This project is supported in part by grant KKF-15-1.

NOTA: O teste de acetilcolina intracoronária foi aprovado pelo comitê de ética local e o protocolo segue as diretrizes da nossa instituição para a investigação humana. 1. Preparação de Soluções de acetilcolina (Ver Tabela Materiais) <ol><li> Misturar a 20 mg acetilcolina com os 2 ml de solvente fornecido com o pacote. </li><li> Adicionar a solução de ACH 2 ml a 98 ml de NaCl a 0,9%. Isto corresponde a uma dose de 0,2 mg / ml e é chamada solução de reserva 1. adicionar 9 ml da solução de 1-91 ml de NaCl a 0,9%, o que corresponde a uma dose de 18 ug / ml e é chamada solução-mãe 2. </li><li> Prepare 3 seringas de perfusão (cada um 50 ml) rotulados como &quot;alto&quot;, &quot;médio&quot; e &quot;baixo&quot;. Encher a seringa uma perfusão marcado &quot;alta&quot; com 40 ml de solução-mãe 2. </li><li> Encher a seringa de perfusão 2 (rotulado como &quot;meio&quot;) com 8 ml de uma seringa de perfusão (alto) e adicionar 32 ml de NaCl a 0,9%. Isto corresponde a umadose de 3,6 ug / ml. </li><li> Encher a seringa de perfusão 3 (marcado com &quot;baixa&quot;) com 4 ml da seringa de perfusão 2 (médio) e adicionar 36 ml de NaCl a 0,9%. Isto corresponde a uma dose de 0,36 ug / ml. </li></ol> 2. Preparação das seringas para injeção intracoronária de acetilcolina <ol><li> Prepare 5 seringas para a injeção intracoronária (4 seringas de 5 ml [# 1, # 2, # 3, # 4] e uma seringa de 10 ml). </li><li> Encha a seringa de 5 ml # 1 com 6 ml da seringa de perfusão rotulado como &quot;baixo&quot; (veja o passo 1.5). Isto corresponde a uma dose de aproximadamente 2 mg. </li><li> Encha a seringa de 5 ml # 2 com 6 ml da seringa de perfusão rotulado como &quot;médio&quot;. Isto corresponde a uma dose de aproximadamente 20 ug. </li><li> Encher a seringa de 5 ml # 3 com 5,5 ml a partir da seringa de perfusão marcado &quot;alta&quot;. Isto corresponde a uma dose de aproximadamente 100 ug. </li><li> Encha a seringa de 10 ml com 11 ml da seringa de perfusão rotulada4;. Alta &quot;Isto corresponde a uma dose de aproximadamente 200 ug. </li><li> Encha a seringa de 5 ml # 4 com 4,5 ml da seringa de perfusão identificado como &quot;high&quot;. Isto corresponde a uma dose de aproximadamente 80 ug. Coloque esta seringa de lado e usá-lo apenas para a avaliação da artéria coronária direita. </li></ol> 3. Diagnóstico angiografia coronária <ol><li> Injectar anestesia local, quer na proximidade da artéria radial direita (normalmente 2 ml de mepivacaína) ou na proximidade da artéria femoral direita (geralmente 15 ml de mepivacaína). </li><li> Confirmar o sucesso da anestesia local é através da punção da pele anestesiados com a agulha e perguntando ao paciente se a dor ainda está presente. </li><li> Perfurar a artéria de acordo com a técnica de Seldinger 13 com uma cânula, em seguida, insira o fio através da cânula e removê-lo. Insira a bainha (geralmente 5F) sobre o fio. Realizar a angiografia coronária em condições estéreis. </li><li> Avançar as th fioáspera da bainha para a aorta ascendente e posicionar o cateter de diagnóstico acima da válvula da aorta. Em seguida, retire o fio e se conectar o cateter com a seringa de contraste. NOTA: O agente de contraste contém Iomeprol, Trometamol, ácido clorídrico e água. </li><li> Colocar o cateter de diagnóstico para a artéria coronária esquerda no tronco principal esquerdo e puxando ligeiramente para transformar o cateter. Confirmar o posicionamento correto do cateter por injecção de 2 mL de agente de contraste. </li><li> Execute angiografia coronária de acordo com a técnica de Judkins 14 com injeções manuais de cerca de 10 ml de contraste para visualizar as artérias coronárias em diferentes pontos de vista. NOTA: Normalmente LAO 40 ° e 35 ° RAO são utilizados