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Multiplex RT-nested PCR differentiation of gill-associated virus (Australia) from yellow head virus (Thailand) of Penaeus monodon.

A multiplex RT-nested PCR has been developed to detect and differentiate the closely related prawn viruses, gill-associated virus (GAV) from Australia and yellow head virus (YHV) from Thailand. RT-PCR using primers to conserved sequences in the ORF1b gene amplified a 794 bp region of either GAV or YHV. Nested PCR using a conserved sense primer and either a GAV- or YHV-specific antisense primer to a divergent sequence differentially amplified a 277 bp region of the primary PCR amplicon. Multiplexing the YHV antisense primer with a GAV antisense primer to another divergent sequence allowed the viruses to be distinguished in a single nested PCR. Nested PCR enhanced detection sensitivity between 100- and 1000-fold and GAV or YHV RNA was detectable in approximately 10 fg lymphoid organ total RNA. The multiplex RT-nested PCR was also able to co-detect GAV and YHV RNA mixed over a wide range of concentrations to simulate potential dual-infection states. The robustness of the test was examined using RNA samples from Penaeus monodon prawns infected either chronically or acutely with GAV or YHV and collected at different locations in Eastern Australia and Thailand between 1994 and 1998. GAV- (406 bp) or YHV-specific (277 bp) amplicons were differentially generated in all cases, including five YHV RNA samples in which no primary RT-PCR amplicon was detected. Sequence analysis of GAV and YHV PCR amplicons identified minor variations in the regions targeted by the virus-specific antisense primers. However, none occurred at positions that critically affected the PCR.

Amino Acid Sequence↗

Cytomegalovirus and Epstein-Barr virus DNA transcription in endodontic symptomatic lesions.

OBJECTIVES: Productive Herpesviridae infections are implicated in the etio-pathogenesis of aggressive periodontitis. However, virtually nothing is known about a possible role of herpesviruses in pulpal and periapical pathosis. This study employed a cDNA analysis to determine transcription of human cytomegalovirus (HCMV), Epstein-Barr virus (EBV) and herpes simplex virus (HSV) in 14 recalcitrant periapical lesions and in 2 periapical healthy control sites. METHODS: Periapical samples were collected in conjunction with periapical surgery and kept frozen until virologic examination. RNA was isolated from periapical tissue by using a guanidinium isothiocyanate-acid phenol procedure (TRIZOL LS Reagent, GIBCO BRL, Rockville, MD). cDNAs were amplified by means of oligonucleotides targeting highly conserved regions of the test viruses and the RT-PCR-100 amplification kit (Sigma-Aldrich, St Louis, MO). Standardization of PCR primer sensitivity and validation was carried out according to established methods. Amplification products were identified by agarose gel electrophoresis. RESULTS: HCMV transcript was detected in 12 of 13 symptomatic and in 1 asymptomatic periapical lesion. EBV transcript was demonstrated in 8 of the 13 symptomatic lesions but not in the asymptomatic periapical lesion. HCMV and EBV dual transcription occurred at higher frequency in periapical lesions showing radiographic bone destruction of 5 mm x 7 mm or larger than in smaller size lesions (P = 0.03; Chi-squared test). No HCMV or EBV transcription was identified in the 2 healthy control sites. HSV transcript was not detected in any study site. CONCLUSION: The present data suggest that HCMV or EBV infections participate in the pathogenesis of periapical symptomatic lesions. Herpesviruses may produce periapical pathosis as a direct result of viral infection and replication, or as a consequence of virally induced impairment of the host defense and subsequent increased virulence of resident bacterial pathogens.

Adult↗

Bacterial cell counts in goat milk and their correlations with somatic cell counts, percent fat, and protein.

