Risk of malignant transformation in patients with monoclonal gammopathy of undetermined significance

The acturial probability of malignant transformation was analyzed in a series of 263 patients with monoclonal gammopathy of undetermined significance (MGUS) over a 15-year period and followed from 5 to 20 years. At a median follow-up of 11.5 years, 157 patients (59.7%) had died of causes unrelated to MGUS, 47 (17.9%) were still alive and presented no increase in monoclonal component, 11 (4.1%) presented an increase in monoclonal component without evidence of malignant immunoproliferative disease, and 48 (18.3%) had developed a malignant transformation of MGUS. In particular, MGUS evolved into 35 cases of multiple myeloma, two of solitary plasmacytoma of the bone, four of macroglobulinemia, three of malignant lymphoma, two of amyloidosis, one of chronic lymphocytic leukemia, and one of plasma cell leukemia. The cumulative incidence of malignant transformation was 18.3%; and the actuarial risk of malignant transformation was 6.1, 15.4, and 31.3% at 5, 10 and 20 years, respectively. The multivariate regression analysis according to Cox's proportional hazard model selected among 22 different variables established at initial diagnosis of MGUS only age as the factor significantly (P < 0.011) and negatively (b = -1.104) related to the risk of developing a malignant immunoproliferative disease. Therefore, patients with MGUS present an increased risk of developing a malignant lymphoproliferative or plasma cell proliferative disease, and MGUS could be considered a pre-neoplastic condition. Since no clinical or laboratory features are able to identify in advance the patients at high risk of disease progression, each patient must be followed up periodically and over an indefinite period.

Circadian rhythms of plasma atriopeptin, plasma renin activity and plasma aldosterone in patients with hepatorenal syndrome

The etiology of hepatorenal syndrome (HRS) is still incompletely understood, but the atriopeptin-renin-aldosterone system plays an important role in its pathogenesis. Since this system presents a circadian rhythmicity, the aim of the study was to investigate the circadian rhythm in the circulating concentrations of atriopeptin (atrial natriuretic peptide, pANP), plasma renin activity (PRA) and plasma aldosterone (pA) in patients with HRS, compared with healthy controls. Venous blood samples were drawn during the span of a whole day and every two hours from a peripheral vein in 10 healthy subjects and in 10 patients with HRS. The circulating concentrations of pANP, PRA and pA were determined by radioimmunoassay. Statistical analysis was carried out by the "cosinor" method. The controls presented a significant (p < 0.05) circadian rhythm for each variable, whereas no rhythm (p > 0.05) was found in HRS patients. The pANP, PRA and pA rhythms were significantly (p < 0.05) different between the two groups, HRS patients having higher mean daily concentrations and larger circadian variations of pANP, PRA and pA than controls. Significant relations (p < 0.05) were demonstrated between the mean daily concentrations of pANP and PRA (r = 0.79), PRA and pA (r = 0.73) and PRA and pA (r = 0.76) in the controls; on the contrary, the HRS patients showed only a significant (p < 0.05) positive relation between pANP and PRA (r = 0.71). These results confirm the previous observation that the atriopeptin-renin- aldosterone system presents a well-defined circadian time structure in healthy subjects, while the HRS patients present a complete loss of the secretory sequentiality and of the circadian rhythm, with desynchronization of the whole system. This great upset in the temporal and functional organizations of the system could play an important role in promoting and/or in maintaining the hydro-electrolyte unbalance of HRS.

No influence of aging on the circadian rhythm of erythropoietin in healthy subjects

The diurnal rhythm in the circulating serum levels of erythropoietin (Epo) was investigated in a group of 20 clinically healthy subjects aged 30-55 years and in a group of 20 healthy subjects aged 55-75 years. Venous blood samples were drawn during the span of a whole day every 4 h, starting from midnight, for the determination of serum Epo levels by radioimmunoassay. Statistical analysis was carried out by means of the 'cosinor' method. Both groups presented a significant (p < 0.05) circadian rhythm in serum Epo levels, with maximum in the afternoon. The younger subjects had significantly (p < 0.05) higher mean daily levels and higher diurnal variations of serum Epo than older subjects; no difference (p > 0.05) was found between the groups regarding the peaks of the rhythms. These data confirm the presence of a circadian rhythm in serum EPO levels and suggest that the aging process does not influence the physiological diurnal fluctuations but modifies the mean daily levels and the amplitude of the diurnal variations, such as it occurs for many other variables. This behavior is an index of aging, but does not seem to have clinical implications.

