Care through cohort studies: sociological survey of the PROOF cohort study on vascular and cognitive aging

BACKGROUND

The success of health research depends on the involvement of participants. Few studies have examined the participation of subjects in cohorts. Drawing on a sociological survey on a French cohort around aging, this study proposes to question the nature of interactions between researchers and subjects that would help to understand the motivations of subjects to participate and remain in health research studies.

METHODS

Qualitative study combining participant observation within the research laboratory that conducted the cohort and semi-structured interviews with subjects included in the cohort and with members of the research team.

RESULTS

This study highlights the existence of two-way care: from the laboratory to the subjects and from the cohort to researchers. Health research seems to correspond to a complex association between subjects concerned with aging and the expected benefits of exceptional monitoring. Research is incorporated into subjects' daily lives, allowing a shift in the purpose of research from overmedicalization to medical safety that subjects experienced as a form of care.

CONCLUSIONS

In cohort studies, care is understood as a form of attention to the person through high-quality medical follow-up. Aging is turned into a matter of concern that subjects, in collaboration with researchers, strive to control.

Structural skin changes in elderly people investigated by reflectance confocal microscopy

BACKGROUND

Reflectance confocal microscopy (RCM) is particularly suitable for the study of skin ageing because it provides nearly histological information in vivo and non-invasively. However, there are no studies that evaluated RCM skin features of a large population older than 70 years.

OBJECTIVES

The aim of our investigation was to study age-related skin changes in an elderly population by RCM and to evaluate their topographical and gender differences.

METHODS

We obtained RCM images of photoprotected (volar arm) and chronic (face) and intermittently photoexposed (dorsal forearm) body sites of 209 volunteers (105 women and 104 men, mean age: 77.5, range 74-81 years). 15 previously reported and new RCM parameters related to skin ageing were assessed.

RESULTS

Photoexposed sites had thicker suprapapillary epidermis, more linear, distant and thin furrows, higher presence of mottled pigmentation, polycyclic papillae and coarse and huddled collagen and lower presence of dermal papillae than the photoprotected site. Irregular honeycomb pattern was not higher in photoexposed sites, indicating that it is probably more dependent on intrinsic ageing. Two ageing scores defined for facial skin ageing (epidermal disarray score and epidermal hyperplasia score) were found useful for the identification of photoageing. Gender differences only concerned some RCM parameters (i.e. thickness of different layers of the epidermis, furrows and collagen score) and some body sites, in line with the fact that women and men of our cohort had no major differences in clinically visible skin ageing.

CONCLUSIONS

Our study confirmed that RCM is a powerful non-invasive technique to microscopically quantify ageing signs and our observations contribute to highlight the differences between intrinsic and extrinsic ageing.

Long-lasting active lifestyle and successful cognitive aging in a healthy elderly population: The PROOF cohort

OBJECTIVES

The aim of this study was to determine whether cognitive reserve in the elderly affects the evolution of cognitive performance and what its relationship is with active lifestyles in later life.

METHODS

Cognitive performance was evaluated at baseline and 8 years later in 543 participants of the PROOF cohort, initially aged 67 years. Subjects were categorized as Cognitively Elite (CE), Cognitively Normal (CN) or Cognitively Impaired (CI) at each evaluation. At follow-up, demographic data and lifestyle, including social, intellectual and physical behaviors, were collected by questionnaires.

RESULTS

As much as 69% (n=375) remained unchanged, while 25.5% (n=138) decreased and 5.5% (n=30) improved. When present, the reduction in cognitive status was most often limited to one level, but was dependent on the initial level, affecting up to 73% of the initially CN, but only 58% of the initially CE. Cognitive stability was significantly associated with the degree of social engagement at follow-up (CE: P=0.009; CN: P=0.025).

CONCLUSION

In the healthy elderly, high cognitive ability predicts both cognitive ability and social involvement in later life. Cognitive decline by only one level may also extend the time to reach impairment, underlining the importance of the so-called cognitive reserve.

Sex differences in obstructive sleep apnoea in an elderly French population

Obstructive sleep apnoea (OSA) affects females and males differently, and increases in prevalence with age. The aim of the present study was to characterise clinical, anthropometric and polygraphic sex differences in a large elderly OSA population. A total of 641 subjects aged 68 yrs were examined. Measurements of fat mass, using dual-energy X-ray absorptiometry (DEXA) and polygraphy, were obtained in all subjects. An apnoea/hypopnoea index (AHI) of >15 events·h⁻¹ identified the presence of OSA. OSA was diagnosed in 57% of the sample, 34% having a mild form and 23% having an AHI of >30 events·h⁻¹. Females with OSA exhibited a lower AHI, less severe hypoxaemia and greater peripheral fat mass, and frequently reported anxiety and depression. Comparison of females with and without OSA did not reveal significant differences in clinical, anthropometric and DEXA data. After adjustment for body mass index, hypertension, diabetes, smoking, anxiety and depression, logistic regression analysis revealed that the presence of hypertension was significantly associated with OSA risk in females (OR 1.52, p = 0.04). In a general community healthy population, the prevalence of undiagnosed OSA in females increases with age, with a risk similar to that in males. In females, the clinical spectrum, anthropometric data and fat distribution appear to be more sex-related than OSA-dependent. The occurrence of OSA contributes to hypertensive risk in elderly females.

Is tidal expiratory flow limitation predictive of sleep-related disorders in the elderly?

Sleep-related disorders represent an important health burden and their prevalence increases with age. In patients with snoring or sleepiness, the presence of expiratory flow limitation (EFL), determined via the negative expiratory pressure (NEP) method, is related to the apnoea/hypopnoea index (AHI). In this study, we examined whether EFL can be used to predict obstructive sleep apnoea syndrome (OSAS) in healthy asymptomatic older subjects. A group of 72-yr-old subjects (n = 448, 44% males) with a mean body mass index of 25.5±3.8 kg·m(-2) were examined. All subjects underwent spirometry, NEP (-5 cmH(2)O, sitting position) and ventilatory polygraphy (VP). Spirometry was within normal values in 88% of the group and EFL was present in 143 (32%) subjects with a higher prevalence in females (89 out of 249 versus 54 out of 199 in females and males, respectively). VP showed an AHI<15 h(-1) in 238 subjects (53%) and OSAS with an AHI ≥15 h(-1) in 47%. EFL was found in 15% of subjects with OSAS. Consequently, EFL had low sensitivity and specificity in the prediction of OSAS (31.4% and 67.7%, respectively). We conclude that the prevalence of EFL is elevated in healthy older subjects and cannot be used to predict the presence of sleep-related disorders in an older population.

