Comparativecost-effectivenessanalyses of cardiacmagneticresonanceimaging versus invasive coronary angiography combined with fractional flow reserve testing to diagnose ischemia in coronary artery disease

Introduction: According to guidelines, patients with coronary artery disease (CAD) should undergo revascularization if myocardial ischemia is present. While coronary angiography (CXA) allows the morphological assessment of CAD, the fractional flow reserve (FFR) has proved to be a complementary invasive test to assess the functional significance of CAD, i.e. to detect ischemia. Perfusion Cardiac Magnetic Resonance (CMR) has turned out to be a robust non-invasive technique to assess myocardial ischemia. The objective: is to compare the cost-effectiveness ratio - defined as the costs per patient correctly diagnosed - of two algorithms used to diagnose hemodynamically significant CAD in relation to the pretest likelihood of CAD: 1) aCMRto assess ischemia before referring positive patients to CXA (CMR + CXA), 2) a CXA in all patients combined with a FFR test in patients with angiographically positive stenoses (CXA + FFR). Methods: The costs, evaluated from the health care system perspective in the Swiss, German, the United Kingdom (UK) and the United States (US) contexts, included public prices of the different tests considered as outpatient procedures, complications' costs and costs induced by diagnosis errors (false negative). The effectiveness criterion wasthe ability to accurately identify apatient with significantCAD.Test performancesused in the model were based on the clinical literature. Using a mathematical model, we compared the cost-effectiveness ratio for both algorithms for hypothetical patient cohorts with different pretest likelihood of CAD. Results: The cost-effectiveness ratio decreased hyperbolically with increasing pretest likelihood of CAD for both strategies. CMR + CXA and CXA + FFR were equally costeffective at a pretest likelihood of CAD of 62% in Switzerland, 67% in Germany, 83% in the UK and 84% in the US with costs of CHF 5'794, Euros 1'472, £ 2'685 and $ 2'126 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR. Implications for the health care system/professionals/patients/society These results facilitate decision making for the clinical use of new generations of imaging procedures to detect ischemia. They show to what extent the cost-effectiveness to diagnose CAD depends on the prevalence of the disease.

In vivo study comparing an X-shaped polymethylmethacrylate and a cylindrical collagen implant for deep sclerectomy

Il s'agit de comparer in vivo la sécurité et l'efficacité d'un implant en polyméthylméthacrylate (PMMA) avec un implant standard en collagène dans la sclérectomie profonde (SP) sur une durée de six mois. La population étudiée comprend vingt lapins, chaque lapin étant randomisé pour une SP avec implant en PMMA dans un oeil et implant de collagène dans l'autre oeil. Plusieurs éléments ont été pris en compte dans la comparaison : - la mesure de la pression intraoculaire - l'évolution de l'espace de drainage intrascléral et de la bulle de filtration sous-conjonctivale, suivie par ultrasonographic biomicroscopique (UBM) - la croissance de nouveaux vaisseaux de drainage sous-conjonctivaux, croissance quantifiée par angiographie du segment antérieur à la fluorescéine combinée au vert d'indocyanine - la facilité à l'écoulement de l'humeur aqueuse (C), mesurée à six mois par cannulation-perfusion de la chambre antérieur - la sclère au site de SP, histologiquement comparée à la sclère native opposée à 180°, également à six mois La pression intraoculaire moyenne préopératoire à une, quatre, douze et 24 semaines postopératoires est comparable dans les deux groupes (P>0.1). L'UBM montre une régression légèrement plus rapide (statistiquement non significative) de la bulle de filtration sous-conjonctivale et la persistance d'un espace de drainage intrascléral dans le groupe PMMA (P>0.05). De nouveaux vaisseaux de drainage sont observés à un mois de la chirurgie ; à six mois, ces vaisseaux sont plus nombreux dans le groupe PMMA, tant sur l'analyse angiographique que sur l'analyse histologique (P>0.05). La facilité moyenne à l'écoulement de l'humeur aqueuse est significativement plus élevées à six mois dans les deux groupes par rapport aux valeurs préopératoires (P>0.05), sans qu'il n'y ait de différence entre les deux implants (0.24 ± 0.06 μΙ/min/mmHg [PMMA] et 0.23 ± 0.07 μΙ/min/mmHg [implant en collagène]) (Ρ = 0.39). Cette étude a pu démontrer que la sclérectomie profonde avec implant en collagène ou en PMMA donne des résultats similaires en terme de diminution de l'IOP et d'augmentation de la facilité à l'écoulement de l'humeur aqueuse, sans différence sur le plan des réactions inflammatoires post-intervention.

Endurance training enhances vasodilation induced by nitric oxide in human skin.

