The biomechanical strength of a hardware-free femoral press-fit method for ACL bone-tendon-bone graft fixation.

PURPOSE: The purpose was to investigate graft slippage and ultimate load to failure of a femoral press-fit fixation technique for anterior cruciate ligament (ACL) reconstruction. METHODS: Nine fresh-frozen knees were used. Standardized harvesting of the B-PT-B graft was performed. The femora were cemented into steel rods, and a tunnel was drilled outside-in into the native ACL footprint and expanded using a manual mill bit. The femoral bone block was fixed press-fit. To pull the free end of the graft, it was fixed to a mechanical testing machine using a deep-freezing technique. A motion capture system was used to assess three-dimensional micro-motion. After preconditioning of the graft, 1000 cycles of tensile loading were applied. Finally, an ultimate load to failure test was performed. Graft slippage in mm ultimate load to failure as well as type of failure was noted. RESULTS: In six of the nine measured specimens, a typical pattern of graft slippage was observed during cyclic loading. For technical reasons, the results of three knees had to be discarded. 78.6 % of total graft slippage occurred in the first 100 cycles. Once the block had settled, graft slippage converged to zero, highlighting the importance of initial preconditioning of the graft in the clinical setting. Graft slippage after 1000 cycles varied around 3.4 ± 3.2 mm (R = 1.3-9.8 mm) between the specimens. Ultimate loading (n = 9) revealed two characteristic patterns of failure. In four knees, the tendon ruptured, while in five knees the bone block was pulled out of the femoral tunnel. The median ultimate load to failure was 852 N (R = 448-1349 N). CONCLUSION: The implant-free femoral press-fit fixation provided adequate primary stability with ultimate load to failure pull forces at least equal to published results for interference screws; hence, its clinical application is shown to be safe.

Assessing multiregion avian benefits from strategically targeted agricultural buffers.

Mounting evidence of wildlife population gains from targeted conservation practices has prompted the need to develop and evaluate practices that are integrated into production agriculture systems and targeted toward specific habitat objectives. However, effectiveness of targeted conservation actions across broader landscapes is poorly understood. We evaluated multiregion, multispecies avian densities on row-crop fields with native grass field margins (i.e., buffers) as part of the first U.S. agricultural conservation practice designed to support habitat and population recovery objectives of a national wildlife conservation initiative. We coordinated breeding season point transect surveys for 6 grassland bird species on 1151 row-crop fields with and without native grass buffers (9-37 m) in 14 U.S. states (10 ecoregions) from 2006 to 2011. In most regions, breeding season densities of 5 of 6 targeted bird species were greater in the 500-m surrounding survey points centered on fields with native grass buffers than in landscapes without buffers. Relative effect sizes were greatest for Northern Bobwhite (Colinus virginianus), Dickcissel (Spiza americana), and Field Sparrow (Spizella pusilla) in the Mississippi Alluvial Valley and Eastern Tallgrass Prairie regions. Other species (e.g., Eastern Meadowlark [Sturnella magna], Grasshopper Sparrow [Ammodramus savannarum]) exhibited inconsistent relative effect sizes. Bird densities on fields with and without buffers were greatest in the Central Mixed-grass Prairie region. Our results suggest that strategic use of conservation buffers in regions with the greatest potential for relative density increases in target species will elicit greater range-wide population response than diffuse, uninformed, and broadly distributed implementation of buffers. We recommend integrating multiple conservation practices in broader agricultural landscapes to maximize conservation effectiveness for a larger suite of species.

Prospective clinical trial on dosage optimizing of tranexamic acid in non-emergency cardiac surgery procedures.

