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Biomedical subjects

D L Johnston

Publications and source records attributed to D L Johnston.

At least 19 recordsLinked to original sources

Neuronal apoptosis inhibitory protein expression after traumatic brain injury in the mouse.

Apoptosis of brain cells is triggered by traumatic brain injury (TBI) and is blocked by caspase inhibitors. The neuronal apoptosis inhibitor protein (NAIP), which has been shown to inhibit apoptosis by both caspase-dependant and caspase-independent mechanisms, is neuroprotective in rat models of cerebral ischemia and axotomy. In order to gain a better appreciation of CNS apoptosis following head injury in general and the possible involvement of NAIP specifically, we have configured a mouse model of TBI. In addition to demonstrating apoptosis, the spatiotemporal expression or levels of a number of proteins with apoptosis modulating effects have been determined. Apoptosis of neurons and oligodendrocytes following TBI was observed in brain sections which were triple-stained with in situ end labeling, bisbenzimide and immunofluorescent stain for neuron specific nuclear protein and myelin-associated glycoprotein, respectively. Further evidence for apoptosis following TBI in this model was obtained in brain samples using ligation-mediated PCR amplification of DNA fragments and gel electrophoresis. The temporal profile of apoptosis was similar to the temporal profile of microglial activation determined by CD11b staining and TNFa expression induced by TBI. NAIP staining in sections of cerebral cortex and subcortical white matter increased at 6 h and decreased towards control levels at 24 h post-TBI. Temporal changes in the expression of NAIP were also observed using Western blot analysis of brain samples removed from injured cortex and sub-cortical white matter. At the time that NAIP expression decreased markedly (24 h post-TBI), procaspase-3 levels also decreased, PARP cleavage increased, and the highest levels of apoptosis were observed. These findings have implications in our understanding of traumatically induced programmed cell death and may be useful in the configuration of therapies for this common injury state.

Animals↗

Deep soft tissue infections in the neutropenic pediatric oncology patient.

PURPOSE: Necrotizing fasciitis and myonecrosis can be rapidly fatal without prompt and aggressive medical and surgical therapy. We reviewed our experience with necrotizing fasciitis and myonecrosis in neutropenic pediatric oncology patients to describe associated clinical characteristics and outline therapeutic interventions. PATIENTS AND METHODS: A retrospective chart review was performed for all cases of deep soft tissue infection found in neutropenic pediatric oncology patients during an 11-year period. RESULTS: Seven cases of necrotizing fasciitis and/or myonecrosis associated with chemotherapy-induced neutropenia were diagnosed during the study period. Deep soft tissue infection was diagnosed a median of 14 days after the initiation of chemotherapy. All of the patients presented with fever and pain, generally out of proportion to associated physical findings. Most patients (86%) also had tachycardia and subtle induration at the site of soft tissue infection. The pathogenic organism in four of seven patients originated in the gastrointestinal tract. Patients were treated with antibiotics, surgical debridements, granulocyte colony-stimulating factor, and hyperbaric oxygen. Granulocyte transfusions were administered if there were no signs of neutrophil recovery. Five patients survived their deep soft tissue infection. CONCLUSIONS: The diagnosis of necrotizing fasciitis and/or myonecrosis should be considered in any neutropenic patient with fever, tachycardia, and localized pain out of proportion to the physical findings. Appropriate therapy includes broad-spectrum intravenous antibiotics and urgent surgical intervention. Granulocyte colony-stimulating factor should be administered to all patients to enhance neutrophil recovery. Granulocyte transfusions should be considered if a prolonged period of neutropenia is anticipated.

Adolescent↗

Contrast-enhanced 3D MR breathhold imaging of porcine coronary arteries using fluoroscopic localization and bolus triggering.

The purpose of this study was to develop cardiac-gated contrast-enhanced 3D MRA for imaging the coronary arteries of pigs. Each major coronary artery was imaged individually in a single 3D slab in one breathhold. To permit acquisition within a breathhold, a limited number of partitions (12-16) were collected in a single, oblique, thin 3D slab. Typical resolution of the acquisition was 0.8 (X) x 1.6 (Y) x 1.6 (Z) mm. MR fluoroscopic localization was used to establish the 3D double-oblique orientation. Real-time MR fluoroscopy was also used to instantaneously trigger the 3D scan after detection in the aortic root of the intravenously administered contrast bolus. Six pigs were used in the study. Each pig was scanned on two separate days. Images routinely show the majority of the length of the three principal coronary arteries. Magn Reson Med 42:1159-1165, 1999.

