The BLOSSoM study: Burnout after perinatal LOSS in Midwifery. Results of a nation-wide investigation in Italy

BACKGROUND

Respectful care of bereaved parents after stillbirth plays a pivotal role in enabling the grieving process and reducing the traumatic impact of this life-changing event. Unfortunately, professionals and midwives, in particular, are often emotionally unprepared and frequently left alone when dealing with these stressful events.

AIM

The BLOSSoM (Burnout after perinatal LOSS in Midwifery) study aims to address the levels of professional burnout in Italian midwives and evaluate the psychological impact of bereavement care on professionals.

METHODS

Web-based cross-sectional study, including socio-demographic questionnaire, survey on the knowledge of guidelines for stillbirth management and two psychometric tests: Maslach Burnout Inventory (MBI) and Impact of Event Scale - Revised (IES-R).

FINDINGS

Of 445 female midwives, mean age 35.1 (SD 9.9), working years 11.2 (SD 10.2), 149 (33.4%) reported specific training on stillbirth and 420 (94.6%) highlighted the need for further training and support. Medium to high levels of burnout (Emotional Exhaustion) were present in 65 midwives (15.9%) with a high prevalence of Reduced Personal Accomplishment (292, 64.2%). 'Communicating the diagnosis of death' was considered the hardest task, followed by 'assisting the meeting with the baby'; 109 midwives (24.5%) reported high IES-R scores (>30), suggesting symptoms of PTSD related to stillbirth events; a good level of knowledge of guidelines favoured Personal Accomplishment (OR 0.3 [0.1 - 0.6]). The number of stillbirths assisted by midwives was not associated with burnout levels.

CONCLUSION

Midwives are particularly at risk of developing professional burnout, as early as after five years of work, with a significant association with the psychological impact exerted by stressful events (stillbirth).

The hypothalamic-pituitary-adrenal and -thyroid axes activation lasting one year after an earthquake swarm: results from a big data analysis

PURPOSE

To cope physical and/or psychological threats, the human body activates multiple processes, mediated by a close interconnection among brain, endocrine and inflammatory systems. The aim of the study was to assess the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axes involvement after an acute stressful event (Emilia Romagna earthquake swarm) with a big data approach.

METHODS

A retrospective, observational trial was performed, collecting all biochemical examinations regarding HPA and HPT axes performed in the same laboratory the year before and the year after the earthquake swarm (20-29 May 2012).

RESULTS

Comparing 2576 pre-earthquake to 3021 post-earthquake measurements, a cortisol serum level increase was observed (p < 0.001). Similar increase was evident for urinary free cortisol (p = 0.016), but not for adrenocorticotropic hormone (p = 0.222). The biochemical hypercortisolism incidence increased from 7.6 to 10.3% after earthquakes (p = 0.001). Comparing 68,456 pre-earthquake to 116,521 post-earthquake measurements, a reduction in thyroid-stimulating hormone (TSH) levels was evident (p = 0.018), together with an increase in free triiodothyronine and free thyroxine levels (p < 0.001 and p < 0.001). Moreover, a significant increase in altered TSH after earthquakes was registered considering the epicenter-nearest measurements (p < 0.001). No clinically relevant alterations were observed considering thyroid-specific autoantibodies.

CONCLUSION

A long-term HPA axis activation in the inhabitants of the earthquake-affected areas was highlighted for the first time. Moreover, an increased incidence of biochemical hypercortisolism emerged after earthquakes. We confirmed a recruitment of HPT axis after stressful events, together with increased incidence of altered TSH in the. Our big data study allowed to increase knowledge about the connection between external stressors and endocrine regulation.

The steroid response to human chorionic gonadotropin (hCG) stimulation in men with Klinefelter syndrome does not change using immunoassay or mass spectrometry

PURPOSE

Liquid-chromatography tandem mass-spectrometry (LC-MS/MS) was developed in parallel to Immunoassays (IAs) and today is proposed as the "gold standard" for steroid assays. Leydig cells of men with Klinefelter syndrome (KS) are able to respond to human chorionic gonadotropin (hCG) stimulation, even if testosterone (T) production was impaired. The aim was to evaluate how results obtained by IAs and LC-MS/MS can differently impact on the outcome of a clinical research on gonadal steroidogenesis after hCG stimulation.

METHODS

A longitudinal, prospective, case-control clinical trial. (clinicaltrial.gov NCT02788136) was carried out, enrolling KS men and healthy age-matched controls, stimulated by hCG administration. Serum steroids were evaluated at baseline and for 5 days after intramuscular injection of 5000 IU hCG using both IAs and LC-MS/MS.