The natural history of monoclonal gammopathy of undetermined significance. A 5- to 20-year follow-up of 263 cases

Patients with monoclonal gammopathy of undetermined significance (MGUS) have a serum monoclonal component (M-component), but no evidence of multiple myeloma, macroglobulinaemia, amyloidosis or other plasma cell proliferative disease. A long-term follow-up study (median 11.5 years) has been carried out in 263 cases of MGUS, 159 males (60.5%) and 104 females (39.5%), aged 40-89 years (median 66.5 years). The actuarial probability for malignant transformation was 6.1, 15.4 and 31.3% at 5, 10 and 20 years, respectively. At the final evaluation, 157 patients (59.7%), 119 (45.3%) of whom with no increase and 38 (14.4%) with an increase in serum M-component, died of causes unrelated to MGUS and without development of any plasma cell proliferative disease; 47 patients (17.9%) were still alive without increase in M-component; 11 patients (4.1%) were still alive and at follow-up presented values of serum M-component > 30 g/l without any evidence of plasma cell proliferative or lymphoproliferative disease; 48 patients (18.3%) developed multiple myeloma (35 cases, 13.1%), solitary plasmacytoma of the bone (2 cases, 0.8%), macroglobulinaemia (4 cases, 1.6%), malignant lymphoma (3 cases, 1.2%), amyloidosis (2 cases, 0.8%), chronic lymphocytic leukaemia (1 case, 0.4%), and plasma cell leukaemia (1 case, 0.4%). The patients developing multiple myeloma, solitary plasmacytoma, macroglobulinaemia and plasma cell leukaemia had an increase in serum M-component, whereas no increase was found in malignant lymphoma, amyloidosis and chronic lymphocytic leukaemia. These findings and the data in the literature suggest that MGUS could be considered a preneoplastic condition; since no clinical and laboratory features are able to identify in advance the patients at high risk of disease progression, each patient must be followed up indefinitely.

Cosinor analysis of circadian peak expiratory flow variability in normal subjects, passive smokers, heavy smokers, patients with chronic obstructive pulmonary disease and patients with interstitial lung disease

Peak expiratory flow (PEF) presents a circadian rhythm with a maximum in the afternoon, and a significant variability in its diurnal variations has been reported in normal subjects and in chronic obstructive pulmonary disease (COPD). In order to investigate whether passive smoking, active tobacco smoking, COPD and interstitial lung disease (ILD) are associated with changes in the circadian rhythm of PEF, five groups of adult male subjects, comparable for age, weight and height, were studied: group A: 30 clinically healthy subjects who never smoked, group B: 30 subjects passively exposed to tobacco smoking, group C 30 heavy smokers (> 20 cigarettes daily for at least 5 years), group D: 30 patients with nonasthmatic COPD (emphysema and/or chronic bronchitis), and group E: 15 patients with ILD (pneumoconiosis). Active tobacco smoking and exposure to passive smoking were assessed by the determination of the urinary cotinine concentration. A portable spirometer was used to measure PEF over a whole day, at 0.00, 6.00, 8.00, 10.00, 12.00, 14.00, 16.00, 18.00, 20.00, 22.00, and 24.00 h, all subjects leading a normal life. The 'mean cosinor' method was used for statistical analyses; the PEF variability was evaluated by the amplitude percent mesor (daily mean). All groups showed diurnal fluctuations in PEF values with significant (p < 0.05) circadian rhythms. The peaks of PEF rhythms occurred in the early afternoon, without significant (p > 0.05) differences between the groups. The cosinor mean was significantly (p < 0.05) lower in heavy smokers, in passive smokers, and in COPD patients than in controls. Controls, passive smokers, heavy smokers, COPD and ILD patients presented a PEF amplitude percent mesor (95% confidence limits) of 6.26% (range 4.57-7.95), 7.79% (range 5.07-10.51), 12.60% (range 7.61-17.59), 17.19% (range 10.18-23.50), and 3.98% (range 2.09-5.87), respectively, with significant differences (p < 0.05) between all groups, except between controls and passive smokers. These data suggest that tobacco smoke, both passive and active, does not modify the circadian peak of PEF, but modifies significantly its mesor and amplitude. In this respect, heavy smokers have the same pattern of COPD: lower mesor and greater amplitude; passive smokers present an intermediate situation. An increased diurnal variability in PEF could be considered as an early index of tobacco smoke damage and of developing COPD. When studying diurnal PEF variability, active and passive smoking habits should be considered.

