Dynamics of somatic cell count (SCC) and differential SCC during and following intramammary infections.

Somatic cell count is frequently used as an indicator of intramammary infections (IMI) in dairy cattle worldwide. The newly introduced differential SCC (DSCC) can potentially contribute to detection of IMI. The purpose of this study was to investigate the dynamics of SCC and DSCC after IMI. We used a data set with monthly samples from 2 Danish dairy herds through 1 yr, using bacterial culture to identify IMI. The dynamics of SCC and DSCC with regard to IMI were assessed at quarter level following new IMI with each of 3 defined pathogen groups, major, minor, or "other" pathogens, using general additive models. Both SCC and DSCC increased after IMI, with a more pronounced increase if major or other pathogens were detected compared with minor pathogens. We found that DSCC increased after IMI with other pathogens in both herds and, in herd 2, after IMI caused by major and minor pathogens. We also estimated the duration of increased SCC and DSCC when they exceeded a threshold, done separately for each pathogen group. Major pathogens had the longest-lasting effect in both herds for both SCC and DSCC. We conclude that the magnitude and duration of response of SCC and DSCC to IMI differs between herds and causative pathogens.

Half-Life Extending Modifications of Peptide YY3-36 Direct Receptor-Mediated Internalization.

Peptide YY3-36 (PYY3-36) is an endogenous ligand of the neuropeptide Y2 receptor (Y2R), on which it acts to reduce food intake. Chemically modified PYY3-36 analogues with extended half-lives are potential therapeutics for the treatment of obesity. Here we show that the common half-life extending strategies PEGylation and lipidation not only control PYY3-36's pharmacokinetics but also affect central aspects of its pharmacodynamics. PEGylation of PYY3-36 inhibited endocytosis by increasing receptor dissociation rates (koff), which reduced arrestin-3 (Arr3) activity. This is the first link between Arr3 recruitment and Y2R residence time. C16-lipidation of PYY3-36 had a negligible impact on Y2R signaling, binding, and endocytosis. In contrast, C18acid-lipidation minimized endocytosis, which indicated a decreased internalization through non-arrestin-related mechanisms. We propose a temporal model that connects the properties and position of the half-life extender with receptor Gi versus Arr3 signaling bias. We believe that this will be important for future design of peptide therapeutics.

Association between teat skin colonization and intramammary infection with Staphylococcus aureus and Streptococcus agalactiae in herds with automatic milking systems.

The objective of this study was to investigate the association between teat skin colonization and intramammary infection (IMI) with Staphylococcus aureus or Streptococcus agalactiae at the quarter level in herds with automatic milking systems. Milk and teat skin samples from 1,142 quarters were collected from 300 cows with somatic cell count >200,000 cells/mL from 8 herds positive for Strep. agalactiae. All milk and teat skin samples were cultured on calf blood agar and selective media. A subset of samples from 287 quarters was further analyzed using a PCR assay (Mastit4 PCR; DNA Diagnostic A/S, Risskov, Denmark). Bacterial culture detected Staph. aureus in 93 (8.1%) of the milk samples and 75 (6.6%) of the teat skin samples. Of these, 15 (1.3%) quarters were positive in both the teat skin and milk samples. Streptococcus agalactiae was cultured in 84 (7.4%) of the milk samples and 4 (0.35%) of the teat skin samples. Of these, 3 (0.26%) quarters were positive in both the teat skin and milk samples. The PCR detected Staph. aureus in 29 (10%) of the milk samples and 45 (16%) of the teat skin samples. Of these, 2 (0.7%) quarters were positive in both the teat skin and milk samples. Streptococcus agalactiae was detected in 40 (14%) of the milk samples and 51 (18%) of the teat skin samples. Of these, 16 (5.6%) quarters were positive in both the teat skin and milk samples. Logistic regression was used to investigate the association between teat skin colonization and IMI at the quarter level. Based on bacterial culture results, teat skin colonization with Staph. aureus resulted in 7.8 (95% confidence interval: 2.9; 20.6) times higher odds of Staph. aureus IMI, whereas herd was observed as a major confounder. However, results from the PCR analyses did not support this association. Streptococcus agalactiae was isolated from the teat skin with both PCR and bacterial culture, but the number of positive teat skin samples detected by culture was too low to proceed with further analysis. Based on the PCR results, Strep. agalactiae on teat skin resulted in 3.8 (1.4; 10.1) times higher odds of Strep. agalactiae IMI. Our results suggest that Staph. aureus and Strep. agalactiae on teat skin may be a risk factor for IMI with the same pathogens. Focus on proper teat skin hygiene is therefore recommended also in AMS.

