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[11] Curello S, Ceconi C, Cargnoni A, Cornacchiari A, Ferrari R, Albertini A. Improved procedure for determining glutathione in plasma as an index of myocardial oxidative stress. Clin Chem 1987; 33: 14489. [12] Heusch G, Ferrari R, Hearse DJ, Ruigrok TJC, Schulz R. Myocardial hibernation -- questions and controversies. Cardiovasc Res 1997; 36: 3019. [13] Ferrari R, Cargnoni A, Bernocchi P et al. Metabolic adaptation during a sequence of no-flow and low-flow ischaemia: a possible trigger for hibernation. Circulation 1996; 94: 258796. [14] Heusch G, Rose J, Skyschally A, Post H, Schulz R. Calcium responsiveness in regional myocardial short-term hibernation and stunning in the in situ porcine heart -- inotropic responses to postextrasystolic potentiation and intracoronary calcium. Circulation 1996; 93: 155666. [15] Ito BR. Gradual onset of myocardial ischemia results in reduced myocardial infarction. Association with reduced contractile function and metabolic downregulation. Circulation 1995; 91: 205870. [16] Matsuzaki M, Gallagher KP, Kemper WS, White F, Ross J Jr. Sustained regional dysfunction produced by prolonged coronary stenosis: gradual recovery after reperfusion. Circulation 1983; 68: 17082. [17] Chen C, Li L, Chen LL et al. Incremental doses of dobutamine induce a biphasic rsponse in dysfunctional left ventricular regions subtending coronary stenoses. Circulation 1995; 92: 75666. [18] Chen C, Chen L, Fallon JT et al. Functional and structural alterations with 24hour myocardial hibernation and recovery after reperfusion. A pig model of myocardial hibernation. Circulation 1996; 94: 50716. [19] Topol EJ, Weiss JL, Guzman PA et al. Immediate improvement of dysfunctional myocardial segments after coronary revascularization: detection by intraoperative transesophageal echocardiography. J Coll Cardiol 1984; 4: 112334.
1. Karzai W, Ltte A, Gnicker M, Vorgrimler-Karzai U-M, Priebe H-J. Dobutamine increases oxygen consumption during constant flow cardiopulmonary bypass. British Journal of Anaesthesia 1996; 76: 58. Ruttimann Y, Chiolro R, Jquier E, Breitenstein E, Schutz Y. Effects of dopamine on total oxygen consumption and oxygen delivery in healthy men. American Journal of Physiology 1989; 259: E541E546.
[I-1 'C]acetate. A -test was used to analyze the goodness of fit by the kinetic model to the measured tissue time-activity curve 20, 21 ; and the nonparametric run test was used to test whether the data points about the fitted curve were randomly distributed about the fitted curve 22 ; . The Durbin-Watson test for autocorrelation was applied and the Cochrane-Orcutt procedure was used to correct for the autocorrelated error terms for the regression between measured and estimated MVO2 values 25 ; . RESULTS Hemodynamic and Metabolic Parameters Hemodynamic and metabolic findings for the baseline and the intervention studies are summarized in Tables 1 and 2. The absence of a significant difference between the rate pressure products of the baseline and the dobutamine studies is explained by the way the dogs were selected. In order to get the greatest change in cardiac workload possible, dogs with lower rate pressure products i.e., 21, 000 mmHg min"1 ; were chosen for dobutamine studies whereas several dogs with high rate pressure products at baseline were selected for an intervention with xylazine. Despite the lack of such significant differences, the interventions nevertheless were meaningful as they offered.
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Multiple myeloma cells interacting with the bone marrow microenvironment. However, its toxicity profile is more favorable than the toxicity profile of thalidomide. Its use in front-line therapy and in the treatment of relapsed and refractory disease has been the subject of several clinical studies.
In his book From the Ashes of Angels, Andrew Collins provided historical and scientific evidence showing how Elder gods, who were the flesh and blood members of a race of fallen angels, founded ancient Egypt. Now, in Gods of Eden, he describes the remarkable achievements of their culture. Assembling clues from archaeology, mythology, and religion, Collins shows us how this great society mastered acoustic technology.
