Brain structural changes in women and men during midlife.

Brain development during childhood and adolescence differs between boys and girls. Structural changes continue during adulthood and old age, particularly in terms of brain volume reductions that accelerate beyond age 35 years. We investigated whether brain structural change in mid-life differs between men and women. 43 men and 28 women from the Northern Finland 1966 Birth Cohort underwent MRI brain scans at age 33-35 (SD=0.67) and then again at age 42-44 (SD=0.41). We examined sex differences in total percentage brain volume change (PBVC) and regional brain change with FSL SIENA software. Women showed significant PBVC reduction compared with men between the ages of 33-35 and 42-44 years (Mean=-3.21% in men, Mean=-4.03% in women, F (1, 68)=6.37, p<0.05). In regional analyses, women exhibited greater brain reduction than men in widespread areas. After controlling for total percent brain volume change, men show greater relative regional brain reduction than women in bilateral precentral gyri, bilateral paracingulate gyri, and bilateral supplementary motor cortices. The results indicate sex differences in brain changes in mid-life. Women have more total brain reduction, and more reduction on the outer brain surface than men, whereas men exhibit more brain reduction on the mid-line surface than women after co-varying for total brain volume loss. These changes could contribute to sex differences in midlife behaviour and health.

Association between occupational psychosocial factors and waist circumference is modified by diet among men.

BACKGROUND/OBJECTIVES: Occupational psychosocial stress has been identified as a risk factor for obesity, whereas dietary habits have a key role in weight control. We examined whether dietary habits modify the association between occupational psychosocial factors and waist circumference. SUBJECTS/METHODS: Data comprised 31-year-old men (n=2222) and women (n=2053) in the Northern Finland Birth Cohort 1966. Waist circumference was measured and data on occupational psychosocial factors (demands, control and social support) and other characteristics were obtained through questionnaires. Healthy and unhealthy diet indices were constructed according to the current dietary guidelines. Associations were examined using analysis of variance adjusted for body mass index at age 14, basic education level, leisure-time physical activity, alcohol consumption, smoking, stress-related eating behaviour and parity. RESULTS: Among men, high job demands and high job control were associated with greater waist circumferences, and there were interactions between unhealthy diet and job demands (P=0.043) and job control (P=0.036) in relation to waist circumference. The waist of men with high demands or high control and low consumption of unhealthy foods (red/processed meat, hamburgers and pizzas, fried potatoes, sugar-sweetened soft drinks and white bread) was smaller than that of men with high demands or high control and high consumption of such foods. No associations were found among women. CONCLUSIONS: A diet based on the current dietary guidelines seems to cancel out the adverse effects of occupational psychosocial factors on waist circumference among young men. Longitudinal studies are needed to assess the risks for obesity-related diseases arising from psychosocial work environments and dietary habits.

Cardiorespiratory fitness of finnish adolescents.

We evaluated the accuracy of a submaximal cycle ergometer test to assess cardiorespiratory fitness in adolescents and provided population-based reference values. In a health study of the Northern Finland birth cohort born in 1985 - 1986 (NFBC 1986), cardiorespiratory fitness of 5375 males and females aged 15 to 16 years was measured by a submaximal cycle ergometer test by using a two-stage exercise protocol designed for this survey. A total of 4903 subjects performed two work stages. Maximal workload and peak oxygen consumption were calculated on the basis of heart rate responses by the WHO extrapolation method. An additional 472 subjects were able to finish only one work stage. For them, peak oxygen uptake was calculated by the Astrand nomogram. To evaluate the accuracy of submaximal testing, a validation sample of 90 subjects carried out both a submaximal test and a maximal cycle ergometer test with direct measurement of peak oxygen uptake. The WHO method proved to estimate peak oxygen uptake with reasonable accuracy. The Astrand nomogram method overestimated peak oxygen uptake considerably, and therefore a new single-stage regression method was applied to calculate maximal workload and peak oxygen consumption. Reference values of cardiorespiratory fitness were provided for 2690 males and 2685 females aged 15 to 16 years.

