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1.  Metabolism before, during and after anaesthesia in colic and healthy horses 
Background
Many colic horses are compromised due to the disease state and from hours of starvation and sometimes long trailer rides. This could influence their muscle energy reserves and affect the horses' ability to recover. The principal aim was to follow metabolic parameter before, during, and up to 7 days after anaesthesia in healthy horses and in horses undergoing abdominal surgery due to colic.
Methods
20 healthy horses given anaesthesia alone and 20 colic horses subjected to emergency abdominal surgery were anaesthetised for a mean of 228 minutes and 183 minutes respectively. Blood for analysis of haematology, electrolytes, cortisol, creatine kinase (CK), free fatty acids (FFA), glycerol, glucose and lactate was sampled before, during, and up to 7 days after anaesthesia. Arterial and venous blood gases were obtained before, during and up to 8 hours after recovery. Gluteal muscle biopsy specimens for biochemical analysis of muscle metabolites were obtained at start and end of anaesthesia and 1 h and 1 day after recovery.
Results
Plasma cortisol, FFA, glycerol, glucose, lactate and CK were elevated and serum phosphate and potassium were lower in colic horses before anaesthesia. Muscle adenosine triphosphate (ATP) content was low in several colic horses. Anaesthesia and surgery resulted in a decrease in plasma FFA and glycerol in colic horses whereas levels increased in healthy horses. During anaesthesia muscle and plasma lactate and plasma phosphate increased in both groups. In the colic horses plasma lactate increased further after recovery. Plasma FFA and glycerol increased 8 h after standing in the colic horses. In both groups, plasma concentrations of CK increased and serum phosphate decreased post-anaesthesia. On Day 7 most parameters were not different between groups. Colic horses lost on average 8% of their initial weight. Eleven colic horses completed the study.
Conclusion
Colic horses entered anaesthesia with altered metabolism and in a negative oxygen balance. Muscle oxygenation was insufficient during anaesthesia in both groups, although to a lesser extent in the healthy horses. The post-anaesthetic period was associated with increased lipolysis and weight loss in the colic horses, indicating a negative energy balance during the first week post-operatively.
doi:10.1186/1751-0147-49-34
PMCID: PMC2206032  PMID: 18001483
2.  Cardiac arrhythmias and electrolyte disturbances in colic horses 
Background
Despite increased focus on cardiac arrhythmias in horses, the nature and prevalence is still poorly described. Case reports suggest that arrhythmias occurring secondary to systemic disease are seen more commonly in the clinic than arrhythmias caused by cardiac disease. The aim of this study was to investigate the prevalence of arrhythmias in colic horses referred for hospital treatment. Associations between electrolyte disturbances and arrhythmias were also investigated.
The study population consisted of eight control horses and 22 referred colic horses. A Holter electrocardiography (ECG) was recorded during the first 24 hours of admission. The ECG’s were analysed by a software program followed by manual visual inspection. Arrhythmias registered included second degree atrioventricular (AV) blocks, supraventricular premature complexes (SVPCs), and ventricular premature complexes (VPCs). Blood was collected at admission and again between 12 and 24 hours after ECG was applied, and analysed for concentrations of potassium, sodium, ionised calcium, chloride, glucose, and L-lactate.
Results
Heart rate was 37.4 ± 3.7 bpm in the control group, and 51.6 ± 11.8 bpm, in the colic group, which was significantly different (P < 0.0001). AV blocks and SVPCs were found in both groups, however only colic horses showed VPCs. No significant difference between the two groups was found for AV blocks, SVPCs, and VPCs (P = 0.08 - 0.76). The mean levels of potassium, sodium, ionized calcium, and chloride were significantly lower in the colic group compared to the control group at admission. Mean levels of glucose and L-lactate were significantly elevated in the colic group (P < 0.05).
Conclusions
This study describes prevalence of cardiac arrhythmias and electrolytes concentrations in colic horses compared to healthy controls. Although we only observed VPCs in the colic horses, no significant differences between colic horses and controls were found. Despite the colic horses having electrolyte changes at admission no correlation was found between the electrolyte disturbances and cardiac arrhythmias. Although no clear conclusions can be drawn from the present study, the results indicate that relatively mild colic per se is not pro-arrhythmogenic, whereas severe colic probably are more likely to result in ventricular arrhythmia.
doi:10.1186/s13028-014-0058-y
PMCID: PMC4189753  PMID: 25274423
Equine; Colic; ECG; Arrhythmias; Heart rate; Electrolytes
3.  Detecting early kidney damage in horses with colic by measuring matrix metalloproteinase -9 and -2, other enzymes, urinary glucose and total proteins 
Background
The aim of the study was to investigate urine matrix metalloproteinase (MMP-2 and -9) activity, alkaline phosphatase/creatinine (U-AP/Cr) and gamma-glutamyl-transpeptidase/creatinine (U-GGT/Cr) ratios, glucose concentration, and urine protein/creatinine (U-Prot/Cr) ratio and to compare data with plasma MMP-2 and -9 activity, cystatin-C and creatinine concentrations in colic horses and healthy controls. Horses with surgical colic (n = 5) were compared to healthy stallions (n = 7) that came for castration. Blood and urine samples were collected. MMP gelatinolytic activity was measured by zymography.
Results
We found out that horses with colic had significantly higher urinary MMP-9 complex and proMMP-9 activities than horses in the control group. Colic horses also had higher plasma MMP-2 activity than the control horses. Serum creatinine, although within reference range, was significantly higher in the colic horses than in the control group. There was no significant increase in urinary alkaline phosphatase, gamma-glutamyltranspeptidase or total proteins in the colic horses compared to the control group. A human cystatin-C test (Dako Cytomation latex immunoassay® based on turbidimetry) did not cross react with equine cystatin-C.
Conclusion
The results indicate that plasma MMP-2 may play a role in the pathogenesis of equine colic and urinary MMP-9 in equine kidney damage.
doi:10.1186/1751-0147-49-4
PMCID: PMC1784101  PMID: 17244354
4.  Moderate intra-abdominal hypertension is associated with an increased lactate-pyruvate ratio in the rectus abdominis muscle tissue: a pilot study during laparoscopic surgery 
Annals of Intensive Care  2012;2(Suppl 1):S14.
