Synthesis and Relaxometric Characterization of New Poly[N,N-bis(3-aminopropyl)glycine] (PAPGly) Dendrons Gd-Based Contrast Agents and Their in Vivo Study by Using the Dynamic Contrast-Enhanced MRI Technique at Low Field (1 T).

The synthesis of poly[N,N-bis(3-aminopropyl)glycine] (PAPGly) dendrons Gd-based contrast agents (GdCAs) via an orthogonal protection of the different functional groups and an activation/coupling strategy wherein a specific number of synthetic steps add a generation to the existing dendron has been described. The aim of this protocol is to build up two different generations of dendrons (G-0 or dendron's core, and G-1) with peripheral NH2 groups to conjugate a 1,4,7,10-tetraazacyclododecane-1,4,7-triacetic acid (DO3A) derivative and afterwards to chelate with Gd3+ paramagnetic ions. These complexes, which have a well-defined molecular weight, are of relevance to MRI as an attempt to gain higher 1 H relaxivity by slowing down the rotation of molecule compared to monomeric Gd(III) complexes used as contrast agents and to increase the number of paramagnetic centers present in one molecular structure. From the study of their water 1 H longitudinal relaxation rate at different magnetic fields (NMRD, Nuclear Magnetic Relaxation Dispersion) and by evaluating the variable temperature 17 O-NMR data we determined the parameters characterizing the water exchange rate and the rotational correlation time of each complex, both affecting 1 H relaxivity. Furthermore, these two novel PAPGly GdCAs were objects of i) an in vivo study to determine their biodistributions in healthy C57 mice at several time points, and ii) the Dynamic Contrast-Enhanced MRI (DCE-MRI) approach to assess their contrast efficiency measured in the tumor region of C57BL/6 mice transplanted subcutaneously with B16-F10 melanoma cells. The aim of the comparison of these two dendrons GdCAs, having different molecular weights (MW), is to understand how MW and relaxivity may influence the contrast enhancement capabilities in vivo at low magnetic field (1 T). Significant contrast enhancement was observed in several organs (vessel, spleen and liver), already at 5 min post-injection, for the investigated CAs. Moreover, these CAs induced a marked contrast enhancement in the tumor region, thanks to the enhanced permeability retention effect of those macromolecular structures.

Optimizing Water Exchange Rates and Rotational Mobility for High-Relaxivity of a Novel Gd-DO3A Derivative Complex Conjugated to Inulin as Macromolecular Contrast Agents for MRI.

Thanks to the understanding of the relationships between the residence lifetime τM of the coordinated water molecules to macrocyclic Gd-complexes and the rotational mobility τR of these structures, and according to the theory for paramagnetic relaxation, it is now possible to design macromolecular contrast agents with enhanced relaxivities by optimizing these two parameters through ligand structural modification. We succeeded in accelerating the water exchange rate by inducing steric compression around the water binding site, and by removing the amide function from the DOTA-AA ligand [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid mono(p-aminoanilide)] (L) previously designed. This new ligand 10[2(1-oxo-1-p-propylthioureidophenylpropyl]-1,4,7,10-tetraazacyclodecane-1,4,7-tetraacetic acid (L1 ) was then covalently conjugated to API [O-(aminopropyl)inulin] to get the complex API-(GdL1 )x with intent to slow down the rotational correlation time (τR ) of the macromolecular complex. The evaluation of the longitudinal relaxivity at different magnetic fields and the study of the 17 O-NMR at variable temperature of the low-molecular-weight compound (GdL1 ) showed a slight decrease of the τM value (τM310 = 331 ns vs. τM310 = 450 ns for the GdL complex). Consequently to the increase of the size of the API-(GdL1 )x complex, the rotational correlation time becomes about 360 times longer compared to the monomeric GdL1 complex (τR  = 33,700 ps), which results in an enhanced proton relaxivity.

Ultradian ghrelin pulsatility is disrupted in morbidly obese subjects after weight loss induced by malabsorptive bariatric surgery.