para a artéria coronária direita e LAO 45 ° / 25 ° CRAN, RAO 30 ° / 30 ° CRAN e Rao 20 ° / 30 ° CAUD são utilizados para a artéria coronária esquerda. </li><li> Iniciar os testes acetilcolina após a exclusão de qualquer estenose epicárdica relevante (≥50%) Por avaliação visual. </li></ol> 4. injeção intracoronária de acetilcolina <ol><li> Injectar 6 ml de 2 ug a seringa # 1 para a artéria coronária esquerda. Injectar este dentro de 20 segundos com monitorização contínua do ECG e sintomas do paciente (por exemplo, dor no peito, falta de ar, tontura). Realizar a angiografia coronária da artéria coronária esquerda (geralmente uma projecção RAO 20 ° / 30 ° CAUD é melhor projecção) após a injecção dos 6 ml. </li><li> Realizar a angiografia coronária por injecção de 10 ml de contraste manualmente através da seringa de contraste para dentro do cateter. O 12-lead-ECG deve ser gravado e impresso após cada dose de acetilcolina. Uma pausa de 1 min deve situar-se entre cada dose. </li><li> Injectar 6 ml da seringa 20 ug # 2 na artéria coronária esquerda. Injectar este dentro de 20 segundos com monitorização contínua do ECG e sintomas do paciente. Execute angiografia coronária da artéria coronária esquerda após a injeçãodos 6 ml, tal como mencionado acima. </li><li> Injectar 5,5 mL de 100 ug a seringa # 3 na artéria coronária esquerda. Injectar este dentro de 20 segundos com monitorização contínua do ECG e sintomas do paciente. Realizar a angiografia coronária da artéria coronária esquerda após a injecção de 5,5 ml, como mencionado acima. NOTA: A maioria dos pacientes relatam alguns sintomas, mostram alteração de ECG ou vasoconstrição epicárdico com esta dose. Por vezes, a velocidade da injecção manual do necessita de ser retardado. Como mencionado abaixo diferentes protocolos para ACH-teste estão em utilização com uma velocidade diferente da injecção. Uma injecção mais lenta ao longo de um período de 3 minutos, em comparação com a injecção dentro de 20 seg pode ser também viável. </li><li> Se nenhum espasmo (isto é,&gt; 90% de vasoconstrição em comparação com o estado de relaxamento do vaso, após a injecção de 200 ug nitroglyercine) ocorre na dose de 100 ug continuar com a dose de 200 ug de ACH (seringa de 10 ml). Injectar 11 mL dentro de 20 segundos com monitor contínuoção do ECG e os sintomas do paciente. </li><li> Realizar a angiografia coronária da artéria coronária esquerda após a injecção de 11 ml, tal como mencionados acima (secção 3). Nota: Embora a dose de 200 ug foi aplicado em muitos pacientes, deve ser mencionado que as doses adequadas de acetilcolina intracoronária continuam a ser completamente definido. Alguns autores sugerem que 100 ug deve ser a dose máxima para a artéria coronária esquerda. NOTA: Muitas vezes ocorre bradicardia e a velocidade da injecção tem de ser retardada. </li><li> Injectar 80 ug ACH (4,5 ml, seringa # 4) na artéria coronária direita se não houver resultados anormais são vistos durante os testes da artéria coronária esquerda. Injectar este dentro de 20 segundos com monitorização contínua do ECG e sintomas do paciente. Muitas vezes ocorre bradicardia e a velocidade da injecção tem de ser desacelerado para prevenir a bradicardia e / ou assístole prolongada. </li><li> Execute angiografia coronária da artéria coronária direitaApós a injecção da 4,5 ml (usualmente uma projecção LAO 40 ° / 0 ° é melhor) como mencionado acima (secção 3). </li><li> Injectar nitroglicerina intracoronária com uma dose de 200 mg em cada artéria testado após o teste ou quando os sintomas graves (ou seja, dor no peito ou falta de ar), mudanças de ECG de isquemia ou espasmo epicárdica ocorre. </li><li> Imagem do navio, como mencionado na etapa 4.2 após um minuto para documentar reversão de espasmo. </li></ol>

