Rapid nongenomic estrogen signaling controls alcohol drinking behavior

The sex steroid hormone estrogen is a key modulator of numerous physiological processes and adaptive behaviors, but it may also be co-opted to drive maladaptive behaviors. While many behavioral roles for estrogen signaling have been shown to occur through canonical genomic signaling mechanisms via nuclear receptors, estrogen can also act in a neurotransmitter-like fashion at membrane-associated estrogen receptors to rapidly regulate neuronal function. Early alcohol drinking confers greater risk for alcohol use disorder in women than men, and binge alcohol drinking is correlated with high circulating estrogen but a causal role for estrogen in alcohol drinking has not been established. Here, we demonstrate that gonadally intact female mice consume more alcohol and display an anxiolytic phenotype when they have elevated levels of ovarian-derived estrogen across the estrous cycle. We found that rapid, nongenomic estrogen signaling at membrane-associated estrogen receptor alpha in the bed nucleus of the stria terminalis (BNST) is necessary and sufficient for the pro-alcohol drinking effects of ovarian estrogen signaling, regardless of the transcriptional program of a high ovarian estrogen state. We further show that a population of corticotropin-releasing factor (CRF) BNST neurons (BNSTCRF) is a critical mediator of these effects, as high estrogen rapidly enhances synaptic excitation of BNSTCRF neurons and promotes their role in driving binge alcohol drinking. These findings show a causal role for endogenous, ovarian-derived estrogen in hormonal modulation of risky alcohol consumption and provide the first demonstration of a purely rapid, nongenomic signaling mechanism of ovarian estrogen in the brain controlling behavior in gonadally intact females.

Phenyl bioisosteres in medicinal chemistry: discovery of novel γ-secretase modulators as a potential treatment for Alzheimer's disease

Phenyl rings are one of the most prevalent structural moieties in active pharmaceutical ingredients, even if they often contribute to poor physico-chemical properties. Herein, we propose the use of a bridged piperidine (BP) moiety as a phenyl bioisostere, which could also be seen as a superior phenyl alternative as it led to strongly improved drug like properties, in terms of solubility and lipophilicity. Additionally, this BP moiety compares favorably to the recently reported saturated phenyl bioisosteres. We applied this concept to our γ-secretase modulator (GSM) project for the potential treatment of Alzheimer's disease delivering clinical candidates.

Influence of Pigskin on Salmonella Contamination of Pig Carcasses and Cutting Lines in an Italian Slaughterhouse

Ninety pig carcasses and twenty one food contact surfaces (FCSs) were tested for Salmonella in a slaughterhouse processing ca. 380 pigs/h between 2014-2015. Sampling was performed during seven sessions. Four carcass sites of 100 cm2 each (back, belly, jowl externally, and the diaphragmatic area internally) were swabbed after evisceration. Meat conveyors and dressing tables were tested swabbing areas of 200 to 400 cm2. After pre-enrichment in buffered peptone water, samples were tested by Salmonella MDS® assay and the presumptive positives were confirmed by the ISO 6579 method. Salmonella isolates were serotyped following the Kauffman-White-Le Minor scheme and genotyped by XbaI pulsed field gel electrophoresis. Salmonella was isolated from 16/90 [17.8%; confidence interval (CI) 95%=11.2-26.9] carcasses and 4/21 (19.0%; CI 95%=7.7-40.0) FCSs. Four serovars were identified on carcasses. S. enterica 4,[5],12:i:-was the most prevalent (43.75%), followed by S. Rissen (31.25%), S. Derby (12.5%) and S. Bovismorbificans (12.5%). Two serovars were found on FCSs, namely S. Derby (75%) and S. Livingstone (25%). During one sampling session, a failure in carcass dehairing occurred and caused significantly higher prevalence of carcass contamination (60%) than in the remaining sessions. Moreover, in the same session, Salmonella prevalence was marginally significantly higher on FCSs than in the remaining sampling days, suggesting that dehairing affects contamination not only on carcasses, but also on the working surfaces.

Protein S deficiency. Description of a case associated with chronic inflammatory bowel disease

Thrombotic disease is one of the most relevant clinical problems for morbility and mortality. We can differentiate congenital and acquired forms. In this short communication we describe 1 case observed by us that seems interesting for the association of a congenital and acquired form [Protein S deficiency and inflammatory bowel disease (IBD)] and for the dramatic events suffered before receiving a complete diagnosis and therapy, indicating the importance of recollection of information from the patients, starting from anamnestic data.

Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Oucome dello Scompenso Cardiaco in relazione all'Utilizzo delle Risore

AIMS

This study was designed to identify potential specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for congestive heart failure in departments of cardiology or internal medicine.

