Analysis of General Knowledge on Obstructive Sleep Apnea Syndrome (OSAS) among Italian Pediatricians

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a disorder characterized by partial or total airway obstruction during sleep. Studies have shown variability in the level of knowledge and awareness about OSAS among pediatricians. The management of childhood obstructive sleep apnea syndrome (OSAS) depends on the severity of the disease, the presence of comorbidities, and the child's age. The American Pediatric Academy recommends a multidisciplinary approach involving a pediatrician, a sleep specialist, and an otolaryngologist to provide comprehensive care for children with OSAS. The aim of this cross-sectional study is to evaluate the level of knowledge among pediatricians in Italy regarding the diagnosis of pediatric OSAS.

MATERIAL AND METHODS

An anonymized survey was conducted among Italian pediatricians. The survey was administered electronically using Google Forms, and a total of 350 pediatricians were invited to participate. Out of the 350 invitations, 299 pediatricians responded to the survey. The statistical analysis performed consisted of descriptive analysis. The study included 297 pediatricians.

RESULTS

Pediatricians demonstrated proficiency in identifying common nocturnal and day symptoms of OSAS. A majority (68.9%) considered the oral and otorhinolaryngologist areas during checkups. Approximately 70.6% took patient weight into account, and 62.8% were aware of the regional diagnostic-therapeutic-assistance pathway.

CONCLUSIONS

According to the results of this manuscript, there is evidence of a good level of knowledge about OSAS, but disseminating more information about OSAS and all the health issues associated with this syndrome is suggested. This study also has limitations caused by the complexity of the pathology.

Evaluation of the Italian version of the elderly mobility scale in older hospitalized patients

Introduction

Reliable and valid assessment tools are needed to evaluate and predict physical function in older hospitalized patients. The aim of this study is to develop the Italian version of the Elderly Mobility Scale (I-EMS) and to evaluate its validity and inter-rater reliability for use with geriatric inpatients.

Methods

The study consists of two phases: (i) translation, where EMS version 2 was translated into Italian by two teams, each comprising 2 bilingual physiotherapists; translations were back translated by 2 native English speakers, and a committee of 2 physiotherapists and 1 physician refined the initial I-EMS version, which was pilot-tested for clarity in a group of ten experienced geriatric physiotherapists; (ii) an observational study assessed I-EMS metrics (reliability, validity) in older Italian inpatients at IRCCS INRCA (Ancona, Italy) between September 2022 and April 2023.

Results

No statistically significant differences were found between the scores of individual items and the total score assigned by different raters. The ICC for total I-EMS was 0.951, SEM was 1.10 and MDC95 was 3.06. The absolute agreement and weighted kappa for individual items ranged 80.32-100% and 8.2-1, respectively. The validity of I-EMS was supported by a significant (p < 0.05) correlation with the Barthel Index (r = 0.827 and 0.834 for the I-EMS administered by rater A and rater B, respectively).

Conclusion

I-EMS showed good internal consistency and inter-rater reliability, and confirmed construct validity with respect to BI. Therefore, it can safely be used as an assessment tool for hospitalized Italian geriatric patients.

Clinical trial registration

[ClinicalTrials.gov], [NCT05806242].

Prevention of malocclusion and the importance of early diagnosis in the Italian young population

AIM

Malocclusion is an alteration of the normal relationships between skeletal, muscle and dental structures that can lead to impaired functionality as well as aesthetic alteration of the stomatognathic system. Functional alteration can affect various aspects, ranging from chewing ability to respiratory disorders. Paediatricians and dentists are called to prevent and diagnose these conditions as early as possible in order to preserve the patient's health. The purpose of this research is to study the incidence of malocclusion and its relationship with Obstructive Sleep Apnea Syndrome (OSAS) in a young population. Also, the role of paediatricians and dentists in prevention and early diagnosis of this condition was evaluated METHODS: An anonymous survey was given through Google form to 300 Italian children (139 males and 161 females) from different private dental practices in Italy. No personal information that identifies the individuals was collected, and the data was analysed in aggregate form only. All data was collected and statistically analysed.

CONCLUSION

The data highlight the patients' good attitude towards dental check-ups, which help to intercept malocclusions. Unlike the past, the knowledge of the importance of oral health and dental occlusion is high among young patients, parents and paediatricians. This study underlines the role of paediatricians as key players in the prevention of dental health problems.

Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented.