<ol>
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A variant of the variant.</a> Circulation. 47 (3), 476-485 (1973).</li><li>Yasue, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Induction+of+coronary+artery+spasm+by+acetylcholine+in+patients+with+variant+angina:+possible+role+of+the+parasympathetic+nervous+system+in+the+pathogenesis+of+coronary+artery+spasm.">Induction of coronary artery spasm by acetylcholine in patients with variant angina: possible role of the parasympathetic nervous system in the pathogenesis of coronary artery spasm.</a> Circulation. 74 (5), 955-963 (1986).</li><li>Bell, M. R., Berger, P. B., Holmes, D. R., Mullany, C. J., Bailey, K. R., Gersh, B. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Referral+for+coronary+artery+revascularization+procedures+after+diagnostic+coronary+angiography:+evidence+for+gender+bias?.">Referral for coronary artery revascularization procedures after diagnostic coronary angiography: evidence for gender bias?.</a> J Am Coll Cardiol. 25 (7), 1650-1655 (1995).</li><li>Patel, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+diagnostic+yield+of+elective+coronary+angiography.">Low diagnostic yield of elective coronary angiography.</a> N Engl J Med. 362 (10), 885-895 (2010).</li><li>Pocock, S. J., Henderson, R. A., Seed, P., Treasure, T., Hampton, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quality+of+life,+employment+status,+and+anginal+symptoms+after+coronary+angioplasty+or+bypass+surgery.+3-year+follow-up+in+the+Randomized+Intervention+Treatment+of+Angina.">Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery. 3-year follow-up in the Randomized Intervention Treatment of Angina.</a> Circulation. 94 (2), 135-142 (1996).</li><li>Ong, P., Athanasiadis, A., Borgulya, G., Mahrholdt, H., Kaski, J. C., Sechtem, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=High+prevalence+of+a+pathological+response+to+acetylcholine+testing+in+patients+with+stable+angina+pectoris+and+unobstructed+coronary+arteries.+The+ACOVA+Study+(Abnormal+COronary+VAsomotion+in+patients+with+stable+angina+and+unobstructed+coronary+arteries).">High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries).</a> J Am Coll Cardiol. 59 (7), 655-662 (2012).</li><li>Furchgott, R. F., Zawadzki, J. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+obligatory+role+of+endothelial+cells+in+the+relaxation+of+arterial+smooth+muscle+by+acetylcholine.">The obligatory role of endothelial cells in the relaxation of arterial smooth muscle by acetylcholine.</a> Nature. 288 (5789), 373-376 (1980).</li><li>Shimizu, H., Lee, J. D., Ogawa, K., Hara, A., Nakamura, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coronary+artery+vasoreactivity+to+intracoronary+acetylcholine+infusion+test+in+patients+with+chest+pain+syndrome.">Coronary artery vasoreactivity to intracoronary acetylcholine infusion test in patients with chest pain syndrome.</a> Intern Med. 31 (1), 22-27 (1992).</li><li>Montalescot, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=2013+ESC+guidelines+on+the+management+of+stable+coronary+artery+disease:+the+Task+Force+on+the+management+of+stable+coronary+artery+disease+of+the+European+Society+of+Cardiology.">2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.</a> Eur Heart J. 34 (38), 2949-3003 (2013).</li><li>JCS Joint Working Group. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+diagnosis+and+treatment+of+patients+with+vasospastic+angina+(Coronary+Spastic+Angina)+(JCS+2013).">Guidelines for diagnosis and treatment of patients with vasospastic angina (Coronary Spastic Angina) (JCS 2013).</a> Circ J. 78 (11), 2779-2801 (2014).</li><li>Ong, P., Athanasiadis, A., Sechtem, U. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patterns+of+coronary+vasomotor+responses+to+intracoronary+acetylcholine+provocation.">Patterns of coronary vasomotor responses to intracoronary acetylcholine provocation.</a> Heart. 99 (17), 1288-1295 (2013).</li><li>Seldinger, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+replacement+of+the+needle+in+percutaneous+arteriography;+a+new+technique.">Catheter replacement of the needle in percutaneous arteriography; a new technique.</a> Acta radiol. 39 (5), 368-376 (1953).</li><li>Judkins, M. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Selective+coronary+arteriography.+I.+A+percutaneous+transfemoral+technic.">Selective coronary arteriography. I. 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The authors have nothing to disclose.