Association between C-reactive protein and unrecognised sleep-disordered breathing in the elderly

Elevated levels of C-reactive protein (CRP) have been reported in patients with sleep-disordered breathing (SDB) and may represent an inflammatory marker of cardiovascular risk. However, the association of CRP with SBD in presumed healthy elderly subjects is unknown. In total, 851 (58.5% females) 68-yr-old subjects, who were free of any known cardiac or sleep disorders, were prospectively examined. Subjects underwent unattended polygraphy, and the apnoea/hypopnoea index (AHI) and oxyhaemoglobin desaturation index (ODI) were assessed. Elevated levels of CRP were found on the morning after the sleep study in patients with more severe SDB. A significant correlation was found between CRP levels, time spent at night with arterial oxygen saturation <90% and ODI. No association was found between CRP levels and AHI. After adjustments for body mass index, smoking status, hypertension, diabetes and dyslipidaemia, a significant association remained between CRP levels and ODI >10 events.h(-1). CRP levels were frequently increased in a large sample of elderly subjects free of major cardiovascular disease. CRP levels were not correlated with the AHI and the indices of sleep fragmentation; the ODI >10 events.h(-1) was the strongest predictor of raised CRP level. The present results suggest that, in the elderly, intermittent hypoxaemia may underlie inflammatory processes leading to cardiovascular morbidity.

Microdialysis of insulin-like growth factor-I in human muscle

The determination of the insulin like growth factor I (IGF-I) concentration in the interstitial milieu is of outstanding importance to explore its autocrine/paracrine function. We previously reported a method to calibrate microdialysis probes for lactate and glucose (slope method). In the present study, we investigated the ability of our method to determine the concentration of larger molecules, such as IGF-I. We observed in vitro a close linear relationship (r = 0.86, P < 0.0005) between the recoveries of lactate (RecLac) and of IGF-I (RecIGF-I), giving access to the measurement of IGF-I with the same accuracy as the one previously found for lactate and glucose. In seven human volunteers, we calibrated each probe with the slope method: we first determined in vivo for every probe the specific RecLac/loss ethanol relationship and thereafter, using that relationship, we deduced RecLac from the loss ethanol value measured in every dialysate. This allowed calculation of RecIGF-I from the calculated RecLac value and the in vitro RecLac/RecIGF-I relationship, and finally free IGF-I concentration in muscle interstitial fluid. The mean free IGF-I interstitial concentration was 6.8 +/- 3.2 ng/ml while the mean plasma concentration was 0.4 +/- 0.2 ng/ml. This large gradient from interstitium to plasma for free IGF-I could be related to the local action of this growth factor.

Validation of a new calibration method for human muscle microdialysis at rest and during exercise

Microdialysis presents the unique possibility to measure metabolite concentrations in human interstitial fluid. During exercise, the recovery of these metabolites should be precisely monitored since it is known to increase greatly with muscle blood flow. The loss of ethanol, perfused at low concentration, can be accurately measured and reflects the changes in dialysis conditions. We evaluated whether using the relationship determined in resting metabolic conditions between the loss of ethanol, as reference substance, and the recovery for lactate or glucose would allow us to calculate precisely the concentration of these substances and their variations during exercise. Using the new catheter calibration method (slope method), the error of estimation of lactate and glucose in vitro was limited to -0.6 (5.8)% and -0.7 (6.2)%, respectively. In resting human muscle, the slope method proved to be as accurate as an established calibration technique ("no net flux method") to evaluate interstitial lactate concentration [1.82 (0.58) vs 1.83 (0.47) mM, respectively]. During dynamic knee-extension exercise or light neuromuscular electrical stimulation, the estimated interstitial lactate and glucose concentrations varied differently, but their time course changes remained consistent with their respective plasma values. We conclude that, after an initial calibration step, the slope method allows accurate measurement of interstitial muscle metabolites and it could be used to monitor rapid metabolic changes during exercise.

Predicting sleep apnoea syndrome from heart period: a time-frequency wavelet analysis

Heart rate fluctuations are a typical finding during obstructive sleep apnoea, characterised by bradycardia during the apnoeic phase and tachycardia at the restoration of ventilation. In this study, a time-frequency domain analysis of the nocturnal heart rate variability (HRV) was evaluated as the single diagnostic marker for obstructive sleep apnoea syndrome (OSAS). The predictive accuracy of time-frequency HRV variables (wavelet (Wv) decomposition parameters from level 2 (Wv2) to level 256 (Wv256)) obtained from nocturnal electrocardiogram Holter monitoring were analysed in 147 consecutive patients aged 53.8+/-11.2 yrs referred for possible OSAS. OSAS was diagnosed in 66 patients (44.9%) according to an apnoea/hypopnoea index > or = 10. Using receiver-operating characteristic curves analysis, the most powerful predictor variable was Wv32 (W 0.758, p<0.0001), followed by Wv16 (W 0.729, p<0.0001) and Wv64 (W 0.700, p<0.0001). Classification and Regression Trees methodology generated a decision tree for OSAS prediction including all levels of Wv coefficients, from Wv2 to Wv256 with a sensitivity reaching 92.4% and a specificity of 90.1% (percentage of agreement 91.2%) with this nonparametric analysis. Time-frequency parameters calculated using wavelet transform and extracted from the nocturnal heart period analysis appeared as powerful tools for obstructive sleep apnoea syndrome diagnosis.

Wavelet transform of heart rate variability to assess autonomic nervous system activity does not predict arousal from general anesthesia

PURPOSE

The relationship between autonomic nervous system (ANS) activity and general anesthesia has been explored. Studies have demonstrated partial recovery of heart rate variability (HRV), representative of ANS activity, in the postoperative period, but the arousal period has not been precisely studied. The goals of this study were to analyze modifications of ANS activity during general anesthesia and, more particularly, around the arousal period, to look for predictors of arousal.

