Multidimensional frailty and its association with quality of life and disability: A cross-sectional study in people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (pwMS) have a high risk of frailty. We aim to evaluate frailty using the Tilburg frailty indicator (TFI), a multidimensional self-reported questionnaire, and to explore its relationship with autonomy, quality of life (QoL), and disability.

METHODS

All the patients with MS enrolled completed TFI (frail when TFI score ≥ 5 points), the Groningen Activities Restriction Scale to evaluate autonomy, and the Multiple Sclerosis Impact Scale-29 to evaluate QoL. We collected the Expanded Disability Status Scale (EDSS) score, age and gender. Data were analysed using descriptive analyses, hierarchical multiple regression, and ANCOVA.

RESULTS

A total of 208 pwMS (mean age 44 years, SD=11; 75% women; 89.4% relapsing-remitting) were enrolled. The mean TFI total score was 5.7 points (SD=3.0; range 0-14), with the 62.5% of participants exhibiting frailty. After controlling for age and gender, the EDSS score was associated with the total (β=0.469; R2=0.255; p<0.001) and the physical (β=0.571; R2=0.349; p<0.001) frailty score, with an explained variance of 25.5% and 34.9%, respectively. No relationships between the EDSS and psychological and social frailty domains were detected. The proportion of frail patients with EDSS ≥ 6.0, EDSS within 3.5-5.5, and EDSS ≤ 3.0 was 91.7%, 83.3%, and 66.0%, respectively. Frail patients exhibited higher autonomy impairment (p = 0.017) and worse QoL (p<0.001).

DISCUSSION

We found a high frequency of frail patients with MS. Frailty is more common in patients with higher disability, but it affects also those with low EDSS. In people with MS frailty could be influenced by factors other than disability.

Efficiency of aseptic open vitrification and hermetical cryostorage of human oocytes

The present study reports, as far as is known for the first time, the safety of UV sterilization of liquid nitrogen and hermetical cryostorage of human oocytes by comparing the efficiency of fresh and vitrified sibling oocytes of infertile patients. A prospective randomized study on sibling oocytes of 31 patients was carried out. Metaphase-II oocytes were randomized for intracytoplasmic sperm injection and the supernumerary sibling oocytes were vitrified using a novel Cryotop aseptic procedure (UV liquid nitrogen sterilization and hermetical cryostorage). After unsuccessful attempts with fresh oocytes, vitrified sibling oocytes were injected. Mean outcome measures observed were fertilization, cleavage and top-quality embryo rates. No significant differences were observed between the fresh and vitrified-warmed sibling oocytes: oocyte fertilization was 88.3% versus 84.9%; cleavage 72.6% versus 71.0%; top-quality embryos 33.8% versus 26.3% and mean number of transferred embryos 2.6 ± 0.1 versus 2.5 ± 0.1, respectively. Clinical pregnancy rate per cycle with vitrified-warmed oocytes was 35.5% (implantation rate 17.1%) and seven healthy babies were born. This study demonstrated that UV liquid nitrogen sterilization and hermetical cryostorage does not adversely affect the developmental competence of vitrified oocytes, allowing safe aseptic open vitrification applicable under strict directives on tissue manipulation.

Parental history of premature myocardial infarction is a stronger predictor of increased carotid intima-media thickness than parental history of hypertension

An increased carotid intima-media thickness (IMT) is detectable in young subjects with parental history of premature myocardial infarction (PHPMI) or hypertension (PHH). In this study we evaluated if PHPMI and PHH exert a different influence on carotid IMT and if their conjunction produces additive effects. High-resolution B-mode ultrasonographic evaluation of common carotid artery IMT was acquired from 48 subjects without PHPMI and PHH (22 males, 26 females; mean age 22.1±4.9 years; controls), 24 age- (±1 year) and sex-matched subjects with PHH without PHPMI (PHH-positive/PHPMI-negative subjects), 24 age- and sex-matched subjects with PHPMI without PHH (PHH-negative/PHPMI-positive subjects) and 24 age- and sex-matched subjects with both PHPMI and PHH (PHH/PHPMI-positive subjects). Lipid profile, resting blood pressure, smoking behaviour and body mass index (BMI) were also assessed. Carotid IMT was smaller in controls (0.41±0.07mm) compared to PHH-positive/PHPMI-negative subjects (0.47±0.10, p=0.023), to PHH-negative/PHPMI-positive subjects (0.54±0.11, p<0.001) and to PHH/PHPMI-positive subjects (0.52±0.10mm, p<0.001). Carotid IMT was greater in PHH-negative/PHPMI-positive (p=0.006) and in PHH/PHPMI-positive (p=0.031) than in PHH-positive/PHPMI-negative subjects. No difference in carotid IMT was evident between PHH-negative/PHPMI-positive and PHH/PHPMI-positive subjects (p=0.549). In the comparison among subjects using multiple regression analysis, only PHPMI, age and BMI were independently associated with carotid IMT. In healthy young subjects with PHPMI and/or PHH, carotid IMT is increased. PHPMI is a stronger predictor of increased carotid IMT than PHH. PHH in conjunction with PHPMI does not add any further detrimental effect on carotid IMT.

Use of NaCl saline hydration and N-Acetyl Cysteine to prevent contrast induced nephropathy in different populations of patients at high and low risk undergoing coronary artery angiography

AIM

Contrast-induced nephropathy (CIN) is most commonly defined as acute renal failure occurring within 48-72 h of exposure to intravascular radiographic contrast medium that is not attributable to other causes. In international literature a 25% increase in serum creatinine levels or an increase in absolute values of 0.5 mg/dL from baseline has been suggested to define CIN. The reported incidence of CIN varies widely, ranging from 2% to 50%. This variability results from differences in the presence or absence of risk factors. With a retrospective analysis authors evaluated the use of NaCl saline hydration and N-acetyl cysteine (NAC) to prevent CIN in different populations of patients at high and low risk undergoing coronary artery angiography.

