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Changes in plasma nitrite concentration in the human forearm circulation have recently been shown to reflect acute changes in endothelial nitric oxide synthase (eNOS)-activity. Whether basal plasma nitrite is a general marker of constitutive NOS-activity in vivo is yet unclear. Due to the rapid metabolism of nitrite in blood and the difficulties in its analytical determination literature data on levels of nitrite in mammals are largely inconsistent. We hypothesized that constitutive NOS-activity in the circulatory system is relatively uniform throughout the mammalian kingdom. If true, this should result in comparable systemic plasma nitrite levels in different species. Using three different analytical approaches we determined plasma nitrite concentration to be in a nanomolar range in a variety of species: humans (305 +/- 23 nmol/l), monkeys (367 +/- 62 nmol/l), minipigs (319 +/- 24 nmol/l), dogs (305 +/- 50 nmol/l), rabbits (502 +/- 21 nmol/l), guinea pigs (412 +/- 44 nmol/l), rats (191 +/- 43 nmol/l), and mice (457 +/- 51 nmol/l). Application of different NOS-inhibitors in humans, minipigs, and dogs decreased NOS-activity and thereby increased vascular resistance. This was accompanied by a significant, up to 80%, decrease in plasma nitrite concentration. A comparison of plasma nitrite concentrations between eNOS(-/-) and NOS-inhibited wild-type mice revealed that 70 +/- 5% of plasma nitrite is derived from eNOS. These results provide evidence for a uniform constitutive vascular NOS-activity across mammalian species.

Unlabelled: Local myocardial blood flow measurements are of great importance in experimental and clinical settings. However, a lack of ideal markers is evident. Adenosine is suggested to be a potential candidate because of its high uptake and rapid intracellular sequestration. We specifically tested the hypothesis that the local deposition density of labeled adenosine within the heart reflects local myocardial blood flow., Methods: Tracer microspheres, the recognized standard for local blood flow measurements, were injected and compared with simultaneously injected labeled adenosine ((3)H/(14)C) in tracer concentration into the left atrium of anesthetized Beagle dogs (n = 7). Myocardial deposition densities were assessed through beta-scintillation and gamma-counting measurements in samples (100-128 per heart) of an average wet mass of 487 +/- 54 mg. To challenge local myocardial blood flow distribution, alprostadil was infused into the left circumflex artery in 3 experiments. In 2 other experiments, erythro-9-hydroxy-nonyl-adenine (EHNA) was infused to inhibit degradation of injected adenosine to inosine., Results: Tracer adenosine and microspheres did not exert significant local or systemic hemodynamic effects. Both were almost completely extracted from blood within 2 min and locally retained in the tissue. Deposition densities of tracer microspheres and labeled adenosine correlated closely in each experiment, independently of the respective protocol (control, EHNA, or alprostadil), over a wide range of local myocardial blood flows (0.23-12.9 mL min(-1) g(-1)). The mean correlation coefficient (n = 293) was r = 0.93 (r(2) = 0.86; P < 0.0001), indicating that the deposition density of (3)H-adenosine could explain local blood flow as measured with the tracer microsphere technique with 86% probability., Conclusion: Adenosine appears to be a reliable marker of local blood flow in dog myocardium.

Objective: Although it has been shown recently that acetylcholine (ACh)-induced vasodilation of forearm resistance vessels is predominantly mediated by nitric oxide, direct biochemical evidence for eNOS stimulation by bradykinin (BK) in the human arterial circulation is still lacking. Therefore, the present study was designed to test the hypothesis that in the human forearm vasculature eNOS stimulation significantly contributes to BK-induced vasodilation., Methods: BK was infused in the presence and absence of the NOS inhibitor L-NMMA (8 micromol/min) into the brachial artery of 16 healthy volunteers and the effects compared to muscarinergic eNOS stimulation following acetylcholine infusion. Forearm blood flow (FBF) was measured by venous occlusion plethysmography, and plasma nitrite (NO(2)(-)), which represents a sensitive and specific marker of regional eNOS activity, was determined in the antecubital vein and brachial artery by flow injection analysis. Nitric oxide production was calculated as product of the veno-arterial difference of NO(2)(-) concentration times FBF., Results: Kininergic (BK: 20, 60, 200 ng/min) as well as muscarinergic (ACh: 1, 3, 10 microg/min) stimulation resulted in a dose-dependent increase in FBF and NO(2)(-) in each individual. The relationship between FBF and NO production upon BK infusion was comparable to that obtained with ACh (r = 0.98; n = 64, p < 0.01). Moreover, NOS inhibition reduced both flow responses and NO production (BK: 54 and 75 %; ACh: 57 and 72 %) to a similar extent., Conclusions: These data provide direct biochemical evidence for the involvement of eNOS in bradykinin-induced vasodilation of forearm resistance vessels in humans.