METHODS

We analyzed HRV changes using wavelet transform, a time-frequency analysis that, in contrast to Fourier transform, is able to assess abrupt changes of ANS activity. Seventeen patients (mean +/- SD age: 40.9 +/- 16.4 yr) under general anesthesia for hip or knee surgery, were included in the study. The analysis began one hour before anesthesia, focussed on eye opening, and ended three hours after arousal.

RESULTS

There was a dramatic decrease in HRV after induction, that extended throughout anesthesia and represented a decrease in global autonomic regulation with, however, a relative predominance of vagal tone. At the moment of eye opening, there was an abrupt change in HRV, representing a sudden shift of ANS balance towards the predominance of sympathetic activity, while none of these indices changed seconds before arousal.

CONCLUSIONS

Wavelet analysis of HRV appears to be powerful tool to precisely assess instantaneous changes of HRV during anesthesia. Using this method, there were no identifiable precursory HRV indices of arousal.

Influence of training on NIRS muscle oxygen saturation during submaximal exercise

PURPOSE

Endurance training improves the oxygen delivery and muscle metabolism. Muscle oxygen saturation measured by near infrared spectroscopy (IR-SO(2)), which is primarily influenced by the local delivery/demand balance, should thus be modified by training. We examined this effect by determining the influence of change in blood lactate and muscle capillary density with training on IR-SO(2) in seven healthy young subjects.

METHODS

Two submaximal exercise tests at 50% (Ex1) and 80% pretraining VO(2max) (Ex2) were performed before and after a 4-wk endurance-training program.

RESULTS

VO(2max) increased only slightly (+8%, NS) with training but the training effect was confirmed by the increased capillary density (+31%, P < 0.01) and citrate synthase activity (50%, P < 0.01), determined from muscle biopsy samples. Before training, blood lactate increased during the first 5 min of Ex1 and then remained constant (3.8 +/- 0.5 mmol x L(-1), P < 0.01), whereas it increased continuously during Ex2 (8.9 +/- 1.8 mmol x L(-1), P < 0.001). After training, lactate decreased significantly and remained constant during the two bouts of exercise (2.0 +/- 0.4 and 3.7 +/- 1.2 at the end of Ex1 and Ex2, respectively, both P < 0.001). During Ex1, IR-SO(2) dropped initially at the onset of exercise and recovered progressively without reaching the resting level. Training did not change this pattern of IR-SO(2). During Ex2, IR-SO(2) decreased progressively during the 15 min of exercise (P < 0.05); IR-SO2 kept constant after the initial drop after training. We found a significant relationship (r = 0.42, P = 0.03) between blood lactate and IR-SO(2) at the end of both bouts of exercise; this relationship was closer before training. By contrast, IR-SO(2) or IR-BV was not related to the capillary density.

CONCLUSION

The training-induced adaptation in blood lactate influences IR-SO(2) during mild- to hard-intensity exercise. Thus, NIRS could be used as a noninvasive monitoring of training-induced adaptations.

Chronotropic incompetence response to exercise in congestive heart failure, relationship with the cardiac autonomic status

In chronic congestive heart failure (CHF), attenuated heart rate response to exercise, a manifestation of chronotropic incompetence (CI), contributes to limiting exercise capacity. The present study was thus conducted to evaluate the respective role of chronic attenuation of cardiac vagal tone associated with depressed baroreflex sensitivity or affected cardiac sympathetic responsiveness in CHF patients with CI. Spontaneous cardiac baroreflex sensitivity (BRS) assessed by sequence method and spectral- and time-domain analysis of heart rate variability (HRV) were analysed in 21 chronic CHF patients. All patients performed a symptom-limited exercise test with measurement of gas exchange. Chronic incompetence which was defined as failure to achieve > or =80% of the heart rate reserve (%HRR) given by (HRpeak - HRrest)/(predictive maximal heart rate - HRrest) was observed in 14 (66%) patients. There was no significant difference in age, heart rate, peak oxygen uptake or left ventricular ejection fraction between the patients with and without CI. Although there was no significant difference in BRS, low frequency power of HRV in normalized units (LFnu) and SDNN were significantly lower in CI patients. Percentage of HRR correlated significantly with LFnu on 15 min (r=0.64, P<0.005) and, with LFnu on 24 h (r=0.52, P<0.01), SDNN (r=0.48, P=0.03) and SDANN (r=0.48, P=0.03), but not BRS (r=0.04, P=NS). Autonomic nervous system derangement is a complex process in CHF. The role of basal depressed cardiac sympathetic tone seems to contribute more closely than depressed baroreflex sensitivity to the impaired heart rate response to exercise frequently observed in CHF patients.

A practical method to statistically classify devices according to their relative accuracy

Mathematical methods to statistically compare the relative accuracy of physiological monitoring devices to reference measurements are scarce. We developed such a method to compare any number of devices to each other as well as to reference values. This new statistical comparative procedure uses a combination of different known mathematical processes. The method allows the separation of the error of the devices into two components, the first, being systematic, can be easily amended, while the second, inherent to the technical limitations of the measuring device as well as to the physical properties of the explored phenomenon, cannot be corrected and will thus be used as the comparative criterion for statistics. That method, which is easy to implement should ease comparisons of the accuracy of any number of devices as well as comparison of other sets of physiological values, by giving an easy access to statistical results.

Relation between heart rate variability and training load in middle-distance runners

PURPOSE

Monitoring physical performance is of major importance in competitive sports. Indices commonly used, like resting heart rate, VO2max, and hormones, cannot be easily used because of difficulties in routine use, of variations too small to be reliable, or of technical challenges in acquiring the data.

METHODS

We chose to assess autonomic nervous system activity using heart rate variability in seven middle-distance runners, aged 24.6 +/- 4.8 yr, during their usual training cycle composed of 3 wk of heavy training periods, followed by a relative resting week. The electrocardiogram was recorded overnight twice a week and temporal and frequency indices of heart rate variability, using Fourier and Wavelet transforms, were calculated. Daily training loads and fatigue sensations were estimated with a questionnaire. Similar recordings were performed in a sedentary control group.

RESULTS

The results demonstrated a significant and progressive decrease in parasympathetic indices of up to -41% (P < 0.05) during the 3 wk of heavy training, followed by a significant increase during the relative resting week of up to +46% (P < 0.05). The indices of sympathetic activity followed the opposite trend, first up to +31% and then -24% (P < 0.05), respectively. The percentage increasing mean nocturnal heart rate variation remained below 12% (P < 0.05). There was no significant variation in the control group.