Résumé Il a été démontré que l'exercice physique modifiait le contrôle de la thermorégulation cutané, ce qui se manifeste par une augmentation de la perfusion de la microcirculation de la peau. Pour une même augmentation de température, ce phénomène est plus important chez les sportifs d'endurance que chez les sujets sédentaires. Dans cette étude, nous posons l'hypothèse qu'une composante de cette adaptation peut provenir d'une plus haute capacité des vaisseaux sanguins à répondre à un stimulus vasodilatateur. Pour la tester, nous avons recruté des hommes sains, non fumeurs, soit entraînés (surtout sport d'endurance) ou sédentaires que nous avons partagé en deux classes d'âges (18-35 ans [jeunes] et >50 ans[âgés]). Le flux sanguin cutané était mesuré par un laser-Doppler au niveau de la peau de l'avant-bras. Nous avons alors mesuré la vasodilatation obtenue par les stimuli suivant : Iontophorèse à l'acétylcholine (ACh, un vasodilatateur dépendant de l'endothélium), iontophorèse au nitroprussiate de sodium (SNP, un donneur d'oxyde nitrique) et par libération d'une interruption momentanée du flux artériel huméral (hyperémie réactive). Chez les sujets entraînés, l'effet de l'hyperémie réactive et de l'ACh n'ont pas montré de différence. Par contre, l'augmentation de la perfusion, suivant la iontophorèse de SNP, exprimé en unité de perfusion (PU), était plus importante chez les sujets entraînés que chez les sujets sédentaires (jeunes: 398±54 vs 350±87, p<0.05; âgés: 339±72 vs 307±66, p<0.05). Pour conclure, l'entraînement d'endurance augmente l'effet vasodilatateur de l'oxyde nitrique de la microcirculation cutanée humaine, au moins au niveau de la peau de l'avant-bras. Ces observations ont un intérêt physiologique considérable au vu des résultats d'études récentes qui montrent que le NO sert d'intermédiaire dans la vasodilatation cutanée produite par un stress thermique. Donc, l'augmentation de la bioactivité du NO dans la microcirculation cutanée pourrait être un des mécanismes par lequel l'entraînement physique modifierait le contrôle de la thermorégulation du flux sanguin cutané. Abstract Endurance training modifies the thermoregulatory control of skin blood flow, as manifested by a greater augmentation of skin perfusion for the same increase in core temperature in athletes, in comparison with se-dentary subjects. In this study, we tested the hypothesis that a component of this adaptation might reside in a higher ability of cutaneous blood vessels to respond to vasodilatory stimuli. We recruited healthy nonsmoking males, either endurance trained or sedentary, in two different age ranges (18-35 y and >50 y). Skin blood flow was measured in the forearm skin, using a laser Doppler imager, allowing to record the vasodilatory responses to the following stimuli: iontophoresis of acetylcholine (an endothelium-dependent vasodilator), iontophoresis of sodium nitroprusside (a nitric oxide donor), and release of a temporary interruption of arterial inflow (reactive hyperemia). There was no effect of training on reactive hyperemia or the response to acetylcholine. In contrast, the increase in perfusion following the iontophoresis of sodium nitroprusside, ex-pressed in perfusion units, was larger in trained than in sedentary subjects (younger: 398±54 vs 350±87, p<0.05; older 339±72 vs 307±66, p<0.05). In conclusion, endurance training enhances the vasodilatory effects of nitric oxide in the human dermal microcirculation, at least in forearm skin. These observations have considerable physiologic interest in view of recent data indicating that nitric oxide mediates in part the cutaneous vasodilation induced by heat stress in humans. Therefore, the augmentation of nitric oxide bioactivity in the dermal microcirculation might be one mechanism whereby endurance training modifies the thermoregulatory control of skin blood flow.

Repeated Double-Poling Sprint Training in Hypoxia by Competitive Cross-country Skiers.

PURPOSE: Repeated-sprint training in hypoxia (RSH) was recently shown to improve repeated-sprint ability (RSA) in cycling. This phenomenon is likely to reflect fiber type-dependent, compensatory vasodilation, and therefore, our hypothesis was that RSH is even more beneficial for activities involving upper body muscles, such as double poling during cross-country skiing. METHODS: In a double-blinded fashion, 17 competitive cross-country skiers performed six sessions of repeated sprints (each consisting of four sets of five 10-s sprints, with 20-s intervals of recovery) either in normoxia (RSN, 300 m; FiO2, 20.9%; n = 8) or normobaric hypoxia (RSH, 3000 m; FiO2, 13.8 %; n = 9). Before (pre) and after (post) training, performance was evaluated with an RSA test (10-s all-out sprints-20-s recovery, until peak power output declined by 30%) and a simulated team sprint (team sprint, 3 × 3-min all-out with 3-min rest) on a double-poling ergometer. Triceps brachii oxygenation was measured by near-infrared spectroscopy. RESULTS: From pretraining to posttraining, peak power output in the RSA was increased (P < 0.01) to the same extent (29% ± 13% vs 26% ± 18%, nonsignificant) in RSH and in RSN whereas the number of sprints performed was enhanced in RSH (10.9 ± 5.2 vs 17.1 ± 6.8, P < 0.01) but not in RSN (11.6 ± 5.3 vs 11.7 ± 4.3, nonsignificant). In addition, the amplitude in total hemoglobin variations during sprints throughout RSA rose more in RSH (P < 0.01). Similarly, the average power output during all team sprints improved by 11% ± 9% in RSH and 15% ± 7% in RSN. CONCLUSIONS: Our findings reveal greater improvement in the performance of repeated double-poling sprints, together with larger variations in the perfusion of upper body muscles in RSH compared with those in RSN.