The nervous system in systemic sclerosis (scleroderma). Clinical features and pathogenetic mechanisms

The involvement of the nervous system in SSc is well recognized today. Different pathogenetic mechanisms are suggested that may alternatively explain the multiform appearance of the clinical spectrum (mononeuritis, mononeuritis multiplex, carpal tunnel syndrome, and so forth). It is now clear that the ANS is the earliest structure targeted by the disease in the gastrointestinal tract. The importance of this observation has not yet been adequately interpreted but may, together with the increasing evidence of the nervous system involvement in SSc, become a leading factor in understanding of the importance of the nervous system in the onset, development, and maintenance of the disease.

Peripheral nervous system involvement in systemic sclerosis: the median nerve as target structure

OBJECTIVES

To investigate the frequency and the main electrophysiological characteristics of the canalicolar passage nerve involvement in patients with systemic sclerosis (SSc).

METHODS

Thirty-two SSc patients were enrolled in the study, classified according to the type (diffuse or limited) and the duration (> / < 5 years) of the disease. Sensory-motor nerve conduction studies (NCS) of the upper and lower limbs, in particular at the critical canalicolar points, were conducted by recording the Compound Muscular Action Potential (CMAP) and the Sensory Action Potential (sNAP). The following parameters were evaluated: Motor Nerve Conduction Velocity (MNCV) and Sensory Nerve Conduction Velocity; distal and proximal latency of the CMAP and the onset and peak latency of the sNAP; peak-peak amplitude and negative-peak area of the CMAP and sNAP; and the Terminal Latency Index (TLI) (Terminal Distance/MCNV x Distal latency).

RESULTS

Four (12.5%) patients had a distal neuropathy of the upper limbs (one with monolateral and two with bilateral involvement of the median nerve and one bilateral involvement of the ulnar nerve). Fourteen (43.7%) patients showed a decrement of the median nerve TLI and seven (21.8%) of either the median or the ulnar nerve (Table I). Motor and sensitive conduction velocity and latency studies did not show a statistical difference between SSc patients and controls. The amplitude and area of the CMAP (distal and proximal), sNAP and of the median nerve TLI were significantly decreased in patients with respect to controls.

CONCLUSION

Distal mononeuropathy of the median nerve was the most frequent result in our patients. The involvement of the peripheral nervous system seems to be strictly topographical, following the modifications of the tissues and vascular tone (Raynaud's phenomenon) at the upper acral level. The neurophysiological alterations detected in our study at the wrist level may not be linked merely to a compressive event but also to microvascular involvement. Nerve involvement closely connected with the pathogenesis and distribution of SSc should be considered when peripheral nervous system involvement is the initial symptom of the disease.

Plasma cell leukemia. A report on 11 patients and review of the literature

OBJECTIVE

Plasma-cell leukemia (PCL) is considered the leukemic variant of multiple myeloma. The diagnosis is based on plasmocytosis exceeding 2,000/mm3 and any evidence of clonal plasma cell proliferation. There are two forms of PCL: the primary form occurring in patients without preceding multiple myeloma or monoclonal gammopathy of undetermined significance, and the secondary form arising as a late manifestation in patients with multiple myeloma. Aim of the study was to describe our series of PCL and to report the main clinical and laboratory findings from the largest series in the literature.