CONCLUSION

This study confirmed that heavy training shifted the cardiac autonomic balance toward a predominance of the sympathetic over the parasympathetic drive. When recorded during the night, heart rate variability appeared to be a better tool than resting heart rate to evaluate cumulated physical fatigue, as it magnified the induced changes in autonomic nervous system activity. These results could be of interest for optimizing individual training profiles.

Screening of obstructive sleep apnea syndrome by heart rate variability analysis

BACKGROUND

Enhanced nocturnal heart rate variability (HRV) has been evoked in sleep-related breathing disorders. However, its capacity to detect obstructive sleep apnea syndrome (OSAS) has not been systematically determined. Thus, we evaluated the discriminant power of HRV parameters in a first group of patients (G1) and validated their discriminant capacity in a second group (G2).

METHODS AND RESULTS

In G1, 39 of 91 patients (42.8%) were identified as diseased by polysomnography, as were 24 of 52 patients (46%) in G2. Time-domain HRV variables (SD of NN intervals [SDNN], mean of the standard deviations of all NN intervals for all consecutive 5-minute segments of the recording [SDNN index], square root of the mean of the sum of the squares of differences between adjacent normal RR intervals [r-MSSD], and SD of the averages of NN intervals in all 5-minute segments of the recording [SDANN]) were calculated for daytime and nighttime periods, as well as the differences between daytime and nighttime values (Delta[D/N]). Correlations between HRV variables and OSAS status were analyzed in G1 by use of receiver-operating characteristic (ROC) curves and logistic regression analysis. By ROC curve analysis, 7 variables were significantly associated with OSAS. After adjustment for other variables through multiple logistic regression analysis, Delta[D/N]SDNN index and Delta[D/N] r-MSSD remained significant independent predictors of OSAS, with ORs of 8.22 (95% CI, 3.16 to 21.4) and 2.86 (95% CI, 1.21 to 6.75), respectively. The classification and regression tree methodology demonstrated a sensitivity reaching 89.7% (95% CI, 73.7 to 97.7) with Delta[D/N] SDNN index and a specificity of 98.1% (95% CI, 86.4 to 100) with Delta[D/N] SDNN using appropriate thresholds. These thresholds, applied to G2, yielded a sensitivity of 83% using Delta[D/N] SDNN index and a specificity of 96.5% using Delta[D/N] SDNN.

CONCLUSIONS

Time-domain HRV analysis may represent an accurate and inexpensive screening tool in clinically suspected OSAS patients and may help focus resources on those at the highest risk.

Age-associated alteration of muscle oxygenation measured by near infrared spectroscopy during exercise

The influence of ageing on the capacity to increase muscle oxygen delivery during exercise is unclear. This was investigated by comparing the evolution of Near InfraRed Spectroscopy (NIRS) in 10 old (67 +/- 5 years, Old group) and 13 young subjects (27 +/- 4 years, Young group), during a progressive maximal exercise. The NIRS probe was placed on the vastus lateralis; muscle oxygen saturation - IR-SmO(2) - values were expressed on a scale using an arterial occlusion as the lower reference point and the subsequent reactive hyperaemia as the upper reference point. Resting IR-SmO( 2) was found to be significantly lower in the Old as co mpared to the Young group. During exercise, VO(2) increased similarly as a function of the workload whereas IR-SmO(2) decreased faster in old subjects than in young ones. Conversely, when expressed at the same percentage of VO( 2max), IR-SmO(2) followed a similar evolution in both groups from rest to maximal exercise (27.3 +/- 16.7 vs 24.3 +/- 12.9% decrease, in Old and Young group, respectively, NS). Thus, the initial difference remained constant between the two groups. During recovery, the time to recover the signal variation was not different between the two groups. We concluded that Old subjects demonstrate a systematic lower muscle oxygen saturation than Young ones. This difference could be explained by an age related decrease in muscle blood flow limiting O(2) supply.

Reduced cardiac sympathetic autonomic tone after long-term nasal continuous positive airway pressure in obstructive sleep apnoea syndrome

The increased sympathetic activation that occurs in obstructive sleep apnoea (OSA) may play an important role in associated morbidity. We investigated the effect of long-term (3 month) nasal continuous positive airway pressure (CPAP) on the autonomic nervous system assessed by heart rate variability (HRV). Fourteen patients (12 men), mean age 61.4 +/- 8.1 years, with OSA underwent continuous synchronized electrocardiographic and polysomnographic monitoring. The apnoea/hypopnoea index (AHI) decreased from 50.6 +/- 13.7 to 2.2 +/- 2.5 events h-1 after CPAP. HRV analysis showed significant decreases in low frequency (LF; from 7.12 +/- 1.06 to 6.22 +/- 1.18 ln ms2 Hz-1; P < 0.001), high frequency (HF; from 5.91 +/- 0.87 to 5.62 +/- 0.92 ln ms2 Hz-1; P < 0.05) and LF/HF (from 1.21 +/- 0.12 to 1.11 +/- 0.15 ln ms2 Hz-1; P < 0.001) when the patients were asleep. The decrease in LF/HF was prolonged into the daytime (from 1.33 +/- 0.22 to 1.24 +/- 0.21 ln ms2 Hz-1; P < 0.001). Treatment of OSA by CPAP significantly reduced the parameters of cardiac sympathetic tone, a favourable effect.

Wavelet transform to quantify heart rate variability and to assess its instantaneous changes

Heart rate variability is a recognized parameter for assessing autonomous nervous system activity. Fourier transform, the most commonly used method to analyze variability, does not offer an easy assessment of its dynamics because of limitations inherent in its stationary hypothesis. Conversely, wavelet transform allows analysis of nonstationary signals. We compared the respective yields of Fourier and wavelet transforms in analyzing heart rate variability during dynamic changes in autonomous nervous system balance induced by atropine and propranolol. Fourier and wavelet transforms were applied to sequences of heart rate intervals in six subjects receiving increasing doses of atropine and propranolol. At the lowest doses of atropine administered, heart rate variability increased, followed by a progressive decrease with higher doses. With the first dose of propranolol, there was a significant increase in heart rate variability, which progressively disappeared after the last dose. Wavelet transform gave significantly better quantitative analysis of heart rate variability than did Fourier transform during autonomous nervous system adaptations induced by both agents and provided novel temporally localized information.

