Durvalumab, with or without tremelimumab, plus platinum-etoposide in first-line treatment of extensive-stage small-cell lung cancer: 3-year overall survival update from CASPIAN.

BACKGROUND: In the phase III CASPIAN study, first-line durvalumab in combination with etoposide plus either cisplatin or carboplatin (EP) significantly improved overall survival (OS) versus EP alone in extensive-stage small-cell lung cancer (ES-SCLC). Durvalumab plus tremelimumab plus EP numerically improved OS versus EP, but did not reach statistical significance. Here we report updated OS in censored patients after median follow-up of >3 years. PATIENTS AND METHODS: 805 patients with treatment-naïve ES-SCLC were randomized 1 : 1 : 1 to durvalumab plus EP, durvalumab plus tremelimumab plus EP, or EP. The two primary endpoints were OS for durvalumab plus EP versus EP and for durvalumab plus tremelimumab plus EP versus EP. RESULTS: As of 22 March 2021 (median follow-up 39.4 months, 86% maturity), durvalumab plus EP continued to demonstrate improved OS versus EP: hazard ratio (HR) 0.71 [95% confidence interval (CI) 0.60-0.86; nominal P = 0.0003]; median OS was 12.9 versus 10.5 months, and 36-month OS rate was 17.6% versus 5.8%. Durvalumab plus tremelimumab plus EP continued to numerically improve OS versus EP: HR 0.81 (95% CI: 0.67-0.97; nominal P = 0.0200); median OS was 10.4 months, and 36-month OS rate was 15.3%. Twenty-seven and nineteen patients in the durvalumab plus EP and durvalumab plus tremelimumab plus EP arms, respectively, remained on durvalumab treatment at data cut-off. CONCLUSIONS: Three times more patients were estimated to be alive at 3 years when treated with durvalumab plus EP versus EP, with the majority still receiving durvalumab at data cut-off, further establishing durvalumab plus EP as first-line standard of care for ES-SCLC.

Effect of anisotropy on ventricular vulnerability to unidirectional block and reentry by single premature stimulation during normal sinus rhythm in rat heart.

Single high-intensity premature stimuli when applied to the ventricles during ventricular drive of an ectopic site, as in Winfree's "pinwheel experiment," usually induce reentry arrhythmias in the normal heart, while single low-intensity stimuli barely do. Yet ventricular arrhythmia vulnerability during normal sinus rhythm remains largely unexplored. With a view to define the role of anisotropy on ventricular vulnerability to unidirectional conduction block and reentry, we revisited the pinwheel experiment with reduced constraints in the in situ rat heart. New features included single premature stimulation during normal sinus rhythm, stimulation and unipolar potential mapping from the same high-resolution epicardial electrode array, and progressive increase in stimulation strength and prematurity from diastolic threshold until arrhythmia induction. Measurements were performed with 1-ms cathodal stimuli at multiple test sites (n = 26) in seven rats. Stimulus-induced virtual electrode polarization during sinus beat recovery phase influenced premature ventricular responses. Specifically, gradual increase in stimulus strength and prematurity progressively induced make, break, and graded-response stimulation mechanisms. Hence unidirectional conduction block occurred as follows: 1) along fiber direction, on right and left ventricular free walls (n = 23), initiating figure-eight reentry (n = 17) and tachycardia (n = 12), and 2) across fiber direction, on lower interventricular septum (n = 3), initiating spiral wave reentry (n = 2) and tachycardia (n = 1). Critical time window (55.1 ± 4.7 ms, 68.2 ± 6.0 ms) and stimulus strength lower limit (4.9 ± 0.6 mA) defined vulnerability to reentry. A novel finding of this study was that ventricular tachycardia evolves and is maintained by episodes of scroll-like wave and focal activation couplets. We also found that single low-intensity premature stimuli can induce repetitive ventricular response (n = 13) characterized by focal activations.NEW & NOTEWORTHY We performed ventricular cathodal point stimulation during sinus rhythm by progressively increasing stimulus strength and prematurity. Virtual electrode polarization and recovery gradient progressively induced make, break, and graded-response stimulation mechanisms. Unidirectional conduction block occurred along or across fiber direction, initiating figure-eight or spiral wave reentry, respectively, and tachycardia sustained by scroll wave and focal activations.