Disturbances of nitric oxide (NO) bioavailability may play a key role in vascular dysfunction and in the development of atherosclerotic lesions. Thus assessment of a reduced NO bioavailability in human circulation is of particular interest. Here we summarize potential biomarkers of NO availability in human blood and critically discuss their respective significance and application fields.

Higher doses of inhaled NO exert effects beyond the pulmonary circulation. How such extrapulmonary effects can be reconciled with the presumed short half-life of NO in the blood is unclear. Whereas erythrocytes have been suggested to participate in NO transport, the exact role of plasma in NO delivery in humans is not clear. Therefore, we investigated potential routes of NO decomposition and transport in human plasma. NO consumption in plasma was accompanied by a concentration-dependent increase in nitrite and S-nitrosothiols (RSNOs), with no apparent saturation limit up to 200 micro mol/L. The presence of red blood cells reduced the formation of plasma RSNOs. Intravenous infusion of 30 micro mol/min NO in healthy volunteers increased plasma levels of RSNOs and induced systemic hemodynamic effects at the level of both conduit and resistance vessels, as reflected by dilator responses in the brachial artery and forearm microvasculature. Intravenous application of S-nitrosoglutathione, a potential carrier of bioactive NO, mimicked the vascular effects of NO, whereas nitrite and nitrate were inactive. Changes in plasma nitrosothiols were correlated with vasodilator effects after intravenous application of S-nitrosoglutathione and NO. These findings demonstrate that in humans the pharmacological delivery of NO solutions results in the transport and delivery of NO as RSNOs along the vascular tree.

Objectives: We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF., Background: Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment., Methods: A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography., Results: The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence., Conclusions: Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

Aim: To determine the shunt volume of iatrogenic arteriovenous fistula (AVF) following arterial puncture of the groin and to evaluate its impact on natural history and clinical outcome., Method: Over a period of 12 months, 22 patients (p) with a newly acquired AVF were followed up. The arteriovenous shunt volume was determined by means of colored duplex- and doppler sonography immediately after diagnosis of AVF., Results: Spontaneous closure of AVF was seen in 10 p (46%) during follow-up examination, whereas 12 p (54%) showed a persistence of their AVF. The median (I50) shunt volume of closed AVF was 310 (250-350) ml/min and 350 (160-510) ml/min for persistent fistulae (p = ns). A shunt volume of > or = 400 ml/min was determined as a significant (p < or = 0.05) cut-off point for prolonged persistence of AVF., Conclusion: Because spontaneous closure of AVF was 46% in the course of the first year, conservative management with regular duplex control seems to be justified at least for this duration. Patients with a shunt volume of > or = 400 ml/min have an increased risk of prolonged AVF persistence and therefore should be included in long-term follow-up with special attention to development of hemodynamic relevance.

Although hitherto considered as a strictly locally acting vasodilator, results from recent clinical studies with inhaled nitric oxide (NO) indicate that NO can exert effects beyond the pulmonary circulation. We therefore sought to investigate potential remote vascular effects of intra-arterially applied aqueous NO solution and to identify the mechanisms involved. On bolus application of NO into the brachial artery of 32 healthy volunteers, both diameter of the downstream radial artery and forearm blood flow increased in a dose-dependent manner. Maximum dilator responses were comparable to those after stimulation of endogenous NO formation with acetylcholine and bradykinin. Response kinetics and pattern of NO decomposition suggested that despite the presence of hemoglobin-containing erythrocytes, a significant portion of NO was transported in its unbound form. Infusion of NO (36 micromol/min) into the brachial artery increased levels of plasma nitroso species, nitrite, and nitrate in the draining antecubital vein (by < 2-fold, 30-fold, and 4-fold, respectively), indicative of oxidative and nitrosative chemistry. Infused N-oxides were inactive as vasodilators whereas S-nitrosoglutathione dilated conduit and resistance arteries. Our results suggest that NO can be transported in bioactive form for significant distances along the vascular bed. Both free NO and plasma nitroso species contribute to the dilation of the downstream vasculature.

It is well established that myocardial blood flow is heterogeneous on the local level. During recent years comprehensive studies have been undertaken to assess the relation between myocardial metabolism and spatial blood flow heterogeneity. Based on the type of measurements two major groups of studies have been performed: enzyme activity and tissue metabolite level assessments. Enzyme activity measurements have provided only limited insight into the coupling of local metabolism and flow. This is probably due to the fact that, in addition to estimated Vmax values, local substrate affinity (Km values) and substrate concentrations affect the metabolite fluxes. However, the latter two variables remain normally unknown. In contrast, valuable insight has been obtained concerning flow-metabolism matching from tissue metabolite measurements, especially when connected with mathematical model analyses. The latter permitted the calculation of metabolic flux rates (e.g., production of oxidation water, citric acid cycle flux, glucose uptake, fatty acid uptake) or the translation of the metabolic indexes into physiologically meaningful local metabolite concentrations (e.g., free cytosolic adenosine). The bottom line of the studies reported to date is that the broad range of myocardial flows observed under resting control conditions correlates with local metabolism possibly affected by spatial differences in adrenergic stimulation. Thus, high flow samples exhibit a higher oxidative metabolism than low flow samples. As a result the flow threshold below which local myocardial ischemia ensues is higher in control high flow samples. The importance of these findings with respect to local flow-metabolism matching is underlined by the finding that the probability of developing an infarction following ischemia/reperfusion is related to the functional state of the myocardium under control conditions, i.e., the local level of flow-metabolism matching.