METHODS

From January 2007 to December 2008, 597 patients underwent coronary artery angiography with a low osmolarity contrast agent. Nephrotoxic drugs such as diuretics, metformin, ACE-I and ARBs were stopped at least 24 h before the procedure. The population was divided into two groups: group A (high risk 342 patients, 57.2%) identified for the presence of at least one risk factor such as diabetes, age >65 years, baseline creatinine >1.4 mg/dL and group B (low risk 255 patients, 42.8%) for the absence of any of the risk mentioned above. Only group A was treated with a saline hydration (1 mL/kg/h) plus NAC 600 mg 12 h before and 12 h after the procedure.

RESULTS

The overall incidence of CIN was 6.7% (40 patients). In particular, the incidence of CIN was 4.4% (15 patients) in the group A and 9.8% (25 patients) in the group B respectively (P=0.017). Interestingly, the Contrast Index (volume administrated/theoretical maximum volume) was significantly lower in group B (P<0.005). In the multivariate analysis, including risk factors such as age, diabetes, hypertension, hypercholesterol-mia, current smoke, baseline creatinine level, Contrast Index and hydration, the last variable was the only one inversely correlated independently with the incidence of CIN (P=0.001).

CONCLUSIONS

The hydration with saline and NAC is an effective and low-cost tool in preventing CIN in patients undergoing coronary artery angiography and, according to the current guidelines, should be used in all high-risk patients. Present results show that even in patients at low risk for CIN, hydration could be useful: in fact, despite the Contrast Index was significantly lower in this population, the incidence of CIN was greater, thus suggesting a potential role for hydration also in the low-risk population.

Estrogen receptor polymorphism, estrogen content and idiopathic scoliosis in human: a possible genetic linkage

Idiopathic scoliosis (IS) is a largely diffused disease in human population but its pathogenesis is still unknown. There is a relationship between scoliotic phenotype and the patient age, since in the early stage the pathology shows a ratio of 50% between male and female teenagers. During puberty the sex ratio is 8.4/1 (female/male), suggesting a sex-conditioned manifestation of the disease. Genetic inheritance of idiopathic scoliosis is still unclear although some authors claim for its X-linked dominant inheritance. There is large agreement in considering the IS as a sex-conditioned disease, in terms of steroid content and their receptor activity, although no evidence has been found yet. The blood content of 17beta-estradiol in teenagers with IS shows lower levels than teenagers of the same age without IS. Also testosterone and progesterone content are lower in IS girls with respect to the control girls. Furthermore, we extracted DNA from white blood cells of IS patients and their relatives until the third generation in order to examine estrogen receptor alpha polymorphisms, considering this tool a plausible molecular marker for IS prognosis. In this respect, we identified four polymorphisms in the exons encoding for the steroid binding domain and two other in the trans-activation domain. Our results show a clear relationship with clinical manifestation of IS.

Prognostic value of intra-left ventricular electromechanical asynchrony in patients with mild hypertrophic cardiomyopathy compared with power athletes

OBJECTIVES

We sought to assess the indexes of myocardial activation delay, using Doppler myocardial imaging (DMI), as potential diagnostic tools and predictors of cardiac events in patients with hypertrophic cardiomyopathy (HCM) compared with power athletes.

BACKGROUND

the distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with HCM, which results in heterogeneity of regional LV systolic function.

METHODS

The study population comprised 70 young patients with HCM (mean (SD) age 29.4 (5.9) years) with mild septal hypertrophy (15-19 mm) and 85 age and sex matched athletes with septal thickness >12 mm, followed up for 44.4 (10.8) months. Using pulsed DMI, myocardial peak velocities, systolic time intervals, and myocardial intraventricular and interventricular systolic delays were measured in six different basal myocardial segments.

RESULTS

DMI analysis showed in HCM lower myocardial both systolic and early diastolic peak velocities of all the segments. Patients with HCM also showed significant interventricular and intraventricular delay (p<0.0001), whereas athletes showed homogeneous systolic activation of the ventricular walls. During the follow up, seven sudden deaths occurred in the HCM group, while no cardiovascular event was observed in the group of athletes. In patients with HCM, intraventricular delay on DMI was the most powerful independent predictor of sudden cardiac death (p<0.0001). An intraventricular delay >45 ms identified with high sensitivity and specificity patients with HCM at higher risk of ventricular tachycardia and cardiac events (test accuracy 90.6%).

CONCLUSIONS

DMI may be a valid supporting tool for the differential diagnosis between HCM and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up. Accordingly, such patients may benefit from early intensive treatment and survey. MINIABSTRACT: Doppler myocardial imaging may represent a valid supporting tool for the differential diagnosis between mild hypertrophic cardiomyopathy (HCM) and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up.

Increased carotid intima-media thickness in children-adolescents, and young adults with a parental history of premature myocardial infarction

AIMS

The present study was designed to test whether early carotid structural changes are demonstrable (by high resolution B-mode ultrasound) in children, adolescents and young adults with a history of premature parental myocardial infarction.

METHODS AND RESULTS

One hundred and fourteen healthy young (5 to 30 years) subjects with a parental history of premature myocardial infarction and 114 age- and sex-matched control subjects were enrolled in the study. They were divided into two age groups: children and adolescents (age 5 to 18 years) (54 individuals with a parental history of premature myocardial infarction and their control subjects; mean age 12.8+/-3.8 years) and young adults (age 19 to 30 years) (60 individuals with a parental history and their controls; mean age 23.8+/-3.3 years). All subjects underwent high resolution B-mode ultrasonographic evaluation of common carotid artery intima-media thickness. Lipid profile, resting blood pressure, body mass index and smoking status were also evaluated. In both age groups, compared to controls, subjects with a parental history of premature myocardial infarction had increased intima-media thickness of common carotid arteries (mean of combined sites: age 5-18 years: 0.45+/-0.076 mm vs 0.40+/-0.066 mm in controls, P=0.008; age 19-30 years: 0.48+/-0.077 mm vs 0.45+/-0.078 mm in controls,P =0.007) Offspring of coronary patients showed an unfavourable lipid profile, however, the association between a parental history of premature myocardial infarction and carotid intima-media thickness was independent of lipids, apolipoproteins and other traditional risk factors.

