Brexpiprazole in patients with schizophrenia with or without substance use disorder: an observational study

Background

Partial dopamine D2 receptor agonists are used for psychotic symptoms in adults with schizophrenia spectrum disorders. Recently, interest surged for partial dopamine D2 receptor agonists in substance use disorders (SUDs). Since it is believed that SUDs decrease the efficacy of pharmacotherapy of underlying psychiatric disorders, we tested the efficacy of the partial D2 agonist brexpiprazole in patients with schizophrenia who were either comorbid with a SUD (SUD group) or not comorbid (non-SUD) to assess treatment response and the effect of brexpiprazole on substance craving in SUD.

Methods

We included patients with DSM-5/DSM-5-TR schizophrenia (using SCID-5-CV) aged 18-66 years with either comorbid SUD or non-SUD to treat with brexpiprazole 4 mg/day for 6 months during February-October 2022. Patients were assessed with the Clinical Global Impressions-Severity (CGI-S) scale, the 24-item Brief Psychiatric Rating Scale (BPRS), and the Positive And Negative Syndrome Scale (PANSS) at baseline, weekly for the first 2 months and monthly for the next four. Furthermore, we assessed substance craving in SUD with a visual analog scale for craving (VAScrav) at the same timepoints.

Results

The total sample was 86 (85 analysable) 18- to 64-year-old (mean 39.32 ± 14.09) patients with schizophrenia [51 men (59.3%) and 35 women (40.7%)], of whom 48 SUD (55.8%) (37 men and 11 women) and 38 non-SUD (44.2%) (14 men and 24 women). No serious or persistent adverse events developed over the study period, but one patient dropped out for subjective akathisia. Results indicated the main effects of time with improvements over the course of the study for CGI-S, BPRS, and PANSS in both SUD and non-SUD groups and the entire sample, and for VAScrav in SUD. Brexpiprazole was associated with similar significant improvements in both groups at the 6 month endpoint compared to baseline.

Conclusion

Treatment with brexpiprazole for 6 months improved psychotic symptoms in patients with schizophrenia, independently from whether they belonged to the SUD or the non-SUD group; hence, SUD comorbidity did not confer treatment resistance to brexpiprazole. Furthermore, in the SUD group, we observed reduced substance craving.

A comprehensive evaluation of adverse childhood experiences, social-emotional impairments, and neurodevelopmental disorders in cannabis-use disorder: Implications for clinical practice

BACKGROUND

Adverse childhood experiences (ACEs), social-emotional impairments (SEIs), and neurodevelopmental disorders (NDs) are frequent in psychiatric disorders, including substance-use disorders. We aimed to determine the prevalence of ACE, SEI, or ND in individuals with cannabis-use disorder (CUD). We compared individuals with preCUD-onset ACE, SEI, or ND to those without.

METHODS

We crosssectionally studied 323 inpatients or outpatients with a history of past or current CUD, aged 12-35 years (mean age 22.94 ± 4.79), 64.5% of whom were male. The sample was divided into two groups: the non-premorbid (N = 52) and the premorbid ACE/SEI/ND group (N = 271). Within the premorbid group, further subgroups were based on ACEs, SEI, and NDs. We also analyzed other substance use and psychiatric symptoms/diagnoses based on the non-premorbid-premorbid dichotomy in the CUD sample.

RESULTS

Pre-CUD ACE-SEI-ND had higher prevalence of bipolar, schizoaffective, borderline personality, and attention-deficit/hyperactivity disorders, and a history of agitation, hallucinations, and self-injury. The ACE group had higher rates of agitation, depression, delusions, hallucinations, eating disorders, and use of cocaine, amphetamines, and hallucinogens than the SEI or ND. Patients in the premorbid group initiated cannabis use at an earlier age, experienced the first comorbid psychiatric episode earlier, and were hospitalized earlier than those in the non- premorbid ACE-SEI-ND group.

CONCLUSIONS

PreCUD-onset ACE, SEI, or ND conditions in individuals with CUDare linked to earlier onset of comorbid mental illness. Furthermore, ACEs contribute to significant and potentially severe clinical symptoms, as well as the use of substances other than cannabis.

