Cost of a population-based programme of chest x-ray screening for lung cancer.

BACKGROUND: After the implementation of a population-based programme of chest x-ray (CXR) screening on smokers in Varese, Italy, lung cancer (LC) mortality was significantly reduced. Analysis of the incremental costs due to this type of screening programme is needed to evaluate its economic impact on the healthcare system. METHODS: In July 1997 a population-based cohort, consisting of all high-risk smokers (n=5,815) identified among 60,000 adult residents from the Varese province, was invited to a LC screening programme (an annual CXR for five years) in a general practice setting, and was observed through 2006. Invitees received National Health Service (NHS) usual care, with the addition of CXRs in screening participants. At the end of observation, among the 245 LCs diagnosed in the entire screening-invited cohort the observed LC deaths were 38 fewer than expected. To estimate the incremental direct cost due to screening in the invited cohort for the period July 1997-2006, we compared the direct cost of screening administration, CXR screens and LC management in the invited cohort and in the uninvited and unscreened controls in NHS usual care setting. RESULTS: Over the 9.5 years, the total incremental direct healthcare costs (including screening organization/administration, CXR screens, additional procedures prompted by false-positive tests, overdiagnosed LCs) were estimated to range from euro 607,440 to euro 618,370 (in euros as of 2012), equating to between euro 15,985- euro 16,273 per patient out of the 38 LC deaths averted. CONCLUSIONS: In a general practice setting, the incremental cost for a CXR screening programme targeted at all high-risk smokers in a population of 60,000 adults was estimated to be about euro 65,000 per annum, approx. euro 16,000 for each LC death averted.

Bullous lung disease and neurofibromatosis type-1.

Lung interstitial diseases and bullae are described as possible complications of neurofibromatosis type-1 (NF-1), a genetic disorder inherited as a autosomal-dominant trait. We report the case of a 16-year-old male non-smoker with NF-1, who presented with pneumothorax caused by ruptured lung bullae. The case of this young patient, successfully treated by video-assisted thoracoscopic resection of bullae, supports the concept that pulmonary alterations may be part of the NF-1 syndrome, rather than as an unrelated complication.

Five-year survival of stage IIIA-IIIB (non-N3) non-small cell lung cancer patients after platinum/gemcitabine induction chemotherapy and surgery.

The 5-year survival rate of marginally resectable nonsmall cell lung cancer (NSCLC) patients treated by platinum/gemcitabine induction chemotherapy and surgery is not well documented. We studied 47 consecutive patients with NSCLC stage IIIA-IIIb (non-N3) treated with platinum/gemcitabine induction chemotherapy (median: 3 cycles) and evaluated the objective response, resectability, surgical morbidity/mortality and long-term survival rate. The induction chemotherapy was completed by 45/47 patients. Objective response was: 36% partial, 32% stable disease, 28% progression, 0% complete; two patients (4%) died during induction chemotherapy. Tumor resectability was 74%, postoperative morbidity 34%, mortality nil. 26% of patients were unresectable. in the whole cohort the 5-year survival was 25% (95%CI, 17%-32%) and the median survival was 22 months (28 months in resected patients; 7 months in unresectable).In conclusion, in the intention-to-treat population undergoing platinum/gemcitabine induction chemotherapy, resectability was high (74%) and the 5-year survival rate was 25%. Median survival in resected cases was three-fold greater than in the unresected.

Microwave ablation therapy for treating primary and secondary lung tumours: technical note.

PURPOSE: The purpose of our study was to retrospectively evaluate the feasibility, safety and effectiveness of microwave ablation (MWA) in nine patients with unresectable lung tumour. MATERIALS AND METHODS: Ten lesions were treated in ten ablation sessions in nine patients. The treatments were performed with a microwave generator with 45 W and 915 MHz connected to a 14.5-gauge antenna for 10 min. Antenna placement was performed with computed tomography (CT) fluoroscopy guidance or XperGuide. All patients underwent CT follow-up at 1, 3 and 6 months from the procedure. RESULTS: Technical success was obtained in all cases; mortality at 30 days was 0%. CONCLUSIONS: This study shows that in selected patients, MWA is a valid alternative to other ablative techniques. Further studies are required to demonstrate the short- and long-term effects of this technique and to make a comparison with other available ablation systems, especially with radiofrequency.