Accuracy of an automatic and patient-triggered long-term solid memory ambulatory cardiac event recorder

This study evaluated the R-Test Evolution, a new type of cardiac event recorder bearing both patient-triggered and automatic capabilities. Its 7-day automatic arrhythmia analysis showed promising clinical advantages, especially when investigating patients with unexplained rare events such as syncope, feeling of weakness or faintness, palpitations, stroke, or in patients inconsistent in their use of patient-triggered recordings.

Accuracy of pulse oximetry during intense exercise under severe hypoxic conditions

There is a growing need to measure arterial oxygen saturation with a non-invasive method during heavy exercise under severe hypoxic conditions. Although the accuracy of pulse oximetry has been challenged by several authors, it has not been done under extreme conditions. The purpose of this study was to evaluate the accuracy of a pulse oximeter (Satllite. Datex, Finland) during exercise under hypoxic conditions where arterial oxygen saturation was below 75%, simulating exercise at extreme altitude. Ten healthy non-smoking men performed two exercise studies of 30 min under normoxia and under hypoxia on two consecutive days. The exercise intensity was 80% of maximal O2 consumption of VO2max. Arterial oxygen saturation measured by pulse oximetry was corrected (SpO2[corr]) according to previously published equations and was compared to arterial oxygen saturation (SaO2) in blood samples taken simultaneously from the radial artery. Reference arterial saturation values ranged from 57.2 to 97.6% for the whole data set. This data set was split according to low (SaO2 < or = 75%) and high (SaO2 > 75%) SaO2 values. The error of pulse oximetry (SpO2[corr]-SaO2) was 2.05 (0.87)% [mean (SD)] and 1.80 (1.81)% for high and low SaO2 values, respectively. SpO2[corr] and SaO2 were highly correlated (r = 0.93, SEE = 1.81) for low values. During high-intensity constant workload under severe hypoxic conditions, once corrected, pulse oximetry provides an estimate of SaO2 with a mean error of 2%. Thus, the correction previously described for SpO2 values above 75% saturation applies also to SpO2 values in the range of 57-75% during exercise under hypoxic conditions.

Comparison of muscle near-infrared spectroscopy and femoral blood gases during steady-state exercise in humans

Near-infrared spectroscopy (NIRS) is a noninvasive way of measuring muscular oxygenation. We evaluated the relationship between NIRS signal [infrared muscle oxygen saturation (IR-SO2mus)] and the femoral venous oxygen saturation (SfvO2) during cycling exercise. Six healthy subjects performed a 30-min steady-state exercise at 80% maximal oxygen uptake in normoxia and hypoxia (inspired O2 fraction = 0.105). IR-So2mus was recorded continuously throughout the tests with the NIRS probe located on the vastus lateralis. During exercise, blood samples were withdrawn every 5 min from radial artery and femoral vein catheters. In normoxia, IR-So2mus initiated a transient nonsignificant decrease at 5 min, then returned to preexercise level, whereas SfvO2 showed a fast decrease, reaching 18% saturation at 10 min without further change. By contrast, in hypoxia, IR-SO2mus and SfvO2 demonstrated a parallel decrease then stabilized at 10 min. We conclude that IR-SO2mus appears to parallel SfvO2 when both the arterial and venous oxygen contents decrease during steady-state exercise in hypoxia, whereas IR-SO2mus does not follow SfvO2 change in normoxia.

Maximal blood lactate level acts as a major discriminant variable in exercise testing for coronary artery disease detection in men

BACKGROUND

The interpretation of exercise stress testing for coronary artery disease detection is affected by the many differences in chosen variables and mathematical methods. We conducted a prospective trial to evaluate a global muscle fatigue parameter--the blood lactate level achieved at maximal exercise--as a method of distinguishing between diseased and nondiseased coronary status.

METHODS AND RESULTS

We evaluated 236 consecutive male patients without previous myocardial infarction who had been referred for the diagnosis of coronary artery disease. None of the patients had cardiomyopathy, severe cardiac heart failure, or valvular heart disease. Blood lactate concentration at maximal exercise was measured as well as other classic variables. Correlations between variables and coronary status as assessed by coronary arteriography were described using receiver operating characteristic (ROC) curves and logistic regression analysis. The first four most powerful variables (lactate level, maximal power output, exercise duration, and percentage of maximal predicted heart rate), which are directly representative of the global functional capacity, showed values of 0.777, 0.775, 0.760, and 0.740, respectively, by ROC curve analysis. Mean +/- SD blood lactate level at peak exercise reached 7.68 +/- 2.70 mmol/L in the 153 diseased and 10.56 +/- 2.75 mmol/L in the 83 nondiseased patients (P < .0001). After adjustment for other variables, blood lactate level remained a significant predictor of coronary artery disease by logistic regression analysis (adjusted odds ratio, 1.2; confidence interval, 1.04 to 1.4).

CONCLUSIONS

Global muscle fatigue as assessed by lactate levels in the blood at maximal exercise appears to be a powerful distinguisher of diseased and nondiseased coronary status.

Effects of exposure to hypoxia on the signal-averaged electrocardiogram in healthy subjects

The effects of hypoxia on the signal-averaged ECG (SAECG) were investigated in 26 healthy active subjects with no suggestion of cardiac disease. The SAECG was recorded in each resting subject in normoxic and hypoxic normobaric conditions (inspired O2 fraction 20.7 vs 10.0%) which lowered resting arterial O2 saturation from 98.6 +/- 0.6% to 77.7 +/- 8%. Recordings from four subjects (three men) met the definition of abnormal late potentials at baseline; in all these subjects but one, who exhibited an improved but still abnormal QRS duration, these parameters returned to normal in hypoxic conditions. The duration of the filtered QRS was significantly reduced (from 107.6 +/- 13.2 to 101.6 +/- 11.3 ms, P < 0.01), the duration of the low amplitude signals in the terminal portion of the QRS < 40 microV (LAS) significantly decreased (from 26.5 +/- 9.5 to 22.7 +/- 7.9 ms, P < 0.05) and the root mean square voltage in the last 40 ms (Term-RMS) increased non-significantly (from 55.8 +/- 40.2 to 69.1 +/- 38.3 microV, P = 0.058). Hypoxia determined a higher (P < 0.05) heart rate increase in subjects with abnormal records than in normal subjects. These data could be related to a sympathic discharge. They suggest that: (1) variation in heart rate could affect the SAECG; (2) exposure to hypoxia improves SAECG parameters in healthy subjects, possibly related to sympathetic discharge; (3) abnormal records collected during sinus bradycardia could represent a type of false-positive expression of late potentials in young active adults.