Resident cardiac stem cells.

The introduction of stem cells in cardiology provides new tools in understanding the regenerative processes of the normal and pathologic heart and opens new options for the treatment of cardiovascular diseases. The feasibility of adult bone marrow autologous and allogenic cell therapy of ischemic cardiomyopathies has been demonstrated in humans. However, many unresolved questions remain to link experimental with clinical observations. The demonstration that the heart is a self-renewing organ and that its cell turnover is regulated by myocardial progenitor cells offers novel pathogenetic mechanisms underlying cardiac diseases and raises the possibility to regenerate the damaged heart. Indeed, cardiac stem progenitor cells (CSPCs) have recently been isolated from the human heart by several laboratories although differences in methodology and phenotypic profile have been described. The present review points to the potential role of CSPCs in the onset and development of congestive heart failure and its reversal by regenerative approaches aimed at the preservation and expansion of the resident pool of progenitors.

[The mechanism of impulse initiation: high-resolution epicardial pace-mapping in rat heart]. / Meccanismo di insorgenza del battito stimolato: misura del potenziale epicardico ad alta risoluzione spaziale nel cuore di ratto.

UNLABELLED: Simulations of cardiac tissue bidomain model indicate that point cathodal stimulation gives rise to a dog-bone depolarized region (virtual cathode) extending across fibers, limited by two symmetric hyperpolarized regions (virtual anode) extending along fibers. These predictions were experimentally confirmed by optical mapping studies of transmembrane potentials while no direct validation is reported at the extracellular level. The present study aims at defining the influence of the virtual cathode on extracellular potentials by means of high-density epicardial mapping. METHODS: Epicardial potentials were measured in seven exposed rat hearts by means of a 11 x 11 electrode array with 360 x 540 microns resolution. Cathodal current pulses, 100-200 microA intensity and 1 ms duration, to avoid superposition of stimulus and activation potentials, were delivered from one of the electrode array and unipolar potentials were measured from all other electrodes. RESULTS AND DISCUSSION: a) During stimulus, negative equipotential lines were elliptic along fibers, as expected, but for a 2 mm circular region at the pacing site. b) During 1-2 ms interval between stimulus offset and start of activation, equipotential lines became elliptic across fibers in the presence of the region directly excited by the stimulus field. Start of activation was either symmetric with isochrones initially circular around the pacing site and then elliptic along fibers, or asymmetric initiating at only one side of the pacing site across fibers with isochrones elliptic along fibers. In the latter case, the wave front was blocked through the refractory region directly excited by the stimulus field, subdivided into two wings which collided and merged at the opposite side, giving rise to a plane wave front propagating across fibers away from the pacing site. CONCLUSIONS: High spatial resolution epicardial potential mapping reveals the existence of the virtual cathode and its influence on impulse initiation and conduction. The unexpected existence of a region of conduction block at the pacing site, due to spatial asymmetry of normal cardiac tissue which enhances activation threshold at one of the two sides of the virtual cathode, is intriguing since it is one of the requirements for reentry of conduction in the presence of a circuit with decreased conduction velocity and short duration of refractory period.

Social stress, myocardial damage and arrhythmias in rats with cardiac hypertrophy.

In rat models of cardiac hypertrophy (moderate aortic coarctation: ACm, n=18; severe aortic coarctation: ACs, n=27; aging: OLD, n=25; spontaneous chronic hypertension: SHR, n=18) and properly matched control animals (C(ACm), n=17; C(ACs), n=19; C(OLD), n=24; C(SHR), n=22), we investigated the relative contribution of intense autonomic activity and cardiac structural damage to ventricular arrhythmogenesis. We used an "in vivo" to tissue level approach, by correlating in the same animal: (i) social stress-induced ventricular arrhythmias, telemetrically recorded, and (ii) left ventricular weights (LVW) and amount and geometrical properties of myocardial fibrosis (MF). Arterial blood pressure was significantly higher in ACm (+11%), ACs (+28%) and SHR (+34%) than in controls. LVW were approximately 20% greater in ACm, ACs and OLD and 50% greater in SHR. MF was about twice as great and characterized by more frequent occurrence of microscopic scarring in ACm and ACs, and eight times greater and associated with both a higher number and a larger size of fibrotic foci in OLD and SHR compared to controls. Social stress increased ventricular arrhythmia vulnerability in all models of cardiac hypertrophy, as well as in controls. The arrhythmogenic action of stress was facilitated in ACs, OLD and SHR. A correlation between structural cardiac remodeling and ventricular arrhythmias was found only in SHR and OLD, which exhibited the greatest increase in LVW and/or MF. Social stress proved to be a valuable tool for analyzing the combined effects of autonomic stimulation and altered myocardial substrate on the genesis of potentially life-threatening arrhythmias in social animals.

