Evaluation of a novel ambulatory electrocardiogram monitor (the Carnation Ambulatory Monitor) for use in horses.

INTRODUCTION: Short-term electrocardiogram (ECG) examinations of horses may not detect paroxysmal arrhythmias. Twenty-four hour Holter equipment can be unwieldy and inconvenient for long-term use. This study evaluated a novel long-term ECG patch recorder, the Carnation Ambulatory Monitor (CAM) in horses, determining ideal placement, practicality, durability and performance. ANIMALS: Twenty-one adult mixed-breed horses. METHODS: Prospective observational study. Three horses had ECG patches fitted at selected sites (phase 1); the two most promising sites were used for further wear testing (phase 2) and the best site was chosen for a trial in 18 horses (phase 3), 16 of which had presented for evaluation of cardiac disease. In phase 1, the CAM was compared with a standard telemetric ECG. The CAM ECGs were analysed using proprietary software. RESULTS: The most promising sites for CAM placement were the ventral midline caudal to the xiphisternum and left thorax caudal to the girth. The ventral midline was chosen for further evaluation. The CAM provided reliable and generally excellent ECG quality at rest (median quality score 4.5/5, range 3-5), over extended periods, allowing detection of arrhythmias. The ECG quality was poor during exercise (median quality score 1, range 1-5), except in three horses. In 15/17 placements in the standing horse, greater than 85% of the potential recording time was achieved. CONCLUSIONS: The CAM is a convenient and well-tolerated device for evaluating equine cardiac rhythm at rest over long periods. Further evaluation of the ideal placement site during exercise may increase its diagnostic utility.

Identification of poor response to P2Y12 inhibitors in ACS patients with a new ELISA-based vasodilator-associated stimulated phosphoprotein (VASP) phosphorylation assay.

A new ELISA technique has been developed to measure the vasodilator-associated stimulated phosphoprotein (VASP) platelet reactivity index (PRI) in clopidogrel-treated patients. This technique has not been evaluated in acute coronary syndrome (ACS) patients or in prasugrel-treated patients. We assessed the accuracy of ELISA-VASP to identify high on-treatment platelet reactivity (HPR) in ACS patients in comparison with established platelet function tests. Platelet reactivity was measured in 240 ACS patients treated with clopidogrel (75 or 150 mg) or prasugrel (5 or 10 mg) using flow cytometry (FC-VASP) and the ELISA-VASP technique, light transmission aggregometry (LTA) and VerifyNow-P2Y12 assay (VN-P2Y12). When using the ELISA-VASP PRI, the rate of patients with HPR in the overall ACS population was 15.5%, including a 27% rate in clopidogrel-treated patients and a 4% rate in prasugrel-treated patients. There was a strong correlation between ELISA-VASP PRI and FC-VASP PRI (r = 0.83, r2 = 0.68 p < 0.0001) with an area under the receiver-operating characteristics (ROC) curve to identify HPR (VASP-PRI >50% with FC-VASP) of 0.94, p<0.0001. The threshold of 60% for ELISA-VASP PRI provided the best accuracy (likelihood ratio= 23.67) to identify patients with HPR when compared to FC-VASP, LTA or VN-P2Y12 assays. In conclusion, ELISA-VASP is a fast, easy-to-use and specific test to identify HPR in ACS patients on thienopyridines. A 60% threshold value displays the best accuracy to identify HPR in these patients.

Optimal time for catheterization in NSTE-ACS patients with impaired renal function: insights from the ABOARD Study.