Quality Assessment of Cardiac Magnetic Resonance Images at 1.5/3.0 T: Description and Validation of Standardized Criteria

PURPOSE: Cardiovascular magnetic resonance (CMR) has become a robust and important diagnostic imaging modality in cardiovascular medicine. However,insufficient image quality may compromise its diagnostic accuracy. No standardized criteria are available to assess the quality of CMR studies. We aimed todescribe and validate standardized criteria to evaluate the quality of CMR studies including: a) cine steady-state free precession, b) delayed gadoliniumenhancement, and c) adenosine stress first-pass perfusion. These criteria will serve for the assessment of the image quality in the setting of the Euro-CMR registry.METHOD AND MATERIALS: First, a total of 45 quality criteria were defined (35 qualitative criteria with a score from 0-3, and 10 quantitative criteria). Thequalitative score ranged from 0 to 105. The lower the qualitative score, the better the quality. The quantitative criteria were based on the absolute signal intensity (delayed enhancement) and on the signal increase (perfusion) of the anterior/posterior left ventricular wall after gadolinium injection. These criteria were then applied in 30 patients scanned with a 1.5T system and in 15 patients scanned with a 3.0T system. The examinations were jointly interpreted by 3 CMR experts and 1 study nurse. In these 45 patients the correlation between the results of the quality assessment obtained by the different readers was calculated.RESULTS: On the 1.5T machine, the mean quality score was 3.5. The mean difference between each pair of observers was 0.2 (5.7%) with a mean standarddeviation of 1.4. On the 3.0T machine, the mean quality score was 4.4. The mean difference between each pair of onservers was 0.3 (6.4%) with a meanstandard deviation of 1.6. The quantitative quality assessments between observers were well correlated for the 1.5T machine: R was between 0.78 and 0.99 (pCONCLUSION: The described criteria for the assessment of CMR image quality are robust and have a low inter-observer variability, especially on 1.5T systems.CLINICAL RELEVANCE/APPLICATION: These criteria will allow the standardization of CMR examinations. They will help to improve the overall quality ofexaminations and the comparison between clinical studies.

Lack of antitumour activity of human recombinant tumour necrosis factor-alpha, alone or in combination with melphalan in a nude mouse human melanoma xenograft system.

The most promising developments in the field of isolated limb perfusion have centred around the use of the recombinant cytokine tumour necrosis factor-alpha (rTNF-alpha) in combination with melphalan. While the results of clinical trials are impressive, the exact antitumour mechanisms of rTNF-alpha and its role in combination with melphalan remain unclear. Our aim was to study the antitumour activity of human rTNF-alpha with or without the combination of melphalan in a nude mouse human melanoma xenograft system. In a first attempt to define the maximal tolerated single dose of rTNF-alpha in this setting, 15 animals were exposed to increasing doses of rTNF-alpha (60-2500 microg/kg intraperitoneally). All but one animal survived and tumour growth was not influenced by these single dose applications of rTNF-alpha even at the very high doses. Anti-tumour activity of repeated application of melphalan (three times 9 mg/kg in group 2 and three times 6 mg/kg in group 3), of rTNF-alpha alone (nine doses of 50 microg/kg in group 4), and of rTNF-alpha in combination with melphalan (nine doses of 50 microg/kg rTNF-alpha and three times 6 mg/kg melphalan in group 5) was further compared with non-treated animals (group 1). Tumour growth was significantly inhibited in all animals treated with melphalan (group 2, 3 and 5), but was not decreased in animals treated with rTNF-alpha alone (group 4). Mean final tumour volumes and mean tumour weight were not different in group 2 (789 +/- 836 mm3, 0.38 +/- 0.20 g), group 3 (1173 +/- 591 mm3, 0.55 +/- 0.29 g) and group 5 (230 +/- 632 mm3, 0.37 +/- 0.29 g), but significant lower than group 1 (3156 +/- 1512 mm3, 2.35 +/- 0.90 g) and group 4 (3228 +/- 1990 mm3, 2.00 +/- 1.16 g). There were no significant differences between high and low dose melphalan treatment and between melphalan treatment in combination with rTNF-alpha. Histological examination did not show differences between treated and non-treated animals besides slightly inhibited mitotic activities of tumour cells in melphalan-treated animals. While tumour growth of human xenotransplanted melanoma in nude mice could be inhibited by melphalan, we failed to demonstrate any antitumour effect of rTNF-alpha. The combination of melphalan and rTNF-alpha did not enhance the antiproliferative effect of melphalan alone. Human xenotransplanted tumours on nude mice might not be the ideal experimental setting for studies of potential direct antineoplastic activity of rTNF-alpha, and these results support the concept that TNF-alpha exerts its antitumour activity indirectly, possibly by impairing the tumour vasculature and by activating the immune system.