Cardiac autonomic responses to intermittent social conflict in rats.

Intermittent exposure to the same stressor can lead to a gradual decline in physiological, neuroendocrine and behavioral stress responses (habituation). We investigated possible habituation of cardiac autonomic responsiveness and susceptibility to cardiac arrhythmias in male rats exposed to either intermittent social victory (VIC) or defeat (DEF) stress (10 exposures in each case). Electrocardiograms were recorded via radiotelemetry and the sympathovagal balance at the level of the heart was evaluated via time-domain measurements of heart rate variability, namely average R--R interval (average time interval between two consecutive heart beats, RR), the standard deviation of RR (SD(RR)) and the root-mean-square of successive R--R interval differences (r-MSSD). Values of these parameters were significantly lower in DEF as compared to VIC rats in the second part of the test period (from Minute 6 to Minute 15), suggesting a more pronounced sympathetic dominance in the former group of animals. Accordingly, the occurrence of the most frequent cardiac arrhythmias (ventricular and supraventricular premature beats) was higher in DEF rats. Habituation of cardiac autonomic responsivity was observed across repeated exposure to victory, both in terms of sympathovagal balance and susceptibility to cardiac tachyarrhythmias, whereas no habituation was found in repeatedly defeated animals. A possible explanation to this discrepancy could be the different degree of controllability characterizing the two social challenging situations.

Myocardial remodeling and arrhythmogenesis in moderate cardiac hypertrophy in rats.

In 47 male adult Wistar rats with 4-wk aortic coarctation (AC) and 39 age-matched sham-operated rats (SO) chronically instrumented for telemetry electrocardiogram recording, we investigated the mechanisms of arrhythmogenesis in moderate cardiac hypertrophy, with an approach from "in vivo" toward the cellular level, analyzing 1) stress-induced cardiac arrhythmias in all rats and 2) myocardial fibrosis in 35 animals and action potential duration and density of hyperpolarization-activated current in 19 others at the ventricular level. Aortic banding increased arterial blood pressure, cardiac weight, and ventricular myocyte volume by 11, 25, and 14%, respectively (P < 0.001-0.05). Ventricular arrhythmias occurred at similar rates in AC and SO rats throughout the stress procedure. Action potential duration and hyperpolarization-activated current were about twice as great and myocardial fibrosis about four times greater in AC animals (P < 0.005-0.05). Electrocardiogram data also revealed more supraventricular arrhythmias in AC rats during the baseline period and after stress and fewer atrioventricular block episodes after stress (P < 0.05). Thus stress-induced supraventricular and atrioventricular nodal, but not ventricular, arrhythmias were affected in moderate cardiac hypertrophy when ventricular morphofunctional alterations were evident.

[Simultaneous measurements of electrical coupling and action potential transfer in pairs of ventricular cardiomyocytes]. / Misura contemporanea dell'accoppiamento elettrico e della conduzione del potenziale d'azione in coppie di cardiomiociti ventricolari.

