seconds (2-68 seconds) by the ultrasound approach and 44.5 seconds (2-1,000 seconds) by the landmark approach (p < 0.001). Using ultrasound, puncture of the carotid artery occurred in 1.7% of patients, brachial plexus irritation in 0.4%, and hematoma in 0.2%. In the external landmark group, puncture of the carotid artery occurred in 8.3% of patients (p < 0.001), brachial plexus irritation in 1.7% (p < 0.001), and hematoma in 3.3% (p < 0.001). CONCLUSIONS: Ultrasound-guided cannulation of the internal jugular vein significantly improves success rate, decreases access time, and reduces complication rate. These results suggest that this technique may be preferred in complicated cases or when access problems are anticipated.

Investigation of genesis of gallop sounds in dogs by quantitative phonocardiography and digital frequency analysis.

Several investigators have noted external gallop sounds to be of higher amplitude than their corresponding internal sounds (S3 and S4). In this study we hoped to determine if S3 and S4 are transmitted in the same manner as S1. In 11 closed-chest dogs, external (apical) and left ventricular pressures and sounds were recorded simultaneously with transducers with identical sensitivity and frequency responses. Volume and pressure overload and positive and negative inotropic drugs were used to generate gallop sounds. Recordings were made in the control state and after the various interventions. S3 and S4 were recorded in 17 experiments each. The amplitude of the external S1 was uniformly higher than that of internal S1 and internal gallop sounds were inconspicuous. With use of Fourier transforms, the gain function was determined by comparing internal to external S1. By inverse transform, the amplitude of the internal gallop sounds was predicted from external sounds. The internal sounds of significant amplitude were predicted in many instances, but the actual recordings showed no conspicuous sounds. The absence of internal gallop sounds of expected amplitude as calculated from the external gallop sounds and the gain function derived from the comparison of internal and external S1 make it very unlikely that external gallop sounds are derived from internal sounds.