RESULTS

13 KS patients (36 ± 9 years) not receiving T replacement therapy and 14 controls (32 ± 8 years) were enrolled. T, progesterone, cortisol, 17-hydroxy-progesterone (17OHP) and androstenedione, were significantly higher using IAs than LC-MS/MS. IAs and LC-MS/MS showed direct correlation for all five steroids, although the constant overestimation detected by IAs. Either methodology found the same 17OHP and T increasing profile after hCG stimulation, with equal areas under the curves (AUCs).

CONCLUSIONS

Although a linearity between IA and LC-MS/MS is demonstrated, LC-MS/MS is more sensitive and accurate, whereas IA shows a constant overestimation of sex steroid levels. This result suggests the need of reference intervals built on the specific assay. This fundamental difference between these two methodologies opens a deep reconsideration of what is needed to improve the accuracy of steroid hormone assays.

Human chorionic gonadotropin stimulation gives evidence of differences in testicular steroidogenesis in Klinefelter syndrome, as assessed by liquid chromatography-tandem mass spectrometry

BACKGROUND

Men with Klinefelter syndrome (KS) show hypergonadotropic hypogonadism, but the pathogenesis of hypotestosteronemia remains unclear. Testicular steroidogenesis in KS men was evaluated over three decades ago after human chorionic gonadotropin (hCG) stimulation, but inconclusive results were obtained. Intriguingly, some recent studies show increased intratesticular testosterone concentrations in men with KS.

OBJECTIVE

To analyze serum steroid profile, as a proxy of testicular steroidogenesis, after hCG stimulation in KS compared with control men.

DESIGN

A prospective, longitudinal, case-control, clinical trial.

METHODS

Thirteen KS patients (36±9 years) not receiving testosterone (TS) replacement therapy and 12 eugonadic controls (32±8 years) were enrolled. Serum steroids were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) at baseline and for five consecutive days after intramuscular injection of 5000IU hCG.

RESULTS

Progesterone (P), 17-hydroxyprogesterone (17OHP), TS, and estradiol (E2) showed a significant increase (P<0.001) after hCG stimulation in both groups. On the contrary, androstenedione (AS) and dehydroepiandrosterone did not increase after hCG stimulation. The 17OHP/P ratio increased in both groups (P<0.001), the TS/AS ratio (17β-hydroxysteroid dehydrogenase type 3 (17βHSD3) activity) did not increase after hCG in any group, and the E2/TS ratio (aromatase activity) increased significantly in both groups (P=0.009 in KS and P<0.001 in controls). Luteinizing hormone decreased after hCG in both groups (P=0.014 in KS and P<0.001 in controls), whereas follicle-stimulating hormone decreased only in control men (P<0.001).

CONCLUSION

This study demonstrates for the first time using LC-MS/MS that Leydig cells of KS men are able to respond to hCG stimulation and that the first steps of steroidogenesis are fully functional. However, the TS production in KS men is impaired, possibly related to reduced hydroxysteroid deydrogenase activity due to an unfavorable intratesticular metabolic state.

Thallium 201 for detection of viable myocardium: comparison of different reinjection protocols

BACKGROUND

The finding fo false fixed 201Tl defects by the conventional stress-redistribution protocol is a well-known phenomenon. The aim of this study was to compare two different 201Tl reinjection protocols to identify viable myocardium in the same group of patients.

METHODS AND RESULTS

Twenty-seven patients with ischemic heart disease and at least one persistent defect on 201Tl uptake redistribution images 3 hours after stress were investigated. In the same-day protocol (R1) patients were reinjected with 1 mCi 201Tl immediately after redistribution images, with imaging starting 15 minutes later; in the different-day protocol the patients were reinjected with 2 mCi 48 to 96 hours later. Two sets of images were obtained, 30 (R2) and 180 (R3) minutes after reinjection. The comparison of redistribution and reinjection versus stress images showed a significant (p < 0.01) frequency distribution. The uptake of 201Tl of the 111 irreversible segments at redistribution was enhanced in 35.1% with R1, 43.2% with R2, and 49.5% with R3. The agreement among the three procedures in classifying the segmental defects was high between R2 and R3 (r = 0.81) and lower between the same- and different-day protocols. Of the 19 patients with a dominant scar pattern demonstrated by the conventional stress-redistribution study, 37%, 47%, and 53% were judged mainly ischemic after R1, R2, and R3, respectively. All but three of the 55 segments-showing an increased 201Tl uptake by R3 had an echocardiographic score of 2 or greater.

CONCLUSION

The best technique to differentiate scarred from viable myocardium seems to be the reinjection of a second dose of 201Tl on a different day followed by imaging 3 hours later.