Off-pump coronary artery grafting in patients necessitating multiple distal anastomoses.

OBJECTIVES: Off-pump surgery has become a valuable alternative if a small number of distal anastomoses is required. The aim of the present study was to test the hypothesis that outcome is not altered in multiple distal anastomoses. MATERIAL AND METHODS: During a 4 year period, 350 patients were operated off-pump. 187 patients received one or two distal anastomoses (group A), and 163 patients received more than two distal anastomoses (group B). Pre-operative characteristics, intra-operative details and postoperative outcome were reviewed. RESULTS: In group A, 1.8 +/- 0.4 distal anastomoses were performed, versus 3.2 +/- 0.5 in group B (P < 0.001). There were more sequential distal anastomoses in group B (1.09 in group A versus 1.38 in group B) with a wider use of right internal thoracic and radial arteries. There were more anastomoses performed on the lateral (89% vs. 45%) and on the inferior wall (65% vs. 16%) in group B, compared with group A. The operation time was significantly longer (206 +/- 75 minutes versus 158 +/- 33 minutes) and the operative blood loss significantly higher (748 +/- 516 ml versus 509 +/- 361 ml) in group B. Total blood loss, transfusion requirements, neurological disfunction, hospital stay, troponine I level, postoperative infarction and 30 days mortality did not differ significantly between groups. There were 11 conversions (3.1%), 3 patients in group A and 8 patients in group B (NS). Most conversion occurred imperative while performing an anastomosis on the anterior wall. CONCLUSION: Beating heart surgery with multiple distal anastomoses, can be performed without increased myocardial damage, postoperative morbidity or hospital mortality. Lateral wall grafting could not be identified as a trigger for conversion.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

Natriuretic peptides during the development of doxorubicin-induced left ventricular diastolic dysfunction.

OBJECTIVES: To investigate changes in plasma atrial natriuretic peptide (ANP), N-terminal pro-atrial natriuretic peptide (NT-pro-ANP) and brain natriuretic peptide (BNP) during the development of doxorubicin-induced left ventricular systolic and diastolic dysfunction as measured by echocardiography (ECHO). DESIGN: Prospective study. SETTING: University hospital. SUBJECTS: Twenty-eight adult patients with non-Hodgkin's lymphoma, who received doxorubicin to the cumulative dose of 400-500 mg m(-2). MAIN OUTCOME MEASURES: The relationship between plasma natriuretic peptides and systolic and diastolic ECHO indices after the cumulative doxorubicin doses of 200, 400 and 500 mg m(-2). RESULTS: Left ventricular ejection fraction (LVEF, by 2D ECHO) decreased from 58 +/- 1.7 to 52.5 +/- 1.3% (P=0.036) and fractional shortening (FS) from 34.6 +/- 1.4 to 27.8 +/- 0.9% (P=0.002). Peak E wave velocity decreased from 63.3 +/- 3.2 to 51.3 +/- 2.6 cm s(-1) (P=0.008) resulting in a statistically nonsignificant decrease in E/A ratio from 1.08 +/- 0.01 to 0.85 +/- 0.07. A significant decrease was observed in the percentage of left ventricular filling during the 1/3 of diastole (1/3FF) from 42.2 +/- 1.7 to 36.5 +/- 2.0% (P < 0.001). LV end systolic diameter increased from 32 +/- 1 to 38 +/- 1 mm (P=0.011), whereas left atrial (LA) diameter remained unchanged. Peak filling rate decreased from 4.4 +/- 0.2 to 4.0 +/- 0.2 stroke volume s(-1) (SV s(-1)) (ns). Plasma levels of ANP increased from 16.4 +/- 1.3 to 22.7 +/- 2.4 pmol L(-1) (P=0.002), NT-pro-ANP from 288 +/- 22 to 380 +/- 42 pmol L(-1) (P=0.019) and BNP from 3.3 +/- 0.4 to 8.5 +/- 2.0 pmol L(-1) (P=0.020). There was a significant inverse correlation between the decrease in FS and the increases in plasma NT-pro-ANP (r= -0.524, P=0.018) and plasma BNP (r=0.462, P=0.04) and between the decrease in PFR and the increases in plasma ANP (r= -0.457, P=0.043) and plasma NT-pro-ANP (r= -0.478, P=0.033). Furthermore, after doxorubicin therapy, significant inverse correlations were observed between E/A ratio and plasma ANP (r= -0.535, P=0.008), between E/A ratio and plasma NT-pro-ANP (r= -0.432, P=0.04) and between E/A ratio and plasma BNP (r= -0.557, P=0.006) as well as between 1/3FF and plasma BNP (r= -0.493, P=0.017). There was also a trend for correlation between LA diameter and plasma BNP (r=0.395, P=0.062) and peak E wave velocity and plasma BNP (r= -0.414, P=0.05), respectively. However, no significant correlations were observed between any of the systolic parameters and natriuretic peptide levels. CONCLUSIONS: The results of this prospective study show that during the evolution of doxorubicin-induced LV dysfunction the secretion of natriuretic peptides is more closely associated with the impairment of left ventricular diastolic filling than with the deterioration of LV systolic function.

