Impact of delirium on the short term prognosis of advanced cancer patients. Italian Multicenter Study Group on Palliative Care

BACKGROUND

The objective of this study was to evaluate the impact of delirium on the survival of advanced cancer patients also assessed with a validated prognostic score (the palliative prognostic [PaP] score).

METHODS

The study population was a prospective multicenter consecutive case series of advanced cancer patients for whom chemotherapy was no longer considered viable and who were referred to palliative care programs. Clinical and biologic prognostic factors included in the PaP score were assessed at study entry. The Confusion Assessment Method criteria were applied to screen patients presenting with delirium. Survival times were measured from time of enrollment and death taken as an outcome. Survival curves were traced with the Kaplan-Meier method and comparison were based on log rank tests.

RESULTS

Delirium was found in 109 cases among 393 consecutive patients (27.7%). The diagnosis of delirium was independently associated with male gender, central nervous system metastases, lower performance status, worse clinical prediction of survival, and progestational treatment. The survival curve of patients with delirium was significantly different from the nondelirious patients curve (log rank, 31.6, P < 0.0001). The median survival time was 21 days (95% confidence interval [CI], 16-27) for the delirious patients and 39 days (95% CI 33-49) for the others. Multivariate analysis showed that the diagnosis of delirium and PaP score were independently associated with prognosis.

CONCLUSIONS

The diagnosis of delirium significantly worsens life expectancy prognosticated with the PaP score. By using the PaP score together with the assessment of cognitive status, physicians can correctly predict patients 30-day survival in greater than 70% of cases.

Loss of nocturnal decline of blood pressure in hypertension due to chronic renal failure

The aim of this study was to assess the blood pressure profile of chronic renal failure in comparison with essential hypertension. Thirty hypertensive patients with chronic renal failure due to non-vascular nephropathies were matched by age, sex, and mean 24 h blood pressure, with 30 patients affected by uncomplicated mild-to-moderate essential hypertension. They were studied in an open hospital ward. Diet, meal times, sleep times, and activity schedules were standardized. Noninvasive, automatic, blood pressure recordings were performed for 48 h at sampling intervals of 15 min. The mean 24 h blood pressure almost coincided in the two groups. However, in essential hypertension a mean (+/- SD) nocturnal fall of systolic and diastolic blood pressure was found (12.7 +/- 3.8 and 12.9 +/- 4.8 mm Hg, respectively), while renal patients displayed an average nocturnal increase of 2.7 +/- 8.9 mm Hg and 3.7 +/- 7.8 (P less than .001). The renal patients had also higher heart rates, with a significantly blunted nocturnal fall (4.4 +/- 4.5 beats/min as compared to 9.3 +/- 3.1 beats/min of essential hypertension; P less than .001). Among the renal patients, the day-night blood pressure changes showed no significant correlation with age, creatinine clearance, hematocrit, nocturnal change in heart rate, or day or night mean blood pressure levels. These data suggest that an abnormal day-night pattern of blood pressure is present in chronic renal failure patients independently from external interfering factors. Hence, casual measurements of blood pressure confined to daytime may underestimate a hypertensive condition associated with chronic renal failure.

Injectability evaluation: an open issue

The current work aimed to propose a system of scoring to rationalize and support the selection of the optimal diameter and length of needles. Four formulations at different viscosity and needles ranging from 21 to 26 G and length ranging from 16 to 40 mm were used. Plunger-stopper breakloose force, maximum force (F(max)), and dynamic glide force were measured by a texture analyzer at the crosshead speed of 1 mm/s. Testing was carried out into air or human subcutaneous tissue. The manual injectability of the highest viscosity product was assessed by ten evaluators. The comparison of the panel test score and the quantitative measurements of the forces permitted to score a given needle-syringe-formulation system keeping also in consideration the pressure created in the subcutaneous space and muscles at the injection site. In particular, the following relationship was drawn: at the F(max) up to 250 mPa, the injection was practically impossible; at F(max) ranging from 160 to 250 mPa, the injection was very difficult; at F(max) in the 125-160 mPa range, the injection was feasible, though with some difficulty; when the values of F(max) were lower 125 mPa, the injection went smoothly. On the basis of these preliminary data, a system of scoring the needle-syringe-formulation system is proposed to rationalize and support the selection of the optimal diameter and length of needles, keeping also in consideration the pressure created in the subcutaneous space and muscles at the injection site.

