Can we detect non-functional overreaching in young elite soccer players and middle-long distance runners using field performance tests?

OBJECTIVE: To study whether field performance tests can make a valid distinction between non-functionally overreaching (NFO) athletes and control athletes. DESIGN: Monthly field performance tests were used to determine a performance decrement (PD) throughout a season. Athletes with a minimum of 1 month PD were compared with control athletes without a PD on mood characteristics and resting levels of stress hormones. SETTING: Sporting field and sports medical laboratory. PARTICIPANTS: 129 young elite athletes, 77 soccer players and 52 middle-long distance runners were followed prospectively during the 2006-2007 season. Fifteen of them were invited to the laboratory. Eight athletes showed a performance decrease lasting longer than 1 month, and seven athletes without a performance decrease acted as their controls. MAIN OUTCOME MEASURES: Performance changes over time were measured using field tests. Profile of Mood States and resting levels of adrenocorticotrophic hormone (ACTH) and cortisol in blood were measured in the laboratory. RESULTS: PD athletes showed several symptoms typical of the non-functional state of overreaching (OR). The PD group scored higher on depression and anger than controls. They also showed a specific pattern of correlations between negative mood subscales (tension, fatigue and depression), which was absent in controls. ACTH levels at rest were similar, but lower cortisol levels in PD athletes pointed at a blunted cortisol response. Cortisol levels were decoupled from ACTH levels only in PD athletes. CONCLUSIONS: Implementing performance-related criteria in field tests can help coaches and sports physicians to distinguish NFO athletes from athletes with balanced workload and recovery.

The persistent sciatic artery.

BACKGROUND: A persistent sciatic artery (PSA) is a rare vascular anomaly with an estimated incidence of 0.03-0.06%. During early embryonic development, the sciatic artery usually disappears when the superficial femoral artery has developed properly. This study aimed to assess the clinical presentation and outcome of a PSA. METHOD: A systematic review of all cases of PSA published between 1964 and 2007 was performed. RESULTS: In this review, 159 PSAs were described in 122 patients. The mean age at which the PSA was discovered was 57 years, and the incidence was equally distributed with regards to gender. The majority of PSAs was unilateral (70%) and of the complete type (79%). Ninety-one patients (80%) presented with symptoms including intermittent claudication, ischaemia, a pulsating mass or neurological symptoms. An aneurysm was found in 48%, a stenosis in 7%, an occlusion of the PSA in 9% and an occlusion of an artery distal to the PSA in 6% of the subjects. The treatment depended on the symptoms and classification of the PSA. In nine cases (8%), an amputation was required eventually. CONCLUSION: The PSA is a rare anomaly with a high incidence of complications including aneurysm formation and ischaemia that may lead to amputation. Strategies for follow-up could not be deduced from the available literature.

Respiratory muscle strength in stable adolescent and adult patients with cystic fibrosis.

BACKGROUND: Since available studies have provided conflicting results, this study investigated respiratory muscle function and its relationship with exercise capacity, degree of dyspnoea and leg discomfort, and quality of life in patients with Cystic Fibrosis (CF). METHODS: Using a cross-sectional design, 27 clinically stable adolescent and adult patients (f/m: 14/13, age: 26+/-7 years) were included. Data of respiratory muscle strength (P(i)max and P(e)max), lung function (spirometry), peripheral muscle strength (peak isometric quadriceps and hand-grip strength), symptom-limited exercise capacity (modified shuttle test, MST), post-exercise dyspnoea and leg discomfort (Borg scores), and quality of life (CFQ-14+, MRC) were obtained for further analysis. RESULTS: P(i)max of the total patient group was significantly higher than reference values (P(i)max=124+/-32% predicted), and correlated positively with the walk/run distance of the MST (r(s)=0.59, p=0.00). Female patients showed more dyspnoea and a more impaired lung function than male patients. However, P(i)max and P(e)max (% predicted) showed a tendency to be higher in female than in male patients. CONCLUSION: Increased work of breathing will have a conditioning effect on the respiratory muscles, suggesting that training-related inspiratory muscle strength can play a positive role in the limited exercise capacity of CF patients.