Assessment for prognosis during and after myocardial infarction. A plea for a stratified approach

Right after the first signs and symptoms of acute myocardial infarctions the prognosis is determined by the interventions which are carried out at that time. Preservation of as much myocardial tissue is the key element. Early deobstruction and reperfusion of the myocardium at jeopardy can lead to limitation of the ultimate infarct size, improved ventricular function and a halving of the 1-year mortality. Early supportive therapy with beta-blockade and calcium antagonists may enhance this effect. Data in 533 patients randomized to either a reperfusion strategy or to conventional therapy, combined with those from the recent literature on thrombolysis and early beta-blockade, provide the basis for this point of view. Once infarction is unavoidable and in the process of completion, probably 3-4 h after onset of symptoms, only supportive therapy is recommended, which will hardly change the outcome except for interventions during clinical care such as defibrillation. In 351 other survivors of myocardial infarction the value of clinical variables, a symptom-limited bicycle stress test at discharge, radionuclide ventriculography and 24-hour ambulatory electrocardiogram was compared in predicting 1-year survival. A history of previous myocardial infarction and heart failure during the current episode proved to be the strongest clinical predictors of death. Similarly, a low ejection fraction (less than 40%) and an insufficient blood pressure rise during stress testing (less than 30 mm Hg) identified a high risk group. Stress-test-induced angina and ST depression as well as ventricular arrhythmias from 24-hour electrocardiography were less good as predictors. In these patients treatment should be individualized and may require arteriography. Patients eligible for and completing a normal bicycle stress test after myocardial infarction proved to be a low risk group, which may constitute 65% of the total, seen in tertiary referral centers and even more in community hospitals. They neither require therapy nor further investigation. A subgroup with an intermediate risk can be identified when clinical variables, stress testing and/or resting radionuclide ventriculography are abnormal. This group requires 'tailored' therapy. Therefore, after infarction recovery, we recommend a pre-discharge stress test routinely to complement the clinical evaluation, since it also provides information on physical capacity, the indication of arrhythmias and the presence of myocardial ischemia. Thus, optimal management of acute myocardial infarction requires a stratified approach, which does not require expensive testing procedures.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

Intraoperative transesophageal echo-Doppler evaluation of stentless aortic xenografts. Incidence and significance of moderate gradients

BACKGROUND

The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien (CLOB) Stentless Porcine Aortic Bioprosthesis.

METHODS

Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4+/-10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE).

RESULTS

The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n=4; mild, n=1). There was one paravalvular leak (trivial, n=1). At follow-up examination (mean 37+/-12 months), 24 of 25 patients exhibited low mean gradients (7.25+/-2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8-0.9 cm(2).

CONCLUSIONS

Intraoperative TEE was effective in assessing prosthetic stentless valve function.

Refinements in stress echocardiographic techniques improve inter-institutional agreement in interpretation of dobutamine stress echocardiograms

AIMS

To determine the degree of inter-institutional agreement in the assessment of dobutamine stress echocardiograms using modern stress echocardiographic technology in combination with standardized data acquisition and assessment criteria.

METHOD AND RESULTS

Among six experienced institutions, 150 dobutamine stress echocardiograms (dobutamine up to 40 microg x kg(-1) min(-1) and atropine up to 1 mg) were performed on patients with suspected coronary artery disease using fundamental and harmonic imaging following a consistent digital acquisition protocol. Each dobutamine stress echocardiogram was assessed at every institution regarding endocardial visibility and left ventricular wall motion without knowledge of any other data using standardized reading criteria. No patients were excluded due to poor image quality or inadequate stress level. Coronary angiography was performed within 4 weeks. Coronary angiography demonstrated significant coronary artery disease (> or = 50% diameter stenosis) in 87 patients. Using harmonic imaging an average of 5.2+/-0.9 institutions agreed on dobutamine stress echocardiogram results as being normal or abnormal (mean kappa 0.55; 95% CI 0.50-0.60). Agreement was higher in patients with no (equal assessment of dobutamine stress echocardiogram results by 5.5+/-0.8 institutions) or three-vessel coronary artery disease (5.4+/- 0.8 institutions) and lower in one- or two- vessel disease (5.0+/-0.9 and 5.2+/-1.0 institutions, respectively; P=0.041). Disagreement on test results was greater in only minor wall motion abnormalities. Agreement on dobutamine stress echocardiogram results was lower using fundamental imaging (mean kappa 0.49; 95% CI 0.44-0.54; P<0.01 vs harmonic imaging).

CONCLUSION

Modern echocardiographic technology in combination with standardized digital image processing and uniform reading criteria results in a higher inter-institutional agreement in the interpretation of dobutamine stress echocardiogram compared to historic reports.