Gamma irradiation effects on poly(DL-lactictide-co-glycolide) microspheres

Gamma radiation treatment plays an increasingly important role in the sterilization/sanitization of pharmaceutical products. However, irradiation may affect the stability of the product and thus its safety of use. We investigated the influence of ionizing radiation on modified release microparticulate drug delivery systems made of two types of polylactide-co-glycolide copolymers (PLG): RG 503 and RG 503H; these polymers have identical molecular weights but different chemical structures. The effect of gamma radiation on polymer stability of the raw polymers (P) and related microspheres (Ms) was evaluated. Samples were irradiated at different irradiation doses (5, 15 and 25 kGy) using 60Co as radiation source. The microspheres were prepared using the spray drying technique. Degradation of PLG and related microspheres was evaluated during six months in terms of average molecular weight (Mw) loss by gel permeation chromatography (GPC) and variation in glass transition temperature (Tg) using differential calorimetry (DSC). The presence of free radicals in the product was tested by electron paramagnetic resonance (EPR). Both P and Ms showed a trend in decreasing their Mw at time 0 as a function of irradiation dose. For RG503 the decay in Mw is always negligible for doses below 15 kGy while it is about 10% for 25 kGy. After 150 days Mw decay was 25% in the microspheres and 20% in the raw polymer. It was not possible to evaluate the radiation effect, at different storage times, for RG503H because this polymer resulted to be unstable even in the regular storage conditions without being irradiated. The concentration of radiation-induced free radicals was higher in RG 503H (both P and Ms) and they were more stable than the free radicals species observed in the case of polymer RG 503. Alterations and/or production of new radicals were observed on exposure of RG 503H microspheres to the light. Radiolytic degradation of RG 503 under vacuum is characterized by a prevalence of the chain scission events leading to a decrease of Mw. Some crosslinking can occur mainly in the post irradiation stage through the decay and coupling of the hydrogen abstraction radicals. A hydroperoxydative cycle, whose mechanism is suggested, is generated in the presence of oxygen.

Circadian rhythms of atrial natriuretic peptide, renin, aldosterone, cortisol, blood pressure and heart rate in normal and hypertensive subjects

The occurrence and extent of a circadian rhythm in the circulating concentrations of atrial natriuretic peptide (ANP) are still matters of controversy. Only a few data are available in humans relating the time structure of plasma ANP levels with the circadian patterns of other hormones and cardiovascular variables. In a group of hospitalized normal volunteers (six men and four women, 16-76 years old), and in a group of hospitalized hypertensives (seven men and three women, 18-76 years old), we investigated the circadian variability of ANP and its temporal relationship with the circadian rhythms of blood pressure (BP) and heart rate (HR), and plasma renin activity (PRA), plasma aldosterone (PA) and plasma cortisol (PC) levels, by using a chronobiological inferential statistic method. At the end of a synchronizing period of 1 week (the diet and daily schedule were standardized), the subjects underwent automatic BP and HR monitoring, and blood sampling for 24 h. A statistically significant mean circadian rhythm was demonstrated for ANP, BP, HR, PRA, PA and PC in both normal and hypertensive subjects. The mean circadian acrophase of ANP (calculated to occur at around 04.00 h) anticipated the corresponding acrophases of the other hormones; BP and HR rhythms appeared to be in antiphase with ANP rhythm, i.e. the peak of BP and HR rhythms more or less coincided with the trough in ANP rhythm. A significant increase in the daily levels (assessed by the circadian mesor) of ANP was present in hypertensive subjects when compared with normal controls. In essential hypertension the circadian rhythm of ANP was set at higher circulating levels, but otherwise it was similar to the circadian rhythm found in normals. ANP mesors correlated significantly with renin and aldosterone mesors in normal subjects but not in hypertensive patients. ANP appears to anticipate awakening in its circadian periodic rise. On the basis of the considerable acrophase asynchronism, it seems possible to exclude any causal relations between the periodic changes of ANP and the rhythmic fluctuations of the other hormones that we studied. In contrast, important relations may be hypothesized between ANP levels and BP and HR values, on the basis of their antiphase rhythms.