É possível implementar o teste de acetilcolina na rotina clínica diária no laboratório de cateterização. Além da preparação das soluções de ACH existem várias questões técnicas que têm de ser resolvidas antes de iniciar o teste, incluindo ECG radioluscente leva para 12 derivações registro contínuo ECG. Isto é essencial para ser capaz de detectar alterações no ECG isquémicos transitórios durante o ensaio. Além disso, é importante saber que as soluções de ACH só pode ser utilizada durante 2 h....

angina de peito é a marca da doença arterial coronariana e o conceito de uma estenose epicárdica causando isquemia do miocárdio e angina induzida por exercício foi estabelecida há muitos anos. No entanto, muitos pacientes com angina de peito não têm a tríade típica de dor retro-esternal, início durante o exercício e alívio por nitroglicerina ou descanso. Frequentemente os pacientes relatam angina em repouso, ou uma combinação de angina de esforço e de repouso, bem como falta de ar ao esforço como uma possível equivalente angina. Em 1959 Prinzmetal foi o primeiro a introduzir o conceito de espasmo transitória das artérias coronárias, causando angina em repouso associado com elevação do segmento ST no eletrocardiograma (ECG), mas com a capacidade de exercício preservada 1. Esta hipótese foi confirmada mais tarde usando a angiografia coronária e parecia que espasmo coronariano pode estar presente em pacientes com estenose do epicárdio ou artérias coronárias normais 2. No 1980ies provocação acetilcolina intracoronária testar (ACH-teste) para a detecção de espasmo da artéria coronária foi fundada no Japão e, posteriormente, o interessado em pesquisa clínica para o espasmo coronariano aumentou 3. No entanto, após a introdução da intervenção coronária percutânea em 1977 e o primeiro implante de stent em 1986, o interesse em distúrbios vasomotores coronárias diminuiu consideravelmente, pelo menos na Europa e nos Estados Unidos. Isto pode ser também devido à natureza invasiva da ACH-teste (devido à meia-vida curta de ACH, só pode ser administrado dentro das artérias coronárias para a avaliação de espasmo coronário). Ainda assim, muitos pacientes com sinais e sintomas de isquemia miocárdica não têm qualquer estenose epicárdica relevante sobre 4,5,6 angiografia coronária. Em tais pacientes testes acetilcolina provocação intracoronária é útil para detectar um distúrbio vasomotor coronária clinicamente relevante e instituir tratamento médico adequado <sup&gt; 7. A acetilcolina é um neurotransmissor no sistema nervoso parassimpático. Ele actua através nicotinérgicos, bem como receptores muscarinergic (mAChR). Estes últimos são importantes para a homeostase vascular e a acetilcolina se liga em mAChR como um agonista não-selectivo. A activação destes receptores ao nível endotelial leva a vasodilatação mediada por óxido nítrico Considerando que a activação de mAChR sobre as células musculares lisas vasculares leva à vasoconstrição 8. Dependendo da integridade do endotélio e a reactividade das células musculares lisas, o efeito líquido de administração intracoronária de acetilcolina é vasodilatação ou vasoconstrição. A resposta fisiológica das artérias coronárias em resposta a acetilcolina, em seres humanos não é totalmente compreendido, mas tem sido relatado que a vasodilatação, bem como a vasoconstrição de até 25% do diâmetro do vaso pode ser fisiológica, como mostrado em pacientes com artérias coronárias normais e não será pec anginaToris 9. Testes de acetilcolina provocação intracoronária tem sido recomendado pela Sociedade Europeia de Cardiologia 10, bem como as normas da Sociedade de circulação japonesas 11 para avaliação do epicárdio e / ou espasmo microvascular em pacientes com angina de peito e artérias coronárias desobstruídas. Testes de acetilcolina provocação intracoronária foi estabelecida na rotina clínica diária na sala de cateterismo da nossa instituição em 2003. Desde 2006, um protocolo padronizado foi seguido 12. ACH-teste é geralmente realizado em todos os pacientes com sinais e sintomas de isquemia miocárdica ainda sem estenose epicárdica relevante (&lt;50%) na angiografia coronária. ACH-teste é realizado imediatamente após a angiografia coronária de diagnóstico de acordo com o protocolo descrito abaixo. Ergonovina é um outro agente que é usada para testes de provocação espasmo com um mecanismo de acção diferente. Detalhadoinformações sobre testes ergonovine pode ser encontrada em outro lugar 12.

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	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:528px;">Vial of 20 mg acetylcholine chloride powder and 1 Ampoule of 2 mL diluent</td>
			<td style="width:151px;">Bausch &#38; Lomb&#160;</td>
			<td style="width:165px;">NDC 24 208-539-20</td>
			<td style="width:80px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">3 x 100 ml NaCl 0.9 %</td>
			<td>BBraun</td>
			<td>3200950</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">3 x syringe 50 ml each</td>
			<td>BBraun</td>
			<td>4187903</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;1 x 2 ml syringe</td>
			<td>BBraun</td>
			<td>4606027V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;1 x 10 ml syringe</td>
			<td>BBraun</td>
			<td>4606108V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">2 x cannula 20 G 70mm</td>
			<td>BBraun</td>
			<td>4665791</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">&#160;5 x 5 ml syringe</td>
			<td>BBraun</td>
			<td>4606051V</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Contrast agent Imeron 350 with a 10ml syringe for contrast injection</td>
			<td>Bracco Imaging</td>
			<td>30699.03.00</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Coronary angiography suite (AXIOM Artis MP eco )</td>
			<td>Siemens</td>
			<td>n/a</td>
			<td></td>
		</tr>
	</tbody>
</table>

intracoronary acetylcholine provocation testing for assessment of coronary vasomotor disorders

Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the catheterization laboratory which was introduced more than 30 years ago. Due to the short half-life of acetylcholine it can only be applied directly into the coronary arteries. Several studies have demonstrated the safety and clinical usefulness of this test. However, acetylcholine testing is only rarely applied in the U.S. or Europe. Nevertheless, it has been shown that 62% of Caucasian patients with stable angina and unobstructed coronary arteries on coronary angiography suffer from coronary vasomotor disorders that can be diagnosed with acetylcholine testing. In recent years it has been appreciated that the ACH-test not only assesses the presence of epicardial spasm but that it can also be useful for the detection of coronary microvascular spam. In such cases no epicardial spasm is seen after injection of acetylcholine but ischemic ECG shifts are present together with a reproduction of the patient's symptoms during the test. This article describes the experience with the ACH-test and its implementation in daily clinical routine.

Interpretação do teste de acetilcolina é baseada em três critérios. Em primeiro lugar, o paciente é orientado ao longo do teste ou não sintomas ocorrem. Freqüentemente, os pacientes relatam uma reprodução de suas habituais sintomas como dor no peito, falta de ar ou outros sintomas. Isto representa um aspecto importante para a interpretação global do teste. Em segundo lugar, um registro de 12 derivações-ECG é continuamente realizada durante todo o teste com uma ênfase espe...