Coagulation indicators in chronic stable effort angina and unstable angina: relationship with acute phase reactants and clinical outcome

The aim of the study was to evaluate which pattern of coagulation indicators characterizes unstable angina and, particularly, its relationship with short-term prognosis. Forty patients with unstable angina (UA Group) at admission in the intensive care unit, 40 patients with chronic stable effort angina (SEA Group), and 20 age- and sex-matched healthy controls were studied. Blood coagulation indicators were fibrinogen, prothrombin fragment F1 + 2 (F1 + 2), thrombus precursor protein (TpP), and D-dimer. C reactive protein (CRP) and cardiac Troponin I (cTnI) have also been determined and compared. Patients in the UA Group were followed for in-hospital adverse events (sudden death, acute myocardial infarction and angina refractory to medical therapy). CRP, D-dimer and cTnI plasma levels were significantly lower in the SEA Group than in the UA Group; the same trend was found for fibrinogen and F1 + 2 plasma levels, although not statistically significant. The TpP was similar in all groups. The control group showed the lowest levels for all indicators. Within the UA Group, 17 patients developed adverse events during hospitalization; F1 + 2, D-dimer, cTnI and CRP plasma levels were higher in these patients than in those with good outcome. Relative risks for adverse events associated with the highest tertile of D-dimer, cTnI, and CRP plasma levels were 8.4 (95% confidence interval, 1.5-48.9), 6.7 (95% confidence interval, 1.1-38.6) and 5.2 (95% confidence interval, 1.1-25.2), respectively. D-Dimer is significantly increased in patients with unstable angina and, in particular, in those who develop an adverse event.

Noninvasive risk stratification in women with uncomplicated acute myocardial infarction

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

Safety of pacemaker implantation prior to radiofrequency ablation of atrioventricular junction in a single session procedure

RF current delivery may cause acute and chronic dysfunction of previously implanted pacemakers. The aim of this study was to assess prospectively the effects of RF energy on Thera I and Kappa pacemakers in 70 consecutive patients (mean age 70 +/- 11 years, mean left ventricular ejection fraction 48 +/- 15%) who underwent RF ablation of the AV junction for antiarrhythmic drug refractory atrial fibrillation (permanent in 42 patients, paroxysmal in 28). These pacing systems incorporate protection elements to avoid electromagnetic interference. The pacemakers (Thera DR 7960 I in 20 patients, Thera SR 8960 I in 30, Kappa DR 600-601 in 8, Kappa SR 700-701 in 12) were implanted prior to RF ablation in a single session procedure and were transiently programmed to VVI mode at a rate of 30 beats/min. Capsure SP and Z unibipolar leads were used. During RF application there was continuous monitoring of three ECG leads, endocavitary electrograms, and event markers. Complete AV block was achieved in all cases after 3.6 +/- 2.9 RF pulses and 100 +/- 75 seconds of RF energy delivery. The mean time of pacemaker implantation and RF ablation was 60 +/- 20 minutes. Transient or permanent pacemaker dysfunction including under/oversensing, reversion to a "noise-mode" pacing, pacing inhibition, reprogramming, or recycling were not observed. Leads impedance, sensing, and pacing thresholds remained in the normal range in the acute and long-term phase (average follow-up 18 +/- 12 months). In conclusion, Thera I and Kappa pacemakers exhibit excellent protection against interference produced by RF current. The functional integrity of the pacemakers and Capsure leads was observed in the acute and chronic phases. Thus, the implantation of these pacing systems prior to RF ablation of the AV junction can be recommended.

Stress echocardiography and exercise electrocardiography for risk stratification after non-Q-wave uncomplicated myocardial infarction

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 68 consecutive patients. Our data show that stress echocardiography and exercise electrocardiography offer similar prognostic information after uncomplicated non-Q-wave AMI.

Radiofrequency ablation of atrioventricular junction and pacemaker implantation versus modulation of atrioventricular conduction in drug refractory atrial fibrillation

Modulation of atrioventricular (AV) node conduction and radiofrequency ablation of AV junction are alternative approaches to control ventricular rate in drug refractory atrial fibrillation (AF). In 2 centers, 120 patients were treated either with AV junction ablation (center 1, group 1, 60 patients [30 men, aged 64 +/- 11 years], paroxysmal AF in 24 patients) or with modulation (group 2, 60 patients [32 men, aged 58 +/- 12 years], paroxysmal AF in 43 patients). In group 1, complete AV block was achieved in all patients. In group 2, the procedure was performed in sinus rhythm (30 patients), prolonging the Wenckebach cycle length from 328 +/- 85 to 466 +/- 80 ms (p <0.01) or during AF (30 patients), decreasing ventricular rate from 178 +/- 35 to 96 +/- 35 beats/min (p <0.01), and to <100 beats/min in 17 patients (61%). Complete AV block was induced in 9 of 60 patients (15%). In groups 1 and 2, at a follow-up of 27 +/- 7 and 26 +/- 6 months, there were 2 deaths (1 cardiac, 1 sudden death) and 1 death for end-stage heart failure, respectively. Hospital readmissions decreased from 3.2 to 0.2 and from 4.2 to 0.2/year; late AF recurrences at of >120 beats/min were documented in 6% and 12%, respectively. Symptom score analysis including effort and rest dyspnea, exercise intolerance, weakness, and palpitation showed a significant improvement in both treatment groups, when acutely effective, in patients with paroxysmal and/or chronic AF. In conclusion, ablation of the AV junction shows a higher acute success rate compared with modulation of the AV node conduction in patients with drug refractory AF. Depending on the acute success, both approaches therefore were similarly effective in achieving long-term ventricular rate control and symptom score improvement.