METHODS AND RESULTS

From 1 July to 31 December 1998, we prospectively recorded epidemiological and clinical data from patients with congestive heart failure consecutively admitted to 11 departments of cardiology and 12 departments of internal medicine in Liguria, a northern area of Italy. The overall study population included 749 patients; 22% were treated by cardiologists and 78% by internists (P<0.0001). Patients managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%) and exercise stress testing (20% vs 0.5%) than those managed by internists (P=0.001). At discharge, patients treated by cardiologists were more likely to be prescribed beta-blockers (41% to 4%) and ACE inhibitors (100% to 74%) than those treated by internists (P<0.0001), and the latter medication at higher dosages by cardiologists than internists. In addition, patients followed by cardiologists were younger (70+/-9 to 79+/-1 years;P<0.0001), more likely to be male (61% to 50%;P=0.011) and to have coronary artery disease (57% to 45%;P<0.006) than those followed by internists. Conversely, patients followed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation and renal failure (P<0.03). In the overall study population, 53 patients (7%) died during hospitalization. Patients treated by cardiologists had a mortality not significantly different from that of patients treated by internists (10% and 6%, respectively;P=0.067), although congestive heart failure was more severe on admission in patients treated by cardiologists.

CONCLUSION

Cardiologists follow published guidelines for congestive heart failure more strictly than internists, but treat a smaller number of patients who are younger, have more severe congestive heart failure and fewer co-morbidities than those managed by internists.

Long-term prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk

To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 +/- 13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis.

Value of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease: a report from the Echo-Persantine and Echo-Dobutamine International Cooperative Studies

OBJECTIVES

This study sought to verify the effectiveness of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease.

BACKGROUND

Noninvasive prognostic assessment of single-vessel disease is an unresolved issue to date.

METHODS

The study evaluated prospectively collected data from 754 patients with angiographic single-vessel disease who underwent either dipyridamole (n = 576) or dobutamine (n = 178) stress echocardiography. Invasive treatment (coronary revascularization within 3 months of stress testing) was performed in 260 patients and medical treatment in 494.

RESULTS

Echocardiographic positivity was observed in 421 patients (56%). Patients treated invasively had a higher incidence of stress test positivity (69% vs. 49%, p < 0.001) and left anterior descending coronary artery involvement (60% vs. 46%, p < 0.001) than patients maintained with medical therapy. During a mean follow-up of 37 months, 54 hard cardiac events occurred (14 deaths, 40 nonfatal infarctions): 37 in medically and 17 in invasively treated patients (7.5% vs. 6.5%, p = NS). On Cox analysis, a positive result on stress testing was the only independent prognostic predictor in medically treated patients (relative risk 2.92, 95% confidence interval 1.29 to 6.59). The 4-year infarction-free survival rate was higher for a negative than a positive stress test result in medically (93.9% vs. 87.3%, p = 0.009) but not invasively treated patients (92.7% vs. 97.1%, p = 0.545). Moreover, a significantly higher 4-year infarction-free survival rate was found in invasively versus medically treated patients with a positive (p = 0.012), but not in those with a negative, stress test result (p = 0.853).

CONCLUSIONS

Pharmacologic stress echocardiography is effective in risk stratification of single-vessel disease and can accurately discriminate patients in whom coronary revascularization can have the maximal beneficial effect. These findings have a potential favorable impact on the cost-effectiveness of invasive procedures.

Left atrial appendage function assessed by transesophageal echocardiography before and on the day after elective cardioversion for nonvalvular atrial fibrillation

We investigated left atrial appendage function by transesophageal echocardiography, on the day after external electrical cardioversion to sinus rhythm, in 41 patients with nonvalvular atrial fibrillation. After cardioversion, appendage contraction synchronized with the electrical and mechanical activity of the atrium, which was restored in about 70% of the patients.

Chronic aneurysmatic dilatation: a possible source of lethal embolization in patients with acute myocardial infarction undergoing thrombolysis

Left ventricular thrombosis is relatively common after acute myocardial infarction, especially in the anterior site, and represents a possible cause of potentially lethal peripheral embolization 1. Therefore, several studies have been performed in order to assess the efficacy of different antithrombotic drugs in resolving the detected thrombi or reducing their embolic potential. Fibrinolytic agents appear effective in this regard: in the majority of cases, they produce complete lysis and resolution of the thrombi. However, this treatment may itself cause embolic complications by producing a rapid fragmentation of thrombus and the subsequent emission of disrupted portions of the intracardiac mass into the systemic vascular bed [2]. This dramatic effect of thrombolysis has suggested the possibility that even the standard treatment of acute myocardial infarction with fibrinolysis implies a danger of embolization in those patients in whom a left ventricular thrombus may be present either from a previous myocardial infarction or from a very early thrombus development. However, this hypothesis has not yet been confirmed by direct observation. We report the case of a patient with a first acute anterior myocardial infarction, in whom the thrombolytic treatment induced lysis and embolization from a left ventricular thrombus present in an aneurysmatic dilatation of the infero-posterior wall due to a previous inferior myocardial infarction.