Determinants of antimicrobial treatment for udder health in Danish dairy cattle herds.

Societal pressure to limit the use of antibiotics in livestock production systems, including dairy cattle systems, is consistently increasing. To motivate farmers to reduce antibiotic usage, it is important to understand the factors that determine whether a cow will be treated with antibiotics or not. If farmers' usual practices regarding antibiotic treatments are taken into account, they may be motivated to adopt control measures that can facilitate prudent use of antibiotics and are at the same time cost-effective. In this study, we analyzed database recordings of milk yield and somatic cell count from the routine milk recording scheme, clinical registrations of mastitis and PCR results, and cow factors such as days in milk and parity in relation to antibiotic treatments for 518 dairy herds in Denmark. Farm-wise logistic regressions were used to predict antimicrobial treatment based on these factors. The resulting regression coefficients of 422 herds were further analyzed by principal component analysis and clustering to determine the driving predictors for treatment in different groups of farms. The results showed that determinants that were most important for predicting antibiotic treatments vary from one farm to another. Health indicators such as PCR or somatic cell count were most indicative for treatment on some farms, whereas other groups seemed to depend more on production factors (milk yield) or later culling of the cows. This shows that farmers behave differently and differences can be identified in register data. This information can be considered when developing cost-effective herd-specific control measures of mastitis to promote prudent use of antibiotics in Danish dairy cattle farms.

Relation between tetR and tetA expression in tetracycline resistant Escherichia coli.

BACKGROUND: Tetracyclines are among the most used antibiotics in livestock worldwide. Resistance is widely disseminated in Escherichia coli, where it is generally mediated by tetracycline efflux pumps, such as TetA. Expression of tetracycline efflux pumps is tightly controlled by the repressor TetR, which has been shown to be tetracycline-responsive at sub-MIC tetracycline concentrations. The objective of this study was to investigate the effects of increasing tetracycline concentrations on the growth of TetA-producing E. coli, and to determine how expression of tetA and tetR related to each other in different growth phases in the presence of tetracycline. RESULTS: A tetracycline resistant E. coli strain containing tetA and tetR on the chromosome was constructed and cultured in the presence of increasing concentrations of tetracycline. Expression of tetR and tetA was measured at four time points in different growth phases by quantitative real-time PCR. The TetA-producing E. coli exhibited prolonged lag phase with increasing concentrations of tetracycline, while expression of tetA and tetR increased and decreased, respectively, with increasing tetracycline concentration. The levels of tetA and tetR mRNA varied depending on growth phase, resulting in a gradual decrease of the tetA/tetR ratio from approximately 4 in the lag phase to approximately 2 in the stationary phase. CONCLUSION: This study shows that the expression of tetR and tetA is tetracycline concentration- and growth phase-dependent, contributing to improved understanding of the relationships between E. coli growth, tetracycline exposure and expression of tetracycline resistance.

CTX-M-1 ß-lactamase expression in Escherichia coli is dependent on cefotaxime concentration, growth phase and gene location.