CONCLUSIONS

Vascular structural changes associated with a parental history of premature myocardial infarction are already detectable in childhood and adolescence and occur independently of several traditional cardiovascular risk factors.

[Media-intima thickness: what is it? how is it measured? what is its clinical significance? what are the pending problems?]

During the past 20 years, several hundred peer-reviewed publications have documented the critical scientific steps in the determination of the usefulness of B-mode ultrasound measurements of the carotid artery intima-media thickness (IMT) for the detection and monitoring of artery wall atherosclerotic disease. Since the initial validation study of the IMT, carotid ultrasound IMT measurements have been performed in a large number of individuals with "traditional" and "non traditional" cardiovascular risk factors, have been shown to correlate with the severity of atherosclerotic lesions in other vascular territories, and have been used as outcome measures in clinical trials evaluating the various effects of treatment on the progression/regression of atherosclerosis. Furthermore, in longitudinal studies, carotid IMT has been shown to be an independent predictor of stroke and coronary events. However, before this powerful indicator of arterial wall atherosclerotic disease can be used in clinical settings as a routine test for the prediction of an individual's cardiovascular risk, some unresolved issues need to be addressed.

Arterial abnormalities in the offspring of patients with premature myocardial infarction

BACKGROUND

Findings from epidemiologic and autopsy studies suggest that the offspring of patients with premature coronary disease may be at increased risk for atherosclerosis. We undertook a study to determine whether changes in brachial-artery reactivity and thickness of the carotid intima and media, two markers of early atherosclerosis, are present in adolescents and young adults with a parental history of premature myocardial infarction.

METHODS

We enrolled 40 healthy young people whose parents had had premature myocardial infarction (48 percent male; mean [+/-SD] age, 19.0+/-5.2 years) and 40 control subjects who were matched with the first group according to age and sex. All the subjects underwent high-resolution B-mode ultrasound examinations for the measurement of the brachial-artery vasodilatory response after arterial occlusion (i.e., reactive hyperemia) and the intima-media thickness of the distal common carotid arteries. Lipid profiles, blood pressure while at rest, body-mass index, and smoking status were also determined.

RESULTS

As compared with the control subjects, the offspring of patients with premature myocardial infarction had lower flow-mediated reactivity of the brachial arteries (5.7+/-5.0 percent, vs. 10.2+/-6.6 percent in the control subjects; P=0.001) and greater mean intima-media thickness of the common carotid artery (0.49+/-0.08 mm, vs. 0.44+/-0.07 mm in the control subjects, P=0.004). In the subjects with a parental history of premature myocardial infarction, an inverse association was found between brachial-artery reactivity and carotid intima-media thickness (r=-0.46, P=0.003). In a conditional logistic-regression analysis, both brachial-artery reactivity and carotid intima-media thickness were significantly and independently correlated with a parental history of premature myocardial infarction.

CONCLUSIONS

Structural and functional changes are present at an early age in the arteries of persons with a parental history of premature myocardial infarction.

[Personal, familial and environmental factors influencing the inclination of smoking in adolescents: differences between sexes and between city and small-town dwellers]

Smoking is a major health hazard. Most cigarette smokers start by the age of 18 years. The purpose of this study was to assess the prevalence of the intention to smoke among the students of a metropolitan compared to a non-metropolitan high school. The influence of age, sex, demographic and socio-economic variables, and the role of smoking models of family members and friends, were examined. Nine hundred forty-five students (529 males and 416 females; mean age 15.8 +/- 1.5 years) attending a high school in Naples and 442 students (223 males and 219 females; mean age 16.1 +/- 1.6 years) in Capua, a small town 40 Km distant from Naples, filled in an extensive questionnaire on smoking. The prevalence of intention to smoke was 10.4% in Naples and 9.3% in Capua. It was related to age (p < 0.01) in Naples, but not in Capua. The prevalence of smokers was 24.2% in Naples (males 21.6%, females 27.6%; p = 0.038) and 24.1% in Capua (males 29.2%, females 19%; p = 0.017). As expected, in both cities intention to smoke was associated (p < 0.001) with the strength of existing smoking habit. Students smoking over 21 cigarettes/week were more likely to continue than students smoking less 21 cigarettes/week, both in Naples and in Capua. More than half of smoking students, in both cities, were irresolute about their habit in the subsequent year. In Naples, intention to smoke of male students was associated with mother's (p = 0.02) and siblings' (p < 0.0001) smoking habit; in female students intention to smoke was associated with father's (p = 0.02), mother's (p < 0.001), parents' (p < 0.01) and siblings' smoking habit (p = 0.0002). In Capua an association was evident, in male students, between intention to smoke and paternal smoking habit (p = 0.04); in female students, intention to smoke was associated with siblings' smoking habit (p = 0.03). In Naples and in Capua, for both sexes, intention to smoke was related to smoking habits of the best friend of the same sex (p < 0.0005), the best friend of the opposite sex (p < 0.00005) and friends (p < 0.00001). Multivariate analysis showed, in Naples, an independent relation between adolescent intention to smoke and age (p = 0.01), smoking status of student (p < 0.0001) and friends' smoking habit (p = 0.01). In male students intention to smoke was associated with age (p = 0.003), smoking habit of student (p < 0.0001), mother's (p = 0.02) and friends' (p = 0.02), whereas in females it was associated with smoking behavior of student (p < 0.0001). In Capua student intention to smoke was related to the smoking status of the student (p < 0.0001) and of the best friend of the opposite sex (p < 0.04); in male as in female students, intention to smoke was associated with smoking habit of the student (p < 0.0001). In conclusion, prevalence of adolescents' intention to smoke is similar in two distinct populations of high school students of a city and a small town. Smoking is at higher prevalence among females in the city and among males in the small town. Intention to smoke increases with age, in the great city, and is related to student's existing habit and peer models. More than half of smoking students, in both cities, were irresolute about their habit in the subsequent year. This study has identified some variables associated with adolescents' intention to smoke; we feel that these findings may contribute to a better understanding of smoking behavior among adolescents and may have preventive implications.