Dipyridamole echocardiographic test performed 3 days after an acute myocardial infarction: feasibility, tolerability, safety and in-hospital prognostic value

In recent years, increasing evidence has pointed to the potential of dipyridamole stress echocardiography as a fast, effective, inexpensive method of risk stratification after an acute myocardial infarction. A very early stratification by this test could improve the patient's management and reduce the duration of in-hospital stay, and, thus, the costs. Two-hundred and fifty-one consecutive patients (208 male, age 58 +/- 11) with a two-dimensional echocardiogram of good technical quality underwent a dipyridamole echocardiographic test (DET) 70 +/- 6 h after an acute myocardial infarction. Criterion for positivity was the identification of a transient regional asynergy that was absent or of a lower degree in the baseline examination. Positivity was defined as 'at low-dose' or 'at high-dose' if the asynergy was detected before or after the 8th min of a drug infusion. All tests were performed without any major side effects. DET was positive in 149 (59%) and negative in 102 (41%) patients. During the hospital stay, cardiac events (death, reinfarction, angina) occurred in 52/251 patients: in 49/149 with a positive and in 3/102 with a negative test (sensitivity 94%, negative predictive value 97%, P < 0.00001). Severe events (death and reinfarction) occurred in 14/251: in 12/149 with a positive DET and in 2/102 with a negative DET (sensitivity 86%; negative predictive value: 98%; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Methotrexate, mitoxantrone, 5-fluorouracil and leucovorin in metastatic breast cancer patients

We have evaluated the efficacy and toxicity of a chemotherapy consisting of methotrexate, mitoxantrone, 5-Fluorouracil and leucovorin in 21 advanced breast cancer patients. Among 20 evaluable patients, objective response was obtained in 6 patients (30%) with two complete responses, stable disease in 4 patients (20%), while 10 patients (50%) progressed. Median progression-free survival and survival were 10 and 15 months, respectively. The most frequently observed side-effects were myelosuppression and emesis; one patient, who had previously received doxorubicin at the maximum dose-limiting cardiac toxicity, died of congestive heart failure after the third cycle. This treatment is moderately effective for advanced breast cancer patients.

Atropine increases the accuracy of dobutamine stress echocardiography in patients taking beta-blockers

Dobutamine-atropine stress echocardiography is used for the non-invasive diagnosis of coronary artery disease, but stress test results may be influenced by beta-blockers. The aim of this study was to assess if the addition of atropine can compensate for the presence of beta-blockers in dobutamine stress echocardiography. Twenty-six patients referred for evaluation of chest pain were studied twice, on and off metoprolol 100 mg b.i.d. (in random order sequence) with a wash-out period of at least 48 h. Dobutamine stress echocardiography was performed using up to 40 micrograms.kg-1.min-1, followed, if necessary, by the addition of atropine to achieve 85% of the age-predicted maximal heart rate, unless symptoms or markers of ischaemia appeared. Atropine was given to patients on beta-blockers more often [(22/26) vs (6/26)] than to those off beta-blockers (P < 0.001). Heart rate at every stage of the test was lower on beta-blockers. Chest pain occurred in patients on beta-blockers significantly less than in those off beta-blockers (8% vs 46%), and the addition of atropine made no significant difference (31% vs 46%). During dobutamine stress, new wall motion abnormalities occurred in three patients on beta-blockers (12%); this number increased to 15 after the addition of atropine (57%). New or worsened wall motion abnormalities occurred in 12 patients (46%) off beta-blockers with dobutamine alone and in 14 patients after adding atropine (53%).(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative ultrasonic analysis of myocardium in patients with thalassemia major and iron overload

BACKGROUND

Patients with beta-thalassemia major present with severe anemia and need continuous transfusion therapy. The consequent iron overload leads to hemochromatosis. Initial cardiac dysfunction has been documented even in thalassemics without clinical manifestations of heart failure as well as by conventional echocardiographic-Doppler techniques. The purpose of this study was to assess the acoustic quantitative properties of myocardium in patients with iron overload.

METHODS AND RESULTS

Thirty-eight patients with beta-thalassemia major, without clinical signs of cardiac failure, and 20 age- and sex-matched young controls were studied by echocardiography. An on-line analysis of the ultrasonic radiofrequency signal was performed to obtain quantitative operator-independent measurements of the integrated backscatter (IB) signal of the ventricular septum and the posterior wall. The integrated values of the radiofrequency signal were normalized for the pericardial interface and expressed in percent (IB%). Thalassemic patients had been receiving transfusion therapy for 16 +/- 5 years and had received 313 +/- 138 transfusion units; they all had received chelation treatment (desferroxiamine) for 9 +/- 2 years. Patients and controls showed comparable values of echocardiographically assessed percent fractional shortening (32 +/- 3% versus 36 +/- 4%, p = NS), whereas thalassemics showed higher values of left ventricular mass index (118 +/- 30 versus 98 +/- 15 g/m2, p < 0.05). The IB% values were higher in patients with thalassemia major than in controls for both septum (35 +/- 14% versus 21 +/- 6%, p < 0.001) and posterior wall (16 +/- 6% versus 11 +/- 3%, p < 0.001). In thalassemic patients, no significant correlation was found between the septum IB% value and hematological parameters, such as the total number of transfusions (r = 0.2, p = NS) or the mean ferritin value (r = 0.1, p = NS). No significant correlation was also found between the septum IB% value and the echocardiographically assessed left ventricular mass index (r = 0.2, p = NS).

CONCLUSIONS

These data demonstrate that myocardial reflectivity is abnormally increased in patients with thalassemia major under transfusion treatment, probably due to myocardial iron deposits and/or secondary structural changes. These quantitatively assessed abnormalities in regional reflectivity can be detected when conventional echocardiographic parameters of systolic left ventricular function are undistinguishable from normal controls.