Energetic status and mitochondrial oxidative capacity of rat skeletal muscle in response to creatine analogue ingestion

A creatine analogue, beta-guanidinopropionic acid (beta-GPA), was administered in the food (1% w/w) of 8 male rats for 6 weeks, while 8 control rats received a standard diet. Mitochondrial oxidative capacity and cytosolic modulators of mitochondrial oxidative phosphorylation (free ADP, ATP-to-free ADP ratio) were evaluated in the soleus and extensor digitorum longus (EDL) muscles. Mitochondrial adaptation to the diet was significantly different between muscles. Citrate synthase activity and mitochondrial ATP synthesis rate were 35 and 45% higher in EDL muscle, respectively, whereas they were virtually unchanged in the soleus muscle. In both muscles, 3-hydroxyacyl-CoA dehydrogenase activity remained unaffected. Regardless of muscle type, creatine, phosphocreatine and ATP concentrations, as well as the total adenine nucleotide content (ATP + ADP + AMP), were significantly lower in beta-GPA fed rats. Whereas free ADP concentration remained unchanged, a significantly greater decrease in ATP-to-free ADP ratio was observed in EDL than in the soleus muscle. It is suggested that regulation of mitochondrial oxidative phosphorylation, through changes in metabolite concentrations, could be an important factor to consider for mitochondrial adaptation induced by beta-GPA feeding.

Elevated nocturnal blood pressure assessed by ambulatory automatic monitoring during a stay at high altitude

The aim of this study was to explore, in healthy children, the arterial blood pressure response to a 3-week stay at high altitude (4200 m). An auscultatory automatic ambulatory pressuremeter was used to avoid undue environmental influence on the measurement. The blood pressure was monitored three times in a group of ten boys, aged 10.5 (CI 0.9 years): at sea level (control values), at an altitude of 2100 m after at least 24 h of acclimatization and after at least 24 h at 4200 m altitude. Each period of monitoring extended over 24 h with 10-min intervals between successive measurements. Arterial blood pressure was evaluated separately for the night and day periods. Nocturnal recordings revealed an increase with altitude in systolic as well as in the diastolic blood pressure. Because of the technique used to gather data, this is thought to have represented an independent effect of altitude without interference from the medical environment or diurnal activity.

[Ambulatory measurement of Korotkoff sounds timing (QKD interval) in a normal population]

Ambulatory monitoring of Korotkoff sounds appearance time (QKD interval) was performed during 24 hours in 131 normal subjects (85 males, 46 females, aged 14-78 years, mean 36 +/- 15 years) with a new device (Diasys 200RK, Novacor-France). This device allows simultaneous measurements of blood pressure, heart rate and QKD interval at programmed intervals, every 15 minutes in this study. For each patient we calculated the average 24th QKD interval, the QKD interval for a systolic BP of 100 mmHg and a heart rate of 60 bt/min (QKD: 100-60), and the slope (S) of the variations of the QKD interval against systolic BP and pulse pressure (PP). Results are presented for each 10 years age group (mean +/- SD).

Pre-acclimatization to high altitude using exercise with normobaric hypoxic gas mixtures

Pre-acclimatization was conducted using a new method elaborated in our laboratory, combining high intensity exercise while breathing hypoxia normobaric gas mixtures. The training consisted in a daily training during three weeks, 6 days a week, two hours a day, on bicycle ergometer. Eighteen subjects aging 22.2 +/- 1.4 years (11 males, 7 females) were matched in two similar groups: one group trained in normoxic conditions (NG) while the other group (HG) trained with a progressive decrease of the fraction of inspired oxygen (from 12.2% to 10.0%). Maximal oxygen uptake (VO2max) were measured before and after the protocol period in both hypoxic (VO2max H, FIO2 = 10.4%) and normoxic (VO2max N) conditions, for the 2 groups. Training induced a similar O2max N increase in the two groups. The ratio VO2max H/VO2max N was calculated. As expected, in NG group, this ratio decreased significantly (from 63.9 +/- 4.3 to 57.5 +/- 3.1%, p < 0.01) after the training period compared to the initial value, diminution associated with an elevation of VO2max N (from 48.4 +/- 9.0 to 52.9 +/- 9.0 ml.min-1 x kg-1, p < 0.01). Conversely, in HG group, this ratio was not significantly diminished (from 61.7 +/- 3.8 to 60.5 +/- 5.2%, NS) in spite of a similar increase of VO2max N (from 47.5 +/- 5.5 to 50.7 +/- 4.9 ml.min-1 x kg-1, p < 0.01). This does not follow the diminution of the ratio usually described when VO2max N reach higher values.(ABSTRACT TRUNCATED AT 250 WORDS)

Raynaud's phenomenon of the lung. A reality both in primary and secondary Raynaud syndrome

Vasospasm of RP is thought to occur in the lungs. To assess pulmonary vasospasm, we analyzed the early and late Dsb variations after a digital CPT. Sixteen normal volunteers and 20 patients (7 with primary, 13 with secondary RP) were included. A clinical RP was conducted on ten patients, nine with secondary and one with primary RP. The Dsb analysis showed: no significant variations in control subjects, a quick and short fall in primary RP significant after 15 min and a delayed fall in secondary RP significant after 45 min. A Dsb decrease was noticed even if no clinical RP occurred. The pallor phase of RP was associated with a concomitant decrease in the DCO and the hyperemic phase, with a Dsb increase. These results agree with those of previous studies with a few differences.