Oxygen uptake kinetics in chronic heart failure: clinical and physiological aspects.

One of the hallmark symptoms of patients with chronic heart failure (CHF) is exercise intolerance. Therefore, exercise testing has become an important tool for the evaluation and monitoring of heart failure. Whereas the maximal aerobic capacity (peak VO(2)) is a reliable indicator of the severity and prognosis of heart failure, submaximal exercise parameters may be more closely related to the ability to perform daily activities. As such, oxygen (O(2)) uptake kinetics, describing the rate change of O(2) uptake during onset or recovery of submaximal constant-load exercise (O(2) onset and recovery kinetics, respectively), have been shown to be useful parameters for objectively evaluating the functional capacity of CHF patients. However, their evaluation in this population is not a routine part of daily clinical practice. Possible reasons for this include a lack of standardisation of the assessment methodology and a limited number of studies evaluating the clinical use of O(2) uptake kinetics in CHF patients. In addition, the pathophysiological mechanisms underlying the delay in O(2) uptake kinetics in these patients are not completely understood. This review discusses the current literature on the clinical potency and physiological determinants of O(2) uptake kinetics in CHF patients and provides directions for future research. (Neth Heart J 2009;17:238-44.Neth Heart J 2009;17:238-44.).

Reduction of free fatty acids by acipimox enhances the growth hormone (GH) responses to GH-releasing peptide 2 in elderly men.

GH release is increased by reducing circulating free fatty acids (FFAs). Aging is associated with decreased plasma GH concentrations. We evaluated GH releasing capacity in nine healthy elderly men after administration of GH-releasing peptide 2 (GHRP-2), with or without pretreatment with the antilipolytic drug acipimox, and compared the GHRP-2-induced GH release with the response to GHRH. The area under the curve (AUC) of the GH response after GHRP-2 alone was 4.8 times higher compared with GHRH alone (1834 +/- 255 vs. 382 +/- 78 microg/L.60 min, P: < 0.001). Acipimox, which reduced FFAs from 607 micromol/L to 180 micromol/L, increased the GH AUC to 1087 after GHRH and to 2956 microg/L.60 min after GHRP-2 (P: < 0.01). The AUC after acipimox/GHRP-2 were positively correlated with the AUC after GHRP-2 alone (r = 0.93, P: < 0.01); this was also observed between acipimox/GHRH and GHRH alone (r = 0.73, P: = 0.03). Significant negative correlations were observed between basal FFAs and AUC after GHRH or GHRP-2 after combining the data with and without acipimox (r = 0.58, P: = 0.01 and r = 0.48, P: = 0.04, respectively), and between basal FFAs and GH at t = 0 (r = -0.44, P: = 0.001). Interestingly, GHRP-2 administration was followed by a significant early rise in plasma FFAs by 60% (P = 0.01), indicating an acute lipolytic effect. In conclusion, reduction of circulating FFAs strongly enhances GHRP-2-stimulated GH release in elderly men. The data indicate that the decreased GH release associated with aging can be reversed by acipimox and that the pituitary GH secretory capacity in elderly men is still sufficient.

Visceral adipose tissue is associated with circulating high affinity growth hormone-binding protein.

Recent data show that body fat distribution, specifically visceral fat accumulation, is associated with the regulation of GH secretion. To our knowledge no studies have been performed with regard to the relationship between plasma high affinity GH-binding protein (GHBP) levels and fat distribution in humans. To address this question, we measured plasma GHBP and insulin-like growth factor I levels as well as visceral, sc abdominal, and hip adipose tissue (AT) areas by using magnetic resonance imaging scanning in 12 patients with GH deficiency (GHD) and in 12 age- and sex-matched healthy subjects. The GHD patients were subsequently treated with GH replacement therapy. Regardless of the GH status of the subjects, body mass index and visceral AT area were positively correlated to plasma GHBP (r = 0.70; P < 0.01 and r = 0.73; P < 0.01, respectively), whereas the sc AT areas at the abdominal level tended to correlate positively with GHBP levels, but did not reach significance (r = 0.44; P = 0.07). The sc AT areas at the hip level were not correlated with plasma GHBP levels. In the GHD patients the pretreatment visceral and abdominal sc AT areas were positively correlated with the change in GHBP levels after GH replacement (r = 0.82; P < 0.01 and r = 0.75; P < 0.01, respectively). The pretreatment sc AT area at the hip level was not associated with the therapy-induced changes in plasma GHBP (r = 0.28; P > 0.10). In summary, this study shows that visceral fat is associated with circulating GHBP levels, suggesting that visceral fat mass may be involved in the regulation of the plasma GHBP level. Further, the amount of abdominal fat in GHD patients may partially determine the plasma GHBP response to GH replacement therapy.