Standardized guidelines for the interpretation of dobutamine echocardiography reduce interinstitutional variance in interpretation

Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 microg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p=0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p <0.0001), and a low peak rate-pressure product (OR 0.93, 95% CI 0.43 to 2.27, p=0.0382) to result in a low interinstitutional agreement. Standardization of image display in cine loop format and of dobutamine stress echo interpretation criteria resulted in improvement in test result categorization as normal or abnormal, with a kappa value of 0.50, compared with 0.39 using the original subjective interpretation. In conclusion, image quality, the severity of induced wall motion abnormalities, and the obtained rate-pressure product have a significant impact on the interpretation homogeneity of dobutamine echocardiograms. Standardization of image display in cine loop format and of reading criteria results in improved interinstitutional agreement in interpretation of stress echocardiograms.

Hospital Reengineering Project at the "Policlinico A. Gemelli"

The "Policlinico A. Gemelli" in the context of ongoing change in the Italian Health Care Service, has developed a Strategic Plan for 1996-2000. In this context a major role is played by the reengineering project, divided into there sequential phases of implementation. The natural evolution of this project results in a department-oriented organization in order to complete and implement change.

Analysis of interinstitutional observer agreement in interpretation of dobutamine stress echocardiograms

OBJECTIVES

This study sought to determine the degree of interinstitutional agreement in the interpretation of dobutamine stress echocardiograms.

BACKGROUND

Dobutamine stress echocardiography involves subjective interpretation. Consistent methods for acquisition and interpretation are of critical importance for obtaining high interobserver agreement and for facilitating communication of test results.

METHODS

Five experienced centers were each asked to submit 30 dobutamine stress echocardiograms (dobutamine up to 40 micrograms/kg body weight per min and atropine up to 1 mg) obtained in patients undergoing coronary angiography. Thus, a total of 150 dobutamine stress echocardiograms were interpreted by each center without knowledge of any other patient data. Left ventricular wall motion was assessed using a 16-segment model but was otherwise not standardized. No patient was excluded because of poor image quality or inadequate stress level. Echocardiographic image quality was assessed using a five-point scale.

RESULTS

Angiographically significant coronary artery disease (> or = 50% diameter stenosis) was present in 95 patients (63%). By a majority decision (three or more centers), the sensitivity, specificity and accuracy of dobutamine echocardiography were 76%, 87% and 80%, respectively. Abnormal or normal results of stress echocardiography were agreed on by four or all five of the centers in 73% of patients (mean kappa value 0.37, fair agreement only). Agreement on the left anterior descending artery territory (78%) was similar to that for the combined right coronary artery/left circumflex artery territory (74%), and for specific segments the agreement ranged from 84% to 97% and was highest for the basal anterior segment and lowest for the basal inferior segment. Agreement was higher in patients with no (82%) or three-vessel coronary artery disease (100%) and lower in patients with one- or two-vessel disease (61% and 68%, respectively). Agreement on positivity or negativity of stress test results was 100% for patients with the highest image quality but only 43% for those with the lowest image quality (p = 0.003).

CONCLUSIONS

The current heterogeneity in data acquisition and assessment criteria among different centers results in low interinstitutional agreement in interpretation of stress echocardiograms. Agreement is higher in patients with no or advanced coronary artery disease and substantially lower in those with limited echocardiographic image quality. To increase interinstitutional agreement, better standardization of image acquisition and reading criteria of stress echocardiography is recommended.

A new locus for arrhythmogenic right ventricular dysplasia on the long arm of chromosome 14

Familial arrhythmogenic right ventricular cardiomyopathy or dysplasia (ARVD) is an idiopathic heart muscle disease with an autosomal-dominant pattern of transmission, characterized by fibro-fatty replacement of the right ventricular myocardium and ventricular arrhythmias. Recently, linkage to the chromosome 14q23-q24 (locus D14S42) has been reported in two families. In the present study, three unrelated families with ARVD were investigated. According to strict diagnostic criteria, 13 of 37 members were considered to be affected. Linkage to the D14S42 locus was excluded. On the other hand, linkage was found in the region 14q12-q22 in all three families (cumulative two-point lod score is 3.26 for D14S252), with no recombination between the detected locus and the disease gene. With multipoint linkage analysis, a maximal cumulative lod score of 4.7 was obtained in the region between loci D14S252 and D14S257. These data indicate that a novel gene causing familial ARVD (provisionally named ARVD2) maps to the long arm of chromosome 14, thus supporting the hypothesis of genetic heterogeneity in this disease.

