Insomnia and menopause: a narrative review on mechanisms and treatments

The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.

AB0992 CONNECTING SLEEP QUALITY, PAIN AND MOOD DISTURBANCES IN JUVENILE FIBROMYALGIA

Background:

Subjective sleep problems, including difficulties falling asleep, waking up, un-restorative sleep and daytime sleepiness are highly prevalent in patients with juvenile fibromyalgia (JFM). Sleep disturbances has been considered a consequence of severe pain and depression, but also in healthy individuals sleep deprivation is also a risk factor for the development of chronic widespread pain, tenderness and fatigue, suggesting the important role of sleep in pain control and in the pathophysiology of fibromyalgia.

Objectives:

To estimate the incidence of polysomnographic alterations in JFM and to explore the relationship between sleep problems and the musculoskeletal pain, fatigue and mood and anxiety disorders.

Methods:

21 patients (M 3; F 18; mean age 16,1) with JFM were included. The objective sleep quality was measured by overnight polysomnography (PSG) (using the EMBLETTA MPR PG device). PSG data were compared to age and sex-matched controls. The subjective sleep disturbances were assessed by the Sleep Condition Indicator (SCI). Musculoskeletal symptoms were evaluated by using the widespread pain index (WPI). Pain intensity was evaluated on a 0-10 visual analogical scale (PVAS). Fatigue was assessed by using the Symptom Severity (SS) questionnaire. Mood and anxiety disorders were evaluated by using the Children Depression Index (CDI) and the Multidimensional Anxiety Scale for Children (MASC). Comparison of categorical data was performed by means of the Fisher’s Exact test. The relationship between sleep quality and clinical symptoms were assessed using Spearman’s rank order correlation coefficient (rs). All statistical test were 2-sided and p values less than 0.05 were considered statistically significant.

Results:

Nineteen out of 21 (90.5%) patients complained subjective sleep disturbances and un-restorative sleep. Seven out of 21 (33.3%) patients had mood and anxiety disorders. Eight out of 21 patients (38.1%) showed an electroencephalographic pattern of alpha wave intrusion in slow wave sleep (SWS). SCI was significantly correlated to CDI score rs -0,775 (p≤0,0001), MASC 0,61 (p=0,005), WPI -0,731 (p=0,001), SSI 0,492 (p=0,038), PVAS -0,590 (p=0,006).

Conclusion:

A substantial percentage of JFM patients experience sleep disturbances, which are, correlated with the severity of the muscolskeletal sympotms and mood and anxiety disorders. One third of JFM patients have alpha intrusion in the SWS. The important role of sleep in pain control suggests that the development of treatments to improve sleep quality may lead to more effective management of fibromyalgia in the future.

References:

[1]Ting TV et. al 2010 American College of Rheumatology Adult Fibromyalgia Criteria for Use in an Adolescent Female Population with Juvenile Fibromyalgia. J Pediatr. 2016 Feb;169:181-7.

[2]Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol. 2015;11:513-20.

[3]Roizenblatt S et al. Alpha sleep characteristics in fibromyalgia. Arthritis Rheum. 2001;44, 222–230.

Disclosure of Interests:

None declared

P2685Improving myocardial perfusion in refractory angina: extracorporeal shockwave myocardial revascularization in a monocentric cohort

Background

The incidence of patients with refractory angina (RA) is increasing. Medical therapy for RA is limited and prognosis is poor. Experimental data and small clinical studies suggest that the use of Extracorporeal shockwave myocardial revascularization (ESMR) may contribute to angiogenesis and improve symptoms in patients with RA.

Purpose

The aim of this study was to assess the efficacy of ESMR in the improvement of myocardial perfusion and symptoms in patients with RA.

Methods

Patients with RA despite optimal medical therapy and not suitable for further myocardial revascularization were enrolled and underwent ESMR. Characteristics such as angina class scores (CCS class score), nitroglycerin consumption and hospitalization rate among cases (patients with RA who received ESMR) and controls (patients with RA who did not receive ESMR) were compared at baseline and 6 months after ESMR therapy. In patients receiving ESMR the effect of on cardiac perfusion was assessed at six months.

