New squatting test indices are useful for assessing baroreflex sensitivity in diabetes mellitus.

AIMS: The heart rate (HR) responses after performance of the squatting and standing manoeuvre are thought to be a useful tool to assess autonomic neuropathy in diabetics. Our aim was to develop new simple squatting test indices and to analyse their applicability to the assessment of baroreflex sensitivity (BRS) in patients with diabetes. METHODS: Twenty healthy volunteers (mean age 23.2 +/- 3.8 years) and 51 patients with diabetes (mean age 55.9 +/- 10.6 years) were enrolled in study 1 and study 2, respectively. Each subject stood for 3 min (basal period), then squatted down for 1 min (Sq) and stood up again for 1 min (St). In study 1, the squatting test was performed before and after pharmacological autonomic blockade. In study 2, we measured HR in each period and calculated the difference between basal HR and HRSq (DeltaHRSq) and between HRSt and HRSq (DeltaHRSt). BRS was also measured using the phenylephrine method in diabetic patients. RESULTS: In healthy individuals during autonomic blockade, HR changes were mainly controlled by the vagal tone during squatting and by the sympathetic tone during standing. In diabetic patients, DeltaHRSq and DeltaHRSt positively correlated (r = 0.86, P < 0.0001) and both DeltaHRSq and DeltaHRSt significantly correlated with BRS (r = 0.66, P < 0.0001 and r = 0.61, P < 0.0001, respectively). CONCLUSIONS: The new squatting test indices provide useful information for assessing autonomic neuropathy and for identifying diabetic patients at high risk of cardiovascular events.

Development of a new method for assessing the cardiac baroreflex: response to downward tilting in patients with diabetes mellitus.

OBJECTIVE: To investigate the clinical value of a new non-invasive method for assessing baroreflex sensitivity using downward tilting. PATIENTS: 34 patients with diabetes mellitus, mean (SD) age, 53.6 (11.8) years. DESIGN: Arterial blood pressure and ECG were recorded simultaneously while the patients were on a tilt table. After 20 minutes at a 70 degrees upright tilt, the patients were returned to the supine position at a speed of 3.2 degrees /s (downward tilting baroreflex sensitivity test, DT-BRS). A beat to beat systolic blood pressure increase associated with a corresponding lengthening of the RR interval was noted during downward tilting. Baroreflex sensitivity was also assessed using the conventional method of an intravenous injection of phenylephrine (Phe-BRS). Heart rate variability was analysed during rest and tilting. RESULTS: The slope of the regression line for systolic blood pressure v RR interval during downward tilting was highly correlated with Phe-BRS (r = 0.83, p < 0.0001). Both DT-BRS and Phe-BRS were correlated with the high frequency (HF) component of resting heart rate variability (p < 0.005) and with the ratio of the low frequency to the high frequency component (LF/HF) during upright tilting (p < 0.005). DT-BRS and Phe-BRS were also correlated with the difference between rest and tilting values of HF and LF/HF (p < 0.005). CONCLUSIONS: DT-BRS provides a physiological, non-invasive method for determining baroreflex sensitivity and may be a useful index of reflex cardiac vagal and sympathetic function in patients with diabetes mellitus.

Effect of essential hypertension on cardiac autonomic function in type 2 diabetic patients.

OBJECTIVES: The aim of this study was to examine the effects of essential hypertension on cardiac autonomic function in type 2 diabetic patients. BACKGROUND: Hypertension is common in type 2 diabetic patients and is associated with a high mortality. However, the combined effects of type 2 diabetes and essential hypertension on cardiac autonomic function have not been fully elucidated. METHODS: Thirty-three patients with type 2 diabetes were assigned to a hypertensive diabetic group (n = 15; age: 56 +/- 8 years, mean +/- SD) or an age-matched normotensive diabetic group (n = 18, 56 +/- 6 years). Cardiac autonomic function was assessed by baroreflex sensitivity (BRS), heart rate variability (HRV), plasma norepinephrine concentration and cardiac 123I-metaiodobenzylguanidine (MIBG) scintigraphic findings. RESULTS: Baroreflex sensitivity was lower in the hypertensive diabetic group than it was in the normotensive diabetic group (p < 0.05). The early and delayed myocardial uptake of 123I-MIBG was lower (p < 0.01 and p < 0.05, respectively), and the percent washout rate of 123I-MIBG was higher (p < 0.05) in the hypertensive diabetic group. However, the high frequency (HF) power and the ratio of low frequency (LF) power to HF power (LF/HF) of HRV and plasma norepinephrine concentration were not significantly different. The homeostasis model assessment index was higher in the hypertensive diabetic group than it was in the normotensive diabetic group (p < 0.01). CONCLUSIONS: Our results indicate that essential hypertension acts synergistically with type 2 diabetes to depress cardiac reflex vagal and sympathetic function, and the results also suggest that insulin resistance may play a pathogenic role in these processes.

