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Biomedical subjects

R Roberts

Publications and source records attributed to R Roberts.

At least 271 records · Page 15Linked to original sources

Detection of a new mutation in the beta-myosin heavy chain gene in an individual with hypertrophic cardiomyopathy.

Familial hypertrophic cardiomyopathy (FHCM) is an autosomal dominant disease affecting primarily the myocardium. The gene responsible for FHCM has been localized to chromosome 14 in some families and several mutations have been described in the beta-myosin heavy chain (beta MHC), a candidate gene for the disease. We recently identified a family with HCM in whom we did not detect any of the known mutations in the beta MHC gene (the alpha/beta MHC hybrid gene and the missense mutation in exons 13 and 9). However, we did observe a novel 9.5-kb BamHI restriction fragment length polymorphism detected by a beta MHC probe on Southern blots of DNA from the proband of this family. Similarly, a novel 3.8-kb TaqI polymorphism and a novel 4.3-kb HindIII polymorphism were detected on Southern blots of DNA from the same proband. Polymerase chain reaction (PCR) was used to amplify the segment of the beta MHC that was detected by pSC14 probe. PCR amplification of the distal 3'-end of the beta MHC gene yielded an additional product in the DNA template from the proband which was subsequently cloned and sequenced. The sequence analysis showed a 2.4-kb nucleotide deletion involving one allele of the beta MHC gene. The deletion includes part of the intron 39, exon 40 including the 3'-untranslated region and the polyadenylation signal, and part of the beta-alpha MHC intergenic region. This deletion was inherited in Mendelian fashion in an additional three members of this small family of which only the proband has developed clinically diagnosed HCM at a very late onset (age 59 yr), the other three family members are younger and have not developed the disease at the ages of 10, 32, and 33 yr.

Aged↗

Informatics Workup.

We introduce the concept of a Medical Informatics Workup performed by fourth year medical students working in a busy inner-city Emergency Room. These students use portable computers (Macintosh PowerBook 170s connected to a removable cartridge hard drive and CD-ROM drive) to do the patient workups. The PowerBook 170 contains the automated medical record entry software (IMR-E), five expert system software packages, and a program that allows the PowerBook to emulate a PC-compatible computer. With this configuration the student has a portable system that allows for the creation of a computerized medical record at the patient's bedside, along with the ability to analyze the data and generate a list of differential diagnoses.

Angina Pectoris↗

Outcome of pregnancy in an Oxford-Cardiff cohort of women with previous bacteriuria.

To investigate the influence of asymptomatic bacteriuria in childhood on subsequent pregnancy, we reviewed the outcome of 139 pregnancies in 88 women who were first identified during a programme of screening schoolgirls for asymptomatic bacteriuria carried out between 1970-1972. Data were analysed for the following groups: 50 pregnancies in 28 women with known renal scars (group 1); 16 pregnancies in 14 women with normal kidneys and reflux (group 2); 73 pregnancies in 46 women with normal urinary tracts (group 3); 139 healthy controls. Women in group 1 had a 3.3-fold increased relative risk of hypertension (p < 0.01) and a 7.6-fold increased risk of pre-eclampsia (p < 0.05) compared to controls, and a higher rate of obstetric interventions, including emergency caesarean section. Women in groups 2 and 3 appeared to carry a slightly increased risk of hypertension during the last trimester (RR = 1.8) but there were no significant differences in this or the incidence of pre-eclampsia or mode of delivery. Bacteriuria was more prevalent in all index groups compared to controls (37 per cent vs. 8 per cent, p < 0.01) and included four cases of acute pyelonephritis in in the study group. Fetal outcome was satisfactory in all cases. These results suggest that women with renal scars are at risk of hypertension and pre-eclampsia during pregnancy but that modern obstetric care minimizes these risks.

Adult↗

Factors determining improvement in left ventricular function after reperfusion therapy for acute myocardial infarction: primacy of baseline ejection fraction.