Safety and efficacy of computerized closed-loop delivery of arbutamine: a new pharmacologic myocardial stress modality for the assessment of coronary artery disease. The European Arbutamine Study Group

This study evaluated the efficacy of computer-controlled closed-loop delivery of a new synthetic catecholamine, arbutamine, when given to induce myocardial ischemia detected by electrocardiography and echocardiography with a high (10 beats/min/min) and low (6 beats/min/min) rate of increase in heart rate (heart rate slope) in 70 patients with coronary artery disease. The electrocardiographic sensitivity for the detection of myocardial ischemia was 52% for the low slope and 51% for the high slope. The corresponding figures for echocardiographic sensitivity were 83% and 79% for the low and high slopes, respectively. There were no significant differences in changes from baseline to maximum in pharmacodynamic variables, although the mean times to reach maximum heart rate and systolic blood pressure were 1.4 minutes shorter (p = 0.001) and 3.7 minutes shorter (p < 0.05), respectively, for the high-slope regimen. The duration of the infusion was shorter (p < 0.001) for the high slope. In this study, closed-loop arbutamine administration was effective and safe in the detection of coronary artery disease for both heart rate slope regimens.

The relationship between maternal relaxation and plasma beta-endorphin levels during parturition

beta-endorphin (beta-EP) levels increase in maternal plasma starting from the 10th to the 12th week of pregnancy and reach a peak during labor and at delivery. Respiratory autogenous training (RAT) has been acclaimed as one of the most effective non-pharmacological methods of obtaining hypoalgesia and relaxing perineal muscles during labor. In order to study the effects of the RAT method in both maternal and fetal beta-EP levels during labor, 28 pregnant women were enrolled in this study. Fourteen attended a RAT program, while the others (control group) did not. beta-EP levels in both groups were measured in maternal plasma at early and late labor, at delivery and on the 4th day of the puerperium and in umbilical cord blood at birth. From late labor on, beta-EP maternal plasma levels increased significantly less in the RAT group than in the control group. The gap in the beta-EP levels between both groups was still significant at puerperium and in umbilical cord blood. In conclusion, the RAT method favorably modulates the secretion of beta-EP during labor and at delivery. This result supports the effectiveness of the RAT method in reducing both maternal and fetal stress during labor.

The couvade syndrome

The couvade syndrome can be considered to be the psychosomatic equivalent of primitive rituals of initiation into paternity. Various symptoms have been described in the husbands of pregnant women with an incidence from 11% to 65%. The most common of these are: variations in appetite, nausea, insomnia and weight gain. Seventy-three couples with the women in the last month of pregnancy were given a questionnaire; as a reference group, 73 men without pregnant wives or children under 1 year of age were taken. An emotional involvement connected with pregnancy was reported in 91.78% of the men. This involvement was expressed as changes in sexual habits in 87.67% of cases, fear and anxiety in 36.98% and curiosity in 47.94%. With the exception of nausea, physical symptoms were less frequent in the men with pregnant wives than in those without pregnant wives. These data cannot confirm the existence of the couvade syndrome with its own physical symptoms but we think that some male experiences, which constitute a peculiar imaginary and behavioral reality of the father-to-be, do exist.

Hormone replacement therapy in perimenopausal women with a low dose oral contraceptive preparation: effects on bone mineral density and metabolism

In a 2-year longitudinal, calcium-controlled study we evaluated bone density and metabolism in perimenopausal women with initial ovarian failure, and the effects of hormone replacement with a low dose oral contraceptive preparation (OC). In perimenopausal oligomenorrhoic women (n = 16) a significant (P < 0.01) increase in cycle length and plasma FSH levels as well as a parallel decrease in plasma estradiol levels (P < 0.01) were evident. In this group, despite the calcium supplementation (500 mg/day), a significant (P < 0.001) increase in the biochemical markers of bone remodelling paralleled a significant (P < 0.001) decrease (-3.4% after 24 months) in bone density. Conversely, in premenopausal oligomenorrhoic women treated with a low dose oral contraceptive (OC) formulation (30 mcg ethinyl estradiol plus 75 mcg gestodene, n = 16), bone markers showed a significant (P < 0.01) decrease, that paralleled a slight but significant (P < 0.01) increase (+1.71%) in bone density. These data suggest that premenopausal administration of OC can prevent the acceleration of bone turnover and reverse the decrease in bone density that follows the premenopausal impairment of ovarian function.

Haemostasis profile in smoking and nonsmoking women taking low-dose oral contraceptives

The effects of oral contraceptives on coagulation in 258 nonsmoking and in 190 smoking women were determined. In smokers and in nonsmokers taking oral contraceptives, fibrinogen and fibrinopeptide A concentrations were higher than in oral contraceptive nonusers. In nonsmokers, oral contraceptives increased antithrombin III activity. The effects on coagulation of oral contraceptives with a different ethinylestradiol content (from 35 mcg to 20 mcg) were then evaluated in 333 of these women. The biggest changes in coagulation were observed in smokers taking the preparation with the highest estrogen content. Reduction of the ethinylestradiol dose caused a decrease of the changes in coagulation induced by oral contraceptives both in smokers and nonsmokers. These results might suggest that during oral contraception the coagulation system is affected mainly in smokers and that the decrease of the estrogen dose might lower the effects of the association of smoking and oral contraception on coagulation.

