Repeated delta1-opioid receptor stimulation reduces delta2-opioid receptor responses in the SA node.

Ultra-low-dose methionine-enkephalin-arginine-phenylalanine improves vagal transmission (vagotonic) and decreases heart rate via delta(1)-opioid receptors within the sinoatrial (SA) node. Higher doses activate delta(2)-opioid receptors, interrupt vagal transmission (vagolytic), and reduce the bradycardia. Preconditioning-like occlusion of the nodal artery produced a vagotonic response that was reversed by the delta(1)-antagonist 7-benzylidenaltrexone (BNTX). The following study tested the hypothesis that extended delta(1)-opioid receptor stimulation reduces subsequent delta(2)-receptor responses. The delta(2)-agonist deltorphin II was introduced in the SA node by microdialysis to evaluate delta(2) responses before and after infusion of the delta(1)-agonist TAN-67. TAN-67 reduced the vagolytic effect of deltorphin by two-thirds. When the delta(1)-antagonist BNTX was combined with TAN-67, the deltorphin response was preserved, suggesting that attrition of the prior response was mediated by delta(1) activity. When TAN-67 was omitted in time control studies, some loss of delta(2) responses was apparent in the absence of the delta(1) treatment. This loss was also eliminated by BNTX, suggesting that the attenuation of the response after deltorphin alone was also the result of delta(1) activity. Additional studies tested TAN-67 alone in the absence of prior deltorphin. When time controls were conducted without the initial deltorphin treatment, a robust vagolytic response was observed. When TAN-67 preceded the delayed deltorphin, the vagolytic response was eroded, indicating an independent effect of TAN-67. BNTX infused afterward was unable to restore the delta(2) response. These data support the conclusion that the loss of the delta(2) response resulted from reduced delta(2) activity mediated by continued delta(1)-receptor stimulation and not the arithmetic consequence of increased competition from that same delta(1) receptor.

Recurrent seizure diagnosed by the insertable loop recorder.

INTRODUCTION: The Insertable Loop Recorder (ILR) has emerged as an important new tool in the diagnostic armamentarium for patients with syncope. METHODS AND RESULTS: A case report illustrates how the ILR unexpectedly led to the diagnosis of seizure as the explanation for a man's recurrent, but infrequent episodes of sudden loss of consciousness. CONCLUSIONS: This case raises the possibility that the development of implantable recording devices which monitor physiologic parameters other than cardiac rhythm (eg. brain, nerve or muscle activity) may provide the long-term monitoring capability needed to improve the diagnostic yield for conditions, such as seizures, which occur infrequently.

Metabolic and cognitive response to human traumatic brain injury: a quantitative proton magnetic resonance study.

Proton magnetic resonance spectroscopy (1H-MRS) offers a unique insight into brain cellular metabolism following traumatic brain injury (TBI). The aim of the present study was to assess change in neurometabolite markers of brain injury during the recovery period following TBI. We studied 19 TBI patients at 1.5, 3, and 6 months postinjury and 28 controls. We used 1H-MRS to quantify N-acetylaspartate (NAA), creatine (Cre), choline (Cho), and myoinositol (mIns) in occipitoparietal gray matter (GM) and white matter (WM) remote from the primary injury focus. Neuropsychological testing quantified cognitive impairment and recovery. At 1.5 months, we found cognitive impairment (mean z score = -1.36 vs. 0.18,p < 0.01), lower NAA (GM: 12.42 mM vs. 13.03, p = 0.01; WM: 11.75 vs. 12.81, p < 0.01), and elevated Cho (GM: 1.51 vs. 1.25, p < 0.01; WM: 1.98 vs. 1.79, p < 0.01) in TBI patients compared with controls. GM NAA at 1.5 months predicted cognitive function at outcome (6 months postinjury; r = 0.63, p = 0.04). GM NAA continued to fall by 0.46 mM between 1.5 and 3 months (p = 0.02) indicating continuing neuronal loss, metabolic dysfunction, or both. Between 3 and 6 months, WM NAA increased by 0.55 mM (p = 0.06) suggesting metabolic recovery. Patients with poorer outcomes had elevated mean GM Cho at 3 months postinjury, suggesting active inflammation, as compared to patients with better outcomes (p = 0.002). 1H-MRS offers a noninvasive approach to assessing neuronal injury and inflammation following TBI, and may provide unique data for patient management and assessment of therapeutic efficacy.