OBJECTIVES: Knowledge about the regulatory mechanisms of CTX-M ß-lactamase-encoding genes in Escherichia coli is limited. The objectives of this study were to determine the growth response of CTX-M-1-producing E. coli exposed to cefotaxime and to investigate how blaCTX-M-1 expression at mRNA and protein levels is influenced by cefotaxime concentration, growth phase and gene location (chromosome versus plasmid). METHODS: Two isogenic E. coli strains, MG1655/CTX-M-1 and MG1655/IncI1/CTX-M-1, containing blaCTX-M-1 on the chromosome and on a wild-type IncI1 plasmid, respectively, were constructed and the MIC of cefotaxime was determined. Growth of the two strains was studied in the presence of increasing concentrations of cefotaxime ranging from 0 to 512 mg/L. The levels of mRNA and protein in different growth phases and at different cefotaxime concentrations were studied by qPCR and selected-reaction-monitoring MS, respectively. RESULTS: The MICs of cefotaxime were 168 and 252 mg/L for MG1655/CTX-M-1 and MG1655/IncI1/CTX-M-1, respectively. Both strains displayed a prolonged lag phase when exposed to cefotaxime. The mRNA of blaCTX-M-1 and CTX-M-1 protein levels increased in the presence of high cefotaxime concentrations and varied with growth phase. Higher mRNA expression levels were detected for MG1655/CTX-M-1 compared with MG1655/IncI1/CTX-M-1, but a higher protein level was found for MG1655/IncI1/CTX-M-1 compared with MG1655/CTX-M-1, the latter corresponding well with the higher MIC for this strain. CONCLUSIONS: blaCTX-M-1 mRNA expression and CTX-M-1 protein levels were dependent on cefotaxime concentration, growth phase and gene location. These results provide insight into the expression of cephalosporin resistance in CTX-M-1-producing E. coli, improving our understanding of the relationship between antimicrobial therapy and the expression of resistance mechanisms.

Immunogenic and protective efficacy of recombinant protein GtxA-N against Gallibacterium anatis challenge in chickens.

Gallibacterium anatis is a major cause of reproductive tract infections in chickens. Here, we aimed to evaluate the efficacy of the recombinant protein GtxA-N at protecting hens, by addressing three objectives; (i) evaluating the antibody response following immunization (ii) scoring and comparing lesions, following challenge with G. anatis, in immunized and non-immunized hens and (iii) investigating if the anti-GtxA-N antibody titre in individual hens correlated with the observed lesions. Two consecutive experiments were performed in hens. In the first experiment hens were immunized with GtxA-N on day 0 and day 14, infected with G. anatis on day 28 and euthanized on day 56. The GtxA-N antibody response was assessed in pooled serum samples throughout the experiment, using an indirect enzyme-linked immunosorbent assay (ELISA). In the second experiment the GtxA-N antibody titres were assessed in individual hens before and after immunization. Subsequently, the hens were inoculated with G. anatis and finally all hens where euthanized and submitted for post mortem examination 48 h after inoculation. Immunization elicited strong antibody responses that lasted at least 8 weeks (P < .0001). The individual antibody titres observed in response to immunization varied considerably among hens (range: 174,100-281,500). Lesion scores following G. anatis infection were significantly lower in immunized hens compared to non-immunized hens (P = .004). Within the immunized group, no correlation was found between the individual antibody titres and the lesion scores. This study clearly demonstrated GtxA-N as a vaccine antigen able of inducing protective immunity against G. anatis.

Assessing the influence of mechanical ventilation on blood gases and blood pressure in rattlesnakes.