Results

Among screened patients, 159 met the inclusion/exclusion criteria. 151 patients were enrolled in the present study and 121 treated with ESMR. There were 121 patients in the treatment group and 29 patients in the control group. The mean age of the patients was 70±8.8 years in the case group and 71±5.3 years in the control group. Other characteristics were similar in both groups. After ESMR myocardial perfusion by SPECT significantly improved: mean SSS was reduced from 21.2±9.42 to 14.2±10, with a 33% relative reduction (p=0.0001). Clinical follow up of both group demonstrated a significant improvement CCS class score at six months (1.5±0.6 in treatment and 1.92±0.69 in controls; p 0.0013) a significant improvement NYHA class score (1.4±0.6 in cases and 1.73±0.59 in controls; p 0.008); also, nitroglycerin consumption (29% in case cases, and 44.8% in controls; P 0.15) and hospitalization rate were reduced in the treatment group compared to control (16% vs. 37.9%; P 0.02).

Clinical outcome of two groups at 6 months follow up Treatment group (n=121) Control group (n=29) p CCS class 1.5±0.6 1.92±0.7 <0.001 NYHA class 1.4±0.6 1.7±0.6 <0.008 Nitrates uptake 35 (29%) 13 (45%) <0.15 Admission to emergency department 20 (16%) 11 (38%) <0.02

SPECT results after 6 months follow up

Conclusion

ESMR therapy is a non-invasive safe and potentially effective new option for patients with refractory angina. This study confirms the beneficial effect of ESMR therapy on cardiac symptoms, myocardial perfusion and hospitalizations in patients with refractory angina.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

18F-FDG uptake and calcifications on positron emission tomography/computed tomography in octogenarians with severe aortic stenosis

AIM

The degree of inflammation within the atherosclerotic plaque can be detected non-invasively by positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG). The incidence of aortic plaques with 18F-FDG increased uptake in octogenarians with aortic stenosis is unknown. Aim of this study was to evaluate the frequency of inflamed aortic atherosclerotic plaques in octogenarians with or without severe aortic stenosis and their correlations with calcifications.

METHODS

The study group comprised 27 patients older than 80 years who underwent a 18FDG PET/CT. Nine patients with severe symptomatic aortic stenosis, eligible to TAVI procedure (TAVI Group), and 18 patients age and sex matched, without clinical evidence of aortic stenosis (No TAVI Group), were selected and analysed.

RESULTS

In the whole population 4/27 patients (9.3%) had a significant focal aortic vessel wall 18F-FDG increased uptake: 1 patient (11.1%) in TAVI group and 3 in non-TAVI Group (16.7%). Overall 81 aortic segments were analysed. 18F-FDG uptake rates were similar in the two groups (1/27, 3.7% in TAVI Group and 3/54, 5.5% in No TAVI Group, P=0.7). At CT scan calcifications were significantly more frequent in the TAVI Group compared to non-TAVI Group (23/27, 85.2% and 28/54, 51.8% P=0.005). None of the sites of arterial calcification had an increased focal 18F-FDG uptake.

CONCLUSION

Irrespectively to the presence of aortic stenosis, a significant FDG plaque uptake in octogenarians is rare while calcifications are extremely frequent.

Long term clinical outcomes in DES implantation for unprotected left main disease

AIM

Generate a long term follow-up and evaluate the impact of clinical and procedural characteristics on long term events in percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation for unprotected left main coronary artery (ULMCA) disease.

METHODS

Ninety-seven consecutive patients who underwent PCI with DES, either sirolimus (SES) or paclitaxel-eluting stent (PES), for de novo lesions in ULMCA were analyzed. No patients were excluded. Mean follow-up was 3 years (range 1-6.7 years).

RESULTS

Technical and procedural success rate were 100% and 95.9%. According to the Academic Research Consortium definitions, cardiac death occurred in 6.1% of patients, reinfarction, target vessel revascularization (TVR) and target lesion revascularization (TLR) occurred in 6.1%, 17.5% and 4.2% of patients respectively. Definite stent thrombosis (ST) incidence was 1%, whereas possible ST occurred in 4.2% of patients. Postdilation was performed in 49.5% of patients and was, among all clinical and procedural characteristics, the only factor at multivariate analysis significantly related to lower MACE (25% vs. 46.9%, P=0.024, CI: 0.202 to 0.889) and TVR (8.3% vs. 26.5%, P=0.03 CI: 0.096-0.895).