Prevalence of heavy smokers in the year 2000 in the province of Varese, Italy.

BACKGROUND: Knowing the prevalence of heavy smokers (HS) by gender and age is a pre-requisite for bringing into effect public health measures against smoking-related diseases. Smoking prevalence data is available for the Italian Regions, however it is generally unknown for the Italian Provinces. METHODS: In the year 2000 a survey of smoking prevalence was conducted by 47 general practitioners (GPs), by personal interview, in a large sample of the Varese Province population 45-74 years of age (28,034 subjects; 13,528 men, 14,506 women). Each surveyed subject was categorised either as ever HS (current/former smoker of at least 10 pack-years) or as non HS. The information on smoking habit collected by the GPs was anonymously pooled for analysis. Prevalence figures of smoking were tabulated by gender and by 5-year age-strata. RESULTS: In the population 45-74 years of age the percentage of ever HS overall was 22.3% (34.4% of men; 11.0% of women). The prevalence of ever HS in both sexes combined progressively decreased with advancing age, from 23.6% (45-49 year stratum) to 19.5% (70-74 year stratum). Current HS were 24.5% of men and 9.5% of women. CONCLUSIONS: The year 2000 survey on smoking habit, showing 22.3% prevalence of ever HS in age range 45-74 years, is the first conducted in the Varese Province using a large population sample. The data on heavy cigarette smoking presented in this paper, stratified by gender and age, may be used to monitor changes in the smoking habit and in the incidence of smoking-related illnesses at the provincial level.

Markers of airway inflammation in pulmonary diseases assessed by induced sputum.

During recent years there has been a growing interest in using non-invasive biomarkers to understand and monitor the airway inflammation in subjects with respiratory tract disorders. To date, the best validated and performing non-invasive biomarkers are measures of inflammation in induced sputum in both cellular and fluid phase, which can provide biological insights into the pathogenesis of respiratory diseases such as asthma and chronic obstructive pulmonary disease. The purpose of this review is to examine the principal literature on the different markers of inflammation in pulmonary diseases assessed by induced sputum analysis in either cellular or fluid phase.

Pulmonary resections of single metastases from colorectal cancer.

BACKGROUND: Surgical resection is the treatment of choice of pulmonary metastases from colorectal cancer. We retrospectively reviewed our experience of pulmonary resections of single metastases from colorectal cancer, in order to document postoperative clinical outcome and survival. MATERIALS AND METHODS: In the years 1997-2007, in 23 patients we performed 26 curative resections of pulmonary metastases from colorectal cancer (19 rectal and 7 colon; 12 males and 11 females; mean age 64.5 years). All patients had single lung metastasis. Three of the 23 patients underwent re-resection of the lung for treatment of a subsequent lung metastasis. Interval between resection of primary tumor and diagnosis of lung metastasis (disease-free interval (DFI)) was >36 months in 19 patients (73%) and was <36 months in 7 patients (27%). In 21 patients the metastases were metachronous; in 2 patients metastases were synchronous with primary colorectal cancer. The type of lung resection was wedge resection in 18 cases (70%); lobectomy in 6 cases (23%); pneumonectomy in 2 cases (7%). Of the 18 wedge resections, 12 (66%) were done thoracoscopically. After lung metastasectomy patients were followed up for 5-121 months (median: 61 months). RESULTS: We had 1 early postoperative mortality (after re-resection) from cardiac complication (3.8%). Postoperative morbidity (within 30 days) was observed in 7 cases (27%): 1 pneumonia, 1 empyema, 1 arrhythmia and 4 prolonged air leaks requiring chest drainage >7 days. Median survival was 74 months (Kaplan-Meier). CONCLUSIONS: Resection of single metachronous lung metastases from colorectal cancer has low mortality and morbidity and in our experience it correlated with prolonged postoperative survival. Re-resection of the lung for treatment of subsequent metachronous metastases carries higher risk.

Characterization of apoptosis induced by marine natural products in non small cell lung cancer A549 cells.