Animals↗

Pulmonary function monitoring during adenosine myocardial perfusion scintigraphy in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To determine whether adenosine could be safely administered to patients with chronic obstructive pulmonary disease (COPD) for coronary vasodilatation during perfusion scintigraphy without causing bronchospasm. MATERIAL AND METHODS: The study was divided into two phases. In the monitoring phase, patients with COPD were pretreated with an inhaled bronchodilator (albuterol) and had pulmonary function monitored during the infusion of a graduated dose of adenosine. Eligibility for entry into this phase of the study was determined on the basis of results of pulmonary function testing (PFT) during resting. Once we had shown that adenosine could be safely administered to patients with COPD, an implementation phase was begun. Entry did not require resting PFT, and patients were administered adenosine without monitoring of pulmonary function. Differences between patients with normal pulmonary function or mild COPD and those with more severe COPD were analyzed statistically. RESULTS: Of 94 patients entered into the monitoring phase, none had obvious bronchospasm. The dosage of adenosine was reduced in four patients because of a decrease in forced expiratory volume in 1 second (FEV1) of 20% in comparison with baseline (FEV1 before administration of albuterol). The mean FEV1 decreased slightly from 1.83 L after administration of albuterol to 1.78 L during the maximal adenosine dose. Patients with a remote history of asthma, positive result of a methacholine challenge test, or mild COPD (FEV1 60 to 80% of the maximal predicted value for age) did not differ significantly in their response to infusion of adenosine from those with moderate or severe COPD (FEV1 30 to 59% of the maximum predicted for age). Of 117 patients in the implementation phase, 2 had bronchospasm during infusion of adenosine that was quickly terminated by stopping the administration in one patient and reducing the dose of adenosine in the other. CONCLUSION: This study shows that adenosine can be safely administered intravenously to selected patients with known or suspected COPD to produce coronary vasodilatation for myocardial perfusion imaging. Patients who are within the guidelines established for this study should be considered for adenosine coronary vasodilatation with use of bronchodilator pretreatment, a graduated dose of adenosine, and regular chest auscultation during the infusion.

Adenosine↗

Clinical determinants of hemodynamic and symptomatic responses in 2,000 patients during adenosine scintigraphy.

OBJECTIVE: To determine whether subsets of patients referred for a clinically indicated radionuclide adenosine stress study respond differently to a standard infusion of adenosine. MATERIAL AND METHODS: We assessed multiple clinical and hemodynamic variables in the first 2,000 patients who underwent adenosine perfusion studies in our laboratory. A relevant clinical variable was defined as one that was significantly associated with changes in heart rate and blood pressure during adenosine infusion. Relevant clinical variables that were most significantly related to hemodynamic variables included age, gender, rhythm (atrial fibrillation), diabetes, and left ventricular function. These variables were then related to symptomatic responses (adverse effects) to adenosine infusion. To determine whether the different peripheral responses to adenosine reflected clinically important differences in coronary vasodilatation, we compared perfusion imaging with coronary angiographic findings in the 408 patients who underwent both studies within 6 months of each other. RESULTS: The decrease in systolic blood pressure was greater and the reflex tachycardia was less in patients 70 years of age or older and in those with insulin-dependent diabetes in comparison with younger patients and those without type 1 diabetes. Men had smaller decreases in blood pressure and smaller increases in heart rate than did women. Patients with atrial fibrillation and those with left ventricular ejection fraction less than 40% had smaller decreases in blood pressure and smaller increases in heart rate than did those in sinus rhythm or those with an ejection fraction of 40% or more. Age 70 years or older, male gender, atrial fibrillation, and left ventricular ejection fraction less than 40% were associated with fewer symptoms and less severe chest pain in comparison with patients without these variables. For patients with coronary angiograms, the relationship between coronary artery disease evident on angiography and perfusion abnormalities noted on scintigraphy was not different for any of the relevant clinical variables. CONCLUSION: Common clinical patient subsets are associated with different peripheral hemodynamic and symptomatic responses to infusion of adenosine. Despite these observations, however, the ability to detect coronary artery disease with perfusion imaging is not obviously altered.

