Effects of unloading and positive inotropic interventions on left ventricular function in asymptomatic patients with chronic severe aortic insufficiency.

The effect of an unloading (nifedipine, 20 mg sublingually) and of a combined unloading and positive inotropic intervention (nifedipine plus digoxin, 0.5 mg intravenously) on left ventricular performance was assessed in 48 patients with chronic severe aortic insufficiency. The left ventricular pump function-myocardial contractility relation (ejection fraction, EF vs. peak arterial pressure to end-systolic volume ratio, PAP/ESV), and the pump function-afterload relation (EF vs. mean systolic wall stress, MWS) were constructed by means of quantitative M-mode and two-dimensional echocardiography. In patients with normal control pump function (n = 14), nifedipine markedly decreased MWS, moving the patients to a new, more advantageous EF-MWS relation. In the 34 patients with abnormal pump function, the myocardial contractility level was the mean factor conditioning the response to pharmacological intervention. Patients with a value of PAP/ESV greater than 2.5 (n = 22) had normalization of EF after nifedipine and were upgraded to a more advantageous outlook for left ventricular mechanics EF-MWS and EF-PAP/ESV relations. Of the 12 patients without normalization of EF after nifedipine, only the 4 patients with PAP/ESV greater than 2 had normalization of pump function indices after combined administration of nifedipine and digoxin

Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction

ObjectivesWe examined the influence of medical treatment on the results of surgery in terms of long-term survival and functional results in patients with chronic, severe aortic regurgitation (AR).BackgroundAsymptomatic patients with AR and a reduced left ventricular ejection fraction (LVEF) are at high risk because of a higher-than-expected long-term mortality. The influence of preoperative medical therapy on the outcome after aortic valve replacement (AVR) is not well known.MethodsSurgery was indicated for the appearance of a reduced LVEF (<50%). At the time of AVR, there were 134 patients treated with nifedipine (group A), and 132 received no medication (group B).ResultsOperative mortality was similar in the two groups (0.75% vs. 0.76%, p = NS). The LVEF normalized in all of group A, whereas it remained abnormal in 36 group B patients (28%). At 10-year follow-up, LVEF persisted higher in group A (62 ± 5% vs. 48 ± 4%, p < 0.001). Five-year survival was similar in the two groups (94 ± 2% vs. 94 ± 3%, p = NS). Group A showed a 10-year survival not different from expected and significantly higher than that in group B (85 ± 4% vs. 78 ± 5%, p < 0.001), which had a worse survival than expected.ConclusionsUnloading treatment with nifedipine in AR allows one to indicate AVR at the appearance of a reduced LVEF with a low operative mortality and an optimal long-term outcome. The concept of surgical correction of AR indicated for reduced LVEF may not be applied to all patients. Indeed, in a large amount of untreated patients, a reduced LVEF preoperatively is not reversed by prompt surgery, indicating irreversible myocardial damage, and 10-year survival is worse than expected

Hypertrophic cardiomyopathy: two-dimensional echocardiographic score versus clinical and electrocardiographic findings.

The severity and site of hypertrophy is important in determining the clinical picture and the natural history of hypertrophic cardiomyopathy (HCM). We evaluated left ventricular hypertrophy by means of two-dimensional echocardiographic score and score index, and correlated these findings with symptoms, electrovector-cardiographic data, and ventricular arrhythmias. A total of 42 patients with HCM were studied by clinical examination, ECG, VCG, M-mode and 2D echocardiography, and 24-h Holter monitoring. The extent and severity of the hypertrophic process were calculated by a score system. The left ventricle was divided into 11 segments and a hypertrophic score (HS) was given to each segment. A hypertrophy score index (HSI) was also calculated by dividing the number of hypertrophied segments by 13. No correlation was found between symptoms and HS and HSI, nor ECG-VCG abnormalities and HS and HSI. A statistically significant relationship between the severity of ventricular arrhythmias and HS and HSI was found (p less than 0.01). The mechanism responsible for ventricular tachyarrhythmias in severe and diffuse hypertrophy might reside in the high intraventricular pressures which produce or worsen areas of myocardial ischemia

Multistarter from Organic Viticulture for Red Wine Montepulciano d’Abruzzo Production