UNLABELLED: After withdrawal of aprotinin in 2008 only tranexamic acid (TxA, Cyclocapron, Pfitzer, Germany) remains available as antihyperfibrinolytic agent in Europe. Dosage (from 1 g to 20 g) and application strategy (single shot i.v., infusion i.v., topical) reflect an indiscriminate use of TXA in cardiac surgery. We use data analysis of three registries to evaluate safety issues and sufficiency of different TxA dosages in our center. METHODS: Registry 1: Single shot ultra-low dose TxA (1 g in priming volume). Registry 2: Single shot medium dose TxA (5 g in priming volume). Registry 3: Single shot medium dose TxA (3 g in priming volume) and continuous, weight-adapted administration during cross clamping. Independence of surgeon's preference was achieved by changing dosage every surgery day regardless of operation schedule. RESULTS: Data analysis was carried out on 1182 consecutive, elective patients (1 g TxA n = 415; 3 g + x g TA n = 367; mean TxA dose 4.4 g ± 1.0 g; 5 g TxA n = 400). Patient characteristics were well matched in all three registries (mean age: 69 ± 9.5y, BMI 28.2 ± 4.7, Creatinin 107.5 ± 52.8 µM), as were performed surgical procedures (excluding organ transplantation). Postoperative data showed no significant differences for blood loss and major adverse events (1 g vs. 3 + g vs. 5 g: blood loss: 894 ± 1479 vs. 903 ± 1282 vs. 1004 ± 1604 ml; stroke: 1.5 vs. 1.6 vs. 1.5%; myocardial infarction 2.7 vs. 3.3 vs. 1.3%; 30d mortality 3.9 vs. 4.2 vs. 4.8%, respectively). Secondary endpoints (de novo dialysis, transfusion requirement, ICU and total treatment time) showed no significant differences between registries. CONCLUSION: Use of 1 g TxA is safe and sufficient for elective patients with on pump cardiac surgery and thus has been established as strategy of choice in our center.

Airports offer unrealized potential for alternative energy production.

Scaling up for alternative energy such as solar, wind, and biofuel raises a number of environmental issues, notably changes in land use and adverse effects on wildlife. Airports offer one of the few land uses where reductions in wildlife abundance and habitat quality are necessary and socially acceptable, due to risk of wildlife collisions with aircraft. There are several uncertainties and limitations to establishing alternative energy production at airports, such as ensuring these facilities do not create wildlife attractants or other hazards. However, with careful planning, locating alternative energy projects at airports could help mitigate many of the challenges currently facing policy makers, developers, and conservationists.

Effects of the Conservation Reserve Program on northern bobwhite and grassland birds.

The Conservation Reserve Program (CRP) has converted just over 36 million acres of cropland into potential wildlife habitat, primarily grassland. Thus, the CRP should benefit grassland songbirds, a group of species that is declining across the United States and is of conservation concern. Additionally, the CRP is an important part of multi-agency, regional efforts to restore northern bobwhite populations. However, comprehensive assessments of the wildlife benefits of CRP at regional scales are lacking. We used Breeding Bird Survey and National Resources Inventory data to assess the potential for the CRP to benefit northern bobwhite and other grassland birds with overlapping ranges and similar habitat associations. We built regression models for 15 species in seven different ecological regions. Forty-nine of 108 total models contained significant CRP effects (P < 0.05), and 48 of the 49 contained positive effects. Responses to CRP varied across ecological regions. Only eastern meadowlark was positively-related to CRP in all the ecological regions, and western meadowlark was the only species never related to CRP. CRP was a strong predictor of bird abundance compared to other land cover types. The potential for CRP habitat as a regional conservation tool to benefit declining grassland bird populations should continue to be assessed at a variety of spatial scales. We caution that bird-CRP relations varied from region to region and among species. Because the NRI provides relatively coarse resolution information on CRP, more detailed information about CRP habitats (spatial arrangement, age of the habitat (time since planting), specific conservation practices used) should be included in future assessments to fully understand where and to what extent CRP can benefit grassland birds.

Pulsatile gonadotropin-releasing hormone stimulation of gonadotropin subunit transcription in rat pituitaries: evidence for the involvement of Jun N-terminal kinase but not p38.