Spread and modulation of electrical activity in cardiac tissue requires intercellular transfer of current via gap junctions, specialised regions of densely packed ionic channels. Electrotonic interaction is determined not merely by intercellular electrical resistance (Rj) but rather by the interplay of Rj and sarcolemmal passive and active electrical properties (Zaniboni et al., Spitzer et al.). In this work we combined a well established protocol to measure Rj in cell pairs (Weingart e Maurer) with a stimulation protocol which allowed to simultaneously study parameters relative to action potential transfer during sequential stimulation. Current clamp experiments, performed on cardiomyocyte pairs held in double-patch configuration, allowed to simultaneously monitor, at a relatively high frequency (1 Hz), membrane resistance (Rm), resting potential (Vm), maximum depolarization rate (dv/dtmax) and time to peak of dv/dtmax in both cells as well as Rj. Spontaneous electrical uncoupling was observed in guinea pig cell pairs with little or no effect on action potential transfer. Pharmacological uncoupling with 40 microM beta-glycyrrhetinic acid reached, in one case, a much higher level of Rj and dramatically increased time delay for action potential appearance. When only Rj was measured over a short time interval after approximately two minutes from cell-attachments, values of Rj approximately 40 M omega in rat cell pairs (n = 20) and Rj approximately 15 M omega in guinea pig cell pairs (n = 24) were obtained. The possibility of monitoring simultaneously active and intercellular/cellular passive electrical properties makes this protocol particularly suitable to study dynamic changes in Rj during action potential transfer.

Different sympathovagal modulation of heart rate during social and nonsocial stress episodes in wild-type rats.

The acute consequences of a social aversive stimulus (defeat) on the autonomic control upon the electrical activity of the heart were measured and compared to those observed in three nonsocial stress paradigms, namely restraint, shock-probe test, and swimming. Electrocardiograms were recorded from rats via radiotelemetry, and the autonomic neural control of the heart was evaluated via measures of heart rate and heart rate variability, such as the average R-R interval (RR), the standard deviation of RR (SD), the coefficient of variance (SD/RR), and the root-mean-square of successive R-R interval differences (r-MSSD). Although all stressors induced significant reductions of average R-R interval, the effect of defeat was significantly larger (p < 0.05). The social stimulus also determined a significant decrease in the variability indexes (p < 0.01 for all), whereas in the other stress conditions they were either unchanged or increased (SD/RR during restraint, p < 0.05; SD and SD/RR during swimming, p < 0.05 and p < 0.01). Cardiac arrhythmias (mostly ventricular premature beats, VPBs) were far more frequent during defeat than during the other challenging situations (p < 0.01), with an average of 33.5 +/- 6.5 VPBs per 15-min test recording. These data suggest that during defeat autonomic control was shifted toward a sympathetic dominance, whereas in rats exposed to nonsocial stressors, although significant heart rate accelerations were also found, sympathovagal balance was substantially maintained. These differences in autonomic stress responsivity explain the different susceptibility to ventricular arrhythmias and indicate that a social challenge can be far more detrimental for cardiac electrical stability than other nonsocial aversive stimuli.

Social stress, autonomic neural activation, and cardiac activity in rats.

Animal models of social stress represent a useful experimental tool to investigate the relationship between psychological stress, autonomic neural activity and cardiovascular disease. This paper summarizes the results obtained in a series of experiments performed on rats and aimed at verifying whether social challenges produce specific modifications in the autonomic neural control of heart rate and whether these changes can be detrimental for cardiac electrical stability. Short-term electrocardiographic recordings were performed via radiotelemetry and the autonomic input to the heart evaluated by means of time-domain heart rate variability measures. Compared to other stress contexts, a social defeat experience produces a strong shift of autonomic balance toward sympathetic dominance, poorly antagonized by vagal rebound, and associated with the occurrence of cardiac tachyarrhythmias. These effects were particularly severe when a wild-type strain of rats was studied. The data also suggest that the cardiac autonomic responses produced by different types of social contexts (dominant-subordinate interaction, dominant-dominant confrontation, social defeat) are related to different degrees of emotional activation, which in turn are likely modulated by the social rank of the experimental animal and the opponent, the prior experience with the stressor, and the level of controllability over the stimulus.

High-density epicardial mapping during current injection and ventricular activation in rat hearts.