Effect of sulpiride on ischemia- and reperfusion-induced heart damage, in rats

In an experimental model of heart ischemia, obtained in anesthetized rats with the permanent ligature of the left anterior descending coronary artery, the intravenous (iv) injection of I-sulpiride (6-25 micrograms/kg) dose-dependently reduced the lethality rate, the incidence and severity of ventricular dysrhythmias and infarct size during the early phase of ischemia (first 30 min after coronary ligation). Lethality and there incidence and duration of ventricular dysrhythmias were also significantly reduced by the same IV doses of I-sulpiride in a model of coronary reperfusion. These results show that a specific dopamine antagonist is able to limit ischemia- and reperfusion-induced myocardial damage and suggest that endogenous dopamine may exert a deleterious effect in such conditions.

Capsaicin prevents the adrenocorticotropin-induced improvement of cardiovascular function and survival in hemorrhage-shocked rats

A volume-controlled hemorrhagic shock was produced in anesthetized rats by intermittent bleeding from an iliac vein over a period of 20-30 min, until the carotid mean arterial pressure (MAP) stabilized around 20-24 mmHg. In this condition, which caused the death of all saline-treated animals within 25-30 min, the intravenous (i.v.) bolus injection of the adrenocorticotropin fragment 1-24 (ACTH(1-24)) at a dose of 160 micrograms/kg promptly restored MAP, as well as pulse pressure, heart rate and respiratory function, and greatly prolonged the survival time. Capsaicin (125 mg/kg cumulatively, s.c., 1 week before) completely prevented the anti-shock effect of ACTH(1-24), which, on the other hand, was shared by i.v. [Nle11]-substance P (SP) (200-300 micrograms/kg). Finally the SP-antagonist [D-Arg1,D-Pro2,D-Trp7,9,Leu11]-SP prevented the effect of ACTH(1-24). These results suggest that SP-containing nerve fibers are required for the effect of ACTH in hemorrhagic shock.

Reversal of experimental hemorrhagic shock by dimethylphenylpiperazinium (DMPP)

In a rat model of hemorrhagic shock which caused the death of all control rats within 30 min, i.v. injection of the ganglion-stimulating drug dimethylphenylpiperazinium (DMPP) caused a dose-dependent reversal of the shock condition--without the need for reinfusion of the shed blood--starting from the dose of 4 ng/kg i.v. Shock reversal was associated with the mobilization of residual blood and improvement in blood flow, particularly at the carotid level. These results could influence our thinking on pathophysiology and first-aid management of shock.

Influence of ACTH-(1-24) on metabolic acidosis and hypoxemia induced by massive hemorrhage in rats

In anesthetized rats, step-wise bleeding to a severe condition of hemorrhagic shock causes a decrease in arterial and venous pH and in venous PO2 and SO2 and an increase in arterial PO2 and in venous PCO2 and lactic acid. The intravenous bolus injection of ACTH-(1-24) (160 micrograms/kg)--which causes a rapid and sustained reversal of the shock condition--produces a gradual and almost complete recovery (within 60 min) of venous PO2, PCO2 and SO2; on the other hand, the normalization of blood pH and lactate is preceded by a further worsening during the first minutes after treatment. On the whole, these data are compatible with the ACTH-(1-24)-induced mobilization of the residual blood--which is pooled in poorly oxygenated tissues--and with the improved circulatory and respiratory functions.

Influence of TRH on regional blood flow and metabolic acidosis in a model of volume-controlled hemorrhagic shock in rats

In anesthetized rats, massive bleeding to a severe condition of hemorrhagic shock (invariably leading to death within 30 min) was obviously associated with a dramatic decrease in tissue blood flow and with profound modifications of several blood parameters leading to metabolic acidosis: decrease in arterial and venous pH, bicarbonate and BE, decrease in arterial pCO2 and in venous pO2 and SO2, increase in arterial pO2, venous pCO2 and venous lactate. The i.v. bolus injection of protirelin tartrate (TRH-T, 4 mg/kg), which produces a prompt and sustained reversal of the shock condition, caused a rapid increase in venous pO2, pCO2 and SO2; on the other hand, arterial and venous pH, bicarbonate and BE continued to decrease--and venous lactate to increase during the first few minutes after treatment. However venous pCO2 and lactate, as well as arterial and venous pH, returned to the pre-bleeding values within 60 min after treatment. The data are in keeping with the TRH-T-induced improvement of circulatory and respiratory functions, with mobilization of the residual blood from its capillary pooling and consequent immission of acid metabolites into the blood stream.