CONCLUSION

Long term follow-up in PCI of ULMCA disease shows favorable clinical results. Stent postdilation seems to have a protective role in DES PCI for ULMCA disease.

Effects of EPC capture stent and CD34+ mobilization in acute myocardial infarction

AIM

Percutaneous coronary intervention (PCI) is the gold standard for the treatment of acute myocardial infarction (AMI), with the main limitation of in-stent restenosis for BMS and late stent thrombosis (ST) for both BMS and DES. Endothelial progenitor cells (EPC) CD34+ capture stents, promoting vascular healing, may be advantageous in preventing ST. Aim of the study is to evaluate the outcomes of AMI patients treated with EPC CD34+ capture stent and describe the mobilization kinetics of CD34+ and their clinical correlation.

METHODS

Fifty AMI patients underwent primary PCI with EPC CD34+ capture stent. Serial assays of CD34+ were performed by flow-cytometric analysis.

RESULTS

Procedural success rate was 100%. At six-months follow-up cardiac death, myocardial infarction, target lesion revascularization (TLR) and target vessel revascularization (TVR) occurred respectively in 2%, 4%, 10% and 12% of patients. No case of ST was observed. The MACE-free survival was 81,2%. The mean peak value of plasmatic CD34+ was 4.69±3.76 cells/μL. A positive correlation was found between CD34+ concentration, age and infarct area. No correlation was detected between CD34+ concentration and occurrence of TVR, TLR and MACE.

CONCLUSION

EPC capture stent implantation seems to be safe and effective in the clinical setting of AMI, representing a possible alternative to BMS and DES. CD34+ cells plasmatic concentration seems not to correlate to coronary restenosis and atheromasic disease progression.

Rationale and results of percutaneous coronary revascularization with endothelial progenitor cell capture stent in high-risk patients requiring undeferrable non-cardiac surgery

AIM

Drug eluting stents (DES) are currently the gold standard for the treatment of significant coronary artery stenosis in high risk patients. In case of undeferrable non-cardiac surgery their use is still a challenge, due to the need of a prolonged dual antiplatelet therapy. We aimed to prospectively evaluate the efficacy and safety of the implantation of endothelial progenitor cells (EPC) capture stent followed by a short dual anti-platelet therapy (DAT) period in a high risk population of patients undergoing undeferrable non-cardiac surgery.

METHODS

We examined all consecutive patients who received EPCs capture stents and underwent non-cardiac surgery within 60 days of percutaneous coronary intervention. Our primary outcome was the occurrences of cardiac death, myocardial infarction (MI), stent thrombosis (ST), target vessel revascularization (TVR) and major adverse cardiac events (MACE).

RESULTS

Twenty-six patients underwent PCI and were enrolled, but only 20 underwent surgical intervention. Technical and procedural success rates were both 100%. No perioperative MACE was detected. After a mean long term follow-up of 15.4±10.3 months, 2 cases of cardiac death (10%), were recorded. No case of stent thrombosis was reported; no case of ischemia driven TLR was detected. The total MACE-free survival probability was 66.5%.

CONCLUSION

EPC capture stent implantation in high-risk patients requiring undeferrable non-cardiac surgery seems to allow early cand safe discontinuation of DAT, and may be an attractive alternative to conventional stents.

Evaluation of the topical hemostatic efficacy and safety of TISSEEL VH S/D fibrin sealant compared with currently licensed TISSEEL VH in patients undergoing cardiac surgery: a phase 3, randomized, double-blind clinical study

AIM

TISSEEL VH is the only commercially available fibrin sealant indicated as an adjunct to conventional methods of hemostasis during cardiac surgery. A next generation fibrin sealant (TISSEEL VH S/D) has been developed in frozen, ready-to-use form with an added virus inactivation step (solvent/detergent [S/D] treatment) to provide added safety and convenience to the currently licensed product. This study was performed to compare efficacy and safety of the two products.

METHODS

Phase 3, prospective, randomized, double-blind, multicenter study to compare TISSEEL VH S/D to TISSEEL VH during cardiac surgery. The primary efficacy endpoint was the proportion of patients who achieved hemostasis at the primary treatment site within 5 min, and maintained hemostasis until surgical closure.