OBJECTIVE: To characterize the impact of mechanical positive pressure ventilation on heart rate (HR), arterial blood pressure, blood gases, lactate, glucose, sodium, potassium and calcium concentrations in rattlesnakes during anesthesia and the subsequent recovery period. STUDY DESIGN: Prospective, randomized trial. ANIMALS: Twenty one fasted adult South American rattlesnakes (Crotalus durissus terrificus). METHODS: Snakes were anesthetized with propofol (15 mg kg(-1)) intravenously, endotracheally intubated and assigned to one of four ventilation regimens: Spontaneous ventilation, or mechanical ventilation at a tidal volume of 30 mL kg(-1) at 1 breath every 90 seconds, 5 breaths minute(-1), or 15 breaths minute(-1). Arterial blood was collected from indwelling catheters at 30, 40, and 60 minutes and 2, 6, and 24 hours following induction of anesthesia and analyzed for pH, PaO2, PaCO2, and selected variables. Mean arterial blood pressure (MAP) and HR were recorded at 30, 40, 60 minutes and 24 hours. RESULTS: Spontaneous ventilation and 1 breath every 90 seconds resulted in a mild hypercapnia (PaCO2 22.4 ± 4.3 mmHg [3.0 ± 0.6 kPa] and 24.5 ± 1.6 mmHg [3.3 ± 0.2 kPa], respectively), 5 breaths minute(-1) resulted in normocapnia (14.2 ± 2.7 mmHg [1.9 ± 0.4 kPa]), while 15 breaths minute(-1) caused marked hypocapnia (8.2 ± 2.5 mmHg [1.1 ± 0.3 kPa]). Following recovery, blood gases of the four groups were similar from 2 hours. Anesthesia, independent of ventilation was associated with significantly elevated glucose, lactate and potassium concentrations compared to values at 24 hours (p < 0.0001). MAP increased significantly with increasing ventilation frequency (p < 0.001). HR did not vary among regimens. CONCLUSIONS AND CLINICAL RELEVANCE: Mechanical ventilation had a profound impact on blood gases and blood pressure. The results support the use of mechanical ventilation with a frequency of 1-2 breaths minute(-1) at a tidal volume of 30 mL kg(-1) during anesthesia in fasted snakes.

DENTAL LESIONS IN THE LOWLAND TAPIR (TAPIRUS TERRESTRIS).

Dental ailments, mandibular swelling, and dentoalveolar abscesses are common in tapirs, but knowledge about prevalence or etiology of these lesions in the Tapiridae family in general, and in lowland tapirs (Tapirus terrestris) in particular, is scarce. A recent study identified resorptive lesions of unknown etiology as a common problem in the Malayan tapir (Tapirus indicus). In order to investigate the type and prevalence of dental lesions occurring in lowland tapirs, and to compare these with findings with the Malayan tapir, skulls and teeth from 46 deceased lowland tapirs were visually and radiographically examined. The specimens were divided into subpopulations according to age (juveniles, young adults, adults) and origin (free-range or captive). Dental lesions were identified in 24% (11/46) of the study population. The most common pathologic findings were complicated dental fractures with associated periapical reaction (15%) and periapical reactions of various degrees without associated detectable dental pathology (13%). All these lesions likely originated from dental trauma. As in Malayan tapirs, juveniles had significantly fewer lesions than adults. This study shows that dental lesions present frequent problems for lowland tapirs, occurring both in captive and in free-ranging individuals, and indicates that increasing age should be considered a risk factor for the development of these lesions. Notably, the predominant dental problems in lowland tapirs and Malayan tapirs are not the same.

Consideration of QRS complex in addition to ST segment abnormalities in the estimation of the 'risk region' during acute inferior myocardial infarction.

BACKGROUND: The myocardial area at risk (MaR) has been estimated in patients with acute myocardial infarction (AMI) by using ST segment based ECG methods. However, as the process from ischemia to infarction progresses, the ST segment deviation is typically replaced by QRS abnormalities, causing a falsely low estimation of the total MaR if determined by using ST segment based methods. A previous study showed the value of the consideration of the abnormalities in the QRS complex, in addition to those in the ST segment estimating the total MaR for patients with anterior AMI. The purpose of this study was to investigate the same method for patients with inferior AMI. METHODS: Thirty-two patients with acute inferior ST elevation myocardial infarction received (99m)Tc-Sestamibi before percutaneous coronary intervention. SPECT was performed within 2 hours after treatment and was used as a gold standard for the estimation of the total MaR. The ECG recorded at admission in the hospital was used for the ECG estimates of the total MaR. This included a ST segment estimation of the ischemic component of the total MaR (Aldrich score) and an estimation of the infarcted component of the total MaR in the acute phase of AMI by QRS abnormalities (Selvester score). These scores were added for the combined ECG score. RESULTS: The ischemic component of the total MaR estimated by the Aldrich score alone no statistically significant correlation with SPECT (r=0.17, p=0.36). The infarcted component of the total MaR estimated by the Selvester score showed a significant correlation with SPECT (r=0.55, p=0.001). When the Aldrich and Selvester scores were combined, the correlation with SPECT improved (r=0.58, p<0.001). Both the Aldrich and Selvester score alone underestimated the mean MaR measured by SPECT (respectively p=0.007 and p<0.0001). There was no statistically significant difference between the mean MaR estimated by the sum of Aldrich and Selvester and the MaR measured by SPECT (p=0.636). CONCLUSION: The estimation of the total MaR was more accurate by taking both ST deviation and QRS abnormalities in account than by using either method alone. A new ECG method to determine the total MaR during acute coronary occlusion should consider both its ischemic and infarcted components.