Background
The development of intra-abdominal hypertension [IAH] in critically ill patients admitted to the ICU is an independent predictor of mortality. In an attempt to find an early, clinically relevant metabolic signal of modest IAH, we investigated abdominal wall metabolite concentrations in a small group of patients undergoing laparoscopic surgery. We hypothesized that elevated intra-abdominal pressure [IAP] due to pneumoperitoneum leads to an increased lactate/pyruvate [L/P] ratio in the rectus abdominis muscle [RAM], indicating anaerobic metabolism.
Method
Six patients scheduled for elective laparoscopic gastric fundoplication were studied. Two hours before surgery, a microdialysis catheter (CMA 60, CMA Small Systems AB, Solna, Sweden) was inserted into the RAM under local anaesthesia. Catheter placement was confirmed by ultrasound. The microdialysis perfusion rate was set at 0.3 μL/min. Dialysate was collected hourly prior to pneumoperitoneum, during pneumoperitoneum, and for 2 h after pneumoperitoneum resolution. IAP was maintained at 12 to 13 mmHg during the surgery. The glucose, glycerol, pyruvate and lactate contents of the dialysate were measured.
Results
The median (interquartile range) L/P ratio was 10.3 (7.1 to 15.5) mmol/L at baseline. One hour of pneumoperitoneum increased the L/P ratio to 16.0 (13.6 to 35.3) mmol/L (p = 0.03). The median pneumoperitoneum duration was 86 (77 to 111) min. The L/P ratio at 2 h post-pneumoperitoneum was not different from that at baseline (p = 1.0). No changes in glycerol or glucose levels were observed.
Conclusions
IAH of 12 to 13 mmHg, even for a relatively short duration, is associated with metabolic changes in the abdominal wall muscle tissue of patients undergoing laparoscopic surgery. We suggest that tissue hypoperfusion occurs even during a modest increase in IAP, and intramuscular metabolic monitoring could therefore serve as an early warning sign of deteriorating tissue perfusion.
doi:10.1186/2110-5820-2-S1-S14
PMCID: PMC3390303  PMID: 22873415
microdialysis; intra-abdominal pressure; intra-abdominal hypertension; lactate-to-pyruvate ratio; muscle ischemia; early clinical sign
5.  The relationship between respiratory exchange ratio, plasma lactate and muscle lactate concentrations in exercising horses using a valved gas collection system. 
A valved gas collection system for horses was validated, then used to examine the relationship between the respiratory exchange ratio (RER), and plasma and muscle lactate in exercising horses. Four healthy Standardbred horses were trained to breathe through the apparatus while exercising on a treadmill. Comparisons of arterial blood gas tensions were made at 3 work levels for each horse, without (control), and with the gas collection system present. At the highest work level, the arterial oxygen tension (PaO2) was significantly lower (P < 0.05), and the arterial carbon dioxide tension (PaCO2) was significantly higher (P < 0.05), than control levels when the apparatus was present; however arterial oxygen content remained unchanged. The horses completed a standardized incremental treadmill test on 4 occasions to determine the repeatability of measurements of oxygen consumption (VO2), carbon dioxide production (VCO2), inspired minute ventilation (VI), respiratory exchange ratio (RER), ventilatory equivalent for oxygen (VI/VO2), tidal volume (VT), and ventilatory frequency (VF). All gas exchange and respiratory measurements showed good reproducibility with the mean coefficient of variation of the 4 horses ranging from 3.8 to 12%. We examined the relationship between 3 indices of energy metabolism in horses performing treadmill exercise: respiratory exchange ratio (RER), central venous plasma and muscle lactate concentrations. A relationship between RER and plasma lactate concentration was established. To compare muscle and plasma lactate concentrations, the horses completed a discontinuous exercise test without the gas collection apparatus present. Significant relationships (P < 0.05), between plasma lactate concentration and RER, and between plasma and muscle lactate concentration, were described for each horse. The valved gas collection system produced a measurable but tolerable degree of interference to respiration, and provided reproducible measurements of gas exchange and ventilatory measurements. It was concluded that measurements of both gas exchange and blood lactate may be used to indicate increased glycolytic activity within exercising skeletal muscle.
PMCID: PMC1263828  PMID: 8809378
6.  The prevalence and nature of cardiac arrhythmias in horses following general anaesthesia and surgery 
Background
The prevalence and nature of arrhythmias in horses following general anaesthesia and surgery is poorly documented. It has been proposed that horses undergoing emergency surgery for gastrointestinal disorders may be at particular risk of developing arrhythmias. Our primary objective was to determine the prevalence and nature of arrhythmias in horses following anaesthesia in a clinical setting and to establish if there was a difference in the prevalence of arrhythmias between horses with and without gastrointestinal disease undergoing surgery. Our secondary objective was to assess selected available risk factors for association with the development of arrhythmias following anaesthesia and surgery.
Methods
Horses with evidence of gastrointestinal disease undergoing an exploratory laparotomy and horses with no evidence of gastrointestinal disease undergoing orthopaedic surgery between September 2009 and January 2011 were recruited prospectively. A telemetric electrocardiogram (ECG) was fitted to each horse following recovery from anaesthesia and left in place for 24 hours. Selected electrolytes were measured before, during and after surgery and data was extracted from clinical records for analysis. Recorded ECGs were analysed and the arrhythmias characterised. Multivariable logistic regression was used to identify risk factors associated with the development of arrhythmias.
Results
Sixty-seven horses with gastrointestinal disease and 37 without gastrointestinal disease were recruited. Arrhythmias were very common during the post-operative period in both groups of horses. Supra-ventricular and bradyarrhythmias predominated in both groups. There were no significant differences in prevalence of any type of arrhythmias between the horses with or without gastrointestinal disease. Post-operative tachycardia and sodium derangements were associated with the development of any type of arrhythmia.
Conclusions
This is the first study to report the prevalence of arrhythmias in horses during the post-operative period in a clinical setting. This study shows that arrhythmias are very common in horses following surgery. It showed no differences between those horses with or without gastrointestinal disease. Arrhythmias occurring in horses during the post-anaesthetic period require further investigation.
doi:10.1186/1751-0147-53-62
PMCID: PMC3269988  PMID: 22112936
equine; post-anaesthetic; electrocardiography; arrhythmia
7.  Surgical treatment of equine colic - a retrospective study of 297 surgeries in Norway 2005–2011 
Background
Colic, defined as pain originating from the abdomen, is a common condition in horses. Most of the cases resolve spontaneously or after medical treatment, but a few require surgical treatment. Surgical treatment of colic in horses is resource-demanding and expensive, and information on prognosis is therefore important for both owners and surgeons. In the present study, surgical cases in two equine hospitals in Norway between 2005 and 2011 were reviewed. The aim of the study was to describe associations between prognostic indicators, diagnoses and short term survival by use of random effects logistic regression.
