Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013--linked to an international outbreak.

In May 2013, a European alert was issued regarding a hepatitis A virus (HAV) outbreak in Italy. In June 2013, HAV subgenotype IA with an identical sequence was identified in Ireland in three cases who had not travelled to Italy. The investigation consisted of descriptive epidemiology, a case-control study, microbiological testing of human and food specimens, molecular typing of positive specimens and food traceback. We identified 21 outbreak cases (14 confirmed primary cases) with symptom onset between 31 January and 11 October 2013. For the case-control study, we recruited 11 confirmed primary cases and 42 matched controls. Cases were more likely than controls to have eaten berry cheesecake (matched odds ratio (mOR): 12; 95% confidence interval (CI): 1.3-114), whole frozen berries (mOR: 9.5; 95% CI: 1.0-89), yoghurt containing frozen berries (mOR: 6.6, 95% CI: 1.2-37) or raw celery (mOR: 4; 95% CI: 1.2-16). Among cases, 91% had consumed at least one of four products containing frozen berries (mOR: 12; 95% CI: 1.5-94). Sixteen food samples tested were all negative for HAV. As products containing frozen berries were implicated in the outbreak, the public were advised to heat-treat frozen berries before consumption.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April - 3 October 2009.

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

The utilisation and expenditure of medicines for the prophylaxis and treatment of osteoporosis.

The elderly population represent the fastest growing age-group and the incidence of osteoporotic related fractures is likely to increase with continued ageing of the population. This study determined the prescribing patterns on the Health Services Executive's (HSE) Primary Care Reimbursement Services Scheme (HSE-PCRS) of medicines dispensed for the prophylaxis and treatment of osteoporosis in Ireland. The HSE - PCRS prescription databases were analysed for the years 2004/2005. Approximately 65% of patients (total 60,000) were dispensed either Alendronate (Fosamax once weekly) or Risedronate (Actonel once weekly). The majority of the patients (69.3%) were over 70 years. The study identified that the longer a patient was prescribed prednisolone the greater the likelihood of subsequently being prescribed a bisphosphonate. Approximately 50% of patients on long-term steroids did not receive prophylaxis for osteoporosis. There were low levels of co-prescribing (2.5%) with potentially interacting drugs. Levels of co-prescribing with proton pump inhibitors was 22%.

Formation and Stabilization of Rhizosheaths of Zea mays L. (Effect of Soil Water Content).

Field observations have shown that rhizosheaths of grasses formed under dry conditions are larger, more coherent, and more strongly bound to the roots than those formed in wet soils. We have quantified these effects in a model system in which corn (Zea mays L.) primary roots were grown through a 30-cm-deep prepared soil profile that consisted of a central, horizontal, "dry" (9% water content) or "wet" (20% water content) layer (4 cm thick) sandwiched between damp soil (15-17% water content). Rhizosheaths formed in dry layers were 5 times the volume of the subtending root. In wet layers, rhizosheaths were only 1.5 times the root volume. Fractions of the rhizosheath soil were removed from individual roots by three successive treatments; sonication, hot water, and abrasion. Sonication removed 50 and 90% of the soil from rhizosheaths formed in dry and wet soils, respectively. After the heat treatment, 35% of the soil still adhered to those root portions where rhizosheaths had developed in dry soil, compared with 2% where sheaths had formed in wet soil. Root hairs were 4.5 times more abundant and were more distorted on portions of roots from dry layers than from wet layers. Drier soil enhanced adhesiveness of rhizosheath mucilages and stimulated the formation of root hairs; both effects stabilize the rhizosheath. Extensive and stable rhizosheaths may function in nutrient acquisition in dry soils.

A Nitrogen-Fixing Endophyte of Sugarcane Stems (A New Role for the Apoplast).