BACKGROUND: To assess the impact of impaired renal function (IRF) and timing of catheterization (immediate versus delayed intervention) on outcomes in intermediate/high risk NSTE-ACS patients. METHODS: We performed a post-hoc analysis of the randomized ABOARD population to compare 1) patients with vs. without IRF and 2) the two intervention strategies in patients with IRF. A creatinine clearance <60 mL/min defined IRF. The primary endpoint was the in-hospital peak troponin I value; the secondary endpoints were a) the composite of death, myocardial infarction, urgent revascularization or recurrent ischemia (death/MI/UR/RI) and b) STEEPLE major bleeding (MB) at 1-month follow-up. RESULTS: Among the 345 patients, 75 (21.7%) had IRF. Patients with IRF were older, had more comorbidities and were at higher cardiovascular risk. Radial catheterization was predominant (84%). Among IRF patients, 37 (49%) and 38 (51%) patients were randomized to an immediate and delayed strategy, respectively. The primary and secondary endpoints rates were not different for the two comparisons. IRF was associated with more death (5.3% vs. 1.1%, p=0.043) and non-CABG MB (9.3% vs. 2.2%, p=0.001). In patients with IRF, a delayed strategy was associated with more recurrent ischemia (28.9% vs. 8.1%, p=0.021). Absence of clopidogrel pretreatment, insulin therapy and left main culprit lesion were independently associated with death/MI/UR/RI, while age and CABG surgery were related with MB. CONCLUSION: IRF is associated with worse outcomes in NSTE-ACS patients. The primary results of the ABOARD study apply also to patients with IRF in which the timing of catheterization does not impact hard outcomes.

Current antiplatelet options for NSTE-ACS patients.

Non-ST elevation (NSTE) myocardial infarction and unstable angina are the most common clinical presentations of acute coronary syndrome (ACS). Platelet activation is central to the pathogenesis of NSTE-ACS and consensus guidelines that advocate early revascularization supported by intensive antiplatelet therapy. This review examines the drugs used concurrently with aspirin as dual antiplatelet therapy in the NSTE-ACS setting. Clopidogrel represented an important therapeutic advance. However, variations in platelet response and a relatively slow onset of action compromise outcomes with clopidogrel. Evidence reviewed in this article shows that in NSTE-ACS patients, ticagrelor and prasugrel are more effective than clopidogrel and are relatively well tolerated, with an acceptable and manageable bleeding risk. The literature suggests several differences between ticagrelor and prasugrel that should allow clinicians to better tailor treatment to the patient. Head-to-head comparisons are now needed to compare directly the risks and benefits of ticagrelor and prasugrel in NSTE-ACS. Further studies also need to address other outstanding issues such as the benefits and risks of prasugrel pre-treatment and to stratify efficacy and tolerability according to diabetes mellitus (DM) and other co-morbidities. In the meantime, the issues discussed in this review should enhance clinicians' ability to optimize and individualize NSTE-ACS treatment, thereby further reducing the morbidity and mortality associated with this common cardiovascular condition.

Short-term effects of the smoke-free legislation on haemostasis and systemic inflammation due to second hand smoke exposure. The AERER study.

It was the objective of this study to assess the effect of the implementation of the smoke-free legislation on haemostasis and systemic inflammation in second-hand smoking (SHS)-exposed healthy volunteers. Fibrin-rich clot properties, platelet reactivity and inflammatory biomarkers were measured before and four months following the implementation of the smoke-free legislation in gender and age-matched healthy volunteers exposed (n=23, exposed) and unexposed (n=23, controls) to occupational SHS. The primary objective was to compare fibrin-rich clot stiffness before and after implementation of the smoke-free legislation. There was 40% reduction in fibrin-rich clot stiffness following the implementation of the smoke-free legislation in SHS-exposed volunteers (17 ± 7 vs. 10.6 ± 7 dynes/cm², before and after, respectively, p=0.001). These dramatic changes were associated with a 20% reduction in fibrin fiber density (p<0.01) and a 20% reduction in clot lysis time (p=0.05). No change in fibrin properties was observed in the control group of SHS-unexposed volunteers related to the implementation of the smoke-free legislation. Of interest, neither platelet reactivity nor systemic inflammatory biomarkers were changed in either group. The smoke-free legislation is associated with significant changes in fibrin-rich clot properties toward a less thrombogenic conformation with a better fibrinolysis response while neither platelet reactivity nor systemic inflammatory biomarkers are modified. These improvements may explain the observed reduction in acute coronary syndrome following the implementation of the smoke-free legislation.

VNS in patients with previous unsuccessful resective epilepsy surgery: antiepileptic and psychotropic effects.