[Family and friends who smoke: influence on adolescents]

BACKGROUND

Smoking is the leading preventable cause of death. Most cigarette smokers take up the habit during adolescence. The purpose of this study was to assess the prevalence of cigarette smoking behavior among the students of a metropolitan high school as compared to those attending a non-metropolitan high school, examining age, sex and demographic and socioeconomic differences, as well as the influence of smoking models (family members and friends) on smoking behavior among adolescents.

METHODS AND RESULTS

Nine hundred seventy-eight students (544 males, 434 females; mean age 15.8 +/- 1.5 years) attending a high school in the city of Naples and 467 students (235 males, 232 females; mean age 16 +/- 1.5 years) from a high school of Capua, a small town 40 kilometers away from Naples, filled out an extensive questionnaire on smoking. The prevalence of smokers was 24.2% (males 21.8%, females 28.2%; p = 0.02) in Naples and 23.8% in Capua (males 29.8%, females 19.2%; p < 0.001) and was related to age (p < 0.001) both in Naples and in Capua. In Naples, smoking behavior among male students was associated with smoking by sibling (p = 0.00005), whereas an association with father (p = 0.0003), mother (p = 0.00005), parental (p = 0.0002) and sibling (p = 0.00002) smoking was observed among females. In Capua, an association was evident only between smoking in female students and sibling smoking habits (p = 0.02). In both Naples and Capua, smoking status of the students was related to smoking habits of best friends of the same sex, best friends of the opposite sex and friends. Multivariate analysis showed an independent relationship in Naples between adolescent smoking behavior and smoking status of siblings (p = 0.01), best friends of the same sex (p < 0.001) and best friends of the opposite sex (p < 0.001). In males, smoking behavior was associated with the smoking behavior of best friends of the same (p < 0.001) and of the opposite sex (p = 0.01), whereas in females, it was linked with the smoking behavior of siblings (p = 0.05), mother (p < 0.05) and best friends of the same sex (p < 0.001). In Capua, student smoking was related to smoking among friends (p < 0.001) and this held true for both males (p = 0.05) and females (p < 0.0001).

CONCLUSIONS

The prevalence of smoking habits among teenagers is similar in two distinct populations of high school students from a city and from a small town. Smoking showed a higher prevalence among females in the city and among males in the small town. It increases with age and is related to peer and family smoking models. This study has identified several variables associated with smoking status among adolescents. We thus feel that these findings may contribute to a better understanding of smoking behavior among teenagers and may have prevention implications.

Influence of autonomic tone on QT interval duration

The autonomic tone has been shown to influence the duration of the QT interval, however the independent contribution of sympathetic and parasympathetic tone is not fully elucidated. The influence of autonomic tone on QT duration was studied in 10 young healthy volunteers by evaluating the changes in QT and RR duration induced by i.v. isoproterenol infusion and by standing before and after i.v. administration of propranolol or atropine. Furthermore, the relationship between RR interval and QT duration was evaluated during nocturnal sinus arrhythmia and submaximal exercise test. Low doses of isoproterenol reduced RR (p < 0.01) but not QT interval duration, while higher doses influenced both RR (p < 0.0001) and QT (p < 0.001) duration. Propranolol did not influence standing-induced shortening of RR and QT intervals; on the contrary, atropine administration abolished standing-induced QT interval shortening, without influencing RR changes. QT duration resulted significantly related to preceding RR interval at peak exercise (r = 0.87, p < 0.001) and during nocturnal sinus arrhythmia (r = 0.73, p < 0.0005), however, the regression lines showing the correlation between QT and preceding RR interval were different. Both sympathetic and parasympathetic tone appear to contribute to heart rate-independent changes in QT duration. In the basal state parasympathetic more than sympathetic tone influences the relation QT-heart rate. Major increases of sympathetic nervous system activity may change the relation QT-heart rate. Thus, in case of abrupt autonomic changes, any proposed formula for heart rate correction of QT may result inappropriate, also in the normal range of heart rate.

[Lipoprotein (a) and serum lipid levels young subjects with parents suffering from myocardial infarct]

BACKGROUND

Elevated concentrations of lipoprotein (a) have been shown to increase the risk of coronary artery disease, especially in females, and have been found to be elevated in white US children with parental myocardial infarction.

METHODS

To confirm the generality of this finding and to determine the influence of gender, we studied 143 children with parental myocardial infarction (cases), 71 males and 72 females, mean age 17 +/- 5 years, body mass index 22.1 +/- 3.8 and 102 controls, 50 males and 52 females, mean age 18 +/- 5 years, body mass index 23 +/- 4.3.

RESULTS

The serum cholesterol and lipoprotein (a) levels were significantly higher, whereas the HDL level was significantly lower in cases than in controls; lipoprotein (a) levels > 30 md/dl were significantly more prevalent in cases than in controls. Among the males, serum HDL cholesterol was significantly lower in cases than in controls, whereas no significant differences were found in serum total cholesterol and in lipoprotein (a). Among the females, cases had lower HDL cholesterol level and higher serum total cholesterol and lipoprotein (a) levels in comparison to controls.

CONCLUSION

Children with parental myocardial infarction, in particular the females, have a more unfavourable serum lipid profile than controls.

Diastolic dysfunction in patients with non-insulin-dependent diabetes mellitus of short duration

To determine whether abnormal left ventricular diastolic function is present at an early stage of non-insulin-dependent diabetes mellitus (NIDDM), left ventricular diastolic filling was evaluated by pulsed doppler echocardiography in 16 normotensive patients with NIDDM of short duration (1.8 +/- 1 years, mean +/- SD) and no evidence of microangiopathy, and in 16 healthy volunteers comparable for age, body mass index, and sex distribution. All patients showed normal systolic function. The interventricular septum thickness, left atrial diameter, and left ventricular mass index were increased in the diabetic as compared with the control group (p < 0.01, p < 0.01, and p < 0.02, respectively). Isovolumic relaxation time and atrial peak filling velocity were greater in diabetic patients (p < 0.001, and p < 0.01, respectively), whereas early to atrial peak filling velocity ratio was significantly reduced (p < 0.05). This study demonstrates that an impairment of left ventricular diastolic function occurs early in the natural history of NIDDM, and that this abnormality is unlikely to be related to clinical evidence of microangiopathic complications.