The intercellular spaces of sugarcane (Saccharum officinarum L.) stem parenchyma are filled with solution (determined by cryoscanning microscopy), which can be removed aseptically by centrifugation. It contained 12% sucrose (Suc; pH 5.5.) and yielded pure cultures of an acid-producing bacterium (approximately 104 bacteria/mL extracted fluid) on N-poor medium containing 10% Suc (pH 5.5). This bacterium was identical with the type culture of Acetobacter diazotrophicus, a recently discovered N2-fixing bacterium specific to sugarcane, with respect to nine biochemical and morphological characteristics, including acetylene reduction in air. Similar bacteria were observed in situ in the intercellular spaces. This demonstrates the presence of an N2-fixing endophyte living in apoplastic fluid of plant tissue and also that the fluid approximates the composition of the endophytes's optimal culture medium. The apoplastic fluid occupied 3% of the stem volume; this approximates 3 tons of fluid/ha of the crop. This endogenous culture broth consisting of substrate and N2-fixing bacteria may be enough volume to account for earlier reports that some cultivars of sugarcane are independent of N fertilizers. It is suggested that genetic manipulation of apoplastic fluid composition may facilitate the establishment of similar symbioses with endophytic bacteria in other crop plants.

Tansley Review No. 22 What becomes of the transpiration stream?

Changes of view on the course of the transpiration stream beyond the veins in leaves are followed from the imbibition theory of Sachs, through the (symplastic) endosmotic theory of Pfeffer (which prevailed almost unquestioned until the late 1930s), to Strugger's experiments with fluorescent dye tracers and the epifluorescence microscope. This latter work persuaded many to return to the apoplastic-(wall)-path viewpoint, which, despite early and late criticisms that were never rebutted, is still widely held. Tracer experiments of the same kind are still frequently published without consideration of the evidence that they do not reveal the paths of water movement. Experiments on rehydration kinetics of leaves have not produced unequivocal evidence for either path. The detailed destinies of the solutes that reach the leaf in the transpiration stream have received little attention. Consideration of physical principles governing flow and evaporation in a transpiring leaf emphasizes that: (1) Diffusion over interveinal distances at the rates in water will account for substantial solute movement in a few minutes, even in the absence of flow. (2) Diffusion can occur also against opposing now. (3) Volume fluxes in veins are determined by the diameter of the largest leaves examined contain high conductance supply veins which are tapped into by low-conductance distributing veins. (4) Edges and teeth of leaves will be places of especially rapid evaporation, and they often have high-conductance veins leading to them. (5) Solutes in the stream will tend to accumulate at leaf margins. On the basis of recent work, the view is maintained that the water of the stream enters the symplast through cell membranes very close to tracheary elements. Also, that this occurs locally over a small area of membrane. Many solutes in the stream are left outside in the apoplast. This produces regions of high solute concentration in the apoplast and an enrichment of solutes in the stream as it perfuses the leaf. Solutes that enter the symplast are not so easily tracked. Suggestions about where some of them may go can be gained from a fluorescent probe that identifies particular cells (scavenging cells) as having H+ -ATPase porter systems to scrub selected solutes from the stream. Unpublished case-histories are presented which illustrate many aspects of these processes and principles. These are: (1) Maize leaf veins, where the symplastic water path starts at the parenchyma sheath; (2) Lupin veins, where the symplastic path starts at the bundle sheath and where solutes are concentrated in blind terminations; (3) The edges of maize leaves where flow is enhanced by a large vein (open to the apoplast), and solutes are deposited in the apoplast by evaporation; (4) Poplar leaf teeth, which receive strong flows, and where the epithem cells are scavenging cells; (5) Mimosa leaf marginal hairs, which have scavenging cells at their base; (6) Active hydathodes, whose epithem cells are scavenging cells; (7) Pine needle transfusion tissue, which is a site of both solute enrichment (in the tracheids), and scavenging (in the parenchyma); (8) Estimates are made of diffusion coefficients of a solute both along and at right angles to the major diffusive pathway in wheat leaves. The first is 1000 times the second, but is 1/100 of free diffusion in water. Five general themes of the behaviour and organization of the transpiration stream are induced from the facts reviewed. These are: (1) The stream is channelled into courses of graded intensities by the interplay of the physical forces with the anatomical features, each course with a distinct contribution to the processing of the stream. (2) Water enters the symplast at precise locations as close as possible to the tracheary elements. (3) As the stream moves through the leaf its solute concentration is enriched many-fold at predictable sites. (4) Solutes excluded from the symplast diffuse from these sources of high concentration in specially formed wall paths, in precise patterns, at rates which can be measured, and which are low compared with diffusion in water. (5) Other solutes permeate the symplast, often over the surfaces of groups of cells which are organized into recognized structural features. CONTENTS Summary 341 I. What becomes of the transpiration stream ? 342 II. Review 343 III. Preview 355 IV. Overview 361 Acknowledgements 365 References 365.