Representative milk samples at morning and afternoon milking were collected periodically for 5 mo from 32 does in a Prairie View A&M University milking herd to test the concentrations of total bacterial, coliform, and staphylococcus counts and to determine the correlations among the bacterial cell counts, somatic cell counts, percent fat, and percent protein. Bacterial cell counts were assayed by microbiogical methods using different nutrient media for the three cell types. Somatic cell counts were determined by an automated fluorescent microscopic somatic cell counter. Percent fat and protein were analyzed by an automated dual beam infrared absorption analyzer. Mean counts for total bacterial, coliform, staphylococcus, and somatic cell were 2.54 X 10(4), .966 X 10(3), 3.32 X 10(3), and 9.08 X 10(5) cells/ml, respectively. The Nubian goats had higher counts in all three bacterial cell types than the Alpines, and the difference in staphylococcus counts between breeds was significant (P less than .05). However, Alpine milk contained slightly higher somatic cell counts than the Nubians. None of the correlation coefficients (r) between somatic cell and bacterial cell counts was significant for the pooled data from the two breeds, but r between staphylococcus and somatic cell counts for Alpine breed was significant (P less than .05). The r between somatic cell counts and percent fat or protein were significant (P less than .01) for combined or separated breed data. Bacterial cell counts could not explain high somatic cell counts in the goat milk with the present testing standards of cow milk.

Animals↗

Thrombin-activated microglia contribute to death of dopaminergic neurons in rat mesencephalic cultures: dual roles of mitogen-activated protein kinase signaling pathways.

This study evaluated the role of thrombin-activated microglia in the neurodegeneration of mesencephalic cultures. Immunocytochemical and biochemical evidence indicated that in co-cultures consisting of rat cortical microglia and mesencephalic neurons, thrombin led to nonselective loss of mesencephalic neurons. Accompanying neurodegeneration, microglial activation was obvious, evidenced by expression of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-1beta, inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX-2) and by increasing production of TNF-alpha and nitric oxide (NO). In mesencephalic neurons treated with conditioned media (CM) taken from thrombin-activated microglia, the number of dopaminergic neurons was significantly attenuated. The neurotoxicity of the CM was diminished when it was derived from microglia co-treated with thrombin and either an extracellular signal-regulated kinase 1/2 (ERK1/2) pathway inhibitor (PD98059) or a p38-mitogen-activated protein kinase (p38-MAPK) inhibitor (SB203580). Moreover, jun N-terminal kinase (JNK) and p38-MAPK were activated in mesencephalic neurons treated with CM of thrombin-activated microglia. Inhibition of JNK and p38-MAPK rescued the dopaminergic neurons. Collectively, these results indicate that thrombin-activated microglia induce neurodegeneration in cultured mesencephalic neurons and that the MAPKs actively participate in both microglial activation and neurodegeneration. The present data carefully suggest that microglial activation triggered by thrombin may be involved in the neuropathological processes of dopaminergic neuronal cell death that occur in Parkinson's disease.

Animals↗

A modified therapeutic community for homeless persons with co-occurring disorders of substance abuse and mental illness in a shelter: an outcome study.

This article reports on a study conducted to determine the effectiveness of a modified therapeutic community (MTC) shelter on client outcomes. The seven-study hypotheses focused on whether greater effectiveness in the MTC would be demonstrated in longer periods of sobriety, fewer days of psychiatric hospitalization, shorter lengths of stay in a shelter, positive discharge from the shelter, medication compliance, housing placement within the first year, and appropriate housing placement according to level of functioning. The study utilized a quasi-experimental design with two groups: 1) an experimental group (E) homeless persons with co-occurring disorders (COD) of substance abuse/dependence and mental illness who reside in a modified therapeutic community (N = 70); and 2) a comparison group (C) of veterans with CODs living in a general shelter (N = 70). The data collection procedures involved a retrospective review of closed case records for subjects in the facilities from September 1, 1998-June 1, 2000 for the MTC shelter, and from June 1, 1999-June 1, 2000 for the general shelter. Baseline differences between the E and C groups were found in age, length of homelessness, years of education, years of work experience, veteran status, marital status, and psychiatric diagnosis; all except for veteran status were unrelated to outcomes and were controlled in subsequent analyses. Significant difference was found on medication compliance when controlled for both groups. Overall, this study showed some promise for the MTC approach. The study also raised a question as to the contribution of veteran status to the differences between groups and to treatment of CODs.