The accurate noninvasive diagnosis and functional evaluation of coronary artery disease is an important step in selecting the appropriate management strategy. Dobutamine stress myocardial perfusion imaging is an alternative to exercise in patients with limited exercise capacity. In many centers, the test is performed on patients who have a contraindication for vasodilator stress testing. Recent studies have shown hyperemia induced by the standard dobutamineatropine stress test is not less than hyperemia induced by dipyridamole. The feasibility of the test is 90% and is often higher in patients without -blocker therapy. The safety of the test has been well studied and was also demonstrated in specific patients groups, such as patients with left ventricular dysfunction, the elderly, and heart transplant recipients. The diagnostic accuracy has been demonstrated in patients with and without myocardial infarction and in specific groups such as those with hypertension, left ventricular hypertrophy, and heart transplant recipients and after revascularization. The technique has a high sensitivity for prediction of functional recovery in patients with myocardial dysfunction referred for revascularization. The presence and severity of myocardial perfusion abnormalities assessed by this method are powerful predictors of cardiac events, incremental to clinical data. This article describes the methodology, safety, feasibility, diagnostic accuracy, and prognostic value of dobutamine stress myocardial perfusion imaging in patients with known or suspected coronary artery disease, with additional considerations for the application of the test in specific patient groups. Key Words: dobutamine; stress tests; myocardial perfusion imaging; coronary artery disease J Nucl Med 2002; 43: 1634 and docetaxel.
42 vs. 17mmHg in normal rats ; . Rats were randomized to receive simvastatin or control solution by gavage from week 11. RESULTS: All rats that received control solution died at week 13. When rats with severe PAH received simvastatin 2 mg kg day, by gavage ; from week 11, there was 100% survival, reversal of PAH at week 13 mPAP 36mmHg ; and week 17 mPAP 24mmHg ; . Simvastatin therapy was associated with reduced right ventricular hypertrophy and reduced proliferation and increased apoptosis of pathological smooth muscle cells in the neointima and medial walls of pulmonary arteries. Longitudinal transcriptional profiling revealed that simvastatin downregulated inflammatory genes fos, jun, and TNF- , and upregulated cell cycle inhibitor p27Kip1 and endothelial Nitric oxide synthase eNOS ; . CONCLUSION: Simvastatin reverses monocrotaline-induced pulmonary arterial hypertension and confers a 100% survival advantage. CLINICAL IMPLICATIONS: Simvastatin is a candidate therapy for human pulmonary hypertension. Study of the effect of simvastatin in humans is indicated. DISCLOSURE: J.L. Faul, Merck, Grant monies. Speaker's forum. SUCCESSFUL MANAGEMENT OF PREGNANCY IN SIX PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION PAH ; Dianne L. Zwicke, MD * ; Brian P. Buggy, MD; Wayne Evans, MD. St. Luke's Medical Center, Milwaukee, WI PURPOSE: Maternal mortality is a known complication of pregnancy in PAH patients. Most maternal deaths occur during the immediate postpartum period. We present the successful clinical management of six pregnant women, including the delivery of six viable infants. METHODS: Six women were referred to the pulmonary hypertension clinic for management of moderate to severe PAH during their pregnancies. The underlying disease states included 1 with SLE anticardiolipin antibody syndrome, 2 with PPH, 2 with PAH after corrected congenital heart disease, and 1 with stenosis of a bioprosthetic mitral valve with persistent PAH. Clinic visits occurred monthly until 28 weeks gestation, at which time weekly visits with echocardiographic imaging of the right heart was completed. The delivery date was dictated by any deterioration in right ventricular function. All physicans participating in the delivery were included in a pre-delivery planning meeting. RESULTS: The average age of the women was 25.1 range 22-34 ; years. The average gestational time at delivery was 35 weeks range 33 weeks 3 days - 36 weeks 4 days ; . Four deliveries were scheduled with epidural anesthesia, while 2 had scheduled C-sections with general anesthesia. Epoprostanol, nitric oxide, and dobutamine were utilized in their management. The average length of the hospital stay for the mothers was 5 days, while the average stay for the infants was 8 days. Three of the mothers developed right heart failure symptoms prior to delivery, but all six proceeded through the deliveries safely and successfully. CONCLUSIONS: Six consecutive pregnant women with PAH were successfully managed and delivered without adverse outcome to the mother or the baby. Weekly surveillance of right ventricular function beginning at week 28 was critical in scheduling the timing of delivery. We attributed the successful management and survival to this close monitoring and induction of delivery before term. CLINICAL IMPLICATIONS: Although pregnancy with PAH is extremely high risk, appropriate clinical and hemodynamic management, with close attention to right ventricular function can result in a successful outcome. DISCLOSURE: D.L. Zwicke, None. PULMONARY ARTERIAL HYPERTENSION: PATIENT TRANSITION FROM EPOPROSTENOL TO BOSENTAN Zoheir Bshouty, MD, PhD, FRCPC * ; Frann Martins Da Ponte, RN, BN. Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada PURPOSE: We hypothesized that giving bosentan to patients with pulmonary arterial hypertension currently receiving epoprostenol, will allow systematic epoprostenol weaning with no decline in World Health Organization WHO ; functional class or exercise capacity, minimize medication side effects, and significantly reduce cost of therapy. METHODS: Five patients with primary pulmonary hypertension which were stable with continuous IV infusion of epoprostenol were initiated on 62.5 mg bid of bosentan; the dose was increased to 125 mg bid at Week 4. By Week 12, subjects were weaned down to a goal of at least 25% of epoprostenol dose at study entry. Patients were then admitted to hospital for complete epoprostenol discontinuation. Right-heart catheterization with epoprostenol challenge was performed four to six weeks after epoprostenol discontinuation, and echocardiograms were done at baseline and at 12 and 24 weeks. Exercise capacity was evaluated with monthly measurement of six-minute walk test 6MWT ; up to Week 24. Laboratory assessments were carried out monthly. RESULTS: All patients were titrated to the 25% epoprostenol goal. One patient discontinued the study protocol before complete epoprostenol discontinuation due to significant elevations in alanine aminotransferase levels 8 times upper limit of normal ; . The remaining four patients were successfully weaned off epoprostenol. Epoprostenol challenge during catheterization produced no further improvement in pulmonary pressures in any of the four patients. Echocardiography remained unchanged in all five patients. WHO functional class remained unchanged in four out of the five patients and improved from IV to III in one patient. Two of four patients experienced further increases in 6MWT at Week 24; the mean increase was 19.7 33.26% mean baseline 6MWT was 384.5 171.9 m ; . There were no significant adverse events observed in the four patients who completed the study. CONCLUSIONS: The use of bosentan in the down-titration and the eventual discontinuation of epoprostenol in patients with stable primary pulmonary hypertension are safe. CLINICAL IMPLICATIONS: Bosentan is as effective as epoprostenol in the management of stable pulmonary arterial hypertension. DISCLOSURE: Z. Bshouty, None.
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Patients with possible acute coronary syndromes in the emergency department. J Cardiol. 2003; 91: 1099-102. ; Tsutsui JM, Xie F, O'Leary EL, et al. Diagnostic accuracy and prognostic value of dobutamine stress myocardial contrast echocardiography in patients with suspected acute coronary syndromes. Echocardiography. 2005; 22: 487-95. ; Tong KL, Kaul S, Wang XQ, et al. Myocardial contrast echocardiography versus Thrombolysis In Myocardial Infarction score in patients presenting to the emergency department with chest pain and a nondiagnostic electrocardiogram. J Coll Cardiol. 2005; 46: 920-927. ; Abe Y, Muro T, Sakanoue Y, et al. Intravenous myocardial contrast echocardiography predicts regional and global left ventricular remodelling after acute myocardial infarction: comparison with low dose dobutamine stress echocardiography. Heart. 2005; 91: 1578-83. ; Hagendorff A, Goeckritz A, Pfeiffer D, et al. Myocardial contrast echocardiography demonstrates myocardial hypoperfusion in the LAD territory in patients with acute chest pain at rest--a prospective study using power Doppler harmonic imaging with intravenous bolus application. Eur J Echocardiogr. 2004; 5: 132-41. ; Rocchi G, Kasprzak JD, Galema TW, et al. Usefulness of power Doppler contrast echocardiography to identify reperfusion after acute myocardial infarction. J Cardiol. 2001; 87: 278-82. ; Kloner RA. Does reperfusion injury exist in humans? J Coll Cardiol. 1993; 21: 537-45. ; Iwakura K, Ito H, Kawano S, et al. Predictive factors for development of the no-reflow phenomenon in patients with reperfused anterior wall acute myocardial infarction. J Coll Cardiol. 2001; 38: 472-77. ; Balcells E, Powers ER, Lepper W, et al. Detection of myocardial viability by contrast echocardiography in acute infarction predicts recovery of resting function and contractile reserve. J Coll Cardiol. 2003; 41: 827-33. ; Bolognese L, Carrabba N, Parodi G, et al. Impact of microvascular dysfunction on left ventricular remodeling and long-term clinical outcome after primary coronary angioplasty for acute myocardial infarction. Circulation. 2004; 109: 1121-26 and docusate.