We investigated whether Jun N-terminal kinase (JNK) and p38 mediate gonadotropin subunit transcriptional responses to pulsatile GnRH in normal rat pituitaries. A single pulse of GnRH or vehicle was given to female rats in vivo, pituitaries collected, and phosphorylated JNK and p38 measured. GnRH stimulated an increase in JNK phosphorylation within 5 min, which peaked 15 min after GnRH (3-fold). GnRH also increased p38 phosphorylation 2.3-fold 15 min after stimulus. Rat pituitary cells were given 60-min pulses of GnRH or media plus the JNK inhibitor SP600125 (SP, 20 microM), p38 inhibitor SB203580 (20 microM), or vehicle. In vehicle-treated groups, GnRH pulses increased LHbeta and FSHbeta primary transcript (PT) levels 3-fold. SP suppressed both basal and GnRH-induced increases in FSHbeta PT by half, but the magnitude of responses to GnRH was unchanged. In contrast, SP had no effect on basal LHbeta PT but suppressed the stimulatory response to GnRH. SB203580 had no effect on the actions of GnRH on either LH or FSHbeta PTs. Lbeta-T2 cells were transfected with dominant/negative expression vectors for MAPK kinase (MKK)-4 and/or MKK-7 plus a rat LHbeta promoter-luciferase construct. GnRH stimulated a 50-fold increase in LHbeta promoter activity, and the combination of MKK-4 and -7 dominant/negatives suppressed the response by 80%. Thus, JNK (but not p38) regulates both LHbeta and FSHbeta transcription in a differential manner. For LHbeta, JNK is essential in mediating responses to pulsatile GnRH. JNK also regulates FSHbeta transcription (i.e. maintaining basal expression) but does not play a role in responses to GnRH.

Testosterone stimulates follicle-stimulating hormone beta transcription via activation of extracellular signal-regulated kinase: evidence in rat pituitary cells.

This study investigated whether estradiol (E2) or testosterone (T) activate extracellular signal-regulated kinase (ERK) and calcium/calmodulin-dependent kinase II (Ca/CaMK II), as indicated by enzyme phosphorylation in rat pituitaries. In vivo studies used adult female rats given E2, T, or empty silastic capsules (vehicle controls). Twenty-four hours later, the rats were given a single pulse of GnRH (300 ng) or BSA-saline (to controls) and killed 5 min later. GnRH stimulated a two- to three-fold rise in activated Ca/CaMK II, and E2 and T had no effect on Ca/CaMK II activation. In contrast, both GnRH and T stimulated threefold increases in ERK activity, with additive effects seen following the combination of GnRH+T. E2 had no effect on ERK activity. In alpha T3 clonal gonadotrope cells, dihydrotestosterone did not activate ERK alone but enhanced and prolonged the ERK responses to GnRH, demonstrating direct effects on the gonadotrope. Thus, the ERK response to GnRH plus androgen was enhanced in both rat pituitary and alpha T3 cells. In vitro studies with cultured rat pituitary cells examined the effect of GnRH+/-T in the presence of the mitogen-activated protein (MAP) kinase kinase inhibitor, PD-098059 (PD). Results showed that PD suppressed ERK activational and FSH beta transcriptional responses to T. These findings suggest that one site of T regulation of FSH beta transcription is through the selective stimulation of the ERK pathway.

Regulation of gonadotropin subunit gene transcription.

Reproductive function in mammals is regulated by the pituitary gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH are secreted by the gonadotrope cell and act on the gonad in a sequential and synergistic manner to initiate sexual maturation and maintain cyclic reproductive function. The synthesis and secretion of LH and FSH are regulated mainly by the pulsatile release of the hypothalamic decapeptide hormone gonadotropin-releasing hormone (GnRH). The control of differential LH and FSH synthesis and secretion is complex and involves the interplay between the gonads, hypothalamus and pituitary. In this review, the transcriptional regulation of the gonadotropin subunit genes is discussed in a physiologic setting, and we aimed to examine the mechanisms that drive those changes.

Gonadotropin-releasing hormone stimulation of gonadotropin subunit transcription: evidence for the involvement of calcium/calmodulin-dependent kinase II (Ca/CAMK II) activation in rat pituitaries.