Results
In the present study, 162 out of 297 (54.5%) surgeries resulted in the horse being discharged from the hospital. Excluding cases euthanized during surgery, the overall short-term survival was 74.0% (162 out of 219 surgeries). Seventy-eight (26.3%) of the horses were euthanized during surgery, due to grave or poor prognosis. In univariable analyses, duration of colic signs, heart rate, capillary refill time, mucosal membrane appearance, intestinal sounds, affected gastrointestinal segment, hematocrit, intestinal resection, hospital and surgeon board-certification had P-value <0.20 and were assessed in multivariable analyses. Respiration rate, rectal temperature and lactate in blood also had univariable P <0.20, but were left out from multivariable analyses due to too high levels of missing values. A random effect of primary surgeon was included and breed, sex and age were tested in multivariable analyses as possible confounders; and hospital was included to control for hospital routine differences. In the final multivariable model the variables mucosal membrane appearance, affected gastrointestinal segment and surgeon board-certification significantly influenced survival. The random surgeon effect was not significant.
Conclusions
The present study showed that prognostic parameters and diagnoses of surgical treatment of horses with colic in Norway are in accordance with reports from other parts of the world. The significant effect of board-certification of surgeon is not reported in previous studies. The general short-term survival rate was somewhat lower than reported in other studies, partly due to more horses being euthanized intraoperatively in the present study. This might be because of economical or animal welfare reasons.
doi:10.1186/1751-0147-56-38
PMCID: PMC4077634  PMID: 24934123
8.  Online rapid sampling microdialysis (rsMD) using enzyme-based electroanalysis for dynamic detection of ischaemia during free flap reconstructive surgery 
Analytical and Bioanalytical Chemistry  2013;405(11):3881-3888.
We describe an enzyme-based electroanalysis system for real-time analysis of a clinical microdialysis sampling stream during surgery. Free flap tissue transfer is used widely in reconstructive surgery after resection of tumours or in other situations such as following major trauma. However, there is a risk of flap failure, due to thrombosis in the flap pedicle, leading to tissue ischaemia. Conventional clinical assessment is particularly difficult in such ‘buried’ flaps where access to the tissue is limited. Rapid sampling microdialysis (rsMD) is an enzyme-based electrochemical detection method, which is particularly suited to monitoring metabolism. This online flow injection system analyses a dialysate flow stream from an implanted microdialysis probe every 30 s for levels of glucose and lactate. Here, we report its first use in the monitoring of free flap reconstructive surgery, from flap detachment to re-vascularisation and overnight in the intensive care unit. The on-set of ischaemia by both arterial clamping and failure of venous drainage was seen as an increase in lactate and decrease in glucose levels. Glucose levels returned to normal within 10 min of successful arterial anastomosis, whilst lactate took longer to clear. The use of the lactate/glucose ratio provides a clear predictor of ischaemia on-set and subsequent recovery, as it is insensitive to changes in blood flow such as those caused by topical vasodilators, like papaverine. The use of storage tubing to preserve the time course of dialysate, when technical difficulties arise, until offline analysis can occur, is also shown. The potential use of rsMD in free flap surgery and tissue monitoring is highly promising.
FigureFree flap surgery timeline: The flap is raised and MD probe inserted. Glucose and lactate levels were monitored at 1 minute intervals throughout flap removal and the reconstruction of the tongue. Grey lines indicate key events as communicated by the surgeons in real time.
doi:10.1007/s00216-013-6770-z
PMCID: PMC3608874  PMID: 23435450
Microdialysis; Free tissue transfer; Glucose; Lactate; Real time; Ischaemia
9.  Dissociative Anaesthesia During Field and Hospital Conditions for Castration of Colts 
Acta Veterinaria Scandinavica  2006;47(1):1-11.
The principal aim of this study was to evaluate dissociative anaesthesia for castration of colts during field conditions. Three dissociative anaesthetic protocols were evaluated during castration of colts in an animal hospital. The protocol considered to be the most suitable was thereafter evaluated during castration of colts under field conditions. Respiratory and haemodynamic parameters and the response to surgery were determined during anaesthesia. All horses breathed air spontaneously during anaesthesia. Under hospital conditions 26 colts were randomised to receive one of three anaesthetic protocols: Romifidine and tiletamine-zolazepam (RZ); acepromazine, romifidine and tiletamine-zolazepam (ARZ); or acepromazine, romifidine, butorphanol and tiletamine-zolazepam (ARBZ). The surgeon was blinded to the anaesthetic protocol used and decided whether supplemental anaesthesia was needed to complete surgery. Under field conditions 31 colts were castrated during anaesthesia with the ARBZ protocol. All inductions, anaesthesia and recoveries were calm and without excitation under both hospital and field conditions. Surgery was performed within 5–20 minutes after the horses had assumed lateral recumbency during both hospital and field castrations. Under hospital conditions some horses needed supplemental anaesthesia with all three anaesthetic protocols to complete surgery. Interestingly, none of the horses castrated with protocol ARBZ under field conditions needed additional anaesthesia. Cardiorespiratory changes were within acceptable limits in these clinically healthy colts.
doi:10.1186/1751-0147-47-1
PMCID: PMC1618963  PMID: 16722301
Intravenous dissociative anaesthesia; field conditions; horse; mixed venous oxygen tension; jugular venous oxygen tension; castration
10.  Effects of muscle glycogen depletion on some metabolic and physiological responses to submaximal treadmill exercise. 