Watch this Scientific Journal Video about Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders at JoVE.com

Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders

Intracoronary acetylcholine testing has been established for the assessment of epicardial coronary spasm more than 30 years ago. Recently, the focus has shifted towards the microcirculation and it has been shown that microvascular spasm can be detected using ACH-testing. This article describes the ACH-test and its implementation in daily routine.

Teste de Provocação acetilcolina intracoronária de Avaliação de Coronária Disorders vasomotores

Intracoronary acetylcholine provocation testing (ACH-test) is an established method for assessment of epicardial coronary artery spasm in the ...

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JoVE Journal

Medicine

15.6K visualizações.  Robert-Bosch-Krankenhaus. Intracoronary acetylcholine testing has been established for the assessment of epicardial coronary spasm more than 30 years ago. Recently, the focus has shifted towards the microcirculation and it has been shown that microvascular spasm can be detected using ACH-testing. This article describes the ACH-test and its implementation in daily routine.

Vídeo: Intracoronary Acetylcholine Provocation Testing for Assessment of Coronary Vasomotor Disorders

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression across speech subsystems, and for addressing the critical need for sensitive outcome measures for ongoing experimental treatment trials. To address this need, we are obtaining longitudinal profiles of bulbar impairment in 100 individuals based on a comprehensive instrumentation-based assessment that yield objective measures. Using instrumental approaches to quantify speech-related behaviors is very important in a field that has primarily relied on subjective, auditory-perceptual forms of speech assessment1. Our assessment protocol measures performance across all of the speech subsystems, which include respiratory, phonatory (laryngeal), resonatory (velopharyngeal), and articulatory. The articulatory subsystem is divided into the facial components (jaw and lip), and the tongue. Prior research has suggested that each speech subsystem responds differently to neurological diseases such as ALS. The current protocol is designed to test the performance of each speech subsystem as independently from other subsystems as possible. The speech subsystems are evaluated in the context of more global changes to speech performance. These speech system level variables include speaking rate and intelligibility of speech.
The protocol requires specialized instrumentation, and commercial and custom software. The respiratory, phonatory, and resonatory subsystems are evaluated using pressure-flow (aerodynamic) and acoustic methods. The articulatory subsystem is assessed using 3D motion tracking techniques. The objective measures that are used to quantify bulbar impairment have been well established in the speech literature and show sensitivity to changes in bulbar function with disease progression. The result of the assessment is a comprehensive, across-subsystem performance profile for each participant. The profile, when compared to the same measures obtained from healthy controls, is used for diagnostic purposes. Currently, we are testing the sensitivity and specificity of these measures for diagnosis of ALS and for predicting the rate of disease progression. In the long term, the more refined endophenotype of bulbar ALS derived from this work is expected to strengthen future efforts to identify the genetic loci of ALS and improve diagnostic and treatment specificity of the disease as a whole. The objective assessment that is demonstrated in this video may be used to assess a broad range of speech motor impairments, including those related to stroke, traumatic brain injury, multiple sclerosis, and Parkinson disease.

A Protocol for Comprehensive Assessment of Bulbar Dysfunction in Amyotrophic Lateral Sclerosis ALS

Objective assessments of the physiological mechanisms that support speech are needed to monitor disease onset and progression in persons with ALS and to quantify treatment effects in clinical trials. In this video, we present a comprehensive, instrumentation-based protocol for quantifying speech motor performance in clinical populations.

Um Protocolo de Avaliação Abrangente de Disfunção Bulbar em Esclerose Lateral Amiotrófica (ALS)

Improved methods for assessing bulbar impairment are necessary for expediting diagnosis of bulbar dysfunction in ALS, for predicting disease progression ...

Medicina

Use of a Hanging Weight System for Coronary Artery Occlusion in Mice

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. Cardioprotection by ischemic preconditioning (IP) remains an area of intense investigation. To further elucidate its molecular basis, the use of knockout mouse studies is particularly important 7, 14, 30, 39. Despite the fact that previous studies have already successfully performed cardiac ischemia and reperfusion in mice, this model is technically very challenging. Particularly, visual identification of the coronary artery, placement of the suture around the vessel and coronary occlusion by tying off the vessel with a supported knot is technically difficult. In addition, re-opening the knot for intermittent reperfusion of the coronary artery during IP without causing surgical trauma adds additional challenge. Moreover, if the knot is not tied down strong enough, inadvertent reperfusion due to imperfect occlusion of the coronary may affect the results. In fact, this can easily occur due to the movement of the beating heart.
Based on potential problems associated with using a knotted coronary occlusion system, we adopted a previously published model of chronic cardiomyopathy based on a hanging weight system for intermittent coronary artery occlusion during IP 39. In fact, coronary artery occlusion can thus be achieved without having to occlude the coronary by a knot. Moreover, reperfusion of the vessel can be easily achieved by supporting the hanging weights which are in a remote localization from cardiac tissues.
We tested this system systematically, including variation of ischemia and reperfusion times, preconditioning regiments, body temperature and genetic backgrounds39. In addition to infarct staining, we tested cardiac troponin I (cTnI)
as a marker of myocardial infarction in this model. In fact, plasma levels of cTnI correlated with infarct sizes (R2=0.8). Finally, we could show in several studies that this technique yields highly reproducible infarct sizes during murine IP and myocardial infarction6, 8, 30, 40, 41. Therefore, this technique may be helpful for researchers who pursue molecular mechanisms involved in cardioprotection by IP using a genetic approach in mice with targeted gene deletion. Further studies on cardiac IP using transgenic mice may consider this technique.