BACKGROUND: Suppression of ghrelin production after Roux-en-Y gastric bypass that suggested its contribution to appetite reduction has been reported. OBJECTIVE: Because biliopancreatic diversion (BPD) does not affect appetite, we compared ghrelin production and 24-h pulsatility between healthy control subjects and obese subjects before and after BPD. DESIGN: A computerized algorithm identified peak heights, clearance rate, and peak frequency of ghrelin over 24 h. Twenty-four-hour energy expenditure was measured in the calorimetric chamber, and energy intakes were computed. Insulin sensitivity was measured with a euglycemic-hyperinsulinemic clamp. RESULTS: Mean (+/-SD) 24-h plasma ghrelin concentrations were significantly (P < 0.0001) higher in control than in obese subjects (338.17 +/- 22.09 and 164.47 +/- 29.19 microg/L, respectively), but they increased to 204.64 +/- 28.51 microg/L in the obese subjects after BPD (P < 0.01). The pulsatility index was 0.098 +/- 0.016 and 0.041 +/- 0.014 microg . L(-1) . min(-1) in control and obese subjects, respectively (P < 0.01), and decreased to 0.025 +/- 0.007 microg . l(-1) . min(-1) after BPD (P < 0.05). Energy intakes before and after BFP did not differ significantly. Although metabolizable energy after BPD was 40% of the energy intake, that (per kg fat-free mass) after BPD did not different significantly from that before BPD. CONCLUSIONS: Weight loss induced by malabsorptive bariatric surgery is associated with greater ghrelin concentrations, which, however, remain consistently lower than those in control subjects, whereas ghrelin pulsatility is subverted. Higher ghrelin concentrations may contribute to the high calorie intakes observed in post-BPD subjects. The lack of normal pulsatility may explain the new impulse of these subjects to eat very frequently.

Leptin pulsatility in formerly obese women.

Plasma leptin and growth hormone (GH) profile and pulsatility have been studied in morbidly obese subjects before and 14 months after bilio-pancreatic diversion (BPD), a bariatric technique producing massive lipid malabsorption. The maximum leptin diurnal variation (acrophase) decreased (10.27+/-1.70 vs. 22.60+/-2.79 ng x ml(-1); P=0.001), while its pulsatility index (PI) increased (1.084+/-0.005 vs. 1.050+/-0.004 ng x ml(-1) x min(-1); P=0.02) after BPD. Plasma GH acrophase increased (P=0.0001) from 0.91+/-0.20 to 4.58+/-0.80 microg x l(-1) x min(-1) after BPD as well as GH PI (1.70+/-0.13 vs. 1.20+/-0.04 microg x l(-1) x min(-1); P=0.024). Whole-body glucose uptake (M), assessed by euglycemic-hyperinsulinemic clamp, almost doubled after BPD (from 0.274+/-0.022 to 0.573+/-0.027 mmol x kgFFM(-1) x min(-1); P<0.0001), while 24 h lipid oxidation was significantly (P<0.0001) reduced (131.94+/-35.58 vs. 44.56+/-15.10 g). However, the average lipid oxidation was 97.2+/-3.1% (P<0.01) of the metabolizable lipid intake after the bariatric operation, while it was 69.2+/-8.5% before. After the operation, skeletal muscle ACC2 mRNA decreased (P<0.0001) from 452.82+/-76.35 to 182.45+/-40.69% of cyclophilin mRNA as did the malonyl-CoA (from 0.28+/-0.02 to 0.16+/-0.01 nmol x g(-1); P<0.0001). Leptin changes negatively correlated with M changes (R2=0.69, P<0.001). In a stepwise regression (R2=0.87, P=0.0055), only changes in 24 h free fatty acids (B=0.105+/-0.018, P=0.002) and glucose/insulin ratio (B=0.247+/-0.081, P=0.029) were the best predictors of leptin variations. In conclusion, the reversion of insulin resistance after BPD might allow reversal of leptin resistance, restoration of leptin pulsatility, and consequent inhibition of ACC2 mRNA expression, translating to a reduced synthesis of malonyl-CoA, which, in turn, results in increased fatty acid oxidation. Finally, since leptin inhibits GH secretion, a reduction of circulating leptin levels might have produced an increase in GH secretion, as observed in our series.