The intracellular pathways mediating GnRH regulation of gonadotropin subunit transcription remain to be fully characterized, and the present study examined whether calcium/calmodulin-dependent kinase II (Ca/CAMK II) plays a role in the rat pituitary. Preliminary studies demonstrated that a single pulse of GnRH given to adult rats stimulated a transient 2.5-fold rise in Ca/CAMK II activity (as determined by an increase in Ca/CAMK II phosphorylation), with peak values at 5 min, returning to basal 45 min after the pulse. Further studies examined the alpha, LHbeta, and FSHbeta transcriptional responses to GnRH or Bay K 8644+KCl (BK+KCl) pulses in vitro in the absence or presence of the Ca/CAMK II-specific inhibitor, KN-93. Gonadotropin subunit transcription was assessed by measuring primary transcripts (PTs) by quantitative RT-PCR. In time-course studies, both GnRH and BK+KCl pulses given alone increased all three subunit PTs after 6 h (2- to 4-fold). PT responses to GnRH increased over time (3- to 8-fold over basal at 24 h), although BK+KCl was ineffective after 24 h. KN-93 reduced the LHbeta and FSHbeta transcriptional responses to GnRH by 50-60% and completely suppressed the alphaPT response. In contrast, KN-93 showed no inhibitory effects on basal transcriptional activity or LH or FSH secretion. In fact, KN-93 tended to increase basal alpha, LHbeta, and FSHbeta PT levels and enhance LH secretory responses to GnRH. These results reveal that Ca/CAMK II plays a central role in the transmission of pulsatile GnRH signals from the plasma membrane to the rat alpha, LHbeta, and FSHbeta subunit genes.

Gonadotropin subunit transcriptional responses to calcium signals in the rat: evidence for regulation by pulse frequency.

Alterations in the frequency of calcium influx signals to rat pituitary cells can regulate the expression of gonadotropin subunit mRNAs in a differential manner, producing effects that are similar to those previously found for GnRH. The present study was conducted to investigate whether this reflects a transcriptional response to calcium pulse frequency, as determined by alterations in primary transcript (PT) expression. Perifused rat pituitary cells were given pulses of the calcium channel-activator Bay K 8644 (BK; with 10 mM KCl in the injectate) for 6 h. The response to alterations in pulse dose was examined by giving pulses of 1, 3, or 10 microM BK at 60-min intervals. Maximal increases in LHbeta and FSHbeta PTs were obtained with the 3-microM BK pulse dose and with the 10-microM dose for alpha. To investigate the effect of calcium pulse frequency, 3-microM BK pulses were given at intervals of 15, 60, or 180 min. Alpha PT was selectively stimulated by 15-min pulses and LHbeta by 15- and 60-min pulses of BK. In contrast, FSHbeta PT was maximally stimulated by the slower, 180-min pulse interval. These findings reveal that pulsatile increases in intracellular calcium stimulate alpha, LHbeta, and FSHbeta transcription in a differential manner. Thus, intermittent changes in intracellular calcium appear to be important in the transmission of GnRH pulse signals from the plasma membrane to the gene, and they may mediate the differential actions of pulse frequency on gonadotropin subunit gene expression.

Seroepidemiology of low and high oncogenic risk types of human papillomavirus in a predominantly male cohort of STD clinic patients.

Human papillomaviruses (HPV) infecting the genital tract are associated with warts and anogenital malignancies. Although HPV is a highly prevalent sexually transmitted disease (STD), the majority of research has focused on female cohorts due to gender specific sequelae. Our objective was to measure the epidemiological features and seroprevalences of HPV-6/11 and 16 in a predominantly male group of STD clinic patients. High-risk individuals (n=687), who attended the public STD clinic were administered a behavioural questionnaire and serum tested for antibodies against HPV-6/11 and HPV-16 capsids via capture enzyme-linked immunosorbent assay. Despite the male predominance in this study, women were significantly more likely to have antibodies against both HPV-6/11 and HPV-16. Condom use appeared to be partially protective against HPV-16 seropositivity only. In conclusion, despite exhibiting increased risk behaviour, men were less likely to be HPV seropositive. Additional studies utilizing male cohorts are warranted to further elucidate this phenomenon.