A murine model for myocardial ischemia and ischemic preconditioning is an important tool study cardioprotective mechanisms in vivo. Here, we report an easy applicable in situ model for cardiac IP using a hanging-weight system for coronary artery occlusion.

Uso de um Sistema de Peso de suspensão para oclusão da artéria coronária em ratos

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. ...

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Técnica modificada para ligação da artéria coronária em ratos

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment (RMCA) in Individuals with Chronic Spinal Cord Injury

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination is disrupted by spinal cord injury (SCI), control of respiratory muscles innervated below the injury level is compromised1,2 leading to respiratory muscle dysfunction and pulmonary complications. These conditions are among the leading causes of death in patients with SCI3. Standard pulmonary function tests that assess respiratory motor function include spirometrical and maximum airway pressure outcomes: Forced Vital Capacity (FVC), Forced Expiratory Volume in one second (FEV1), Maximal Inspiratory Pressure (PImax) and Maximal Expiratory Pressure (PEmax)4,5. These values provide indirect measurements of respiratory muscle performance6. In clinical practice and research, a surface electromyography (sEMG) recorded from respiratory muscles can be used to assess respiratory motor function and help to diagnose neuromuscular pathology. However, variability in the sEMG amplitude inhibits efforts to develop objective and direct measures of respiratory motor function6. Based on a multi-muscle sEMG approach to characterize motor control of limb muscles7, known as the voluntary response index (VRI)8, we developed an analytical tool to characterize respiratory motor control directly from sEMG data recorded from multiple respiratory muscles during the voluntary respiratory tasks. We have termed this the Respiratory Motor Control Assessment (RMCA)9. This vector analysis method quantifies the amount and distribution of activity across muscles and presents it in the form of an index that relates the degree to which sEMG output within a test-subject resembles that from a group of healthy (non-injured) controls. The resulting index value has been shown to have high face validity, sensitivity and specificity9-11. We showed previously9 that the RMCA outcomes significantly correlate with levels of SCI and pulmonary function measures. We are presenting here the method to quantitatively compare post-spinal cord injury respiratory multi-muscle activation patterns to those of healthy individuals.

Evaluation of Respiratory Muscle Activation Using Respiratory Motor Control Assessment RMCA in Individuals with Chronic Spinal Cord Injury

The purpose of this publication is to present our original work on a multi-muscle surface electromyographic approach to quantitatively characterize respiratory muscle activation patterns in individuals with chronic spinal cord injury using vector-based analysis.

Avaliação da ativação muscular respiratória Usando respiratória Motor Control Assessment (ACMD) em indivíduos com lesão medular crônica

During breathing, activation of respiratory muscles is coordinated by integrated input from the brain, brainstem, and spinal cord. When this coordination ...

A Novel Application of Musculoskeletal Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon motion during dynamic tasks and can provide a complementary methodological approach for biomechanical studies in a clinical or laboratory setting. Towards this goal, methods for quantification of muscle kinematics from ultrasound imagery are being developed based on image processing. The temporal resolution of these methods is typically not sufficient for highly dynamic tasks, such as drop-landing. We propose a new approach that utilizes a Doppler method for quantifying muscle kinematics. We have developed a novel vector tissue Doppler imaging (vTDI) technique that can be used to measure musculoskeletal contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities using ultrasound. The goal of this preliminary study was to investigate the repeatability and potential applicability of the vTDI technique in measuring musculoskeletal velocities during a drop-landing task, in healthy subjects. The vTDI measurements can be performed concurrently with other biomechanical techniques, such as 3D motion capture for joint kinematics and kinetics, electromyography for timing of muscle activation and force plates for ground reaction force. Integration of these complementary techniques could lead to a better understanding of dynamic muscle function and dysfunction underlying the pathogenesis and pathophysiology of musculoskeletal disorders.

We describe a new ultrasound-based vector tissue Doppler imaging technique to measure muscle contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities. This approach provides complementary measurements of dynamic muscle function and could lead to a better understanding of mechanisms underlying musculoskeletal disorders.