Estimation of respiratory gas exchange: a comparative study of linear and nonlinear model-based estimation techniques.

Monitoring of respiratory gas exchange in humans is an important task in order to establish the physical condition of the patient and to control important physiological indices. In a previous work, we proposed an approximated linear dynamical model of gas exchange within a controlled volume, to be used as a basis for Kalman filtering technique in order to improve the accuracy of the estimates. In this paper, we propose an alternative nonlinear dynamical model of the same phenomenon and suggest the use of a nonlinear estimation technique. A simulation study demonstrates that operative conditions exist where the latter results are more accurate than the estimates based on the linear model. A set of controlled experiments are also designed in order to create situations in which the above difference is significant. In the paper it is evidenced that, in different operative conditions, the analysis both of simulated and experimental data, give systematically the same indications about the choice of the filtering method. The conclusive result of this paper is that a nonlinear model, and the corresponding nonlinear estimation technique, turn out to be convenient when the operative volume and the accuracy of the instrumentation of the experimental set up are both low (operative volumes of about ten liters and flows measurements errors with variances not less than 1 [liter/min]2). It should be also remarked that the proposed model-based estimation techniques, both linear and nonlinear, are highly superior to conventional methods used in medical practice. The present study provides insights and guidelines that can also be useful when dealing with similar gas exchange estimation problems in many other different application areas.

Restoration of adiponectin pulsatility in severely obese subjects after weight loss.

Diurnal variations of adiponectin levels have been studied in normal-weight men and in diabetic and nondiabetic obese subjects, but no data have been reported in obese subjects after weight loss. We collected blood samples at 1-h intervals over 24 h from seven severely obese subjects before and after massive weight loss consequent to surgical operation (bilio-pancreatic diversion [BPD]) to measure adiponectin, insulin, glucose, and cortisol levels. Insulin sensitivity was assessed by euglycemic-hyperinsulinemic clamp (M value). Studies of diurnal variations and pulsatility of adiponectin, insulin, and cortisol were performed. The pulsatility index (PI) of adiponectin increased after BPD from 0.04 to 0.11 microg/min (P = 0.01). Insulin PI significantly increased after the operation (1.50 vs. 1.08 pmol.l(-1).min(-1), P = 0.01), while cortisol PI did not significantly change. The adiponectin clearance rate changed from 0.001 +/- 10(-4).min(-1) before BPD to 0.004 +/- 8. 10(-4).min(-1) after BPD (P = 0.03). Insulin clearance increased from 0.006 +/- 6. 10(-4).min(-1) before BPD to 0.009 +/- 4.10(-4). min(-1) after BPD (P = 0.02). The M value doubled after surgery (27.08 +/- 8.5 vs. 53.34 +/- 9.3 micromol.kg(FFM)(-1).min(-1); P < 0.001) becoming similar to the values currently reported for normal-weight subjects. In conclusion, in formerly severely obese subjects, weight loss paired with the reversibility of insulin resistance restores homeostatic control of the adiponectin secretion, contributing to the reduction of cardiovascular risk already described in these patients.

[Risk stratification after acute myocardial infarction: limitations of dobutamine stress echocardiography in females]. / Stratificazione del rischio dopo infarto miocardico acuto: limiti dell'eco-stress dobutamina nel sesso femminile.

BACKGROUND: Dobutamine stress echocardiography (DSE) is an imaging test widely used for risk stratification of patients after acute myocardial infarction. METHODS: We evaluated the sensitivity of DSE with respect to the gender and the stenotic coronary artery in patients who survived a myocardial infarction and with angiographic evidence of single-vessel coronary artery disease. RESULTS: The sensitivity of DSE was generally low. In particular, it was significantly lower in the presence of stenosis of the left circumflex and right coronary arteries with respect to the left anterior descending coronary artery. In females it was lower, especially when the stenosis involved the right coronary and left circumflex arteries. CONCLUSIONS: Our data suggest that in female gender the use of other imaging tests and particularly of coronarography should be strongly recommended for risk stratification after acute myocardial infarction.