Neuroendocrine changes during the evolution of doxorubicin-induced left ventricular dysfunction in adult lymphoma patients.

Doxorubicin-induced cardiotoxicity was used as a model to prospectively investigate neuroendocrine changes during the development of left ventricular dysfunction. Radionuclide ventriculography, frequency domain analysis of heart rate variability (HRV), and plasma noradrenaline and natriuretic peptide measurements were performed in 27 adult lymphoma patients at baseline and after cumulative doxorubicin doses of 200, 400 and 500 mg/m(2). The left ventricular ejection fraction (LVEF) decreased from 58.1+/-1.4% to 50.3+/-1.1% (P<0.001) and 49.3+/-1.7% (P<0.001) after cumulative doxorubicin doses of 400 and 500 mg/m(2) respectively. With a doxorubicin dose of up to 400 mg/m(2) there was an increase in sympathetic tone, characterized by a decrease in the normalized high-frequency (HF(nu)) power (P=0.011), and increases in the normalized low-frequency (LF(nu)) power (P=0.011), the LF/HF ratio (P=0.021) and the plasma noradrenaline concentration (P=0.034). The decrease in LVEF was correlated with the changes in LF(nu) and HF(nu) power (r=0.540, P=0.012) and LF/HF ratio (r=-0.452, P=0.04). However, after the cumulative doxorubicin dose of 500 mg/m(2) the changes in HRV components and plasma noradrenaline levels returned towards baseline. This was accompanied by increased concentrations of plasma atrial natriuretic peptide (P=0.004) and brain natriuretic peptide (P=0.021). Our findings suggest that doxorubicin-induced left ventricular dysfunction is associated with an early change in sympathovagal balance towards sympathetic predominance. Along with further progression of left ventricular dysfunction, there is an attenuation of sympathetic tone, which may be attributable to sympatho-adrenal inhibition by increased secretion of natriuretic peptides.

Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.

This report describes a 43-year-old patient presenting with an aneurysm located at the junction between the innominate artery and aorta, with spontaneous fistulization into the trachea. Emergency treatment of this unusually located lesion was undertaken to prevent intratracheal rupture. After ligation of the innominate artery, right common carotid artery, and right subclavian artery due to the risk of infection, the tracheal fistula was treated by direct closure and exclusion using an autologous pericardial flap. The procedure was performed under extracorporeal circulation and circulatory arrest with profound hypothermia.

Comparison of echocardiography and radionuclide ventriculography in the follow-up of left ventricular systolic function in adult lymphoma patients during doxorubicin therapy.