METHODS

Review of all cases of PCL observed from 1976 to 1994 in our Medical Divisions. Med-line research of the largest (more than 5 cases reports) series of PCL from 1969 to 1994.

RESULTS

Eleven cases of PCL were identified. We diagnosed 6 cases with primary PCL out of a total of 512 patients with monoclonal gammopathy (incidence, 1.2%), 4 cases of secondary PCL as terminal phase out of 220 patients with multiple myeloma (incidence, 1.8%), and 1 case of secondary PCL as evolution of monoclonal gammopathy of undertermined significance out of 226 cases (incidence, 0.4%). From our and literature review, that identified 203 cases of primary PCL and 157 cases of secondary PCL, the clinical and the laboratory features did not significantly differ between primary and secondary forms of PCL, whereas significant differences exist between the two forms regarding response to therapy and median survival. In our series, the mean survival was 14 months for primary PCL and 6.8 months for secondary PCL. Two of the 6 patients with primary PCL obtained a complete remission, with a duration of 28 and 23 months, respectively; only 1 patient with secondary PCL had a response to chemotherapy, with a remission of 6 months.

CONCLUSION

Our observation and literature data indicate that PCL, both primary and secondary, is a very poor prognosis disease, that the response rate is higher with combination chemotherapy than single agents, and that primary PCL has a relatively better survival, since secondary plasma PCL usually shows resistance to any type of chemotherapy.

Circadian rhythm of serum erythropoietin in multiple myeloma

The diurnal rhythm in the circulating serum levels of erythropoietin (EPO) were determined in a group of 20 adult clinically-healthy subjects, in a group of 10 patients with myeloma without renal impairment and 10 patients with myeloma and renal failure. Venous blood samples were drawn during the span of a whole day and every 4 hr, starting from midnight, for the measurement of serum EPO levels by radioimmunoassay (RIA). Statistical analysis was carried out by means of the "cosinor" method. Results show that the controls and the myeloma patients without renal insufficiency present significant (P < 0.05) circadian rhythms in serum EPO levels; no rhythm (P < 0.05) was detected in patients with myeloma and renal failure. Patients with myeloma and renal failure have significant (P < 0.05) lower mean daily levels and diurnal fluctuations of EPO than the other groups, whereas the patients with myeloma without renal involvement present higher (P < 0.05) mean daily levels and lower (P < 0.05) diurnal variations of EPO than controls; no differences (P > 0.05) exist between the groups regarding peaks of rhythms. These data confirm the existence of a physiological circadian rhythm in serum EPO concentrations, with maximum in the afternoon, and they suggest that renal failure is an important cause of anemia and loss of EPO circadian rhythm in patients with myeloma.

Risk of monoclonal gammopathy of undetermined significance: a case-referent study

A retrospective study was conducted in 285 cases of monoclonal gammopathy of undetermined significance (MGUS) and in 570 sex- and age-matched hospital controls in order to investigate the possible association between socioeconomic status, residence, alcohol and tobacco habits, occupation, occupational exposure to toxic substances, chronic antigenic stimulation, and risk of MGUS. Significant associations with the risk of MGUS were found for farmers (P < 0.005) and for workers in industry (P < 0.025). Occupational exposure to asbestos, fertilizers, mineral oils and petroleum, paints and related products, pesticides, and radiation was significantly (P < 0.05) associated with an increase in risk of MGUS. Chronic immune-stimulating conditions, when considered as a group, presented a significant (P < 0.025) association with the risk of MGUS, but no specific disease has been found to be significantly associated. These data are in agreement with the previous reports on multiple myeloma, suggesting that these factors may play an important role in the development of monoclonal gammopathies. However, these findings need to be confirmed in prospective larger population-based studies.

The atrial natriuretic peptide-renin-aldosterone system in hepatorenal syndrome

BACKGROUND

Hepatorenal syndrome (HRS) is a functional acute renal failure occurring in patients with advanced liver disease: the etiology of HRS is still unknown, but a role in its development and maintaining is played by the atrial natriuretic peptide-renin-aldosterone system. Aim of the study was to investigate the circulating plasma levels of the atrial natriuretic peptide (pANP), plasma renin activity (PRA) and plasma aldosterone (pA) in a group of HRS patients, compared to healthy controls.