Adult↗

Differences in vertebral structure and strength of inbred female mouse strains.

This study assessed mouse strain-related differences in vertebral biomechanics and histomorphometry in inbred mice strains shown to differ in bone mineral content (BMC) and areal density (BMD) (as measured by pDEXA). Lumbar vertebrae L3 to L5 were collected from three mice strains (C3H/HeJ[C3], C57BL/6J[B6], and DBA/2J[D2], n=12/strain, 4-month-old female, 22.2 +/- 0.3g). BMC and BMD were measured in L3 and L4 using peripheral dual energy x-ray absorptiometry. The L4 vertebral body was then mechanically tested in compression to determine structural properties (ultimate/yield load, stiffness) from load-displacement curves and derive apparent material properties (ultimate/yield stress, and modulus of elasticity). L5 was processed for histomorphometric evaluation. Vertebral BMC and BMD were greater in C3 than in B6 and D2 mice. Vertebral trabecular/cancellous bone volume was smaller in C3 than in D2 and B6 mice. Trabecular bone formation rates were greater in D2 than in B6 and C3 mice. Osteoid surface was smaller in C3 mice than in B6 and D2 mice. Differences in osteoclast and mineralizing surfaces were not detected among the three mouse strains. In addition, there were no significant differences in biomechanical properties between the three strains. Despite the greatest BMC and areal BMD in C3 mice, the lack of strain-related differences in vertebral body strength data suggests that the biomechanical properties may be affected by the bone distribution and/or complex combination of cortical and cancellous bone at this site.

Absorptiometry, Photon↗

Comparison of dual-energy x-ray absorptiometry and measurement of total body water content by deuterium oxide dilution for estimating body composition in dogs.

OBJECTIVE: To compare percentage of body fat (%BF) estimates from dual-energy x-ray absorptiometry (DEXA) with those derived from total body water (TBW) determination by deuterium oxide (D2O) dilution. ANIMALS: 31 healthy, adult, purebred dogs of various ages and breeds (body weight, 15 to 39 kg). PROCEDURE: The TBW was measured by D2O dilution and subsequent analysis via nuclear magnetic resonance (NMR). Blood was collected before and 2 hours after IV administration of 275 mg of D2O/kg of body weight. Plasma was separated and stored at -30 C until analysis by deuterium NMR. The DEXA scans were obtained immediately after blood collection from dogs under general anesthesia. RESULTS: Measurements of %BF by DEXA averaged 15.8% higher than calculated estimates of TBW content by D2O dilution. The linear regression of %BF by TBW content on %BF by DEXA had a slope of 1.04 and a correlation coefficient of 0.84, indicating excellent relative agreement between methods despite the significant difference in absolute agreement between the 2 methods. The average difference between methods did not differ by breed, sex, body condition score, body weight, or %BF, as measured by DEXA. CONCLUSION: Comparability of our data with those of previous studies suggest that DEXA is useful for in vivo estimation of body composition in healthy dogs. Body fat estimated by D2O dilution will be less than that determined by DEXA, despite excellent relative agreement between methods.

Absorptiometry, Photon↗

Assessing ethnicity in New Zealand health research.

AIMS: To investigate the patterns and criteria reported for categorisation of ethnicity in a sample of health research reports which made comparisons between Maori and non-Maori. METHODS: A total of 98 research reports, which made comparisons between Maori and non-Maori samples, were selected from the New Zealand Medical Journal over five 12-month periods and one 24-month period between 1980 and 1996. RESULTS: Only 19% of the 98 articles reported any information about the criteria used for categorising ethnicity. Only three articles mentioned how people of dual or multiple ethnicity were categorised. Although the term 'race' was commonly used in the 1980s, the terms 'ethnicity' and 'ethnic group' were more widely used later to describe ethnicity. CONCLUSIONS: Much of the New Zealand research comparing Maori and non-Maori samples is likely to have unacknowledged error. Most articles did not meet minimum expected standards for reporting procedures for categorising ethnicity. There seemed to be little awareness of the major changes which have taken place in the New Zealand Census question concerning ethnicity between 1981 and 1996. Some suggestions were made for effective practice when assessing and reporting ethnicity in New Zealand research.