Induction of postprandial inflammatory response in adult onset growth hormone deficiency is related to plasma remnant-like particle-cholesterol concentration.

Increased cardiovascular mortality due to premature atherosclerosis is a clinical feature in the adult-onset GH deficiency (AGHD) syndrome. Inflammation is a key feature in atherogenesis and may be triggered by postprandial lipoprotein remnants. We hypothesized that increased postprandial lipoprotein remnant levels in AGHD may be associated with an inflammatory response. In this case-control study, 10 AGHD patients [6 males and 4 females; age, 48 +/- 9 yr; body mass index (BMI), 26.9 +/- 2.6 kg/m(2)] and 10 healthy control subjects (matched for age, BMI, gender, baseline lipid levels, and apolipoprotein E genotype) were included. They all ingested an oral fat load. Fasting and postprandial levels of plasma remnant-like particle-cholesterol (RLP-C; 0.31 +/- 0.13 mmol/liter and 4.14 +/- 1.37 mmol/liter.h in GHD; 0.18 +/- 0.06 mmol/liter and 2.56 +/- 1.02 mmol/liter.h in controls, respectively) were significantly increased in AGHD patients compared with control subjects. The median inflammatory cytokines, IL-6 and TNF-alpha, were higher in the fasting [3.9 (range, 3.1-11.9) pg/ml and 6.8 (range, 2.5-27.6) pg/ml, respectively] and postprandial [151.7 (range, 87.0-294.3) pg/ml.24 h and 289.9 (range, 87.5-617.6) pg/ml.24 h, respectively] states in AGHD than in controls [fasting, 0.9 (range, 0.2-5.2) pg/ml and 2.8 (range, 2.5-5.7) pg/ml; and postprandial, 54.5 (range, 11.50-126.5) pg/ml.24 h and 118.3 (range, 81.2-243.1) pg/ml.24 h, respectively]. In addition, postprandial profile of RLP-C and IL-6 in AGHD and in the total group were significantly associated (r(2) = 0.44, P < 0.05; and r(2) = 0.38, P < 0.01, respectively). In conclusion, the increased postprandial RLP-C level in GHD is associated with an inflammatory response that may result in increased susceptibility for premature atherosclerosis.

Insulin-like growth factor-I and cognitive function in healthy older men.

The GH/insulin-like growth factor-I (GH/IGF-I) axis is known to be involved in aging of physiological functions. Recent studies indicate that the GH/IGF-I axis may be associated with cognitive functioning. The aim of the present study was to determine whether the age-related decline in circulating levels of IGF-I, as an index of anabolic status, is associated with cognitive functions that are known to decline with aging, but not with cognitive functions not sensitive to aging. Twenty five healthy older men with well-preserved functional ability participated in the study. We also administered neuropsychological tests of general knowledge, vocabulary, basic visual perception, reading ability, visuoconstructive ability, perceptual-motor speed, mental tracking, and verbal long-term memory. Performance on the last four tests decline with aging, whereas the first four of these tests have been shown not to be sensitive to cognitive aging. Mean age of the subjects was 69.1 +/- 3.4 (SD) yr (range 65-76 yr), their mean body mass index was 27.0 +/- 2.4 kg/m2, and their mean IGF-I level was 122 ng/mL (range: 50-220). We found IGF-I levels to be significantly associated with the performances (controlled for education) on the Digit Symbol Substitution test (r = 0.52, P = 0.009) and the Concept Shifting Task (r = -0.55, P = 0.005), which measure perceptual-motor and mental processing speed. Subjects with higher IGF-I levels performed better on these tests, performance on which is known to decline with aging. In conclusion, the results of this study support the hypothesis that circulating IGF-I may play a role in the age-related reduction of certain cognitive functions, specifically speed of information processing.