Beer increases plasma antioxidant capacity in humans

The positive association of a moderate intake of alcoholic beverages with a low risk for cardiovascular disease, in addition to ethanol itself, may be linked to their polyphenol content. This article describes the effect of acute ingestion of beer, dealcoholized beer, and ethanol (4.5% v/v) on the total plasma antioxidant status of subjects, and the change in the high performance liquid chromatography profile of some selected phenolic acids (caffeic, sinapic, syringic, and vanillic acids) in 14 healthy humans. Plasma was collected at various times: before (T0), 1 hour after (T1), and 2 hours after (T2) drinking. The study is part of a larger research planned to identify both the impact of brewing on minor components potentially present in beer and their metabolic fate in humans. Beer was able to induce a significant (P < 0.05) increase in plasma antioxidant capacity at T1 (mean +/- SD: T0 1,353 +/- 320 microM; T1 1,578 +/- 282 microM), returning close to basal values at T2. All phenolic acids measured in plasma tended to increase after beer intake (20% at T1, 40% at T2). Syringic and sinapic acid reached statistical significance (P < 0.05 by one-way analysis of variance-Fisher's test) at T1 and T2, respectively. Plasma metabolic parameters (glucose, total cholesterol, triglycerides, and uric acid) and plasma antioxidants (alpha-tocopherol and glutathione) remained unchanged. Ethanol removal impaired the absorption of phenolic acids, which did not change over the time of the experiment, accounting for the low (and not statistically significant) increase in plasma antioxidant capacity after dealcoholized beer drinking. Ethanol alone did not affect plasma antioxidant capacity or any of the antioxidant and metabolic parameters measured.

Mineral evolution of bone

A study on the evolution with age of the mineral composition of bones was performed on samples belonging to human and other common mammalian species (cattle, sheep, dog). The study was carried out on the ashes obtained by calcination of the bone samples (1 h at 900 degrees C). The calcined powders were carefully examined by X-ray diffraction, from which precise quantitative evaluation (also confirmed by chemical analysis) of the crystalline phases present was derived. These data were analysed as a function of the introduced fractional age phi, a new relative scale that allows even largely different lifespan species to be compared. An overall linear increase in (Ca + Mg)/P ratio with log phi was found and the other considerations on molecular constitution (especially as regards Mg2+ substituting for Ca2+ in very young subjects) of the various phases detected were formulated and relative implications evaluated. The results appear promising for an improvement of knowledge in the field of biomedical experimentation and clinical implantology.

Gamma irradiation effects on stability of poly(lactide-co-glycolide) microspheres containing clonazepam

This work was aimed at evaluating the effects of gamma irradiation on the stability of microspheres made of a poly(lactide-co-glycolide) copolymer (PLGA) and loaded with 15% w/w of clonazepam (CLO). The influence of CLO on PLGA radiolysis mechanisms and the identification of possible irradiation markers were also investigated. Microspheres were prepared by means of a spray-drying method. gamma Irradiation was carried out either under vacuum or in air, at a dose of 25 kGy, by using a 60Co source. The stability of CLO loaded microspheres was evaluated over a 6-month period on the basis of drug content and dissolution profile. Radiolysis mechanisms were investigated by using electronic paramagnetic resonance (EPR) analysis. The microspheres irradiated under vacuum were stable over the considered period of time. After irradiation in air, CLO release rate increased by approximately 10%, and did not change further in the following period of storage. The EPR analysis showed some radicals arising from both the polymeric matrix and the active ingredient. Polymer/CLO spin transfer reactions suggest that CLO had a radio-stabilising effect on the polymeric matrix. In the loaded microspheres, the intensity in time of the CLO radical signal is sufficient for its possible use as irradiation marker.

Nicotine fast dissolving films made of maltodextrins: a feasibility study

This work aimed to develop a fast-dissolving film made of low dextrose equivalent maltodextrins (MDX) containing nicotine hydrogen tartrate salt (NHT). Particular attention was given to the selection of the suitable taste-masking agent (TMA) and the characterisation of the ductility and flexibility under different mechanical stresses. MDX with two different dextrose equivalents (DEs), namely DE 6 and DE 12, were selected in order to evaluate the effect of polymer molecular weight on film tensile properties. The bitterness and astringency intensity of NHT and the suppression effect of several TMA were evaluated by a Taste-Sensing System. The films were characterised in term of NHT content, tensile properties, disintegration time and drug dissolution test. As expected, placebo films made of MDX DE 6 appeared stiffer and less ductile than film prepared using MDX DE 12. The films disintegrated within 10 s. Among the tested TMA, the milk and mint flavours resulted particularly suitable to mask the taste of NHT. The addition of NHT and taste-masking agents affected film tensile properties; however, the effect of the addition of these components can be counterweighted by modulating the glycerine content and/or the MDX molecular weight. The feasibility of NHT loaded fast-dissolving films was demonstrated.