Physiological correlates of middle-distance running performance. A comparative study between men and women

To compare the relative contributions of their functional capacities to performance in relation to sex, two groups of middle-distance runners (24 men and 14 women) were selected on the basis of performances over 1500-m and 3000-m running races. To be selected for the study, the average running velocity (v) in relation to performances had to be superior to a percentage (90% for men and 88% for women) of the best French v achieved during the season by an athlete of the same sex. Maximal O2 consumption (VO2max) and energy cost of running (CR) were measured in the 2 months preceding the track season. This allowed us to calculate the maximal v that could be sustained under aerobic conditions, va,max. A v:va,max ratio derived from 1500-m to 3000-m races was used to calculate the maximal duration of a competitive race for which v = va,max (tva,max). In both groups va,max was correlated to v. The relationships calculated for each distance were similar in both sexes. The CR [0.179 (SD 0.010) ml.kg-1 x m-1 in the women versus 0.177 (SD 0.010) in the men] and tva,max [7.0 (SD 2.0) min versus 8.4 (SD 2.1)] also showed no difference. The relationships between VO2max and body mass (mb) calculated in the men and the women were different. At the same mb the women had a 10% lower CR than the men; their lower mb thus resulted in an identical CR.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of ambulatory blood pressure determination: a comparative study

This study was designed to discriminate, according to their accuracy, between three ambulatory pressurometers (Diasys 200R, Novacor; P IV, Del Mar Avionics; SpaceLab 90202, SpaceLab). The evaluation was performed against invasive arterial reference measurements. Accuracy was assessed by calculating the error on pressure (EOP) as the difference between invasive and non-invasive measurement of arterial blood pressure. For the systolic values, accuracy (mean of EOP differences) and uncertainty (SD of these differences) were -0.9 +/- 9.7, -4.3 +/- 10.1 and -16.7 +/- 10.1 mmHg for, respectively, Diasys, PIV and SpaceLab. For diastolic values, they were, respectively, 5.9 +/- 6.7, 6.8 +/- 8.5 and 9.1 +/- 6.6 mmHg. EOP was then separated in two different types of errors: (i) the error of dispersion appreciated by the index of homogeneity calculated by a Lehmann analysis and leading to a statistical classification (ii) the error due to the drift of EOP with the reference value, this last error being easier to correct. Two different behaviours were observed for the EOP: (i) the drift of EOP of systolic values was significantly larger for the oscillometric (SpaceLab) than for the auscultatory (Diasys and P IV) method, with no difference between Diasys and P IV (ii) the homogeneity index was not statistically different among these three devices. These data suggest that, in case the correction of the drift of EOP is carried out, there is no statistical significant difference in accuracy between these three pressurometers. However, in our experimental conditions, the two ambulatory pressurometers recording the Korotkoff sounds have a better accuracy than the one using the oscillometric approach.

Assessment of running velocity at maximal oxygen uptake

To investigate the different ways of assessing the running velocity at which maximal oxygen uptake (VO2max) occurs, or maximal aerobic velocity (vamax), 32 well-trained runners (8 female and 24 male) were studied. The vamax and the running velocity corresponding to a blood lactate concentration of 4 mmol.l-1 (vla4) were measured during a progressive treadmill session. Within the week preceding or following the treadmill measurement the subjects completed a Université de Montreal Track-Test (UMTT). The velocity corresponding to the last stage of this test (vUMTT) was slightly higher than vamax: 6.08 m.s-1, SD 0.41, vs 6.01 m.s-1, SD 0.44 (P less than 0.03) but these two velocities were strongly correlated (r = 0.92, P less than 0.001). The heart rate values corresponding to these velocities were similar and well correlated (r = 0.79, P less than 0.01); the corresponding blood lactate values had similar mean values: 10.5 mmol.l-1, SD 2.7 vs 11.8 mmol.l-1, SD 2.5, but were not correlated. Both vamax and vUMTT correlated well with the best performance sustained over 1500 m during the season. These results suggest that the UMTT provides a value of vamax as accurately as a treadmill measurement and that either could be used to measure the running velocity corresponding to VO2max. The v1a4 was 86.6%, SD 2.6 of vamax; these two velocities correlated strongly. Thus, in well trained runners, v1a4, when measured with a well-defined procedure, corresponds to a constant fraction of vamax and depends then on VO2max and the energy cost of running.

Post-competition blood lactate concentrations as indicators of anaerobic energy expenditure during 400-m and 800-m races

The relationships between anaerobic glycolysis and the average velocity (v) sustained during running were studied in 17 top level athletes (11 males and 6 females). A blood sample was obtained within 10 min of the completion of major competitions over 400 m, 800 m and 1500 m and the blood lactate concentration [la]b was measured. In both male and female athletes [la]b was related to the relative performance, as expressed as a percentage of the athlete's best v of the season. Over 400 m, r = 0.85 (P less than 0.01) and r = 0.80 (P less than 0.05) in males and females, respectively. Over 800 m, the corresponding values were r = 0.76 (P less than 0.01) and r = 0.91 (P less than 0.01). In male runners [la]b was correlated to v: r = 0.89 (P less than 0.01) and r = 0.71 (P less than 0.02) over 400 m and 800 m, respectively. No relationship to relative performance or v was obtained over 1500 m. Energy expenditure during competition running was estimated in male runners from the [la]b values. This estimate was based mainly on the assumption that a 1 mmol.1-1 increase in [la]b corresponded to the energy produced by the utilization of 3.30 ml.O kg-1. The energy cost of running was estimated, by dividing the estimated total energy expenditure by the race distance, at 0.211 ml.kg-1.min-1 over 800 m and 0.274 ml.kg-1.m-1 over 400 m.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy of pulse oximetry during moderate exercise: a comparative study

This study was designed to discriminate, according to their accuracy, between eight pulse oximeters (PO) using a realistic evaluation performed by means of a moderate exercise to provide artefacts and thus represent a typical clinical situation. Accuracy was assessed by calculating error on saturation (EOS) as the difference between simultaneous measurement of non-invasive (SpO2) and invasive functional (SfO2) arterial blood oxygen saturation. An index of homogeneity of EOS (InH), calculated using a Lehmann analysis, was chosen as a representative of error dispersion, leading to a statistical classification; the influence on error introduced by the drift of EOS with SfO2 was thus eliminated. We obtained a clear-cut separation of the eight PO (Datex Satlite (DA), Kontron 7840 (KO), Nellcor 200 (NE), Novametrix 505 (NO), Ohmeda 3700 (OH), PPG-Hellige (PP), Physiocontrol 1600 (PH), and Radiometer Oxi (RA] into two statistically different subgroups by comparing their InH standard deviation (SD). There is a highly statistically significant difference between the accuracy measured for the high precision subgroup with an InH SD ranging from +/- 1.6 to +/- 1.9% SaO2 (DA, PH, and RA), and that measured for the low precision subgroup whose InH SD ranges from +/- 2.8 to +/- 5.0% SaO2 (NE, OH, NO, KO, PP). These results suggest that, in our clinical conditions, there is a wide range of inhomogeneity of error from one PO to another. The error introduced by the drift of EOS with SfO2 should be considered separately.