OBJECTIVES: To assess the efficacy of vagus nerve stimulation (VNS) in patients with medically and surgically intractable complex partial seizures (CPS). PATIENTS AND METHODS: Sixteen patients with previous temporal [15] and frontal [one] resections were treated with VNS between 1994 and 1999 at King's College Hospital, London, UK. Post-operative video-electroencephalogram telemetry had shown that CPS started from the operated side in 12 patients, contralaterally in three and bilaterally independently in one. RESULTS: Three patients (18.75%) had 50% or more reduction in seizure frequency, but one showed severe worsening of epilepsy, which remitted upon VNS discontinuation. The antiepileptic effect of VNS was not different with respect to the type of operation (anterior temporal lobectomy vs amygdalohippocampectomy), the side of operation, or the side of seizure onset. We observed psychotropic effects in two patients with post-ictal psychosis, in two others with depression, and in a child with severe behavioral disorder. CONCLUSIONS: VNS may have a rather limited antiepileptic role to play in patients with persistent seizures following epilepsy surgery, but may independently possess useful antipsychotic and mood-stabilizing properties.

Fibroma (myxoma) molle in a hamster (Mesocricetus auratus).

An adult female Syrian hamster (Mesocricetus auratus) presented with a large, ulcerated lesion in its right cheek pouch; this wound interfered with the animal's ability to masticate. As a result, the hamster became inappetant and lethargic and lost about 25% of its original body weight within 6 to 9 weeks of presentation. The mass was surgically excised and submitted for histopathological evaluation. Microscopically, the mass was characterized as a neoplastic process partially encapsulated with fibrous connective tissue in the submucosa. Loosely arranged bundles of spindle to stellate cells with round to oval hyperchromatic nuclei and amphophilic cytoplasm were abundant. Some cells had multiple nucleoli, and some mitotic figures were observed. Special stains were used to definitively diagnose fibroma (myxoma) molle, a rare spontaneous neoplastic lesion in the hamster.

A perioperative acuity measurement system.

An integrative acuity measurement system has been developed to increase efficiency and effectiveness of care delivery. Patients are classified into groups on the basis of nursing care required, thus facilitating both determination of actual nursing cost and accurate projection of staffing needs. It provides a universal language among perioperative departments for measuring similar outcomes.

Compliance with prescribed drug therapy in asthma.

Morbidity and mortality from asthma in the Western world is increasing despite effective prophylactic drugs. Beta agonists are increasingly considered causal; while under-prescribing of inhaled steroids or other anti-inflammatories are accepted as causes for the problems, but the role of non-compliance with inhaled asthma therapy is rarely mentioned. Using a novel electromechanical counter MDI actuations have been recorded in three small (9-11 patients), short (2-3 weeks) studies. When aware compliance with prescribed inhaled steroids was under scrutiny, six patients were fully compliant, two took just 70% of the prescribed regimen, but two did not follow the prescribed regimen at all. When unaware of scrutiny, six out of 11 were compliant but five patients were estimated as taking less than 30-51% of the prescribed dose of inhaled steroid. When asked to monitor rescue bronchodilator usage patients consistently under-recorded. Under-use as well as under prescription of inhaled steroids and under-estimation (8) of beta 2-agonists use may be contributory factors to the present increase in asthma mortality and morbidity. These potential problems of poor compliance need larger scale studies to show how and if behaviour can be altered to improve compliance.

Generation and multiplication of plantlets from callus derived from Haplopappus gracilus (Nutt.) Gray and their karyotype analysis.

Unopened flower heads of Haplopappus gracilis (2n = 4) provided primary explants for callus production and subsequent induction of organized growth. Callus was initiated from small (3-5 mm in length) floral buds with benzylaminopurine (BAP) (44.4 micromoles; 10 mg/l) and naphthalene acetic acid (NAA) (0.54 micromole; 0.1 mg/l). Lowering the BAP level to 4.44 micromoles (1 mg/l) but maintaining the NAA level, gave rise to organized but highly compressed shoot growing points from an otherwise undifferentiated callus mass. Shoots selected from such cultures were maintainable and could be proliferated by growing 1-1.5-cm stem tip cuttings on Murashige and Skoog basal medium (solidified with agar) containing 0.444 micromole (0.1 mg/l) BAP and 0.054 micromole (0.01 mg/l) NAA. The stem tip multiplication rates obtainable by these means permit reliable strategies for shoot multiplication or production of rooted plantlets. Prolonged subculture and maintenance of shoots on growth regulator-free medium leads to in vitro flowering and greatly reduces rooting capacity. Karyotype analysis of chromosomes from root tip cells at metaphase and chromosome measurements show that karyologically uniform plantlets (based on chromosome number and morphology) can be obtained.