The purpose of this study is to report new methods for manufacturing precision electrode arrays for recording high-resolution potential distributions from epicardial surfaces of small-animal hearts. Electrode arrays of 64 leads (8 x 8) and 121 leads (11 x 11) were constructed with a tulle substrate to which insulated, fine silver wires (60-micrometer diameter) were attached by knots at mesh node intervals of 540 x 720 micrometers. Insulation was removed at the tips of the knots. Potential distributions and waveforms were recorded from saline solutions and rat heart epicardium during ventricular paced beats and during passive current injection in the diastolic interval. Electrical responses obtained from rat epicardium compared favorably with those observed in studies of larger-animal hearts, which used arrays having greater electrode spacing, and revealed the effects of myocardial anisotropy. Epicardial potentials measured early after stimulation in the region surrounding the pacing site were interpreted in terms of potentials generated by an equivalent quadrupolar source. We conclude that electrode arrays for epicardial mapping of small hearts can be constructed with sufficient ease and precision to allow detailed study of fiber structure and electrophysiology in these hearts in normal and pathological conditions.

Dependence of temporal variability of ventricular recovery on myocardial fibrosis. Role of mechanoelectric feedback?

OBJECTIVE: The study was aimed at establishing the effect of factors involved in the expression of mechanoelectric feedback in the heart, such as R-R interval and connective tissue, on time dependent changes in ventricular recovery, as determined at the body surface by beat to beat variability of QRST integral maps (BBV-IM). METHODS: We used 15 normal 6-month-old Wistar rats. In each anesthetized animal, we performed a 3-minute continuous recording of 44. The simultaneous chest ECGs. The signals were interactively processed, 1) to determine mean R-R interval and R-R variability throughout the recording period and 2) to compute QRST integral maps from approximately 50 beats belonging to the end of expiration. Then BBV-IM was calculated and expressed as percentage of beats significantly differing from a template. At sacrifice, the amount of myocardial fibrosis was morphometrically evaluated. RESULTS: R-R interval was 149 ms +/- 4, R-R interval variability 0.008 +/- 0.001 and BBV-IM 30.7% +/- 4.4. Myocardial fibrosis expressed as % volume of left ventricular myocardium, numerical density of fibrotic foci and average cross-sectional area of the foci was 3.0% +/- 0.4, 3.8 +/- 0.6 and 4.4 microns(2)/1000 +/- 0.1 respectively, BB-IM was positively correlated to the % volume of fibrosis (r = 0.83, P < 0.0003). Both measurements were positively correlated to R-R interval (BBV-IM: r = 0.83, P < 0.0001; % volume of fibrosis: r = 0.87, P < 0.001) and negatively correlated to cardiac weights (BBV-IM: r = -0.79, P < 0.0005; % volume of fibrosis: r = -0.75, P < 0.001). CONCLUSION: Beat to beat changes in ventricular repolarization attributable to mechanoelectric transduction can be detected at the body surface by means of BBV-IM.

Effects of galanin and the galanin receptor antagonist galantide on plasma catecholamine levels during a psychosocial stress stimulus in rats.

The aim of this study was to investigate the role played by the neuropeptide galanin (GAL) in the regulation of sympathoadrenal function. We evaluated the effects of rat GAL (rGAL) and of the putative GAL receptor antagonist galantide (GLT) on epinephrine (E) and norepinephrine (NE) plasma levels in conscious freely moving male rats, during a psychosocial stress condition. Four groups of male rats were challenged by a stress stimulus, obtained by exposing the animals to a resident conspecific fighter (intruder model), following an intravenous injection with (1) rGAL + saline (SAL), (2) GLT + SAL, (3) rGAL + GLT, or (4) SAL + SAL. Plasma levels of both E and NE were also measured in an additional group of male rats not exposed to any stressor stimulus. The results (mean+/-SEM) showed that rats exposed to the stressor stimulus (intruder rats) exhibited a significant increase above baseline in circulating levels of both E (peak values of 834.13+/-115.13 pmol/l vs. basal values of 309.31+/-32.93 pmol/l; p < 0.01) and NE (peak values of 5,299.03+/-450.62 pmol/l vs. basal values of 2,798.24+/-311.56 pmol/l; p < 0.01) in comparison to control, nonstressed rats. The comparison of the areas under the curve response (AUC) among treatments in the intruder rats revealed that rGAL + SAL injections resulted in a further increase in E levels when compared to SAL + SAL treatment (AUC values: 8.26+/-0.64 vs. 25.38+/-5.52 nmol/ 1/20 min in SAL + SAL vs. rGAL + SAL treatment, respectively; p < 0.02). No significant changes in stress-induced E plasma levels were found following GLT + SAL treatment in comparison to SAL + SAL injections. When the intruder rats were submitted to rGAL + GLT injections, the increments in E levels were found to be higher than those observed following SAL + SAL treatment (AUC values: 8.26+/-0.64 vs. 36.00+/-13.76 nmol/ 1/20 min in SAL + SAL vs. rGAL + GLT treatment, p < 0.03); however, the values were not significantly different from those observed in rGAL + SAL-injected rats. No significant changes in stress-induced NE levels were found in either treatment group when compared to SAL + SAL-injected intruder rats. The results of this study demonstrate that rGAL administration leads to an increase in the E response to the stress stimulus without any effect on NE response. Galantide does not affect either the physiological stress-induced elevation of plasma catecholamines or the effects of rGAL on E plasma levels in response to stress. Therefore, GLT does not appear to behave as a GAL receptor antagonist in the regulation of sympathoadrenal function in rats.

