C43 A CASE REPORT OF A GIANT RIGHT CORONARY ARTERY ANEURYSM: ROLE OF CONTRAST ECHOCARDIOGRAPHY

A giant coronary aneurysm is rare entity and it is defined if the diameter is 4–fold greater the reference vessel diameter or if it is > 20 mm in diameter. We report the case of a 73–years–old man without prior history of cardiac disease, admitted in Emergency Department for abdominal pain with normal ECG. Abdominal CT scan showed no pathological findings. At thoracic level it was reported a suspected pericardial cyst (75x80 mm), with partial compression of right chambers (Fig. 1). Echocardiography confirmed the presence of a giant round cystic–appearance lesion characterized by the presence of an anechoic space with internal echogenic swirling flow pattern at the level of right atrioventricular groove with mild compressive effect on right chambers. (Fig. 2). The color Doppler mode showed a faint signal, without a clear evidence of flow origin. A bubble test with agitated saline contrast medium injected through antecubital vein, shows no evidence of contrast uptake by the mass. In order to better characterize the lesion, we use echocardiographic contrast agent (SonoVue®), which showed a clear pattern of blood flow inside the mass with a probable origin at a very limited region (Fig. 2a–2b). At that level it was also possible to sample an ECG–synchronized systo–diastolic pulse–wave (PW)–Doppler pattern (peak velocity 125 cm/s), typical for a coronary artery flow. According to these echocardiographic findings, we supposed a giant right coronary aneurysm. Coronary Computed Tomography Angiography with 3D reconstruction showed a giant aneurysm of the right coronary artery at mid–level, preceded by a mild aneurysm of the proximal tract and two small aneurysms of the circumflex artery and diffuse atherosclerosis diseases with significant stenosis on mid left anterior descending artery (LAD). The coronary angiography confirmed the presence of the giant aneurysm in mild tract of right coronary artery preceded by a small one in the proximal tract andthe two small aneurysm of the circumflex artery and a critical stenosis of mid tract of LAD. The patient underwent surgical treatment of the aneurysm and coronary artery bypass graft (Fig. 3). Computed Tomography Coronary Angiography is the best method for coronary artery anatomy and coronary abnormalities. In case of giant coronary abnormalities, the use of echo contrast agent provides further important information about perfusion and/or flow assessment and it helped to clarify the diagnosis.

Predictors of one year all-cause death in acute heart failure patients enrolled in the nationwide BLITZ-HF study

Background

Outcomes of patients admitted for acute heart failure (AHF) are generally poor, then it is important to recognize outcome predictors in order to better identify and manage patients at higher risk.

Aims

To identify independent predictors of 1-year all-cause death in AHF patients enrolled by Italian cardiology sites participating to the BLITZ-HF study.

Methods

BLITZ-HF was a prospective nationwide study based on a web based recording system used during two enrollment periods (08/03/2017 – 04/09/2017 and 24/12/2017 – 09/04/2018). Overall, 7218 patients with acute and chronic HF were enrolled by 106 sites, 58 were lost to follow-up. Patients were followed for a median of 370 days [IQR 339–395]. Cox proportional hazards models were used to identify the independent predictors of all-cause death from hospital admission to 1-year follow-up. Demographic variables and baseline characteristics statistically significant at univariate analysis were included in the multivariable models. Different Cox proportional models were fitted: 1) adjusted for age and gender, 2) model 1 + clinical variables, 3) model 2 + laboratory and instrumental examinations, 4) model 3 + therapy.

Results

The present analysis refers to the 1470 patients admitted for AHF not lost to follow-up. Mean age was 73±12, with nearly 50% having more than 75 years of age. Female gender accounted for about one third of cases. More than half were de novo HF patients and 43% had an ischemic aetiology. Nearly 40% had a history of atrial fibrillation (AF) and chronic kidney disease (CKD) and one fifth had a history of COPD and peripheral obstructive artery disease. Furthermore, mean systolic blood pressure (SBP) on admission was 131±28 and, heart rate (HR) was 91±25. The majority of HF patients had reduced EF (HFrEF) (58%), followed by HF with preserved EF (HFpEF) (24%) and HF with mid range EF (HFmrEF) (18%).