Modeling the effect of direct and indirect contamination of on-farm bulk tank milk with Mycobacterium avium subsp. paratuberculosis.

Mycobacterium avium subsp. paratuberculosis (MAP) in milk of bovine origin is suspected of being implicated in Crohn's disease in humans. Milk can be contaminated via direct excretion of MAP in milk or indirectly via fecal contamination of the milk. This study aimed at estimating the level of MAP in farm bulk tank milk and simulating the effect of direct and indirect contamination with MAP. The effect of discarding milk from test-positive cows at different prevalences was assessed. The concentration of MAP in milk was estimated using a simulation model, while taking direct and indirect contamination with MAP into account. Direct MAP contamination of milk was related to infection stages, while indirect contamination was associated with within-herd prevalence and distribution of cows in different stages of infection. Discarding of milk based on diagnostic test results was included as a control option. Median MAP load in farm bulk tank milk at within-herd infection prevalences from 7.5% to 60% were estimated to be 0.54-7.53 CFU/mL milk. Maximum concentration at the prevalence of 60% could be 1186 CFU/mL caused by shedding of high amounts of MAP in feces. At the prevalence of 15%, discarding milk from test positive cows would result in discarding 11% of milk and reduce the MAP level by 80%. Due to poor sensitivity of the diagnostic test, removing test-positive cows would not further reduce the already low concentration of MAP and it would not guarantee the milk as MAP-free. The model was relatively simple yet capable of capturing true infection status and associated contributions from milk and feces. Further knowledge on distribution of fecal excretion from infected cows is required because very few "super-shedders" might play a major role.

Immunohistochemical study of CD31 and α-SMA expression for age estimation of porcine skin wounds.

Age estimation of wounds in veterinary forensic investigations is based on the presence and amount of granulation tissue. However, accurate age assessment is challenging and new time-dependent markers are warranted to support and improve the current procedure. The objective of this study was to evaluate the expression of CD31-positive blood vessels and α-smooth muscle action (α-SMA)-positive myofibroblasts in granulation tissue in order to evaluate their value as markers for porcine wound age estimation in a veterinary forensic context. Immunohistochemical expression of CD31 and α-SMA in 14 experimental porcine skin wounds of different ages (4, 6, 8, 10, 18, 27 and 35 days) and 11 forensic porcine wound specimens (of unknown age) were evaluated. CD31-positive blood vessels and α-SMA-positive myofibroblasts were present in the granulation tissue in the experimental wounds at all time points. A significant decrease in the mean blood vessel counts was found in wounds aged 18, 27 and 35 days compared with wounds aged 6 days (P < 0.001), when assessing both the superficial and deep part of the wound bed. α-SMA expression was lower at 27 and 35 days post wounding compared with 6-18 days post wounding. Combined assessment of three parameters (mean blood vessel counts in the superficial and deep wound beds and α-SMA expression) could approximately specify the age of the wounds as either 6-18 days or ≥27 days. In two of the forensic cases a combination of the three parameters yielded results that were similar to the experimental wounds, indicating a wound age of 6-18 days or ≥27 days, respectively. In the remaining forensic cases a combination of the three parameters did not show the same expression pattern as in the experimental wounds. The results indicate that in some forensic cases the application of CD31 and α-SMA markers appeared to support the current procedure for porcine wound age estimation, but this must be combined with pathological characteristics.

Risk factors for development of foot lesions in captive flamingos (Phoenicopteridae).