Predicting cardiac mortality after uncomplicated myocardial infarction by exercise radionuclide ventriculography and exercise-induced ST segment elevation

In 183 consecutive patients with recent, uncomplicated myocardial infarction, the following variables were associated with 4-year cardiac death: haemodynamic decompensation with exercise (P = 0.01), left ventricular ejection fraction at rest (P = 0.004) and at peak exercise (P = 0.003), persistent ST segment elevation at rest in the area of infarction = (P = 0.004), exercise-induced ST segment elevation (P = 0.02), and late aneurysmal evolution (P = 0.01). Exercise left ventricular ejection fraction was the sole variable selected by Cox regression analysis as an independent predictor of cardiac death. In 40 patients with ST segment elevation at rest, left ventricular ejection fraction was 42 +/- 17% at rest and 40 +/- 18% at peak exercise, versus 52 +/- 12% and 52 +/- 14% in the remaining patients (both P less than 0.01). Among these 40, 16 (all with anterior infarction) also had exercise-induced ST segment elevation; their ejection fraction was 32 +/- 13% at rest, 30 +/- 13% during exercise, versus 53 +/- 15% and 53 +/- 15% in 129 patients with no ST segment elevation either at rest, or during exercise (both P less than 0.01). The 4-year risk of death was 20% in the former 40 patients, 36% in the latter 16, while in the complete absence of ST segment elevation, such risk was 3%. All 14 patients with ST segment elevation only during exercise were alive after 4 years: their left ventricular ejection fraction was 47 +/- 12% at rest, 45 +/- 13% with exercise. ST segment elevation was associated with late aneurysmal evolution but not with exercise-induced ischaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular thrombus in anterior acute myocardial infarction after thrombolysis. A GISSI-2 connected study

BACKGROUND

Streptokinase reduces the incidence of left ventricular thrombosis after acute myocardial infarction. However, it is unknown whether a similar effect can be obtained with different thrombolytic agents and whether subcutaneous calcium heparin can have an additional efficacy.

METHODS AND RESULTS

To compare the effects of two different thrombolytic agents combined or not with heparin on the incidence and features of left ventricular thrombi and their related embolic events, we performed a GISSI-2 ancillary echocardiographic study (the first echocardiogram obtained within 48 hours of symptoms onset and the second before hospital discharge) that enrolled 180 consecutive patients (mean age, 63 +/- 11 years, 142 men) with a first anterior acute myocardial infarction. Patients were randomized into four groups of treatment: recombinant tissue-type plasminogen activator (rt-PA) (n = 47), rt-PA plus heparin (n = 45), streptokinase (n = 39), and streptokinase plus heparin (n = 49). Left ventricular thrombosis was observed in 51 of 180 patients (28%). No significant differences were found concerning the incidence of thrombi in the four treatment groups. Mural shape of left ventricular thrombi was found more frequently than the protruding shape (71% versus 29% at the first examination, 64% versus 36% at the second), particularly in heparin-treated patients (93% versus 7% at first examination, 70% versus 30% at the second). Only one embolic event (0.5%) occurred during the hospitalization.

CONCLUSIONS

We conclude that 1) the rate of left ventricular thrombi does not differ in patients with acute myocardial infarction treated either with streptokinase or rt-PA, 2) subcutaneous heparin, when begun 12 hours after intravenous thrombolysis, does not appear to further reduce the occurrence of thrombi but seems to influence the shape of left ventricular thrombi, and 3) during the predischarge period, embolic events are rare in patients treated by thrombolysis.

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.

Left ventricular thrombi: changes in size and in platelet deposition during treatment with indobufen and ticlopidine

This study was designed to evaluate whether indobufen and ticlopidine can induce changes in the size of left ventricular thrombi and variations in the deposition of platelets on thrombus surface. Forty-seven patients with left ventricular thrombosis, who were not treated with antithrombotic drugs, were prospectively evaluated with 111In-oxine platelet imaging and two-dimensional echocardiography. The first scintigraphic examination was negative in 15 of the 47 patients with left ventricular thrombosis, thus they were excluded from further evaluation. The remaining 32 patients with evidence of labeled platelet deposition on the thrombus were divided into three groups. Group 1 comprises 11 patients treated with different doses of ticlopidine: 6 with 250 mg/day, and 5 with 500 mg/day. Group 2 comprises 12 patients who received 400 mg/day of indobufen. Group 3 comprises 9 patients who were not treated with antithrombotic drugs. All 32 patients underwent repeated 111In-oxine platelet imaging and echocardiography 40 +/- 11 days after the first examination. During treatment with ticlopidine, deposition of labeled platelets on the thrombus became absent in 2 patients (500 mg/day), and reduced in 5 (2 treated with 250 and 3 with 500 mg/day). A decrease of platelet deposition on the thrombus was also observed in 5 of the 12 patients receiving indobufen and in only 1 of 9 controls. With regard to thrombus dimensions, 1 patient treated with ticlopidine showed a decrease in thrombus size associated with a reduction of the scintigraphic activity. In conclusion, a decrease of the platelet uptake on the thrombus surface, without significant changes in the size, was detected in most patients during treatment with indobufen and ticlopidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Early appearance of left ventricular thrombi after anterior myocardial infarction: a marker of higher in-hospital mortality in patients not treated with antithrombotic drugs