RESULTS

The proportion of patients who achieved hemostasis at the primary treatment site within 5 min, and maintained hemostasis until surgical closure was 88.2% for TISSEEL VH S/D and 89.6% for TISSEEL VH in the intent-to-treat population. The difference in proportions, TISSEEL VH S/D minus TISSEEL VH, was 1.4% with a standard error of 3.70%. The lower 97.5% confidence bound of this difference was 8.6%, which is above the predefined noninferiority margin of 15%. Therefore, TISSEEL VH S/D is at least as efficacious as TISSEEL VH. The safety profile of TISSEEL VH S/D was very similar to that of currently licensed TISSEEL VH as assessed by the safety endpoints.

CONCLUSION

TISSEEL VH S/D is safe and effective for use as an adjunct to hemostasis in patients undergoing cardiac surgery.

Polyethylene glycol but not mifepristone prevents intestinal lymphocyte loss following treadmill exercise in mice

Circulating lymphocyte numbers decrease following intense physical activity, possibly due to exercise-induced apoptosis. Increased reactive oxygen species (ROS) and glucocorticoids (GC) following exercise contribute to lymphocyte apoptosis. Intestinal lymphocyte (IL) numbers also decrease following exercise.

AIM

The purpose of this study was to determine the contribution of GC to exercise-induced IL loss.

METHODS

Female C57BL/6 mice (n = 178) were randomized to five drug conditions: (1) single injection of the glucocorticoid receptor antagonist mifepristone (MIF) solubilized in polyethylene glycol (PEG); (2) three injections of MIF (repeated MIF) PEG; (3) single injection of PEG (PEG); (4) three injections of PEG (repeated PEG); or (5) repeated injections of saline (SAL). Within each drug group mice were further randomized to exercise conditions: (1) control condition (non-exercised); (2) treadmill running with sacrifice immediately following the exercise; or (3) treadmill running with sacrifice 24 h after completion of the exercise.

RESULTS

There was a significant exercise effect, across all T lymphocyte subsets, in SAL (P < 0.01), PEG (P < 0.01) and MIF (P < 0.01) treated mice but not in mice given repeated PEG or repeated MIF exposure. The exercise effect was due to reduced IL numbers 24 h post-exercise compared with non-exercised controls.

CONCLUSION

These results suggest that GC are not directly responsible for IL cell loss following exercise. Repeated exposure to PEG may confer protection in the gastrointestinal tract from exercise-induced lymphocyte depletion. Because PEG inhibits ROS generation in experimental cell injury, the mechanisms for IL loss after exercise may involve oxidative stress.

Intravenous catecholamine administration affects mouse intestinal lymphocyte number and apoptosis

The purposes of this study were to determine plasma and intestinal epinephrine (E) and norepinephrine (NE) concentrations in mice after exercise stress and, the effect of intravenous injection of E and NE (at concentrations during exercise) on viability of intestinal lymphocytes (IL). Exhaustive exercise significantly elevated plasma E and NE, and intestinal E, compared with sedentary animals. Twenty-four hours after intravenous NE administration, IL counts were higher (p<0.001) and % apoptotic IL were lower (p<0.001) than saline conditions. E resulted in fewer apoptotic IL at 24 h compared to saline controls. E and NE differentially influence IL numbers at 24 h after injection although both result in fewer % apoptotic IL relative to mice given saline only.

β-adrenergic receptor blockade during exercise decreases intestinal lymphocyte apoptosis but not cell loss in mice

Catecholamines induce apoptosis in various lymphoid populations. This process can occur with both α- and β-adrenoreceptors. Heavy exercise increases plasma catecholamine concentrations, and is also a cause of lymphocyte apoptosis, a possible explanation for postexercise lymphocytopenia. The purpose of this study was to examine the effects of adrenoreceptor antagonism on exercise-induced decreases and apoptosis of intestinal lymphocytes. Mice received an intraperitoneal injection of phentolamine (a nonselective α-blocker), nadolol (a nonselective β-blocker), or saline (vehicle) prior to an exhaustive bout of exercise. Total intestinal lymphocyte numbers, percent and number of CD3+ lymphocytes, and cell viability were assessed. Neither α- nor β-antagonism prevented exercise-induced cell loss in the intestine; however, pretreatment with nadolol significantly reduced the number of apoptotic and necrotic cells. Phentolamine administration appeared to increase the incidence of cell death among intestinal lymphocytes. Both drugs decreased the percentage of CD3+ intestinal lymphocytes. Our study suggests that catecholamines are not responsible for postexercise lymphocytopenia, but β-adrenoceptor blockade may confer protection against exercise-induced apoptosis of intestinal lymphocytes.Key words: catecholamines, exhaustive exercise, apoptosis, intestinal lymphocytes, rodents.