Fine veins of dicotyledon leaves as sites for enrichment of solutes of the xylem sap.

The apoplastic tracer sulphorhodamine G (SR) was used as an indicator of the flumes, the sites where water left the apoplast and entered the symplast, in a selection of dicotyledon leaves. At these flumes the dye is deposited as crystals after a pulse of dye is fed to the transpiration stream, followed or not by a water chase. In contrast to wheat, the dicotyledons showed SR cystals inside the tracheary elements of the finest leaf veins. At short pulse times the crystals were in the stems of the branch-trees of the fine veins, but after longer pulses, had moved to the vein termini. The dye solution was moving very slowly in the tracheary elements as it approached the ends of the branch-trees, since the axial flow there is nearly balanced by radial leakage. These results are interpreted as evidence that most of the transpiration water enters the symplast in the vein sheaths of the fine veins, and that these veins are places where many of the natural solutes of the xylem sap will be enriched to quite high concentrations.

A simple method for locating the start of symplastic water flow (flumes) in leaves.

The identification of sites in leaves where transpiration water crosses cell membranes and enters the symplast has previously been made using freeze-substitution to locate concentrations of dye [e.g. sulphorhodamine (SR)] moving with the transpiration stream, and left outside the membranes where the water passes through. These concentrations were called sumps, and the sites of entry to the symplast were called flumes. A simple method of locating sumps, and therefore flumes, is described. Fresh leaves, fed SR solution through their cut petioles for pulse periods of 0.5 h or more, followed or not by a chase of water, were sectioned by hand under paraffin oil, and the sections mounted in the same fluid. Observation of the sections by simple bright-field microscopy revealed sumps of SR at the same sites, and of the same crystalline nature as found in the freeze-substituted preparations. The saving in preparation time is of the order of > 100-fold, at the sacrifice of resolution (5-10 µm compared with 0.2 µm). A limited survey of grass, sedge and dicotyledon leaves by this method confirmed in all essentials the results found by freeze-substitution, and in addition, revealed flumes at the fusoid cells on the flanks of the veins of bamboo leaves, and at the same position next to the water tissue of Cyperus leaves. The rate of accumulation of crystalline SR in the sumps inside tracheary elements suggests that the concentration of this non-permeating solute in the xylem sap increased by about 1000-fold in the finest veins during 1-2 h of transpiration in the dye solution.

Sites of entry of water into the symplast of maize roots.

Following our publication of a new method of calculating rates of water uptake by roots from measurements of the rate of accumulation on the roots of a marker solute, this paper describes the sites of accumulation of the solute, which indicate the sites where the water entered the symplast. Sulphorhodamine G (SR) was supplied in aeroponic mist culture to large maize plants with fully developed root systems. Root samples were collected after 4 to 8 h of transpiration in the dye-mist from both axes and branches of the main roots, and from non-transpiring (detopped) controls, frozen rapidly, freeze-substituted, and embedded and sectioned by an anhydrous procedure that preserves the SR in place. Whole mounts and sections were examined by bright-field, polarizing and epifluorescence microscopy. Major accumulations of SR were all at the outer surface of the roots, on Epidermal or root hair cell walls, or, in older roots where the epidermal cells were separating or dead, on the outer wall of the hypodermis. On some branch roots, though not on any main axes, the accumulations of SR were conspicuously aligned in the grooves over anticlinal cell walls of the epidermis. Non-transpiring plants showed very slight accumulations. Diffusion of SR into the cell wall apoplast was limited by the suberized lamellae and Casparian bands of the hypodermis, except in some branch roots, where SR diffused throughout the cortical cell walls. In parts of roots where the epidermis and hypodermis had been damaged, SR diffused through cell walls of the cortex from the wound site. These patterns of accumulation show that water enters the symplast of roots at the outermost cell membranes of the root, whether they are epidermal or hypodermal cells. Water enters roots with fully developed hypodermises at high rates. The rote of the hypodermal suberization is to limit solute movement in the wall apoplast. A symplastic path for water throughout the cortex, endodermis and living cells of the stele is suggested.

