Monika Lechleitner

Decreased High-Energy Phosphate Ratios in the Myocardium of Men with Diabetes Mellitus Type I

AIMS/HYPOTHESIS To investigate whether alterations in high-energy phosphates occur in the myocardium of persons with diabetes mellitus type I. Microvascular abnormalities and dysfunction via thickening of the basement membrane are known to occur in diabetic patients. Myocardial high-energy phosphates have been shown to be reduced by ischemia, and alterations of the cardiac metabolism are the primary consequence of myocardial ischemia. METHODS The present study involved 34 male patients (mean age 35.5 +/- 10.1) with diabetes mellitus type I and 35 healthy male volunteers (mean age 36 +/- 8.6) as age-matched controls. Phosphorus-31 magnetic resonance spectroscopic imaging of the heart was performed in all subjects using a 1.5-T whole-body magnetic resonance scanner. The ratios of phosphocreatine (PCr) to beta-adenosinetriphosphate (beta-ATP) were calculated. Moreover, echocardiographic evaluation and stress tests were performed in all individuals. RESULTS The myocardium of patients with diabetes mellitus type I showed significantly decreased ratios of PCr to beta-ATP compared with healthy controls in the left ventricle (1.90 +/- 0.4 vs. 2.15 +/- 0.3, p < 0.05). We found a moderate negative correlation between the ratio of PCr to beta-ATP in the left ventricle and both, the diastolic left ventricular function (E/A; r = -0.41) and the glycohemoglobin A1c (GHbA1c; r = -0.42). CONCLUSION This study demonstrates for the first time a decreased ratio of PCr to beta-ATP in the myocardium of persons with diabetes mellitus type I without a known history of coronary heart disease.

3‐Hydroxy‐3‐methylglutaryl Coenzyme A Reductase Inhibitors Improve Myocardial High‐Energy Phosphate Metabolism in Men

PURPOSE We intended to prove that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors or statins have a beneficial impact on the human myocardial, high-energy, phosphate metabolism. METHODS The present study included 18 male patients (mean age 49.8 +/- 10.3) with statin-treated, familiar hypercholesterolemia (FH) and 13 male patients with untreated FH (mean age 44.6 +/- 9.5). Twenty-six healthy male volunteers served as controls (mean age 44.2 +/- 12.1). Phosphorus-31, two-dimensional chemical shift imaging (31P 2D CSI) of the heart was performed in all subjects using a 1.5 Tesla whole-body magnetic resonance (MR) scanner. The ratios between phosphocreatine (PCr) and beta-adenosine-triphosphate (beta-ATP) were calculated for the left ventricular myocardium. Furthermore, echocardiographic evaluation and stress tests were performed in all individuals. RESULTS The untreated patients with FH exhibited a significant decrease in left ventricular PCr to beta-ATP ratios (1.78 +/- 0.34) compared with statin-treated FH patients (2.15 +/- 0.26, p < 0.001) and healthy controls (2.04 +/- 0.26, p = 0.009). The left ventricular PCr-to-beta-ATP ratios of the treated FH patients were in the range of the healthy controls. CONCLUSIONS Our study shows for the first time an-improvement of the high-energy, phosphate metabolism in the left ventricular myocardium of patients with statin-treated FH compared with untreated FH patients.

High prevalence of pelvic floor muscle dysfunction in hospitalized elderly women with urinary incontinence

Introduction and hypothesisThe purpose of this study was to determine pelvic floor muscle (PFM) function in hospitalized elderly women with urinary incontinence (UI).MethodsA cross-sectional study was performed using data of 704 patients, routinely collected by means of a clinical UI assessment.ResultsOnly 25.5% of the patients were able to perform normal PFM contractions (Oxford grading scale score ≥3); 74.5% were unable to contract their PFM or showed weak PFM activity without circular contraction or elevation of the vagina. Vulvovaginal mucosal dystrophy was noted in 84% of the patients. A significant positive correlation of PFM function was found to cognitive status (MMSE score), mobility (Tinetti performance score), and history of previous PFM training; a negative correlation of PFM function was found to patients’ age and vulvovaginal mucosal dystrophy, and no significant correlation to body mass index, parity, or history of hysterectomy.ConclusionsTargeted clinical UI assessment including digital vaginal palpation should be performed in all incontinent elderly women in order to detect PFM dysfunction and to optimize therapeutic measures.

Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor

OBJECTIVE To prove a basic physiological principle in healthy women, demonstrating different movement patterns of diaphragm, pelvic floor, and muscular wall surrounding the abdominal cavity during a Valsalva maneuver as opposed to a straining maneuver, by means of real-time dynamic magnetic resonance imaging (MRI). STUDY DESIGN The study was performed at Hochzirl Hospital, Austria and Department of Radiology, Medical University Innsbruck, Austria. Four healthy women underwent MRI measurements in a 1.5-T whole body MR-scanner. Coronal, sagittal, and axial slices were acquired simultaneously and a dynamic MRI sequence was used to assess cranio-caudal movements of the diaphragm and pelvic floor and of concomitant changes in anterolateral abdominal muscle thickness and abdominal diameter at the umbilical level. RESULTS Both the Valsalva maneuver and the straining maneuver began with deep inspiration and downward movement of the diaphragm. During the exertion phase of both maneuvers, abdominal muscle thickness increased and abdominal diameter decreased. During the Valsalva maneuver, the pelvic floor moved cranially parallel to the diaphragm, whereas during the straining maneuver, the pelvic floor was markedly displaced caudally. CONCLUSION The Valsalva maneuver reflects an expiratory pattern with diaphragm and pelvic floor elevation, whereas during straining the pelvic floor descends.