Data Collection↗

Compliance with mental health and other specialty care referrals among Medicare/Medicaid dual enrollees.

OBJECTIVES: To examine and compare non-compliance with mental health and other specialty referrals among low-income elderly. METHODS: A survey of 2,128 community-dwelling elderly assessed mental health and other specialty referral in the past year and compliance with these referrals. Non-compliant participants and those who had encountered difficulties in arranging referral appointments were asked about the barriers. RESULTS: 16.7% with mental health referrals vs. 4.8% with other specialty referrals did not comply (p < .001). The main reason for non-compliance with mental health referrals was lack of perceived need. DISCUSSION: Lack of perceived need for professional help is a major barrier to specialty mental health care.

Aged↗

Combined antidepressants: clinical experience.

OBJECTIVE: To review the current literature on the use of combinations of antidepressive agents. METHOD: Literature searches were undertaken and reviewed on the use of combinations of antidepressants. RESULTS: Data sources included surveys, analyses of prescription records, decision algorithms, clinical reports, and studies comparing the monotherapy with combination therapy. More recent surveys recommend combining different selective serotonin reuptake inhibitors (SSRIs), an SSRI plus bupropion or dual action antidepressants plus an SSRI. Decision algorithms recommend an SSRI plus tricyclic antidepressant (TCA) and more recently bupropion plus venlafaxine or mirtazapine. Few controlled clinical trials comparing the combined therapy with monotherapy have been conducted. Beneficial effects have been reported with combinations of TCAs plus mianserin or SSRIs plus mirtazapine. CONCLUSION: Adding or combining antidepressant medications has advantages for the speed of onset and maintaining the existing response. More rigorous clinical trials comparing combination therapy with monotherapy and for the development of rational treatment guidelines are required.

Algorithms↗

Childhood abuse history and substance use among men and women receiving detoxification services.

According to data collected from women and adolescents, a strong link exists between childhood abuse history and substance abuse. Using a sample of 274 women and 556 men receiving detoxification services, we explored whether the same pattern emerged across genders and types of abuse. Results revealed 20% of men and more than 50% of women reported childhood physical or sexual abuse. Sexual or physical abuse had negative sequelae, regardless of gender. Individuals with abuse history reported earlier age of onset of drinking, more problems associated with use of alcohol/drugs, more severe psychopathology, and more lifetime arrests, arrests related to substance use, and arrests related to mental health. Prevention and proactive intervention activities are crucial to prevent negative sequelae of childhood victimization.

Adult↗

Cortisol secretion and rate of bone loss in a population-based cohort of elderly men and women.

Although excessive glucocorticoids are a well-recognized cause of osteoporosis, little is known about the role of endogenous glucocorticoids in determining skeletal mass. We have performed a detailed study of the hypothalamic-pituitary-adrenal (HPA) axis to explore the relationships between cortisol secretion and adult bone mass in 151 healthy men and 96 healthy women aged 61 to 73 years. At baseline and 4-year follow-up, bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the lumbar spine and proximal femur; a lifestyle questionnaire was completed; and height, weight, and waist and hip circumferences were measured. At follow-up subjects underwent a very low-dose (0.25 mg) dexamethasone suppression test, a low-dose (1 microg) short synacthen test, and a 24-hour urine collection for measurement of cortisol and its metabolites. In men, elevated peak plasma cortisol was associated with accelerated loss of mineral density in the lumbar spine (r = 0.16, P = 0.05). This relationship remained significant after adjustment for testosterone, estradiol, 25-hydroxyvitamin D, and parathyroid hormone levels (r = 0.22, P = 0.01) and after additional adjustment for age, (BM), activity, cigarette and alcohol consumption, and Kellgren/Lawrence score (r = 0.19, P = 0.03). In contrast in women, elevated peak plasma cortisol was associated with lower baseline BMD at the femoral neck (r = -0.23, P = 0.03) and greater femoral neck loss rate (r = 0.24, P = 0.02). There was no association between plasma cortisol concentrations after dexamethasone or urinary total cortisol metabolite excretion and bone density or bone loss rate at any site. These data provide evidence that circulating endogenous glucocorticoids influence the rate of involutional bone loss in healthy individuals.