The aim of this study was to investigate the effects of reduced muscle glycogen concentration on some physiological and metabolic responses during moderate intensity treadmill exercise in horses. Six Thoroughbred geldings were randomly allocated to 2 treatments (protocols A and B) or control in a 3 x 3 replicated Latin square design. In protocol A, horses performed low intensity exercise while horses in protocol B performed short bursts of high intensity exercise. Protocol A was designed to induce glycogen depletion mainly of slow twitch muscle fibers while protocol B aimed to deplete mainly fast twitch muscle fibers. Horses in the control group did not undergo exercise prior to the exercise test. Five hours after glycogen depletion, horses performed treadmill exercise at 60% VO2max at a treadmill slope of 10% until fatigue (20-30 min). The induced glycogen depletion prior to exercise had no significant effect on plasma glucose, insulin, or lactate concentrations during the exercise test, and there was no effect on glycogen utilization rate, although respiratory exchange ratios were lower in the glycogen-depleted groups. The VO2, heart rate and central blood temperature did not vary significantly between the protocols A and B and control throughout the exercise test. It was concluded that 20-30% depletion of glycogen concentration in the middle gluteal muscle resulted in a shift towards fat metabolism, but does not significantly affect heart rate, oxygen uptake, or concentrations of plasma glucose and lactate during moderate intensity exercise.
PMCID: PMC1189559  PMID: 10534002
11.  Is Metabolic Flexibility Altered in Multiple Sclerosis Patients? 
PLoS ONE  2012;7(8):e43675.
Objectives
Metabolic flexibility is defined as ability to adjust fuel oxidation to fuel availability. Multiple sclerosis (MS) results in reduced muscle strength and exercise intolerance. We tested the hypothesis that altered metabolic flexibility contributes to exercise intolerance in MS patients.
Methods
We studied 16 patients (all on glatiramer) and 16 matched healthy controls. Energy expenditure (EE), and carbohydrate (COX) and lipid oxidation (LOX) rates were determined by calorimetry, before and after an oral glucose load. We made measurements either at rest (canopy device) or during 40 min low-grade (0.5 W/kg) exercise (metabolic chamber). We also obtained plasma, and adipose tissue and skeletal muscle dialysate samples by microdialysis to study tissue-level metabolism under resting conditions.
Results
At rest, fasting and postprandial plasma glucose, insulin, and free fatty acid levels did not differ between patients and controls. Fasting and postprandial COX was higher and LOX lower in patients. In adipose, fasting and postprandial dialysate glucose, lactate, and glycerol levels were higher in patients vs. controls. In muscle, fasting and postprandial dialysate metabolite levels did not differ significantly between the groups. During exercise, EE did not differ between the groups. However, COX increased sharply over 20 min in patients, without reaching a steady state, followed by an immediate decrease within the next 20 min and fell even below basal levels after exercise in patients, compared to controls.
Conclusions
Glucose tolerance is not impaired in MS patients. At rest, there is no indication for metabolic inflexibility or mitochondrial dysfunction in skeletal muscle. The increased adipose tissue lipolytic activity might result from glatiramer treatment. Autonomic dysfunction might cause dysregulation of postprandial thermogenesis at rest and lipid mobilization during exercise.
doi:10.1371/journal.pone.0043675
PMCID: PMC3429505  PMID: 22952735
12.  Detection and comparison of nitric oxide in clinically normal horses and those with naturally acquired small intestinal strangulation obstruction. 
The purpose of this study was to determine whether nitric oxide (NO) is present in clinically normal horses under basal conditions and if it increases secondary to naturally acquired small intestinal strangulation obstruction. Thirty-one horses were used; 20 horses with naturally acquired small intestinal strangulation obstruction and 11 clinically normal horses with no signs of gastrointestinal tract disease. Jugular venous blood, abdominal fluid, and urine were collected for NO quantification. Plasma, abdominal fluid, and urine were stored at -70 degrees C until analyzed for NO using a chemiluminescent method. Biopsy specimens collected from the affected jejunal segment, during anesthesia or after immediately after euthanasia, or from the midjejunum of control horses, were divided into subsections for fixation in zinc formalin and cryopreservation in OCT gel. Nicotinamide adenine dinucleotide phosphate (reduced) (NADPH) diaphorase histochemical stains were performed on cryopreserved tissues and inducible nitric oxide synthase (iNOS) and nitrotyrosine immunohistochemical stains were performed on formalin-fixed, paraffin-embedded tissues. There were significantly greater plasma and abdominal fluid NO concentrations in affected horses as compared with controls, but there were no significant differences between horses for urine NO concentrations. There was a significant decrease in NADPH diaphorase stain in mucosal epithelium, vasculature, and leukocytes, and in submucosal plexi in affected horses compared with control horses. There was a significant increase in iNOS staining in mucosal and submucosal leukocytes and in mucosal leukocyte nitrotyrosine staining of the affected compared with control horses. Endothelial NOS and neuronal NOS are present under basal conditions in the jejunum of horses and probably mediate physiologic or cytoprotective effects. Plasma and abdominal fluid, but not urine, NO concentrations increase subsequent to small intestinal strangulation obstruction; this may be associated with increased mucosal and submucosal iNOS staining in leukocytes, which was likely due to increased expression subsequent to stimuli associated with ischemia. The increased nitrotyrosine staining in mucosal leukocytes of affected horses likely reflects the presence of peroxynitrite subsequent to increased NO and superoxide production and may reflect a cytotoxic role of NO in small intestinal strangulation obstruction in horses.
Images
PMCID: PMC1189558  PMID: 10534001
13.  Electrocautery causes more ischemic peritoneal tissue damage than ultrasonic dissection 
Surgical Endoscopy  2010;25(6):1827-1834.
Background
Minimizing peritoneal tissue injury during abdominal surgery has the benefit of reducing postoperative inflammatory response, pain, and adhesion formation. Ultrasonic dissection seems to reduce tissue damage. This study aimed to compare electrocautery and ultrasonic dissection in terms of peritoneal tissue ischemia measured by microdialysis.
Methods
In this study, 18 Wistar rats underwent a median laparotomy and had a peritoneal microdialysis catheter implanted in the left lateral sidewall. The animals were randomly assigned to receive two standard peritoneal incisions parallel to the catheter by either ultrasonic dissection or electrocautery. After the operation, samples of microdialysis dialysate were taken every 2 h until 72 h postoperatively for measurements of pyruvate, lactate, glucose, and glycerol, and ratios were calculated.
Results
The mean lactate–pyruvate ratio (LPR), lactate–glucose ratio (LGR), and glycerol concentration were significantly higher in the electrocautery group than in the ultrasonic dissection group until respectively 34, 48, and 48 h after surgery. The mean areas under the curve (AUC) of LPR, LGR, and glycerol concentration also were higher in the electrocautery group than in the ultrasonic dissection group (4,387 vs. 1,639, P = 0.011; 59 vs. 21, P = 0.008; 7,438 vs. 4,169, P = 0.008, respectively).