Differential Response to Three Antidepressants in Patients with Major Depressive Episode Who Suffered Covid-19-Related Trauma

BACKGROUND

The Covid 19 pandemic might have impacted response to drug treatment in major depressive episode (MDE). We compared responses to three different antidepressant drugs, i.e., vortioxetine, sertraline, and trazodone, in outpatients with MDE during Major Depressive Disorder (MDD), Bipolar Disorder (BD), or schizophrenia and related psychoses (SSOPDs) during two time periods, i.e., before and after suffering Covid-19-related trauma.

METHODS

We conducted an observational study on clinically stabilised for at least 6 months outpatients with MDE during the course of MDD (N=58), BD (N=33), or SSOPDs (N=51). Patients, whose baseline assessments of Montgomery-Åsberg Rating Scale (MADRS), Hamilton Anxiety Rating Scale (Ham-A), Brief Psychiatric Rating Scale (BPRS), Visual Analogue Scale for Craving (VAS-crav) and World Health Organization Quality of Life, Brief version (WHOQOL-BREF) were available, were recruited at the time they suffered Covid-19-related traumas. Fifty patients, prior to the pandemic, when they were clinically stable, were treated with 15 mg/die vortioxetine, 44 with 450 mg/die trazodone, and 48 with 150 mg/die sertraline. After experiencing a major Covid-19-related personal trauma, patients showed clinical worsening which required dosage adjustment (20 mg/day vortioxetine; 600 mg/day trazodone, and 200 mg/day sertraline) and, for some of them, hospitalisation. Scores on the MADRS, Ham-A, BPRS, VAS-crav and WHOQOL-BREF were compared drug-wise and genderwise with Student's t test for continuous variables and Χ2 for categorical variables.

RESULTS

The sample consisted of 142 outpatients (age, mean 39.63 ± 16.84; 70 men and 72 women); women were older than men (mean age 43.18 ± 17.61 vs. 35.98 ± 15.30; p=0.01). The two genders did not differ on other variables. For all treatments, worsening symptoms were observed at the time of trauma, followed by slow recovery with treatment readjustment. Trauma-related worsening in patients on vortioxetine was less intense than patients on the other two antidepressants and recovery was faster. All drugs were associated with an improvement in QoL. The vortioxetine group showed a lower hospitalisation rate (24%) than sertraline (35.4%) and trazodone (38.6%), but this was not significant (p=0.27).

CONCLUSION

All drugs improved symptoms of Covid-19 trauma in patients with MDE, with vortioxetine showing a small advantage. No differences between vortioxetine, sertraline and trazodone were found as concerning the need for hospitalisation.

Treatment-resistant schizophrenia: Addressing white matter integrity, intracortical glutamate levels, clinical and cognitive profiles between early- and adult-onset patients

BACKGROUND

Treatment-resistance in schizophrenia is 30-40%. Its neurobiology remains unclear; to explore it, we conducted a combined spectrometry/tractography/cognitive battery and psychopathological rating study on patients with treatment-resistant schizophrenia (TRS), dividing the sample into early-onset (N = 21) and adult-onset TRS (N = 20). Previous studies did not differentiate between early- (onset 13-18 years) and adult-onset (>18 years at formal diagnosis of schizophrenia) TRS.

METHODS

We evaluated cross-sectionally 41 TRS patients (26 male and 15 female) and 20 matched healthy controls (HCs) with psychopathological and cognitive testing prior to participating in brain imaging scanning using magnetic resonance spectroscopy and diffusion tensor imaging to determine the relationship between their symptoms and their glutamate levels and white matter integrity.

RESULTS

TRS patients scored lower than HCs on all cognitive domains; early-onset patients performed better than adult-onset patients only on the Symbol Coding domain. TRS correlated with symptom severity, especially negative symptoms. Glutamate levels and glutamate/creatine were increased in anterior cingulate cortex. Diffusion tensor imaging showed low fractional anisotropy in TRS patients in specific white matter tracts compared to HCs (bilateral anterior thalamic radiation, cortico-spinal tract, forceps minor, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, superior longitudinal fasciculus, and right uncinate fasciculus).