Regulation of gonadotropin subunit transcription after ovariectomy in the rat: measurement of subunit primary transcripts reveals differential roles of GnRH and inhibin.

The aim of this study was to determine if the changes in gonadotropin subunit gene expression following ovariectomy reflect transcriptional and/or posttranscriptional regulation by GnRH or inhibin. Subunit transcription rates were determined by recently developed quantitative RT-PCR for subunit primary transcripts (as an indicator of gene transcription), which allow us to measure both mRNA and PT from RNA extracted from a single pituitary. Following ovariectomy, LHbeta PT concentrations increased 2- to 3-fold between 72 h and 7 d, paralleling changes in serum LH and LHbeta mRNA. In contrast, serum FSH, FSHbeta mRNA, and FSHbeta PT concentrations were 6- to 9-fold greater 12-24 h after ovariectomy followed by an additional 2.5-fold increase at 72 h. Although alpha RNA was elevated at 72 h after ovariectomy, alpha-primary transcript did not change. GnRH antagonist prevented the increase in LHbeta-PT at 72 h, but had no effect on the increase in FSHbetaPT at 12 h and was only partially effective at 72 h. The acute GnRH-independent increase in FSHbeta-primary transcript after ovariectomy could be duplicated by the administration of inhibin antiserum to intact rats; inhibin-alpha antiserum did not affect LHbeta-primary transcript, but increased FSHbeta-primary transcript concentrations 8- to 11-fold. The half-disappearance rates of LHbeta and FSHbeta primary transcripts were measured after GnRH blockade or administration of recombinant human inhibin A. The half-disappearance times for LHbeta and FSHbeta primary transcripts following GnRH blockade were 13 and 17 min, respectively; the mRNAs did not change. The effects of inhibin were specific for FSHbeta; 60 min after inhibin FSHbeta-primary transcript was undetectable with a half-disappearance time of 19 min, additionally FSHbeta mRNA levels also fell with a half-life of 94 min. In conclusion, these data support previous evidence that GnRH regulates gonadotropin gene expression primarily at the level of transcription. However, the acute increase in FSHbeta-primary transcript after ovariectomy or immunoneutralization of inhibin-alpha, and the rapid fall in FSHbeta-primary transcript following rh inhibin, provide novel evidence that inhibin suppresses FSHbeta gene transcription in addition to its action in regulating FSHbeta mRNA stability.

Electron beam computed tomography screening of the coronary arteries: experience with 3,263 patients at Walter Reed Army Medical Center.

The U.S. Department of Defense desires to reduce the impact of coronary atherosclerosis on its active duty, retired, and dependent populations. Electron beam computed tomography (EBCT) is currently the best way to noninvasively image the coronary arteries directly. Between August 1997 and February 1999, a total of 3,263 patients were scanned by EBCT in the Radiology Department at Walter Reed Army Medical Center. Scans were performed on 2,415 men (74%) and 848 women (26%). The most common age group was 50 to 54 years (25%). Coronary calcification was found in approximately half of the patients (46%), and the magnitude of the score was strongly associated with age and male gender. Average scores increased exponentially with age, doubling every 7 years. In men, average scores ranged from 17 units in those aged 35 to 39 years to 842 in those older than 70 years old. In women, average scores ranged from 1 in those 35 to 39 years to 162 in those older than 70 years. Significant numbers of patients fell into the high-risk categories, with 8% of men in their 40s, 20% of men in their 50s, 33% of men in their 60s, and 49% of men in their 70s with high scores. Scores of more than 400 units were seen in 368 patients (8%) overall. There is a large amount of coronary calcium present in military personnel and their dependents, in patterns that are consistent with previous studies. Many patients had very high scores that are consistent with advanced coronary artery disease. EBCT should play a central role in the identification of occult calcific atherosclerosis of the coronary arteries in military, retired, and dependent patients.