OBJECTIVES: To compare echocardiography (ECHO) and radionuclide ventriculography (RVG) in the monitoring of left ventricular systolic function during doxorubicin therapy in adult lymphoma patients. DESIGN: Prospective study. SETTINGS: University hospital. SUBJECTS: A total of 28 adult patients who received doxorubicin to a cumulative dose of 400-500 mg m(-2). MAIN OUTCOME MEASURES: ECHO and RVG were performed at baseline and after cumulative doxorubicin doses of 200, 400 and 500 mg m(-2). RESULTS: At baseline, the mean (+/-SE) left ventricular ejection fractions (LVEF) were 58 +/- 1.3, 71 +/- 1.8 and 58 +/- 1.7% as determined by RVG, M-mode ECHO and two-dimensional (2D) ECHO, respectively. After the cumulative doxorubicin dose of 500 mg m(-2) LVEF decreased to 49.6 +/- 1.7% (RVG) (P < 0.001), 62 +/- 1.6% (M-mode) (P=0.006) and 52.5 +/- 1.3% (2D ECHO) (P=0.036). Although a significant correlation between LVEF determined by RVG and M-mode ECHO (r=0.615, P=0.002) and a trend between RVG and 2D ECHO (r=0.364, P=0.096) were observed, there were substantial differences in the results of individual patients. In the agreement analysis using the method of Bland and Altman there was a mean difference of 12% units with the upper limit of agreement +26% units and the lower limit of agreement -2.1% units for LVEF determinations with M-mode ECHO and RVG, and a mean difference of 3.3% units with upper and lower limits of agreement +19.6 and -13.1% units for LVEF determinations with 2D ECHO and RVG, respectively. CONCLUSION: We found only a moderate agreement between left ventricular systolic function determined by ECHO and RVG methods. Thus, in the follow-up of left ventricular function in adult patients during doxorubicin therapy, the guidelines based on LVEF measurement by RVG cannot be applied to ECHO. Consequently, RVG remains the method of choice in this context.

Anthracycline-induced cardiomyopathy: long-term effects on myocardial cell integrity, cardiac adrenergic innervation and fatty acid uptake.

Cardiotoxicity of anthracyclines is a clinical challenge in cancer chemotherapy. Limited data is available on the physiological mechanisms responsible for anthracycline-induced heart failure or its recovery. We studied four patients with a history of severe anthracycline-induced heart failure manifested 2-116 months earlier by using radionuclide ventriculography for the measurement of left ventricular function, indium-111-antimyosin scintigraphy for the detection of myocardial cell injury and iodine-123-metaiodobenzylguanidine (MIBG) scintigraphy for the assessment of cardiac adrenergic innervation. Myocardial perfusion and fatty acid utilization were assessed with iodine-123-paraphenyl pentadecanoid acid (pPPA) and single photon emission computed tomography (SPECT). Symptoms of congestive heart failure (CHF) were still present in two patients whereas the others were asymptomatic at the time of the study. The patients who showed complete clinical recovery had normal or near normal left ventricular ejection fraction (LVEF) (47 and 52%), whereas the patients with symptoms of heart failure had low ejection fractions (21 and 31%). All patients presented with abnormal antimyosin uptake and decreased myocardial MIBG uptake. Patients with low ejection fraction tended to have higher antimyosin uptake suggesting more severe, persistent myocyte injury. All but one patient showed normal fatty acid utilization. These data suggest that patients with a history of severe anthracycline-induced cardiomyopathy have persistent myocardial cell injury and adrenergic dysfunction up to 10 years after the development of heart failure. These findings seem to be present regardless of recovery of left ventricular function.

Cardiac adrenergic innervation within the first 3 months after acute myocardial infarction.

It is widely accepted that myocardial infarction results in adrenergic denervation of the infarcted and peri-infarcted myocardium. On the contrary, the concept of re-innervation of adrenergic nerve fibres is less well established. Although there is evidence of partial re-innervation occuring several months after myocardial infarction, the extent and time scale of re-innervation are only poorly known. In this study we investigated changes in cardiac adrenergic innervation and myocardial perfusion during the early convalescence period (the first 3 months) after an acute myocardial infarction. Single-photon emission computed tomographic imaging was conducted in 15 men 1 week and 3 months after an acute myocardial infarction with I123-metaiodobentzylguanidine (MIBG) and Tc99m-sestamibi (MIBI) to determine the extent of adrenergic denervation and impaired perfusion, respectively. A MIBG and MIBI defect was determined as regional uptake

Cardiac adrenergic denervation in patients with non-Q-wave versus Q-wave myocardial infarction.