CONCLUSIONS

We identified specific magnetic resonance spectroscopy and diffusion tensor imaging alterations in TRS patients. Adult-onset TRS differed little from early-onset TRS on most measures; this points to alterations being present since the outset of schizophrenia and may constitute a biological signature of treatment-resistance.

Developmental trajectories in psychiatric disorders: does substance/alcohol use moderate the effects of affective temperaments as moderators of age at onset? A study in post-acute, hospitalized patients with psychotic or DSM-5 bipolar or major depressive disorders

BACKGROUND

Age-at-onset (AAO) affects psychiatric disorder outcome; substance (SUDs) or alcohol use disorders (AUDs) may influence their onset. Affective temperaments may affect early AAO and drug-use proneness. Objectives: To investigate whether SUD/AUD moderated temperamental effects in determining AAO of mental disorders. Methods: We included 300 post-acute inpatients with schizophrenia-spectrum and other psychotic (SSOPDs), major depressive (MDD) or bipolar (BD) disorders (168 men; mean age, 40.63 years ± 11.82 men, 43.21 years ± 12.69 women) with (N = 110) or without (N = 190) SUD/AUD. Patients completed cross-sectionally TEMPS-A. We carried moderation analysis with each regression-significant TEMPS temperament as independent variable, SUD/AUD presence/absence as dichotomous moderator, and AAO as dependent variable. Significance was set at p < 0.05. Results: AAO was lower in patients with SUD/AUD diagnosis than in patients without (23.74 ± 10.09 vs. 27.73 ± 10.35, respectively, p = 0.001, η2 = 0.034). SUD/AUD patients scored higher on the hyperthymic (10.22 ± 4.08, p < 0.001, η2 = 0.069) and irritable (8.26 ± 4.69, p < 0.01, η2 = 0.026) temperaments than nonSUD/AUD patients. Moderation analysis showed only direct effects of irritable (β = -0.55, p < 0.005) and hyperthymic (β = -0.95, p < 0.001) temperaments on AAO and no significant SUD/AUD and interaction effects. Limitations. Cross-sectional design. Conclusions: When irritable and hyperthymic traits prevail over other temperaments, AAO is earlier in SSOPDs, MDD, and BD. SUD/AUD presence/absence does not moderate the relationship between temperament and AAO.

Vortioxetine vs. Other Antidepressants in Patients with Major Depressive Episode With or Without Substance Use Disorder

Background

Major Depressive Episodes (MDEs) may characterise many psychiatric disorders. Its pharmacotherapy is laid with unmet needs, rendering the testing of new drugs necessary.

Objective

To compare the effects of vortioxetine with those of other antidepressants (OADs) in a 1-year naturalistic setting.

Methods

We included 126 adult patients with anMDE in the course of major depressive (MDD), bipolar (BD), or schizophrenia spectrum disorders (SSOPDs), with or without substance use disorder (SUD), who received 5-20 mg/day oral vortioxetine, and compared them with 100 patients receiving OADs at baseline and after 1, 3, 8, and 12 months on their scores on the MADRS, the CGI-S, the 24-item BPRS, the YMRS, the Hamilton Anxiety Rating Scale, a Visual Analogue Scale for craving, the Columbia-Suicide Severity Rating Scale, and the WHOQOL-BREF.

Results

Patients on vortioxetine improved similarly to those on OADs on all measures, independently from having or not a comorbid SUD. However, they improved with time better than their OADcounterparts if affected by BD or SSOPDs, but not MDD, on the CGI-S, BPRS depression, anxiety, and manic symptoms. SUD hampered the response of anxiety to treatment. Men improved on depression with time better than women.

Conclusion

MDEs responded to vortioxetine similarly to OADs by improving in depression, general psychopathology, anxiety, suicidal thinking, and quality-of-life, independently from SUD comorbidity. MDEs of patients with BD or SSOPDs on vortioxetine responded better than that of patients on OADs. Clinical Trial Registration No. 17354N.