The effect of omeprazole on gastro-oesophageal reflux and symptoms during strenuous exercise.

BACKGROUND: Strenuous exercise exacerbates gastro-oesophageal reflux and symptoms and this may be diminished by antisecretory medication with omeprazole. METHODS: Fourteen well-trained athletes (13 men, one woman), who indicated suffering from either heartburn, regurgitation or chest pain during competition running, performed two experimental trials at 2-week intervals using a randomized, double-blind, placebo-controlled crossover design. During the 6 days preceding the trial and on the trial day itself either 20 mg of omeprazole or a placebo was administered. Two hours after a low-fat breakfast and 1 h after the last study dose, the trial started with five successive 50-min periods: rest, three running periods on a treadmill, and recovery. Reflux (percentage time and number of periods oesophageal pH <4) was measured with an ambulant pH system during these periods. RESULTS: Compared to rest, reflux lasted significantly longer and occurred more frequently during the first running period, irrespective of the intervention, whereas during the second running period this effect was only observed with the placebo. Reflux occurred for longer and more frequently with the placebo than with omeprazole, but this was significant during the first two running periods only. Seven subjects reported heartburn, regurgitation and/or chest pain during exercise, irrespective of the intervention. Only a minority of the symptom periods was actually associated with acid reflux and in all cases this concerned periods with heartburn. CONCLUSIONS: Running-induced acid reflux, but not symptoms, were decreased by omeprazole, probably because most symptoms were not related to acid reflux.

High-affinity growth hormone binding protein, insulin-like growth factor I and insulin-like growth factor binding protein 3 in adults with growth hormone deficiency.

The high-affinity growth hormone binding protein (GHBP) circulates in human blood and represents the extracellular domain of the growth hormone (GH) receptor. The effects of GH deficiency on GHBP in adults are not clear. The aim of this study was to evaluate serum GHBP levels in adults with GH deficiency and to assess whether GHBP measurement may contribute to the diagnosis of adult GH deficiency, based on a two-step model. We measured insulin-like growth factor I (IGF-I), IGF binding protein 3 (IGFBP-3) and GHBP levels in serum samples of 36 patients with adult-onset GH deficiency. The GHBP levels were measured by FPLC size-exclusion chromatography; IGF-I and IGFBP-3 levels were measured by RIA. Serum GHBP levels were elevated above the upper limit of the 95% confidence interval in 26 patients, whereas IGF-I and IGFBP-3 levels were low in 10 patients and in 16 patients, respectively. The combination of low serum IGF-I and low IGFBP-3 levels was found in 10 patients. In nine patients, serum IGF-I levels were low, with elevated GHBP levels. Low serum IGF-I, low IGFBP-3 and elevated GHBP levels were found in five patients. Only four out of 36 patients had serum IGF-I, IGFBP-3 and GHBP levels that were within the 95% confidence interval of the control values. We conclude that adults with acquired GH deficiency have elevated GHBP levels in comparison to healthy subjects. We suggest that measurement of GHBP levels might contribute to the diagnosis of adult GH deficiency, though further research is required to study the additional value of GHBP measurements.

High-affinity growth hormone (GH)-binding protein (GHBP), body fat mass, and insulin-like growth factor-binding protein-3 predict the GHBP response to GH therapy in adult GH deficiency syndrome.