A Aplicação da novela da Musculoskeletal Ecografia

Ultrasound is an attractive modality for imaging muscle and tendon  motion during dynamic tasks and can provide a complementary methodological  approach ...

Ultrasound Based Assessment of Coronary Artery Flow and Coronary Flow Reserve Using the Pressure Overload Model in Mice

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow reserve (CFR) in humans. Reduced CFR is accompanied by marked intramyocardial and pericoronary fibrosis and is used as an indication of the severity of dysfunction. This study explores, step-by-step, the real-time changes measured in the coronary flow velocity, CFR and systolic to diastolic peak velocity (S/D) ratio in the setting of an aortic banding model in mice. By using a Doppler transthoracic imaging technique that yields reproducible and reliable data, the method assesses changes in flow in the septal coronary artery (SCA), for a period of over two weeks in mice, that previously either underwent aortic banding or thoracotomy. 
During imaging, hyperemia in all mice was induced by isoflurane, an anesthetic that increased coronary flow velocity when compared with resting flow. All images were acquired by a single imager. Two ratios, (1) CFR, the ratio between hyperemic and baseline flow velocities, and (2) systolic (S) to diastolic (D) flow were determined, using a proprietary software and by two independent observers. Importantly, the observed changes in coronary flow preceded LV dysfunction as evidenced by normal LV mass and fractional shortening (FS). 
The method was benchmarked against the current gold standard of coronary assessment, histopathology. The latter technique showed clear pathologic changes in the coronary artery in the form of peri-coronary fibrosis that correlated to the flow changes as assessed by echocardiography. 
The study underscores the value of using a non-invasive technique to monitor coronary circulation in mouse hearts. The method minimizes redundant use of research animals and demonstrates that advanced ultrasound-based indices, such as CFR and S/D ratios, can serve as viable diagnostic tools in a variety of investigational protocols including drug studies and the study of genetically modified strains.

Coronary flow reserve (CFR) is useful for assessment of myocardial oxygen demand and evaluation of cardiovascular risk. This study establishes a step-by-step transthoracic Doppler echocardiographic (TTDE) method for longitudinal monitoring of the changes in CFR, as measured from coronary artery in mice, under the experimental pressure overload of aortic banding.

Avaliação ultra-som base de Artéria Coronária Flow e Fluxo Coronariano Reserve Usando o modelo de sobrecarga de pressão no Mice

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow ...

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized in clinical trials, despite being a burden for both study participants and researchers. This method requires participant literacy, it is time consuming, labor intensive, and can easily lead to under-reporting. With advancements in technology, there is a growing interest in electronic diaries that automate the dietary assessment process. These are focused on improving accuracy, reducing both time and cost and providing users with a visual and more enjoyable experience. The methodology presented here aimed to validate the &#39;Boden Food Plate&#39;, a novel web-based platform for self-recording of food and drink items, compared to a traditional estimated food diary. The application was also rated on a satisfaction scale by study participants using a paper-based questionnaire. Sixty-seven participants completed the dietary measures on both the three-day electronic and paper food diaries. For the analysis, only dietary data completed at both study time points (baseline and week six) was utilized. Despite small mean differences between dietary data collection methods, Bland Altman analysis showed fairly wide 95% limits of agreement between the electronic platform and the written estimated food diary and there were few cases which did not fall within the 95% confidence intervals. Overall, participants found the electronic food diary to be more fun than the paper method and as easy to use as hard copy diaries. The new platform has potential as a self-recording tool for the collection of dietary data, particularly when utilized in clinical trial settings. However, further validation studies are needed to improve the validity of this novel electronic dietary data collection tool.

The &#39;Boden Food Plate&#39; is an electronic food diary designed to be an interactive and fun method to collect dietary intake using visual depictions. The purpose of this study was to validate the web-based application against a traditional three-day estimated food diary method.

«Placa de Boden Food»: novo método interativo baseado na Web para a avaliação da ingestão alimentar

Different methods can be used in research to assess dietary intake, many of which are still paper-based. Written estimated food diaries are often utilized ...

Coronary Progenitor Cells and Soluble Biomarkers in Cardiovascular Prognosis after Coronary Angioplasty

Major adverse cardiovascular events (MACEs) negatively impact the cardiovascular prognosis of patients undergoing coronary angioplasty due to coronary ischemic injury. The extent of coronary damage and the mechanisms of vascular repair are factors influencing the future development of MACEs. Intrinsic vascular features like the plaque characteristics and coronary artery complexity have demonstrated prognostic information for MACEs. However, the use of intracoronary circulating biomarkers has been postulated as a convenient method for the early identification and prognosis of MACEs, as they more closely reflect dynamic mechanisms involving coronary damage and repair. Determination of coronary circulating biomarkers during angioplasty, such as the number of subpopulations of mononuclear progenitor cells (MPCs) as well as the concentration of soluble molecules reflecting inflammation, cell adhesion, and repair, allows for assessment of future developments and the prognosis of MACEs 6 months post coronary angioplasty. This method is highlighted by its translational nature and better performance than peripheral blood circulating biomarkers regarding prediction of MACEs and its effect on the cardiovascular prognosis, which may be applied for risk stratification of patients with coronary artery disease undergoing angioplasty.