Decisions in the emergency room and that it was not responsible for any negligence, if found, of the doctor. In support of its motion, DeSoto General submitted the report issued by the medical review panel. In opposition to the motion, the plaintiffs filed the affidavit of Dr. Lige Borroughs Rushing, a physician board certified in internal medicine, rhuematology, and geriatrics. Dr. Rushing opined that Dr. Leggio breached the standard of care with regard to Wilburn's treatment by: 1. Failing to explore additional and or alternative treatment for her phantom limb pain; 2. Failing to seek consultation; 3. Failing to adequately evaluate Wilburn's depression; and 4. Failing to adequately treat Wilburn's depression. Although Dr. Rushing's opinion criticizes the acts or omissions of Dr. Leggio, and not the hospital, DeSoto General can be held liable for the negligent acts of Dr. Leggio through the law of vicarious liability once a plaintiff has established the employment relationship between the two. The medical review panel is a pre-trial screening procedure designed to give both parties a preliminary view of the merits of the case. Everett v. Goldman, 359 So.2d 1256, 1264 La. 1978 Rowsey v. Jones, 26, 823 La. App. 2d Cir. 5 10 95 ; , 655 So.2d 560, 576. Contrary to DeSoto General's.
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The diseases called the chronic intoxications generally have a marked effect upon all the body fluids. As indicated in a former paper, the first effect of the cancer intoxication is noted in the decreased resistance of the red blood corpuscles. The hemoglobin is kept in the red corpuscles by the isotonic condition of the blood plasma. This is a simple matter of chemistry. As long as the chlorids and alkalies in the plasma keep up the osmotic balance the hemoglobin will remain in the red corpuscles. But whenever a hemolytic toxin of any kind is liberated in the body, this osmotic balance is broken and anemia from the loss of hemoglobin is initiated. There is immediately a reaction of defense. The chemistry and rationale of this defense is very simple. Sodium chlorid and the alkalies are a part of the daily ingestion. In health they are eliminated in the ratio of their ingestion. The presence of chlorid of sodium or common salt greatly aids dialysis. It is eliminated by the skin, the intestine and the kidneys. The normal content of the urine is from ten to fifteen grams of sodium chlorid in 24 hours. The human organism generally has enough sodium chlorid on hand to supply hydrochloric acid to the gastric juice and to protect the blood from hemolysis. Whenever there is a toxic attack on the red blood corpuscles, the alkalies and chlorids are used to raise the osmotic tension of the blood plasma and thus retain `the hemoglobin in the red corpuscles. Therefore in cancer patients the one notable feature in the urine is the low percentage of chlorids. The retained chlorids thrown into the blood plasma create a condition of concentration of the blood plasma which may be said to be physiologic for the cancerous. But this cannot go on indefinitely. When the blood plasma attains a concentration which protects t h e corpuscles, the chlorids return to the urine until such time as they are again needed for the and dofetilide.
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The left. The terms "activation" and "deactivation" are used here in the functional neuroimaging sense and are not equivalent to excitation and inhibition in the neurophysiological sense and dok.
Atropine superimposes a marked chronotropic stress to dipyridamole and dobutamine increasing oxygen demand, decreasing, at the same time, myocardial oxygen supply by shortening the diastole whose duration is important for perfusion in the presence of maximal vasodilatation and increasing the ischemic potential of stress echocardiography.