Right bundle branch block, persistent ST-segment elevation in V1-V3 and sudden cardiac death: always a distinct syndrome?

Right bundle branch block, persistent ST segment elevation in right precordial leads and sudden cardiac death, unexplainable by currently known disease, define a new distinct clinical and electrocardiographic syndrome. This report describe a patient with these features, whose physical examination, echocardiography, chest computed tomography and right ventricular angiography were normal. However, despite the negativity of these examinations, cardiac nuclear magnetic resonance allowed the identification of right ventricular dysplasia. Thus, right ventricular dysplasia should be considered in the differential diagnosis of the syndrome characterized by right bundle branch block, persistent ST segment elevation and sudden cardiac death.

[Reference values for the echocardiographic calculation of left ventricular mass in normal children between the ages of 0 and 6]

BACKGROUND

Echocardiographic assessment of left ventricular mass (LVM) and mass/volume ratio (LVM/V) is an accurate method for evaluating left ventricular hypertrophy. However, reference values for LVM and left ventricular volume (V) in children under 6 years of age have not been well established.

METHODS

Therefore, we evaluated 106 consecutive children (60 males, 46 females, mean age +/- SD 35 +/- 28 months, range 0-72) free of cardiovascular disease by clinical, electrocardiographic and echocardiographic examination. LVM and V were determined by M-mode echocardiography.

RESULTS

The 5th and 95th percentile values of LVM were: 7 and 21 grams for infants aged 0 to 6 months; 13 and 32 grams for 7 to 24 months; 23 and 41 grams for 25 to 36 months; 23 and 59 grams for 37 to 48 months; 30 and 60 grams for 49 and 60 months; 36 and 98 grams for 61 and 72 months. The 5th and 95th percentile values of V were: 4 and 20 ml for infants aged 0 to 6 months; 12 and 36 ml for 7 to 24 months; 16 and 43 ml for 25 to 36 months; 20 to 55 ml for 37 to 48 months; 27 to 64 ml for 49 to 60 months; 39 to 74 ml for 61 to 72 months. The 5th and 95th percentile values of M/V ranged between 1 and 2.3 for infants aged 0 to 6 months, and 0.7-1.2 for those aged 61 to 72 months. LVM, V and LVM/V were significantly (p < 0.0001) related to age, height, weight and body surface area, but were unrelated to gender.

Relationship between QT interval duration and exercise-induced ventricular arrhythmias

This study was performed to determine if QT prolongation before and during early exercise is related to the occurrence of exercise-induced ventricular arrhythmias (EIVA). EIVA occurred in 47 of 142 patients with angiographic evidence of coronary artery disease (CAD); no EIVA occurred among the 22 patients without CAD (OV). Resting QTc and QT intervals during early exercise were similar in patients without EIVA, irrespective of the presence or absence of CAD; however resting QTc was significantly longer in CAD patients who showed EIVA (443 +/- 40 ms; P less than 0.01) than in CAD patients without EIVA (424 +/- 37 ms) and in OV patients (421 +/- 32 ms). During early exercise, the QT interval remained significantly longer in patients with than in those without EIVA. There was a trend toward increasing resting QTc in patients who exhibited EIVA more severe than grade 3. When resting QTc was longer than 440 ms, subsequent EIVA were correctly predicted in CAD patients with a sensitivity of 43%, a specificity of 72% and a predictive accuracy of 63%. Thus, a trend toward longer resting QTc values exists in CAD patients who develop EIVA; however, a long resting QTc (greater than 440 ms) appears to be only a weak predictor of subsequent EIVA.

Effects of aging and beta-adrenergic-blockade on standing-induced QT/QS2 changes

In order to evaluate whether the changes in the electrical systole/electromechanical systole ratio (QT/QS2) may reflect the effects of beta-adrenergic stimulation on the heart, we studied the variations of this ratio induced by active standing. We studied 45 healthy volunteers aged 15 to 82 years, subdivided into three groups; Group 1 (mean age 22 +/- 4 years), Group 2 (mean age 44 +/- 6 years), and Group 3 (mean age 74 +/- 6 years). Fifteen subjects repeated the test after propranolol administration (0.1 mg/kg iv). Resting QT/QS2 ratio increased slightly, but not significantly, with age. Upright position significantly increased QT/QS2 ratio in all groups. Changes in heart rate (r = -.43), electromechanical systole (r = .55) and QT/QS2 were significantly correlated with age. Propranolol prevented the increase in QT/QS2 ratio induced by active standing. Therefore, QT/QS2 changes induced by standing are correlated with age and are inhibited or reduced by beta-blockade. QT/QS2 changes can be used to monitor adrenergic activity, even if their value is limited by the overlapping responses of the individual cases.

Relationship between QT/QS2 ratio and angiographic severity of coronary heart disease

The relationship between QT/QS2 ratio and angiographic severity of coronary heart disease (CHD) was determined in 99 patients who underwent coronary arteriography because of chest pain. Sixteen control patients with normal coronary arteriograms and normal left ventricular function and 83 patients with angiographic evidence of CHD were studied. QT/QS2 ratio and systolic time intervals were calculated from poligraphic recordings taken at rest. In control subjects QT/QS2 ratio was significantly shorter (0.91 +/- 0.04) than in patients with double (0.95 +/- 0.07; p less than 0.05 versus control subjects) and triple vessel coronary artery disease (0.95 +/- 0.05; p less than 0.05 versus control subjects). QT/QS2 ratio was significantly higher (p less than 0.01) in patients with 3 areas or more of left ventricular abnormal wall motion (LV AWM) (0.98 +/- 0.05) than in patients with none (0.92 +/- 0.06) or just 1-2 areas (0.93 +/- 0.06) of LV AWM. Multiple regression analysis revealed no relation between the number of coronary stenoses and QT/QS2 (t = 0.86; p = NS), while a relation was identified between the number of asynergic segments and QT/QS2 (t = 1.99; p less than 0.05). A significant correlation was found between QT/QS2 and PEP/LVET (r = 0.39; p less than 0.001). Setting the upper normal limit at 2 standard deviations from the mean of control subjects (QT/QS2 = 0.99), QT/QS2 criterion yielded a 30% sensitivity, a 94% specificity and a 96% predictive accuracy in diagnosing CHD. We conclude that in CHD patients QT/QS2 ratio is influenced by the extension of LV AWM. Although a low sensitivity may limit its use, a QT/QS2 value higher than 0.99 in a patient with chest pain strongly suggests CHD and thus this criterion may be diagnostically useful.