Improvement in left ventricular ejection fraction is a measure of salvage of ischemic myocardium after reperfusion therapy for acute myocardial infarction. The degree of improvement in left ventricular ejection fraction may be influenced by many factors. Therefore, 137 patients in whom paired radionuclide angiograms were obtained within 24 h of acute infarction and before hospital discharge were retrospectively evaluated to determine which factors most affect improvement in ejection fraction. Only baseline ejection fraction correlated significantly with improvement in ejection fraction by both univariate analysis (ejection fraction as a continuous variable; p less than 0.001; ejection fraction as a categorical variable, less than or equal to 45% versus greater than 45%, p less than 0.0001) and multivariate analysis (p less than 0.0001). Reperfusion status (patent versus occluded infarct artery) and extent of coronary artery disease (one, two or three vessel) were significant factors by multivariate but not by univariate analysis. Location of infarction, treatment modality and time to treatment did not correlate with change in ejection fraction by either statistical technique. Thus, of those factors tested, baseline left ventricular ejection fraction is the most potent predictor of improvement in ventricular function after acute infarction. Knowledge of baseline ejection fraction may be helpful in deciding whether to treat some patients with equivocal indications or contraindications for reperfusion therapy. Clinical trials of reperfusion strategies should stratify patients on the basis of baseline ejection fraction if ejection fraction is to be used as an end point for myocardial salvage.

Adult↗

Time course of creatine kinase release after termination of sustained ventricular dysrhythmias.

Differentiation between primary and secondary (caused by acute myocardial infarction) ventricular fibrillation has important therapeutic and prognostic implications. The diagnosis of myocardial infarction is based on clinical, ECG, and creatine kinase MB isoenzyme (MBCK) activity. Enzymatic criteria might not be able to confirm the diagnosis of myocardial infarction after recent cardioversion. The routine use of electrophysiologic studies involving the induction and termination of ventricular dysrhythmias provides a setting in which enzyme release as a result of cardioversion alone can be examined. Therefore a systematic investigation of the magnitude and time course of creatine kinase (CK) and MBCK release was performed after termination of ventricular dysrhythmias in 57 patients undergoing electrophysiologic studies. Of patients requiring external cardioversion, only 50% had an elevation in CK and MBCK activity. Elevation when present corrected with the number of shocks and cumulative energy delivered. The magnitude of MBCK release exceeded 10% of the total CK activity in 9% of observations. Pace-termination of ventricular tachycardia did not result in enzyme release. Arrhythmia characteristics, coronary artery disease, and left ventricular function did not affect the magnitude of the time course of enzyme release. These data suggest that cardioversion with multiple shocks may result in a component of MBCK release, and thus a false positive diagnosis of primary acute myocardial infarction may be made by relying exclusively on the enzyme release pattern.

Clinical Enzyme Tests↗

Selective versus routine predischarge coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction. TIMI II Investigators.

To ascertain whether predischarge arteriography is beneficial in patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA), heparin and aspirin, the outcome of 197 patients in the Thrombolysis in Myocardial Infarction (TIMI) IIA study assigned to conservative management and routine predischarge coronary arteriography (routine catheterization group) was compared with the outcome of 1,461 patients from the TIMI IIB study assigned to conservative management without routine coronary arteriography unless ischemia recurred spontaneously or on predischarge exercise testing (selective catheterization group). The two groups were similar with regard to important baseline variables. During the initial hospital stay, coronary arteriography was performed in 93.9% of the routine catheterization group and 34.7% of the selective catheterization group (p less than 0.001), but the frequency of coronary revascularization (angioplasty or coronary artery bypass surgery) was similar in the two groups (24.4% versus 20.7%, p = NS). Coronary arteriograms showed a predominance of zero or one vessel disease (stenosis greater than or equal to 60%) in both groups (routine catheterization group 73.1%, selective catheterization group 61.3%). During the 1st year after infarction, rehospitalization for cardiac reasons and the interim performance of coronary arteriography were more common in the selective catheterization group (37.9% versus 27.6%, p = 0.007 and 28.6% versus 11.6%, p less than 0.001, respectively); however, the interim rates of death, nonfatal reinfarction and performance of coronary revascularization procedures were similar. At the end of 1 year, coronary arteriography had been performed one or more times in 98.9% of the routine catheterization group and 59.4% of the selective catheterization group (p less than 0.001), whereas death and nonfatal reinfarction had occurred in 10.2% versus 7.0% (p = 0.10) and 8.6% versus 9.0% (p = 0.87), respectively. Because the selective coronary arteriography policy exposes about 40% fewer patients to the small but finite risks and inconvenience of the procedure without compromising the 1 year survival or reinfarction rates, it seems to be an appropriate management strategy.