The study objective was to investigate which baseline factors can accurately predict plasma high-affinity growth hormone (GH)-binding protein (GHBP) levels after GH replacement therapy in patients with GH deficiency (GHD). The study group consisted of 36 GHD patients (22 men and 14 women; mean age, 43.1 years; (range, 21 to 60) known to have adult-onset GHD for many years (range, 4 to 22). They were randomly divided into a GH-treated group (n = 19) and a placebo group (n = 17). Body composition (assessed by bioelectrical impendance analysis [BIA]), plasma GHBP (fast protein liquid chromatography [FPLC] size-exclusion gel chromatography), insulin-like growth factor-I (IGF-I), and IGF-binding protein-3 ([IGFBP-3] radioimmunoassays) were measured before and after 6 months. A stepwise multiple linear regression analysis with the plasma GHBP level after 6 months as the dependent variable was used to unravel significant explanatory (or predictor) variables. In contrast to placebo therapy, GH replacement therapy increased the mean plasma levels of IGF-I and IGFBP-3 to the normal range, whereas a small but statistically significant increase in plasma GHBP was observed. The combination of baseline plasma GHBP, body fat mass, and IGFBP-3 predicts posttreatment GHBP levels accurately (adjusted R2 = .97), indicating that baseline variables such as age, gender, fat-free mass, and IGF-I have no contribution. Furthermore, reliability analysis showed that the observed and predicted values for GHBP fit a strict parallel model. These findings indicate that the variations in body fat mass and IGFBP-3 among adult GHD subjects explain the reported variable response of GHBP to GH replacement therapy.

Growth hormone, insulin-like growth factor I and cognitive function in adults.

This review focuses on the possible contribution of the growth hormone (GH)-insulin-like growth factor I (IGF-I) axis to cognitive function. Binding sites for GH and IGF-I are found in various areas of the brain. Their distribution suggests that GH and IGF-I contribute to the function of the hippocampus, a brain structure important for the maintenance of cognitive functions such as learning and memory. Evidence for cognitive deficits in GH-deficient individuals has been found in various studies, some of which have shown that these deficits can be reversed by GH substitution therapy. In addition to examining conditions of GH deficiency, this article reviews studies evaluating the correlation between the cognitive deficits associated with ageing and age-related decreases in GH or IGF-I secretion. Based on the available data, one might hypothesize that relative GH or IGF-I deficiency could contribute to the deterioration of cognitive functions observed in the elderly.

Somatotropic-axis deficiency affects brain substrates of selective attention in childhood-onset growth hormone deficient patients.

Reduced levels of growth hormone (GH) and insulin-like growth factor-1 (IGF-1) are associated with deteriorated cognitive performance in senescence. Little work has been done on the effect of GH and IGF-1 on a crucial aspect of cognition, selective attention. This study investigated the effect of GH/IGF-1 on performance and brain potentials (EEG) during a selective-attention task in patients with low levels of GH and IGF-1 (childhood-onset growth hormone deficiency) compared to healthy controls. Detection of occasional visual target patterns was impaired in patients. This was paralleled by a reduction in an attention-related brain potential, which has been associated previously with anterior cingulate cortex functioning.

Growth hormone responses during strenuous exercise: the role of GH-releasing hormone and GH-releasing peptide-2.

PURPOSE AND METHODS: This study was designed to investigate the role of two effective releasers of growth hormone (GH): GHRH and GHRP-2 during exercise (EX). Eight healthy male subjects (ages: 22 +/- 1.2 (mean +/- SD) yr, BMI: 22.5 +/- 2.2 kg x m(-2)) were exposed to maximally stimulating dose of 100 microg GHRH iv, and 200 microg GHRP-2 iv, during incremental EX on a cycle ergometer to exhaustion. GH responses after EX alone were compared with the responses after the combined administration of the same EX plus GHRH, EX plus GHRP-2, and EX plus GHRH plus GHRP-2. Blood samples were obtained in the fasted state at intervals for 2 h postexercise and the area under the GH response curve (AUC) was calculated by trapezoidal integration. RESULTS: Significant differences (P < 0.003) were observed between the AUCs after administration of EX alone (mean +/- SEM): 2,324 +/- 312 microg x L(-1) 120 min, after EX plus GHRH: 6,952 +/- 1,083, after EX plus GHRP-2: 14,674 +/- 2,210, and after the combination EX plus GHRH plus GHRP-2: 17,673 +/- 1,670. However, AUCs after each combination did not differ significantly from those after arithmetical addition of each separate stimulus, indicating that the mechanisms of the respective stimuli do not interact. Linear regression analysis on mean GH responses between 20 and 30 min after the start of EX showed that EX alone and GHRH alone explain about 59% (adj. R2) of the GH response to the combination EX plus GHRH. The ratio of the respective regression coefficients (GHRH vs EX) was about 2:1 (instead of 1:1), indicating that EX seems to potentiate the activity of GHRH. GHRH alone and EX alone also explained about 74% of the response to the combination EX plus GHRP-2. In the latter response, a synergistic action of GHRP-2 on GHRH could be observed. CONCLUSIONS: The data indicate that under strenuous EX conditions, endogenous GHRH activity causes a further increase of GH release. A GHRP-2 mediated mechanism in the central neuroendocrine regulation acts as a "booster," possibly by stimulating the effects of GHRH and/or an unknown hypothalamic factor, as well as by stimulating the pituitary GH release directly.