Foot lesions are highly prevalent in captive flamingos (Phoenicopterus spp.); however, the etiology of these lesions remains mainly speculative. The objectives of this study were to identify climatic factors (latitude, temperature, and housing) and surface factors influencing the risk of four different types of foot lesions (hyperkeratosis, nodular lesions, papillomatous growths, and fissures) in captive flamingos. The study was based on photos of 445 pairs of flamingo foot soles. Data originating from 337 birds in 10 different zoos were included. The odds of birds having hyperkeratosis, papillomatous growths, and fissures were higher for flamingos living north of the 53rd degree of latitude, for flamingos exposed to a mean temperature of 15 degrees C or less during the previous 4 wk, and for birds housed in indoor exhibits for at least 90% of the time during the previous 4 wk (compared to flamingos housed outdoor for at least 90% of the time in the same time period). Concrete-type floors increased the odds of flamingos having hyperkeratosis and fissures. Certain substrates increased the odds of one type of lesion while decreasing the odds of having other lesion types. In conclusion, both climate and substrate appear to affect the odds of developing different types of foot lesions.

Gross and histopathological evaluation of umbilical outpouchings in pigs.

Clinical presentations of umbilical outpouchings (UOs) in pigs cover a variety of pathological manifestations. Pigs with UOs often do not reach the abattoir as they die due to complications or are euthanized for welfare concerns. The primary objective was to characterize the gross appearance of UOs in pigs with respect to the different types of pathological manifestations. Also the association between the pathological manifestation and presence of a wound on the UO was evaluated. Pigs (in different age groups, n = 444) with an UO were sampled in Denmark from different locations (two herds and at an abattoir) and examined post mortem. Tissue samples from animals with an enterocystoma or internal umbilical proliferations were collected for histological and immunohistochemical characterization. Hernia umbilicalis was the most frequent cause (72%, n = 320) of the UOs. It was the only diagnosis in 57% (n = 254) of the pigs, and in 15% (n = 66) of the pigs the hernia appeared in combination with other manifestations. Thus, 28% (n = 124) of the pigs were diagnosed with an enterocystoma, internal umbilical proliferations, subcutaneous abscess/ fibrosis or another diagnosis, presented alone or in combination. The distribution of diagnoses varied in the different age groups. Overall, 38% (110/291) of the pigs presented a wound on the UOs post mortem. The age of the pigs confounded the relation between the pathological manifestation and the presence of a wound. The odds that an UO had a wound were lower among pigs with a subcutaneous abscess/ fibrosis compared to pigs diagnosed with an umbilical hernia or enterocystoma (OR, 0.3; 95% Cl, 0.1-0.7). The odds of wounds were higher among weaners (OR, 4.3; 95% Cl 2.3-8.3) and finishers (OR, 6.5; 95% Cl, 3.4-12.7) compared with piglets from the farrowing unit. The area of wounds ranged from 0.03 to 78.5 cm2 and increased with age (P < 0.001). Histologically and immunohistochemically the enterocystomas and internal umbilical proliferations seemed to be lined with mesothelial cells and both had a content comparable with mesenchymal embryonic connective tissue. However, only the cavities of the enterocystomas were also lined with mesothelial cells. In conclusion, UOs in pigs are caused by complex pathological conditions with hernia umbilicalis as the dominating diagnosis. Knowledge clarifying the different pathological manifestations causing an UO and the presence of wounds on the UOs is essential for future prevention strategies.

Atrial fibrillatory rate as predictor of recurrence of atrial fibrillation in horses treated medically or with electrical cardioversion.