Aged↗

Isolation of a human chromosome 14-only somatic cell hybrid: analysis using Alu and LINE-based PCR.

Interspecific somatic cell hybrids containing single human chromosomes are valuable reagents for localization of cloned genes and DNA fragments to specific chromosomes, for the development of chromosome-specific libraries, and for generation of hybrid cell lines containing subchromosomal regions. A CHO somatic cell hybrid containing a single, intact human chromosome 14 (MHR14) was developed and confirmed by LINE PCR amplification gel pattern, by Alu-517 PCR product dot blot hybridization, and by cytogenetic analysis. MHR14 will serve as the chromosome source for the development of a radiation map of human chromosome 14.

Animals↗

Serial Alu sequence transposition interrupting a human B creatine kinase pseudogene.

We have isolated, sequenced, and characterized a single-copy B creatine kinase pseudogene. The chromosomal assignment of this gene is 16p13 and a unique sequence probe from this locus detects EcoRI restriction fragment length polymorphisms of 7.8 and 5.4 kb. In 26 unrelated individuals, the frequencies for the 7.8- and 5.4-kb B creatine kinase pseudogene alleles were calculated to be 17.3 and 82.7%, respectively. The B creatine kinase pseudogene is interrupted by a 904-bp DNA insertion composed of three Alu repeat sequences in tandem flanked by an 18-bp direct repeat, derived from the pseudogene sequence. Nucleotide sequence analysis of the Alu elements suggests that the Alu sequences were incorporated into this locus in three separate integration events. Several complex clustered Alu repeat sequences without defined integration borders have been previously identified at different genomic loci. This is the first evidence that complex tandem Alu elements can integrate in an apparently serial manner in the human genome and supports the contention that Alu repeats integrate nonrandomly into the human genome.

Animals↗

Corticosteroid side-chain oxidations--I. Structural effects on the excreted isotope ratios of 4-14C- and 21-3H-labelled corticosteroid metabolites in rabbit urine.

The metabolic fates of 4-14C- and 21-3H-labelled corticosteroids have been investigated in the rabbit by analysis of the normalized isotope ratios of neutral and acidic metabolites excreted in the urine. Isotope ratios of excreted radioactivity declined in the order cortisol (F) greater than corticosterone (B) greater than 11-desoxycortisol (S) greater than deoxycorticosterone (DOC). Steroid acids, isolated in alumina fraction C, represented 19.0, 15.0, 9.7 and 2.7% of the doses of DOC, B, S and F, respectively, and the isotope ratios declined in the order F greater than B greater than S greater than DOC. HPLC of steroid acid methyl ester derivatives indicated generally low isotope ratios for DOC and S steroid acids, consistent with complete side-chain oxidation to 20-oxo-21-oic acids and/or 17-carboxylic acids. Several B metabolite methyl esters peaks also exhibited low isotope ratios, but both B and F metabolites gave methyl esters that retained significant tritium consistent with the presence of 20-hydroxysteroid acids. The 21-hydroxy-steroid metabolite fractions had isotope ratios of F = S greater than B greater than DOC. HPLC showed that 20-oxo (tetrahydro) metabolites of B and F had reduced isotope ratios unlike the C-20 reduced (hexahydro) metabolites of DOC and S. It may be concluded that the metabolic fate of the corticoid side-chain in the rabbit is dependent on the steroid structure and may result in the excretion of both 20-oxo and 20-hydroxysteroid acids.

Adrenal Cortex Hormones↗

Bleeding complications following initiation of thrombolytic therapy for acute myocardial infarction: a comparison of helicopter-transported and nontransported patients.