In the last years the use of a multistarter fermentation process has been proposed to improve the organoleptic characteristics of wines. In the present study the fermentation performances and the interactions of mixed and sequential cultures of Hanseniaspora uvarum, Candida zemplinina, and a strain of Saccharomyces cerevisiae isolated from organic musts were investigated. To evaluate the oenological performances of the tested strains microvinifications in pasteurized red grape juice from Montepulciano d’Abruzzo cultivar were compared. The course of fermentation has been controlled through classical determinations (CO2 evolution, ethanol, glycerol, pH, total titratable acidity, sugar content, free sulfur dioxide (SO2), dry extract, sugars, organic acids, and volatile compounds). Moreover, the yeast population was determined by both culture-dependent and independent approaches. In particular, the pure culture of H. uvarum and C. zemplinina did not end the fermentation. On the contrary, when S. cerevisiae was added, fermentations were faster confirming that yeast interactions influence the fermentation kinetics. Moreover, C. zemplinina showed a good interaction with S. cerevisiae by increasing the fermentation kinetic in high gravity Montepulciano must, with low ethyl acetate and acetic acid production. This study confirmed that non-Saccharomyces yeasts play a crucial role also in organic wines and their activity could be modulated through the selection of appropriate strains that correctly interact with S. cerevisiae

Food borne bacterial models for detection of benzo[a]pyrene-DNA adducts formation using RAPD-PCR

Random amplified polymorphic DNA (RAPD) PCR is a feasible method to evaluate genotoxin-induced DNA damage and mutations. In this study, Lactobacillus plantarum ATCC 14917T, Enterococcus faecium DSMZ 20477T, Escherichia coli PQ37 and Saccharomyces cerevisiae S441 were screened for DNA genetic alterations by DNA fingerprinting using M13 and LA1 primers after treatment with three compounds forming covalent adducts with DNA [benzo[a]pyrenediol epoxide (BPDE), methyl methanesulfonate and 1,2,3,4-diepoxybutane (DEB)]. M13 RAPD fingerprinting revealed that the total number of bands decreased in all treated DNA compared to control samples and generally the lost bands were characterized by high molecular weight. Some extra bands were detected for L. plantarum and E. faecium, while in E. coli and S. cerevisiae DNAs BPDE and DEB treatments did not result in new extra bands. Besides qualitatively analysis, cluster analysis based on Unweighted Pair-Group Method with Average algorithm was performed to compare DNA fingerprints before and after treatments. This analysis confirmed the absence of significant differences between negative controls and treated DNA in S. cerevisiae and E. coli however the disappearance of some bands can be detected. The data indicate that this approach can be used for DNA damage detection and mutations induced by genotoxic compounds and highlighted the possible use of L. plantarum and E. faecium M13 based fingerprinting as reference for hazard identification in risk assessment

Myocardial dysfunction and abnormal left ventricular exercise response in autonomic diabetic patients

In diabetic patients, the pathophysiologic mechanisms of exercise-induced left ventricular (LV) dysfunction remain controversial. In this study, the role of myocardial contractility recruitment in determining an abnormal LV response to isometric or dynamic exercise has been investigated in 14 diabetic patients with autonomic dysfunction. Ischemic heart disease was excluded by the absence of LV wall motion abnormalities induced by isotonic and isometric exercise and by coronary angiography. Left ventricular and myocardial function were studied at rest, and during isometric and isotonic exercise, by two-dimensional echocardiography; moreover, recruitment of an inotropic reserve was assessed by postextrasystolic potentiation at rest and at peak handgrip. An abnormal response of LV ejection fraction to isometric (9/14) or to dynamic (8/14) exercise was frequent in study patients. In these patients, baseline myocardial contractility was normal, and the significant increase in ejection fraction by postextrasystolic potentiation indicated a normal contractile reserve (65 +/- 7% vs. 74 +/- 6%, p = 0.001). Nevertheless, the downward displacement of LV ejection fraction-systolic wall stress relationships during exercise suggests an inadequate increase in myocardial contractility. However, the abnormal ejection fraction at peak handgrip was completely reversed by postextrasystolic potentiation (67 +/- 6% vs. 58.1 +/- 10%, p = 0.008), a potent inotropic stimulation independent of the integrity of adrenergic cardiac receptors. A defective inotropic recruitment, despite the presence of a normal LV contractile reserve, plays an important role in deexercise LV dysfunction in diabetic patients with autonomic neuropathy

Design strategies to improve patient motivation during robot-aided rehabilitation