Quantitative coronary angiography in the estimation of the functional significance of coronary stenosis: correlations with dobutamine-atropine stress test

OBJECTIVES

The purpose of this study was to determine the predictive value of quantitative coronary angiography in the assessment of the functional significance of coronary stenosis as judged from the development of left ventricular wall motion abnormalities during dobutamine-atropine stress echocardiography.

BACKGROUND

Coronary angiography is the reference method for assessment of the accuracy of noninvasive diagnostic imaging techniques to detect the presence of significant coronary stenosis. However, use of arbitrary cutoff criteria for the interpretation of angiographic data may considerably influence the true diagnostic accuracy of the technique investigated.

METHODS

Thirty-four patients without previous myocardial infarction and with single-vessel coronary stenosis were studied with both quantitative angiography and dobutamine-atropine stress echocardiography. Two different techniques of quantitative angiographic analysis--edge detection and videodensitometry--were used for measurement of minimal lumen diameter, percent diameter stenosis and percent area stenosis. Two-dimensional echocardiographic images were collected during incremental doses of intravenous dobutamine and later analyzed using a 16-segment left ventricular model. Angiographic cutoff criteria were derived from receiver-operating curves to define the functional significance of coronary stenosis on the basis of dobutamine-atropine stress echocardiography.

RESULTS

The angiographic cutoff values with the best predictive value for the development of left ventricular wall motion abnormalities during dobutamine-atropine stress echocardiography were minimal lumen diameter of 1.07 mm, percent diameter stenosis of 52% and percent area stenosis of 75%. Minimal lumen diameter was found to have the best predictive value for a positive dobutamine stress test (odds ratio 51, sensitivity 94%, specificity 75%).

CONCLUSIONS

Automated quantitative angiographic measurement of minimal lumen diameter is a practical and useful index for determining both the anatomic and functional significance of coronary stenosis, and a value of 1.07 mm is the best predictor for a positive dobutamine stress test.

Times and sites of relapses after negative second look in advanced epithelial ovarian cancer

In the present work the Authors analyse the role and significance of second-look laparotomy in the management of epithelial ovarian cancer. Eighty-three patients with advanced epithelial ovarian cancer (stage III-IV) followed at the Institutes of Gynecology of Padua and Pisa Universities underwent a negative second-look at a median time of 6 months after first surgery. The incidence of relapse after the negative second-look was 45.8% and the mean time of relapse was 27.4 months. Advanced surgical-pathological stage, the presence of residual disease > 2 cm and serous histotype are risk factors for relapse after a negative second-look. These data confirm that, because of its poor prognostic value, a negative second-look laparotomy should not influence the choice of second line chemotherapy and, consequently is no longer routinely performed in our Institutes.

Elevated serum levels of neopterin and soluble interleukin-2 receptor in patients with ovarian cancer

Preoperative serum neopterin, soluble interleukin-2 receptor (sIL-2R), and CA125 levels were assayed in 47 patients with ovarian cancer and 113 patients with benign ovarian disease undergoing laparotomy. The cutoff limits of the antigens for the preoperative evaluation of ovarian cancer were fixed according to the Youden plot, using the patients with benign ovarian disease as controls. These limits were 7.9 nmole/liter for neopterin, 71 U/ml for sIL-2R, and 83 U/ml for CA125. The preoperative mean values of serum neopterin and sIL-2R were significantly higher in patients with ovarian cancer than in those with benign ovarian disease. Therefore these tests would seem to be useful in distinguishing benign from malignant ovarian masses. Serum levels of neopterin, sIL-2R, and CA125 above the cutoff limits were detected in 66.0, 78.7, and 76.6% of patients with ovarian cancer. Patients with advanced-stage disease (FIGO > or = III) were significantly more likely to have a higher percentage of elevated values of sIL-2R and CA125, but not neopterin, compared to patients with early-stage disease. However, neopterin was the antigen most often raised in early disease. As for advanced ovarian cancer, preoperative serum sIL-2R levels were higher in patients who developed progressive disease than in those who were progression-free (P = 0.02) after a median follow-up time of 18 months. Furthermore, a trend to higher preoperative serum neopterin values was found in the former patients (P = 0.08). Tumor progression occurred in 3 of 8 (37.5%) patients with low serum preoperative neopterin (< 7.9 nmole/liter) and in 16 of 19 (84.2%) patients with elevated serum neopterin, respectively (P = 0.027). Multivariate analysis on a larger number of patients followed for a longer time is warranted to elucidate the prognostic relevance of these immunologic markers in ovarian cancer. Changes in serum neopterin, sIL-2R, and CA125 levels correlated with the disease course in 50.0, 54.8, and 92.9% of 42 instances, respectively. Moreover, serum CA125 was more sensitive than the other two antigens in the early detection of tumor progression. Therefore serial neopterin and sIL-2R measurements seem to be of limited value in monitoring the disease course in patients with ovarian cancer.