Age-adjusted outcomes in traumatic flail chest injuries in the elderly

Severe chest trauma does not independently predict poor outcome in elderly patients. We chose a specific injury, flail chest, to determine whether age factored into outcome of these patients. A retrospective chart review of all trauma admissions to our Level I trauma center between January 1994 and January 1998 sustaining flail chest was undertaken. Sixty-eight patients were identified, but ten patients were excluded because of death on arrival. Fifty-eight patients were included in the study and separated into groups. The first group comprised those under the age of 55 (n = 32) and the second comprised those over age 55 (n = 26). Parameters evaluated were age, Injury Severity Score (ISS), neurologic injury, the need for mechanical ventilation, need for tracheostomy, length of stay, and death. Statistical analysis was performed with Wilcoxon t test, chi2, and logistic regression where appropriate. A 95 per cent confidence interval was sought as determinant of significance. Of the 58 surviving patients analyzed there was no significant difference between the groups regarding ISS, length of stay, days on the ventilator, head injury, tracheostomy, or development of pneumonia or adult respiratory distress syndrome. The likelihood of death was shown to increase by 132 per cent for every 10 years starting at the second decade and continuing to the eighth decade of life. The likelihood of death also increased by 30 per cent for each unit increase in ISS. The likelihood of death decreased by 23 per cent for every day survived in the hospital. Blunt chest trauma directly impacts respiratory mechanics. Elderly patients are more likely to have comorbid conditions and less likely to tolerate traumatic respiratory compromise. Age (and its effects on the body) is the strongest predictor of outcome with flail chest and is associated with an increased mortality (P < or = 0.05).

Transmyocardial laser revascularization: current status

Transmyocardial laser revascularization (TMLR) has been widely evaluated for treatment of the ischemic myocardium either in conjunction with coronary artery bypass grafting or as sole therapy. Clinically, it has shown significant improvement for angina symptoms, but the mechanism by which this modality works is unknown at this time. The original premise on which transmyocardial revascularization was established depended on its ability to essentially generate channels that would directly carry blood from the ventricle into the ischemic myocardium. This theory, however, has not been substantiated, so other mechanisms have been postulated. This article gives a historical perspective on the advent of transmyocardial revascularization and the many animal and human studies that have paved the way for its clinical use. Current controversies are examined, along with the new advances in laser technology and where the future of TMLR is headed.

Effect of tumor bulk on local control and survival of patients with T1 glottic cancer

PURPOSE

To evaluate the effect of tumor bulk in relation to various tumor-related prognostic factors and treatment-related variables on local control and survival of patients with T1 N0 M0 squamous cell carcinoma of the glottis.

MATERIALS AND METHODS

In 114 patients with T1 squamous cell carcinoma of the glottic larynx who were irradiated with curative intent, we determined the effect of tumor bulk in relation to mucosal extent (stage and anterior commissure involvement), histologic differentiation and various radiation factors, especially overall treatment time on local control and survival. Tumors were classified retrospectively as small surface lesions or bulky tumors. Seventy-seven patients had small lesions and 37 had bulky tumors. The anterior commissure was involved with cancer in 43 patients. The overall duration of irradiation ranged from 39 to 64 days. The median follow-up time was 6 years (range 5-24 years).

RESULTS

The 5-year actuarial local control rate for all patients was 82% after radiotherapy and 92% after salvage laryngectomy. On univariate analysis, bulky tumors and tumors involving the anterior commissure showed an adverse effect on local control, whereas the overall duration of irradiation had a borderline significance. The actuarial local control rate was 91% for small tumors and 58% for bulky tumors (P = 0.0002), 88% when the anterior commissure was not involved and 67% when the anterior commissure was involved (P = 0.01) and 89% when radiation was given in less than 50 days and 73% when irradiation exceeded 50 days (P = 0.06). On multivariate analysis. tumor bulk was the only significant factor that affected local control (P = 0.02). The 5-year actuarial survival for all patients was 73% and the disease-free survival was 92%.