Detection of a silent myocardial infarction with Phosphor-31 two-dimensional chemical shift imaging (31P 2-D CSI)

Background: Phosphor-31 two-dimensional chemical shift imaging (31P 2-D CSI) is a well-established noninvasive technique in experimental research on regional myocardial ischemia, and it permits in vivo monitoring of high-energy phosphate metabolism in the myocardium without requiring external tracers, wherein phosphocreatinine (PCr) and β-adenosine triphosphate (β-ATP) are the main components of investigation. The decrease of PCr is one of the earliest reactions to acute myocardial ischemia, but also fixed defects after myocardial infarction (MI) showed a reduced ratio of PCr/β-ATP, probably because of a remodeling process taking place in the noninfarcted tissue.Case Report: A 55-year-old patient with diabetes mellitus type 1 is reported, who presented within the scope of a study at the University Hospital Innsbruck, Austria, and in whom 31P 2-D CSI helped to detect a so far unknown coronary heart disease (CHD).Conclusion: In the presented case, 31P 2-D CSI for the first time helped to reveal a severe CHD and a so far unknown MI, and and if the calculated voxel size was chosen small enough, even a satisfying localization of the lesion became possible.Hintergrund: Beim Phosphor-31 zweidimensionalen Chemical Shift Imaging (31P 2-D CSI) handelt es sich um eine in der experimentellen Kardiologie etablierte, nichtinvasive Methode zur Messung des Energiestoffwechsels der Herzmuskulatur ohne die Notwendigkeit, von außen Substanzen zuzuführen. Die im Myokard selbst vorkommenden energiereichen Phosphate Phosphokreatinin (PCr) und β-Adenosintriphosphat (β-ATP) sind die wesentlichen untersuchten Komponenten. Die Abnahme von PCr gehört zu den frühesten Reaktionen auf eine akute Ischämie, aber auch bei den fixierten Defekten eines Myokardinfarkts konnte ein vermindertes PCr/β-ATP-Verhältnis nachgewiesen werden. Dies wird hauptsächlich auf Umbauvorgänge im angrenzenden, funktionalen Myokard mit daraus resultierenden Veränderungen des Energiestoffwechsels zurückgeführt.Fallbeschreibung: Berichtet wird über einen 55-jährigen Patienten mit Diabetes mellitus Typ 1, welcher im Rahmen einer Studie an der Universitätsklinik Innsbruck, Österreich, vorstellig wurde und bei dem ein 31P 2-D CSI dazu beitrug, eine bis dato unbekannte koronare Herzkrankheit zu diagnostizieren.Schlussfolgerung: Beim vorgestellten Patienten wurden mit Hilfe etablierter Untersuchungsmethoden eine bisher unbekannte schwere Koronarstenose und ein asymptomatisch abgelaufener Myokardinfarkt diagnostiziert, wobei bereits zuvor eine deutlich erniedrigte Ratio von PCr/β-ATP bei der 31P 2-D CSI-Untersuchung den Verdacht auf ein pathologisches Geschehen gelenkt hatte und durch die Berechnung eines entsprechend kleinen Volumens auch die Lokalisation der Läsion möglich wurde.

Comment on the recently published IUGA/ICS joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

Dear Editor, We comment here on the recently published BIUGA/ICS joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction^ [1]. We consider that it lacks relevant and well-established scientific findings regarding pelvic floor muscle (PFM) physiology and function accumulated over the past 15 years. In 2005, Messelink et al. [2] before describing different conditions, symptoms and signs of PFM dysfunction, first defined normal PFM function as muscle contraction and relaxation and adequate reaction to changes in intra-abdomina pressure. Such a definition of normal PFM function is the sine qua non before defining, assessing, diagnosing, treating, or preventing PFM dysfunction. Since the standardization by Messelink et al., advanced neurophysiological and imaging techniques have opened new views on PFM physiology and function, especially regarding complex synergies between the PFMs and other muscle groups surrounding the abdominal cavity. Hodges et al. [3] and others have demonstrated the involvement of the PFMs in respiration and postural control, and synergies between the PFMs and expiratory muscles, particularly the anterolateral abdominal muscles. Laycock et al. [4] introduced the New PERFECT scheme to evaluate and document not only PFM basic tone, muscle contraction and relaxation, but also cocontraction with other muscle groups, and PFM performance and timing during changes in intraabdominal pressure. By means of dynamic magnetic resonance imaging, Talasz et al. [5] demonstrated cyclic movements and displacement of the PFMs in concerted synergy with other muscle groups surrounding the abdominal cavity during breathing, coughing, and performing the Valsalva and straining manoeuvres. We find it disappointing that the recent joint report [1] ignores the above-mentioned and other relevant findings. Instead of citing clear scientific evidence of cocontraction of the PFMs and other muscle groups, and of disparate involvement of the PFMs during different phases of breathing, Valsalva and straining manoeuvres, the authors refer to the Oxford Dictionary (http:// oxforddictionaries.com/) as the Bfinal authority .̂ The described therapeutic measures [1] may alleviate certain conditions, symptoms or signs of PFM dysfunction. However, correct PFM function, i.e. contraction and relaxation at appropriate times, will most likely not be restored without recognizing the dynamic integration of the PFMs from a holistic perspective within the human body. We are concerned that implementation of new diagnostic and therapeutic strategies addressing PFM dysfunction, which we frequently encounter in daily practice, will be impeded if complex PFM physiology in conjunction with respiration and other body functions is entirely ignored by renowned experts.