Aripiprazole Long-Acting Injection During First Episode Schizophrenia-An Exploratory Analysis

Background: Long-acting injectable (LAI) aripiprazole was found to be efficacious in schizophrenia. In common clinical practice, the use of LAIs is often restricted to chronic patients with frequent relapses and poor adherence. Recently, some investigators advanced the idea of early LAI use also in young people with schizophrenia at their first psychotic episode (FEP). Objective: Our study aimed to assess the effect of LAI aripiprazole once monthly (AOM) in the treatment of FEP in patients aged 18-26 years. Methods: We included 50 patients with DSM-5 schizophrenia as assessed with SCID, and used the Clinical Global Impressions Scale-Severity of Illness (CGI-S) and the Positive and Negative Syndrome Scale (PANSS) to assess symptom severity and the World Health Organization Quality of Life (WHOQOL), the Short Form Health Survey (SF-36) and the Personal and Social Performance Scale (PSP) to assess quality of life (QoL) and global health perception at baseline and 3, 6, 9, and 12 months after the first AOM injection. Results: AOM was associated with a progressive improvement, compared to baseline, of both positive (p < 0.001) and negative (p < 0.001) symptoms and in general psychopathology (p < 0.001) and decrease in global severity (p < 0.001). We also observed progressive improvement in QoL and social and personal functioning. Treatment adherence was 78% at study endpoint. Our results support that AOM may improve psychotic symptoms, QoL and social functioning in young FEP patients. Further studies should compare AOM to its oral formulation in the treatment of young patients with schizophrenia at the outset of their illness.

Head-to-head comparison of 1-year aripiprazole long-acting injectable (LAI) versus paliperidone LAI in comorbid psychosis and substance use disorder: impact on clinical status, substance craving, and quality of life

BACKGROUND

To overcome nonadherence in patients with psychosis switch to long-acting injectable (LAI) antipsychotic formulations is adopted. Most oral versus LAI comparisons showed similar antipsychotic responses. Psychoses often overlap with substance use disorder (SUD). Head-to-head LAI comparisons have hitherto focused only on non-comorbid populations.

OBJECTIVE

The objective of this study was to compare two LAIs, administered for 12 months, in initially hospitalized patients with psychosis comorbid with SUD in their clinical and quality of life (QoL) outcomes.

PATIENTS AND METHODS

Inpatients were recruited during 2016 and switched randomly to 400 mg intramuscular aripiprazole monohydrate (AM) (N=50) or to 100 mg intramuscular paliperidone palmitate (PP) once-monthly (N=51); patients were discharged and followed up for 12 months. Patients were rated at baseline and after 1 year through the Clinical Global Impression scale - severity (CGIs), substance craving intensity was rated through a visual analog scale for substance craving, and QoL through the World Health Organization (WHOQOL-BREF) scale. We addressed confounders with backward stepwise logistic regression and three-way analysis of variance.

RESULTS

PP were older and had more cases of schizophrenia spectrum and less bipolar disorders than AM, but AM had a stronger craving for substances at baseline. Both LAIs were associated with significant improvements in all outcomes, with AM displaying stronger effect sizes than PP. The two groups did not differ on baseline WHOQOL-BREF scores in any domain, but at the 1-year follow-up, AM fared better on all domains. The two groups did not differ in final severity, but PP scored higher than AM in craving at the 1-year endpoint.Limitation: The CGIs is not a refined tool for severity and the substance craving may be subject to recall bias.

CONCLUSION

1-year AM and PP was followed by improved clinical status and QoL and reduced substance craving in a population with psychosis and SUD comorbidity. AM, compared to PP, improved craving and QoL at the 1-year follow-up.

A hand-carried cardiac ultrasound device in the outpatient cardiology clinic reduces the need for standard echocardiography

OBJECTIVE

To assess the potential value and cost-effectiveness of a hand-carried ultrasound (HCU) device in an outpatient cardiology clinic.

METHODS

222 consecutive patients were prospectively enrolled in the study. When standard echocardiography (SE) was specifically indicated on the basis of clinical history, electrocardiogram and physical examination, the same cardiologist (level-2 or level-3 trained) immediately performed an HCU examination. The cardiologist then reassessed the clinical situation to confirm or cancel the SE request according to the information provided by HCU. The SE examination was performed by a sonographer and examined in a blinded fashion by a cardiologist expert in echocardiography. Findings from the two examinations were compared.