Left ventricular thrombus may develop both early and late after acute anterior myocardial infarction. To assess the possible prognostic implication of the time of thrombus appearance, 125 patients (87 males; age ranging from 35 to 92 years, mean: 65 +/- 10 years) consecutively admitted to our coronary care unit within 24 h of a first acute anterior myocardial infarction, untreated with antithrombotic drugs, underwent serial two-dimensional echocardiographic studies during hospitalization, then monthly for a follow-up of 1-48 (mean: 23 +/- 16) months among survivors. Left ventricular thrombi, detected in 71 patients (57%), appeared from 1 to 362 (mean: 13 +/- 44) days after acute infarction. In 40 patients (56%), early thrombus development, within 48 h of symptom onset, was noted. During the study period, 52 patients (42%) died. Global mortality rate was similar in patients with thrombi compared with those without thrombi (32/71: 45%, vs 20/54: 37%; P = ns). However, in-hospital mortality of patients who developed left ventricular thrombi within 48 h (17/40: 42.5%) was significantly higher compared with both patients with later thrombus appearance (4/31: 13%; P less than 0.008) and those without thrombi (10/54: 20%; P less than 0.01). Embolic events were more frequent in patients with thrombi (9/71, 13% vs 1/54, 2%; P less than 0.02), but there was no relationship with the time of thrombus appearance. The values of peak CPK levels and the degree of left ventricular wall motion abnormalities observed in patients with early left ventricular thrombus were significantly higher than the values detected in patients without thrombi, but similar to those obtained in patients with later thrombus occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of thrombolytic treatment followed by full dose anticoagulation on the frequency of left ventricular thrombi in acute myocardial infarction

This study evaluated the influence of thrombolysis followed by full anticoagulation on the frequency of left ventricular (LV) thrombi after acute myocardial infarction (AMI). Nineteen consecutive patients with a first anterior wall AMI who received 1,500,000 IU of streptokinase within 3 hours of symptom onset, followed by full anticoagulation, underwent echocardiographic studies within 24 hours of symptoms, and then on days 2, 3, 5, 7, 12, 30 and 90. Forty-four patients, with comparable clinical features and echocardiographic protocol but without antithrombotic therapy, served as the control group. LV thrombi developed in 4 of 19 (21%) treated patients and in 23 of 44 (52%) control subjects (p = 0.02). LV aneurysm or major wall motion abnormalities were noted in 8 of 19 (42%) treated patients and in 30 of 44 (68%) control subjects (p less than 0.05). No significant difference was found between treated and untreated patients when comparing the incidence of thrombi in the subgroups of patients with aneurysm or major wall motion abnormalities (3 of 8 vs 21 of 30) and in the subgroups with less extensive LV dysfunction. Thrombi disappeared during hospitalization in 3 of 4 treated patients, but in none of the controls. Fewer patients treated with intravenous streptokinase followed by full anticoagulation developed LV thrombi compared to patients treated with conventional therapy. This difference may be related to a reduced occurrence of major LV wall motion abnormalities. Resolution of thrombi frequently occurs in the hospital phase of AMI; therefore, only frequent echocardiographic examinations can assess the true frequency of LV thrombi.

[Supravalvular aortic stenosis: clinical and genetic study of a family group]

We describe a family with a high frequency of supravalvular aortic stenosis. The family includes 5 generations and 80 subjects (prospective study in 66, on whom physical examination, ECG, M-mode and two-dimensional echocardiogram were performed, and retrospective analysis of available data in 14). This is the largest family group with this disease studied so far. Thirty-six subjects (45%) were found to be affected. On the basis of the echocardiographic image and of the haemodynamic gradient (when available), three different degrees of supravalvular aortic stenosis were identified. The disease was found to be severe in 8 subjects (22%), moderate in 6 (17%), mild in 13 (36%) and undefined in 8 (22%). In 4 cases multiple pulmonary stenoses were associated with supravalvular aortic stenosis, while in one subject multiple pulmonary stenoses were noted in the absence of aortic abnormalities. In the family we studied, the supravalvular aortic stenosis gene is transmitted with a pattern of inheritance consistent with an autosomal dominant trait with variable expressivity and penetrance (penetrance coefficient = 0.86). A high mortality rate in early childhood was observed, while symptoms and ECG abnormalities were not related to the degree of the stenosis. Furthermore, we found a high rate of mitral valve echocardiographic abnormalities, such as mitral prolapse and systolic anterior motion. The absence of Williams dysmorphic somatic features in the many generations as well as in the large number of patients we studied, appears to exclude the coexistence of Williams and Eisenberg's syndromes in the same family group.