[Infusion of flecainide in a patient with atrial fibrillation and latent Brugada's syndrome has determined modifications of the electrocardiogram similar to those of a septal myocardial infarct]. / L'infusione di flecainide in un paziente con fibrillazione atriale e sindrome di Brugada latente ha determinato modificazioni dell'elettrocardiogramma simili a quelle di un infarto miocardico settale.

ST-segment elevation in the presence of typical chest pain is a fundamental criterion for the diagnosis of acute myocardial infarction. We describe the case of a 62-year-old male with latent Brugada syndrome in whom the intravenous infusion of flecainide for paroxysmal atrial fibrillation caused ECG abnormalities similar to those of an acute septal myocardial infarction. The patient was not submitted to systemic thrombolysis since accurate echocardiographic evaluation was not suggestive of the presence of any wall motion abnormality and blood analysis did not reveal any increase in the levels of myocardial enzymes. The clinical outcome was not complicated and the patient was finally discharged.

The Gd3+ complex of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid mono(p-isothiocyanatoanilide) conjugated to inulin: a potential stable macromolecular contrast agent for MRI.

Reaction of DOTA-NCSA [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid mono(p-isothiocyanatoanilide)] with O-(aminopropyl)inulin (degree of polymerization 25) provided a chelate that formed a kinetically extremely stable Gd(3+) complex. No transmetalation was observed with Zn(2+). The conjugate has a relaxivity of 21.7 s(-1) mM(-1) at 20 MHz and 37 °C, and each molecule of the inulin carries on average 35 Gd(3+) ions. The parameters governing the relaxivity of this material and of a low-molecular-weight model compound prepared by conjugation of DOTA-NCSA and propylamine were evaluated by investigation of their water (1)H longitudinal relaxation rate enhancements at different magnetic fields (NMRD) and by studying variable temperature (17)O NMR data. The high relaxivity of the inulin conjugate can be ascribed to the efficient slowing down of the molecular tumbling by this carrier. The rotational correlation time at 37 °C of this material is 1460 ps, whereas that of the model compound is 84 ps. Furthermore, both complexes do not interact significantly with human serum albumin, as shown by their NMRD profiles, and do not undergo transmetallation by zinc ions. The inulin conjugate thus has potential for application as a contrast agent for MRI, particularly as a blood pool agent.

[Exercise stress test and dobutamine stress echocardiography for the prognostic stratification after uncomplicated acute myocardial infarction]. / ECG da sforzo ed eco-stress dobutamina nella stratificazione del rischio dopo infarto miocardico acuto non complicato.

BACKGROUND: Exercise stress test and dobutamine stress echocardiography are usually performed early after an uncomplicated acute myocardial infarction in the prognostic stratification of patients to define the optimal diagnostic and therapeutic procedure. The aim of this study was to evaluate if the association of an imaging test could increase exercise test capability to identify patients with residual ischemia and patients at high risk of events in the follow-up. METHODS: Four hundred and forty-two consecutive patients underwent exercise stress testing and dobutamine stress echocardiography before discharge and subsequently coronary angiography within 30 days. In case of submaximal negative result at the exercise test, this was repeated 20 days after discharge. The follow-up lasted 26.8 +/- 9 months. The endpoints were death, reinfarction, and unstable angina requiring hospitalization or revascularization intervention. RESULTS: Both tests and their association showed a higher sensitivity in males; in females dobutamine stress echocardiography had a higher specificity. In females, the addition of dobutamine stress echocardiography increased either the negative or the positive prognostic values of exercise stress test by 31% and 5.6%, respectively. In males, the negative prognostic value increased by 15.5%, whereas the positive prognostic value decreased by 12%. A low exercise capability (<6 METs) showed an event predictive value independent of test results and any other variables. The event-free survival curves correlated with exercise capability differed shortly after the first months both in males and females. CONCLUSIONS: These results suggest different stratification procedures with regard to gender: in males, the exercise stress test might be sufficient at discharge, to be repeated 20 days later, if submaximal negative. In females, it seems to be useful to associate an imaging test at discharge. In any case, the exercise stress test remains the main step in the stratification procedure also for its capability to identify patients who are at high risk of events in the follow-up.