Conclusion
Electrosurgery causes more ischemic peritoneal tissue damage than ultrasonic dissection.
doi:10.1007/s00464-010-1474-3
PMCID: PMC3109994  PMID: 21140171
Adhesions; Electrocautery; Ischemia; Microdialysis; Ultrasonic dissection
14.  Analyte Flux at a Biomaterial–Tissue Interface over Time: Implications for Sensors for Type 1 and 2 Diabetes Mellitus 
Objective
The very presence of an implanted sensor (a foreign body) causes changes in the adjacent tissue that may alter the analytes being sensed. The objective of this study was to investigate changes in glucose availability and local tissue metabolism at the sensor–tissue interface in patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM).
Method
Microdialysis was used to model implanted sensors. Capillary glucose and subcutaneous (sc) microdialysate analytes were monitored in five T1DM and five T2DM patients. Analytes included glucose, glycolysis metabolites (lactate, pyruvate), a lipolysis metabolite (glycerol), and a protein degradation byproduct (urea). On eight consecutive days, four measurements were taken during a period of steady state blood glucose.
Results
Microdialysate glucose and microdialysate-to-blood-glucose ratio increased over the first several days in all patients. Although glucose recovery eventually stabilized, the lactate levels continued to rise. These trends were explained by local inflammatory and microvascular changes observed in histological analysis of biopsy samples. Urea concentrations mirrored glucose trends. Urea is neither produced nor consumed in sc tissue, and so the initially increasing urea trend is explained by increased local capillary presence during the inflammatory process. Pyruvate in T2DM microdialysate was significantly higher than in T1DM, an observation that is possibly explained by mitochondrial dysfunction in T2DM. Glycerol in T2DM microdialysate (but not in T1DM) was higher than in healthy volunteers, which is likely explained by sc insulin resistance (insulin is a potent antilipolytic hormone). Urea was also higher in microdialysate of patients with diabetes mellitus compared to healthy volunteers. Urea is a byproduct of protein degradation, which is known to be inhibited by insulin. Therefore, insulin deficiency or resistance may explain the higher urea levels. To our knowledge, this is the first histological evaluation of a human tissue biopsy containing an implanted glucose monitoring device.
Conclusions
Monitoring metabolic changes at a material–tissue interface combined with biopsy histology helped to formulate an understanding of physiological changes adjacent to implanted glucose sensors. Microdialysate glucose trends were similar over 1-week in T1DM and T2DM; however, differences in other analytes indicated wound healing and metabolic activities in the two patient groups differ. We propose explanations for the specific observed differences based on differential insulin insufficiency/resistance and mitochondrial dysfunction in T1DM versus T2DM.
PMCID: PMC2956810  PMID: 20920426
biosensors; diabetes mellitus; foreign body response; glucose metabolism; material–tissue interaction; microdialysis
15.  Interstitial glycerol as a marker for membrane phospholipid degradation in the acutely injured human brain 
OBJECTIVE— Brain interstitial glycerol was studied as a potential marker for membrane phospholipid degradation in acute human brain injury.
METHODS—Glycerol was measured in microdialysis samples from the frontal lobe cortex in four patients in the neurointensive care unit, during the acute phase after severe aneurysmal subarachnoid haemorrhage. Microdialysis probes were inserted in conjunction with a ventriculostomy used for routine intracranial pressure monitoring. Clinical events involving hypoxia/ischaemia were diagnosed by neurological signs, neuroimaging (CT and PET), and neurochemical changes of the dialysate—for example, lactate/pyruvate ratios and hypoxanthine concentrations.
RESULTS—Altogether 1554 chemical analyses on 518 microdialysis samples were performed. Clinical events involving secondary hypoxia/ischaemia were generally associated with pronounced increases (up to 15-fold) of the dialysate glycerol concentration. In a patient with a stable condition and no signs of secondary hypoxia/ischaemia the glycerol concentration remained low. Simultaneous determination of glycerol in arterial plasma samples showed that the changes in brain interstitial glycerol could not be attributed to systemic changes and an injured blood brain barrier.
CONCLUSIONS—This study suggests that membrane phospholipid degradation occurs in human cerebral ischaemia. Interstitial glycerol harvested by microdialysis seems to be a promising tool for monitoring of membrane lipolysis in acute brain injury. The marker may be useful for studies on cell membrane injury mechanisms mediated by for example, Ca2+ disturbances, excitatory amino acids, and reactive oxygen species; and in the evaluation of new neuroprotective therapeutic strategies. 


PMCID: PMC2170060  PMID: 9576540
16.  Evaluation of plasma muscle enzyme activity as an indicator of lesion characteristics and prognosis in horses undergoing celiotomy for acute gastrointestinal pain 
BMC Veterinary Research  2014;10(Suppl 1):S7.
Background
In horses undergoing celiotomy for acute gastrointestinal pain, identification of variables correlating with lesion severity and location, and survival provide veterinarians and owners with information that aids in making informed decisions regarding appropriate treatment. Muscle enzyme activity is often increased in horses undergoing celiotomy for acute gastrointestinal pain and it is not known if muscle enzyme activity increase is specific to lesion type or impacts prognosis for survival. The objective of this study was to evaluate the relationship of pre-operative increase in muscle enzyme activities with intestinal lesion characteristics, specifically lesion location (large versus small intestine) and whether it was strangulating versus nonstrangulating, and case survival in horses undergoing celiotomy for acute gastrointestinal pain.
Methods
Records of 241 horses undergoing exploratory laparotomy for colic were reviewed retrospectively. Evaluation of preoperative plasma aspartate aminotransferase (AST), creatine kinase (CK), sorbitol dehydrogenase (SDH), and gamma-glutamyltransferase (GGT) activities, fibrinogen and glucose concentrations, and hematocrit (HCT) and their association with gastrointestinal lesion characteristics and survival was performed.
Results
Pre-operative increase in plasma CK and AST activity, and HCT and decrease in plasma bilirubin concentration were significantly associated with presence of lesions resulting in intestinal ischemia. Increase in plasma CK activity and HCT were significantly associated with a decreased probability of survival to hospital discharge. Plasma GGT and SDH activity, and glucose and fibrinogen concentration were not significantly associated with survival or severity of disease in multivariate analysis.