One year all-cause mortality was 16.6%. Independent predictors of all-cause mortality are shown in the Table. In the final model adjusted for age, gender, clinical variables, laboratory and instrumental examinations and medical treatments, the following variables resulted as independent predictors of one-year all-cause mortality: age (HR 1.02), Confuse/obnubilate mental status (HR 2.07), creatinine >1.5 mg/dl (HR 1.54), BUN >43 mg/dl, (HR 2.74), aortic stenosis (HR 1.70), inotrope use (HR 1.43), IV furosemide >125 mg (HR 1.74), SBP (HR 0.99).

Conclusions

In our study several independent predictors of one-year all-cause mortality have been identified, confirming and reinforcing previous findings. Interestingly, our independent predictors derived from different domains (demographic, clinical, biohumoral, instrumental and treatment variables). These findings further underline the importance of a comprehensive assessment in the prognostic evaluation of AHF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

Clinical characteristics, management and outcomes in patients with new onset or worsening acute heart failure enrolled in the nationwide BLITZ-HF study

Background

Real world observational clinical data is important to better characterize heterogeneous groups of patients, such those with acute heart failure (AHF), in order to phenotype patients with different prognosis and to generate hypotheses regarding management in clinical practice or patient selection for planning randomised clinical trials.

Aims

To describe clinical characteristics, management and outcomes of acute heart failure (AHF) patients admitted for a first HF episode (de novo) or for worsening chronic HF (WHF) and enrolled by Italian cardiology sites participating to the nationwide BLITZ-HF study.

Methods

BLITZ-HF was a prospective nationwide study based on a web-based recording system used during two enrollment periods (08/03/2017 – 04/09/2017 and 24/12/2017 – 09/04/2018). Overall, 7218 patients with acute and chronic HF were enrolled by 106 sites.

Results

The present analysis refers to the 1470 out of 1494 patients admitted for AHF not lost to follow-up, of which 822 (56%) presented with de novo and 648 (44%) with WHF. Patients were followed for a median of 370 days [IQR 339–395]. Mean age was significantly higher in patients with WHF 74±12 (vs 72±12 in de novo, p<0.001), while no gender differences were observed (WHF 35% vs de novo 36%). Compared to de novo, patients with WHF had more frequently a history of treated hypertension (66% vs 61%, p=0.028), atrial fibrillation (52% vs 29%, p<0.0001), previous myocardial infarction and coronary revascularization (41% vs 19% and 38% vs 18% respectively, both p<0.0001), a previous device implantation (34% vs 6%, p<0.0001). Non cardiac comorbidities such as CKD and COPD resulted in a higher rate among patients with WHF (51% vs 28% and 26% vs 17%, both p<0.0001). We also found significant differences between the two groups in terms HF ejection fraction categories (HFrEF 64.5% vs 52.3%, HFmrEF 13.9% vs 21.4%, HFpEF 21.6% vs 26.3%, for WHF vs de novo, p<0.0001). On admission, patients with WHF presented with lower systolic blood pressure (124±27 vs 135±28, p<0.0001), lower hart rate (87±23 vs 95±26, p<0.0001), higher creatinine levels (1.5±0.7 vs 1.3±0.8, p<0.0001). Both inotropes and high dose of IV furosemide (>150 mg) were more frequently used among WHF patients (22.8% vs 9.7% and 35.7% vs 19.7%, p<0.0001).

Figure and table show Kaplan-Meyer curves for one year all-cause mortality and detailed in-hospital and one-year outcomes regarding mortality (total and CV) and hospitalizations (all, CV and HF) as well as the combined outcome of HF hospitalization and all-cause mortality. Patients with WHF had significantly worse outcomes compared to those with de novo HF.