The effects of different marine derived agents were studied in A549 cell growth. These drugs induced cell cycle arrest at the G2-M phase associated with the up-regulation of GADD45alpha-gamma and down-regulation of c-Myc. In treated cells, GADD45alpha-gamma and c-Myc were up- and down-regulated, respectively. A cascade of events leading to apoptotic mitochondrial 'intrinsic' pathway was observed in treated cells: (1) dephosphorylation of BAD serine136; (2) BAD dissociation from 14-3-3 followed by its association with BCL-XL; (3) cytochrome c release; (4) caspase-3 activation, and (5) cleavage of vimentin. Caspase(s) inhibitor prevented the formation of cleavage products and, in turn, apoptosis was inhibited through a p53-independent mechanism. Moreover, these compounds did not activate NF-kappaB. Our findings may offer new insights into the mechanisms of action of these agents in A549 cells. The better understanding of their effects might be important to fully exploit the potential of these new drugs.

Lung cancer in Teesside (UK) and Varese (Italy): a comparison of management and survival.

BACKGROUND: The survival of lung cancer patients in the UK is lower than in other similar European countries. The reasons for this are unclear. METHODS: Two areas were selected with a similar incidence of lung cancer: Teesside in Northern England and Varese in Northern Italy. Data were collected prospectively on all new cases of lung cancer diagnosed in the year 2000. Comparisons were made of basic demographic characteristics, management, and survival. RESULTS: There were 268 cases of lung cancer in Teesside and 243 in Varese. Patients in Teesside were older (p<0.05), were more likely to have smoked (p<0.001), had a higher occupational risk (p<0.001), higher co-morbidity (p<0.05), and poorer performance status (p<0.001). Fewer patients in Teesside presented as an incidental finding (p<0.001) and the histological confirmation rate was lower than in Varese (p<0.01). In Teesside there were more large cell carcinomas (p<0.001), more small cell carcinomas (p<0.05), and fewer early stage non-small cell lung cancers (p<0.05). The resection rate was lower in Teesside (7% v 24%; p<0.01) and more patients received no specific anti-cancer treatment (50% v 25%; p<0.001). Overall 3 year survival was lower in Teesside (7% v 14%; p<0.001). Surgical resection was the strongest multivariate survival predictor in Varese (HR = 0.46) and Teesside (HR = 0.31). Co-morbidity in Teesside resulted in a significantly lower resection rate (p<0.001). CONCLUSIONS: Patients with lung cancer in Teesside presented at a later stage, with more aggressive types of tumour, and had higher co-morbidity than patients in Varese. As a result, the resection rate was significantly lower and survival was worse.

[Postoperative pneumonia caused by Candida in 500 lung surgery patients]. / Le polmoniti da Candida in 500 interventi di resezione polmonare.

BACKGROUND: Postoperative infections continue to be one of the most frequent complications in hospitalized patients. The incidence of fungal infection has been steadily rising. While Candida albicans remains the most common yeast species isolated in hospitalized patients, other Candida species have been increasingly isolated. METHODS: From 1996 to 2001, a prospective study of 500 consecutive lung surgery patients treated by the same surgical team was conducted to monitor the number of postoperative infections and to evaluate the epidemiology of bacterial and fungal infections. RESULTS: At least one postoperative infection developed in 18% of patients. Of the 51 patients who developed postoperative pneumonia, 24 underwent microbiological examination of sputum. In 19 of them, the culture yielded isolates of one or more Candida species. Slightly under half of patients (47%) with cultures positive for mycetes received treatment with fluconazole until the clinical infection resolved. The drug was well tolerated by all treated patients. CONCLUSIONS: The incidence of fungal infection has increased also at our center. In 19 of 24 patients with postoperative pneumonia, sputum cultures yielded Candida species isolates. Many factors may be contributing to the rise in fungal infections after surgery. As pneumonia caused by Candida led to a significantly longer length of hospital stay in our case series, we draw attention to the importance of early diagnosis of postoperative mycotic lung disease in order to institute timely and targeted therapy.

Risk factors in surgery.

Improved surgical and anesthetic techniques and postoperative care have not significantly changed wound infection rates over the last 30 years. Many risk factors, related both to the host and to the surgical practice, have been identified in different studies. Control of nosocomial infections has become more challenging recently, due to a widespread bacterial resistance to antibiotics and to more frequent surgical indications in elderly patients at increased risk. A change in the microbiology of postoperative infections has also been noticed, characterized by a greater incidence of infections caused by methicillin-resistant Staphylococcus aureus, by polymicrobic flora and by fungi. This paper reviews the most important risk factors encountered in general surgery, that we observed during a 6-year prospective study of wound infection carried out in our Department of Surgery at the University of Insubria in Varese. Furthermore, the epidemiologic data on wound infections recorded in 4,002 patients undergoing general surgical procedures (mostly gastrointestinal operations), are presented and discussed.