Clinical course and prognosis of hypertrophic cardiomyopathy in an outpatient population

Hypertrophic cardiomyopathy has been investigated mainly at referral institutions. Thus, the clinical history of the disease that emerges from published studies could be influenced by a bias in patient selection. In the present study, we compared the clinical features of an outpatient population of 25 patients who had hypertrophic cardiomyopathy with those reported in 78 studies published during the past five years. In the 25 study patients, age, sex, and the extent of left ventricular hypertrophy, as well as the prevalence of diastolic filling abnormalities, subaortic obstruction, and ventricular arrhythmias, were similar to those in patients described in the literature. Cardiac symptoms, however, were much less severe in the study patients. Eighteen patients (72 percent) were asymptomatic, six (24 percent) had mild symptoms, and only one (4 percent) had moderate-to-severe symptoms. Of 24 patients followed for a mean period of 4.4 years (range, 2.9 to 5.7), none died or had clinical deterioration. Of 3404 patients described in the 78 studies we reviewed, 2483 (73 percent) came from only two referral institutions. Of the 1721 patients in whom severity of symptoms was reported, 757 (44 percent) had moderate-to-severe symptoms. However, 727 (96 percent) of these patients were studied at one of the same two referral institutions. We conclude that the natural history of hypertrophic cardiomyopathy may be more benign than can be inferred from published reports.

Familial supravalvular aortic stenosis: a genetic study

Supravalvular aortic stenosis (McKusick 18550) is a rare hereditary condition with autosomal dominant transmission. However, the available data have been limited to small family groups which do not allow the definition of the degree of penetrance of the disease. The present study describes a large family with a high frequency of supravalvular aortic stenosis including five generations and 80 subjects, the largest family group with this disease studied so far. The study was carried out prospectively in 66 subjects (clinical examination, ECG, M mode and two dimensional echocardiography). In 14 subjects available data were examined retrospectively. In 10 patients cardiac catheterisation was performed (prospective study in eight). The disease was present in 36 (45%) of the 80 subjects investigated, on the basis of clinical, echocardiographic, and haemodynamic (when available) criteria. The disease was found to be severe in eight cases (22%), moderate in six cases (17%), mild in 13 (36%), and undefined in eight (22%) patients. In one case (3%), multiple pulmonary stenoses were noted in the absence of supravalvular aortic stenosis. Genetic analysis of these data shows, for the first time, the degree of penetrance of the supravalvular aortic stenosis trait (K = 0.86) and confirms that it is transmitted with incomplete penetrance and variable expressivity.

Two-dimensional and Doppler echocardiographic diagnosis of left ventricular pseudoaneurysm

In an oligosymptomatic patient with recent acute anterior myocardial infarction, two-dimensional and Doppler echocardiography allowed us to detect, unmistakably, the presence of an apical pseudoaneurysm. Prompt and successful repair was made without performing left ventriculography. To our knowledge, this is the first case of pseudoaneurysm referred for surgery on the basis of echocardiographic findings.

Activity of left ventricular thrombi of different ages. Assessment with indium-oxine platelet imaging and cross-sectional echocardiography

To evaluate the possible relation between the age of intracardiac thrombi and the presence and degree of their activity, 29 patients with left ventricular thrombi that developed after an anterior myocardial infarction were evaluated by means of 111In-oxine autologous platelet imaging. None of the patients was treated with anticoagulants or platelet inhibitors during either the acute phase of infarction or the follow-up. The time of appearance and the shape of left ventricular thrombi were assessed by serial cross-sectional echocardiograms, obtained within 24 hours of onset of the chest pain, every 24 hours until the fifth day, every 48 hours until the 15th day, and then every month for a follow-up of 1 to 17 months (mean: 8 months). At the time of the scintigraphic examination, left ventricular thrombi were aged 1 month in 9 patients, and 2 to 14 months in the remaining 20 patients. 111In-oxine imaging with autologous platelets was obtained in all patients at 4, 24, 48 and 72 hours, in the sagittal, 30 degrees and 45 degrees left anterior oblique projections. In 25 patients the degree of haematological activity of the thrombi was evaluated by dividing the values of thrombus activity/background activity, obtained at 4, 24, 48 and 72 hours, respectively, by the value observed at 4 hours (uptake index). Scintigraphic imaging showed the presence of an active thrombus in every patient. In the 9 patients with recent thrombi, the uptake index was significantly greater than in subjects with older ones (P less than 0.01). Hence, in patients with anterior myocardial infarction, untreated with anticoagulants or platelet inhibitors, haematologically active thrombi can be observed even more than one year after their appearance. The uptake of platelets on the surface of thrombi is greater in recent left ventricular thrombi than in older ones.

Spontaneous morphologic changes in left ventricular thrombi: a prospective two-dimensional echocardiographic study

Previous retrospective echocardiographic studies have reported a higher embolic potential of left ventricular thrombi with protruding configuration and patterns of mobility. The present study was performed to prospectively assess the shape and mobility patterns of left ventricular thrombi and their spontaneous changes with time. Two-dimensional echocardiograms were obtained in 109 consecutive patients with acute anterior myocardial infarction within 24 hr of the onset of symptoms, every 24 hr until day 5, every 48 hr until day 15, and then every month for a follow-up of 1 to 29 (mean 14 +/- 8) months in the survivors. None of the patients were treated with anticoagulants or platelet inhibitors during the study period. Left ventricular thrombi, detected in 59 patients (54%), appeared from 1 to 362 (mean 12 +/- 47) days after myocardial infarction. At first detection, the shape was mural in 21 patients and protruding in 38; patterns of mobility were present in eight patients. During follow-up, changes in the shape of the thrombi were noted in 24 patients (41%; from mural to protruding in nine, from protruding to mural in 15). These variations were encountered between 2 and 490 (mean 64 +/- 117) days after the first observation of the thrombus. Patterns of mobility, previously detected in eight patients, disappeared in five of eight within 2 to 28 (mean 14 +/- 11) days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiographic and anatomic evaluation of left ventricular thrombosis]