Gastrointestinal mucosal integrity after prolonged exercise with fluid supplementation.

PURPOSE: Studies on the effect of exercise on gastrointestinal (GI) mucosal integrity have been limited to occult-blood tests, which were often nonspecific for human blood. The aim of our study was to investigate more aspects of this integrity. METHODS: We examined the effect of prolonged exercise and carbohydrate (CHO) supplementation on mucosal integrity in 22 male triathletes by measuring fecal lysozyme, alpha1-antitrypsin, and occult-blood loss, which was examined by two tests specific for human blood (Colon-Albumin and Monohaem test). Exercise consisted of two 150-min tests (alternately running, cycling, and running at 70-75% VO2max), either with a 7.0% CHO drink or water (W). Furthermore, GI symptoms during exercise were registered by questionnaire. RESULTS: Three subjects showed human albumin only in the first stool after exercise: twice with W and once with CHO. However, human hemoglobin (Hb) could not be detected in these samples. Four other subjects showed an elevated lysozyme concentration after exercise with CHO but not with W. Elevated alpha1-antitrypsin values were found in three of seven specimens in which either positive albumin tests and/or an elevated lysozyme concentration were demonstrated. Twenty-one subjects (95%) reported one or more GI symptoms during exercise. Incidence rates of different GI symptoms varied from 5 to 68%. Most symptoms were more frequent and lasted longer during running than during cycling but did not differ significantly between supplements and were not related to any mucosal integrity parameter. CONCLUSIONS: GI blood loss during exercise is of no clinical importance, at least in our study design with a group of well-trained male subjects who consumed a relatively high amount of fluid (up to 2.3 L). Nevertheless, an increased alpha1-antitrypsin and lysozyme concentration may indicate a transient local mucosal damage with an inflammatory response.

Gastrointestinal symptoms during long-distance walking.

PURPOSE: Gastrointestinal (GI) symptoms are common during prolonged intense exercise. To examine whether GI symptoms are also common during prolonged exercise of lower intensity, we obtained data on incidence, duration, and severity of GI symptoms during four consecutive days walking with a total distance of 203 km for men and 164 km for women. METHODS: The research population consisted of 79 men and 76 women, aged 30-49 yr, who responded to a questionnaire and a diary concerning anthropometric data, activity pattern, dietary intake, and GI symptoms. RESULTS: The results show that 24% of the subjects experienced one or more symptoms. Nausea, headache, and flatulence were the most frequent symptoms. Nine subjects dropped out during the race, two of whom indicated that they stopped as a result of one or more GI symptoms. Logistic regression analysis revealed that the occurrence of GI symptoms was a significant exercise-limiting factor. Univariate analysis showed that incidence and duration of GI symptoms were significantly related to the subjects' experience (number of prior participations to the event), body weight loss during walking, and several components of the diet before and during the event. A significant relationship between GI symptoms and age, gender, training status, and walking speed could not be found. CONCLUSIONS: We conclude that GI symptoms during long-distance walking can impair exercise performance, although these symptoms occur less frequently and are less severe in comparison with prolonged intense exercise.