Conclusions

In our study we confirm the heterogeneity of AHF patients and the importance of identify and characterize different subgroups. Patients with WHF have a more severe clinical profile and worse in-hospital and one-year clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

BLITZ-HF study: a nationwide initiative to assess and improve guidelines recommendations adherence in cardiology centers managing patients with acute and chronic heart failure

Background

Physicians adherence to heart failure (HF) guidelines is generally sub-optimal with consequent negative prognostic implications. Strategies to improve adherence to guideline recommendations are strongly needed.

Aims

To assess and improve adherence of Italian cardiology sites to guidelines recommendations on performance indicators in patients with acute (AHF) and chronic heart failure (CHF).

Methods

BLITZ-HF was a prospective study based on a web based recording system used during two enrollment periods (phase 1 and 3), interspersed by face-to-face macro-regional benchmark analysis and educational meetings (phase 2). Both management (creatinine and echocardiographic evaluations or discharge follow-up planning) and treatment (according to ejection fraction categories, focusing on guidelines directed medical treatments - GDMTs) performance indicators were considered for patients in both settings.

Results

Overall, 7218 patients with acute and chronic HF were enrolled at 106 sites. During the enrollment phases, 3920 and 3298 patients were included respectively, 84% with CHF and 16% with AHF in phase 1, 74% with CHF and 26% with AHF in phase 3. In Figure 1 we report adherence to management and treatment indicators in the two enrollment phases. Among AHF patients improvement was obtained in two of seven indicators. A significant rise in echocardiographic evaluation was observed, while discharge schedule of a cardiology ambulatory evaluation within four weeks was overall poor (less than 50%) and did not improve in the 3 phase. Overall GDMTs prescription rate in HFrEF was good and we observed a nominal increase in betablockers prescription rate in Phase 3. Among CHF patients with HFpEF and HFmrEF we observed a performance increase in two of three indicators: creatinine end echocardiographic evaluations, while oral anticoagulation in atrial fibrillation remained stably high. Performance measures in CHF HFrEF patients improved in six of nine indicators although significantly only in two. Prescription rate of GDMTs was good already in phase 1 and a significant increase in ACE-I/ARB or ARNI prescription was reported, with a nominal increase in the use of one of these three drugs in combination with MRAs and a BB.

Conclusions

A structured multifaceted educational intervention can improve adherence to HF guidelines on several indicators in a context of an already elevated level of adherence to guideline recommendations. Extension of this approach to other non-cardiology health professional settings, in which patients with HF are generally managed, should be considered.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

Community Acquired Pneumonia in Internal Medicine: A One-Year Retrospective Study Based on Pneumonia Severity Index

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

Sarcopenia is more than a muscular deficit

Sarcopenia is a complex process that appears in aged muscle associated with a decrease in mass, strength, and velocity of contraction. This process is the result of many molecular, cellular and functional alterations. It has been suggested that sarcopenia may be triggered by reactive oxygen species (ROS) that have accumulated throughout one's lifetime. We found a significant increase in oxidation of DNA and lipids in the elderly muscle, more evident in males, and a reduction in catalase and glutathione transferase activities. Experiments on Ca2+ transport showed an abnormal functional response of aged muscle after exposure to caffeine, which increases the opening of Ca2+ channels, as well a reduced activity of the Ca2+ pump in elderly males. From these results we concluded that oxidative stress play an important role in muscle aging and that oxidative damage is much more evident in elderly males, suggesting a gender difference may be related to hormonal factors. The progression of sarcopenia is directly related to a significant reduction of the regenerative potential of muscle normally due to a type of adult stem cells, known as satellite cells, which lie outside the sarcolemma and remain quiescent until external stimuli trigger as growth factors (IGF-1 or mIGF-1) their re-entry into the cell cycle. One possibility is that the anti oxidative capacity of satellite cells could also be altered and this, in turn, determines the decrease of their regenerative capacity. Data concerning this hypothesis are discussed

The 'real' woman with heart failure. Impact of sex on current in-hospital management of heart failure by cardiologists and internists

AIM

To identify differences between sexes in the clinical profile, use of resources, management and outcome in a large population of 'real world' patients with heart failure (HF).