Conclusions
Plasma muscle enyzme activity may be useful as a prognostic indicator in equine colic cases. Given that increases in plasma CK and AST activity were significantly associated with nonsurvival and the presence of intestinal ischemia, preoperative increase in these enzyme activities could assist in identification of disease severity and prognosis of horses undergoing celiotomy for acute gastrointestinal pain. Further study is indicated to elucidate the etiology of increased muscle enzyme activity in horses with surgical colic disease observed in this preliminary study.
doi:10.1186/1746-6148-10-S1-S7
PMCID: PMC4122891  PMID: 25237781
17.  Myeloperoxidase assay in plasma and peritoneal fluid of horses with gastrointestinal disease 
Gastrointestinal disorders, especially strangulating intestinal obstructions, are still a major cause of illness and death in the horse. Circulating lipopolysaccharides may activate both neutrophils and monocytes. The activated neutrophils release myeloperoxidase (MPO), a specific enzyme with strong oxidative activity. The aim of this study was to evaluate MPO concentrations in the plasma and peritoneal fluid (PF) of horses with colic and to check the hypothesis that these concentrations would be higher in a case of strangulating obstruction than in cases of nonstrangulating disease. By using a specific enzyme-linked immunosorbent assay for equine MPO, we determined the MPO concentrations in horses admitted to a clinic for colic. Horses with nonstrangulating or strangulating obstruction of the large intestine (NSLI or SLI), strangulating obstruction of the small intestine (SSI), or inflammatory bowel disease (IBD) were compared with healthy horses. The horses with SLI, SSI, or IBD had significantly higher MPO levels in plasma and PF than did those in the other 2 groups. The mean plasma level was significantly higher in the horses with NSLI than in the healthy horses. High MPO values in PF indicated necrotic bowel. These results show that neutrophil activation occurs during nonstrangulating and strangulating intestinal obstruction in horses and that the plasma and PF MPO concentrations may be a marker of the severity of the disease.
PMCID: PMC2117365  PMID: 18214160
18.  Detection and comparison of nitric oxide in clinically healthy horses and those with naturally acquired strangulating large colon volvulus 
Abstract
The objective of the study was to determine whether nitric oxide (NO) is present in clinically healthy horses (control) under basal conditions, and if it increases secondary to naturally acquired strangulating large colon volvulus (affected). Eleven affected horses and 10 controls were studied. Jugular venous blood, abdominal fluid, and urine were collected. The NO concentrations were standardized to the creatinine concentration in the respective samples. A biopsy specimen collected from the large colon pelvic flexure at surgery was divided into subsections for processing for inducible nitric synthase (iNOS) and nitrotyrosine (NT) immunohistochemical staining and reduced nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase histochemical staining. There were no significant differences in plasma, abdominal fluid, or urine NO concentrations between affected and control horses. There was a significant decrease in submucosal arteriolar and venular endothelium, submucosal plexus, mucosal leukocyte, mucosal and musclaris vasculature, and myenteric plexus NADPH diaphorase staining in affected versus control horses. There was a significant increase in iNOS staining in mucosal leukocytes and vasculature in affected versus control horses. Other than a greater number of positively stained mucosal leukocytes in affected horses, there were no significant differences between affected and control horses for NT staining. The presence of NADPH diaphorase staining in the endothelium and submucosal neurons suggests endothelial and neuronal NOS are present under basal conditions in the large colon of horses. Increased iNOS and NT staining in mucosal leukocytes of affected horses suggests involvement of the NO pathway in large colon volvulus. The reasons for the lack of a significant difference in plasma, abdominal fluid, and urine NO concentrations between affected and control horses are unknown.
PMCID: PMC1142177  PMID: 15971674
19.  Physiological response to a breed evaluation field test in Icelandic horses 
Animal  2014;8(3):431-439.
This study examined the response in terms of heart rate (HR), respiratory rate (RR), haematocrit (Htc), rectal temperature (RT), and some plasma variables in Icelandic horses of different sexes and ages performing the riding assessment in a breed evaluation field test (BEFT). The study was conducted in Iceland on 266 horses (180 mares and 86 stallions, divided into four age groups; 4, 5, 6 and ⩾7 years old). RT and RR were recorded and blood samples were taken before the warm-up and after the riding assessment. Horse HR, velocity and distance were recorded during the warm-up, the riding assessment and a 5-min recovery period. The distance covered in the BEFT was 2.9±0.4 km (range: 1.8 to 3.8 km, n=248), the duration was 9:37±1:22 min:s (range: 5:07 to 15:32 min:s, n=260) and the average speed was 17.8±1.4 km/h (range: 13.2 to 21.3 km/h, n=248). Average HR was 184±13 b.p.m. (range: 138 to 210 b.p.m., n=102) and peak HR 224±9 b.p.m. (range: 195 to 238 b.p.m., n=102), and 36% of the BEFT was performed at HR ⩾200 b.p.m. Post-exercise plasma lactate concentration (Lac) was 18.0±6.5 mmol/l (range: 2.1 to 34.4 mmol/l, n=266), and there was an increase in total plasma protein, plasma creatine kinase and aspartate amino transferase concentration, as well as RR, RT and Htc. Stallions covered a longer total distance (in the warm-up and BEFT) (P<0.05), at a faster speed during BEFT (P<0.001) than mares and had higher Htc and lower HR and post-exercise Lac values. There were few effects of age, but the 4- and 5-year-old horses had lower Htc than older horses and 4-year-old horses had higher post-exercise RR than older horses, although they were ridden for a shorter distance, shorter duration and at lower peak velocity (P<0.1). The results showed that the riding assessment in the BEFT is a high-intensity exercise. The results also showed that aerobic fitness was higher in stallions and that age had a limited effect on the physiological response. It is suggested that these results should be used as a guide for the development of training programmes and fitness tests in Icelandic horses that would improve both performance and welfare of the horse.
doi:10.1017/S1751731113002309
PMCID: PMC3942816  PMID: 24387835
exercise physiology; hematological parameters; lactate; heart rate; Icelandic horse
20.  A prospective study on a cohort of horses and ponies selected for participation in the European Eventing Championship: reasons for withdrawal and predictive value of fitness tests 
Background
Eventing is generally recognized as a challenging equestrian discipline and wastage figures for this discipline are relatively high. There is a need for information that provides insight into the causes of wastage and withdrawal from competition, for animal welfare and economic reasons. The aim of the present investigation was to conduct a prospective study following the entire national selection of event horses (n = 20) and ponies (n = 9) in the Netherlands that prepared for the European Championship in 2010 (ponies) and 2011 (horses), noting causes of withdrawal and monitoring fitness using standardized exercise tests (SETs), with heart rate (HR; beats/min), speed (V; m/s) and plasma lactate concentrations (LA; mmol/L) as measured parameters.