Bone loss in perimenopausal women: a longitudinal study

A longitudinal evaluation of bone mineral density (BMD) and metabolism was performed in premenopausal women. During the 2-year observation period, the menstrual pattern, plasma estradiol and FSH levels as well as the values of bone markers and BMD did not show any significant modification in a group of eumenorrhoic women (n = 37). Conversely, in age-matched oligomenorrhoic women (n = 37) a significant (P < 0.05) increase in the cycle length with a concomitant significant (P < 0.05) increase in circulating plasma FSH and parallel decrease of plasma estradiol levels (P < 0.05) was evident. In this group a significant (P < 0.05) increase in both urinary excretion of OH-P/Cr and plasma BGP levels paralleled a significant (P < 0.05) decrease in radial BMD. These data suggest that premenopausal impairment of ovarian function can lead to a bone loss in a significant proportion of women in which prevention should be considered before menopause.

Longitudinal evaluation of perimenopausal vertebral bone loss: effects of a low-dose oral contraceptive preparation on bone mineral density and metabolism

OBJECTIVE

To characterize the pattern of biochemical markers of bone metabolism and vertebral bone mineral density in eumenorrheic and oligomenorrheic perimenopausal women and to assess the effects of a combined oral contraceptive (OC) preparation on bone mass and metabolism.

METHODS

Bone biochemical markers and vertebral bone density were evaluated in a longitudinal 2-year follow-up study conducted in healthy, normally menstruating perimenopausal women, perimenopausal oligomenorrheic women, and age-matched oligomenorrheic OC-treated women (20 micrograms ethinyl estradiol [E2] plus 0.15 mg desogestrel) (n = 27 in each group). The results were analyzed by factorial or repeated-measures analysis of variance, as appropriate.

RESULTS

During our observation period, there were no significant modifications in menstrual cycle, plasma FSH and E2 levels, biochemical markers of bone turnover, and vertebral bone density in normal women. Conversely, oligomenorrheic women showed an increase in the cycle length with a concomitant decrease of plasma E2 and a corresponding rise in circulating plasma FSH levels (P < .05). In this group, an increase in both urinary excretion of hydroxyproline and plasma osteocalcin levels paralleled a significant decrease in vertebral bone density (P < .0001). In OC-treated women, the pattern of osteocalcin showed no modification, whereas urinary excretion of hydroxyproline showed a decrease, which paralleled a significant (P < .001) increase in vertebral bone density.

CONCLUSION

Perimenopausal OC administration can prevent the increase in bone turnover and the decrease in bone density that follow the perimenopausal impairment of ovarian function.

Clinical comparison of two low-dose oral contraceptives, Minulet and Mercilon, in women over 30 years of age

A comparative study of two low-dose oral contraceptives, gestodene (GES) 75 mcg/ethinyl oestradiol (EE) 30 mcg and desogestrel (DES) 150 mcg/EE 20 mcg, was conducted in women over 30 years of age. This randomised, open-label study was organised in Denmark, Italy, New Zealand and United Kingdom. A total of 505 women received GES/EE and 501 received DES/EE for 6 consecutive menstrual cycles. The two groups were comparable in terms of demographic and gynaecologic characteristics at baseline. However, the menstrual flow length was slightly longer in the GES/EE group before the start of the treatment. The mean age (+/- SD) was 35 +/- 4 years in the GES/EE group and 35 +/- 5 years in the DES/EE group. The subjects in the GES/EE group contributed data for a total of 2800 cycles and those in the DES/EE group, data for 2796 cycles. There were no pregnancies on medication with either preparation. The results showed that there were significantly more normal cycles in the GES/EE group for cycles 1 to 6. Irregular bleeding between withdrawal bleeds occurred in 10% of GES/EE and 18.5% of DES/EE cycles. Absence of all bleeding was reported in 29 (1%) and 63 (2%) cycles, respectively. The incidence of missed pills was low in both groups (11% of cycles). No significant differences were observed in cycle length or withdrawal bleeding episode length. Withdrawal bleeding mean intensity was statistically significantly greater with GES/EE. However, for both preparations, the mean intensity was close to light bleeding. No clinically significant differences were noted in weight, blood pressure, Papanicolaou smears or laboratory data. Sixty-eight (13.5%) subjects in the GES/EE group and 64 (12.8%) in the DES/EE group discontinued before the end of the study. Among them, 37 (7%) and 40 (8%) in the respective groups withdrew because of adverse reactions. There was no difference between groups in terms of primary reasons for withdrawal. The most frequently reported complaints that led to discontinuation in both groups were headache, nausea and metrorrhagia. Breast tenderness led to the discontinuation of 1 subject in the GES/EE group and 3 in the DES/EE group. These results show excellent cycle control, efficacy and very low rate of side effects with both GES/EE and DES/EE. These low-dose oral contraceptives could be well suited to healthy nonsmoking women requiring contraception up to the age of menopause.