METHODS

A prospective cross-sectional survey was conducted on 2127 consecutive patients (47% women) admitted with HF to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000.

RESULTS

Women were older, had a higher prevalence of atrial fibrillation, and more frequently a hypertensive or valvular aetiology. Females were admitted more frequently in Medical than in Cardiology Departments. The rate of invasive and non-invasive procedures was lower in women than in men, slightly higher if managed by cardiologists. Women were less frequently prescribed ACE-inhibitors, amiodarone, and spironolactone, and more frequently prescribed digoxin. In-hospital mortality was similar, without difference between health-care providers. A 6-month follow-up was performed in 56.4% of the cases in both setting, but less frequently in women. Event rates were similar with nearly half of patients re-hospitalised at least once.

CONCLUSION

The 'real' HF woman has generally a more severe disease; she is an old lady who is more frequently hospitalised in a medical unit, receives few diagnostic, and cardiovascular procedures and pharmacological therapy, has a relatively low probability of dying in hospital, but a high likelihood of requiring readmission.

Interaction Connecting Leptin-Obesity-Insulin Dependent Diabetes Mellitus

Obesity is a chronic disease that is increasing in prevalence and represents an important risk factor for the developement of diabetes, heart disease, hypertension and many forms of cancer. Fat distribution has a profound influence on health risks. For example, increased deposits of visceral, or abdominal fat correlate with risks for many diseases. The leptin system is an important and essential regulating factor for body weight and developement. Many studies have demonstrated that leptin plays an important role in behavior disorders such as obesity and anorexia. In recent studies insulin resistance has received considerable attention in the development of the metabolic syndrome, a cluster of disorders comprising glucose intolerance, dyslipidemia, hypertension, and dysfibrinolysis that is associated with type-2 diabetes and cardiovascular disease. The aim of this short review is to define the interaction between leptin, obesity and insulin dependent diabetes mellitus.

[Chlamydia pneumoniae and Helicobacter pylori infections in acute myocardial infarction]

BACKGROUND

Increasing evidence suggests an acute or chronic linkage between infection and acute coronary syndromes. The aim of this study was to assess the frequency of Chlamydia pneumoniae (CP) and Helicobacter pylori (HP) antibodies in patients with angiographically defined acute myocardial infarction and in population controls. Case patients and controls were drawn from the same geographic area (city of Messina and its province).

METHODS

Blood samples were collected in 206 incident cases of acute myocardial infarction presenting to the Coronary Care Unit (196 men, 10 women, mean age 58+/-7 years) in the period from March 1997 to June 1999. Case patients were selected if they were non-smokers, non-diabetic and if they had no history of hypertension. The control group consisted of 142 healthy subjects, without a known history of smoking, diabetes, and hypertension. Controls were matched to acute myocardial infarction patients for age, sex and socio-economic status. Commercial ELISA assay was used to measure IgG antibody to HP (positive titer > 8 IU/ml) and indirect immunofluorescence method was used to assess IgG antibody anti-CP (IgG titer > 1:64 was considered a marker of chronic infection).

RESULTS

No significant difference was observed in the frequency of HP antibodies in acute myocardial infarction patients and in the control group (43.3 vs 41.5%, p = NS, odds ratio-OR 1, 95% confidence interval-CI 0.7-1.6). On the contrary, CP titers were increased in 83% of acute myocardial infarction patients, and in 57% of control subjects (p < 0.001, OR 3.6, 95% CI 2.2-5.7). In acute myocardial infarction patients seropositivity for CP was associated with increased basal fibrinogen levels (539 vs 445 mg/dl). No correlation was found between seropositivity to CP and C-reactive protein, and with total or fractionated cholesterol and triglyceride concentrations.

CONCLUSIONS

The present data indicate that, in our sample, acute myocardial infarction was associated with an increased frequency of CP seropositivity. The presence of CP antibodies was not associated with elevated levels of C-reactive protein. Our data support the need for controlled studies to investigate the role of these infective agents as a trigger of acute coronary syndromes.