Planing frozen hydrated plant specimens for SEM observation and EDX microanalysis.

A procedure is described for forming a flat face on a frozen piece of plant tissue, which may then be observed fully-hydrated or lightly etched, and coated or uncoated with a metal film, in scanning electron microscopy (SEM). The frozen sample was planed with a glass knife at -80 degrees C in a cryo-ultramicrotome. The sections were discarded, and the planed block face placed on the cold stage in the microscope column, either for observation uncoated at low kV, or for light etching (-90 degrees C) to reveal the cell outlines. If a higher accelerating voltage was needed, the face was given an evaporative coating of Al in the cryo-preparation chamber and returned to the column. The advantages of the planed face over the usual fracture face are illustrated: imaging at a chosen rather than a chance position; clearer cellular and subcellular detail; preservation of hydrated gels like mucilage and swollen cell walls; the possibility of making serial parallel sections through the same piece of tissue; opportunities for accurate morphometric analyses on the planed face; capacity to produce longitudinal sections; preservation of very delicate structures that are destroyed by fixation and drying. A major advantage of the Al-coated planed face is the increased accuracy of energy-dispersive X-ray (EDX) microanalyses on a smooth rather than a rough surface. Tests are included which show that neither the light etching employed, nor successive planing, interferes with the analyses of elements in the frozen face.

Contributions to the debate on water transport.

The useful criticisms of my theory of water transport by Comstock (American Journal of Botany 86: 1077-1081) and by Stiller and Sperry (American Journal of Botany 86: 1082-1086) are acknowledged and reviewed. I make the following responses. (1) Tensile stresses to contain tissue pressure are kept within modest limits by the organization of vascular tissues into cylindrical bundles with small ratios of radius/boundary thickness. (2) The balance of pressures within tissues of a nontranspiring leaf is best understood by treating it as a single compartment containing several pressure-generating engines whose resultant is the pressure throughout the compartment. An error in the published notional balances for a transpiring leaf is corrected. (3) The argument against a valve in the transpiring leaf, which allows water out but not in, is not convincing. (4) The "robust and extremely consistent" cohesion theory gains this status by neglecting large bodies of experimental fact, once well known to plant physiologists. (5) The demonstration that living cells are not involved in the refilling of embolisms in birch stems is welcomed as an important advance. However, the major questions remain unresolved. (6) Proof is still needed that embolisms in vessels are not refilled by the collapse of gas bubbles under small positive pressures during conductance measurement. (7) The survival of unbroken water threads in vessels under centrifugal stress has still not been demonstrated. (8) Both questions 6 and 7 can be easily answered by direct observation of gas/liquid volumes in frozen stems in the cryo-scanning electron microscope.

Embolisms and refilling in the maize leaf lamina, and the role of the protoxylem lacuna.

The proportion of embolized vessels in the veins of maize leaf laminas was measured during 24 h by direct counting in snap-frozen samples in the cryo-scanning electron microscope. All vessels were sap filled at night. Vessels of intermediate and small veins, and the small tracheary elements of lateral veins, were sap filled throughout the 24 h. The large metaxylem vessels of lateral veins were embolized during the day. The percentage of these vessels embolized was maximum (>70%) at 1400, and declined during the afternoon to 20% at dusk. Leaf water potential reached a minimum (-1.2 MPa) at dusk. The protoxylem lacuna of the lateral veins was much less embolized than the large vessels, although it was of comparable diameter. The observations are interpreted in terms of the refilling hypothesis that is part of the compensating pressure theory of water transport.

Retention in situ and spectral analysis of fluorescent vacuole components in sections of plant tissues.

The contents of plant vacuoles vary in different organs and with the health of the plant, but little is known of the cell-to-cell distribution of soluble organic compounds within plant tissues. Soluble fluorescent phenolic compounds can be immobilized in plant tissues using an anhydrous freeze-substitution and resin embedment process. The vacuolar fluorescence can be characterized in fluorescence photomicrographs for variations in color and intensity, or more quantitatively with spectra obtained using a microspectrofluorometer. This is demonstrated here in freeze-substituted roots and leaves of soybean. Excitation and emission spectra of individual vacuoles can be compared with spectra of pure compounds to form profiles of the varied phenolic contents of plant vacuoles. Such analyses will add an important anatomical dimension to the study of plant defense and stress responses.