Many vibration-based damage detection techniques have been developed for structural health monitoring. Among them, strain-based methods seems to be suitable for an effective use of FBG-sensed data. For example, Yao et al. 1992 ; , Yam et al. 1996 ; , and Maeck et al. 1999 ; introduced the strain mode shape based methods for damage identification. In the methods, damage detection and localization is executed based on the changes in strain mode shapes of the structure in the undamaged and damaged states. Although the strain mode shape approach may be effective, it is not yet easily employed for continuous online monitoring using FBG sensors. The strain mode shape can be directly determined from measured strain frequency response functions with known input and output. For an online application, however, damage detection must be done continuously with the structure in service, which may be able to use only output information. Moreover, high frequency modes are measured to effectively detect and localize small damages in structures when using the strain mode shapes. It is, because of limitations of the experimental instrumentation, difficult to measure higher frequency response data. The aim of this study is to develope a damage detection technique for online structural health monitoring based on FBG sensed signal. To achieve this aim, output only modal parameter identification using frequency domain decomposion FDD ; method is employed to estimate the strain mode shape. Then, the modal flexibility-based scheme is proposed to detect and localize small multiple damages in structures. A numerical study is performed to illustrate the validity of the FDD method. An experimental study is also conducted to show the effectiveness of the proposed method for damage detection and localization and dolasetron.
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Taken together, our data on -blockers, as those of others 4 ; , indicate that outcome is most likely to be improved in higher-risk patients undergoing major surgical procedures. Patients may be selected with the help of validated risk stratification indices 43, 44 ; . Yet, even with pharmacologic intervention, a subset of patients will nevertheless sustain cardiac complications, and there are few data indicating how to differentiate those high-risk surgical patients who may be adequately managed with cardioprotective drugs alone from those in whom myocardial revascularization should be considered first. One study suggests that this type of stratification may be aided by additional diagnostic testing such as dobutamine stress echocardiography 45 ; . Although and doral.
Warnings increase in heart rate orblood see also blood ; pressure dobutamine hydrochloride may cause a marked increase in heart rate or blood pressure, especially systolic pressure and dobutamine.
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Many patients have persistently low blood pressure when receiving dopamine therapy. Evidence suggests that norepinephrine is superior to dopamine in the treatment of hypotension associated with septic shock. Martin and colleagues 14 ; studied 32 patients with septic shock unresponsive to fluids. They randomly assigned patients to receive a 6hour infusion of either dopamine or norepinephrine. Fifteen of 16 patients in the norepinephrine group had improved hemodynamics compared with 5 of 16 the dopamine group. Patients who received norepinephrine had higher urine output and more improvement in lactic acid levels than patients who received dopamine. Several other studies have shown improved splanchnic tissue perfusion with norepinephrine compared with dopamine. Like norepinephrine, epinephrine and phenylephrine are more potent vasoconstrictors than dopamine. Few clinical studies have compared these agents, but limited data thus far suggest that norepinephrine is the agent of choice for treatment of hypotension related to septic shock. Dobutamine should be reserved for patients with a persistently low cardiac index or underlying left ventricular dysfunction. In general, we do not set an upper limit on such agents as norepinephrine or phenylephrine, but it is our experience that patients who require more than 200 micrograms min of norepinephrine for longer than 24 hours rarely survive. Vasopressin Pitressin ; also has been evaluated in a few studies to assess its pressor effect in septic shock. It has little pressor effect in healthy persons, but it has been shown to increase blood pressure in patients with sepsis 15, 16 ; . This may occur through improvement of sympathetic function, which has been shown to be abnormal in sepsis. Patients with septic shock have been shown to have low circulating levels of vasopressin. The data to this point are too limited to make firm recommendations, but further study is warranted. Antibiotics Antibiotics remain one of the few therapies that have been shown to reduce mortality rates in septic shock. They should be administered within 2 hours of the recognition of sepsis. The agent chosen depends largely on the host status and suspected causative organism. Important factors to consider include the suspected source of infection, nature of the pathogen most likely responsible community or nosocomial ; , local resistance patterns, and underlying immune status of the patient. Sicker patients require broader coverage. For any given pathogen or source, numerous regimens are likely to be effective table 3.
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