Ultrastructural changes in rat cornea after prolonged hypobaric hypoxia

A study was performed to evaluate the effect of prolonged environmental hypobaric hypoxia on the ultrastructure of rat cornea. 60-day-old female Wistar rats were exposed to a simulated altitude of 5,500 m (350 mmHg) and pO2 of 76 mmHg for 30 days. Control rats were exposed to atmospheric sea level pressure (760 mmHg) and pO2 of 150 mmHg, for the same period. Ultrastructural analysis of the corneal epithelium did not reveal any relevant difference between control and treated rats. In contrast, the corneal stroma of rats subjected to hypoxia showed vascularization with advanced vessel differentiation and signs of active proliferation. The endothelium of hypoxic cornea showed swollen mitochondria and large empty cytoplasmic areas. The endothelial intercellular junctions could hardly be identified in the hypoxic condition. Nevertheless, the most evident change in hypoxic cornea was in Descemet's membrane, which was considerably thickened, to approximately twice that of the control specimen. These results suggest that environmental hypobaric hypoxia induces marked alterations in the corneal stroma and endothelium morphology, probably related to reduced oxygen tension in the aqueous humor, consequent to hypoxemia.

Thrombolytic therapy with urokinase reduces increased circulating endothelial adhesion molecules in acute myocardial infarction

The aim was to investigate circulating E-selectin and Intercellular Adhesion Molecule-1 (ICAM-1) in acute myocardial infarction. Our study was carried out in 80 patients, 40 hospitalized for acute myocardial infarction (AMI), 20 suffering from chronic stable angina and 20 healthy control subjects. Samples of venous blood were taken from all patients at the moment of hospitalization and after 2, 4, 6, 8, 10, 12 and 24 hours from the thrombolytic treatment (AMI + urokinase) or conventional therapy (AMI + nitroglycerin), for the dosage of creatinine kinase (CK) and adhesion molecules. The CK was determined by means of a Hitachi 901 automatic analyser using an enzymatic method (reagents Boheringer-Biochemia, Germany). Soluble E-selectin (sE-selectin) and soluble ICAM-1 (sICAM-1) were measured in the serum using a specific immunoassay (British Biotechnology Products). The serum levels of Tumor Necrosis Factor (TNF-alpha) were evaluated using an immunoenzymatic assay to quantitate the serum levels of the cytokine (British Biotechnology Products). Patients with acute myocardial infarction (AMI) had increased serum levels of soluble E-selectin (sE-selectin; AMI + urokinase = 312 +/- 20 ng/ml; AMI + nitroglycerin = 334 +/- 15 ng/ml) and soluble ICAM-1 (sICAM-1; AMI + urokinase = 629 +/- 30 ng/ml; AMI + nitroglycerin = 655 +/- 25 ng/ml) compared to both patients with chronic angina (sE-selectin = 67 +/- 10 ng/ml; sICAM-1 = 230 +/- 20 ng/ml) and healthy control subjects (sE-selectin = 53 +/- 15 ng/ml; sICAM-1 200 +/- 16 ng/ml). Furthermore patients with acute myocardial infarction also had increased serum levels of Tumor Necrosis Factor (TNF-alpha = 309 +/- 10 pg/ml; control subjects = 13 +/- 5 pg/ml). Thrombolytic therapy with urokinase (1,000,000 IU as an intravenous bolus for 5 minutes, followed by an infusion of an additional 1,000,000 IU for the following two hours) succeeded in producing reperfusion and reduced the serum levels of sE-selectin (52 +/- 13 ng/ml) and sICAM-1 (202 +/- 31 ng/ml). In contrast patients not eligible for thrombolytic therapy and therefore treated with conventional therapy (a continuous i.v. infusion of nitroglycerin at the dose of 50 mg/die) did not show any significant reduction in both sE-selectin and sICAM-1 throughout the study. Our results confirm previous experimental data and indicate that adhesion mechanisms supporting leukocyte-endothelium interaction may also be operative in human acute myocardial infarction.