RESULTS

HCU was performed in 108/222 patients, and a definite diagnosis was established in 34 of them (31%), making SE examination potentially avoidable. In the 74 patients with inconclusive HCU results and for whom SE was still indicated, the decision was mainly dictated by the lack of spectral Doppler modality in the HCU system. The overall agreement between HCU and SE for diagnosis of normal/abnormal echocardiograms was 73% (kappa = 0.4). On the basis of the potentially avoided SE examinations and the obviated need for a second cardiac consultation, a total cost saving of euro2142 per 100 patients referred for echocardiography was estimated.

CONCLUSIONS

The use of a simple HCU device in the outpatient cardiology clinic allowed reliable diagnosis in one third of the patients referred for echocardiography, which translates into cost and time saving benefits.

Interpenetrating network formation in gellan--agarose gel composites

Thermal, mechanical, turbidity, and microscope evidence is provided which strongly suggests molecular interpenetrating network (IPN) formation by mixtures of the bacterial and seaweed polysaccharides gellan and agarose. There is no evidence for synergistic coupling of the networks, and simple phase separation (demixing) can definitely be ruled out. Some changes in the gellan gelling behavior are suggested, however, by the increased gellan effective concentrations implicit in cure curve data. The dependence of this effect on the agarose nominal concentration seems consistent with a previous model that focused on gelling parameters, and changes in these rather than real concentration effects. In large deformation mechanical tests, the influence of agarose added to gellan is to re-enforce the network (higher compression and shear moduli, higher stresses-to-break) without significantly changing the strain to break, or the gellan brittle failure mechanism.

New insight into agarose gel mechanical properties

The current study focuses on the effects of the molecular weight on the mechanical behavior of agarose gels. The small strain rheology and large strain deformation/failure behavior of three different molecular weight agarose gels have been examined, with the results expressed in term of molar concentration. For small deformation strains, the gelation temperature at low concentrations and the critical concentration for gel formation are strongly affected by the molecular weight. In addition, the elasticity of the network is also very sensitive to this parameter. It has been demonstrated that the experimental gelation cure curves can be superimposed on a universal gelation master curve, independent of the cure time. This would indicate self-similarity of the network at different scales, irrespective of concentration. A relationship between the elastic modulus and the molecular weight has been extracted from these results, where the molecular weight dependence exhibits a power law exponent of 2.42. For large deformation strains, the Poisson ratio has been estimated to be 0.5 for each of the agarose types examined, which indicates that these gels are incompressible. The strain at failure is largely dependent on the molecular weight, and is essentially independent of the biopolymer concentration. This result highlights the fact that the strain at failure is sensitive to the connectivity distances in the gel network. However, the failure stress and Young's modulus of agarose gels show a dependence on both concentration and molecular weight. The observations regarding Young's modulus are in good agreement with those found for small deformation strain rheology for the shear modulus. One of the primary advantages of using the lowest molecular weight agarose is that higher molar concentrations can be reached (more molecules per unit volume). However, the mechanical response of agarose gels is very sensitive to the molecular weight at fixed molar concentration, and if the present results are extrapolated to very low molecular weight, it can be suggested that below a limiting molecular weight a percolating network will not be formed, as suggested by the Cascade model (Carbohydr. Polym. 1994, 23, 247-251). This speculation is based on the influence of the "connectivity" at long distances, which influences the strain at failure (when the strain at failure is zero, the system is not connective).

Effect of electrode configuration and capacitor size on internal atrial defibrillation threshold using leads currently used for ventricular defibrillation

BACKGROUND

Previous studies have shown that endocardial atrial defibrillation, using lead configurations specifically designed for ventricular defibrillation, is feasible but the substantial patient discomfort might prevent the widespread use of the technique unless significant improvements in shock tolerability are achieved. It has been suggested that the peak voltage or the peak current but not the total energy delivered determines the patient pain perception and therefore, lower defibrillating voltage and current achieved with modifications in lead and waveforms may increase shock tolerability. This study was undertaken to evaluate the effect, on the atrial defibrillation threshold (ADFT), of the addition of a patch electrode (mimicking the can electrode) to the right ventricle (RV)-superior vena cava (SVC) lead configuration. The influence of capacitor size on ADFT using the RV-SVC+skin patch configuration was also assessed.