The aim of this study was to assess the correspondence between two-dimensional echocardiographic (2D-Echo) and anatomic features of left ventricular thrombi (LVT), with particular reference to LVT shape and dimensions. The study population was composed of 23 patients who were admitted to our intensive cardiac care unit with an anterior acute myocardial infarction and who died during the hospitalization. Every patient underwent serial echocardiographic examinations, the last one performed within the 24 hours preceding death. The diagnosis of LVT required the agreement of three independent observers. Doubtful cases were considered as negative. With regard to shape, the LVT were defined as mural or protruding. Two measures of the LVT were obtained in each case: the longest dimension and the greatest one perpendicular to the initial dimension. At post-mortem examination we obtained sections of the heart comparable with an echocardiographic four chamber view. LVT were detected by 2D-Echo in 12/23 cases. Post-mortem examination confirmed the presence of LVT in these 12 patients. A thin apical thrombotic layer, whose presence had been defined previously as doubtful, was observed in another patient. The sensitivity of 2D-Echo was 92% and the specificity 100%. At 2D-Echo, shape was mural in 2 patients and protruding in 10. Complete agreement was found between 2D-Echo and anatomic findings as far as the morphology of LVT is concerned. The 2D-Echo measurements of LVT showed a high correlation with autopsy (r = 0.95; r = 0.86); we conclude that 2D-Echo provides accurate evaluations of the shape and the dimensions of LVT.

[Clinical applicability of myocardial scintigraphy with gallium-67 in the study of dilated cardiomyopathy]

Gallium-67-citrate imaging has been recently proposed, in addition to endocardial biopsy, to detect myocardial inflammation in idiopathic dilated cardiomyopathy (IDCM). In order to evaluate the clinical usefulness of this method, 33 patients (pts) suffering from IDCM, 24 pts with various other cardiac diseases (inflammatory etiology in 7), and 11 controls underwent Gallium-67 scintigraphy (anterior and 30 degrees left anterior oblique projections; acquisition at 48 and 72 hrs). In 31 pts repeated scintigraphic examinations (at least two) were obtained. Scans were interpreted by two independent observers. Positivity of scintigrams was based on three different criteria: 1) myocardial activity greater than that of the sternum; 2) presence of focal myocardial activity; 3) semiquantitative index (index = activity of sternum/myocardial activity). Significant differences, either in the percentage of positive scans or in the values of the semiquantitative index, were found between controls and all pts with cardiac diseases. However, no difference was observed when comparing pts with IDCM to pts with other cardiac diseases. Finally, among the pts with cardiac disorders other than IDCM, the qualitative and semiquantitative results of the 7 pts with inflammatory etiology of the disease were similar to those obtained in the remaining 17. Of those pts who underwent longitudinal study, about a third showed modified scintigraphic results later on. No significant difference in behaviour was observed between IDCM and other cardiac disorders. Therefore, we conclude that Gallium 67-citrate imaging does not appear to be a suitable method for the identification of pts. with IDCM. The usefulness of this technique should be tested in samples of pts should previously selected with other more specific methods.

Noninvasive assessment of left ventricular diastolic function: comparative analysis of pulsed Doppler ultrasound and digitized M-mode echocardiography

The relation between Doppler and digitized M-mode echocardiographic indexes of left ventricular (LV) diastolic function was analyzed. Diastolic variables obtained with these 2 techniques were compared in 19 normal volunteers and in 25 patients with a variety of cardiac diseases. The 2 techniques were in agreement in distinguishing normal from abnormal diastolic function in 20 of the 25 patients (80%) with cardiac disease. Furthermore, a close linear relation with a high correlation coefficient and a small standard error of the estimate was identified between measurements of isovolumic relaxation determined by Doppler and by M-mode echocardiography (r = 0.82, standard error of the estimate = 18 ms). Doppler indexes of diastolic filling such as the slope (descent) and the duration of the early diastolic flow-velocity peak did not show a close correlation with the peak rate and the time to peak rate of increase in LV internal dimension determined by digitized echocardiography. Thus, Doppler and digitized echocardiography were consistent in distinguishing normal from abnormal diastolic function in most of the study patients, although specific variables of LV ventricular filling determined by the 2 techniques were not closely related. In addition, Doppler and M-mode echocardiographic measurements of isovolumic relaxation showed an excellent correlation.