The energetics of middle-distance running

In order to assess the relative contribution of aerobic processes to running velocity (v), 27 male athletes were selected on the basis of their middle-distance performances over 800, 1500, 3000 or 5000 m, during the 1987 track season. To be selected for study, the average running velocity (v) corresponding to their performances had to be superior to 90% of the best French v of the season. Maximum O2 consumption (VO2max) and energy cost of running (C) had been measured within the 2 months preceding the track season, which, together with oxygen consumption at rest (VO2rest) allowed us to calculate the maximal v that could be sustained under aerobic conditions: vamax = (VO2max - VO2rest) x C-1. The treadmill running v corresponding to a blood lactate of 4 mmol.l-1 (vla4), was also calculated. In the whole group, C was significantly related to height (r = -0.43; P less than 0.03). Neither C nor VO2max (with, in this case, the exception of the 3000 m athletes) were correlated to v. On the other hand, vamax was significantly correlated to v over distances longer than 800 m. These v were also correlated to vla4. However vla4 occurred at 87.5% SD 3.3% of vamax, this relationship was interpreted as being an expression of the correlation between vamax and v. Calculation of vamax provided a useful means of analysing the performances. At the level of achievement studied, v sustained over 3000 m corresponded to vamax.(ABSTRACT TRUNCATED AT 250 WORDS)

[Nyctohemeral blood pressure profiling by automatic measurement in ambulatory hypertensive patients. Treatment with acebutolol]

Variations in night and day blood pressure were evaluated in 11 patients with essential hypertension. The instrument used (Pressurometer II) automatically records blood pressure every 15 minutes for a mean period of 22 hours and ECG tracings continuously. The mean values of arterial pressure and heart rate were significantly higher during day time than at night, revealing a relative "hypotension" and "bradycardia" during sleep. The cardioselective beta-blocker acebutolol induced a significant fall in diurnal and nocturnal blood pressure, thus uniformly lowering the 24-hour profile.

Acute hemodynamic effects of intravenous amiodarone in patients with coronary artery disease

The acute hemodynamic effects of intravenous amiodarone (Cordarone injectable; Labaz) were studied during cardiac catheterization in 16 male patients with coronary artery disease (age range, 38-64 years; mean, 53 years). Amiodarone was administered as a bolus at a dosage of 5 mg/kg bodyweight over a 1-min period. Measurements were made 5, 10, and 15 min thereafter. The drug had little effect on heart rate, aortic pressure, cardiac index, and vascular resistances. There were small and nonsignificant increases in left ventricular end-diastolic pressure and end-diastolic volume. The ejection fraction decreased slightly and not significantly. In addition to some increases in pulmonary wedge, pulmonary artery, and right atrial pressures, the significant findings were a 15% decrease in maximal dP/dt and a 12% decrease in left ventricular work. These changes point to a slight negative inotropic effect of amiodarone.

[Global ventricular function and synchronism of contraction during and after exertion]

Phase analysis and ejection fraction (EF) of the left ventricle were obtained by radionuclide angiography in 53 patients at rest, during submaximal exercise and 3-8 minutes after exercise. The standard deviation of the peak of the histogram of phases (SDP) was used as an index of the synchronicity of regional contraction. The material comprised 13 sportsmen and 40 patients who underwent coronarography, 12 of whom had normal coronaries and 28 significant lesions. EF, while comparable in the three groups at rest, increased significantly on effort in normals and did not change in patients with coronary disease. At rest SDP was higher in coronary patients than in normals (p less than 0.01), and during exercise, it increased, but decreased in normals (p less than 0.01). After exercise, mean EF decreased in comparison with exercise in normals (p less than 0.01), while the opposite was the case in coronary patients. Normals had lower SDP values in the post-exercise period than at rest; on the other hand, SDP of coronary patients was significantly higher in the post-exercise period than at rest (p less than 0.001). Phase analysis during, and particularly after, exercise was found to be superior to EF in detecting ischemic left-ventricular dysfunction, and should be used in conjunction with EF to evaluate patients suspect for coronary disease.

[Evaluation of a delayed-action beta blocker by 24-hour ambulatory recording of the arterial pressure]

Twelve students aged 21 to 39 years (mean age 26) with borderline hypertension underwent three 24 hours ambulatory recordings of blood pressure using an Avionics Pressurometer II device: the first recording under basic conditions, the second after taking placebo and the third after being treated for 3 days with a betablocker of long acting effect (oxprenolol R 160 mg) in a randomized study. The blood pressure mean profile showed a double peak during daily activity with a progressive lowering of the blood pressure during sleep. The effect on the blood pressure of long acting oxprenolol begins four hours later, remains for about ten hours and may be still present next day. The shape of the circadian blood pressure profile is not modified. No significant difference between the pressure profiles on the basic conditions and placebo is noticed.

[Evaluation of a method for ambulatory and automatic measurement of nyctohemeral arterial pressure]

This study was designed to evaluate a method of automatic non-invasive ambulatory blood pressure monitoring. Using a Del Mar Avionics Pressurometer II, we tested 12 normal subjects at rest and during exercise in our laboratory, and 12 patients with borderline hypertension during 24 hours of normal activity. At rest correlation coefficient of sequential measurements between pressurometer and a standard mercury sphygmomanometer were 0.96 for individual systolic measurements, 0.65 for individual diastolic measurements, and 0.99 for sequentially coupled diastolic or systolic measurements. The same correlation coefficients were found during a low level exercise test on cycloergometer (50 watts); at a higher level (75 watts), the correlation coefficient for systolic measurements is still high (0.93), whereas for diastolic measurements the correlation coefficient is low (0.45) in our experimental conditions. Fifty-eight non-invasive ambulatory recordings were obtained during normal daily activities. About 10% of the measurements were eliminated because of artefacts. We conclude that the nycthemeral fluctuations of the blood pressure can be reasonably estimated by the Del Mar Avionics Pressurometer II, but that such results can be obtained only if special attention is given to the positioning of the pressurometer on a motivated patient.