Results
In SET-I, performed at the beginning of the season, horses (n = 17) had a mean VLA4 (V at LA 4 mmol/L) of 10.3 ± 0.4 m/s with a mean V200 (V at 200 beats/min) of 11.4 ± 0.8 m/s and ponies (n = 9) a mean VLA4 of 7.8 ± 0.9 m/s and V200 of 9.6 ± 0.7 m/s. Before SET-II, performed six weeks before the European Championship, 16/20 horses and 6/9 ponies were withdrawn. The most common reason for withdrawal was locomotor injury (9/16 horses, 4/6 ponies; P < 0.001 and P = 0.011, respectively). Other reasons included an animal ‘not meeting the competition criteria’ (4/16 horses, 2/6 ponies) and being sold (3/16 horses). Animals were divided on the basis of VLA4 and recovery-HR during SET-I into good and average performers. Average performers were significantly more likely to be injured (50.0%) than good performers (0%, P = 0.05). In a subpopulation of ten horses, in which all condition training sessions were evaluated for HR and speed, HRpeak was significantly lower in horses that stayed sound (186 ± 9 beats/min) compared with horses withdrawn from training and competition because of injury (201 ± 5 beats/min; P = 0.016).
Conclusions
Of the national selection, 45% of all animals were unavailable for the European Championship because of locomotor injuries. Field tests were useful in assessing the potential injury risk, as individuals with better fitness indices (good performers) were less likely to become injured than average performers. Furthermore, monitoring of training sessions showed predictive value for future injuries, as horses withdrawn because of injury later on showed already higher peak HRs during condition training than horses that stayed sound. Therefore the increase in peak HR seemed to precede visible lameness in a horse.
doi:10.1186/1746-6148-9-182
PMCID: PMC3848563  PMID: 24034152
Horse; Eventing; Exercise; Fitness; Monitoring; Training
21.  Systemic and colonic venous plasma biochemical alterations in horses during low-flow ischemia and reperfusion of the large colon. 
The purpose of this study was to determine the effects of low-flow ischemia and reperfusion (I-R) of the large colon on 16 systemic venous (SV) and colonic venous (CV) plasma biochemical variables in horses. Horses (n = 24) were randomly allocated to 3 groups: sham-operated (n = 6), 6 h ischemia (n = 9), and 3 h ischemia followed by 3 h reperfusion (n = 9). SV and CV heparinized blood was collected at 0, 1, 3, 3.25, 4, and 6 h. The SV-CV difference was calculated for each variable. The SV, CV, and SV-CV difference for albumin, total protein, and calcium decreased significantly (P < 0.05) across time in horses of all groups, but there were no differences among groups. SV phosphorous was significantly increased from baseline (BL) at 1 to 6 h in horses of all groups, but there were no differences among groups. CV phosphorous was significantly greater than BL from 1 to 6 h in group-2 horses and from 1 to 3 h in group-3 horses. SV potassium was not different among groups, but was significantly higher at 6 h, compared with BL in horses of all groups. CV potassium was significantly greater than BL from 1 to 6 h in horses of groups 2 and 3. SV glucose was greater at 6 h compared with all previous times in horses of all groups, but there were no difference among groups. CV glucose was significantly lower than BL and group-1 values in horses of groups 2 and 3 during ischemia, but returned to BL during reperfusion in group-3 horses. CV anion gap was significantly greater and SV-CV anion gap was significantly more negative in horses of groups 2 and 3, compared with group-1 horses during ischemia. The biologic relevance of these alterations is unknown, but they may contribute to histopathologic, hemodynamic, and metabolic alterations characteristic of low-flow I-R. Alternatively, these alterations may simply reflect colonic injury sustained during I-R. Results suggest that the colon utilizes glucose as a fuel and generates acid anions during low-flow ischemia. Increased CV phosphorous and potassium during I-R likely occurs as a result of leakage of intracellular stores subsequent to cellular damage.
PMCID: PMC1189436  PMID: 9442934
22.  Insulin induced hypoglycaemia: comparison of glucose and glycerol concentrations in plasma and microdialysate from subcutaneous adipose tissue 
AIMS—To investigate the dynamics between plasma and dialysate glucose during hypoglycaemia in children.
STUDY DESIGN—Six children in prepuberty or early puberty were investigated by multiple blood sampling and microdialysis of subcutaneous adipose tissue during a standard arginine-insulin tolerance test. Glucose and glycerol, as an index of lipolysis, were measured in samples from both compartments. Plasma concentrations of insulin and the main counterregulatory hormones were also measured.
RESULTS—Plasma and dialysate glucose concentrations were very similar at baseline and increased in concert after infusion of arginine, probably in response to glucagon release. After insulin injection, glucose in both plasma and dialysate fell in parallel. The subsequent hypoglycaemic stress response induced a rapid rebound in the plasma concentration with a mean (SD) delay in the dialysate of 16 (3) minutes. Plasma glycerol was approximately fivefold lower than in the dialysate and did not fluctuate significantly. Dialysate glycerol decreased with arginine infusion and reached a nadir immediately following insulin administration. Subsequently, the antilipolytic effect of insulin was overcome by the hypoglycaemic stress response, and lipolysis prevailed in spite of hyperinsulinaemia. 
CONCLUSION—After rapidly induced hypoglycaemia, rebound of interstitial glucose concentrations is significantly delayed compared with plasma concentrations, and the antilipolytic effect of hyperinsulinaemia is opposed possibly by the hypoglycaemic stress response. 


PMCID: PMC1717783  PMID: 10325757
23.  Microdialysis of paraspinal muscle in healthy volunteers and patients underwent posterior lumbar fusion surgery 
European Spine Journal  2009;18(11):1604-1609.