Absorptiometry, Photon↗

Mass balance study of [14C]M100240, a dual angiotensin-converting enzyme/neutral endopeptidase inhibitor, in healthy male subjects.

[4S-[4alpha,7alpha(R*),12bbeta]]-7[[2-(acetylthio)-1-oxo-3-phenylpropyl]amino]-1,2,3,4,6,7,8,12b-octahydro-6-oxo-pyrido[2,1-a][2]benzazepine-4-carboxylic acid (M100240) is an acetate thioester of MDL 100,173-a dual angiotensin-converting enzyme/neutral endopeptidase inhibitor currently in phase II development. The mass balance of [(14)C]M100240 was assessed following oral administration of [(14)C]M100240. Healthy male subjects were given a single 25-mg dose of [(14)C]M100240 (50 microCi) as an oral solution under fasting conditions. Blood samples and excreta were collected postdose. (14)C-radioactivity was measured by liquid scintillation counting. Plasma concentrations of M100240 and MDL 100,173 were determined by LC/MS/MS methods. Pharmacokinetic parameters were calculated. About 98% of the total radioactive dose was recovered within 7 days of oral administration, with most of the radioactivity recovered within 72 hours. Of the recovered radioactive dose, 49.4% and 48.5% were recovered in the urine and feces, respectively. Unchanged M100240 and MDL 100,173 were not detected in the excreta. On average, 76% of the total radioactivity in the blood was associated with the plasma fraction. M100240 accounted for less than 0.06% of the (14)C-radioactivity in plasma and MDL 100,173 accounted for 15.8% (AUC( infinity )) of (14)C-radioactivity in plasma after oral dosing. These data suggest that the drug was absorbed but rapidly converted to its metabolites either presystemically or postsystemically. Up to 78% of the total radioactivity was identified as MDL 100,173. The apparent terminal elimination half-life of MDL 100,173 was longer than that of (14)C-radioactivity, attributable to assay sensitivity and the saturable binding phenomenon commonly associated with angiotensin-converting enzyme inhibitors. M100240 undergoes extensive metabolism in humans, and its metabolites are excreted relatively equally in feces and urine.

Administration, Oral↗

Probing striato-thalamic function in obsessive-compulsive disorder and Tourette syndrome using neuroimaging methods.

In summary, contemporary pathophysiological models of OCD and related disorders implicate CSTC circuitry. In this chapter, we have reviewed relevant concepts related to implicit learning and more specifically, the use of an implicit sequence learning paradigm as a probe of striato-thalamic function. An initial PET investigation of patients with OCD confirmed a priori hypotheses of failure to recruit right striatum, despite the absence of a performance deficit (22). A modified version of the SRT was studied in conjunction with fMRI and yielded reliable right-lateralized striatal activation in a cohort of 10 male subjects, with clear spatial dissociation of caudate and putamen activation foci (119). Subsequent studies in our laboratory suggest that this paradigm also yields a reliable temporal window of thalamic deactivation, and hence a means for assessing thalamic gating in human subjects (120). Finally, as presented in this chapter, preliminary data from the fMRI-SRT in patients with OCD and TS as well as normal control subjects appear to replicate and extend the findings from our original PET-SRT study in OCD. Future investigations in our laboratory will seek to elaborate upon these preliminary results. In particular, we intend to study psychiatric comparison groups to establish the generalizability and/or specificity of these findings across disorders. Within OCD, we hope to explore the relationship between abnormal brain-activation patterns and symptom dimensions (34). Further, by studying subjects with remitted OCD who have been successfully treated, we hope to determine whether the observed brain-activation abnormalities represent state or trait markers. Finally, we have already begun to test a hypothesis of parallel processing deficiency in OCD by using a dual-task version of the SRT that makes simultaneous demands on implicit and explicit information processing systems (128). It is our hope that this program of research will yield new insights about OCD and related disorders, including TS. Most importantly, as other teams of investigators pursue complementary lines of inquiry, it is our wish that collective efforts in this field will lead to improved diagnosis and treatment, if not cure or prevention, for those who are afflicted with these illnesses.