Screening for lung cancer.

The large clinical studies of lung cancer screening carried out more than 20 years ago were interpreted as evidence against screening. Those studies have been recently reassessed in the light of methodologic flaws in the randomization of subjects at risk for lung cancer. There is no evidence to support the former conclusion that screening is ineffective and the consequent official recommendation not to screen for lung cancer. The hypothesis of overdiagnosis of lung cancers diagnosed by screening is false. Clinical evidence supports the concept that the current dogma against screening for lung cancer is untrue. Indeed, the 5-year survival rate of patients with NSCLC detected in stage I and radically resected ranges from 60% to 80%. This rate is in sharp contrast to the 10% survival rate of stage I NSCLC not resected. About 90% of lung cancer cases are detected among smokers and former smokers; these well-known at-risk subjects should be offered a screening test with the goal of detecting the disease when it is in stage I. It is expected that the techniques for early detection of lung cancer will be refined and become more sensitive in the near future, so that it will be possible to detect an increasingly large proportion of lung cancers when they are truly in stage I (i.e., nonmetastatic) and curable by radical surgical resection. Low-dose helical CT scan is currently believed to represent a very useful technique for screening for lung cancer, with a higher sensitivity than chest radiograph screening. Chest radiography for lung cancer screening, however, is cheaper and ubiquitously available, and it should still be recommended if CT scan is locally unavailable. As underscored in a recent commentary in The Lancet, the existing public health policy discouraging the screening for lung cancer is in urgent need of reconsideration.

Stage I nonsmall cell lung carcinoma: analysis of survival and implications for screening.

BACKGROUND: Skepticism about the radical curability of lung carcinoma, even when diagnosed in Stage I, has been long fostered by the epidemiologists' dogma against lung cancer screening, and by official recommendations not to screen for lung carcinoma. Follow-up of patients with asymptomatic screen-detected Stage I nonsmall cell lung carcinoma (NSCLC), however, shows that patients who underwent radical resection have long term survival rates, whereas patients nonsurgically treated or undergoing suboptimal operations have much poorer prognosis. The latter clinical outcome data strongly suggest the importance of detecting lung carcinoma when it is in Stage I and cast serious doubts on the recommendation not to screen for lung carcinoma. DATA: The scrutiny of the biology, epidemiology, and clinical features of Stage I NSCLC clarifies important aspects of the ongoing controversy concerning the value of screening for early diagnosis (Stage I) of lung carcinoma. The biologic characteristics of Stage I NSCLC (histologic types, doubling time, metastases) indicate its malignant potential. The asymptomatic screen-diagnosed Stage I carcinomas have longer doubling time than the more advanced cancers; nevertheless, they are not overdiagnosed tumors because they cause fatal outcome if they are not resected. Chest X-ray screening identifies approximately 50% of cancers in Stage I. Screening by helical low dose computed tomography scan detects greater than 80% of lung carcinomas in Stage I. The resectability, the surgical techniques (lobectomy vs. limited resections), and the influence of the extent of surgical resection of Stage I NSCLC on prognosis are reviewed. These data show that radical surgical treatment offers 5-year survival rate to 60-80% of patients with Stage I NSCLC. SYNTHESIS: Asymptomatic Stage I lung carcinomas, detected by screening or by incidental findings, are truly malignant, because they metastasize and cause fatal outcome if they are not radically resected. The possibility to cure lung carcinomas relies on radical resection (lobectomy or, less frequently, pneumonectomy) of early diagnosed (Stage I) disease, which is usually asymptomatic. The limited parenchymal resections (segment or wedge resections) do not fulfill the requirements of radicality because they are accompanied by higher incidence of local recurrences and shorter survival rates. CONCLUSIONS: The documented improvement of long term survival of NSCLC, which can be achieved by early diagnosis and radical resection, strongly indicates that the current dogma against lung cancer screening is untrue. Every effort should be made to detect the disease when it is in Stage I and radically operable, by implementing screening in at risk smokers and former smokers, with the most effective screening method that is locally available.

Lung cancer screening in cigarette smokers in the province of Varese, Italy.