In spite of smaller infarct size and better preserved left ventricular function the long-term prognosis after a non-Q-wave infarction is not better than after a Q-wave infarction. In fact, the risk of sudden cardiac death is higher in patients with a non-Q-wave infarction than in patients with a Q-wave infarction. One possible reason for postinfarction arrhythmias is cardiac adrenergic denervation resulting from myocardial infarction. In this study we compared cardiac adrenergic innervation after non-Q-wave and Q-wave infarctions. Single-photon emission tomography using iodine-123 metaiodobentzylguanidine (MIBG) and technetium-99m sestamibi (MIBI) tracers were conducted in order to compare cardiac adrenergic denervation and myocardial perfusion in 12 patients with a non-Q-wave infarction and 15 patients with a Q-wave infarction. MIBG and MIBI defects were determined as regional uptake < or = 30% of maximal myocardial activity. The size of MIBI defects calculated as a percentage of left ventricular mass was significantly smaller in patients with a non-Q-wave infarction than in patients with a Q-wave infarction (4%+/-3% vs 9%+/-7%, P<0.05, respectively). According to the maximal serum creatine kinase activity, less myocardium was damaged in patients with a non-Q-wave infarction than in patients with a Q-wave infarction (502+/-436 IU/l vs 1878+/-1265 IU/l, P<0.001). In spite of this, the extent of MIBG defects was similar in patients with a non-Q-wave and patients with a Q-wave infarction (21%+/-18% vs 23%+/-12%, respectively). In addition, the size of MIBG defect correlated with the infarct size (maximal creatine kinase activity) (r=0.52, P<0.05) after a Q-wave infarction but not after a non-Q-wave infarction. In conclusion, despite a smaller infarct size in non-Q-wave infarct patients, the extent of cardiac adrenergic denervation was similar in patients with a non-Q-wave and patients with a Q-wave infarction. In addition, the extent of cardiac adrenergic denervation was related to the infarct size in patients with a Q-wave infarction but not in patients with a non-Q-wave infarction.

Dependence of cold-related coronary and respiratory symptoms on age and exposure to cold.

Cold causes cardiopulmonary stress often perceived as shortness of breath or chest pain, and causes exacerbation of these symptoms in persons suffering heart or lung disease. We investigated the prevalence of these symptoms and their association with sex, age and cold exposure in a population-based sample of 1,785 persons who lived in three areas of Finland. The exposure to cold was measured by the annual number cold days (mean daily temperature below 0 degree C) in the resident locality and weekly hours spent in the cold in winter. Shortness of breath was 25% and chest pain 52% more common in females than in males, and their prevalence increased by 24% and 77%, respectively, for every 10 years of age. The prevalence of shortness of breath increased by 5% and chest pain by 6% for every 10 cold days in the resident locality, and by 6% and 7% for every 10 hours spent in the cold, respectively. We suggest that environmental cold, measured by the number of cold days throughout the year and weekly hours spent in the cold, may provoke cardiopulmonary symptoms independent of sex and age.

Similar effect of revascularization on technetium-99m( )sestamibi and 15-(p-iodophenyl)pentadecanoic acid uptake in myocardial infarction patients.