METHODS

In 10 patients (pts) (Group 1) cardioversion thresholds were evaluated using biphasic shocks in two different configurations: 1) right ventricle (RV) to superior vena cava (SVC); 2) RV to SVC+skin patch. In a second group of twelve patients (Group 2) atrial defibrillation thresholds of biphasic waveforms that differed with the total capacitance (90 or 170 microF) were assessed using the RV to SVC+skin patch configuration.

RESULTS

In Group 1 AF was terminated in 10/10 pts (100 %) with both configurations. There was no significant difference in delivered energy at the defibrillation threshold between the two configurations (7.1 +/- 5.1 J vs 7.1 +/- 2.6 J; p < 0.05). In group 2 AF was terminated in 12/12 pts (100%) with both waveforms. The 170 microF waveform provided a significantly lower defibrillating voltage (323.7 +/- 74.6 V vs 380 +/- 70.2 V; p < 0.03) and current (8.1 +/- 2.7 A vs 10.0 +/- 2.3 A; p < 0.04) than the 90 microF waveform. All pts, in both groups, perceived the shock of the lowest energy tested (180 V) as painful or uncomfortable.

CONCLUSIONS

The addition of a patch electrode to the RV-SVC lead configuration does not reduce the ADFT. Shocks from larger capacitors defibrillate with lower voltage and current but pts still perceive low energy subthreshold shocks as painful or uncomfortable.

[The concurrent implantation of a last-generation automatic defibrillator and a 2-chamber pacemaker]

BACKGROUND

Potentially lethal interactions between concomitantly implanted pacemaker and automatic first-generation cardioverter-defibrillator have been reported. We therefore evaluated the reliability and safety of simultaneous implantation of dual-chamber pacemakers with a fourth generation cardioverter-defibrillator incorporating an improved arrhythmia detection system.

METHODS

Concomitant implantation of an automatic cardioverter defibrillator and a dual-chamber pacemaker was performed in four patients for malignant tachyarrhythmias and symptomatic bradycardia. Two Jewel 7219C and two Micro Jewel 7223 (Medtronic Inc.) implantable cardioverter defibrillators were connected to an endocardial lead (Medtronic Mod. 6936). In 2 patients with a previously implanted cardioverter-defibrillator, the pacemaker was connected to bipolar atrial and ventricular leads. In the 2 patients who already had a dual-chamber pacemaker, the unipolar pacing leads implanted previously were used. At the time of implantation of the second device, interaction testing was performed evaluating ventricular fibrillation detection during high-output asynchronous pacing. Testing for malfunctions, reprogramming or variations of pacing thresholds of the pacemakers after electric shocks was also carried out. Moreover, intracavitary signals, stimulation thresholds and electrical therapies delivered were evaluated during follow-up.

RESULTS

During interaction testing, induced ventricular fibrillation was detected, with no delay, in 4/4 cases (100%). After a mean follow-up of 6.3 +/- 5 months (range 2-13), 5 shocks for ventricular fibrillation, 10 shocks for fast ventricular tachycardia and 72 antitachycardia pacings were delivered. All these electrical therapies were considered appropriate. No symptomatic sustained tachyarrhythmia remained undetected.

CONCLUSIONS

These data suggest that concomitant implantation of a fourth-generation automatic cardioverter-defibrillator and a dual-chamber pacemaker using either unipolar or bipolar leads can be performed safely. Extreme caution and rigorous interactions testing is nevertheless advised when considering this device combination.