Clinical and angiographic follow-up after single long GFX coronary stent implantation.

In order to identify predictors of late restenosis after GFX stent implantation, procedural and 6-month clinical and angiographic follow-up data of prospectively entered 141 consecutive lesions treated with a single long (24 or 30 mm) GFX stent were compared to 66 consecutive lesions requiring a single short (12 or 18 mm) stent. The initial clinical success rate of 97% and thrombosis rate of 1.4% with long stents were similar to 97% and 0% with short stents (P = NS). Their respective binary restenosis rates were 34.7% and 23.3% for long and short stents as a whole (P = NS), but being 10.0% for 12 mm, 26.0% for 18 mm, 31.3% for 24 mm, and 39.2% for 30 mm. When proximal and distal reference diameters at baseline were compared between the lesions with and without restenosis, proximal reference diameters were not statistically different (3.02+/-0.42 mm vs. 3.18+/-0.62 mm) and the restenosis group had significantly smaller distal reference diameters (2.15+/-0.48 mm vs. 2.55+/-0.53 mm, P<0.0001). The treatment of long lesions with single long-stent implantation can be accomplished with high success and low complication rates. Single long-stent implantation may be effective, if the distal reference size of the long narrowing is big enough to accept the stent.

Malignant neurocardiogenic vasovagal syncope associated with chronic exaggerated vagal tone.

A head-up tilt test was performed in a 23-year-old woman with a history of two syncopal episodes. The patient developed abrupt syncope with 48 seconds of sinus arrest. Analysis of the high frequency (HF) power of heart rate variability over 24 hours before and after metoprolol therapy showed a significantly elevated HF power in this patient compared to age- and sex-matched healthy subjects. It is suggested that an exaggerated resting vagal tone might be associated with the pathogenesis of prolonged asystole in our patient.

Oxidative stress alters arginine metabolism in rat brain: effect of sub-convulsive hyperbaric oxygen exposure.

The effect of hyperbaric oxygenation on arginine metabolism was investigated. Rats were exposed to oxygen at 3 atmospheres absolute for 2 h. Under these conditions, lipid peroxidation and activation of the anti-oxidant system were observed. Levels of thiobarbiturate reactive substances and carbon-centered radicals were increased in the cerebral cortex, while superoxide dismutase activity was also increased in the mitochondrial and cytosolic fraction of cerebrocortical homogenates. This suggested that the increase of both Mn and Cu,Zn-superoxide dismutase activities was probably an early compensatory reaction to oxidative stress. Levels of arginine as well as its metabolite, guanidinoacetic acid, were increased in the cerebral cortex. This increase seemed to be, at least in part, explained by a decrease in the arginase activity in the same region. Moreover, arginase activity in the brain showed heterogeneous distribution. Arginine: glycine amidinotransferase activity was decreased in the pons-medulla oblongata. The observed effects of hyperbaric oxygenation seem to favor nitric oxide generation.

[Accurate placement of central venous catheters using right atrial electrocardiography].

We have evaluated the effectiveness of central venous catheter placement using right atrial electrocardiography (RAECG). Consecutive patients under general anesthesia (n = 42) who required a central venous catheter underwent RAECG-guided catheter insertion procedure via right internal jugular vein. Catheter tip position was verified by post procedure portable chest radiography. Forty of 42 catheter tips were placed above the superior vena cava-right atrial junction, and none of them had its associated complications. The average insertion depth of catheters was 16.4 cm. We also attempted to predict the optimal catheter insertion depth for each patient from the previous measurements of external landmarks, but it was found to be difficult to predict reliably. In this point of view, we should use RAECG technique to make sure the proper positioning of the catheter tip.

Silent cortical strokes associated with atrial fibrillation.

To clarify whether silent cortical strokes (SCS) could be a predictor of symptomatic stroke in patients with atrial fibrillation (AF), 72 patients with AF (50 with chronic AF, 22 with paroxysmal AF) were studied. Patients with mitral stenosis, history of myocardial infarction, or dilated cardiomyopathy were excluded from this study. Using cranial magnetic resonance imaging (MRI), the patients were divided into those with SCS (23 patients, Group 1) and those without SCS (49 patients, Group 2). The incidence of symptomatic stroke was then compared between the two groups. Three patients (13%) in Group 1 developed symptomatic brain infarction; this is statistically significant (p < 0.05), compared with the patients in Group 2, none of whom experienced symptomatic stroke. We suggest that SCS is a predictor of symptomatic cerebral infarct in patients with AF. Therefore, it is thought to be important to diagnose SCS using cranial MRI or computed tomography and to keep patients with SCS under close surveillance.