Diclofenac fast-dissolving film: suppression of bitterness by a taste-sensing system

CONTEXT

The selection of a proper taste-masking agent (TMA) is a critical issue in the development of fast-dissolving films containing bitter drugs.

OBJECTIVE

This work is aimed to evaluate the suppression of the bitter taste of a maltodextrin fast-dissolving film loaded with 13.4 mg sodium diclofenac (DS) by adding TMAs.

METHODS

The films were prepared by casting and drying aqueous mixtures of maltodextrin (DE = 6), glycerin, sorbitan oleate, and DS. Films were characterized in terms of thickness, tensile properties, film disintegration time, and drug dissolution time. The bitterness intensity of DS and the masking effect of TMAs were evaluated by an electronic tongue.

RESULTS

The 'mint' and 'licorice' flavors and sucralose mixture resulted appropriate to mask DS bitterness as confirmed by a panel of volunteers. The addition of these TMAs did not significantly affect the film disintegration time (15-20 seconds) and DS dissolution rate (about 5 minutes).

CONCLUSION

The electronic tongue was allowed to discriminate the effect of the TMA also in the presence of other hydrosoluble constituents of the film. Therefore, because of its simplicity and rapidity, this technique could assist or even replace the sensory evaluation in the development of fast-dissolving films.

Polymethacrylates as crystallization inhibitors in monolayer transdermal patches containing ibuprofen

The feasibility of a monolayer patch based on polydimethylsiloxane pressure sensitive adhesive containing ibuprofen (IB) in supersaturated condition was studied. The efficacy of three low molecular weight excipients (propylene glycol, PG, Cremophor EL and Cremophor RH) and of two copolymers of methacrylic acid (Eudragit((R)) E, EuE, and Eudragit((R)) RL, EuRL) as IB crystallization inhibitors was tested. The performances of the patches were evaluated in terms of drug release and human stratum corneum and epidermis (SCE) permeation profile. The interactions between IB and the other excipients were investigated by ATR-FT-IR spectroscopy. The stability of the patches, prepared without adding crystallization inhibitors, was unsatisfactory because crystals grew in less than 1 month. Among the low molecular weight molecules, only PG inhibited the IB crystallization up to 50 days without affecting the IB skin permeation profile. The addition of EuE or EuRL in the matrices prevented drug crystallization for more than 12 months. EuE significantly reduced the IB in vitro release rate and the IB permeated amount through the SCE compared to other formulations. These phenomena are attributed to a stronger association between IB and EuE than IB and EuRL.

Polymethacrylate salts as new low-swellable mucoadhesive materials

The sodium and potassium salts of the methacrylic copolymers Eudragit L100 and Eudragit S100 were prepared with the aim to develop new low-swellable mucoadhesive materials intended for the preparation of buccal dosage forms. The physico-chemical characterization of the copolymers and the corresponding sodium and potassium salts was performed by using Fourier-transform infrared (FT-IR) spectroscopy and thermal analysis. When ionization occurred, the carboxylic acid group absorption band (1730 cm(-1)) was replaced by another characteristic band at 1560 cm(-1). After salification the T(g) of the two polymers shifted towards higher values and it was not significantly influenced by the contraion nature. The intrinsic dissolution rate at infinite rotation speed (7.354<G( infinity )<9.196) was about 6- to 7-fold higher than that of a low nominal viscosity hydroxypropylmethylcelluloses (HPMC). Moreover, the Eudragit salts did not show an evident swelling layer and their dissolution is governed by erosion. The adhesion properties of these materials, evaluated by texture analysis, overlapped with those of Carbopol 934P. On the basis of the in vivo bioadhesion test, the prepared methacrylic salts can be considered interesting for the preparation of both buccal tablets and patches with good patient compliance due to their low swelling properties.