CONCLUSION

This study shows that tumor bulk has a highly significant effect on the radiation control of T1 glottic cancer. Patients who had bulky tumors had lower local control and disease-free survival rates than those patients who had small tumors.

Pathologic changes in a long-term heterotopic heart transplant survivor

This report concerns the pathologic findings observed at autopsy in a 10-year-old heterotopic heart transplant under cyclosporine treatment. The allograft showed a diffuse multivessel atherosclerotic disease whereas in the recipient heart coronary arteries and aorta were focally affected by atherosclerosis. The proliferating cell nuclear antigen had significantly increased expression in the allograft vessels in comparison with the recipient.

Effect of magnetic resonance imaging on implantable eyelid weights

Implanted upper eyelid gold weights are used to prevent corneal injury in patients with facial nerve paralysis. Some of these individuals require postoperative radiographic surveillance for recurrent lateral skull base disease. Magnetic resonance imaging (MRI) provides the most accurate radiologic assessment; however, there is concern about the safety of performing MRI in patients with any metallic implant. Potential risks include local tissue heating and implant migration. Gold weights of 0.8 and 1.4 g were placed in an open chamber and were exposed to a magnetic field of 1.5 T. There was no measurable motion or displacement of the weights. The results were similar in 6 rats in which gold weights were subcutaneously implanted. Additionally, histologic examination of the implant sites revealed no adverse tissue effects attributable to MRI-generated heating of the implants. When carbon steel implants in the rat model were subjected to the magnetic field, there was no displacement of the implants and no adverse tissue effects were noted, despite the fact that a carbon steel implant in an open chamber demonstrated significant migration. The absence of motion of the gold weight implants combined with the lack of adverse tissue effects suggests the relative safety of performing MRI in patients with previously placed gold weights as upper eyelid implants.

[Is coronary angioplasty less costly than aortocoronary bypass?]

We retrospectively compared the cost-benefit ratio of coronary bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). Data were obtained on 40 CABG's and 40 PTCA's patients treated from 15/2/86 to 15/9/86. All patients had at last 1-year follow-up. PTCA and CABG groups had similar baseline clinical and angiographic criteria. We analyzed the following cost components: real estate, biomedical products, drugs, hospital charges, medical fees, cardiac and non-cardiac tests. Total cost of CABG exceeds that of PTCA by a factor of 1.64: 15,095,000 vs 9,201,346 Italian liras (ILit). Taking into account early and late medical and surgical complications, the factor decreases to 1.39: 15,746,500 vs 11,323,000 ILit. After 1 year of follow-up the factor decreases to 1.18: 16,613,500 vs 14,027,500 ILit. Our data show that the initial savings were reduced when complications and follow-up are considered, but PTCA's patients had shorter hospitalization, earlier return to work, lower psychosocial stress.

3,4-Methylenedioxymethamphetamine ("ecstasy") selectively destroys brain serotonin terminals in rhesus monkeys

3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"), an amphetamine analog, is a "designer drug" which is being increasingly abused. The potential neurotoxic hazard of MDMA in humans was assessed by examining the effects of repeated systemic administration of MDMA on selected neurochemical and behavioral measures in rhesus monkeys. In the first study, MDMA (2.5 or 10 mg/kg twice daily for 4 days) produced selective and significant neurochemical decreases in cerebrospinal fluid (CSF) concentrations of 5-hydroxyindoleacetic acid (5-HIAA) and brain concentrations of serotonin and 5-HIAA. At the high dose of MDMA, a selective decrease in serotonin uptake sites (reflecting destruction of brain serotonin terminals) was observed. To determine if these changes after high dose MDMA were pharmacologic or truly neurotoxic, in a subsequent study monkeys were treated with MDMA (10 mg/kg twice daily for 4 days) and then monitored for 14 weeks. Throughout this period, CSF 5-HIAA was decreased in MDMA-treated animals but not in saline-injected controls. At the end of this period, significant decreases in the concentration of serotonin, 5-HIAA and serotonin uptake sites were observed in cerebral cortex and striatum but not in hypothalamus or spinal cord. In contrast to these widespread alterations in serotonin markers, comparable noradrenergic and dopaminergic measures in CSF and brain appeared generally unaffected. These data demonstrating potent and selective effects of MDMA on various brain serotonin parameters in rhesus monkeys suggest that the drug may produce similar effects in humans.