A microcomputer-based system for the accurate continuous measurement of ventilation and blood pressure parameters under anaesthesia.

A microcomputer system for the measurement of parameters of ventilation and blood pressure in the spontaneously breathing anaesthetized patient is described. The system continuously calculates minute volume, respiratory frequency, and mean end tidal carbon dioxide concentration. Additionally four cardiovascular parameters are measured. The inputs are obtained from a wet-wedge spirometer, a capnograph and a blood pressure monitor. The methods of computer calculation are described in detail. The computer-generated results are compared with those obtained by manual calculation. The system described has the capacity to record and display a wide variety of further measurements made during anaesthesia. This system provides invaluable information for research and teaching, but may also be useful during routine anaesthesia.

A double-blind study of the respiratory effects of nalbuphine hydrochloride in spontaneously breathing anesthetized patients.

Nalbuphine hydrochloride 0.2 mg/kg was compared with meperidine 0.5 mg/kg in a double-blind study in 20 patients undergoing elective inguinal hernia repair while breathing spontaneously under general anesthesia. The respiratory effects of the two drugs studied were continuously and accurately recorded with a wet wedge spirometer throughout the procedure. The acute respiratory effects of these analgesic drugs could therefore be assessed. The measurements recorded before any surgical stimulation showed that both nalbuphine and meperidine produce a similar degree of respiratory depression. These results are at variance with earlier studies that drew conclusions from measurements that were neither continuous nor accurate. Nalbuphine was found to be a satisfactory analgesic adjuvant in this anesthetic technique.

An electronic processor for use with a whole body plethysmograph to determine specific airways conductance.

The panting manoeuvre traces produced by a whole body plethysmograph during the measurement of specific airways conductance (sGaw) are traditionally analysed by hand. Since this technique is tedious and time consuming it is prone to error, as well as suffering from considerable inter-observer variability. We describe a new inexpensive analogue electronic processor which rapidly produces readouts of sGaw and overcomes many of the problems associated with hand analysis. The system takes as its inputs the mouth flow and plethysmograph volume outputs from a pressure-corrected flow-displacement whole body plethysmograph, but it could be adapted for use with other types of plethysmograph. Since the processor is intended mainly for use during serial measurements of sGaw it does not carry out an unnecessary correction for flowmeter resistance. Using an electronic simulator of sGaw signals the output of the processor was found to be linear to better than 2% of full scale and to be insensitive to drift on the volume signal. The system has been comprehensively evaluated using signals from both normal subjects and patients. The processor output was found to agree well with the results of hand analysis, an agreement which was comparable with that obtained from computer based systems. For the normal subjects the equal value line adequately described the relationship between the processor and hand estimates of sGaw. However, for patients the slope of the best fit line was 18% less than unity but the correlation coefficient was high: 0.95. Reproducibility was found to be better than 3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Meptazinol--a cause of respiratory depression in general anaesthesia.

The respiratory effects of meptazinol 1 mg kg-1 have been compared with those of pethidine 0.5 mg kg-1 and 1 mg kg-1 in a double-blind trial in 30 patients undergoing arthroscopic meniscectomy under general anaesthesia. Respiratory depression was seen in all treatment groups. Pethidine 1 mg kg-1 produced respiratory depression which was greater than that produced by meptazinol 1 mg kg-1. The least depressant respiratory effects were seen in the group receiving pethidine 0.5 mg kg-1. We submit that the measurement of tidal volume enhances the assessment of the respiratory effects of analgesic drugs during anaesthesia.

The generation and display of signals from electro-mechanical spirometers.

We have investigated how faithfully the electronic circuitry in two commonly used electro-mechanical spirometers records maximal expiratory flow-time and flow-volume curves according to the criteria of the American Thoracic Society. We have made an assessment of the speed of response necessary for X-Y plotters to record such curves accurately. Using an instrumentation recorder to record and subsequently replay flow-time and flow-volume curves onto a general purpose X-Y plotter, we have found that faithful reproduction could be obtained with a four-fold reduction in the replay speed compared to the recording speed. Consideration should be given to the influence of the spirometer and recording device used when interpreting the results of maximal expiratory manoeuvres.