Regulation of gonadotropin subunit gene transcription by gonadotropin-releasing hormone: measurement of primary transcript ribonucleic acids by quantitative reverse transcription-polymerase chain reaction assays.

GnRH regulates the synthesis and secretion of the pituitary gonadotropins LH and FSH. One of the actions of GnRH on the gonadotropin subunit genes (alpha, LHbeta, and FSHbeta) is the regulation of transcription [messenger RNA (mRNA) synthesis]. Gonadotropin subunit transcription rates increase after gonadectomy and following exogenous GnRH pulses. However, prior studies of subunit mRNA synthesis were limited by the available methodology that did not allow simultaneous measurement of gene transcription and mature mRNA concentrations. The purpose of the current studies was to: 1) develop a reliable and sensitive method for assessing transcription rates by measuring gonadotropin subunit primary transcript RNAs (PT, RNA before intron splicing); 2) investigate the PT responses to GnRH following castration or exogenous GnRH pulses; 3) characterize the half-disappearance time for the three PT species after GnRH withdrawal; and 4) correlate changes in PT concentration with steady-state gonadotropin subunit mRNA levels measured in the same pituitary RNA samples. Using oligonucleotide primers that flanked intron-exon boundaries, quantitative RT-PCR assays for each subunit PT species were developed. These assays require only ng amounts of RNA to measure each gonadotropin subunit PT and allow us to measure both PTs and steady-state mRNAs in a single pituitary RNA sample. Primary transcript concentrations in intact male rats showed a relative abundance of alpha > LHbeta congruent with FSHbeta, similar to the relationship found previously for mRNA levels. Additionally, each PT species was only 1-2% as abundant as the corresponding mRNA. One week after castration, gonadotropin subunit PT levels were increased (alpha: 3-fold, LHbeta: 6-fold, and FSHbeta: 3-fold) in a pattern similar to subunit mRNAs. Administration of GnRH antagonist to 7-day castrate male rats resulted in a rapid decline in PT concentrations with a half-disappearance time of 2.7 h for LHbeta and 0.8 h for FSHbeta, significantly faster than earlier measurements of the half-disappearance time for mature mRNA. Finally, in a GnRH-deficient male rat model, LHbeta and FSHbeta PT concentrations increased 4- to 6-fold 5 min after a GnRH pulse and then declined toward levels seen in control animals. These data indicate that the effects of GnRH on subunit gene transcription are an important determinant of gonadotropin regulation. The appearance and disappearance of PT RNA occurs more rapidly than changes in mature mRNA. Additionally, concentrations are elevated in long term castrates, and following an exogenous GnRH pulse the transcriptional burst is rapid and brief.

A premature termination codon in either exon of minute virus of mice P4 promoter-generated pre-mRNA can inhibit nuclear splicing of the intervening intron in an open reading frame-dependent manner.

How premature translation termination codons (PTCs) mediate effects on nuclear RNA processing is unclear. Here we show that a PTC at nucleotide (nt) 385 in the NS1/2 shared exon of P4-generated pre-mRNAs of the autonomous parvovirus minute virus of mice caused a decrease in the accumulated levels of doubly spliced R2 relative to singly spliced R1, although the total accumulated levels of R1 plus R2 remained the same. The effect of this PTC was evident within nuclear RNA, was mediated by a PTC and not a missense transversion mutation at this position, and could be suppressed by improvement of the large intron splice sites and by mutation of the AUG that initiated translation of R1 and R2. In contrast to the PTC at nt 385, the reading frame-dependent effect of the PTC at nt 2018 depended neither on the initiating AUG nor the normal termination codon for NS2; however, it could be suppressed by a single nucleotide deletion mutation in the upstream NS1/2 common exon that shifted the 2018 PTC out of the NS2 open reading frame. This suggested that there was recognition and communication of reading frame between exons on a pre-mRNA in the nucleus prior to or concomitant with splicing.