Diagnostic value of the ratio of recovery systolic blood pressure to peak exercise systolic blood pressure for the detection of coronary artery disease

It has been previously reported that at treadmill exercise testing an abnormal ratio of recovery systolic blood pressure (SBP) to peak exercise SBP is more sensitive than exercise-induced angina or ST segment depression for diagnosing coronary artery disease (CAD). To investigate whether the SBP ratio keeps its diagnostic value during upright bicycle exercise, we evaluated the ratio of postexercise SBP to peak SBP in 73 patients with angiographically documented CAD and in 48 patients with normal coronary arteries (OV group) undergoing maximal stress testing on a bicycle ergometer. Three minutes after exercise ended, SBP ratio was significantly higher in the CAD than in the OV group (0.79 +/- 0.1 vs 0.71 +/- 0.08; p less than .001). Setting the upper normal limits of the recovery SBP ratio at 2 SDs from the mean for the OV group (SBP ratio = 0.98 and 0.88 at 1 and 3 min after exercise, respectively), with an increase or no change in SBP ratio at between 1 and 3 min of recovery considered an abnormal response, the sensitivity of SBP ratio was 30%, the specificity was 83%, and the accuracy was 51%. The respective values for ST depression were 81% (p less than .0001 vs SBP ratio), 48% (p less than .001 vs SBP ratio), and 67% (p less than .01 vs SBP ratio). Thus, for bicycle ergometer exercise testing, ST segment depression seems to be more accurate than SBP ratio in diagnosing CAD.

Evaluation of exercise-induced Q-wave amplitude changes and their clinical value

We studied the influence of exercise level, severity of coronary artery disease (CAD), presence of previous myocardial infarction (MI), anterior or diaphragmatic, on the clinical value of exertional Q wave changes (Delta-Q). We retrospectively evaluated the exercise electrocardiograms of 62 patients without angiographic evidence of CAD and 133 patients with CAD; 28 of them had single (SVD) and 105 multivessel disease (MVD). Forty-one patients had a previous diaphragmatic MI and 23 anterior. The sensitivity, specificity and predictive value of Delta-Q were compared to the ST criterion. The exercise level affected Delta-Q. ST and Delta-Q had similar specificity and predictive values. The extent of CAD did not affect the sensitivity of Delta-Q and this method was better than ST to detect SVD patients. The Delta-Q criterion was equally as efficient as ST in MVD patients without MI and with diaphragmatic MI. The loss of septal forces on resting electrocardiograms made useless Delta-Q analysis on patients with anterior MI. The improvement of sensitivity in SVD patients by Delta-Q might be of clinical value since these latter are frequently not diagnosed by the ST criterion.

[Diagnostic value of changes in the Q wave induced by exertion]

In order to evaluate the diagnostic value of exercise-induced Q wave changes and its relationship with the extent of coronary involvement and presence and location of a previous myocardial infarction, we examined the stress electrocardiograms of 188 consecutive patients with chest pain. Coronary arteriography shoved single vessel disease (SV) in 28 patients and multivessel disease (MV) in 130 patients; a previous myocardial infarction was present in 64 patients. The Q wave amplitude was measured as average of ten values in CM5 at rest and at peak exercise; a Delta-Q less than 0, i.e. reduction or no change of Q wave at peak exercise, was considered a positive response for coronary artery disease. The Delta-Q criterion shoved a significantly better sensitivity than ST depression, as a whole, but this improvement was nullified when patients with anterior myocardial infarction were excluded; as well specificity of Delta-Q although better than ST, did not allow a significant improvement for the diagnostic value of stress test. We also evaluated the diagnostic accuracy for multivessel coronary artery disease of both criteria positive was 78% whereas the negative predictive value of both criteria negative was 91%. We concluded that the exercise-induced Delta-Q less than 0 is a good indicator of coronary artery disease, although not superior to ST depression; the negativity of both criteria seems to be highly reliable for the exclusion of multivessel coronary artery disease.

[Effect of beta-receptor block on QT/QS2 behavior during isometric and dynamic exercise]

Our study is aimed to evaluate the change of QT/QS2 ratio in normal subjects during both isometric and dynamic exercise before and after propranolol administration. We studied 10 young volunteers healthy subjects who performed an isometric exercise by squeezing a grip dynamometer at 70% of their maximal voluntary contraction as long as possible. They also performed a dynamic exercise undergoing a submaximal bicycle stress test. Both tests were performed before and after administration of propranolol (0.15 mg/Kg e.v.) QT and QS2 intervals were measured at rest, during exercise and in the recovery period. Heart rate and blood pressure were also determined. Isometric exercise induces a significant shortening of both intervals although minor for QT so that the ratio significantly increases in comparison to baseline (p less than .001). At rest propranolol induces a significant decrease of heart rate and only a slight lengthening of QT and QS2 so that the ratio is unchanged. During exercise propranolol does not influence the increase of heart rate and blood pressure and the shortening of QT interval but prevent exercise-induced QS2 shortening so that the ratio after beta-blockade is significantly reduced at the peak of exercise (p less than .005). During dynamic exercise QT and QS2 behaviour is similar to that of isometric exercise; in fact both intervals are shortened and QS2 decrease is major than QT so that the ratio increases (p less than .001). These results confirm that QT/QS2 ratio can monitor the effects of adrenergic stimulation on the heart during physiological manoeuvres enhancing sympathetic discharge like occurs during both isometric and dynamic exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative and qualitative analysis of the relationship between exercise-induced R wave amplitude changes and severity of coronary artery disease

The correlation between R wave voltage variations (delta R) and the angiographic severity of coronary artery disease (CAD) at progressively increasing heart rate (HR) steps was evaluated in 51 patients (pts) without CAD (OV), in 42 pts with single (SVD), in 43 with double (DVD) and in 59 pts with triple vessel disease (TVD). At the end of stress the sensitivity of delta R was higher in DVD and TVD pts than in SVD pts. There was no clear correlation between exercise-induced R wave changes and the angiographic severity of CAD, since the qualitative and quantitative delta R evaluation during effort showed similar changes in delta R for a wide range of HR's in the entire study population. Since different degrees of exercise tolerance were found in pts with SVD, DVD and TVD, we hypothesize that the correlation between delta R and the severity of CAD at the end of stress testing may be artifactual.