Nicotine reverses hemorrhagic shock in rats

Cholinergic mechanisms are currently thought to play an essential role in blood pressure homeostasis. Here we show that, in urethane-anaesthetized rats bled to severe hemorrhagic shock, the i.v. administration of nicotine 0.2-50 micrograms/kg causes a prompt, sustained and dose-dependent improvement in cardiovascular and respiratory functions, the animals' survival rate being significantly higher than that of animals treated with saline. These effects are prevented by bilateral cervical vagotomy and by concurrent local anaesthesia of the carotid bodies, which suggests that stimulation of visceral afferents is the main mechanism of action of nicotine in hemorrhagic shock.

Afferent vagal fibres and central cholinergic mechanisms are involved in the TRH-induced reversal of haemorrhagic shock

In a model of haemorrhagic shock causing the death of all saline-treated rats within 25.8 +/- 2.7 min after treatment, the intravenous injection of thyrotropin-releasing hormone tartrate (TRH-T) at the dose of 4 mg/kg induces a prompt and sustained increase of arterial pressure and pulse amplitude, with survival of all rats. Bilateral vagotomy, atropine sulphate (2 mg/kg intraperitoneally) and hemicholinium-3 (20 micrograms/rat intracerebroventricularly) partially prevent the TRH-T-induced shock reversal, whereas atropine methylbromide has no effect. These data indicate that afferent vagal fibres, brain cholinergic neurons and central muscarinic receptors play a role in the mechanism of the anti-shock effect of TRH-T.

Ischemia- and reperfusion-induced arrhythmias are prevented by putrescine

The influence of putrescine on cardiac arrhythmias induced by either permanent ligature of the left anterior coronary artery or heart reperfusion following a 5-min coronary occlusion was studied in anesthetized rats. Reperfusion-induced arrhythmias were significantly prevented by the i.v. injection of 150-200 mg/kg of putrescine, the survival rate being 100% in treated animals and 40% in controls. At a dose level of 200-300 mg/kg i.v., putrescine also significantly reduced the duration of ventricular tachycardia induced by permanent coronary occlusion. These findings show that putrescine significantly reduces the consequences of cardiac ischemia and reperfusion, probably as a consequence of its multiple stabilizing effects at the membrane level.

Antidiuretic and nephrotoxic effects of putrescine in rats

Putrescine, intraperitoneally injected either into intact or into hypophysectomized rats, caused a reduction in urine volume at doses of 200-300 mg/kg. At doses of 100 mg/kg or more, there was also a significant loss of potassium. The highest dose (300 mg/kg) caused haemoglobinuria, proteinuria, increased natriuresis, increased urinary osmolarity, reduced aldosteronaemia, ectasis of glomerular capillaries and tubular damage. The underlying mechanism(s) are probably mostly linked to the strong cationic charge of putrescine and to its binding to fixed anions of tubular-cell membrane.

TRH reverses the ECG and EEG ischemic changes induced by massive hemorrhage in rats

In a rat model of volume-controlled hemorrhagic shock causing the death of all saline-treated animals within 30 min of treatment, the intravenous bolus injection of thyrotropin- releasing hormone tartrate (TRH-T) at the dose of 4 mg/kg induced the prompt and sustained disappearance of the ECG and EEG signs of heart and brain ischemia, along with the reversal of hypotension and respiratory depression and with 100% survival rate at the end of the 2 h observation period. These data confirm that, in a pre-terminal condition induced by massive hemorrhage, timely treatment with TRH-T will restore heart and brain perfusion to levels compatible with survival and with functional recovery from ischemia and maintain it at those levels for some hours.

Influence of gonadotropin-releasing hormone on castration-induced 'depression' in mice: a behavioral and binding study

Long-term (33-35 days) castration caused a significant increase in the duration of immobility of male and female mice in the tail suspension test (an animal model of depression), and a significant decrease in the maximum number (Bmax) of [3H]imipramine binding sites in the cerebral cortex of male mice. In the tail suspension test, gonadotropin-releasing hormone (GnRH), s.c. injected 3 times at 3-h intervals at doses of 0.2, 2 or 20 micrograms/kg, did not significantly modify the duration of immobility of castrated animals and did not reduce that of sham-operated ones, while desipramine (20 mg/kg s.c. 1 h before testing) restored immobility to normal in castrated animals and reduced it significantly in sham-operated ones. The same treatment schedule with GnRH produced an increase in the number of [3H]imipramine Bmax in cortical membranes that was statistically significant at the dose of 2 micrograms/kg. It is concluded that the castration-induced depression-like behavior in mice seems not to be due to the decreased levels and release of GnRH, and that GnRH has no antidepressant-like effect in mice, at least at our dose levels; however, GnRH seems to increase the number of cortical [3H]imipramine binding sites.

