Superiority of endothelin-1 over norepinephrine in exercise-induced alterations of the conduit artery tone of the non-exercised arm in patients with chronic heart failure

This study is aimed at examining the relative importance of norepinephrine and endothelin-1 in treadmill exercise-induced changes in brachial arterial tone of the non-exercised arm in patients with chronic heart failure (CHF). Brachial artery diameter and blood flow were measured before and after exercise in eight healthy volunteers and 18 patients with stable chronic heart failure by high-resolution ultrasound. Maximal exercise resulted in brachial artery dilatation in controls (4.42+/-0.39 vs. 4.77+/-0.39 mm; P<0. 0001) in contrast to constriction seen in the patients (5.27+/-0.67 vs. 5.12+/-0.66 mm; P=0.07). Both groups demonstrated a significant increase in blood flow after exercise. The pre-exercise (2.83+/-0.76 vs. 1.69+/-0.15 pmol/l; P=0.0004), post-exercise (4.15+/-1.5 vs. 2. 02+/-0.34 pmol/l; P=0.0004) and the percent increase (47.15+/-32.5 vs. 19.0+/-10.5%; P=0.02) in endothelin-1 levels were significantly greater in patients than in controls. In contrast to endothelin-1, the exercise-induced percent increase in norepinephrine was greater in controls than patients (100.7+/-51.8 vs. 49.8+/-43.4%; P=0.01). The percent change in the diameter of the brachial artery in response to maximal exercise was significantly correlated to pre- (r=0.634; P=0.003) and post-exercise (r=0.467; P=0.05) endothelin-1 levels in patients but not in controls [pre-exercise (r=0.07; P=0. 86), post-exercise (r=0.310; P=0.47)]. The change in the diameter of the brachial artery did not correlate with pre- or post-exercise plasma norepinephrine levels in either group. These findings suggest that endothelin-1 is potentially more important than norepinephrine in contributing exercise-induced brachial artery constriction in patients with chronic heart failure.

Prognostic value of changes over time in exercise capacity and echocardiographic measurements in patients with chronic heart failure

AIMS

This study sought to examine the predictive values of changes over time in exercise capacity and echocardiographic measurements of ventricular dimensions or function in predicting mortality in patients with chronic heart failure.

METHODS AND RESULTS

Sixty-two patients with chronic heart failure (58 men, mean [+/-SD] age 60+/-10 years, mean peak oxygen consumption (VO(2)) 18.2+/- 5.9 ml. kg(-1). min(-1), mean left ventricular ejection fraction 38.9+/-15. 8%) who underwent both treadmill exercise testing and echocardiographic examination on two occasions, separated by 19+/-15 months were followed-up for a mean of 17 months (interquartile range 9-30 months). During the follow-up period, 19 patients (30%) died and three (4.8%) underwent heart transplantation. Of measurements taken at a single time-point (visit 2) exercise duration, peak VO(2), ventilatory response to exercise (VE/VCO(2)), left atrial diameter and left ventricular ejection fraction were found, by Cox proportional-hazard analysis, to predict the outcome in these patients (all P<0.05). Of the changes in parameters between visit 1 to visit 2, only changes in peak VO(2)per year (P=0.026) predicted non-transplanted survival (independent of changes in left ventricular ejection fraction and VE/VCO(2)). In Kaplan-Meier survival analysis patients with increased peak VO(2)over time (n=28) showed a better prognosis at 2 years (cumulative survival 75% [95% confidence interval: 56-95%] than those with a decrease in peak VO(2)(n=34, cumulative survival 50% [95% confidence interval: 31-68%]).

CONCLUSIONS

Although single estimates of peak VO(2), VE/VCO(2)and left ventricular ejection fraction have significant prognostic importance in patients with chronic heart failure, when monitoring changes over time only peak VO(2)remains a significant predictor of outcome.

Superior sulcus tumors: combined modality

Twenty-four patients with superior sulcus tumors were seen between 1955 and 1989. Fifteen of these patients received combined-modality therapy. In 2 patients, this consisted of primary operation followed by postoperative radiotherapy, and, in 13, high-dose conventionally fractionated preoperative radiotherapy (5,500 to 6,475 cGy) followed by en bloc resection. Of the 13 patients who received radiotherapy preoperatively, 7 survived free of disease beyond 5 years and 2 others remained without evidence of disease after a shorter follow-up (greater than 2 years). The long-term survival in the combined-modality patients in this small series is superior to that reported for other patients receiving combined-modality therapy, and the morbidity appears to be within accepted limits despite the aggressive preoperative radiotherapy program. One postoperative death occurred in our only octogenarian, but there were no other acute complications. High-dose preoperative radiotherapy using current techniques and fractionation appears to be feasible in conjunction with contemporary surgical techniques. We believe this type of preoperative radiotherapy contributed to the apparent superior survival rate in this series and may also be applicable in the setting of other locally advanced (stage III) bronchogenic carcinomas.

Herpes simplex encephalitis in third trimester of pregnancy: successful outcome for mother and child

A woman with herpes simplex encephalitis (HSE) in the third trimester of pregnancy is described. She was treated with acyclovir and recovered completely to deliver a normal child per vaginam at term. She had no evidence of genital or disseminated herpes virus infection. This paper illustrates that (1) the outcome of HSE in pregnancy can be favorable both for the mother and the offspring, (2) early diagnosis and use of acyclovir therapy is essential for successful outcome, and (3) the use of acyclovir in the third trimester of pregnancy was not harmful to the mother or fetus.

Exercise and health: participation and promotion by general practitioners

A survey of 2599 general practitioners was undertaken to assess personal participation, attitudes and facilities for the promotion of exercise and health. The majority of the 1049 respondents took part in two or more vigorous physical activities during an average week and believed in the importance of exercise for health and wellbeing. Most respondents accepted the importance of fitness assessments in the management of certain diseases but were unable to undertake tests, other than taking a simple history, through lack of time, equipment, staff and space.It is suggested that health authorities might do more to support the growing interest and enthusiasm for exercise promotion among general practitioners by sponsoring more postgraduate training in the physiology of exercise and practical methods of fitness testing. The provision of additional staff, equipment and facilities to support these promotion initiatives should also be encouraged.