Early reactivation of ischaemia after abrupt discontinuation of heparin in acute myocardial infarction

Intravenous heparin after thrombolytic therapy for acute myocardial infarction is an effective, widely used treatment. Six cases of acute myocardial infarction are reported with early disease reactivation following the abrupt discontinuation of heparin infusion three days after alteplase thrombolysis and concomitant aspirin therapy. Immediate reinfusion of heparin resulted in regression of symptomatic ischaemia in all six patients. The activated partial thromboplastin time values, determined four hours before the discontinuation of heparin therapy, were within the therapeutic range in five of the six patients, and no difference was found in the values obtained one hour after the reinfusion of heparin (P = 0.065).

Myocardial bridging involving more than one site of the left anterior descending coronary artery: an uncommon cause of acute ischemic syndrome

An infrequent angiographic finding is reported of myocardial bridging involving more than one site of the left anterior descending coronary artery in a symptomatic patient with ischemia exacerbated by nitroglycerin administration. Beta-blocker therapy alone was followed by a favorable long-term outcome.

[Aortic stenosis and coronary pathology. Their implications for the transvalvular gradient]

To assess the incidence of coronary artery disease in patients with valvular aortic stenosis and its implication on peak systolic valvular gradient, 31 consecutive patients who underwent cardiac catheterization were examined. Associated significant coronary artery disease (> 50% reduction in luminal diameter evaluated in proximal segments and right dominant circulation) was present in 54.8% of patients. There was no difference in the distribution of risk factors among patients with and without significant luminal narrowings. The prevalence of coronary artery disease was found not to be significantly correlated with age (p = 0.276). There was no relationship between typical angina pectoris and the presence of coronary artery disease (p = 0.063). Fourty-seven percent of cases resulted free of chest pain. Ejection fraction was found to be significantly lower in patients with coronary artery disease (45 +/- 14.2%) than in patients without coronary artery disease (65.1 +/- 3.9%; p = 0.03) and a reverse relationship was observed between the presence of coronary artery disease and peak systolic valvular gradient (p = 0.006) which, in turn, correlated significantly with ejection fraction (r = 0.68; p = 0.023). These data demonstrate that the value of peak systolic valvular gradient, as the only index for the evaluation of the severity of aortic stenosis, is greatly limited in patients with associated coronary artery disease. Moreover, confirming the guidelines of the American College of Cardiology and of the American Heart Association task force, these data also stress the necessity of performing coronary angiography regardless angina pectoris is present or not.

[Unusual anatomic coronary variants: parallel left anterior descending artery. Description of 3 cases]

Three cases with a variation of the classic anatomic left anterior descending artery pattern, encountered unexpectedly during coronary arteriography, are reported. The importance of this unusual and rare coronary artery pattern is only anatomic, and the possibility to carry out these findings by the coronary arteriography, can increase their occurrence instead of an incidental finding.

[Inappropriate gonadotropin secretion in the polycystic ovary syndrome]

In this study was investigated the diagnostic significance of double stimulation test with (that is of 25 micrograms rapid injection intravenously twice at an interval of 120 minutes and the misure of maximal net increment of serum LH after the first GnRH injection expressed as delta 1 and after the second injection, expressed as delta 2) to discriminate patients with idiopatic hirsutism. This test was effectuated on 8 patients with PCO (presence of polycystic ovaries on Ecografya and/or Laparoscopy) and 8 patients with idiopatic hirsutism (presence of normal morphology ovaries). Basal LH, FSH, E1, E2 and delta 4 levels were also measured. The value of LH delta 2 were more elevated in patients with PCO (p less than 0,0002) than the patients with idiopatic hirsutism. Consequently it as been value of LH delta 2 to discriminate the two different groups of patients. In PCO patients were also found: -a positive linear correlation between LH delta 1 and basal concentration serum of E2 (p less than 0,001); -a significant increase of basal levels serum of delta 4 (p less than 0,02); while the values of basal LH and LH delta 1 were found superior only on 4 of the initial 8 patients, the basal values of E1 and E2 were at the superior found of the norm and basal FSH, FSH delta 1 and FSH delta 2 values were found normals.