Complications associated with rapid caffeine application to cardiac myocytes that are not voltage clamped.

The rapid application of caffeine to cardiac myocytes is commonly used to assess changes in the Ca2+ content of the sarcoplasmic reticulum (SR) and to study other parameters of intracellular Ca2+ regulation. Here we examined the effects of rapid caffeine application on membrane potential, intracellular Ca2+, and cell shortening in ventricular myocytes (rat, rabbit, guinea pig, dog) and atrial myocytes (rabbit) that were not voltage clamped. Conditioning pacing was used to achieve a steady-state level of SR Ca2+ loading prior to caffeine (10 mM) application. Caffeine transiently depolarized myocytes as expected from activation of forward Na+-Ca2+ exchange. However, we also found in each species (50% rat, 36% rabbit ventricular, 53% rabbit atrial, 56% guinea pig, 31% dog) that the caffeine-induced depolarization could also trigger an action potential. Caffeine-triggered potentials were completely blocked by thapsigargin (1 microM). The Ca2+ transient and contraction that accompanied caffeine-triggered action potentials had a larger magnitude and slower rate of decline (or relaxation) than occurred during caffeine-induced subthreshold depolarizations. Thus, the use of rapid caffeine application to study SR function and [Ca2+]i regulation in myocytes that are not voltage clamped can yield erroneous results.

Electrode positioning for reliable telemetry ECG recordings during social stress in unrestrained rats.

We describe a surgical procedure for optimizing the location of telemetry ECG leads in rats. The new location was aimed at obtaining an accurate representation of ECG features throughout the cardiac cycle by limiting the voltage instability usually observed during intense somatomotor activity and improving the signal-to-noise ratio. The two electrodes (wire loops) were fixed on the dorsal surface of the xiphoid process and in the anterior mediastinum close to the right atrium. The implantation procedure was fast, little invasive, and allowed animals to completely recover from intervention. The performance of the "improved" location (IL, n = 10) with respect to two subcutaneous (SC) positionings ("conventional positioning" CSP, n = 5; "updated location," USL, n = 5) was evaluated by comparing ECGs obtained in baseline, stress and recovery conditions and during different behavioral activities (immobility and grooming). The resident-intruder test (emotional/physical challenge) was chosen as experimental stress paradigm. The noise level of ECGs obtained from IL rats was lower than in CSP and USL animals, in all recording conditions. Percentages of correctly recognized beats (CRBs) over the total number of beats (TBs) were significantly higher in IL rats than in CSP and USL animals, both in baseline conditions (99% vs. 11% and 40%) and situations involving high somatomotor activity (stress: 97%, 5% and 16% recovery; 97%, 7% and 15%) (p < 0.01). The performance of IL as compared to CSP and USL was also better when percentages during grooming and immobility were considered (grooming: 93% vs. 4% and 23%: immobility: 97%, 6%, and 33%; p < 0.01).

Behavioral and electrocardiographic responses to social stress in male rats.

