When the heart is stopped for good: hypotension-bradycardia paradox revisited

In vasovagal syncope, occurrence of bradycardia/asystole in the wake of hypotension has often been considered paradoxical. The major objective of this teaching module is to critically examine the pathophysiological mechanism and significance of the hypotension-bradycardia paradox unique to this condition. We narrate here how we discussed the pathophysiology of vasovagal syncope in a large classroom session attended by 275 doctors and medical students. A case study was used to describe the typical clinical presentation of vasovagal syncope. The pathophysiological mechanisms involved were then discussed systematically using a series of open-ended questions. We made it clear 1) that the occurrence of bradycardia or asystole in the face of acute severe hypotension is a mechanism to possibly minimize further blood loss, prevent myocardial damage, and increase ventricular filling; and 2) that fainting, which occurs as a consequence of this, is a homeostatic mechanism that serves to restore venous return and cerebral blood flow before blood pressure is normalized by neural reflex mechanisms. Eighty-four percent of participants reported that they were satisfied with the session. The information contained herein could be used to explain to any suitable audience the neural regulation of blood pressure in the face of acute severe hypotension and the pathophysiology of vasovagal syncope.     

Alteration of ingestive behaviours by nucleus accumbens in normal and streptozotocin-induced diabetic rats

Twenty-four hour basal food and water intakes were recorded in Wistar rats. Diabetes was produced in a group of rats by injecting streptozotocin (STZ, 75 mg/kg, b.w., IP) and their post-diabetic basal food and water intakes were recorded. Noradrenaline (2 microg) and dopamine (2 microg) were injected separately into the nucleus accumbens through the implanted cannula in non-diabetic and diabetic animals and their 24 hr food and water intakes were recorded. Food and water intakes were also recorded following bilateral electrolytic lesions of nucleus accumbens in both the groups of rats. In diabetic rats, basal food and water intakes were significantly increased in comparison to basal intakes of non-diabetic rats. Following injection of noradrenaline, a significant increase in water intake but not food intake was seen in non-diabetic rats, whereas food and water intakes remained unchanged in diabetic rats. Following injection of dopamine, a significant increase in food and water intakes was observed in non-diabetic rats, whereas dopamine-induced increase in food intake was absent in diabetic rats. The bilateral lesions of nucleus accumbens resulted in a significant inhibition of food and water intakes in non-diabetic rats, whereas inhibition of water intake without change in food intake observed in diabetic rats. However, no difference was observed in the pattern of change in water intake following lesions or dopamine injections between non-diabetic and diabetic rats, whereas difference was observed for food intake. The results suggest that nucleus accumbens activity changes for food intake, but not for water intake in diabetes.     

Novel nucleosides as potent influenza viral inhibitors

Influenza virus infection constitutes a significant health problem in need of more effective therapies. We have recently identified ((2R,3S,4R,5R)-3-acetoxy-5-(4-benzamido-2-oxopyrimidin-1(2H)-yl)-4-fluoro-3,4-dimethyl-tetrahydrofuran-2-yl) methyl benzoate (18c) as a potent influenza virus inhibitor. We now here report the synthesis and evaluation of a series of C-3′ modified ribose nucleosides. These novel compounds were prepared, primarily by taking known ((2R,3R,4R)-3-benzoyloxy-4-fluoro-4-methyl-5-oxo-tetrahydrofuran-2-yl)methyl benzoate (1) and converting it in to C-3 keto sugar (7), reacting C-3 keto group with methyl magnesium bromide, followed by coupling these sugars with purine and pyrimidine bases. Anti influenza viral activity was determined by screening against both A and B viral strains.     

What does one mean by "arterial blood oxygenation?"