[Respiratory and cardiac activity during sleep at high altitude (4650 m. above sea level)]

In this study, the relationship between the cardiac rhythm and ventilatory rhythm, during the sleep, at high altitude (4560 s.l.- Peruvian Andes) has been evaluated in native acclimated, and long-term resident people. The experimental observation has been performed from 11.00 p.m. to 7.00 a m. (when the barometric pressure was 430 mmHg, pO2 was 90 mmHg and paO2 was 71 mmHg) by using an eight channel polygraph for EEG, usefully modified for ECG and pneumographic recordings. In agreement with the observations of other Authors, a periodic breathing was recorded when the theta rhythm (low amplitude waves, characteristic of the second stage of the sleep) appeared in the EEG. During the REM stage of the sleep, the respiration becomes irregular, without periodicity in the ventilatory rhythm. Any statistical difference was not observed between European and Andinian subjects. During the N-REM phases of the sleep, the cardiac activity was often clearly dissociated from respiratory cycles. This finding suggests that, during the 2 and 4 phases of the sleep, in our experimental conditions, the cardio-inhibitory and cardio-acceleratory centers seem to lose the correlation with the regulatory centers of the breathing.

[Correlations between dietetic fiber and serum levels of total cholesterol and HDL-cholesterol]

We have studied 10 male subjects, in good health to look for a probable correlation between dietetic fibre and serum concentration of total cholesterol, cholesterol-HDL and triglycerides. The dosages have been made before and immediately after that the subjects had assumed, with a diet, during 13 weeks, 10 g for day of dietetic fibre. The results show a significative statistical decrease and increase. Show a significative statistical decrease (p less than 0,025) of total cholesterol and that in agreement with the literature, and an increase (p less than 0,0125) of cholesterol-HDL. Consequently it's possible to affirm that the dietetic fibre has an antiatherogenic capacity.

[Changes in hematologic parameters in 120 Somalian subjects]

We have studied in Somali subjects (120), compared with 120 Caucasus subjects the hemoglobin, the hematocrit, the number of red cells, the MCV, the MCH and MCHC. The results demonstrate that in Somali subjects have significant reduction of all parameters, and the reasons of those blood disorders in this tropical country must be associated with the scourges of poverty and malnutrition.

[Findings of the importance of dietetic fiber in the regulation of cholesterolemia]

We studied the variations of some lipid indexes in cholesterolemia, lipidemia and triglycerides in relation to a diet rich in bulk. Seven adult male subjects in good health were tested for cholesterol, lipid and triglycerides before and after a two week period of a dialy diet of 40 g of whole wheat bran containing about 10g of fiber. At the some time the lipid, cholesterol and triglycerides limits were measured in 3 groups of rabbits. The first groups was subjected to a normal diet, the second group was subjected to a diet of bleached flour and vitamins, and the third group had a diet similar to the second group but with the addition of 40 g whole wheat bran. The results of our investigation demonstrated a statistically significant decrease of cholesterol lipid and triglycerides levels the special diets at the some time we did not see in increase in the third group of rabbit. Our study seems to indicate that dietetic fibers exercise a vital role in regulating the concentration of plasma lipids even if the subject continues to consume a diet rich in fats. From this we see to importance of the dietetic fibers as a protective factor in the prevention of ateriosclerotic.

[Evaluation of various hematologic parameters in Andean miners (Morococha-Peru 4560 m)]

In other Author's previous studies refer that prolonged CO exposure, as chronic altitude exposure, causes marked increases in Hb and Htc levels. We had intended to study these hematologic changes on three non-smokers' group : Miners of the Andes working at CO exposure ambients, Residents and European Subjects living a. s. l. and exposed at 4560 m. Statistical analysis, according with literature, has shown significant difference in the three groups' Hb and Htc ratio, in comparison with sea level control values. We had moreover observed that HbCO of the Miners' group reached, sometimes, 8, 2% values. It does not seem, however, that the higher HbCO levels noted in the Miners' group are sufficiently elevated for producing a further increase in Hb and Htc ratio compared to the other two control group.