The plasma level of NO(x), i.e., the sum of NO(2)- and NO(3)-, is frequently used to assess NO bioavailability in vivo. However, little is known about the kinetics of NO conversion to these metabolites under physiological conditions. Moreover, plasma nitrite recently has been proposed to represent a delivery source for intravascular NO. We therefore sought to investigate in humans whether changes in NO(x) concentration are a reliable marker for endothelial NO production and whether physiological concentrations of nitrite are vasoactive. NO(2)- and NO(3)- concentrations were measured in blood sampled from the antecubital vein and brachial artery of 24 healthy volunteers. No significant arterial-venous gradient was observed for either NO(2)- or NO(3)-. Endothelial NO synthase (eNOS) stimulation with acetylcholine (1-10 microg/min) dose-dependently augmented venous NO(2)- levels by maximally 71%. This effect was paralleled by an almost 4-fold increase in forearm blood flow (FBF), whereas an equieffective dose of papaverine produced no change in venous NO(2)-. Intraarterial infusion of NO(2)- had no effect on FBF. NOS inhibition (N(G)-monomethyl-l-arginine; 4-12 micromol/min) dose-dependently reduced basal NO(2)- and FBF and blunted acetylcholine-induced vasodilation and NO release by more than 80% and 90%, respectively. In contrast, venous NO(3)- and total NO(x) remained unchanged as did systemic arterial NO(2)- and NO(3)- levels during all these interventions. FBF and NO release showed a positive association (r = 0.85; P < 0.001). These results contradict the current paradigm that plasma NO(3)- and/or total NO(x) are generally useful markers of endogenous NO production and demonstrate that only NO(2)- reflects acute changes in regional eNOS activity. Our results further demonstrate that physiological levels of nitrite are vasodilator-inactive.

Aim: Brachial artery ultrasonography is used to measure flow-mediated dilatation (FMD) as a marker of endothelial function in patients at risk for atherosclerosis. Major disadvantages are the time-consuming manual readings and the high within- and between-observer variability. The authors hypothesize that the ultrasound-based determination of endothelial function can be simplified and refined by an automated analysis system., Methods and Results: FMD was quantified by a 7.5 MHz linear transducer following 5 minutes of ischemia of the proximal forearm in 8 healthy volunteers on two occasions. Brachial artery diameter was comparatively assessed 1. manually from the video signal and 2. by a PC-based analyzing system. For the manual readings the mean differences for the FMD were 2.5 +/- 2.3% between-reader, 2.0 +/- 0.9% within-reader and 2.1 +/- 1.5% for scans on different days in contrast to 0.8 +/- 0.4 (between-reader), 0.8 +/- 0.6 (within-reader) and 1.3 +/- 0.9% (day-to-day) for the computerized system. The coefficient of variability for the measurement of arterial diameter was 1.34% for manual readings and 0.78% for the automated analysis system. The mean time for manual readings from S-VHS tapes was 35 minutes in contrast to 9 minutes for the PC-based analysis system., Conclusions: The new automated analysis system for the boundary detection of the vascular wall reduces the variability and greatly increases the speed of the measurements to determine endothelial function. In future, these advantages will help to screen larger numbers of individuals for endothelial dysfunction, particularly for follow-up and intervention trials, and to reduce the variability between different laboratories.