METHODS

Venous blood samples were drawn at 8:00 am in 36 healthy controls and in 20 patients with HRS following liver cirrhosis for the radioimmunoassay measurement of the circulating pANP, PRA and pA levels. The mean values of each variable were compared between the two groups by the "t" test; linear regression analysis was used to correlate the values of pANP and PRA, pANP and pA, and PRA and pA in the two groups.

RESULTS

HRS patient presented significant (p < 0.05) higher levels of pANP, PRA and pA than controls. Significant (p < 0.001) relations were found in healthy subjects between pANP and PRA (r = -0.78), pANP and pA (r = -0.68), and PRA and pA (r = 0.71), whereas the HRS group have only a significant (p < 0.001) positive relation between pANP and PRA (r = 0.67).

CONCLUSIONS

These data indicate that HRS is not due to a deficiency in circulating pANP. The elevated pANP levels in HRS may suggest a renal insensitivity to its natriuretic effects, and the derangement in the relationships and function in the atrial natriuretic peptide-renin-aldosterone system could be considered an important pathophysiologic mechanism in the hydro-electrolyte unbalance of HRS.

Circadian rhythm of serum erythropoietin in healthy subjects

BACKGROUND

The diurnal rhythm in the circulating serum levels of erythropoietin (EPO) was investigated in healthy subjects.

METHODS

Venous blood samples were drawn during the span of a whole day every four hours, starting from midnight, for the determination of serum Epo levels by RIA in 40 clinically healthy normocytemic subjects, 27 males and 13 females, aged 30-75 years. Statistical analysis was carried out by means of the "cosinor" method.

RESULTS

Serum EPO presents a significant (p < 0.05) circadian rhythm with higher levels in the afternoon and lower levels in the nightime.

CONCLUSIONS

These data confirm the presence of a circadian rhythm in serum EPO levels. The mechanisms behind the circadian rhythmicity are still unknown. For clinical evaluation of the serum EPO values, the time of day for collection of blood samples has to be taken into consideration.

Lack of sympathetic involvement in dermatitis confined to the median nerve territory. A case report

Both decreased and increased sympathetic nerve activity has been suggested as a possible underlying mechanism in inflammatory skin lesions. Modulation of sympathetic function has been proposed in the treatment of dermatitis. This case report describes the investigation strategy and normal findings in a case of dermatitis strictly confined to the median nerve territory, illustrating the need for specific tests of sympathetic function when pharmacological as well as physical sympatho-modulatory therapies are considered.

Prognostic factors in multiple myeloma: selection using Cox's proportional hazard model

The pretreatment characteristics of 210 patients with multiple myeloma, observed between 1980 and 1994, were evaluated as potential prognostic factors for survival. Multivariate analysis according to Cox's proportional hazard model identified in the 160 dead patients with myeloma, among 26 different single prognostic variables, the following factors in order of importance: beta 2-microglobulin; bone marrow plasma cell percentage, hemoglobinemia, degree of lytic bone lesions, serum creatinine, and serum albumin. By analysis of these variables a prognostic index (PI), that considers the regression coefficients derived by Cox's model of all significant factors, was obtained. Using this it was possible to separate the whole patient group into three stages: stage I (PI < 1.485, 67 patients), stage II (PI: 1.485-2.090, 76 patients), and stage III (PI > 2.090, 67 patients), with a median survivals of 68, 36 and 13 months (P < 0.0001), respectively. Also the responses to therapy (P < 0.0001) and the survival curves (P < 0.00001) presented significant differences among the three subgroups. Knowledge of these factors could be of value in predicting prognosis and in planning therapy in patients with multiple myeloma.