BACKGROUND: Motivation is an important factor in rehabilitation and frequently used as a determinant of rehabilitation outcome. Several factors can influence patient motivation and so improve exercise adherence. This paper presents the design of two robot devices for use in the rehabilitation of upper limb movements, that can motivate patients during the execution of the assigned motor tasks by enhancing the gaming aspects of rehabilitation. In addition, a regular review of the obtained performance can reinforce in patients' minds the importance of exercising and encourage them to continue, so improving their motivation and consequently adherence to the program. In view of this, we also developed an evaluation metric that could characterize the rate of improvement and quantify the changes in the obtained performance. METHODS: Two groups (G1, n = 8 and G2, n = 12) of patients with chronic stroke were enrolled in a 3-week rehabilitation program including standard physical therapy (45 min. daily) plus treatment by means of robot devices (40 min., twice daily) respectively for wrist (G1) and elbow-shoulder movements (G2). Both groups were evaluated by means of standard clinical assessment scales and the new robot measured evaluation metric. Patients' motivation was assessed in 9/12 G2 patients by means of the Intrinsic Motivation Inventory (IMI) questionnaire. RESULTS: Both groups reduced their motor deficit and showed a significant improvement in clinical scales and the robot measured parameters. The IMI assessed in G2 patients showed high scores for interest, usefulness and importance subscales and low values for tension and pain subscales. CONCLUSION: Thanks to the design features of the two robot devices the therapist could easily adapt training to the individual by selecting different difficulty levels of the motor task tailored to each patient's disability. The gaming aspects incorporated in the two rehabilitation robots helped maintain patients' interest high during execution of the assigned tasks by providing feedback on performance. The evaluation metric gave a precise measure of patients' performance and thus provides a tool to help therapists promote patient motivation and hence adherence to the training program

Bulk ion heating with ICRH in JET DT plasmas

Reactor relevant ICRH scenarios have been assessed during DT experiments on the JET tokamak using H mode divertor discharges with ITER-like shapes and safety factors. Deuterium minority heating in tritium plasmas was demonstrated for the first time. For 9% deuterium, an ICRH power of 6 MW gave 1.66 MW of fusion power from reactions between suprathermal deuterons and thermal tritons. The Q value of the steady state discharge reached 0.22 for the length of the RF flat-top (2.7 s), corresponding to three plasma energy replacement times. The Doppler broadened neutron spectrum showed a deuteron energy of 125 keV, which was optimum for fusion and close to the critical energy. Thus, strong bulk ion heating was obtained at the same time as high fusion efficiency. Deuterium fractions around 20% produced the strongest ion heating together with a strong reduction of the suprathermal deuteron tail. The ELMs had low amplitude and high frequency and each ELM transported less plasma energy content than the 1% required by ITER. The energy confinement time, on the ITERH97-P scale, was 0.90, which is sufficient for ignition in ITER. 3He minority heating, in approximately 50:50 D:T plasmas with up to 10% 3He, also demonstrated strong bulk ion heating. Central ion temperatures up to 13 keV were achieved, together with central electron temperatures up to 12 keV. The normalized H mode confinement time was 0.95. Second harmonic tritium heating produced energetic tritons above the critical energy. This scheme heats the electrons in JET, unlike in ITER where the lower power density will allow mainly ion heating. The inverted scenario of tritium minority ICRH in a deuterium plasma was demonstrated as a successful heating method producing both suprathermal neutrons and bulk ion heating. Theoretical calculations of the DT reactivity mostly give excellent agreement with the measured reaction rates

Correlation analysis for energy losses, waiting times and durations of type I edge-localized modes in the Joint European Torus

Several important ELM control techniques are in large part motivated by the empirically observed inverse relationship between average ELM energy loss and ELM frequency in a plasma. However, to ensure a reliable effect on the energy released by the ELMs, it is important that this relation is verified for individual ELM events. Therefore, in this work the relation between ELM energy loss (W-ELM) and waiting time (Delta t(ELM)) is investigated for individual ELMs in a set of ITER-like wall plasmas in JET. A comparison is made with the results from a set of carbon-wall and nitrogen-seeded ITER-like wall JET plasmas. It is found that the correlation between W-ELM and Delta t(ELM) for individual ELMs varies from strongly positive to zero. Furthermore, the effect of the extended collapse phase often accompanying ELMs from unseeded JET ILW plasmas and referred to as the slow transport event (STE) is studied on the distribution of ELM durations, and on the correlation between W-ELM and Delta t(ELM). A high correlation between W-ELM and Delta t(ELM), comparable to CW plasmas is only found in nitrogen-seeded ILW plasmas. Finally, a regression analysis is performed using plasma engineering parameters as predictors for determining the region of the plasma operational space with a high correlation between W-ELM and Delta t(ELM)