Effects of papaveroline-monosulphate on the systemic and regional circulation in the dog

The effects of papaveroline 6'-sulphonic of N-methylglucamine (UTEN), administered by intravenous injection in doses ranging from 10 to 20 mg/kg, on cardiac dynamics and peripheral blood flow distribution were studied in conscious and anesthetized dogs, using electromagnetic flowmeters implanted around the ascending aorta, pulmonary artery, left coronary artery, superior mesenteric artery, and renal and external iliac arteries. In the conscious dogs, blood pressure after the injection of the drug showed an initial fall and returned to normal control values after a transitory increase. The changes in aortic pressure were accompanied by an increase in heart rate, cardiac output, stroke volume and cardiac work. The administration of UTEN was also associated with an increase in the peripheral blood flow and a decrease in their calculated resistances and in total peripheral resistances. Similar variations were observed in the anesthetized dogs. The effects of UTEN were compared with those of other vasodilator drugs (papaverine, isoxsuprine and D.E.D.). From the results obtained it is possible to conclude that UTEN produces a vasodilation in all investigated vessels, whereas other vasodilator agents only act in some particular vascular beds; moreover, the effect of UTEN is longer-lasting. There is also a probable constriction in the capacitance vessels, as shown by haemodynamic changes in the pulmonary circulation.

[Blood sugar and the hematocrit: relation to acclimatization at 4560 m. altitude]

We had intended to study the relation between glycemia and hematocrit during high altitude acclimatization (Morococha, Peru-4560 m) and to observe if, subsequently to an increase of hematocrit, glycemia should become lower. From obtained results upon 176 hematologic observations of glycemia, hematocrit, hemoglobin and erythrocyte production, on 38 healthy European subjects (27-58 years aged), it doesn't result, from the first analysis, the existence of this relation. We reserve ourselves, in any case, to accomplish further tests, such as insulinemic dosage for evaluating pancreatic activity.

[Hemodynamic modifications induced by volatile anesthetics halothane, penthrane, ethrane) I. Cardiovascular effects]

We had intended to reckon quantitatively the effects of volatile anaesthetics(Halothane, Ethrane, methoxyflurane or Penthrane) upon cardiovascular system of healthy young mongrel dogs, 5-8 days interval each other. After administration of a Halothane and Penthrane, heart rate(HR) increases of about 30%; blood pressure(BP) is decreasing of same percentage. Halothane causes a slight increase upon pulmonary arterial pressure(PAP), while pulmonary arterial flow(PAF) reaches 40% more than control values. Penthrane decreases of 30% PAP and of about 40% PAF. Ethranic anaesthesia produces a slight fall on HR and BP, while PAP doesn't result significatively modified; a marked decrease(40%) is observed on PAF. Aortic flow(AF) is diminished(from 20 to 30%) by administration of these anaesthetics.

IN CONCLUSION

Halothane causes very significative modifications on circulation, less modifications are produced by Penthrane, while Ethrane doesn't produce any changes.

[Hemodynamic modifications induced by volatile anesthetics halothane, penthrane, ethrane). II. Effect on myocardial contraction and myocardial response to hypoxia]

We had intended to reckon quantitatively the effects of volatile anaesthetics about myocardial contractility and coronary circulation, on rest and after total occlusion of the left circumflex coronary artery for 15 sec on young healthy mongrel dogs. Halothane decreases coronary flow of about 20% while Penthrane increase coronary flow (CF) of 30% after 20 sec and later it stabilizes to 10% higher than the control values. Ethrane causes a light initial decrease and later CF returns to control values. During occlusion, derivative of left ventricular pressure (LVP) is reduced from Halothane, which also causes a marked decrement of hyperemia. By means of penthranic anaesthesia, during occlusive phase, we observed a shortening in contraction and relaxation speed. Ethrane doesn't modify the hyperemic coronary flow nor cardiodynamic parameters during occlusive period, while the latter parameters are sensibly varying during restore.