Transport in living plants.

This paper provides a general over-view to introduce the subsequent papers on particular topics of plant transport. A revised statement is given of the transport processes reviewed in Ann. Rev. Fluid Mech., 9, 275 (1977), outlining the tissue and cell structures of the plant body which carry out the long distance movements of water, mineral nutrients, and organic material. Some of the questions posed in that review are now better understood, e.g. the breaking of xylem water columns under tension, the loading of sugars into phloem in leaves, and the dissemination of water in leaf veins. Intractable questions remain to which there are no agreed answers, especially the organisation within phloem sieve tubes and the relative roles of the apoplast and symplast in the uptake of water and mineral ions by roots. New techniques are available for tracing water-soluble substances at high resolution in microscopic preparations which may lead to the resolving of some of these questions.

[Phase variations in the left coronary transstenotic pressure gradient before and after dilatation by percutaneous coronary angioplasty]. / Variations phasiques du gradient de pression transsténotique coronaire gauche avant et après dilatation par angioplastie coronaire percutanée.

The concept of significant coronary stenosis may be approached by studying the effects of the narrowing not in absolute values of pressure and flow but by studying the mode of blood flow across the stenosis. Ten patients with isolated stenosis of the LAD were studied for phasic variations of the transstenotic pressure gradient before and after dilatation. The material used was a ST 3.7 catheter with a 0.12 inch guide. Instantaneous pressure recording throughout the cardiac cycle were obtained using a computer. After dilatation, the area of the stenosis minus the area of transverse section of the dilating catheter increased from 0.5 +/- 0.3 to 2.2 +/- 0.3 mm2, the average gradient between the aorta and the post stenotic LAD decreased from 75 +/- 10 to 12 +/- 8 mmHg, and the ratio between the mean diastolic gradient and mean gradient increased from 75 +/- 7 to 245 +/- 30% (p less than 0.01 for the 3 parameters, paired t test). These results show that the LAD transstenotic pressure gradient is not phasic in severe stenosis. It becomes phasic, only in diastole, after dilatation of the stenosis (slight residual stenosis due to the catheter). This difference may be due to the type of flow, continuous and dependent on the stenosis before dilatation, or phasic dependent on the distal coronary circulation after dilatation. Analysis of the phasic changes of coronary flow may be useful for the evaluation of the severity of left coronary stenosis in the absence of pressure measurements.

[Treatment by redilatation and thrombolysis of occlusion occurring during percutaneous coronary angioplasty]. / Traitement par redilatation et thrombolyse des occlusions survenant lors des angioplasties coronaires percutanées.

In patients who develop acute coronary occlusion during or after percutaneous coronary angioplasty, surgery is not mandatory, and other treatments may be considered, namely redilatation and/or thrombolysis. Between June, 1984 and January, 1988 we performed 500 dilatations of coronary arteries, not counting the attempts made in the acute phase of myocardial infarction. Acute coronary occlusion without angiographic image of occlusive dissection occurred in 31 patients (6.2%) and was treated by attempted redilatation and intracoronary thrombolysis. In 10 patients (group A) either the occlusion could not be removed and emergency surgery was tried (5 cases with 2 infarctions and 1 death), or the occlusion was removed but myocardial infarction took place (5 cases). In 21 patients (group B), the occlusion was removed and the outcome was favourable without myocardial infarction. Altogether, myocardial infarction or death occurred in only 8 cases, or 26% of acute occlusions. The clinical and angiographic features of the two groups before and after angioplasty were compared; two of them differentiated group A from group B: (1) unstable angina, 7/10 in group A, 4/21 in group B (p less than 0.01), and (2) degree of stenosis, 93.1% in group A, 78% in group B (p less than 0.01). When coronary occlusion occurs during or after coronary angioplasty and is poorly tolerated with fall in blood pressure, surgery must be contemplated at once, even after recanalization of the vessel and subsidence of ischaemia. In all other cases, treatment with both redilatation and thrombolysis should restore the benefits of angioplasty without myocardial infarction.

[Doppler study of phasic variations of blood flow velocity in the anterior interventricular artery]. / Etude Doppler des variations phasiques des vitesses du sang dans l'artère interventriculaire antérieure.