Unipolar electrogram characteristics predictive of successful radiofrequency catheter ablation of accessory pathways.

INTRODUCTION: The purpose of this study was to determine the characteristics of the unipolar electrogram that are most helpful in predicting successful radiofrequency ablation of accessory pathways. METHODS AND RESULTS: The unipolar electrogram was analyzed at 185 ablation sites in 53 patients; 94 attempts were directed at the site of earliest atrial activation ("atrial group") and 91 at the site of earliest ventricular activation ("ventricular group"). The electrogram was analyzed for several features, including pattern ("QS" or "initial R"). Unipolar pattern: Overall, a "QS" pattern was seen at 55% of unsuccessful, 75% of temporarily successful, and 90% of permanently successful sites. For the atrial group, the respective frequencies were 53%, 77%, and 92%, and for the ventricular group, 57%, 73%, and 86%. The difference in pattern distribution between unsuccessful and permanently successful sites was significant for all groups: overall, P < 0.0001; atrial group, P = 0.0005; ventricular group, P = 0.02. Absence of a "QS" pattern (i.e., "initial R") predicted a 92% chance of unsuccessful ablation. Additional features: Activation times were significantly shorter at permanently successful than at unsuccessful (P < 0.0001) or temporarily successful sites (P = 0.0002). No significant differences were found in atrial or ventricular amplitudes or in A/V ratios. Intrinsic deflection slew was lower at temporarily successful sites (P = 0.03 vs all other sites). CONCLUSION: Ablation at sites revealing an "initial R" pattern (i.e., absent "QS") is very unlikely to be successful. Activation time is shorter at successful sites. These features are equally applicable when mapping the atrial potential as when mapping the ventricular potential.

Variation and persistence of methicillin-resistant Staphylococcus aureus strains among individual patients over extended periods of time.

To determine the strain variation and persistence among isolates of methicillin-resistant Staphylococcus aureus (MRSA) cultured from patients with colonization over extended time spans, pulsed-field gel electrophoresis was used to analyze the isolates from 47 patients for whom at least two mecA-positive isolates collected a minimum of six months apart were available. For 22 (47%) patients, the isolates represented multiple distinct strains of Staphylococcus aureus, while 20 (43%) patients had only a single strain detected; five (11%) patients had similar, genetically related isolates. MRSA were frequently associated with mucocutaneous abnormalities; 29 (62%) patients had focal cutaneous defects, and ten (21%) had chronic dermatitis. Multiple strains of MRSA were detected more frequently than single strains among patients in whom the initial focus of MRSA resolved clinically and another mucocutaneous defect subsequently developed compared to patients with clinically persistent foci (11/15 versus 9/23, respectively; p = 0.05, Fisher's exact test). Among the 21 patients in this series for whom isolates cultured within a two-month time span were available, there were seven (33%) patients with multiple strains of MRSA, including one patient with polyclonal bacteremia. In summary, patients with long-term MRSA colonization often have several different strains of MRSA, which typically change overtime in association with removal or resolution of a colonized focus and the recurrence of mucocutaneous defects.

Polyclonal infections due to Mycobacterium avium complex in patients with AIDS detected by pulsed-field gel electrophoresis of sequential clinical isolates.