Changes in mu opiate receptors following inescapable shock

Rats exposed to inescapable shock exhibit profound hypoalgesia. Pharmacological evidence has suggested that changes in endogenous opiate activity may be responsible for the hypoalgesic response. We measured the binding of [3H]DAGO, a selective mu-opiate receptor agonist, in brains of rats exposed to no shock, inescapable shock, or escapable shock. Binding of [3H]DAGO in the midbrains of rats in the inescapable shock group was decreased relative to the other two groups. The decrease in binding appeared to result from a decrease in number of mu-receptors and not a change in affinity. These results support the hypothesis that inescapable shock produces long-term changes in endogenous opiate systems.

[Myocardial scintigraphy with thallium-201 in the evaluation of aortocoronary bypass patients]

We have compared the results of 201-Thallium scintigraphy (201 TI Sc) and those of coronary angiography in 48 patients (Pts) at a mean time of 13 months after a coronary artery by-pass grafting operation (CABG). Forty-six pts were males and 2 females, with a mean age of 52 years (range 37-66). Eighteen pts (37%) had had a myocardial infarction (MI) before the operation, 4 (8%) had a perioperative and 3 (6%) a postoperative MI. Nineteen pts (40%) had angina, 9 (19%) atypical chest pain, 6 (12%) shortness of breath or easy fatigability and 14 (29%) had no symptoms. The overall CABG patency was 74% (left anterior descending: 73%, left circumflex: 71%, right coronary artery: 80%). The 201 TI was injected at peak exercise and its myocardial uptake was recorded immediately and after four hours at rest. The 201 TI Sc has shown a sensibility (SN), specificity (SP), positive predictive (PV-pos) and negative predictive value (PV-neg) of 86, 82, 64 and 94% respectively, compared to coronary angiography. In the single patient evaluation the 201 TI Sc has shown a SN, SP, PV-pos, PV-neg of 95, 85, 82 and 96% respectively versus 90, 82, 78 and 92% of the standard exercise test associated with a positive history for 1) residual angina and 2) peri or postoperative MI. The 201 TI Sc has not shown to be significantly superior to standard exercise testing and history in the evaluation of graft patency. However it allows a topographic localization of the disease which is not feasible with the latter techniques. The 201 TI Sc can better predict the patency rather than the occlusion of the grafts because there is a high number of false positives due to residual ungrafted native disease in the territory of a good functioning graft. The 201 TI scintigraphy can give a functional evaluation of borderline grafts stenoses beside the pure anatomic definition of angiography thanks to its capability to qualitatively assess the regional myocardial blood flow during stress.

Long-term follow-up after a controlled randomized post-myocardial infarction rehabilitation programme: effects on morbidity and mortality

Prognosis during 4.5 years of follow-up after myocardial infarction (MI) in 2 groups of patients 25 to 65 years of age was related to physical rehabilitation and usual risk factors. We randomized 167 patients to a rehabilitation (R) group and a control (C) group (84 and 83 patients respectively). At the end of the training period, the R group had a significantly higher work capacity, a higher double product reached during the stress test and lower triglycerides. During the 55 months of follow-up after the physical training or the equivalent spontaneous activity, we observed the prevalence of risk factors and of cardiac events such as angina, new MI, unstable angina, coronary bypass grafting and cardiac death. Survival rate was 92.6% in the R group and 93.7% in the C group. There was no relationship between serum cholesterol levels, tobacco smoking, and blood pressure and mortality and morbidity after the infarction. R patients were more symptom-free (44% against 30%), and had almost the same number of episodes of unstable angina and of cardiac death. 6.1% of the R group and 11.2% of the C group developed a new myocardial infarction. As in previous randomized studies we did not reach statistical significance for long-term benefit, perhaps because of the low sample size. However, our study confirmed a favorable tendency in terms of symptoms and the self confidence of the R patients.