[Left ventricular diastolic function in type I diabetes. A longitudinal echocardiographic study]

The present study was performed to assess the extent of left ventricular diastolic abnormalities and their possible progression with time in patients with type I (insulin dependent) diabetes. Two echocardiographic examinations were performed at an interval of 5 years in 18 study patients. Left ventricular diastolic function was assessed by computer digitized analysis of the M-mode echocardiographic tracings. During the study period all patients remained in satisfactory metabolic control and without retinopathy. Twelve normal subjects, matched for age and sex, were used as control group. Peak rate of left ventricular posterior wall excursion and the peak rate of increase in left ventricular internal dimensions were significantly reduced in patients with diabetes (14.12 +/- 2.5; 16.48 +/- 3.9 cm/sec) compared with controls (17.25 +/- 2.8; 20.41 +/- 3.6 cm/sec) (p less than .005; p less than .01). In addition time to peak rate of increase in left ventricular internal dimensions, isovolumic relaxation index and isovolumic relaxation time were significantly prolonged in patients with diabetes (63.66 +/- 16.5; 23.9 +/- 9; 72.7 +/- 14 msec) compared to controls (46.83 +/- 9.8; 13.4 +/- 4; 61.1 +/- 12 msec) (p less than .005; p less than .001; p less than .05). In the study patients, no relation was found between the extent of diastolic abnormalities and age, duration of the disease and insulin dosage. The extent of left ventricular diastolic dysfunction did not show significant changes during follow-up. Our results indicate that diastolic abnormalities are common in patients with type I diabetes and are not related to the duration of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance and natural history of left ventricular thrombi in patients with acute anterior myocardial infarction: a two-dimensional echocardiographic study

Fifty-eight patients with transmural anterior myocardial infarction were prospectively studied with serial two-dimensional echocardiography to determine the clinical implications and prognostic significance of detection of left ventricular thrombus during acute myocardial infarction, the incidence of systemic embolization, and the possible occurrence of spontaneous regression of left ventricular thrombi. Patients were not treated with anticoagulants or platelet inhibitors during the acute phase of infarction or during follow-up. Two-dimensional echocardiograms were obtained within 24 hr of myocardial infarction, every 24 hr until day 5, every 48 hr until day 15, and every month for a follow-up of 2 to 11 months (mean 7), in the surviving patients; a total of 774 echocardiograms were obtained. Left ventricular thrombi were identified in 24 (41%) of the 58 study patients, and developed within 48 hr of infarction in 11 of these patients. Ten (91%) of the 11 patients with early thrombus formation died during hospitalization or during follow-up, while only two (15%) of the 13 who developed a thrombus after 48 hr of infarction died (p less than .005). Incidence of Killip class III or IV, total lactic dehydrogenase values, and extent of wall motion abnormalities were significantly higher in patients who developed a thrombus within 48 hr of infarction than in patients without thrombus. On the other hand, in patients who developed a thrombus after 48 hr of infarction, these parameters were not significantly different from those in patients who did not develop a thrombus. Spontaneous regression of thrombi was documented in three (20%) of the 15 patients who survived the acute phase of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Diastolic abnormalities in patients with hypertrophic cardiomyopathy: relation to magnitude of left ventricular hypertrophy

To investigate the relationship between diastolic abnormalities and left ventricular hypertrophy, 52 patients with hypertrophic cardiomyopathy (HCM) and 22 normal subjects were studied with digitized M mode echocardiography and two-dimensional echocardiography. Echocardiographic indexes of diastolic function were compared in patients with different extent of left ventricular hypertrophy. Time interval from minimum left ventricular internal dimension to mitral valve opening and time to peak rate of increase in left ventricular internal dimension were significantly prolonged (80 +/- 31 and 100 +/- 37 msec, respectively) in patients with HCM and the most extensive left ventricular hypertrophy compared with those in patients with mild left ventricular hypertrophy (59 +/- 25 and 74 +/- 34 msec, respectively; p less than .01). Furthermore, peak rate of posterior wall diastolic excursion was significantly reduced in those patients with HCM and posterior wall hypertrophy (8.3 +/- 4.0 cm/sec) compared with that in patients with HCM but normal posterior wall thickness (11.2 +/- 3.4 cm/sec; p less than .002). However, abnormal M mode echocardiographic indexes of diastolic function were also identified in a substantial proportion of patients (i.e., 73%) with HCM and only mild left ventricular hypertrophy. In these patients, time interval from minimum left ventricular internal dimension to mitral valve opening (59 +/- 25 msec), peak rate (12 +/- 4 cm/sec), and time to peak rate of increase in left ventricular internal dimension (74 +/- 34 msec) were significantly different from normal (25 +/- 12 msec, 21 +/- 3 cm/sec, and 49 +/- 12 msec, respectively; p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of extra load on the mechanical behavior of skeletal muscle

Eleven international jumpers and throwers engaged in year round training were divided into experimental (n = 6) and control (n = 5) groups. The experimental group was tested before and after a 3 weeks simulated hypergravity period, and again 4 weeks after the hypergravity period. The high gravity condition was created by wearing a vest weighing about 13% of the subjects body weight. The vest was worn from morning to evening including the training sessions, and only removed during sleep. The daily training of all subjects consisted of classical weight training and jumping drills. No changes in the ordinary training program were allowed in the experimental group, except for the use of the vest. Vertical jumps, drop jumps and a 15 s continuous jumping test were used to measure the explosive power characteristics of the subjects. After the hypergravity period the experimental subjects demonstrated significant (5-10%, P less than 0.05-0.01) improvements in most of the variables studied: however, 4 weeks after cessation of the high gravity period they tended to return towards the starting values. No changes were observed in the results of the control group. The improvement observed in the experimental subjects was explained as fast adaptation to the simulated high gravity field. It is suggested that adaptation had occurred both in neuromuscular functions and in metabolic processes.