Internal cardioversion of chronic atrial fibrillation in patients

Transvenous internal cardioversion of chronic AF using a right atrium (RA) coronary sinus (CS) vector requires more energy than cardioversion of paroxysmal AF. Chronic AF is not terminated in 25% of patients using biphasic shocks up to 10 J. We therefore evaluated efficacy, safety, and tolerability of internal cardioversion using a "unipolar" configuration (RA to skin patch) and biphasic shocks in patients with long-lasting AF and different heart disease. In each patient, biphasic R wave synchronous shocks were delivered between a large defibrillating surface area electrode in the RA and a skin patch in the left prepectoral position. Defibrillation protocol started with a test shock of 0.4 J. Shocks were repeated and increased until termination of AF or a maximum of 34 J. Sedation was used when the patient described the shock as painful. This study included 11 patients with a mean age of 67 +/- 8 years (range 56-83). AF duration was > or = 1 month in all patients with a mean duration of 11 +/- 11 months (range 2-36). Underlying heart disease was present in all patients and the mean left atrial dimension was 43 +/- 9 mm (range 26-57). AF was terminated in 10 of 11 patients (91%) with a mean delivered energy of the successful shocks of 18.7 +/- 8.7 J (median energy 16.9 J; range 7.3-32.5) and a mean leading edge voltage of 564 +/- 129 V. The mean shock impedance at the defibrillation threshold was 71 +/- 13 omega (range 59-103). A total of 131 shocks were delivered without any complication and proarrhythmia episodes. We conclude that low energy "unipolar" internal cardioversion is a simple, safe, and effective technique for termination of chronic AF in patients with heart disease. The procedure is often tolerated under light sedation.

Transesophageal echocardiographic color Doppler evaluation of pulmonary vein flow during ventricular pacing

Hemodynamic changes induced by ventriculo-atrial retroconduction has been considered an important factor in pacemaker syndrome. The contraction of atrial muscles, when the mitral valve is closed, induces a reverse systolic flow into the pulmonary veins, because the outlet of the pulmonary vein in the left atrium is not protected by a valve. The profile of the pulmonary vein forward flow of 25 patients was examined using transesophageal echocardiography (TEE) technique. Doppler evaluation of velocity-time integrals of forward flow (fVTI) and reverse flow (rVTI) was measured both during sinus rhythm or fully automatic (DDD) pacing, and ventricular demand pacing (VVI) accompanied by ventriculoatrial (VA) retroconduction or atrioventricular (AV) dissociation. The mean fVTI was reduced from 21.1 cm +/- 6.2 cm in DDD or sinus rhythm (SR) to 16.4 cm +/- 6.6 cm in VVI (p < 0.001). The mean rVTI was increased from 1.4 cm +/- 0.8 cm in DDD or SR to 4.3 cm +/- 1.8 cm in VVI (p < 0.001). The degree of such alterations varied considerably from patient to patient and this may explain the variability of clinical symptoms reported for pacemaker syndrome. It has not been possible to establish a direct correlation between the magnitude of hemodynamic changes and the severity of the symptoms observed because all the patients were in sequential stimulation or in SR and were temporarily submitted to VVI stimulation during the echocardiographic examination.

[A reduction of left ventricular hypertrophy and an improvement in diastolic function after therapy with nifedipine retard in patients with hypertensive cardiopathy]

Left ventricular (LV) hypertrophy with increased LV mass is associated with abnormal LV diastolic filling in patients with hypertension. To assess the effect of antihypertensive therapy on LV mass (M), LV wall stress (SS) and rapid LV filling, 16 patients (12 males, 4 females), mean age 57 +/- 8 years, were treated with nifedipine slow release (NSR, 20 mg bid) for 12 months and evaluated by Doppler echocardiography at baseline and at 3, 6, 9, 12 months from the beginning of treatment. No other cardiovascular drugs were given during the study. Systolic and diastolic blood pressure (SBP, DBP), LVM/m2 body surface (bs; M/m2), LVSS, LV end-diastolic and end-systolic diameters (EDD/m2, ESD/m2) bs, left atrial diameter (LAD), fractional shortening index (FS%), isovolumic relaxation time (IVRT), E/A velocities ratio at mitral Doppler spectrum (E/A) were measured at each examination. During treatment, systolic and diastolic blood pressure, LVM, LVSS, LV end-systolic diameter and isovolumic relaxation time decreased and FS% and E/A significantly increased as compared with baseline values, EDD and LAD did not change significantly. The reduction of LVSS was of greater extent compared with that of LVM, at short and at mid-term, probably for a fibrotic component of LVM induced by chronic systolic overload. Changes of ESD and FS% were less evident compared with LVSS, possibly depending on their contribution to LVSS normalization. In conclusion, our experience indicates that NSR is an effective antihypertensive agent at short and mid-term.(ABSTRACT TRUNCATED AT 250 WORDS)