To study its usefulness as a tracer for assessment of the perfusion and viability of myocardium, 15-(p-iodophenyl)pentadecanoic acid (IPPA) was compared with technetium-99m sestamibi (MIBI). Dual-tracer single-photon emission tomography rest imaging was performed no more than 2 months before and 3 months after coronary artery bypass grafting in 28 patients with previous anterior (n=13) or inferior (n=15) infarction. The size of MIBI and IPPA defects decreased from 14%+/-12% and 13%+/-9% to 10%+/-11% and 9%+/-7%, respectively (P<0.001 for both). The MIBI uptake increased in the infarct zones from 35%+/-11% to 43%+/-8% (P<0.001), and in the peri-infarct zones from 50%+/-11% to 55%+/-10% (P<0.05). The IPPA uptake increased in the infarct zones from 37%+/-11% to 44%+/-13% (P<0.001), and in the peri-infarct zones from 51%+/-11% to 57%+/-12% (P<0.05). In nine patients with improved regional echocardiographic wall motion score after bypass surgery, the pre-operative uptake values of both MIBI and IPPA in the infarct and peri-infarct zones were on average slightly but not significantly higher than in 19 patients with no observed improvement in regional wall motion score. In patients with improved regional wall motion, the MIBI scans and the IPPA scans showed (non-significant) decreases in defect size and increases in infarct and peri-infarct zone uptake after bypass surgery. Similar (in some cases significant) changes were observed in the patients without improvement in wall motion. Thus IPPA and MIBI provided similar information about perfusion and viability in pre- and postoperative evaluation of patients with clinically evident myocardial infarction and with normal global ejection fraction. Regardless of the tracer used, the resolution capability of the dual-tracer method with a rest imaging protocol was not sufficient to differentiate viable from non-viable infarction defects in unselected individual patients with a normal ejection fraction.

Natriuretic peptides as markers of cardiotoxicity during doxorubicin treatment for non-Hodgkin's lymphoma.

Thirty adult patients with non-Hodgkin's lymphoma who were planned to receive up to 8-10 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) to a cumulative doxorubicin dose of 400-500 mg/m2 were studied to evaluate the value of serial plasma atrial natriuretic peptide (ANP), N-terminal pro-ANP (NT-proANP) and brain natriuretic peptide (BNP) measurements in the early detection of doxorubicin-induced left ventricular dysfunction. Plasma levels of natriuretic peptides were measured before every treatment course and 4 wk after the last one. Cardiac function was monitored with serial radionuclide ventriculography. Twenty-eight patients were evaluable for cardiotoxicity. Clinical heart failure developed in 2 patients (7%). Left ventricular ejection fraction (LVEF) decreased from 58.0+/-1.3% to 49.6+/-1.7% (p <0.001). Plasma levels of ANP increased from 16.4+/-1.3 pmol/l to 22.7+/-2.4 pmol/l (p= 0.002), NT-proANP from 288+/-22 to 380+/-42 pmol/l (p = 0.019) and BNP from 3.3+/-0.4 to 8.5+/-2.0 pmol/l (p = 0.020). There was a significant correlation between the increase in plasma ANP and the decrease in LVEF (r = -0.447, p = 0.029), and a trend towards significance between the increase in NT-proANP and the decrease in LVEF (r=-0.390, p=0.059). The decrease in LVEF started very early and could already be seen after the cumulative doxorubicin dose of 200 mg/m2, whereas the increase in plasma natriuretic peptides was not evident until the cumulative doxorubicin dose of 400 mg/m2. Our results show that neuroendocrine activation - increased concentrations of plasma natriuretic peptides - occurs when left ventricular function has reduced substantially and its compensatory capacity has been exceeded resulting in atrial and ventricular overload. Thus, serial natriuretic peptide measurements cannot be used in predicting the impairment of left ventricular function. On the other hand, our study suggests that natriuretic peptides are useful in the detection of subclinical left ventricular dysfunction in patients receiving doxorubicin therapy.

Acute neurohumoral and cardiovascular effects of idarubicin in leukemia patients.