Gastrointestinal problems as a function of carbohydrate supplements and mode of exercise.

The aim of the study was to examine prevalence and duration/seriousness of gastrointestinal (GI) problems as a function of carbohydrate-rich (CHO) supplements and mode of exercise. The relationship between GI problems and a variety of physiological and personal factors (age, exercise experience) was also examined. Thirty-two male tri-athletes performed three experimental trials at 1-wk intervals, each trial on a different supplement: a conventional, semisolid supplement (S; 1.2 g CHO, 0.1 g protein, and 0.02 g fat.kg BW-1 x h-1); an almost isocaloric fluid supplement (F; 1.3 g CHO.kg BW-1 x h-1, no fat, no protein); and a fluid placebo (P). The 3 h of exercise started at 75% VO2max and consisted of alternately cycling (bouts 1 and 3) and running (bouts 2 and 4). GI symptoms were monitored by a questionnaire. Analysis of variance revealed that nausea lasted longer with P as compared with S (P < 0.05). Bloating lasted longer during bout 3 with P as compared with F and S (P < 0.05). Accounting for confounding factors, most GI symptoms occurred more frequently and lasted longer during running than during cycling. Multiple regression analysis revealed significant relationships between nausea and urge to defecate, between an urge to defecate, GI cramps and flatulence, and between belching and side ache. From all other factors energy depletion, CHO malabsorption, exercise intensity, exercise experience, and age were significantly related to GI symptoms during the exercise.

Cardiopulmonary exercise parameters in relation to all-cause mortality in patients with chronic heart failure.

In this study we analysed the all-cause mortality over a period of maximal 6 years in 60 male patients (age: 63.4+/-8.3 years, mean+/-S.D.), suffering from chronic heart failure with resting left ventricular ejection fraction and E/O2 slope as independent factors. We assessed functional NYHA class (II: n=36, III: n=24), radionuclide left ventricular ejection fraction (29.2+/-10.4%) and peak values of heart rate, O2, CO2, E, anaerobic threshold and exercise duration with an incremental work load test on the treadmill. O2 relative to E was based on the individual slopes of the regression of O2 on E during the first 6 min of exercise. These slopes with other exercise-related variables and factors such as etiology, medication, and NYHA class were analysed with a Cox's Regression Method. A survival time analysis (Kaplan-Meier survival curve) was done to establish the influence of E/O2 slope and left ventricular ejection fraction (both split into above and below median values), as well as their interaction, on survival. From all investigated exercise-related variables. E/O2 slope is the most powerful variable regarding prediction of all-cause mortality in our group of chronic heart failure patients. Concerning risk stratification, the subgroup (n=18) with a relatively high left ventricular ejection fraction (>28%) and flat E/O2 slope (<27.6) had most survivors (77.8%) after about 3 years, while the subgroup (n=12) with a relatively high left ventricular ejection fraction (>28%), but a steep E/O2 slope (>27.6) had least survivors (33.3%). This difference in percentage is highly significant (P=0.0025). The fact that E/O2 slope and left ventricular ejection fraction show comparable main and interaction effects between measures of exercise tolerance (e.g., anaerobic threshold, peak O2, exercise duration) on the one hand, and all-cause mortality on the other, suggests the existence of common sources of variance. Based on our analysis, it is unlikely that effects on all-cause mortality are mediated through phenomena related to exercise tolerance. Therefore, we hypothesize that the effects on exercise tolerance and all-cause mortality both depend on common factors, which cause both cardiac and peripheral organ (c.q. muscular) dysfunctions. Moreover, this study clearly shows that E/O2 slope during incremental exercise is an important prognostic marker for risk stratification in chronic heart failure patients, NYHA class II and III.

[Chondrosarcoma of the bony thoracic wall]. / Chondrosarcoom van de benige thoraxwand.

An 85-year-old man was admitted because of a slowly growing mass in his left flank, which had been present for 16 years. A very large chondrosarcoma was diagnosed, weighing 8.5 kg. After radical resection of the tumour the patient recovered well. No recurrences developed during follow-up.