Poly(lactide-co-glycolide) microspheres containing bupivacaine: comparison between gamma and beta irradiation effects

The beta- and gamma-irradiation effects on stability of microspheres made of poly(lactide-co-glycolide) 50:50 copolymer (PLGA) containing bupivacaine (BU) were studied. Microspheres containing 10, 25, and 40% w/w, respectively, of BU were prepared by spray drying and irradiated in air with beta- and gamma-irradiation at a dose of 25 kGy. Morphology (atomic force microscopy, particle-size analysis), physico-chemical characteristics (DSC and FT-IR spectroscopy), drug content and in vitro dissolution profile of microspheres were all determined; the stability of irradiated microspheres was evaluated over a 9-month period. The decrease of BU content in gamma-irradiated microspheres was almost always constant independent of the amount of BU per sample, therefore it was in inverse proportion to drug loading (range between 5 and 15%). BU release rate increased immediately after irradiation and increased slightly until 90 days of storage. As far as beta-irradiated microspheres are concerned, BU content decreased in a significant way (approximately 3%) only in microspheres containing 10% w/w of BU. Immediately after irradiation, drug release rate in beta-irradiated microspheres increased less than in the corresponding gamma-irradiated microspheres, and it did not change further over the following storage period. BU-loaded microspheres have been shown to be more stable against beta- than gamma-irradiation. AFM revealed that the surface roughness of the irradiated microspheres increases depending on irradiation. As such, if a parameter is quantifiable, it is proposed as a marker of degradation due to ionizing radiation.

The effect of gamma-irradiation on PLGA/PEG microspheres containing ovalbumin

Poly(ethylene glycol) (PEG) and sodium chloride (NaCl) are excipients used in PLGA microsphere preparation to stabilize proteins and reduce their burst release. No information is till now available in the literature on the effect due to the use of such excipients on the biopharmaceutical performance of gamma-irradiated microparticulate systems. On this purpose, different batches of microspheres containing ovalbumin (OVA) were prepared by using a PLGA 50:50 (average Mr: 13000), different amounts of PEG (Mr: 400 or 4000) and/or sodium chloride. The non-irradiated and irradiated microspheres were characterized in terms of morphology (SEM, particle size distribution), OVA and PEG content and in vitro OVA release. Radiolysis mechanisms of OVA and OVA loaded microspheres were investigated by EPR analysis. Gamma irradiation affects either microsphere morphology or the release of OVA as a function of the amount of PEG, and the use of NaCl. Irradiation significantly reduces release rate of protein from the microspheres containing 15% and 30% of PEG and from controls (microspheres without additives), while no significative effect on protein release rate is highlighted on microspheres containing lower amounts of PEG. EPR investigation shows that increasing amounts of PEG up to 30% have a perturbation effect on OVA radiolysis path.

Ex Vivo Study of Transdermal Permeation of Four Diclofenac Salts from Different Vehicles

The ex vivo permeation of diclofenac was studied using four different salts (sodium, potassium, diethylamine, and epolamine) dissolved in four different solvents (water, propylene glycol (PG), Transcutol, and oleic acid (OA)) as donor phases through a human skin membrane. The four salts show different solubility values and different behavior in the four solvents, which are also permeation enhancers and this fact further is connected to the permeation results. The same order of magnitude of fluxes through the membrane as those previously reported for acidic diclofenac released from buffer solutions of pH >7 were found, taking into account differences originated by different membranes and other parameters tested in the experiments. Saturation concentration for the four salts in different solvents, necessary to calculate permeation coefficients, was critically evaluated; a short discussion made it possible to explain that corrections in the solubility values must be considered, related to the complex behavior in solution of these salts. Statistical processing of the experimental data suggests that differences between the four salts in promoting absorption of the drug is unproven; while differences are evident between the solvents, water is the most effective enhancing vehicle. Aqueous formulations containing diclofenac salt with an organic base appear to be the best combination to promote permeation in topical applications.

Characterization of nifedipine solid dispersions

The sublingual administration of nifedipine (NIF) is currently used in clinical practice. The sublingual administration of NIF solid dispersions (SD), by using a suitable dispenser, appears an interesting approach in the treatment of moderate and severe hypertensive emergencies. With this aim nine SD made of NIF and a low viscosity hydroxypropylmethylcellulose (HPMC) in different ratio were prepared by means of spray-drying technique and their structure was studied. Moreover, the drug dissolution properties from SD were verified. The characteristic peaks of crystalline NIF were not detectable by using the X-ray analysis when the NIF/HPMC ratios were lower than 50/50 w/w. In thermograms obtained from SD, the NIF melting endothermic peak disappeared when NIF/HPMC ratios were lower than 30/70 w/w; the experimental Tg values of SD were lower than the Tg values predicted by Gordon Taylor equation suggesting some type of non-ideality of mixing. In the SD FTIR spectra the NH stretching vibrations and the C=O stretch in esteric groups of NIF shift to free NH and C=O regions indicating the rupture of intermolecular hydrogen bond in the crystalline structure of NIF. The prepared SD improved the NIF dissolution rate in comparison with that of commercial NIF or NIF/HPMC physical mixtures. Moreover, the concentration of NIF in the dissolution medium increased decreasing the NIF content.