[Diagnostic value of gamma glutamyl transpeptidase and the mean corpuscular volume in chronic hepatitis of alcoholic etiology]

In order to assess the diagnostic value of serum gamma-glutamyl-transpeptidase (GGT) and mean corpuscular volume (MCV) as markers of alcoholism in chronic liver diseases, 107 patients with non-alcoholic chronic liver disease and 192 patients with alcoholic liver disèases have been compared. GGT and MCV values were checked two times: the day of admission to hospital and 10 days after complete withdrawal from alcohol. The patients with alcoholic liver diseases present significantly higher values of GGT and MCV in respect with patients with non-alcoholic liver diseases. A significant (p < 0.05) decrease of about 50% in serum GGT levels and of about 3% in MCV was observed after alcohol withdrawal only in the group of alcoholic liver diseases whereas no changes were found in the other group of patients: For the diagnosis of alcoholism in chronic liver diseases, while the sensitivity and the specificity of the several markers vary from 50% to 86%, the positive predictive values of GGT and MCV at admission were 92.2% and 73.4%, and the negative predictive values were 40.2% and 75.7%, respectively. Moreover, the positive predictive values of GGT and MCV after 10 days of alcohol withdrawal were 95.3% and 85.9% and the negative predictive values were 31.8% and 46.7%, respectively. The contemporary decrease in GGT and MCV values does not seem to offer better informations than GGT decrease. These data suggest that, even if GGT and MCV do appear per se as weak indicators of alcoholism during chronic liver diseases, the early decrease in their values, especially in serum GGT, are good and specific markers of alcohol abuse and, consequently, of the alcoholic etiology of liver disease.

Reduction of spastic hypertonia in patients with spinal cord injury: a double-blind comparison of intravenous orphenadrine citrate and placebo

Spasticity is one of the major problems affecting the outcome of rehabilitation in paraplegic patients. Orphenadrine citrate possesses an effective muscle relaxant action in many pathologies. Nevertheless, despite a recognized central site of action, no controlled data are available on its use in the treatment of spastic hypertonia in patients with spinal cord injuries. Therefore, the effect of intravenous administration of 60mg of orphenadrine citrate versus placebo on spastic hypertonia after spinal cord injury was studied in 11 patients. The threshold of the flexion reflex of the lower limb was studied as a neurophysiological correlate of spastic hypertonia. Clinical assessment was made using the Ashworth Spasticity Scale. The threshold, expressed in mAmp, was studied for 60 minutes after the treatment. A significant difference was found using the active drug compared with placebo (p < 0.0001). In 9 patients, the reduction of the abnormal flexion responses after orphenadrine appeared to begin only after 30 minutes. In one patient the onset of the therapeutic effect was early but weak. One patient with severe spastic hypertonia leading to triple flexion when the limb was manipulated did not gain any relief with orphenadrine. The clinical and neurophysiological results suggest an efficacy of orphenadrine citrate in the control of spastic hypertonia in paraplegics. This could be relevant in the rehabilitation strategy, although further studies are needed on the duration of its action.

Circadian rhythms of fibrinogen and antithrombin III in liver cirrhosis

BACKGROUND

Since acquired deficiencies of fibrinogen and antithrombin III are reported in liver cirrhosis and it is known that their plasma levels fluctuate during the day, the circadian rhythms of plasma fibrinogen and plasma antithrombin III were investigated in patients with compensated and decompensated cirrhosis, compared to healthy controls.

METHODS

Three groups of subject were considered: (A) 10 healthy controls; (B) 10 patients with compensated liver cirrhosis; (C) 10 patients with decompensated liver cirrhosis. The fibrinogen and antithrombin III levels were determined in blood samples drawn in each studied subject during the span of a whole day and every three hours starting from midnight. The time-related data were analyzed by means of the "mean-group cosinor" method.

RESULTS

Significant (p < 0.05) circadian rhythms were detected for the two variables in groups A and B, with peaks in the afternoon hours. No significant (p > 0.05) rhythms were found for group C. A significant (p < 0.05) difference was found between the three groups regarding the circadian rhythm of fibrinogen, and between controls and patients with compensated cirrhosis and between compensated and decompensated patients regarding the circadian rhythm of antithrombin III.

CONCLUSIONS

These data suggest that in healthy subjects the plasma levels of fibrinogen and antithrombin III present daily variations with own circadian rhythms, and that liver cirrhosis is associated with chronobiological circadian changes in the coagulation system, related to the stage of the disease. This progressive derangement could be considered as an index of evolution in the natural history of cirrhosis of the liver.