Corpus Striatum↗

Homeless, mentally ill and addicted: the need for abuse and trauma services.

This paper examines an empirical investigation of the lifetime prevalence of trauma (defined as sexual and/or physical abuse) in a cohort of adults enrolled in a federally funded initiative that provides treatment for homeless persons suffering the effects of comorbid substance use and serious mental illness, and considers the impact of this information on clinical programming. Data collected from homeless individuals with co-occurring disorders admitted to the Seeking Treatment and Recovery (STAR) Program during a one year period (n=78) were analyzed for a history of trauma events. Of those individuals evaluated, 79.5% (62/78) acknowledged a history of either physical and/or sexual abuse at some time in their lifetimes. Of this population, 100% of the homeless women (27/27) with co-occurring disorders had experienced a life-altering traumatic event while 68.6% (35/51) of the homeless men also reported trauma histories. We describe the trauma-based interventions made in the STAR Program that have the potential for replication in other initiatives committed to serving homeless individuals with co-occurring disorders.

Adolescent↗

Do pancreatic duct stents cause or prevent pancreatic sepsis?

BACKGROUND: Pancreatic sepsis can occur after contrast injection into an obstructed or disrupted pancreatic duct. Whether stents cause or prevent pancreatic sepsis is unknown. Accordingly, the pancreatic duct bacteriology in patients with pancreatic duct stents was retrospectively reviewed and contrasted with biliary cultures taken from patients at the time of bile duct stent retrieval and/or exchange. METHODS: Of 61 patients (29 men, 32 women; 72 stents; mean age 51 [16] years, range 14-88 years), 36 with pancreatic duct stents had pancreatic duct cultures obtained at the time of stent exchange and/or retrieval. The results of these cultures were compared with bile duct cultures taken from 36 patients at the time of biliary stent exchange/retrieval. Eleven of the 36 patients with pancreatic duct stents also had bile duct stents. Data collected included stent patency, clinical sepsis at initial stent placement or retrieval, administration of antibiotics before the procedure, indication for stent placement, stent duration, and culture results. RESULTS: At stent retrieval and/or exchange, all 61 patients with pancreatic and/or biliary stents had contamination of the respective ducts with multiple enteric bacteria (mean 3.4 organisms in patients with pancreatic duct stents vs. 3.3 in those with bile duct stents). Clostridium perfringens was found in 17% and 0% of patients with, respectively, bile duct and pancreatic duct stents. Among the most common indications for pancreatic duct stent placement were stricture (28), sphincterotomy (9), leak (7), stones (3), and dilated pancreatic duct (1). Indications for a biliary stent included benign stricture (29), malignancy (6), stones (2), cholangitis (1), chronic pancreatitis (1), and dilated common bile duct (1). Pancreatic cultures were taken at a median of 85 days (interquartile range 60-126; range 13-273) and biliary cultures at a median of 87 days (interquartile range 45-149; range 19-927) after stent placement. Eleven patients, 6 with a bile duct stent, 4 with a pancreatic duct stent, and one with dual stents, developed pre-exchange/retrieval clinical sepsis; 3 had pancreatic sepsis. All had received antibiotics at initial placement. In the 11 patients with sepsis (12 stents), 8 stents were completely occluded at exchange/retrieval, 3 were partially occluded, and one was patent. In 50 patients (60 stents), no clinical sepsis developed; 7 stents were patent, 31 partially occluded, and 22 completely obstructed. CONCLUSIONS: (1) Comparable to patients with biliary stents, all patients with pancreatic stents had contamination of the pancreatic ductal system by enteric flora. (2) In contrast to the 17% of patients with bile duct stents who had intraductal Clostridium perfringens, there were no instances of contamination with this organism in patients with pancreatic stent (p = 0.025), although, after adjusting for multiple comparisons, statistical significance was lost. (3) There was a tendency for stent occlusion to predispose to pancreatic sepsis, but occlusion by itself was insufficient (p = 0.106). (4) Further investigation is required to define the additional variables that are associated with the development of pancreatic sepsis.