Evaluation of adhesive properties of patches based on acrylic matrices

Adhesion is an essential property of the dermal and transdermal therapeutic systems (TS). It is influenced by the composition and the thickness of the matrix and also by the characteristics of the backing layer. Our aim was to evaluate the usefulness of the "thumb tack test," the "tack rolling ball test," and the "peel adhesion 180 degrees test" in the development studies and quality control of TS. These tests were performed on two series of placebo patches in which the backing layer was made of artificial silk (series 1) and polyurethane film (series 2). The patches of both series were prepared using five different mixtures of a hydrophilic adhesive copolymer and a hydrophobic nonadhesive copolymer as matrices. Plastoid E 35 L, a copolymer of dimethylaminoethyl methacrylate and neutral methacrylic esters, was used as the adhesive polymer. Eudragit NE 40 D, a copolymer of ethylacrylate and methylmethacrylate, was used as the nonadhesive copolymer. In the standard procedure for the peel adhesion 180 degrees test, used in the tape industries, the adherent is made of stainless steel. Because the latter has a high surface energy, it was not suitable for the analysis of the patches with a polyurethane backing layer. Therefore, the critical surface tension of five alternative materials (rubber, polysiloxane, polyethylene, nylon, polyvinyl chloride) was evaluated. Polyethylene was selected for the modified peel adhesion 180 degrees test, and better results were obtained in terms of feasibility of the test and ability to discriminate between the different patches prepared.

Porous ceramic bodies for drug delivery

An approach to the production of ceramic drug delivery devices is proposed. Two examples of possible ceramics are dealt with: hydroxyapatite weakly modifiable by living tissue and the bioinert alumina. The possibility to control the formed porosity was taken into consideration for both materials. The ratio between the acquired porosity and the quantity and quality of the agents inducing porosity is also described and discussed. A test on the role of porosity was performed on the obtained porous ceramic bodies and a study was made on the release of a substance with pharmacological activity from previously impregnated porous ceramic bodies. This paper is preliminary to a planned work targeted to the preparation of ceramic drug delivery systems.

Effects of captopril on the physical work capacity of normotensive patients with stable-effort angina pectoris

Twelve normotensive patients with coronary artery disease and stable effort-induced angina pectoris were selected: the antiischemic effect of captopril was studied. A maximal cycloergometer effort test was obtained before (base) and after administration of placebo or captopril (50 mg p.o.). The following parameters were measured: heart rate (HR), blood pressure (BP), maximal rate/pressure product (MRPP), maximal workload sustained, (MWS), maximal working time (MWT), and S-T depression at MRPP. The base and placebo were similar. Compared to them captopril augmented the MWT, increased the MWS, reduced S-T depression at MRPP, and decreased the number of patients with effort-induced angina pectoris. The antiischemic effect of captopril seems related both to its effect on HR and BP, and to a local enhancement of coronary blood flow.

Circadian rhythms of atrial natriuretic peptide, blood pressure and heart rate in normal subjects

The occurrence and extent of a circadian rhythm in the circulating concentrations of atrial natriuretic peptide (ANP) is still a matter of controversy. In a group of hospitalized normal volunteers (6 men and 4 women, 16-76 years old), we investigated the circadian variability of ANP and its temporal relation with the circadian rhythms of blood pressure (BP) and heart rate (HR), by using a chronobiological inferential statistical method. At the end of a synchronizing period of 1 week (the diet and the daily schedule were standardized), the subjects underwent automatic BP and HR monitoring, and blood sampling for 24 h. A statistically significant mean circadian rhythm was demonstrated for ANP, BP, and HR. The mean circadian acrophase of ANP was calculated to occur around 4 a.m. BP and HR rhythms appeared to be in antiphase with ANP rhythm, i.e. the peak of BP and HR rhythms more or less coincided with a trough in ANP rhythm. ANP appears to be anticipatory in its circadian periodic rise to awakening. Therefore, postural changes cannot fully account for the diurnal variations observed.