Acute aortic dissection with carotid and coronary malperfusion: from imaging to pathology.

Postmortem imaging, including postmortem computed tomography angiography, has become an integral tool in forensic investigation in recent years. A relatively new technique, multiphase postmortem computed tomography angiography, allows detailed visualization of the vascular system and makes it possible to evaluate the dynamic perfusion of aortic branches, including the coronary arteries. Here, we report a case of aortic dissection involving the ascending aorta (type A) with coronary and carotid malperfusion. This case illustrates the complementary use of many of the diagnostic tools that are now available in forensic practice, from imaging to conventional autopsy to pathologic techniques such as immunohistochemistry.

Role of intracellular cysteines in ENaC function

The epithelial sodium channel (ENaC) regulates the sodium reabsorption in the collecting duct principal cells of the nephron. ENaC is mainly regulated by hormones such as aldosterone and vasopressin, but also by serine proteases, Na+ and divalent cations. The crystallization of an ENaC/Deg member, the Acid Sensing Ion Channel, has been recently published but the pore-lining residues constitution of ENaC internal pore remains unclear. It has been reported that mutation aS589C of the selectivity filter on the aENaC subunit, a three residues G/SxS sequence, renders the channel permeant to divalent cations and sensitive to extracellular Cd2+. We have shown in the first part of my work that the side chain of aSer589 residue is not pointing toward the pore lumen, permitting the Cd2+ to permeate through the ion pore and to coordinate with a native cysteine, gCys546, located in the second transmembrane domain of the gENaC subunit. In a second part, we were interested in the sulfhydryl-reagent intracellular inhibition of ENaC-mediated Na+ current. Kellenberger et al. have shown that ENaC is rapidly and reversibly inhibited by internal sulfhydryl reagents underlying the involvement of intracellular cysteines in the internal regulation of ENaC. We set up a new approach comprising a Substituted Cysteine Analysis Method (SCAM) using intracellular MTSEA-biotin perfusion coupled to functional and biochemical assays. We were thus able to correlate the cysteine-modification of ENaC by methanethiosulfonate (MTS) and its effect on sodium current. This allowed us to determine the amino acids that are accessible to intracellular MTS and the one important for the inhibition of the channel. RESUME : Le canal épithélial sodique ENaC est responsable de la réabsorption du sodium dans les cellules principales du tubule collecteur rénal. Ce canal est essentiellement régulé par voie hormonale via l'aldostérone et la vasopressine mais également par des sérines protéases, le Na+ lui-même et certains cations divalents. La cristallisation du canal sodique sensible au pH acide, ASIC, un autre membre de la famille ENaC/Deg, a été publiée mais les acides aminés constituant le pore interne d'ENaC restent indéterminés. Il a été montré que la mutation aS589C du filtre de sélectivité de la sous-unité aENaC permet le passage de cations divalents et l'inhibition du canal par le Cd2+ extracellulaire. Dans un premier temps, nous avons montré que la chaîne latérale de la aSer589 n'est pas orientée vers l'intérieur du pore, permettant au Cd2+ de traverser le canal et d'interagir avec une cysteine native du second domaine transrnembranaire de la sous-unité γENaC, γCys546. Dans un second temps, nous nous sommes intéressés au mécanisme d'inhibition d'ENaC par les réactifs sulfhydryl internes. Kellenberger et al. ont montré l'implication de cystéines intracellulaires dans la régulation interne d'ENaC par les réactifs sulfhydryl. Nous avons mis en place une nouvelle approche couplant la méthode d'analyse par substitution de cystéines (SCAM) avec des perfusions intracellulaires de MTSEAbiotine. Ainsi, nous pouvons meure en corrélation les modifications des cystéines d'ENaC par les réactifs methanethiosulfonates (MTS) avec leur effet sur le courant sodique, et donc mettre en évidence les acides aminés accessibles aux MTS intracellulaires et ceux qui sont importants dans la fonction du canal.