Adolescent↗

Permanent pacing for cardioinhibitory malignant vasovagal syndrome.

OBJECTIVE: To evaluate the effect of permanent pacing in cardioinhibitory malignant vasovagal syndrome. PATIENTS AND METHODS: 37 patients with permanent pacemakers for cardioinhibitory malignant vasovagal syndrome. All presented with syncope (median six episodes, median frequency two episodes a year) and after conventional investigation and invasive electrophysiological assessment they remained undiagnosed, and without a generally accepted indication for pacemaker implantation. In all vasovagal syncope with cardioinhibition (heart rate at syncope < 60 beats/min) developed during tilt tests performed according to the Westminster protocol (head up tilt at 60 degrees with a footplate support for 45 minutes or until syncope intervenes). Dual chamber pacemakers were implanted in 35 (95%) and VVI pacemakers in the remaining two (5%). RESULTS: Over a mean (SD) follow up since implantation of 50.2 (23.9) months symptomatic improvement occurred in 89%: 62% remained free of syncope and 27% were completely symptom free. The collective syncopal burden of these 37 patients was reduced from 136 to 11 episodes each year. During follow up three patients died from unrelated causes. Patients who become asystolic during the tilt test (sinus pause of at least four seconds) experienced no greater benefit from pacing than those with less extreme cardioinhibition. Patients who remained free of syncope since implantation were younger than those who continued to experience syncope. Patients who remained completely symptom free after implantation were younger, more likely to be male, and had had fewer syncopal episodes before implantation than those who continued to experience syncope or presyncope. No other demographic, clinical, investigative, or pacing variable suggested a more favourable outcome after implant. CONCLUSIONS: This retrospective and uncontrolled experience suggests a possible role for permanent pacing in selected patients with cardioinhibitory malignant vasovagal syndrome. Improved acquisition of tilt test data may enable better selection of patients who are suitable for permanent pacing. A randomised prospective study to compare permanent pacing with no treatment or with medical treatment in cardioinhibitory malignant vasovagal syndrome is indicated.

Adult↗

Survival in patients with class III idiopathic pulmonary arterial hypertension treated with first line oral bosentan compared with an historical cohort of patients started on intravenous epoprostenol.

BACKGROUND: The oral dual endothelin receptor antagonist bosentan improves exercise capacity and delays clinical worsening in patients with pulmonary arterial hypertension, but its use could delay starting intravenous epoprostenol, a life saving treatment. METHODS: Survival in patients with functional class III idiopathic pulmonary arterial hypertension (PAH) treated with bosentan in clinical trials was compared with historical data from similar patients treated with epoprostenol in the clinic. Statistical methods were used to adjust for possible underlying differences between the two groups. RESULTS: Baseline factors for the 139 patients treated with bosentan and the 346 treated with epoprostenol suggested that the epoprostenol cohort had more severe disease-that is, a lower cardiac index (2.01 v 2.39 l/min/m2) and higher pressures and resistance. Kaplan-Meier survival estimates after 1 and 2 years were 97% and 91%, respectively, in the bosentan cohort and 91% and 84% in the epoprostenol cohort. Cox regression analyses adjusting for differences in baseline factors showed a greater probability of death in the epoprostenol cohort (hazard ratio 2.2 (95% confidence interval 1.2 to 4.0) in the model adjusted for haemodynamics). Alternative regression analyses and analyses to adjust for different data collection dates gave consistently similar results. When matched cohorts of 83 patients each were selected, survival estimates were similar. In the bosentan cohort 87% and 75% of patients followed for 1 and 2 years, respectively, remained on monotherapy. CONCLUSIONS: No evidence was found to suggest that initial treatment with oral bosentan, followed by or with the addition of other treatment if needed, adversely affected the long term outcome compared with initial intravenous epoprostenol in patients with class III idiopathic PAH.

Administration, Oral↗