Early treatment with ACTH-(1-24) in a rat model of hemorrhagic shock prolongs survival and extends the time-limit for blood reinfusion to be effective

The ability of ACTH-(1-24) to prolong survival and to extend the deadline for effective blood reinfusion has been studied in a model of lethal hypovolemic shock in the rat. Anesthetized rats were bled to a mean arterial pressure of 18 to 25 mm Hg and then subjected to one of the following iv treatments: a) saline; b) ACTH-(1-24), 160 micrograms/kg; c) blood reinfusion; d) ACTH-(1-24), 160 micrograms/kg; c) blood reinfusion; d) ACTH-(1-24), with saline 5 min after bleeding died within 0.05 h. On the other hand, the treatment with ACTH-(1-24) induced an almost complete and sustained recovery of cardiovascular and respiratory functions associated with a survival time of 44 +/- 18 h, while four of six rats reinfused with the withdrawn blood were still alive 15 days later. The time-lapse between bleeding and treatment was of crucial importance, and neither ACTH-(1-24) injection nor blood reinfusion had any effect if performed 25 min after bleeding. However, treatment with ACTH-(1-24) shortly after bleeding (5 min) greatly improved the effect of a later blood reinfusion. These data indicate that ACTH-(1-24) can prolong survival and permit the time-lapse between blood loss and blood reinfusion to be extended.

Circulatory and respiratory consequences of massive hemorrhage are reversed by protoveratrines

In a rat model of severe hypotension and respiratory depression induced by step-wise bleeding, protoveratrines cause a prompt and sustained improvement of cardiovascular and respiratory functions, both in anesthetized and in conscious animals, seemingly through a magnification of the reflex response originated by the chemoreceptors of aortic and carotid bodies. The restoration of cardiovascular function is attributable to an increase both in total peripheral resistance and cardiac output. The finding could provide the basis for a new approach to the first-aid management of massive blood losses.

Brain M3 muscarinic receptors are involved in the ACTH-induced reversal of hemorrhagic shock

In an experimental model of bleeding-induced hemorrhagic shock causing the death of all saline-treated rats within 30 min, the intravenous injection of ACTH-(1-24) at the dose of 160 micrograms/kg induced a sustained reversal of the shock condition, with almost complete recovery of blood pressure, pulse amplitude, respiratory rate, heart rate, and 100% survival, at least for the 2 h of observation. This effect of ACTH-(1-24) was prevented by the intracerebroventricular injection of 4-DAMP (a highly selective antagonist for M1 and M3 muscarinic receptors), but unaffected by the intracerebroventricular injection of pirenzepine (a highly selective antagonist for M1 muscarinic receptors). These data indicate that an essential step in the complex mechanism of the ACTH-induced shock reversal may be the activation of brain M3 muscarinic receptors.

Influence of morphine on the reversal of haemorrhagic shock induced by cholinergic drugs

In haemorrhage-shocked rats, the recovery of mean arterial pressure (MAP), pulse pressure (PP) and respiratory rate (RR), as well as the improvement of survival rate, induced by the i.v. administration of centrally acting cholinergic drugs (physostigmine, oxotremorine) are not affected by morphine at the dose of 2.5 mg/kg i.v., and only partially (MAP, PP, survival rate) or not at all (RR) prevented by a dose of morphine of 5 mg/kg i.v. These results indicate that the anti-shock effect of cholinergic drugs is largely independent of the opioid tone, this possibly being of practical relevance.

Intracerebroventricular injection of hemicholinium-3 prevents the ACTH-induced, but not the physostigmine-induced, reversal of hemorrhagic shock in rats

In rats bled to hypovolemic shock, the intracerebroventricular injection of hemicholinium-3 (20 micrograms/rat) completely prevented the shock reversal induced by the intravenous injection of ACTH (1-24) (160 micrograms/kg), but had no influence on the shock reversal induced by the intravenous injection of physostigmine (70 micrograms/kg). These data indicate that brain cholinergic neurons are involved in the anti-shock effect of ACTH-peptides, but not in that of centrally acting cholinergic drugs.

Effect of castration and testosterone in experimental models of depression in mice

In the behavioral despair (forced swimming) test and in the tail-suspension test, long-term (30-32 days) castration significantly increased the duration of immobility in mice. Testosterone propionate (1 or 10 mg.kg-1.day sc for 4 days), although not affecting the duration of immobility in sham-operated mice, reduced the duration of immobility in castrated mice to within normal limits. Desipramine (20 mg/kg ip) decreased the duration of immobility both in sham-operated and in castrated animals. These results indicate that castration favors an inactive behavior and that testosterone, although having no "antidepressant" effect per se, is necessary for the male animal to cope normally with adverse environmental situations.