Adenosine↗

Determination of ventricular ejection fraction: a comparison of available imaging methods. The Cardiovascular Imaging Working Group.

Knowledge of left ventricular ejection fraction has been shown to provide diagnostic and prognostic information in patients with known or suspected heart disease. In clinical practice, the ejection fraction can be determined by using one of the five currently available imaging techniques: contrast angiography, echocardiography, radionuclide techniques of blood pool and first pass imaging, electron beam computed tomography, and magnetic resonance imaging. In this review, we discuss the clinical application as well as the advantages and disadvantages of each of these methods as it relates to determination of ventricular ejection fraction.

Angiocardiography↗

Dynamic MR digital subtraction angiography using contrast enhancement, fast data acquisition, and complex subtraction.

A dynamic MR angiography technique, MR digital subtraction angiography (MR DSA), is proposed using fast acquisition, contrast enhancement, and complex subtraction. When a bolus of contrast is injected into a patient, data acquisition begins, dynamically acquiring a thick slab using a fast gradient echo sequence for 10-100 s. Similar to x-ray DSA, a mask is selected from the images without contrast enhancement, and later images are subtracted from the mask to generate angiograms. Complex subtraction is used to overcome the partial volume effects related to the phase difference between the flowing and stationary magnetization in a voxel. Vessel signal is the enhancement of flow magnetization resulting from the contrast bolus. MR DSA was performed in 28 patients, including vessels in the lungs, brains, legs, abdomen, and pelvis. All targeted vessels were well depicted with MR DSA. Corresponding dynamic information (contrast arrival time ta and duration of the arterial phase tav) was measured: ta/tav = 3.4/4.7 s for the lung, 10.3/4.9 s for the brain, 12.8/19.3 for the aorta, 15.2/12.6 s for the leg. MR DSA can provide dynamic angiographic images using a very short acquisition time.

Abdomen↗

Hemodynamic responses and adverse effects associated with adenosine and dipyridamole pharmacologic stress testing: a comparison in 2,000 patients.

OBJECTIVE: To compare the hemodynamic responses and the adverse effects associated with two coronary vasodilators used for pharmacologic stress testing. DESIGN: We retrospectively studied the results of adenosine and dipyridamole perfusion imaging in a large group of patients who underwent pharmacologic stress radionuclide perfusion imaging. MATERIAL AND METHODS: One thousand patients given dipyridamole between April 1989 and April 1991 (before adenosine became available) were compared with 1,000 patients given adenosine between April 1991 and October 1992. A standard protocol was used to infuse the drugs before myocardial perfusion imaging with 201Tl or 99mTc sestamibi. RESULTS: Peak heart rate was higher (85 versus 83 beats/min; P = 0.02) and systolic blood pressure was lower (129 versus 133 mm Hg; P < 0.0001) with adenosine than with dipyridamole. More patients had a decrease in systolic blood pressure of 30 mm Hg or more with adenosine than with dipyridamole (P = 0.002). Horizontal or downsloping ST-segment depression of 1 mm or more occurred in 9% of patients who received adenosine and in 8% of those who received dipyridamole. Adverse effects occurred in 78% of the adenosine study group and in 50% of the dipyridamole group (P < 0.0001). Chest pain was the most common symptom with both drugs. Atrioventricular block occurred in 76 patients who received adenosine but in none who received dipyridamole. Because of adverse effects, 28% of patients who received dipyridamole required extra monitoring time (mean, 6 +/- 5 minutes beyond the standard protocol). Aminophylline was administered to 163 and 6 patients, respectively, in the dipyridamole and adenosine study groups. CONCLUSION: Adenosine causes slightly greater systemic vasodilation than does dipyridamole. Adverse effects occur less often with dipyridamole but, in comparison with adenosine, are more difficult to manage and necessitate more monitoring time as well as fairly frequent intravenous use of aminophylline for reversal.