A high-fructose diet impairs basal and stress-mediated lipid metabolism in healthy male subjects

Rapport de synthèse : La consommation de boissons sucrées contenant du fructose a remarquablement augmenté ces dernières décennies et, on pense qu'elle joue un rôle important dans l'épidémie actuelle d'obésité et de troubles métaboliques. Des études faites sur des rats ont montré qu'une alimentation riche en sucre ou fructose induisait une obésité, une résistance à l'insuline, diabète, dyslipidémie et une hypertension artérielle, tandis que chez l'homme, une alimentation riche en fructose conduit, après quelques jours, au développement d'une hypertryglycémie et une résistance hépatique à l'insuline. Nous avons entrepris une étude de 7 jours d'alimentation riche en fructose ou d'une alimentation contrôlée chez six hommes en bonne santé. Les NEFA plasmatiques et la beta-hydroxybutyrate, l'oxydation nette de lipide (calorimétrie indirecte) et l'oxydation exogène de lipide (13 CO2) ont été surveillés dans des conditions basales, et après un chargement en lipide (huile d'olive marqué au 13C-trioléine), puis durant un stress mental standardisé. La clearance de lactate et les effets métaboliques de la perfusion de lactate exogène ont également été évalués. Nos résultats ont montré que l'alimentation riche en fructose diminue la concentration plasmatique de NEFA, de beta-hydroxybutyrate de même que l'oxydation des lipides dans les conditions de bases et après surcharge en lipides. De plus, l'alimentation riche en fructose amortie l'augmentation des NEFA plasmatique et l'oxydation des lipides exogènes durant le stress mental. Elle augmente également la concentration basale de lactate et la production de lactate de respectivement 31.8% et 53.8%, tandis que la clearance du lactate reste inchangée. L'injection de lactate diminue le taux des NEFA lors de l'alimentation de contrôle et l'alimentation de base, et l'oxydation nette de lipide lors de l'alimentation de contrôle et l'alimentation riche en fructose. Ces résultats indiquent que 7 jours d'alimentation riche en fructose inhibent remarquablement la lipolyse et l'oxydation des lipides. L'alimentation riche en fructose augmente aussi la production de lactate, et l'augmentation de l'utilisation de lactate peut contribuer à supprimer l'oxydation des lipides. Abstact : The effects of a 7 d high-fructose diet (HFrD) or control diet on lipid metabolism were studied in a group of six healthy lean males. Plasma NEFA and β-hydroxybutyrate concentrations, net lipid oxidation (indirect calorimetry) and exogenous lipid oxidation (13CO2 production) were monitored in basal conditions, after lipid loading (olive oil labelled with [13C] triolein) and during a standardised mental stress. Lactate clearance and the metabolic effects of an exogenous lactate infusion were also monitored. The HFrD lowered plasma concentrations of NEFA and (β-hydroxybutyrate as well as lipid oxidation in both basal and after lipid-loading conditions. In addition, the HFrD blunted the increase in plasma NEFA and exogenous lipid oxidation during mental stress. The HFrD also increased basal lactate concentrations by 31.8%, and lactate production by 53.8 %, while lactate clearance remained unchanged. Lactate infusion lowered plasma NEFA with the control diet, and net lipid oxidation with both the HFrD and control diet. These results indicate that a 7 d HFrD markedly inhibits lipolysis and lipid oxidation. The HFrD also increases lactate production, and the ensuing increased lactate utilisation may contribute to suppress lipid oxidation.

Caval collapse during cardiopulmonary bypass: a reproducible bench model.

OBJECTIVES: During open heart surgery, so-called atrial chatter, a phenomenon due to right atria and/or caval collapse, is frequently observed. Collapse of the cava axis during cardiopulmonary bypass (CPB) limits venous drainage and may result downstream in reduced pump flow on (lack of volume) and upstream in increased after-load (stagnation), which in turn may both result in reduced or even inadequate end-organ perfusion. The goal of this study was to reproduce venous collapse in the flow bench. METHODS: In accordance with literature for venous anatomy, a caval tree system is designed (polyethylene, thickness 0.061 mm), which receives venous inflow from nine afferent veins. With water as medium and a preload of 4.4 mmHg, the system has an outflow of 4500 ml/min (Scenario A). After the insertion of a percutaneous venous cannula (23-Fr), the venous model is continuously served by the afferent branches in a venous test bench and venous drainage is augmented with a centrifugal pump (Scenario B). RESULTS: With gravity drainage (siphon: A), spontaneously reversible atrial chatter can be generated in reproducible fashion. Slight reduction in the outflow diameter allows for generation of continuous flow. With augmentation (B), irreversible collapse of the artificial vena cava occurs in reproducible fashion at a given pump speed of 2300 ± 50 RPM and a pump inlet pressure of -112 mmHg. Furthermore, bubbles form at the cannula tip despite the fact that the entire system is immersed in water and air from the environment cannot enter the system. This phenomenon is also known as cavitation and should be avoided because of local damage of both formed blood elements and endothelium, as well embolization. CONCLUSIONS: This caval model provides a realistic picture for the limitations of flow due to spontaneously reversible atrial chatter vs irreversible venous collapse for a given negative pressure during CPB. Temporary interruption of negative pressure in the venous line can allow for recovery of venous drainage. This know-how can be used not only for testing different cannula designs, but also for further optimizing perfusion strategies.