We used the following question in a large classroom session attended by undergraduate medical students and doctors with a Bachelor of Medicine and Bachelor of Surgery (MBBS) degree (240 in all) to test for conceptual understanding as to what constitutes arterial blood oxygenation. The question read as follows: Which one of the following physiological parameters taken alone tells you that arterial blood oxygenation in a critically ill patient is satisfactory? A. (Alveolar-arterial) O(2) gradient=10 mmHg. B. Partial pressure of O(2) in arterial blood=95 mmHg. C. O(2)saturation of hemoglobin>90%. D. Blood hemoglobin concentration=12 g/dl. Only 25 of 240 students correctly indicated that none of the above parameters taken alone could give us this information. Once students turned in their answers, we presented five examples illustrating how none of the above answers could be used alone to assess arterial blood oxygenation. Students were then asked to provide written feedback on their understanding of this topic. The majority of students indicated that they were satisfied that they got rid of a misconception.     

Association between Cardiac Autonomic Function, Oxidative Stress and Inflammatory Response in Impaired Fasting Glucose Subjects: Cross-Sectional Study

Background

The worldwide burden of diabetes in 2030 is projected around 552 million. Diabetes leads to higher risk for cardiovascular diseases (CVD). Altered cardiac autonomic function (CAF) measured by heart rate variability (HRV) is observed in early stages of diabetes but the relationship between impaired fasting glucose (IFG) and HRV is still debatable. The aim of the study was to evaluate the association between CAF, oxidative stress, insulin resistance (IR), and inflammatory response in IFG subjects.

Subjects and Methods

Cross-sectional blinded study. Volunteers recruited from health awareness camps underwent CAF and biochemical tests. Based on fasting plasma glucose (FPG) participants (n = 123) were divided into two groups, normal fasting glucose (n = 76) and IFG (n = 47). The comparison of parameters between the groups was carried out using student t test and Mann-Whitney U test for parametric and non-parametric data respectively. The correlation between the parameters was analyzed by Spearman’s rank correlation using SPSS 13.0.

Results

The resting cardiovagal modulation parameters, heart rate response to forced timed breathing, and orthostatic stress were reduced in IFG subjects. Fasting plasma lipid profile, coronary atherogenic lipid risk factors, IR, thiobarbituric acid reactive substance (TBARS), high sensitive C-reactive protein, and tumor necrosis factor alpha were increased and total antioxidant capacity (TAC) was decreased significantly in IFG group but no significant alteration was observed in high-density lipoprotein (HDL-c). Cardiovagal modulation parameters were negatively correlated with triglycerides, FPG, insulin, IR, TBARS, and inflammatory markers and positively with TAC.

Conclusion

There is a continuous interplay between the altered CAF, hyperinsulinemia, IR, oxidative stress parameters, inflammatory response, and IFG in which one factor perpetuates another leading to the progression of disease.     

What is the ultimate goal in neural regulation of cardiovascular function?

We used the following multiple-choice question after a series of lectures in cardiovascular physiology in the first year of an undergraduate medical curriculum (n = 66) to assess whether students had understood the neural regulation of cardiovascular function. In health, neural cardiovascular mechanisms are geared toward maintaining A) cardiac output, B) total peripheral resistance (TPR), C) arterial blood pressure (BP), D) tissue blood flow. The same question was administered to 275 graduates preparing for postgraduate exams (but not following the same series of lectures as the undergraduates). In both groups, we found a large proportion of incorrect answers (70% in undergraduates and 85% in graduates) and sorted this out by offering a step-by-step explanation and two examples and found it successful: 1) What happens to BP and heart rate (HR) when a person loses 500 ml of blood ( approximately 10% of blood volume) in one minute? 2) What happens to your BP and HR as you get out of bed after a night's sleep? Flow = perfusion pressure/resistance to flow; cardiac output = BP/TPR; BP = cardiac output x TPR = [stroke volume (SV) x HR] x TPR. In both examples, BP decreases and is rapidly brought into the normal range by the arterial baroreflex mechanism. TBF is regulated chiefly by varying local vascular resistance (autoregulation). In summary, the ultimate goal of all neural cardiovascular reflex mechanisms is to maintain arterial BP within a range in which tissues can regulate their own blood flows. Cardiovascular control during exercise was used as an example to emphasize these facts. A discussion of this kind triggered interest in the minds of students and graduates, helping them get rid of a major misconception in about 20-40 minutes.