Adenosine↗

Detection of viable myocardium in segments with fixed defects on thallium-201 scintigraphy: usefulness of magnetic resonance imaging early after acute myocardial infarction.

To determine if magnetic resonance imaging (MRI) can be used to detect tissue viability in segments with persistent 201T1 defects early following acute myocardial infarction, 24 patients underwent MRI and adenosine 201T1 single photon emission computed tomography (SPECT) imaging at approximately 6 days. Infarction was demonstrated on MRI using a velocity-compensated, T2-weighted spin-echo pulse sequence. Wall thickening was assessed using a gradient-echo pulse sequence obtained in the same anatomic position. Viable myocardium was defined by MRI as a segment with increased signal intensity and preserved wall thickening. A fixed defect on the 201T1 SPECT images was defined as the absence of any redistribution 4 hours after the 201T1 infusion. Of 11 patients with redistribution on the 201T1 images in the infarction region, 10 (91%) had preserved wall thickening by MRI. Of 13 patients with fixed defects on the 201T1 images in the infarction region, 6 (46%) had preserved wall thickening by MRI. Of 7 patients with absent thickening, all had one or more segments with absent perfusion on redistribution imaging. Wall thickening tended to occur in patients who received thrombolytic therapy or who underwent revascularization procedures prior to imaging. The results of the present study suggest that spin-echo MRI with motion compensation can be used to identify viable myocardium in patients with fixed defects on 201T1 SPECT following acute myocardial infarction.

Adenosine↗

X-ray computed tomography and magnetic resonance imaging of the cardiovascular system.

Both electron beam (or ultrafast) x-ray computed tomography and magnetic resonance imaging are developing cardiovascular imaging modalities that can provide high temporal and spatial resolution images of the beating heart and the great vessels in the outpatient setting. The three-dimensional registration of these images has facilitated numerous studies, showing that these devices are capable of quantitating cardiovascular anatomy, function, and blood flow. Continued research employing these methodologies has examined both applications that are complementary to more traditional noninvasive cardiology tools, such as two-dimensional echocardiography and radionuclide and perfusion imaging, as well as applications unique to computed tomography or magnetic resonance imaging. This review discusses progress made in x-ray computed tomography, focusing on the application of electron beam computed tomography and new applications of magnetic resonance imaging within the past 2 years. Specific comments are made regarding these applications, as well as the limitations of both with regard to general clinical applications.

Blood Flow Velocity↗

Competency-based orientation in pediatric critical care.

Having recognized the need to update and modify their orientation program, a PICU nursing management team decided to develop a competency-based program. The goal was to facilitate transition of an orientee into a competent entry-level practitioner. This article outlines the procedure used to develop the initial phases: lists of competencies, competency evaluation worksheet and performance checklists. Later, various learning options and additional evaluation methods will be explored.

Child↗

Characterization of acute myocardial infarction by magnetic resonance imaging.

The T2-weighted spin-echo technique is currently the most frequently used magnetic resonance imaging (MRI) method to visualize acute myocardial infarction. However, image quality is often degraded by ghost artifacts from blood flow, and respiratory and cardiac contractile motion. To enhance the usefulness of this technique for detailed characterization of infarction, a velocity-compensated spin-echo pulse sequence was tested by imaging a flow phantom, 6 normal subjects and 17 patients with acute myocardial infarction. After preliminary studies were performed in 7 patients to determine optimal imaging parameters, a standardized imaging protocol was used in the next 10. The location of myocardial infarction identified by the electrocardiogram and coronary anatomy was correctly identified in 10 of 10 patients. Distribution of the injury within the left ventricle was clearly visualized, and showed that patients often had a mixture of transmural and nontransmural injury. Heterogenous distribution of signal intensity within the infarction suggested the presence of hemorrhage. Papillary muscle involvement was readily apparent. Signal intensity of the infarction (brightest segment) was increased by 89 +/- 31% compared with the mean of the remote segments. The myocardial/skeletal muscle ratio was significantly (p less than 0.001) increased for the infarction segments compared with that for remote myocardium, allowing quantitative analysis of segmental signal intensity. The MRI wall motion study obtained as part of this protocol demonstrated wall thickening in 58% of the infarction segments and in 6 of 10 patients. This finding suggested the presence of reversibly injured myocardium. In conclusion, the results demonstrate the potential of MRI for detailed tissue characterization after acute myocardial infarction.