Imaging for clarification of accusation of treatment error

In the assessment of medical malpractice imaging methods can be used for the documentation of crucial morphological findings which are indicative for or against an iatrogenically caused injury. The clarification of deaths in this context can be usefully supported by postmortem imaging (primarily native computed tomography, angiography, magnetic resonance imaging). Postmortem imaging offers significant additional information compared to an autopsy in the detection of iatrogenic air embolisms and documentation of misplaced medical aids before dissection with an inherent danger of relocation. Additional information is supplied by postmortem imaging in the search for sources of bleeding as well as the documentation of perfusion after cardiovascular surgery. Key criteria for the decision to perform postmortem imaging can be obtained from the necessary preliminary inspection of clinical documentation.

Évaluation d'une nouvelle méthode pour l'essai de stérilité des préparations pharmaceutiques

Introduction : Au CHUV, les contrôles microbiologiques des préparations pharmaceutiques stériles produites par la pharmacie de l'hôpital se basent sur l'essai de stérilité de la Pharmacopée Européenne. Avant 2000, une méthode en circuit ouvert était utilisée, puis, dès l'année 2000, une nouvelle méthode développée par H. Ing du service de pharmacie des HUG a été adoptée (méthode « Ing »). Cette dernière permet d'opérer en circuit fermé et de filtrer le milieu de culture. De plus, elle utilise du matériel bon marché (trousse de perfusion, filtres à usage unique). Objectifs : Le présent travail avait pour but : 1) l'évaluation préliminaire de cette méthode (validation). 2) l'évaluation du bénéfice apporté en terme d'incidence de faux positifs sur les préparations stériles filtrables. Matériel et méthode : La validation a été effectuée en analysant des flexs de NaCl 0.9% préalablement inoculés avec 10-100 CFU de 6 souches microbiennes décrites dans la Pharmacopée pour le test de validation, ainsi qu'un flex « contrôle » non inoculé. Le bénéfice de la méthode a été évalué à partir des résultats des essais de routine effectués au laboratoire. Un taux de faux positifs imputable à chaque méthode a ainsi pu être déterminé (i.e. croissance microbienne due à une contamination lors de l'essai et non à une contamination initiale de la préparation pharmaceutique) et la comparaison a été effectuée à l'aide du test statistique de Fisher. Résultats : Une croissance a été observée dans toutes les préparations préalablement inoculées par des micro-organismes. La méthode a donc pu être implantée dans le laboratoire pour les analyses de routine dès février 2000. L'analyse rétrospective des résultats des essais de stérilité effectués sur une période de plus de 4 ans (2 ans avec l'ancienne méthode (système ouvert) et de presque 3 ans avec la nouvelle méthode) montre que l'ancienne méthode produisait un taux de faux positifs de 1.57 %, alors que ce taux n'est que de 0.21% avec la méthode « Ing ». Cette dernière se caractérise donc par un taux de faux positifs significativement plus bas que celui de l'ancienne méthode (p < 0.0001). Conclusion : La méthode « Ing » constitue une technique bien adaptée à l'essai de stérilité pour l'hôpital, suffisamment sensible et conforme aux recommandations de la Pharmacopée. En maintenant le produit dans un espace clos, elle permet de diminuer les risques de contamination susceptibles de se produire lors de l'essai.

Effect of hypoxia on cerebral blood flow regulation during rest and exercise : role of cerebral oxygen delivery on performance