Telemetry ECGs were recorded from Wistar male rats during social stress induced by exposure to aggressive lactating female rats. Behavioral response to maternal attack was evaluated in terms of relative duration of passive submissive (p/s) and active/nonsubmissive (a/ns) patterns. A decrease of R-R interval (R-R) compared to baseline conditions was found, significantly more pronounced than that observed in control animals exposed just to novel environment. R-R variability during social stress was positively correlated with the amount of p/s behavior. R-R fluctuations, episodes of II degree A-V block, and ventricular arrhythmias were also observed. Most R-R fluctuations and II degree A-V blocks were temporally associated with phases of p/s behavior and periods of high R-R variability. Ventricular arrhythmias generally appeared during a/ns behavior and were temporally linked with periods of low R-R variability. Ventricular arrhythmias, low R-R variability, and concomitant a/ns behavior might be related to an increased sympathetic activity. R-R fluctuations and II degree A-V blocks, associated with high R-R variability and p/s behavior, might be related to a predominant inhibitory effect of vagal activation (accentuated antagonism).

Role of platelet-activating factor in hypotension and platelet activation induced by infusion of thrombolytic agents in rabbits.

Infusion of the thrombolytic agents streptokinase (SK, 666 units/kg per minute for 60 minutes) and tissue-type plasminogen activator (t-PA, 10 micrograms/kg per minute for 15 minutes) in rabbits induced a significant hypotension and decrease in platelet count that were completely prevented by treatment with platelet-activating factor (PAF) receptor antagonists SDZ 63-675 and WEB 2170. PAF synthesis by vascular tissue was suggested by its extraction from blood-free heart and aorta of rabbits treated in vivo with SK or t-PA but not of control rabbits. In contrast, PAF was not detected in peripheral blood. Ex vivo studies on platelet aggregation response to ADP and PAF performed on platelet-rich plasma obtained before and after SK and t-PA infusion demonstrated an early hyperaggregable phase, abrogated by PAF receptor antagonists and followed by reduced sensitivity of platelets to PAF. The ED50 values for the aggregation of washed rabbit platelets induced by PAF but not thrombin were significantly increased at 60 and 120 minutes after SK and t-PA infusion, suggesting a specific desensitization of platelets to PAF. In contrast to PAF receptor antagonists, aspirin did not significantly modify the hypotension and the platelet hyperaggregability induced by SK or t-PA or the platelet hypoaggregability induced by t-PA. Thrombocytopenia induced by t-PA, but not by SK, was partially prevented by aspirin. The effect of SK, t-PA, and plasmin on the aggregation of washed platelets from untreated rabbits and from humans was also studied. Whereas SK and t-PA were inactive, plasmin induced dose-dependent platelet aggregation that was inhibited by platelet pretreatment with PAF receptor antagonists. In conclusion, the effect of PAF receptor antagonists observed in the present experimental model suggests that the hypotension and activation of platelets induced by SK and t-PA infusion are mediated by PAF.

Operative treatment of failed repairs of the rotator cuff.

Thirty-one patients had a repeat repair after a failure of a previously performed repair of the rotator cuff, and the causes of the original failure and the results of the repeat repair were analyzed. The clinical situation was complex, with multiple factors contributing to the failures. A large or massive tear of the cuff in thirty patients (97 per cent) and persistent subacromial impingement in twenty-eight patients (90 per cent) were the most common factors associated with failure. The over-all result of the repeat repair was satisfactory in sixteen patients (52 per cent) and unsatisfactory in fifteen (48 per cent). Twenty-five patients (81 per cent) had satisfactory relief of pain. However, fourteen patients (45 per cent) had persistent weakness that led to an unsatisfactory result. The factors that were associated with a better result were an intact acromion, an intact origin of the deltoid muscle, and the finding that the remaining tissue of the rotator cuff was of good quality. The factors that were associated with an inferior result were a previous lateral acromionectomy, a previously detached origin of the deltoid muscle, and the finding that the tissue of the rotator cuff that was available at the time of the repeat operation was of poor quality. Persistent pain is the primary indication for a repeat repair. The functional results are not as predictable, especially when the tissue of the cuff is poor and the deltoid origin has been detached previously.