BACKGROUND: The recurrence rate of atrial fibrillation (AF) in horses after cardioversion to sinus rhythm (SR) is relatively high. Atrial fibrillatory rate (AFR) derived from surface ECG is considered a biomarker for electrical remodelling and could potentially be used for the prediction of successful AF cardioversion and AF recurrence. OBJECTIVES: Evaluate if AFR was associated with successful treatment and could predict AF recurrence in horses. STUDY DESIGN: Retrospective multicentre study. METHODS: Electrocardiograms (ECG) from horses with persistent AF admitted for cardioversion with either medical treatment (quinidine) or transvenous electrical cardioversion (TVEC) were included. Bipolar surface ECG recordings were analysed by spatiotemporal cancellation of QRST complexes and calculation of AFR from the remaining atrial signal. Kaplan-Meier survival curve and Cox regression analyses were performed to assess the relationship between AFR and the risk of AF recurrence. RESULTS: Of the 195 horses included, 74 received quinidine treatment and 121 were treated with TVEC. Ten horses did not cardiovert to SR after quinidine treatment and AFR was higher in these, compared with the horses that successfully cardioverted to SR (median [interquartile range]), (383 [367-422] vs 351 [332-389] fibrillations per minute (fpm), P < .01). Within the first 180 days following AF cardioversion, 12% of the quinidine and 34% of TVEC horses had AF recurrence. For the horses successfully cardioverted with TVEC, AFR above 380 fpm was significantly associated with AF recurrence (hazard ratio = 2.4, 95% confidence interval 1.2-4.8, P = .01). MAIN LIMITATIONS: The treatment groups were different and not randomly allocated, therefore the two treatments cannot be compared. Medical records and the follow-up strategy varied between the centres. CONCLUSIONS: High AFR is associated with failure of quinidine cardioversion and AF recurrence after successful TVEC. As a noninvasive marker that can be retrieved from surface ECG, AFR can be clinically useful in predicting the probability of responding to quinidine treatment as well as maintaining SR after electrical cardioversion.

Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial.

BACKGROUND: Remote ischaemic preconditioning attenuates cardiac injury at elective surgery and angioplasty. We tested the hypothesis that remote ischaemic conditioning during evolving ST-elevation myocardial infarction, and done before primary percutaneous coronary intervention, increases myocardial salvage. METHODS: 333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerised block randomisation to receive primary percutaneous coronary intervention with (n=166 patients) versus without (n=167) remote conditioning (intermittent arm ischaemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to hospital, and primary percutaneous coronary intervention in hospital. The primary endpoint was myocardial salvage index at 30 days after primary percutaneous coronary intervention, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00435266. FINDINGS: 82 patients were excluded on arrival at hospital because they did not meet inclusion criteria, 32 were lost to follow-up, and 77 did not complete the follow-up with data for salvage index. Median salvage index was 0.75 (IQR 0.50-0.93, n=73) in the remote conditioning group versus 0.55 (0.35-0.88, n=69) in the control group, with median difference of 0.10 (95% CI 0.01-0.22; p=0.0333); mean salvage index was 0.69 (SD 0.27) versus 0.57 (0.26), with mean difference of 0.12 (95% CI 0.01-0.21; p=0.0333). Major adverse coronary events were death (n=3 per group), reinfarction (n=1 per group), and heart failure (n=3 per group). INTERPRETATION: Remote ischaemic conditioning before hospital admission increases myocardial salvage, and has a favourable safety profile. Our findings merit a larger trial to establish the effect of remote conditioning on clinical outcomes. FUNDING: Fondation Leducq.

Consideration of QRS complex in addition to ST-segment abnormalities in the estimated "risk region" during acute anterior myocardial infarction.

BACKGROUND: The myocardial area at risk (MaR) has been estimated in patients with acute myocardial infarction (AMI) by using ST segment-based electrocardiographic (ECG) methods. As the process from ischemia to infarction progresses, the ST-segment deviation is typically replaced by QRS abnormalities causing a falsely low estimated total MaR if determined by using ST segment-based methods. The purpose of this study was to investigate if consideration of the abnormalities in the QRS complex, in addition to those in the ST segment, provides a more accurate estimated total MaR during anterior AMI than by considering the ST segment alone. METHODS: Twenty-five patients with acute anterior ST elevation myocardial infarction (STEMI) received technetium Tc 99m-sestamibi before percutaneous coronary intervention. Single photon emission computed tomography (SPECT) was performed within 2 hours after treatment and was used as a criterion standard for the estimated total MaR. The ECG recorded at admission in the hospital was used for the ECG estimated total MaR. This included an ST-segment estimated ischemic component of the total MaR (Aldrich score) and an estimated infarcted component of the total MaR in the acute phase of AMI by QRS abnormalities (Selvester score). These scores were added for the combined ECG score. RESULTS: The ischemic component of the total MaR estimated by the Aldrich score alone had no statistically significant correlation with SPECT (r = 0.21, P = .32). The infarcted component of the total MaR estimated by the Selvester score showed a significant correlation with SPECT (r = 0.49, P = .01). Each score gave a significant underestimated total MaR measured by SPECT (P < .01). When the Aldrich and Selvester scores were combined, the correlation with SPECT was r = 0.47, P = .02. The combined score still underestimated the total MaR by SPECT (P < .01), though the difference was smaller in comparison to either method alone (P < .01). CONCLUSION: The ECG estimated total MaR was more accurate by taking both ST deviation and QRS abnormalities into account than by using either method alone. A new ECG method to determine the total MaR during acute coronary occlusion should consider both its ischemic and infarcted components.