Studies of changes in coronary blood flow during cardiac cycles may be a useful adjuvant to the measurement of coronary flow reserve to evaluate the hydraulic severity of coronary arterial stenoses. We used intracoronary pulsed Doppler velocimetry to measure phasic variations of blood flow in the anterior interventricular artery of 12 patients with angiographically identified stenosis of that vessel. The Doppler signal was obtained by means of a 20 MHz emission from a source placed at the tip of a catheter selectively positioned at the ostium of the anterior interventricular artery, upstream of the stenosis. The increase in severity of stenosis was paralleled by a relative decrease of diastolic blood flow velocity in relation to systolic blood flow velocity. The diastolic/systolic maximum velocities ratio was greater than 1 in 6 patients with a less than 70 p. 100 stenosis (group A) and inferior to 1 in 6 other patients with a 70 p. 100 or more stenosis (group B). In 5 patients of group B this ratio was reversed to normal after percutaneous transluminal angiography. Thus, measurement of intracoronary blood flow velocity may be helpful to evaluate the severity of stenosis, notably in the anterior interventricular artery where angiographic evaluation is difficult.

[Evolution of the primary successes of percutaneous aortic valvuloplasty]. / Evolution des succès primaires de la valvuloplastie aortique percutanée.

Between November 1985 and August 1988, we performed 89 percutaneous aortic valvuloplasties. Sixty-two of these were considered a primary success on the basis of two main criteria: stage I or II on discharge and greater than 50 p. 100 increase in aortic valve area. The mean age of these patients was 78.4 +/- 6.1 years. On actuarial analysis, after 5 months 98 p. 100 of the patients with primary success were alive and 89 p. 100 were in stage I or II and had not been operated upon or redilated. At 15 months 79 p. 100 of the patients with primary success were alive, but only 48 p. 100 were in stage I or II and neither operated upon or redilated. Ultrasonic data obtained one and twelve months after dilatation were compared in 8 patients who had kept the full functional benefit of angioplasty for 14.6 +/- 4.3 months (group 1) and 9 patients who had lost this initial benefit (group 2). In group 1 patients the aortic valve area had moderately and non significantly diminished from 0.92 to 0.72 cm2. In group 2 patients the aortic valve area had gone down from 0.89 to 0.63 cm2 (p less than 0.01), indicating restenosis. We conclude that after the 4th post-valvuloplasty month the medium-term success of the procedure undergoes some degradation, and in these patients the echocardiographic signs of stenosis are clear-cut.

[Reproducibility of myocardial ischemia induced by atrial stimulation]. / Etude de la reproductibilité de l'ischémie myocardique déclenchée par stimulation auriculaire.

Reproducibility of myocardial ischemia induced by atrial pacing (P) was investigated in 25 patients (pts) without previous anterior myocardial infarction and showing a positive exercise stress test. The second period of atrial pacing (P2) was exerted 20 minutes after the first (P1). During P2, a reduction in the parameters reflecting myocardial oxygen requirements (maximal left ventricular pressure, dp/dt max, TTI*HR values) was noted, while the signs of ischemia were less pronounced (ST depression decreasing from 2.3 +/- 1 mm to 1.6 +/- 1.0 mm; % of lactate extraction (%L) decreasing from - 6.4 +/- 25.5 to + 8.5 +/- 19.2; p less than 0.5). The 25 pts were divided into 2 groups according to the ejection fraction (EF greater than .55 16 pts Gr.F+; EF less than .55 9 pts Gr.F-). The distribution of coronary lesions was the same for the 2 groups. During P1 GR.F+ registered a negative % L as opposed to Gr.F-. During P2, the difference in the % L between the 2 groups was also significant (2.6 +/- 19.9% F+ vs 18.9 +/- 14.3% F-; p less than .05). Collateral circulation had no effect upon the results, neither for P1 or P2. This study shows that a second period of atrial pacing, 20 minutes after the first, induced lesser ischemia than the first period of atrial pacing. This phenomenon could explain the paradoxical improvement observed in certain patients after a first episode of angina. These results have implications as regards the necessity of double blind studies compared to placebo when using this technique in the evaluation of the effects of anti-ischemic drugs.