Gonadal steroids deficiency and prolactin response to a met-enkephalin analog in man

The aim of this study was to ascertain whether there is a correlation between gonadal steroids and opioid control of prolactin (PRL) secretion. Four castrated men, aged 18 to 24 years were submitted to intravenous injection of 250 ug of a met-enkephalin analog (D-Ala2-Mephe4-Met-(o)-ol-Enkephalin, FK 33824) (DAMME). In normal men DAMME injection was also performed on the 6th day after treatment with clomiphene citrate (CC) (200 mg/day for 5 days), a specific nonsteroidal estrogen receptor blocker. In castrated men and in normal men after CC treatment, there was a lower PRL response to DAMME than in controls (P less than 0.0005). These results suggest that gonadal steroid deficiency seems to cause a change in the opioid system and/or dopaminergic control of prolactin secretion.

The prognostic significance of clinical history, exercise testing and ambulatory electrocardiography in patients with uncomplicated myocardial infarction

The prognostic value of early clinical history, exercise testing and ambulatory electrocardiography was assessed in 263 men (mean age 50 years) recovering from an uncomplicated myocardial infarction (MI). During a mean follow-up period of 31 months, 11 patients died of cardiac causes, 22 developed a non fatal recurrent MI, 16 unstable angina (UA) and 16 underwent coronary artery bypass surgery. The appearance at the exercise stress test of an ischemic S-T segment depression of 0.2 mV or greater (P less than 0.001) as well as the achievement of a work load of 360 Kg-m/m' or less (P less than 0.01) and of a rate-pressure product of 200 Units or less (P less than 0.01), were found to be predictive of the future development of UA, but neither of cardiac death nor of non fatal recurrent MI. The ischemic response was also seen to be predictive of cardiac death (P less than 0.05). S-T segment depression of 0.1 mV or greater, angina and ventricular ectopic activity during the stress test and clinical history were not of predictive value. Complex ventricular ectopic activity (multiform extrasystoles, couplets and ventricular tachycardia) recorded during 24 hour ambulatory electrocardiogram was seen to be predictive of death and non fatal MI. Whereas some parameters such as the ejection fraction and the extension of coronary artery disease are generally accepted as good predictors for cardiac events, others, such as those derived from exercise testing, history and ambulatory electrocardiography may change their predictive value from one survey to another. These discrepancies are due to differences in patient characteristics, in methodology and in medical management.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of gonadal steroids on the dopamine inhibitory effect on gonadotropin release in men

The aim of this study was to ascertain whether an interrelationship exists between gonadal steroids and the inhibition of gonadotropin secretion by dopamine. The effect of dopamine infusion (4 micrograms/kg/minute intravenously) on gonadotropin plasma levels in four castrated men (18 to 23 years of age) and in four age-matched normal men was studied. Normal subjects were studied before and after treatment with a specific nonsteroidal estrogen receptor antagonist, CC. LH plasma levels in normal subjects receiving CC had a maximum decrease percentage and a net decrease significantly greater (P less than 0.005 and P less than 0.012, respectively) than those before CC treatment. In castrated subjects the maximum decrease percentage was significantly greater (P less than 0.005) than in control subjects, but it did not show any difference from that of normal subjects receiving CC. In none of the group were significant changes in FSH concentration observed. The findings suggest that whenever there is a gonadal steroid deficiency, dopamine infusion causes an increased sensitivity to LH inhibition. This may be due to a lower endogenous dopaminergic influence on LH secretion.

Gonadal steroids and opioid control of gonadotropin secretion in man

The aim of this study was to ascertain whether there was an interrelationship between gonadal steroids and endogenous opioid peptides. The effects of naloxone (20 mg, intravenously) and of a met-enkephalin analog (DAMME) (250 micrograms, intravenously) on gonadotropin secretion in three castrated men (18 to 23 years of age) and in five age-matched normal men were studied. Normal subjects were studied before and after treatment with a specific nonsteroidal estrogen receptor antagonist, clomiphene. Naloxone caused a significant increase in luteinizing hormone (LH) (P less than 0.05); in these subjects, clomiphene treatment significantly increased LH and follicle-stimulating hormone plasma levels but totally suppressed the naloxone-induced rise in LH. In castrated men, naloxone failed to increase plasma LH levels. However, DAMME significantly reduced plasma LH levels in normal, in castrated, and in clomiphene-treated normal subjects. The results demonstrate that in castrated subjects who lack gonadal steroids and in normal subjects with blocked estrogen receptors there is a reduced opioid inhibitory tone on gonadotropin secretion. The effect of DAMME on gonadotropin secretion, however, is not influenced by the gonadal steroid environment.