Adult↗

Serial magnetic resonance imaging in patients following acute myocardial infarction.

The detection of serial changes in magnetic resonance (MR) signal intensity of the heart following acute myocardial infarction may provide a useful method of characterizing tissue healing. Fourteen patients with acute Q-wave infarction underwent T2-weighted, spin-echo cardiac imaging during hospitalization, followed by one or more additional MR studies (total 31) over a 6- to 27-wk period (mean: 3 mo). Visual assessment of the images demonstrated a gradual reduction in signal intensity and localization of the bright signal to the subendocardium of the infarction region over the three-mo study period. A quantitative measurement of signal intensity (infarction/normal myocardium) fell from 1.81 +/- 0.42 on the initial study to 1.34 +/- 0.37 (p less than 0.05) at a mean of 14 wk. Two patients had an increase in signal intensity on the follow-up study and both patients had been readmitted with acute coronary syndromes. In summary, characterization of changes in signal intensity may provide a useful method of assessing myocardial healing following acute myocardial infarction. Further studies are indicated to determine the prognostic significance of these parameters.

Female↗

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↗

Effects of inosine on glycolysis and contracture during myocardial ischemia.

The effects of inosine (INO) on substrate metabolism and rigor formation in ischemic myocardium were examined in isolated rabbit hearts. Metabolite content was assessed in tissue extracts by chemical analysis and in the whole heart by 13C and 31P nuclear magnetic resonance spectroscopy. In ischemic hearts metabolizing either [3-13C]pyruvate or [1-13C]glucose, 1 mM INO increased both total and 13C-labeled alanine content; lactate content was unaffected. At 3 minutes of ischemia, tissue alanine was 1.81 +/- 0.11 microM/g wet wt (mean +/- SEM) in hearts perfused with pyruvate+INO versus 1.23 +/- 0.15 microM/g wet wt in hearts perfused with pyruvate alone (p less than 0.05). INO reduced tissue glycogen during ischemia in pyruvate-perfused hearts. Tissue alanine content in ischemic hearts that were supplied glucose+INO (1.29 +/- 0.13 microM/g wet wt) was greater than in ischemic hearts supplied glucose alone (0.65 +/- 0.14 microM/g wet wt). Alanine was found to originate from pyruvate and was a glycolytic end product in glucose-perfused hearts. INO raised the [3-13C]alanine/[3-13C]lactate ratio in ischemic, intact hearts (glucose = 0.24 +/- 0.07 versus glucose+INO = 0.60 +/- 0.09; pyruvate = 0.49 +/- 0.08 versus pyruvate+INO = 0.89 +/- 0.08). At 7 minutes of ischemia, ATP content fell to 70 +/- 3% with glucose+INO versus 58 +/- 5% with glucose alone. Rigor (stone heart) was delayed from 14.7 +/- 1.3 to 23.2 +/- 1.6 minutes with INO. INO did not change ATP content in ischemic hearts that were supplied pyruvate but delayed rigor (pyruvate = 9.9 +/- 1.2 minutes; pyruvate+INO = 15.6 +/- 1.0 minutes), possibly at the expense of glycogen. Supplemental glucose improved the effectiveness of INO with pyruvate to preserve ATP (pyruvate+glucose = 42 +/- 6%; pyruvate+glucose+INO = 72 +/- 6%) and further delayed rigor (pyruvate+glucose = 13.3 +/- 1.5 minutes; pyruvate+glucose+INO = 20.3 +/- 1.8 minutes). Glucose metabolism supported improved energetic and contractile states in ischemic hearts treated with INO. Thus, cardioprotection of the ischemic heart by INO was associated with preservation of functional integrity and improved energy production due to increased glycolytic activity. Activation of glycolysis in the presence of INO was accommodated by augmented alanine production without the additional accumulation of lactate.

Alanine↗