Invasive infection with organisms of the Mycobacterium avium complex (MAC) is common among patients with advanced human immunodeficiency virus infection. In previous studies, we analyzed multiple individual colonies of MAC isolated from specimens obtained at the same time and observed that 14 to 20% of patients are simultaneously infected with more than one strain. In this study, we examined sequential isolates from 12 patients with AIDS who had two or more MAC isolates available from clinical specimens collected more than 1 week apart; the intervals between the first and last specimens ranged from 8 to 192 (median, 46) days. For each isolate, restriction digests of genomic DNA were analyzed by pulsed-field gel electrophoresis; DNA was prepared by using a protocol, described here in detail, which had been optimized for conditions of bacterial growth and lysis. The pulsed-field gel electrophoresis analysis identified four patients (33%) infected with two different MAC strains. Both M. avium and M. intracellulare were cultured from blood specimens from two patients. In each of the four patients, the second strain was identified from a culture taken within 14 days of the initial study isolate, and in three of these patients, the first strain was detected again in a subsequent culture. These observations suggest that the presence of two different strains among isolates from sequential cultures may reflect ongoing polyclonal infection. We conclude that polyclonal infection with MAC is common among patients with AIDS. The identification of such infections may be critical in the development of effective treatments.

Three-drug synergistic inhibition of HIV-1 replication in vitro by zidovudine, recombinant soluble CD4, and recombinant interferon-alpha A.

Optimal management of human immunodeficiency virus type 1 (HIV-1) infections may require combinations of agents that attack different targets in the viral replicative cycle. Zidovudine (AZT), recombinant soluble CD4 (rsCD4), and recombinant interferon-alpha A (rIFN-alpha A) were evaluated in 2- and 3-drug regimens against HIV-1 replication in vitro. Peripheral blood mononuclear cells and a CD4+ T cell line (H9) were studied using multiple HIV-1 replicative end points. Drug interactions were evaluated by the median-effect principle and the isobologram technique. AZT, rsCD4, and rIFN-alpha A inhibited HIV-1 synergistically in 2- and 3-drug combinations. The 3-drug regimen provided more complete virus suppression than the 2-drug regimens. In H9 cells, single-drug regimens lost effectiveness at 10-14 days and 2-drug regimens lost effectiveness at 14-18 days. In contrast, the 3-drug regimen showed nearly complete suppression over 28 days in culture without toxicity. Clinical trials of these 3 drugs in combination should be considered.

Synergistic inhibition of human immunodeficiency virus type 1 (HIV-1) replication in vitro by recombinant soluble CD4 and 3'-azido-3'-deoxythymidine.

A combination of antiviral therapies that target different sites in the human immunodeficiency virus type 1 (HIV-1) replicative cycle may be necessary for optimal treatment of HIV-1 infections. We evaluated the interactions of a soluble virus receptor (recombinant soluble CD4 or rsT4) and a reverse transcriptase inhibitor (azidothymidine, AZT) against HIV-1 replication in vitro. A variety of cell types was studied including peripheral blood mononuclear cells, a CD4-positive T-cell line, and a CD4-positive human monocyte cell line. The combination of rsT4 and AZT inhibited HIV-1 synergistically over a broad range of drug concentrations and multiplicities of infection in several different HIV-1 replication assays. Drug interactions were evaluated by the median-effect principle and the isobologram technique using a computer analysis. In all of the cell types tested, combinations of rsT4 and AZT were synergistic in vitro, without additive cytotoxicity.

Synergistic inhibition of human immunodeficiency virus type 1 and type 2 replication in vitro by castanospermine and 3'-azido-3'-deoxythymidine.

Castanospermine and 3'-azido-3'-deoxythymidine (zidovudine) were evaluated in combination against human immunodeficiency virus (HIV) replication in vitro. Castanospermine and 3'-azido-3'-deoxythymidine inhibited HIV type 1 synergistically in acutely infected H9 cells. In addition, they synergistically inhibited both HIV type 1 and HIV type 2 in peripheral blood mononuclear cells. There were no additional toxic effects of these agents in combination. Drug interactions were evaluated by the median-effect principle and the isobologram technique. Combinations of a glycosylation inhibitor, such as castanospermine, with 3'-azido-3'-deoxythymidine deserve consideration for HIV-related chemotherapeutic intervention.