Effects of naloxone on catecholamine plasma levels in adult men. A dose-response study

To evaluate a possible role for endogenous opiates in modulating sympathetic-adrenal function in humans, we measured plasma epinephrine and norepinephrine (radioenzymatic method), blood pressure and heart rate in 8 normal men (aged 24-33 years) before and after placebo or different doses (0.4, 4.8, 10 mg) of naloxone. In 6 subjects plasma insulin and glucagon levels were also measured by radioimmunoassay after placebo and 10 mg naloxone. Naloxone had no significant effect upon blood pressure, heart rate, plasma insulin, glucagon or norepinephrine. Placebo, 0.4 and 4.8 mg naloxone caused no significant change in peripheral levels of epinephrine while 10 mg produced an increase in epinephrine concentrations 15 min after iv injection (186 +/- 23 vs 99 +/- 9 pmol/l, P less than 0.01). Since naloxone did not modify plasma levels of insulin and glucagon, an indirect effect of naloxone on adrenal medullary secretion seems to be excluded. These results are in agreement with in vitro experimental data obtained in animals and suggest that endogenous opiates also have a role in modulating adrenal medullary secretion in man.

Effects of different dopaminergic antagonists on bromocriptine-induced inhibition of norepinephrine release

In this study we evaluated the effects of placebo or acute bromocriptine (BC) administration (2.5 mg orally) on plasma catecholamines, systolic and diastolic blood pressure (BP), heart rate, and plasma PRL in six normal subjects [group I, mean age 33.2 +/- 5.4 (SD) yr] in the supine as well as upright position. BC induced a significant decrease in plasma norepinephrine in the supine [167.7 +/- 16.8 (SEM) vs. 101.9 +/- 33.7 pg/ml, P less than 0.005] and upright positions [397.3 +/- 27.7 vs. 211.3 +/- 26.7 pg/ml, P less than 0.005], a decrease in systolic and diastolic BP and a decrease in plasma PRL (P less than 0.01). After standing, epinephrine levels increased significantly (53.6 +/- 11.8 vs. 226.4 +/- 71.0 pg/ml, P less than 0.05). The study was repeated in a second group of seven normal subjects (mean age, 32.3 +/- 12.9 yr) after placebo or metoclopramide (20 mg orally) plus BC. In this group metoclopramide, a central and peripheral antidopaminergic agent, counteracted the BC-induced effects found in group I, both in the basal and stimulated conditions. Plasma PRL increased significantly (P less than 0.025). Finally, to assess the effect of peripheral dopaminergic blockade on BC-induced changes in sympathetic outflow, we repeated the study in seven normal subjects (group III, mean age, 30.1 +/- 5.0 yr) after placebo or domperidone (20 mg orally) plus BC. Domperidone blocked the effects of BC on norepinephrine and BP in the supine position. On standing there was a significant decrease in systolic (P less than 0.05) and diastolic (P less than 0.05) BP and an increase in epinephrine levels (58.9 +/- 12.2 vs. 109.8 +/- 24.6 pg/ml, P less than 0.05) was still observed. Plasma PRL increased significantly (P less than 0.025). The results of this study suggest that the inhibition of sympathetic outflow induced by BC is peripherally mediated. As peripheral dopamine receptor blockade did not counteract all the effects after BC during standing, dopaminergic modulation of central reflex sympathetic activation is suggested.

Effects of long-term molsidomine treatment versus isosorbide dinitrate and placebo on exercise tolerance in stable angina

A single-blind study (n = 59) was performed to assess the effect of long-term (4 week) orally administered molsidomine (2 mg 4 X daily), isosorbide dinitrate (10 mg 4 X daily), and placebo on exercise tolerance performed on the bicycle ergometer by patients with stable angina on effort and with significant coronary artery disease. Isosorbide dinitrate had similar effects to placebo, both failed to modify the pressure-rate product, the sustained work load, and the ST segment depression, but slightly decreased, although not significantly, the incidence of angina. Although not affecting the pressure-rate product and the mean blood pressure, molsidomine decreased significantly the ST segment depression (p less than .05). In conclusion, by markedly reducing preload and because of its long-lasting effect (up to 6 h), the new vasodilator drug molsidomine plays a useful role in the long-term management of stable angina on effort.

[Relation between the QT interval and the severity of ventricular arrhythmias in the early phases of myocardial infarct]

The purpose of our research was to evaluate the relationship between the severity of ventricular arrhythmias in the first hours of myocardial infarction and the duration of electrical systole (QT). Twelve-lead resting electrocardiograms (ECGs) of 66 non-consecutive patients admitted to our Coronary Care Unit for myocardial infarction were retrospectively evaluated. Criteria for retrospective selection of patients were the following: 1) admission to the coronary care unit within 12 hours from the onset of myocardial infarction symptoms; 2) appropriate ECG changes suggesting acute transmural infarction (pathologic Q waves, envolving ST changes) and diagnostic elevation of serum enzymes activity; 3) good-quality ECG recordings with sinus rhythm and no conduction defects, recorded before the beginning of therapy and within the first hours after the onset of symptoms. After this first selection, the following criteria of exclusion were applied: 1) abnormal values of serum Ca++ and K+; 2) historical and/or electrocardiographic findings of a previous myocardial infarction; 3) chronic treatment with antiarrhythmic or beta-blocking drugs, digitalis or other drugs affecting the QT interval; 4) administration of drugs affecting the QT interval before admission; 5) clinical signs of left ventricular failure or cardiogenic shock at admission or during the hospitalization; 6) development of severe ventricular arrhythmias after 24 hours from the onset of symptoms. Three subgroups were individuated : group A: 39 patients with non life-threatening ventricular arrhythmias; group B: 12 patients with episodes of ventricular tachycardia within the first 12 hours of myocardial infarction; group C: 15 patients with episodes of ventricular fibrillation within the first 12 hours of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