BACKGROUND: For heavy cigarette smokers and recent former smokers who have accumulated a high risk of lung carcinoma, a primary objective is the early detection of that disease; this goal can be achieved by annual screening with one of the radiologic imaging methods available. While awaiting for the implementation of computed tomography or of other, more sensitive methods, it is quite reasonable to screen those who are at risk with annual chest X-ray (CXR), an examination that is readily available at low cost. Indeed, with the annual CXR screening of heavy smokers, it is possible to detect about 50% of lung carcinomas in TNM Stage I. The 5-year survival rate of patients with asymptomatic, screen-detected Stage I disease after radical surgery is significantly greater than the survival rate of patients with symptomatic disease. METHODS: At the Center for Thoracic Surgery of the University of Insubria Medical School in Varese we developed a project, called "PRE.DI.CA" (an acronym for "early diagnosis of cancer"), of annual CXR screening for the early diagnosis of asymptomatic lung carcinoma in the high risk population of heavy cigarette smokers and recent former smokers in the province of Varese, Italy. From June 1997 to August 1999, 2444 heavy smokers were enrolled in the PRE.DI.CA project. RESULTS: About 75% of participants complied with the annual screening protocol. Overall, 23 patients (all males) with asymptomatic lung carcinoma were detected by CXR screening; moreover, 1 patient developed symptoms of lung carcinoma 6 months after his initially negative CXR and was diagnosed with interval carcinoma (Stage IIIA). In the initial (prevalence) screening, the authors detected 16 patients with lung carcinoma in 2444 screened participants (0.65%). In the subsequent incidence screening, the authors detected 7 patients with lung carcinoma in 1361 screened participants (0.51%); it is noteworthy that 5 of 7 patients (71%) with lung carcinoma that was detected by incidence CXR screening had Stage I disease. CONCLUSIONS: In the province of Varese, Italy, it is possible to make an early diagnosis of lung carcinoma with CXR annual screening in asymptomatic, high risk smokers. Incidence screening in 1361 participants detected 7 patients with asymptomatic lung carcinoma; 5 of 7 patients (71%) with such screen-detected lung carcinoma had Stage I disease.

Radioimmunoguided surgery and colorectal cancer.

Radioimmunoguided surgery is a technique that aims to delineate the extent of epithelial neoplasms (primary/recurrent) and their spread (local, regional, and distant) which are not adequately visualized by conventional imaging techniques. The target lesion binds radiolabelled, tumour-associated monoclonal antibodies which are administered in the days before surgery and which bind to the target lesion. The radiotracer is detected intraoperatively using a hand-held gamma detecting probe. This identifies the extent of the tumour, involvement of lymph nodes or other organs and may allow a more complete surgical clearance of the tumour. This article provides a basic understanding of the RIGS (radioimmunoguided surgery) technique, the monoclonal antibodies which are used and outlines the advantages and limitations of this technique.

Alterations in lymphocyte subsets as prognosticators of postoperative infections.

OBJECTIVE: To evaluate changes in lymphocyte subsets after major abdominal and thoracic operations, and to correlate changes with the development of clinically relevant infections postoperatively. DESIGN: Open study. SETTING: University hospital, Italy. SUBJECTS: 33 patients who were to undergo major abdominal or thoracic operations. INTERVENTIONS: Lymphocyte subsets were measured by cytofluorimetry before operation and 1, 3, 5, and 7 days postoperatively. MAIN OUTCOME MEASURES: Correlation between changes in the number of lymphocyte subsets and development of infection. RESULTS: Lymphocyte subsets were within the reference range in all patients before operation. 10/33 Patients developed infections (pneumonia, bacteraemia, or wound or urinary tract infections) between the second and the ninth days postoperatively (30%). On day 1 the numbers of all lymphocyte subsets had decreased significantly compared with the preoperative measurements in all patients (CD3 p < 0.01, CD4 p < 0.001, and CD8 p < 0.05). The reduction in CD3 was significantly greater in the group that developed infections (p < 0.001). Among patients who did not develop infections the numbers of lymphocyte subsets had returned to the reference range within a week of operation whereas among patients who developed infections they remained depressed (p < 0.05). CONCLUSION: The synchronous reduction in numbers of all lymphocyte subsets on the first day postoperatively to below 50% of the reference range (CD3 to < 600/microliters, CD4 to < 400/microliters, and CD8 to < 250/microliters) predicted the development of infection postoperatively with an accuracy of 89%, a sensitivity of 80%, and a specificity of 96%.