Putrescine reverses aconitine-induced arrhythmia in rats

Putrescine, (150-300 mg kg-1 i.v.) injected into anaesthetized rats reversed aconitine-induced arrhythmia and restored sinus rhythm. In the same experimental model, quinidine and lignocaine had a transient therapeutic effect, procainamide was practically ineffective and verapamil worsened the aconitine arrhythmia, causing the death of all treated animals. These data demonstrate that putrescine has an antiarrhythmic effect in an experimental model particularly resistant to usual antiarrhythmic treatments.

Reversal of haemorrhagic shock in rats by cholinomimetic drugs

1. In an experimental model of haemorrhagic shock resulting in the death of all rats within 20-30 min, the intravenous (i.v.) injection of the tertiary amine cholinesterase inhibitor physostigmine (17-70 micrograms kg-1) induced a prompt, sustained and dose-dependent improvement of cardiovascular and respiratory function, with marked increase in the volume of circulating blood and survival of all treated animals, at least for the 2 h of observation. 2. Similar results were obtained with the i.v. injection of the cholinoceptor agonist oxotremorine (5-25 micrograms kg-1), while neostigmine (54 or 70 micrograms kg-1), a quaternary cholinesterase inhibitor which cannot cross the blood-brain barrier, had negligible effects. 3. The anti-shock activities of oxotremorine and physostigmine were blocked by the intracerebroventricular injection of either of the combined nicotinic and M2-muscarinic receptor antagonists gallamine and pancuronium, or of the nicotinic antagonist mecamylamine. They were also blocked by intraperitoneal injection of the adrenergic neurone blocking agent guanethidine, but they were not antagonized by either the combined M1- and M2-muscarinic receptor antagonist atropine, the M1-muscarinic receptor antagonist pirenzepine, or the M2-muscarinic receptor 4-diphenylacetoxy-N-methylpiperidine methobromide. 4. It is concluded that cholinomimetic drugs can reverse hypovolaemic shock through central activation (seemingly mediated by nicotinic receptors) of sympathetic tone, with mobilization and redistribution of the residual blood.

[Surgical therapy of post-infarct aneurysm of the left ventricle. Immediate and long-term results]

Between January 1982 and December 1986, 62 patients (59 male and 3 female) ranging in age from 37 to 69 years (mean 53) underwent resection of postinfarction left ventricular aneurysm. The indication for operation was angina in 23 cases (37%), congestive heart failure (CHF) in 7 (11.2%), angina and CHF in 29 (46.8%), rupture in 1; 2 patients were low symptomatic. Ventricular arrhythmias were present in 6 (9.7%) cases and previous systemic embolism in 4 (6.4%). Forty-seven (75.8%) patients had lesions of three coronary arteries with involvement of left main coronary artery in 4 cases; 10 (16.1%) had lesions of two vessels [left anterior descending (LAD) and/or right coronary artery]; 4 (6.4%) had only LAD artery involvement, and 1 had no significant coronary artery stenoses. Left ventricular ejection fraction (EF) was less than 0.30 in 22% of cases, between 0.30 and 0.40 in 25.4% and greater than 0.40 in 50%. The location of the aneurysm was anterolateral or apical (83.8%), posterior (14.5%) and lateral (1.6%). Left ventricular aneurysmectomy with myocardial revascularization was performed in 61 patients (bypass/patient = 2.7), with ventricular septoplasty in 20 and concomitant mitral valve replacement in 3 patients. LAD was grafted in 59.6% of anterior aneurysm. Operative mortality (30 days) was 4.8%, the late mortality, with a follow-up between 12 and 72 months (mean 38), was 6.7% and the actuarial 5 year survival rate was 85% (91% without operative mortality). In our experience, despite no evidence of any operative risk factors, no improvement was noted in radionuclide left ventricular ejection fraction in patients undergoing aneurysmectomy with ventricular septoplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of ovariectomy, estradiol and progesterone on the behavior of mice in an experimental model of depression

In the tail suspension test (an animal model of depression) the duration of immobility during the 6 min of observation was 56.84 +/- 6.54 sec in sham-ovariectomized mice and 113.11 +/- 7.86 sec 30-32 days after ovariectomy. Estradiol (10, 100 or 1,000 micrograms/kg) and progesterone (50, 1,000 or 10,000 micrograms/kg), subcutaneously injected daily 4 times before the test, restored the duration of immobility in ovariectomized mice to normal, while having no effect on sham-operated animals. On the other hand, desipramine (20 mg/kg IP 1 hr before testing) significantly reduced the duration of immobility both in ovariectomized and in sham-operated mice. These data indicate that ovarian sex hormones, while having no "antidepressant," desipramine-like, effect on the behavior of intact adult female mice, have such an effect in ovariectomized mice, and enable the animal to cope in a "normal" way with adverse environmental situations.