QT/QS2 ratio as an index of autonomic tone changes

The effects of changes in sympathetic tone on QT/QS2 ratio were studied in 10 healthy subjects aged 21 to 24 years. The subjects underwent a bicycle ergometer exercise, a tilt test, a decrease in carotid transmural pressure induced by means of pneumatic neck chamber, an i.v. injection of phenylephrine. A phonocardiogram and ECG were simultaneously recorded at a paper speed of 100 mm/s to evaluate QT and QS2 intervals in each test. In basal conditions, the QT/QS2 ratio was less than 1, whereas it increased progressively during the physical exercise and became greater than 1 at peak exercise. Both the upright position and the increase in neck-tissue pressure induced a significant increase in the QT/QS2 ratio as compared with the basal values, whereas i.v. administration of phenylephrine reduced significantly the QT/QS2 ratio. These results demonstrate that those stimuli which induce a rise in adrenergic activity may increase the QT/QS2 ratio. In contrast, the reflex inhibition of the adrenergic activity induced by phenylephrine is accompanied by a reduction in QT/QS2 ratio. Therefore, the QT/QS2 ratio might represent a reliable index of sympathetic cardiac tone.

Influence of heart rate on exercise-induced R-wave amplitude changes in coronary patients and normal subjects

In order to study whether different heart rates achieved at peak exercise by normal subjects and patients with coronary artery disease (CAD) affect the results of analysis of R-wave amplitude changes (delta R), we evaluated delta R at progressively increasing heart rate (HR) steps in 60 normal subjects with negative exercise tests (ET), in 130 patients with CAD, in 88 patients with true positive and 42 with false negative ET, and in 43 patients with no CAD and false positive ET. We found that the sensitivity and specificity of delta R were HR dependent, the former decreasing and the latter increasing with progressively increasing HR steps. Mean values of delta R did not discriminate among the four groups for HRs up to 150 bpm; significant differences were found between normal subjects and CAD patients, both with true positive and false negative stress tests, at HR greater than 150 bpm. False positive patients had mean delta R similar to those found in normal subjects. We hypothesize that quantitative delta R analysis could be useful in ECG diagnosis of false negative and false positive patients at HR greater than 150 bpm.

Plasma catecholamine response to orthostasis in longstanding hypothyroidism

In seven normotensive women affected by long-standing hypothyroidism norepinephrine peripheral levels were found significantly higher than after replacement therapy and than normal controls. After standing norepinephrine peripheral concentrations increased further; such an increase, although percentually lower than after therapy was sufficient to assure an adequate clinical response to orthostasis.

Exercise induced ventricular arrhythmias. Angiographic correlation with the severity of coronary artery disease

We correlated the incidence and degree of exercise induced ventricular arrhythmias (EIVA) with the angiographic severity of coronary artery disease (CAD) in 162 patients with a history of stable effort angina, all showing a positive exercise stress test for myocardial ischemia and a greater than or equal to 70% stenosis of a major coronary artery. Patients were grouped according to the following criteria: presence of electrocardiographic evidence of old transmural myocardial infarction (MI), number of significant coronary stenoses and number of left ventricular (LV) areas showing abnormal segmental wall motion (ASWM). The incidence of EIVA in patients with multivessel CAD was higher than in patients with single vessel CAD, but this difference was not statistically significant. The number of LV areas with ASWM was better correlated with the frequency of EIVA, which was 20.0% in patients with normal LV wall motion, 31.2% in patients with 1 area of ASWM, 54.0% in patients with 2 areas of ASWM (p less than 0.005 vs normal LV wall motion), 74.1% in patients with 3 or more areas of ASWM (p less than 0.001 vs normal LV wall motion and 1 area of ASWM), and 81.8% in patients with LV aneurysm (p less than 0.001 vs normal LV wall motion and 1 area of ASWM, p less than 0.005 vs 2 areas of ASWM). Patients with old MI showed a significantly higher incidence of EIVA than those without MI (p less than 0.001), but this difference was due to the more severe LV asynergy in the MI group. In conclusion, our results show that, in a selected population of patients with CAD, the incidence of EIVA correlates better with the extent of LV segmental wall motion abnormalities than with the number of diseased coronary arteries or the presence of an old transmural MI.

ATP and ADP content of human ejaculated spermatozoa. II. Time-dependent changes after ejaculation

ATP and ADP content of ejaculated spermatozoa of 7 donors were measured by a bioluminescent method within 24 h. The semen samples were kept at room temperature and at prefixed time were tested for motility and viability and extracted for ATP and ADP measurement. ATP pattern in relation to the time was studied with a mathematical model and the resulting curve showed a very high significance (P less than 0.001). ADP decrease with time was not significant and was variable among our subjects. The relationship between ATP decrease (%) and the decrease (%) of viability and motility was not linear, and till now no mathematical model has been found to express this phenomenon.

ATP and ADP content of human ejaculated spermatozoa. I. Relationship with semen physical parameters in normal donors and oligozoospermic patients

ATP and ADP were measured by a bioluminescent method in human ejaculated spermatozoa from 31 normal donors and oligozoospermic patients. ATP and ADP expressed for the sperm total number were significantly correlated (P less than 0.001). ATP snd ADP levels were found significantly correlated with the total motile spermatozoa and with the total viable cells (respectively P less than 0.001 and P less than 0.001 for ATP and P less than 0.001 and P less than 0.001 for ADP). ATP/ADP ratio was found significantly lower in subjects with sperm motility less than 50% (P = 0.024) and total viable cells less than 80% (P = 0.026).