STUDY OBJECTIVE: To evaluate the effect of helicopter transport of acute myocardial infarction (AMI) patients after initiation of thrombolysis on bleeding complications through hospital discharge. DESIGN: Prospectively identified incidence (cohort) study. SETTING: Air medical service of tertiary-care teaching hospital. TYPES OF PARTICIPANTS: Ninety-five consecutive AMI patients transported within 12 hours of the initiation of thrombolysis with recombinant tissue-type plasminogen activator were compared with 119 nontransported AMI patients treated in a similar manner. RESULTS: The transported and nontransported populations were similar with regard to age, sex, and infarct location. Transport was well tolerated with no episodes of cardiac arrest or cardioversion occurring during transport. Hypotension requiring fluids or increased pressors occurred in 18 patients. Bleeding complications of all types occurred in 43.2% of the transported and 49.6% of the nontransported patients, respectively (relative risk, 0.87; 95% confidence interval, 0.65 to 1.17). CONCLUSION: Helicopter transport of AMI patients after initiation of thrombolysis appears to be safe acutely and without a clinically significant increase in risk of bleeding complications through hospital discharge when accomplished by a highly skilled team.

Aircraft↗

Bandwidth-induced errors in parameters used for automated activation time determination during computerized intraoperative cardiac mapping: theoretical limits.

Two parameters commonly used when determining the time of local activation during computerized intraoperative cardiac mapping are the time of the peak in bipolar electrograms (BP) and the time of the largest negative slope (LNS) in monopolar electrograms (MP). The dependence of these parameters upon bandwidth was studied. A database of fast MP and BP was compiled from intraoperative recordings collected from epicardial sock arrays in man. Based on 95%, 99% and 99.9% of total signal power, the bandwidths of each response were determined. After removing specified frequencies using the Fourier transform, errors in determining these parameters were computed and characterized with respect to mean square error (MSE), percent power bandwidth and frequency content. The Fourier transform was used to abruptly filter out undesired upper frequencies. Filtering BP at 200 Hz produced a 1-ms shift in the peak in 17.0% of the electrograms, 0.4% of the peaks shifted by 2 ms and none shifted by more than 2 ms. Comparable shifts in the LNS occurred when filtering MP at 400 Hz. Retention of 95% of the power in a BP rarely (0.9%) changed the time of its peak by more than 1 ms. For MP, retention of 99.9% of the power was required for similar performance (3.6%). Thus, although BP have greater signal power in the higher frequencies than MP, a greater bandwidth is required when recording monopolarly in order to preserve the small amount of power necessary to define the time of the LNS with accuracy comparable to determination of the peak in BP.

Analog-Digital Conversion↗

NMR studies of beta-oxidation and short-chain fatty acid metabolism during recovery of reperfused hearts.

The effects of beta-oxidation on the contractile recovery and metabolic activity of postischemic (10 min) rabbit hearts were examined during reperfusion with the short-chain fatty acid butyrate. Hearts received either 13C-enriched butyrate or acetate to evaluate metabolic targeting with 13C nuclear magnetic resonance (NMR) spectroscopy. Acetate and butyrate supported similar contractility (rate of pressure development, dP/dt) and 31P-NMR-detected, high-energy phosphate (HEP) levels during normal perfusion. In postischemic hearts, butyrate sustained a greater percentage of preischemic dP/dt (83 +/- 4%) than did acetate reperfusion (44 +/- 6%, P less than 0.05) with no differences in HEP. The efficiency of oxygen consumption per unit of work was greater in hearts reperfused with butyrate (2.8 +/- 0.2 microM.g-1.mmHg-1) vs. acetate (3.4 +/- 0.1). Inhibition of butyrate oxidation with 4-bromocrotonic acid (4-BCA) during normal perfusion severely reduced dP/dt and HEP. Acetate supported normal dP/dt and HEP levels during perfusion with 4-BCA and butyrate, but contractile recovery during reperfusion with acetate, 4-BCA, and butyrate (46 +/- 6%) was similar to that with acetate alone. With acetate and butyrate combined at reperfusion, acetate accounted for 56% of substrate entering oxidative metabolism at acetyl CoA and delayed contractile recovery (57 +/- 5% at midpoint and 80 +/- 6% at end). Thus improved respiratory efficiency of contraction in reperfused hearts was related to the activity of beta-oxidation.