Early talk about the past revisited: affect in working-class and middle-class children's co-narrations.

This study contributes to our understanding of sociocultural variation in children's early storytelling by comparing co-narrations produced by children and their families from two European-American communities, one working-class and one middle-class. Six children from each community were observed in their homes at 2;6 and 3;0 years of age, yielding a corpus of nearly 400 naturally-occurring co-narrations of past experience. Analyses of generic properties, content, and emotion talk revealed a complex configuration of similarities and differences. Working-class and middle-class families produced co-narrations that were similar in referential/evaluative functions and temporal structure, with a preponderance of positive content. Working-class families produced twice as many co-narrations as their middle-class counterparts, produced more negative emotion talk, and used more dramatic language for conveying negative emotional experience. These findings suggest that (1) differentiation between working-class and middle-class communities in the content of early narratives may occur primarily with respect to negative experience and (2) researchers need to go beyond emotion state terms in order to accurately represent sociocultural variation in personal storytelling.

Prior revascularization increases the effectiveness of enhanced external counterpulsation.

BACKGROUND AND HYPOTHESIS: Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic angina. However, its usefulness has been felt to be limited in patients with angiographically demonstrated triple-vessel coronary artery disease (CAD), in accord with the hypothesis that a patent vessel is necessary for transmission of the EECP-augmented coronary artery pressure and volume to the distal coronary vasculature. METHODS: The effect of revascularization [coronary artery bypass grafting (CABG)] prior to EECP was examined in 60 patients with CAD and chronic angina (35 without and 25 with prior CABG). Patients were grouped by the extent of CAD (single-, double-, triple-vessel disease in the unrevascularized group) and by the extent of residual disease (number of stenotic native vessels unbypassed or supplied by a stenotic graft in the CABG group). Significant CAD or graft stenoses were defined as stenoses demonstrating > or = 70% luminal diameter narrowing. Benefit was assessed by improvement in post-EECP treatment over pretreatment radionuclide stress testing. RESULTS: Radionuclide stress testing demonstrated a comparable favorable response (80 vs. 71%; p = NS) in patients with prior CABG versus unrevascularized patients. Enhanced external counterpulsation was highly and comparably effective in patients with unrevascularized native single- and double-vessel CAD and in patients with CABG with residual single- and double-vessel CAD (88 vs. 80%; p = NS). Most notably, CABG significantly increased the beneficial response to EECP in those patients with triple-vessel CAD and stenotic grafts compared with unrevascularized patients with triple-vessel CAD (80 vs. 22%; p < 0.05 by chi-square test). CONCLUSION: The results suggest a new role for EECP as an effective treatment for post CABG ischemia, despite extensive CAD and even in the presence of stenotic grafts.

Maximizing the hemodynamic benefit of enhanced external counterpulsation.

BACKGROUND: Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for angina and exertional ischemia in patients with coronary disease. HYPOTHESIS: It is hypothesized that the ability of EECP to enhance the recruitment or development of coronary collaterals in coronary artery disease may be determined by the relative magnitude of diastolic augmentation (DA) and systolic unloading (SU). This study examines the relation between the proposed EECP effectiveness ratio (DA/SU), as assessed by finger plethysmography, and changes in descending aortic flow as assessed by Doppler echocardiography in 15 patients during EECP. METHODS: Varying external cuff pressures (0-275 mmHg) were used to generate a range of DA/SU ratios. The effect on aortic antegrade systolic and retrograde diastolic flow was assessed by Doppler echocardiography to determine whether there was an optimal EECP effectiveness ratio that maximizes the hemodynamic effects of EECP. With increasing DA/SU there was an initial positive linear increase in both systolic and diastolic flow volume. Systolic flow maximized at an effectiveness ratio of 1.5 and diastolic flow at a ratio of 2.0 RESULT: Therefore, effectiveness ratios (DA/SU) in the range of 1.5-2.0 are optimal for maximizing the hemodynamic effects of EECP.