Paraspinal muscle damage is inevitable during conventional posterior lumbar fusion surgery. Minimal invasive surgery is postulated to result in less muscle damage and better outcome. The aim of this study was to monitor metabolic changes of the paraspinal muscle and to evaluate paraspinal muscle damage during surgery using microdialysis (MD). The basic interstitial metabolisms of the paraspinal muscle and the deltoid muscle were monitored using the MD technique in eight patients, who underwent posterior lumbar fusion surgery (six male and two female, median age 57.7 years, range 37–74) and eight healthy individuals for different positions (five male and three female, age 24.1 ± 0.8 years). Concentrations of glucose, glycerol, and lactate pyruvate ratio (L/P) in both tissues were compared. In the healthy group, the glucose and glycerol concentrations and L/P were unchanged in the paraspinal muscle when the body position changed from prone to supine. The glucose concentration and L/P were stable in the paraspinal muscle during the surgery. Glycerol concentrations increased significantly to 243.0 ± 144.1 μM in the paraspinal muscle and 118.9 ± 79.8 μM in the deltoid muscle in the surgery group. Mean glycerol concentration difference (GCD) between the paraspinal muscle and the deltoid tissue was 124.1 μM (P = 0.003, with 95% confidence interval 83.4–164.9 μM). The key metabolism of paraspinal muscle can be monitored by MD during the conventional posterior lumbar fusion surgery. The glycerol concentration in the paraspinal muscle is markedly increased compared with the deltoid muscle during the surgery. It is proposed that GCD can be used to evaluate surgery related paraspinal muscle damage. Changing body position did not affect the paraspinal muscle metabolism in the healthy subjects.
doi:10.1007/s00586-009-1021-x
PMCID: PMC2899392  PMID: 19418074
Glucose; Lactate pyruvate ratio; Glycerol; Paraspinal muscle; Microdialysis
24.  Interday variation and effect of transportation on indirect blood pressure measurements, plasma endothelin-1 and serum cortisol in Standardbred and Icelandic horses 
Background
Systemic hypertension is a prominent feature in humans with metabolic syndrome (MS) and this is partly caused by an enhanced endothelin-1 (ET-1) mediated vasoconstriction. There are indications that systemic hypertension might be a feature in equine metabolic syndrome (EMS) but if ET-1 is involved in the development of hypertension in horses is not known. Increased levels of cortisol have also been found in humans with MS but there are no reports of this in horses. Before blood pressure, plasma ET-1 and serum cortisol can be evaluated in horses with EMS, it is necessary to investigate the interday variation of these parameters on clinically healthy horses. The aims of the present study were therefore to evaluate the interday variation and influence of transportation on systemic blood pressure, plasma ET-1 and serum cortisol in healthy Standardbred and Icelandic horses, and to detect potential breed differences.
Methods
Nine horses of each breed were included in the study. Blood pressure was measured and blood samples were collected between 6 and 9 am on two separate days. Eight of the horses (four of each breed) were transported to a new stable were they stayed overnight. The next morning, the sampling procedure was repeated.
Results
The interday variation was higher for plasma ET-1 (37%) than for indirect pressure measurements (8-21%) and serum cortisol (18%). There were no differences in systemic blood pressure between the two breeds. The Icelandic horses had significantly lower serum cortisol and significantly higher plasma ET-1 concentrations compared to the Standardbred horses. Plasma ET-1 was significantly elevated after transportation, but systemic blood pressure and serum cortisol did not differ from the values obtained in the home environment.
Conclusions
Indirect blood pressure, plasma ET-1 and serum cortisol are of interest as markers for cardiovascular dysfunction in horses with EMS. The elevated plasma ET-1 concentrations recorded after transportation was likely caused by a stress response. This needs to be considered when evaluating plasma ET-1 in horses after transportation. The differences detected in plasma ET-1 and serum cortisol between the two breeds might be related to differences in genetic setup, training status as well as management conditions.
doi:10.1186/1751-0147-54-37
PMCID: PMC3503793  PMID: 22682151
Horse; Plasma endothelin-1; Cortisol; Blood pressure; Transportation
25.  Beta-adrenergic and atrial natriuretic peptide interactions on human cardiovascular and metabolic regulation 
Context
Atrial natriuretic peptide (ANP) has well known cardiovascular effects and modifies lipid and carbohydrate metabolism in humans.
Objective
To determine the metabolic and cardiovascular interaction of beta-adrenergic receptors and ANP.
Design
Cross over study, conducted 2004–2005
Setting
Academic clinical research center
Patients
Ten healthy, young, male subjects (BMI 24±1 kg/m2)
Intervention
We infused intravenously incremental ANP doses (6.25, 12.5, and 25 ng/kg/min) with and without propranolol (0.20 mg/kg in divided doses followed by 0.033 mg/kg/h infusion). Metabolism was monitored through venous blood sampling, intramuscular and subcutaneous microdialysis and indirect calorimetry. Cardiovascular changes where monitored by continuous ECG and beat-by-beat blood pressure recordings.
Main outcome measures
Venous NEFA, glycerol, glucose, insulin; microdialysate glucose, glycerol, lactate, pyruvate.
Results
ANP increased heart rate dose dependently. Beta-adrenergic receptor blockade abolished the response. ANP elicited a dose-dependent increase in serum non-esterified fatty acid and glycerol concentrations. The response was not suppressed with propranolol. Venous glucose and insulin concentrations increased with ANP, both, without or with propranolol. ANP induced lipid mobilization in subcutaneous adipose tissue. In skeletal muscle, microdialysate lactate increased while the lactate to pyruvate ratio decreased, both, with and without propranolol. Higher ANP doses increased lipid oxidation while energy expenditure remained unchanged. Propranolol tended to attenuate the increase in lipid oxidation.
Conclusions
Selected cardiovascular ANP effects are at least partly mediated by beta-adrenergic receptor stimulation. ANP induced changes in lipid mobilization and glycolysis are mediated by another mechanism, presumably stimulation of natriuretic peptide receptors whereas substrate oxidation might be modulated through adrenergic mechanisms.
doi:10.1210/jc.2006-1084
PMCID: PMC2072963  PMID: 16984990
Adipose Tissue; cytology; drug effects; Adrenergic beta-Antagonists; pharmacology; Adult; Atrial Natriuretic Factor; administration & dosage; pharmacology; physiology; Blood Glucose; analysis; Calorimetry, Indirect; Cardiovascular Physiology; Cells, Cultured; Dose-Response Relationship, Drug; Fatty Acids, Nonesterified; blood; Female; Glucose; metabolism; Glycerol; blood; metabolism; Heart Rate; drug effects; Humans; Infusions, Intravenous; Male; Metabolism; Microdialysis; Muscle, Skeletal; drug effects; Propranolol; pharmacology; Receptors, Adrenergic, beta; physiology

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