ODC-polyamine system is involved in morphine analgesia

alpha-Difluoromethylornithine (DFMO) directly infused into a brain-lateral ventricle (12.5, 25 and 50 micrograms/rat) dose- and time-dependently inhibited brain ODC activity. While having no influence per se on pain threshold, DFMO significantly inhibited the analgesic activity of morphine (15 mg/kg i.p.), this effect being obtained when brain ODC activity was reduced by at least 80%. On the other hand, DFMO had no influence on number and affinity of brain opiate binding sites. Morphine per se neither modified whole brain ODC activity nor significantly affected the ODC inhibitory effect of DFMO. In more discrete brain areas (midbrain, brainstem) morphine actually increased ODC activity. The present results indicate that brain ODC/polyamines system may play a role in the analgesic activity of opioids, probably at a post-receptorial level or through a non-opiate receptor-linked mechanism.

Effect of castration and testosterone in experimental models of depression in mice

In the behavioral despair (forced swimming) test and in the tail-suspension test, long-term (30-32 days) castration significantly increased the duration of immobility in mice. Testosterone propionate (1 or 10 mg.kg-1.day sc for 4 days), although not affecting the duration of immobility in sham-operated mice, reduced the duration of immobility in castrated mice to within normal limits. Desipramine (20 mg/kg ip) decreased the duration of immobility both in sham-operated and in castrated animals. These results indicate that castration favors an inactive behavior and that testosterone, although having no "antidepressant" effect per se, is necessary for the male animal to cope normally with adverse environmental situations.

Bombesin reverses bleeding-induced hypovolemic shock, in rats

In an experimental model of bleeding-induced hypovolemic shock causing the death of all saline-treated rats within 26 +/- 4 min, the intravenous injection of bombesin (2.5, 5 or 10 micrograms/kg) dose-dependently restored blood pressure, pulse amplitude, heart rate and respiratory function, and improved survival rate as assessed at the end of the experiment (2 h). The effect on cardiovascular and respiratory functions was prompt (within 1-2 min) and sustained. The release of cholecystokinin seems to be the main mechanism of action, because the anti-shock effect of bombesin is largely prevented by the CCK-antagonist, L-364,718.

Treatment with polyamine synthesis inhibitors reduces the positive inotropic effect of ouabain, noradrenaline and calcium

Polyamines (putrescine, spermidine and spermine) are considered to act as intracellular second messengers by increasing Ca++ influx and mobilizing intracellular calcium. On the other hand, intracellular Ca++ increase is the common final step of the mechanism of action of many inotropic agents. To discover whether the functional integrity of the cardiac ornithine decarboxylase (ODC)/polyamine system is necessary to cope with a stimulated inotropism, we studied the effect of ouabain, noradrenaline, and calcium on ventricle strips obtained from rats treated with polyamine synthesis inhibitors. The combined administration of methylglioxal bis (guanylhydrazone) (MGBG) (single i.p. injection of 50 mgkg-1) and of alpha-di fluoromethylornithine (DFMO) (100 mgkg-1 every 12 h for 7 consecutive days) caused a 62.5% inhibition of ventricular ODC activity, and a significant decrease of the ventricular content of putrescine and spermidine (-59.5%, and -40.1%, respectively). While the basal isometric tension developed by ventricle strips obtained from rats treated with MGBG+DFMO was similar to that developed by ventricle strips from controls, the response to ouabain (1 microM), noradrenaline (10 microM), or Ca++ (3.6 mM) was significantly reduced. It cannot be excluded that effects of MGBG unrelated to the inhibition of polyamine synthesis may have also concurred in part to influence the effect of ouabain, Ca++ and noradrenaline adversely. However, the present results seem to indicate that the heart response to inotropic agents requires an efficient ODC/polyamine system, polyamines probably being involved in calcium ion movements or affecting the Ca++ sensitivity of contractile proteins.