The ST injury vector: electrocardiogram-based estimation of location and extent of myocardial ischemia.

BACKGROUND: Analysis of ST deviations from the 12-lead electrocardiogram allows for estimation of a spatial ST injury vector. The goal of the present study was to compare the location and extent of transmural myocardial ischemia evaluated by myocardial perfusion imaging with the direction and magnitude of the ST injury vector. METHODS: Twelve-lead electrocardiograms were recorded from 75 acute myocardial infarction patients with single-vessel disease and thrombolysis in myocardial infarction (TIMI) flow 0/1 (30 left anterior descending [LAD], 28 right coronary artery [RCA], 17 left circumflex artery [LCX]). ST deviations were measured in the J point in all leads and used to estimate ST injury vectors for each patient. Myocardial perfusion imaging was performed to evaluate the extent and location of myocardial ischemia at the time of coronary intervention. RESULTS: Ninety-two percent of the patients showed ST injury vectors within the expected directional range for the identified anatomic segment of ischemia by myocardial perfusion imaging. ST injury vector direction separated LAD, RCA, and LCX occlusion patients; 90% of the LAD patients showed anterior vectors, 82% of the RCA patients showed posteroinferoseptal vectors, and 59% of the LCX patients showed posteroinferolateral vectors. Eight patients did not fulfill the ST elevation criteria for ST elevation myocardial infarction but showed anterior ST depression and prominent ST injury vectors in the posterior torso direction. There was a moderate correlation between the extent of ischemia and ST injury vector magnitude for the ischemic patients, r = 0.29. CONCLUSION: We found strong agreement between the direction of the ST injury vector and the location of myocardial ischemia. The ST injury vector may be the key to higher diagnostic accuracy for inferobasal transmural ischemia and may help distinguishing between RCA and LCX occlusions in the acute phase.

Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for <12 h vs. 12-72 h.

AIMS: Primary angioplasty for ST-segment elevation myocardial infarction (STEMI) is recommended only if symptom duration is <12 h. We evaluated final infarct size (FIS) and myocardial salvage in early presenters (<12 h) vs. late presenters (12-72 h) undergoing primary angioplasty. METHODS AND RESULTS: Myocardial perfusion imaging (MPI) was performed acutely to assess area at risk (AAR) before angioplasty and repeated after 30 days to assess FIS (% of LV myocardium), salvage index (% non-infarcted AAR), and left ventricular ejection fraction (LVEF). Late presenters (n = 55) compared with early presenters (n = 341) had larger median FIS [14% (inter-quartile range 3-30) vs. 7% (2-18), P = 0.005], lower salvage index [53% (27-89) vs. 69% (45-91), P = 0.05], and lower LVEF [48% (44-58%) vs. 53% (47-59), P = 0.04]. However, FIS, salvage index, and LVEF correlated weakly with symptom duration (R(2)-values <0.10). In patients with TIMI-flow 0 (n = 247), late presenters had lower salvage index than early presenters [44% (23-73) vs. 57% (42-86), P = 0.03], but substantial salvage (>50% of AAR) was observed in 41% of late presenters despite total infarct-artery occlusion. CONCLUSION: FIS is larger in late presenters (>12 h) than early presenters after primary angioplasty for STEMI. However, substantial myocardial salvage can be obtained beyond the 12 h limit, even when the infarct-related artery is totally occluded.