[Immediate post-operative enteral nutrition]. / La nutrizione enterale post-operatoria immediata.

Patients with cancer of the upper digestive tract may present with malnutrition, which may cause immunodepression and an increased rate of postoperative complications. In this study we describe the rationale and the feasibility of immediate postoperative enteral nutrition (NEPI) and evaluate its effectiveness for the nutritional support of patients undergoing surgery of the upper digestive tract. We studied 46 patients undergoing the following procedures: total gastrectomy (n = 22); oesophageal resection (n = 12); duodenocephalopancreasectomy (n = 12). NEPI was started on postoperative day 0 with a polymeric diet (calories: 53% as CHO, 22% as proteins, 25% as lipids) aiming at a calorie intake of 25 Kcal/Kg/day by postoperative day 4. It was possible to administer 24 Kcal/kg/day with the enteral diet from the 4th to the 10th postoperative day. Oral intake was resumed on average on postoperative day 13, and the mean hospital stay was 27 +/- 17 days. Tolerance of NEPI was good in most patients: only 5 patients (11%) interrupted the enteral nutrition. The mean postoperative weight loss was 3.7%. The rate of septic complications was 27%; mortality was nil. The surgical procedures caused a transient and reversible acute-phase decrease of nutritional and immunological parameters in the early postoperative period. However the NEPI preserved the nutritional status postoperatively as shown by the lack of significant changes in the nutritional indices at 10-14 days after surgery, as compared with baseline. In summary, we documented that NEPI can be started from postoperative day 0 with good intestinal tolerance, allowing adequate nutritional support, after extensive surgical procedures on the upper digestive tract.

[Reproducibility of the measurement of thoracic electric impedance]. / Riproducibilità delle misure di impedenza elettrica toracica.

Recordings of thoracic electrical impedance were consecutively taken in 10 normal subjects (age 18-48 years, mean 38.6) two times during the same day, during the following day and after 1 month. The following parameters were evaluated: heart rate, systolic blood pressure, diastolic blood pressure, left ventricular ejection time, pre-ejection time, baseline electrical impedance, DZ positive peak, Q-dZ/dt interval and Heather Index. Data were processed in order to quantify the different source of variability: subjects or biological variability, days, beats. Total variability was expressed in absolute units as coefficient of variation. Results were as follows: Q-dZ/dt interval had the lowest coefficient of variation (7.7%). Inter subject was the largest source of variability for all the indices showed, ranging from 70.5% to 89.3%. On the contrary intraindividual variability was moderate racing from 1% to 2.6% for various impedance measurements. In conclusion, thoracic electrical impedance measurements showed good reproducibility, especially when successive measurements were compared in a same subject.

[The apex cardiogram in normal aged subjects]. / L'apicocardiogramma in soggetti anziani normali.

In 25 healthy subjects aged 60-88 years (mean 74.5) and in 20 healthy subjects aged 16-32 years (mean 23.6) apexcardiographic indices were studied as a function of age. The apex cardiograms (ACG) were obtained using a non-calibrated displacement transducer. With the help of an interactive computer program, 17 ACG indices of systolic and diastolic function were computed. The indices were divided into 2 groups (according to the nomenclature proposed by their Authors): a) systolic indices: electromechanical ventricular interval q-C, systolic upstroke time C-E, time from the beginning of ventricular depolarization to the peak of the first ACG derivative q-dA/dt, time from the onset of systolic slope to the peak of first ACG derivative C-dA/dt, ejection fraction according to Antani et al. 1979 E.F.; b) diastolic indices: electromechanical atrial interval P-a, atrial wave length d.a., height of atrial wave as percent of total ACG deflection a/H, height of atrial wave as percent of total diastolic deflection a/D, ratio of the diastolic wave to the total ACG height D/H, total rapid filling cR, early filling period EFP, rapid filling period RFP, total apexcardiographic relaxation time TART, duration of diastolic period A2-C, total apexcardiographic relaxation time index TARTI and diastolic amplitude time index DATI. Several diastolic indices (a/D, a/H, TART, electromechanical atrial time) were markedly higher (p less than 0.001) or lower (TART and DATI, p less than 0.001) in the older group. Systolic indices showed less significant differences: the electromechanical interval lengthened in the older group (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)