Idarubicin has been shown to have similar or superior antileukemic activity to daunorubicin with less cumulative cardiotoxicity. However, data of acute cardiovascular effects of idarubicin are scanty but may have clinical significance in predicting late cardiovascular complications. In the present study we evaluated prospectively acute neurohumoral and cardiovascular effects of idarubicin containing induction chemotherapy in 10 patients with newly diagnosed AML or MDS. Idarubicin was administered intravenously 12 mg/m2 on d 1, 3 and 5 as a part of the induction chemotherapy. Serial measurements of plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were performed at baseline and the day following each idarubicin infusion. Echocardiography was performed to assess cardiac systolic and diastolic function. Signal averaged electrocardiography (ECG) was recorded to observe myocardial late potentials associated with possible myocardial injury. In addition, ambulatory ECG recording was performed to assess arrhythmias. Plasma concentrations of ANP increased from 18.2 +/- 1.5 pmol/l to 27.8 +/- 3.5 pmol/l (p = 0.011), to 30.2 +/- 3.0 pmol/l (p = 0.002) and to 40.8 +/- 6.0 pmol/l (p = 0.006) after the first, second and third doses of idarubicin, respectively. Similarly, plasma concentration of BNP increased from 6.2 +/- 1.9 to 9.0 +/- 1.8 pmol/l (p = 0.049) and 17.5 +/- 8.1 pmol/l (p = 0.203) after the first and third idarubicin infusion. Concomitantly, there was a trend towards an increase in left ventricular end diastolic diameter (LVEDD) (50.2 +/- 1.8 to 54.4 +/- 2.2 mm, p = 0.070). The increase in plasma BNP concentrations correlated significantly with the increase in LVEDD (r = 0.624; p = 0.002). No significant ECG changes or arrhythmias were associated with idarubicin infusions except in 1 patient who developed abnormal myocardial late potentials. Our results show that idarubicin causes acute neurohumoral activation associated with increased LVEDD indicating subclinical myocardial dysfunction. Whether these acute changes predict late clinical cardiomyopathy should be evaluated in prospective studies with larger number of patients and with higher cumulative anthracycline doses.

Five years of surgical experience with peritoneal dialysis.

In this study, we evaluate retrospectively five years experience with the Swann Neck Missouri DC catheters. Sixty three catheters are placed in 51 patients. The total observation period is 695.6 months and the average time is 13.6 months per patient. The last 21 catheters are coiled type. Infectious complications remain the most worrisome problem in peritoneal dialysis. Exit site infections are seen in 24%, tunnel infections in 8%, peritonitis in 38% and abdominal hernias in 16% of the patients. The results in our series (peritonitis every 29.0 patient-months) are in accordance with data from the literature. The combination of a good surgical technique and an efficient postoperative attendance have reduced this frequency. In the situation of a tunnel infection, surgical removal remains the treatment of choice. To prevent an exit site infection, the entry port must be well nursed and protected. A coexisting abdominal hernia can be repaired during the implantation procedure. Fourty six peritoneal dialysis catheters have been removed. Transplantation and death are the main reasons (59%).

Fulminant amebic colitis: analysis of 55 cases.

UNLABELLED: Fulminant amebic colitis is a rare disease with high morbidity and mortality. PURPOSE: This study was designed to identify the most frequent clinical and histopathologic features of fulminant amebic colitis and to analyze results of surgical treatment and the existence of risk factors for mortality. MATERIALS AND METHODS: A retrospective analysis was conducted of clinical and histopathologic data of 55 patients with fulminant amebic colitis. Data were obtained from the files of autopsies and surgical operations that had been performed at a referral center in Mexico from 1943 through 1994. RESULTS: Median age was 52 (range, 18-79) years. There were 34 men (62 percent) and 21 women (38 percent). Diabetes mellitus and chronic alcoholism were the most frequent diseases in association with fulminant amebic colitis (40 and 31 percent, respectively). The most frequent clinical manifestations were abdominal pain, diarrhea, rectal bleeding, and fever. There was a coexistent amebic liver abscess in 54 percent of patients. The main histopathologic characteristics were necrosis, presence of trophozoites, and acute and/or chronic inflammation. Of 25 patients who underwent surgery, only six survived (operative mortality, 76 percent; overall mortality, 89 percent). The variables that correlated with mortality were longer duration of symptoms, lower count of leukocytes, nonsurgical treatment, nonresective surgical procedure, hospital admission before 1971, and invasion of trophozoites into or through the muscularis. CONCLUSIONS: The results may help to obtain an earlier diagnosis and establish proper treatment of fulminant amebic colitis.