Shaking behaviour induced by putrescine in naive rats: a pharmacological and histological study

In untreated rats, the intraperitoneal injection of putrescine evoked a typical wet-dog shake response, that was maximal at a dose of 300 mg/kg and at room temperature (22 degrees) (number of shakes: 84.00 +/- 17.90/hr). In a hot environment (30 degrees) the number of shakes was markedly reduced (26.90 +/- 5.19/hr). The putrescine-induced shaking behaviour was unaffected by atropine, bicuculline, chlorpheniramine, cimetidine, methysergide, naloxone and noradrenaline, but was markedly antagonized by morphine. Naloxone pretreatment nullified the antagonistic activity of morphine. Histological studies showed marked alterations in brain vascular permeability, which was increased by putrescine. Morphine completely prevented this putrescine-induced vascular effect. These results suggest a correlation between WDS produced by putrescine and increase in brain vascular permeability. Furthermore they show that morphine can affect brain vascular permeability.

Impressive lung uptake during exercise thallium imaging with decrease of systolic blood pressure

A case of very high thallium lung activity during exercise myocardial imaging in a patient with an old myocardial infarction but free from typical angina or heart failure symptoms is reported. The impressively abnormal lung uptake occurred in connection with a stress-induced fall in the systolic blood pressure, pointing out a causal rôle of a transient left ventricular dysfunction and interstitial pulmonary oedema in the genesis of the scintigraphic picture. Three weeks after the test, the patient suddenly died at home.

Putrescine has hypothermic and antipyretic activity, in rats

Intraperitoneal injection of putrescine induced dose-related hypothermia in rats. The effect was more pronounced at room temperature (22 degrees C) than in a warm environment (30 degrees C), the maximum hypothermia (-2.64 +/- 0.29 degrees C, 30 min. after treatment) being obtained with the dose of 300 mg/Kg and remaining significant throughout 3 hr of observation. Putrescine also had antipyretic activity, as it significantly reduced pyrogen-induced fever at a dose level (100 mg/Kg i.p.) ineffective in causing hypothermia in normal rats. The hypothermic and antipyretic effects of putrescine were not associated with any obvious sign of toxicity.

[Percutaneous dilatation of pulmonary valve stenosis]

We present 11 cases of pulmonary valve stenosis who underwent percutaneous dilatation angioplasty. Patients were between 2 and 15 years old (mean age = 6.5 yrs) and all of them except 3 had moderate or severe degree of valve stenosis. Pulmonary anulus diameter ranged between 11 and 23 mm. at ECHO and between 10 and 21 mm. at angio. The catheter was chosen to be 20-40% larger than pulmonary anulus. The mean pressure gradient between RV and PA was 65 mmHg. before dilatation and 21 mmHg. after the procedure. The procedures were without complications, except one in which we observed an intermittent idioventricular rhythm for few days after the procedure. Percutaneous dilatation angioplasty has to be considered the treatment of choice for pulmonary valve stenosis.

Effects on long-term sensitivity to pain and morphine of stress induced in the newborn rat by pain or manipulation

Four times daily from postnatal day 1 to 15, rats were stressed either by being removed from the maternity cage (manipulation stress, MS) or by being placed on a hotplate at 55 degrees C (pain stress, PS). When 70 days old, they were examined for sensitivity to pain and to the analgesic effect of morphine, and for brain opiate receptors. Pain sensitivity of MS and PS rats was not significantly different from that of controls. The analgesic activity of morphine, assessed by the hotplate test at 49 degrees C, was significantly reduced in MS rats, while in PS rats it was similar to that in controls. 3H-dihydromorphine binding studies performed on whole brain synaptic membranes showed a reduction in the maximum number of binding sites in both MS and PS rats; on the other hand, the affinity constant was higher in PS rats, while in MS rats it was similar to that of controls. These data show that the repeated stress of removal from the mother during the first 15 days of life induce a reduction in the number of brain opiate receptors with reduced activity of morphine, while in rats exposed to repeated removal stress associated with painful stimuli the reduction in the number of brain opiate receptors seems to be counterbalanced by their higher affinity.

Low-pressure receptor activity and exaggerated natriuresis in essential hypertension

Urinary sodium excretion, central hemodynamics, and mean arterial pressure (MAP) were studied in 7 normal subjects and 19 hypertensive patients during both central hypervolemia by water immersion to the neck (NI) and extracellular volume expansion by i.v. saline infusion. During 2-hour NI, 12 out of the 19 hypertensives exhibited a significant fall in MAP (p less than 0.001). Exaggerated natriuresis did not occur in these patients (ns). In the remaining 7 hypertensive patients in whom, during NI, MAP was unchanged, exaggerated natriuresis was found (p less than 0.001). During saline infusion, MAP was either unchanged or increased and exaggerated natriuresis was found in all hypertensive patients (p less than 0.001) previously submitted to NI. Our findings suggest that a high MAP is a major determinant of exaggerated natriuresis in arterial hypertension.