Adequate supply of oxygen to the brain is critical for maintaining normal brain function. Severe hypoxia, such as that experienced during high altitude ascent, presents a unique challenge to brain oxygen (O2) supply. During high-intensity exercise, hyperventilation-induced hypocapnia leads to cerebral vasoconstriction, followed by reductions in cerebral blood flow (CBF), oxygen delivery (DO2), and tissue oxygenation. This reduced O2 supply to the brain could potentially account for the reduced performance typically observed during exercise in severe hypoxic conditions. The aims of this thesis were to document the effect of acute and chronic exposure to hypoxia on CBF control, and to determine the role of cerebral DO2 and tissue oxygenation in limiting performance during exercise in severe hypoxia. We assessed CBF, arterial O2 content (CaO2), haemoglobin concentration ([Hb]), partial pressure of arterial O2 (PaO2), cerebrovascular CO2 reactivity, ventilatory response to CO2, cerebral autoregulation (CA), and estimated cerebral DO2 (CBF ⨉ CaO2) at sea level (SL), upon ascent to 5,260 m (ALT1), and following 16 days of acclimatisation to 5,260 m (ALT16). We found an increase in CBF despite an elevated cerebrovascular CO2 reactivity at ALT1, which coincided with a reduced CA. Meanwhile, PaO2 was greatly decreased despite increased ventilatory drive at ALT1, resulting in a concomitant decrease in CaO2. At ALT16, CBF decreased towards SL values, while cerebrovascular CO2 reactivity and ventilatory drive were further elevated. Acclimatisation increased PaO2, [Hb], and therefore CaO2 at ALT16, but these changes did not improve CA compared to ALT1. No differences were observed in cerebral DO2 across SL, ALT1, and ALT16. Our findings demonstrate that cerebral DO2 is maintained during both acute and chronic exposure to 5,260 m, due to the reciprocal changes in CBF and CaO2. We measured middle cerebral artery velocity (MCAv: index of CBF), cerebral DO2, ventilation (VE), and performance during incremental cycling to exhaustion and 15km time trial cycling in both normoxia and severe hypoxia (11% O2, normobaric), with and without added CO2 to the inspirate (CO2 breathing). We found MCAv was higher during exercise in severe hypoxia compared in normoxia, while cerebral tissue oxygenation and DO2 were reduced. CO2 breathing was effective in preventing the development of hyperventilation-induced hypocapnia during intense exercise in both normoxia and hypoxia. As a result, we were able to increase both MCAv and cerebral DO2 during exercise in hypoxia with our CO2 breathing setup. However, we concomitantly increased VE and PaO2 (and presumably respiratory work) due to the increased hypercapnic stimuli with CO2 breathing, which subsequently contributed to the cerebral DO2 increase during hypoxic exercise. While we effectively restored cerebral DO2 during exercise in hypoxia to normoxic values with CO2 breathing, we did not observe any improvement in cerebral tissue oxygenation or exercise performance. Accordingly, our findings do not support the role of reduced cerebral DO2 in limiting exercise performance in severe hypoxia. -- Un apport adéquat en oxygène au niveau du cerveau est primordial pour le maintien des fonctions cérébrales normales. L'hypoxie sévère, telle qu'expérimentée au cours d'ascensions en haute altitude, présente un défi unique pour l'apport cérébral en oxygène (O2). Lors d'exercices à haute intensité, l'hypocapnie induite par l'hyperventilation entraîne une vasoconstriction cérébrale suivie par une réduction du flux sanguin cérébral (CBF), de l'apport en oxygène (DO2), ainsi que de l'oxygénation tissulaire. Cette réduction de l'apport en O2 au cerveau pourrait potentiellement être responsable de la diminution de performance observée au cours d'exercices en condition d'hypoxie sévère. Les buts de cette thèse étaient de documenter l'effet de l'exposition aiguë et chronique à l'hypoxie sur le contrôle du CBF, ainsi que de déterminer le rôle du DO2 cérébral et de l'oxygénation tissulaire comme facteurs limitant la performance lors d'exercices en hypoxie sévère. Nous avons mesuré CBF, le contenu artériel en oxygène (CaO2), la concentration en hémoglobine ([Hb]), la pression partielle artérielle en O2 (PaO2), la réactivité cérébrovasculaire au CO2, la réponse ventilatoire au CO2, et l'autorégulation cérébrale sanguine (CA), et estimé DO2 cérébral (CBF x CaO2), au niveau de la mer (SL), au premier jour à 5.260 m (ALT1) et après seize jours d'acclimatation à 5.260 m (ALT16). Nous avons trouvé des augmentations du CBF et de la réactivité cérébrovasculaire au CO2 après une ascension à 5.260 m. Ces augmentations coïncidaient avec une réduction de l'autorégulation cérébrale. Simultanément, la PaO2 était grandement réduite, malgré l'augmentation de la ventilation (VE), résultant en une diminution de la CaO2. Après seize jours d'acclimatation à 5.260 m, le CBF revenait autour des valeurs observées au niveau de la mer, alors que la réactivité cérébrovasculaire au CO2 et la VE augmentaient par rapport à ALT1. L'acclimatation augmentait la PaO2, la concentration en hémoglobine, et donc la CaO2, mais n'améliorait pas l'autorégulation cérébrale, comparé à ALT1. Aucune différence n'était observée au niveau du DO2 cérébral entre SL, ALT1 et ALT16. Nos résultats montrent que le DO2 cérébral est maintenu constant lors d'expositions aiguë et chronique à 5.260m, ce qui s'explique par la réciprocité des variations du CBF et de la CaO2. Nous avons mesuré la vitesse d'écoulement du sang dans l'artère cérébrale moyenne (MCAv : un indice du CBF), le DO2 cérébral, la VE et la performance lors d'exercice incrémentaux jusqu'à épuisement sur cycloergomètre, ainsi que des contre-la-montres de 15 km en normoxie et en hypoxie sévère (11% O2, normobarique) ; avec ajout ou non de CO2 dans le mélange gazeux inspiré. Nous avons trouvé que MCAv était plus haute pendant l'exercice hypoxique, comparé à la normoxie alors que le DO2 cérébral était réduit. L'ajout de CO2 dans le gaz inspiré était efficace pour prévenir l'hypocapnie induite par l'hyperventilation, qui se développe à l'exercice intense, à la fois en normoxie et en hypoxie. Nous avons pu augmenter MCAv et le DO2 cérébral pendant l'exercice hypoxique, grâce à l'ajout de CO2. Cependant, nous avons augmenté la VE et la PaO2 (et probablement le travail respiratoire) à cause de l'augmentation du stimulus hypercapnique. Alors que nous avons, grâce à l'ajout de CO2, efficacement restauré le DO2 cérébral au cours de l'exercice en hypoxie à des valeurs obtenues en normoxie, nous n'avons observé aucune amélioration dans l'oxygénation du tissu cérébral ou de la performance. En conséquence, nos résultats ne soutiennent pas le rôle d'un DO2 cérébral réduit comme facteur limitant de la performance en hypoxie sévère.