Acetates↗

Impact for molecular biology in cardiology.

The recent development and application of the techniques of recombinant DNA and molecular biology ignited an explosion in biomedical research, which has been embraced by medicine. However, cardiology as a subspecialty has been slower in adopting these techniques, in part because the heart is a nonproliferating organ and in part because it was not easily accessible until recently. The techniques of recombinant DNA were not possible until the 1970s. In that decade four major discoveries occurred that launched molecular biology into the 21st century. These seminal contributions were 1) the discovery and application of specific restriction endonucleases, 2) the discovery of reverse transcriptase, 3) the development of the cloning technique, and 4) the ability to rapidly sequence nucleic acids. The techniques of recombinant DNA offer several unique advantages over existing scientific disciplines, such as the abilities: 1) to perform in vivo structure-function analysis, 2) to genetically engineer drugs, 3) to perform diagnostic in situ hybridization, 4) to isolate genes responsible for hereditary disorders, and 5) to understand the genetic regulation of cardiac growth. These techniques are discussed in their application to cardiac disorders, including the development of new recombinant molecules for the treatment of coronary thrombosis and the potential to modulate the cardiac growth response to various forms of injury such as myocardial infarction and hypertension.

Adaptation, Physiological↗

Design and implementation of a new computerized system for intraoperative cardiac mapping.

A rapid, portable, yet inexpensive and expandable computer-based system utilizing current technology has been developed from experience in the operating room. An efficient operating system well suited for surgery is defined. New technology recording arrays fabricated from multielectrode flexible Kapton strips were developed and found to be easy to use and highly reliable. Novel arrays are created easily for research or special clinical applications. The system displays all incoming data in real time and transfers 16-s epochs to disk on command. After the user defines a beat for analysis, the computer determines the activation time for each channel, rejects unsatisfactory channels, and displays the results for review and modification before plotting the isochronal map on the monitor. The average time to recall data and produce a map is 16 s; if manual review of 120 channels is included, mapping time is less than 4 min. Clinical data recorded during surgery are discussed. The speed and operational ease demonstrated in the operating room make this computer/electrode system valuable both for surgery and for elucidating basic mechanisms of arrhythmias.

Algorithms↗

Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study.

In the Thrombolysis in Myocardial Infarction (TIMI) Phase II trial, patients received intravenous recombinant tissue-type plasminogen activator (rt-PA) and were randomized to either a conservative or an invasive strategy. Within this study, the effects of immediate versus deferred beta-blocker therapy were also assessed in patients eligible for beta-blocker therapy, a group of 1,434 patients of which 720 were randomized to the immediate intravenous group and 714 to the deferred group. In the immediate intravenous group, within 2 hours of initiating rt-PA metoprolol was given (5 mg intravenously at 2-minute intervals over 6 minutes, for a total intravenous dose of 15 mg, followed by 50 mg orally every 12 hours in the first 24 hours and 100 mg orally every 12 hours thereafter). The patients assigned to the deferred group received metoprolol, 50 mg orally twice on day 6, followed by 100 mg orally twice a day thereafter. The therapy was tolerated well in both groups and the primary end point, resting global ejection fraction at hospital discharge, averaged 50.5% and was virtually identical in the two groups. The regional ventricular function was also similar in the two groups. Overall, there was no difference in mortality between the immediate intravenous and deferred groups, but in the subgroup defined as low risk there were no deaths at 6 weeks among those receiving immediate beta-blocker therapy in contrast to seven deaths among those in whom beta-blocker therapy was deferred. These findings for a secondary end point in a subgroup were not considered sufficient to warrant a recommendation regarding clinical use. There was a lower incidence of reinfarction (2.7% versus 5.1%, p = 0.02) and recurrent chest pain (18.8% versus 24.1%, p less than 0.02) at 6 days in the immediate intravenous group. Thus, in appropriate postinfarction patients, beta-blockers are safe when given early after thrombolytic therapy and are associated with decreased myocardial ischemia and reinfarction in the first week but offer no benefit over late administration in improving ventricular function or reducing mortality.

Adrenergic beta-Antagonists↗