Life expectancy in Italian track and field athletes

Nine hundred eighty-three top Italian track and field athletes (700 males and 283 females) were examined for survival, mortality and causes of death for an average follow-up period of 18.6 years starting from their last year of competition as members of the national team. Overall mortality rates were compared to the rates expected on the basis of the life tables for Italian people of the same age, sex and time period. Thirty-four deaths were observed among males (vs 46.6 expected) with a O/E ratio of 0.73, while 3 deaths were observed among women (vs 6.2 expected) with a O/E ratio of 0.48. Neither of these differences was significant, but the O/E ratio for the group as a whole was quite significant (p = 0.0296). Some of the athletes demonstrated behavioural characteristics developed during their active careers that might have contributed to their low mortality rate.

Effects of nifedipine on left ventricular diastolic function in hypertension; echo Doppler study

Hypertensive cardiac disease shows early alteration of left ventricular diastolic filling, characterized by a longer isovolumetric relaxation period and by an altered E/A ratio on the mitral spectral Doppler. We chose ten hypertensive patients who had left ventricular hypertrophy, but no left ventricular dilatation or mitral valve insufficiency and had a good left ventricular shortening fraction (greater than 26%). After the washout period we studied each of the above-mentioned parameters before and after the acute administration of nifedipine, dinitrate isosorbide, and captopril. While captopril and dinitrate isosorbide induced a prolongation of the isovolumic relaxation time and an impairment of the E/A ratio in mitral spectral Doppler (i.e., left ventricular filling), nifedipine induced an improvement in both parameters. The three drugs also induced a similar reduction in systemic blood pressure values (i.e., similar afterload). We therefore suggest that changes in diastolic function in hypertrophied cardiac fibers, induced by nifedipine, may be the result of a double action: one mediated by hemodynamic changes, the other directly affecting the cellular calcium ion exchange.

[Extreme cardiac hypertrophy in athletes. Morphological and functional echographic study]

Cardiac hypertrophy is an adaptation phenomenon of the heart as a result of increased hemodynamic load due to intense and prolonged training in athletes. This is mainly seen in endurance athletes. In some cases cardiac hypertrophy can mimic hypertrophic cardiomyopathy, specially if hypertrophy is mainly localized at the interventricular septum as compared to the left ventricular free wall. In our study we tried to evaluate the different diagnostic features obtained by echocardiography and clinical examination in a group of 23 athletes with marked hypertrophy (all were participants to the 1984 Olympic Games held in Los Angeles) as compared to a group of 11 sportsmen with non-obstructive hypertrophic cardiomyopathy (HC). Cardiomyopathy was diagnosed on the basis of clinical, echocardiographic and angio-scintigraphic findings. The 23 athletes were selected on the basis of M-Mode and 2D echocardiographic thickness of the interventricular septum (IVS) which was in diastole greater than or equal to 15 mm. They were all asymptomatic, only 4 of the 23 athletes had ECG anomalies due to left axis deviation (LAS) and T wave inversion. Only 4 of the subjects with HC had a family history of HC. ECG changes were the following: T wave inversion (9 subjects), left axis deviation (LAD) (4 subjects), deep Q wave in D2-3, aVF, V5-6 (2 subjects) and low voltage R wave in V5-6 (1 subject). All the athletes had marked hypertrophy of the IVS. Interventricular septum thickness (IVST) was 15.7 +/- 0.6 mm, with a range from 15 to 17.5 mm. Posterior wall thickness (PWT) was 13.7 +/- 1.1 with a range from 12 to 16 mm. The sportsmen with HC had an IVST of 16.2 +/- 3.5 mm and a PWT of 11.3 +/- 1.5 mm. The IVST/PWT ratio was significantly lower (p less than 0.01) in the athletes (1.14 +/- 0.02) when compared to the group with HC (1.4 +/- 0.3). In 7 of the subjects with HC the hypertrophy was mainly localized at the anterolateral segment of the interventricular septum (in 4 of these subjects the hypertrophy involved also the antero-lateral part of the left ventricular free wall).(ABSTRACT TRUNCATED AT 400 WORDS)