Electromyographic signal frequency analysis in evaluating muscle fatigue of patients with peripheral arterial disease

Peripheral arterial disease (PAD) patients are commonly classified on the basis of subjective evaluations of pain and fatigue. Surface electromyography (EMG) is an objective method for studying peripheral muscle fatigue. Fifteen patients with PAD and 15 healthy volunteers matched for age and sex were studied. Surface EMG was recorded over the medial gastrocnemius during 100 seconds at 60% of maximal effort. EMG traces were analyzed off-line to obtain the power spectrum. The median frequency was calculated in the first 30 seconds (T0) and between 70 and 100 seconds (T1). Significantly lower T1 values, compared with T0, were found in both the PAD and the control groups (p < .005; p < .05). T0 values were not different between group, whereas T1 values were significantly lower in PAD patients (p < .01). EMG frequency analysis can be considered an easy, painless method providing objective information on muscular performance and fatigue in PAD patients.

Is sympathetic neural hyperactivity in chronic heart failure affected by heart transplantation?

It has been suggested that immunosuppression with cyclosporine induces marked sympathetic neural hyperactivity in heart transplant recipients. In the present study, the resting level of sympathetic nerve activity was investigated with intraneural recording in nine patients with severe chronic heart failure (NYHA class III-IV despite ongoing therapy), in nine heart-transplanted patients with previous heart failure (NYHA class III-IV) receiving standard low-dose triple-drug immunosuppression and in six age-matched controls without cardiovascular disease. Compared to the control group, resting sympathetic nerve discharge was markedly increased in heart failure patients (92 +/- 2 vs 60 +/- 6 B/100 b, P < 0.01), sympathetic nerve activity was lower in the majority of heart failure patients after heart transplantation, and mean burst incidence was significantly lower than in the cardiac failure group (70 +/- 7, P < 0.01). The difference between transplanted patients and the control group was not statistically significant. Thus, heart transplant recipients may reduce the augmented central sympathetic drive associated with cardiac failure despite ongoing cyclosporine treatment.

Morphine injected around the stellate ganglion does not modulate the sympathetic nervous system nor does it provide pain relief

Six patients with a presumptive diagnosis of upper limb reflex sympathetic dystrophy and 1 patient with anaesthesia dolorosa had pain and sympathetic activity assessed before and after injection of bupivacaine and morphine around the stellate ganglion. Sympathetic modulation was assessed by measuring the effect of each injection on the inspiratory gasping response (IGR), a measure of central arousal, the sympathetic skin response (SSR), a measure of peripheral sudomotor activity and the plethsymographic wave (PW), a measure of peripheral vasomotor activity. There were 5 women and 2 men with a mean age of 49 years (range: 41-66 years). The duration of pain varied from 9 months to 7 years. Bupivacaine abolished the IGR and SSR and increased the amplitude of the PW in all patients without any demonstrable sensory or motor blockade in the treated limb, nor did it have any effect on the contralateral IGR or PW. Bupivacaine did provide short-term pain relief in 4 out of 7 patients. Morphine did not produce any demonstrable effect on the sympathetic nervous system nor did it provide pain relief for any patient. Thus these data do not support injection of morphine around the stellate ganglion as it neither modulated sympathetic activity nor provided pain relief.

The role of peripheral sudomotor blockade in the treatment of patients with sympathetically maintained pain

The aim of the present study was to investigate the role of the peripheral cholinergic system in patients with sympathetically maintained pain (SMP). Thirty-three patients with SMP were given Bier's block with 0.6 mg of atropine in 10 ml of saline or 10 ml of saline in a randomised double-blind manner. Pain intensity, pain relief and mood were assessed before and after each block using the visual analogue scale (VAS). In addition pain intensity was assessed at the same time using a categorical scale (CS). There was at least 1 week between each injection, and during this week the patients reported their pain intensity daily, using the CS. Three patients failed to complete both wings of the study and thus the results of the remaining 30 patients were analysed using the Mann-Whitney U test and the Wilcoxon signed-rank test. No significant difference was found between atropine and saline on any parameter.