Quantification of myocardial blood flow with 82Rb positron emission tomography: clinical validation with 15O-water.

PURPOSE: Quantification of myocardial blood flow (MBF) with generator-produced (82)Rb is an attractive alternative for centres without an on-site cyclotron. Our aim was to validate (82)Rb-measured MBF in relation to that measured using (15)O-water, as a tracer 100% of which can be extracted from the circulation even at high flow rates, in healthy control subject and patients with mild coronary artery disease (CAD). METHODS: MBF was measured at rest and during adenosine-induced hyperaemia with (82)Rb and (15)O-water PET in 33 participants (22 control subjects, aged 30 ± 13 years; 11 CAD patients without transmural infarction, aged 60 ± 13 years). A one-tissue compartment (82)Rb model with ventricular spillover correction was used. The (82)Rb flow-dependent extraction rate was derived from (15)O-water measurements in a subset of 11 control subjects. Myocardial flow reserve (MFR) was defined as the hyperaemic/rest MBF. Pearson's correlation r, Bland-Altman 95% limits of agreement (LoA), and Lin's concordance correlation ρ (c) (measuring both precision and accuracy) were used. RESULTS: Over the entire MBF range (0.66-4.7 ml/min/g), concordance was excellent for MBF (r = 0.90, [(82)Rb-(15)O-water] mean difference ± SD = 0.04 ± 0.66 ml/min/g, LoA = -1.26 to 1.33 ml/min/g, ρ(c) = 0.88) and MFR (range 1.79-5.81, r = 0.83, mean difference = 0.14 ± 0.58, LoA = -0.99 to 1.28, ρ(c) = 0.82). Hyperaemic MBF was reduced in CAD patients compared with the subset of 11 control subjects (2.53 ± 0.74 vs. 3.62 ± 0.68 ml/min/g, p = 0.002, for (15)O-water; 2.53 ± 1.01 vs. 3.82 ± 1.21 ml/min/g, p = 0.013, for (82)Rb) and this was paralleled by a lower MFR (2.65 ± 0.62 vs. 3.79 ± 0.98, p = 0.004, for (15)O-water; 2.85 ± 0.91 vs. 3.88 ± 0.91, p = 0.012, for (82)Rb). Myocardial perfusion was homogeneous in 1,114 of 1,122 segments (99.3%) and there were no differences in MBF among the coronary artery territories (p > 0.31). CONCLUSION: Quantification of MBF with (82)Rb with a newly derived correction for the nonlinear extraction function was validated against MBF measured using (15)O-water in control subjects and patients with mild CAD, where it was found to be accurate at high flow rates. (82)Rb-derived MBF estimates seem robust for clinical research, advancing a step further towards its implementation in clinical routine.

Clinical relevance of cerebral autoregulation following subarachnoid haemorrhage.

Subarachnoid haemorrhage (SAH) is a form of stroke that is associated with substantial morbidity, often as a result of cerebral ischaemia that occurs in the following days. These delayed deficits in blood flow have been traditionally attributed to cerebral vasospasm (the narrowing of large arteries), which can lead to cerebral infarction and poor neurological outcome. Data from recent studies, however, show that treatment of vasospasm in patients with SAH, using targeted medication, does not translate to better neurological outcomes, and argue against vasospasm being the sole cause of the delayed ischaemic complications. Cerebral autoregulation-a mechanism that maintains stability of cerebral blood flow in response to changes in cerebral perfusion pressure-has been reported to fail after SAH, often before vasospasm becomes apparent. Failure of autoregulation, therefore, has been implicated in development of delayed cerebral ischaemia. In this Review, we summarize current knowledge about the clinical effect of disturbed cerebral autoregulation following aneurysmal SAH, with emphasis on development of delayed cerebral ischaemia and clinical outcome, and provide a critical assessment of studies of cerebral autoregulation in SAH with respect to the method of blood-flow measurement. Better understanding of cerebral autoregulation following SAH could reveal mechanisms of blood-flow regulation that could be therapeutically targeted to improve patient outcome.