Development of major adverse cardiovascular events, which impact cardiovascular prognosis after coronary angioplasty, are influenced by the extent of coronary damage and vascular repair. The use of novel coronary cellular and soluble biomarkers, reactive to vascular damage and repair, are useful to predict the development of MACEs and prognosis.

Células progenitoras coronárias e biomarcadores solúveis no prognóstico cardiovascular após angioplastia coronária

Major adverse cardiovascular events (MACEs) negatively impact the cardiovascular prognosis of patients undergoing coronary angioplasty due to coronary ...

In Vitro Model of Coronary Angiogenesis

Here, we describe an in vitro culture assay to study coronary angiogenesis. Coronary vessels feed the heart muscle and are of clinical importance. Defects in these vessels represent severe health risks such as in atherosclerosis, which can lead to myocardial infarctions and heart failures in patients. Consequently, coronary artery disease is one of the leading causes of death worldwide. Despite its clinical importance, relatively little progress has been made on how to regenerate damaged coronary arteries. Nevertheless, recent progress has been made in understanding the cellular origin and differentiation pathways of coronary vessel development. The advent of tools and technologies that allow researchers to fluorescently label progenitor cells, follow their fate, and visualize progenies in vivo have been instrumental in understanding coronary vessel development. In vivo studies are valuable, but have limitations in terms of speed, accessibility, and flexibility in experimental design. Alternatively, accurate in vitro models of coronary angiogenesis can circumvent these limitations and allow researchers to interrogate important biological questions with speed and flexibility. The lack of appropriate in vitro model systems may have hindered the progress in understanding the cellular and molecular mechanisms of coronary vessel growth. Here, we describe an in vitro culture system to grow coronary vessels from the sinus venosus (SV) and endocardium (Endo), the two progenitor tissues from which many of the coronary vessels arise. We also confirmed that the cultures accurately recapitulate some of the known in vivo mechanisms. For instance, we show that the angiogenic sprouts in culture from SV downregulate COUP-TFII expression similar to what is observed in vivo. In addition, we show that VEGF-A, a well-known angiogenic factor in vivo, robustly stimulates angiogenesis from both the SV and Endo cultures. Collectively, we have devised an accurate in vitro culture model to study coronary angiogenesis.

In vitro models of coronary angiogenesis can be utilized for the discovery of the cellular and molecular mechanisms of coronary angiogenesis. In vitro explant cultures of sinus venosus and endocardium tissues show robust growth in response to VEGF-A and display a similar pattern of COUP-TFII expression as in vivo.

Modelo In Vitro de Angiogênese Coronariana

Here, we describe an in vitro culture assay to study coronary angiogenesis. Coronary vessels feed the heart muscle and are of clinical importance. Defects ...

Testing Acetylcholine Followed by Adenosine for Invasive Diagnosis of Coronary Vasomotor Disorders

More than 50% of patients with signs and symptoms of myocardial ischemia undergoing coronary angiography have unobstructed coronary arteries. Coronary vasomotor disorders (impaired vasodilatation and/or enhanced vasoconstriction/spasm) represent important functional causes for such a clinical presentation. Although impaired vasodilatation may be assessed with non-invasive techniques such as positron emission tomography or cardiac magnetic resonance imaging, there is currently no reliable non-invasive technique for the diagnosis of coronary spasm available. Thus, invasive diagnostic procedures (IDP) have been developed for the diagnosis of coronary vasomotor disorders including spasm testing as well as assessment of coronary vasodilatation. The identification of the underlying type of disorder (so called endotype) allows the initiation of targeted pharmacological treatments. Despite the fact that such an approach is recommended by the current European Society of Cardiology guidelines for the management of chronic coronary syndromes based on the CorMicA study, comparability of results as well as multicenter trials are currently hampered by major differences in institutional protocols for coronary functional testing. This article describes a comprehensive IDP protocol including intracoronary acetylcholine provocation testing for diagnosis of epicardial/microvascular spasm, followed by Doppler wire-based assessment of coronary flow reserve (CFR) and hyperemic microvascular resistance (HMR) in search of coronary vasodilatory impairment.

Coronary vasomotion disorders represent frequent functional causes of angina in patients with unobstructed coronaries. The underlying mechanism of angina (endotype) in these patients can be determined by a comprehensive invasive diagnostic procedure based on acetylcholine provocation testing followed by Doppler-derived assessment of the coronary flow reserve and microvascular resistance.

Testando acetilcolina seguida de adenosina para diagnóstico invasivo de distúrbios vasomotores coronários

More than 50% of patients with signs and symptoms of myocardial ischemia undergoing coronary angiography have unobstructed coronary arteries. Coronary ...