Effect of hyperbaric oxygenation on the Na+, K(+)-ATPase and membrane fluidity of cerebrocortical membranes after experimental subarachnoid hemorrhage.

It is reported that CNS hemorrhage causes membrane dysfunction and may exacerbate this damage as a result of secondary ischemia or hypoxia. Since hyperbaric oxygenation improves oxygen metabolism, it may reduce this membrane damage. The present study was conducted to reveal whether hyperbaric oxygenation influences membrane alteration after hemorrhage. Thirty minutes after subarachnoid hemorrhage induction, rats were treated with hyperbaric oxygenation 2 ATA for 1 hour. Rats were decapitated 2 hours after subarachnoid hemorrhage induction. Na+, K(+)-ATPase activity measurement and spin-label studies were performed on crude synaptosomal membranes. Subarachnoid hemorrhage decreased Na+, K(+)-ATPase activity. Spin label studies showed that hydrophobic portions of near the membrane surface became more rigid and the mobility of the membrane protein labeled sulfhydryl groups decreased after subarachnoid hemorrhage. Hyperbaric oxygenation significantly ameliorated most of the subarachnoid hemorrhage induced alterations. We conclude that hyperbaric oxygenation may be a beneficial treatment for acute subarachnoid hemorrhage.

Effects of ferric citrate injection on the composition of bile acids in rats.

Ferric citrate was examined for its possible induction of acute and chronic changes in bile acids in rats. Three hours after a single intravenous Fe(III) injection both the biliary bile acid level and the percentage of cholic acid in bile were significantly higher in treated rats than in control rats. However, no significant difference was observed after treatment with the same daily dose for one week. The superoxide dismutase (SOD) activity in liver tissue increased in the chronic group. These results suggest that oxygen free radicals, mainly the hydroxyl radical, promote hydroxylation during bile acid biosynthesis by enhanced monooxygenase activity.

2-Guanidinoethanol increased dopamine release and 3,4-dihydroxyphenylacetic acid content, but not homovanillic acid content in the rat brain: electroneurochemical and enzymological studies.

The effects of 2-guanidinoethanol (GEt) on the release of monoamines and on the activity of their degrading enzymes were studied in order to investigate why 3,4-dihydroxyphenylacetic acid (DO-PAC) increased to a much greater extent than homovanillic acid (HVA) after GEt injection into rat brain. In differential pulse voltammograms recorded using an electrochemically treated carbon fiber electrode, two distinct oxidation peaks, one at 130mV (DOPAC peak) and the other at 300 mV (5-hydroxyindoleacetic acid (5-HIAA) peak), were observed. In the hippocampus, the DOPAC peak increased markedly compared to the peak height recorded prior to the intracerebroventricular injection of GEt (6 mumol). Although the DOPAC peak height increased to 350% 4 hours after GEt injection, the 5-HIAA peak showed no change. In the striatum, the DOPAC peak increased to 150% 3 hours after GEt injection. Serial changes in the extracellular levels of DOPAC, HVA, and 5-HIAA were monitored in the striatum after GEt injection, using an in vivo brain micro-dialysis technique. Although the DOPAC levels strated to increase 80 minutes after GEt injection, HVA and 5-HIAA levels showed no change. On the other hand, monoamineoxidase, which metabolizes dopamine to DOPAC, was not activated and catechol-O-methyltransferase, which metabolizes DOPAC to HVA, were not inhibited by 5 mM of GEt in vitro. These data suggested that GEt increased the release of dopamine, but not of serotonin, and that GEt might restrict the DOPAC transport system.

Effect of 2-guanidinoethanol on levels of monoamines and their metabolites in the rat brain.

The contents of monoamines and their metabolites in rat brains 3 hours after the intracerebroventricular injection of 6 mumol of 2-guanidino-ethanol (GEt) were measured by HPLC. GEt which is a configurational analogue of 4-aminobutanoic acid (GABA) induced severe running fits and tonic-clonic convulsions as well as epileptic discharges. In GEt-administered rats, dopamine (DA) decreased in the cortex, hippocampus and hypothalamus. 3,4-Dihydroxyphenylacetic acid (DOPAC) increased to about the same level in all brain regions, therefore the distribution of DOPAC appeared to be homogeneous in the brain. The homovanillic acid levels also increased in the striatum and hippocampus. No significant change in the norepinephrine contents was observed in any region. The turnover ratio of DA increased significantly except in the striatum. Serotonin levels increased in the hypothalamus and midbrain by GEt administration, though 5-hydroxyindoleacetic acid levels showed no change in any of the brain regions. These data suggest that the activity of dopaminergic and serotonergic neurons are increased by GEt.