The effects of adrenergic stimulation on local myocardial blood flow in the left ventricle were studied in 13 anaesthetized Beagle dogs using the tracer microsphere technique. Adrenergic stimulation was induced by intravenous infusion of orciprenaline (1-2 microg kg-1 min-1) over 15 min or by electrical stimulation of the left ansa subclavia (10 Hz, 1 ms, 4-8 V) over 5 min. Local myocardial blood flow was analysed in 256 samples with an average (+/-SD) mass of 318+/-49 mg from the left ventricular myocardium using a standardized dissection procedure. Orciprenaline increased the average myocardial blood flow from 0.85+/-0.18 to 1.73+/-0.27 ml min-1 g-1, while oxygen consumption and the pressure-rate product increased by 129 and 119% respectively. The coefficients of variation of local myocardial blood flow, a measure of spatial blood flow heterogeneity, were 0.21 and 0.18 under control and orciprenaline respectively. Except for a slight transmural gradient (endomyocardium/epimyocardium flow ratio 1.19) myocardial blood flow did not exhibit significant spatial gradients. Stimulation with orciprenaline increased the average blood flow in all regions of the left ventricle by comparable extents. However, local blood flow during orciprenaline was significantly lower in samples from regions which had a lower blood flow under resting control conditions. A significant positive relationship was obtained between local myocardial blood flow under resting conditions and orciprenaline (r=0.45+/-0.18). Moreover, after recovery from orciprenaline stimulation (i.e. 40-112 min after the end of orciprenaline infusion) local myocardial blood flow exhibited a high degree of correlation with local flow before orciprenaline (r=0.71+/-0.08). Comparable results were obtained with electrical stimulation of the left ansa subclavia. For the comparison stimulation vs. control, the correlation coefficient of local blood flow was 0.52+/-0.04 and for recovery vs. control 0.77+/-0.06. From these results it is concluded firstly that local myocardial blood flow under resting conditions is an important determinant of local flow during adrenergic stimulation. Secondly, the anatomical region does not have any predictive value for the blood flow change during adrenergic stimulation and finally, the close relationship between local blood flow before and after cardiac stimulation indicates that the spatial blood flow heterogeneity is temporally stable over hours.

Objective: To examine trends in survival and death in nonhemophiliac adolescents with human immunodeficiency virus (HIV) infection., Design: Case series., Subjects: All 117 HIV-seropositive adolescents (age range, 13 to 21 years) without hemophilia whose cases were reported through December 1992., Setting: A state with mandatory, name-linked reporting of cases of HIV., Methods: Review of death certificates and public records, and interviews with subjects and key informants., Analyses: Kaplan-Meier and Cox proportional hazards regression analyses of time from the diagnosis of HIV infection to death., Results: Documentation of death or survival was available for 92% (108/117) of the sample. Fourteen percent (15/108) of the subjects were known to have died, mainly of well-recognized complications of acquired immunodeficiency syndrome. Among deceased subjects, the median duration of survival after the diagnosis of HIV was 3 years. Cumulative survival at 8 years after the diagnosis was 52%, with 4 years being the median period of observation (range, < 1 year to 8 years). Stratification of survival functions by gender, race, and mode of transmission revealed no significant (P < .05) differences between groups. However, advancing age at the time of the diagnosis was inversely associated with survival., Conclusions: Despite an apparent advantage to young age, overall survival in this adolescent cohort was shorter than expected. Rather than an inherently rapid progression of disease during adolescence, delays in diagnosis and treatment might better explain the results.

The management of a child with an irreducible ovary remains inconsistent in pediatric surgical centers. An informal survey of senior pediatric surgeons and an extensive review of the literature showed a prevailing view that the trapped ovary is not at significant risk of vascular compromise. Two recent cases prompted a review of our experience from 1984 to 1989, during which 1,699 children with inguinal hernias underwent operation, 386 (23%) of whom were girls. Fifteen girls (4%) had irreducible ovaries present at the time of operation and in 4 of the 15 (27%) the ovary was twisted and infarcted. Two of the 4 girls were known to have an irreducible ovary prior to the day of operation--1 was noted 2 months earlier and 1 was noted 1 month earlier. At the time of the initial diagnosis, neither patient had physical findings of vascular compromise of the ovary. In the other two girls, evidence of an infarcted ovary was present when the hernia was first diagnosed and an emergency operation was performed. A 27% incidence of torsion and strangulation of irreducible ovaries appears to be high, but reports of strangulated ovaries have been reported in 2% to 33% of other series. The normal anatomy is altered when an ovary is trapped in a hernia sac, and these changes make torsion more likely. Although an irreducible ovary is not at great risk of compression of its blood supply, this report identifies a significant risk of torsion. This risk warrants treating the asymptomatic irreducible ovary as any other incarcerated hernia--as a true emergency.

Treatment records of patients with primary untreated Stage IIIB carcinoma of the cervix treated at Indiana University Department of Radiation Oncology from November 1964 through January 1979 were reviewed. During this period, 79 patients were treated; 46 received external therapy using cobalt-60, 15 received a 25-MV photon beam, and 18 received a 25-MV photon beam followed by 45 min of 434-MHz microwave hyperthermia producing central tumor core temperatures of 39.5 to 41.5 degrees C. All patients received similar doses of radiation using combination intracavitary radioactive isotopes and external therapy. Patients who received heat therapy in combination with radiation therapy did not have increased acute or chronic complications of normal tissues. Local tumor control was superior when regional heat therapy was given; however, long-term absolute survival rates were not affected as the survival rate at 5 years was not statistically different in any of the three treatment groups.