Noninvasive assessment of reperfusion and reocclusion after thrombolysis in acute myocardial infarction

The clinical significance of ST-segment changes and of the time course of appearance in serum of different cardiac proteins has been reviewed for the diagnosis of coronary reperfusion and reocclusion after thrombolysis. In particular, the value of serial 12-lead electrocardiographic (ECG) studies, of Holter monitoring, and of continuous multilead computer-assisted ECG monitoring is compared. Regarding the serum proteins, the clinical significance of reperfusion indices described so far for serum creatine kinase (CK), its isoenzyme serum creatinine kinase MB, the CK isoforms, and myoglobin is reviewed. Emphasis is placed on (1) the calculation method used for deriving the reperfusion indices; (2) the sensitivity and the specificity of the reperfusion indices; (3) the minimum turn-around time needed to produce the reperfusion indices (depending on the practicability of the analytical and calculation methods and their applicability in an emergency laboratory); (4) the ability of the indices to produce reliable estimates of reperfusion efficacy of the thrombolytic agents under study; and (5) the ability of the marker proteins to detect reinfarction as well as the suitability of the markers to detect real-time necrosis.

The relative contributions of menopause and aging to postmenopausal vertebral osteopenia

Lumbar spine bone mineral density (BMD) was measured by dual energy x-ray absorptiometry in 2190 normal postmenopausal women (PMW). BMD was loosely correlated (r = 0.15) with height, but stronger positive relations were found with body mass index (BMI; r = 0.25) and body weight (r = 0.31). BMD decreased with age (r = 0.25), but the relation with years since menopause (YSM) was the most potent (r = 0.36). BMD shows a rapid and highly significant (P < 0.0001) decrease in the first 5 YSM, when no relation between BMD and age is present. As the menopausal bone loss is not linear, the BMD values were regressed on the logarithmic transformation of YSM, and the equation was y = -0.183 logYSM + 1.149 (r = 0.44; P < 0.0001). When lumbar BMD was simultaneously regressed on different variables, the correlation with BMI and logYSM remained highly significant, whereas the correlation with age was not significant. The age-related component accounts for a linear 0.4% decrease/yr, starting at the age of 55 yr. In 139 pairs of PMW up to and over 60 yr of age (58 +/- 1.9 and 62.5 +/- 1.5 yr, respectively), matched for YSM (10.3 +/- 2.3), no significant differences in height, weight, or BMI were found. The BMD was significantly (P < 0.001) lower in the younger (0.945 +/- 0.13 g/cm2) than in older PMW (1.006 +/- 0.18 g/cm2) despite their identical YSM. In conclusion, the menopausal (hormonal) component of bone loss and a younger at the menopause represent the major factors in determining involutional vertebral osteopenia in women.

Clinical and endocrine effects of flutamide in hyperandrogenic women

OBJECTIVE

To investigate the clinical and endocrine effects of the antiandrogen flutamide in hirsute women.

DESIGN

Hirsutism was assessed before and after 3 months of treatment with flutamide 500 mg/d. Endocrine evaluations were performed before and during the 2nd month of treatment with flutamide 500 mg or 750 mg/d.

SETTING

Department of Obstetrics and Gynecology, Pisa, Italy.

PARTICIPANTS

Eighteen hirsute women were studied: nine women were hyperandrogenic, and the other 9 had an idiopathic hirsutism.

INTERVENTIONS

Women were randomly treated with flutamide 500 mg/d (9 patients) or 750 mg/d (9 patients) for 3 and 2 months, respectively. Six received placebo 1 month before flutamide treatment.

MAIN OUTCOME MEASURES

Hirsutism was assessed by measuring hair diameter. Follicle-stimulating hormone and LH responses to GnRH were evaluated. Basal plasma levels of T, androstenedione (A), 17-hydroxyprogesterone (17-OHP), DHEAS, cortisol (F), and sex hormone-binding globulin (SHBG) were evaluated. The same hormones were determined after a single dose of flutamide (250 or 500 mg) or placebo throughout a 12-hour period and in samples collected 60 and 120 minutes after ACTH intravenous injection.

RESULTS

Hair diameter was reduced by 30%. Both dosages of flutamide did not change basal and stimulated gonadotropin, T, A, 17-OHP, F, and SHBG levels. Both dosages reduced stimulated DHEAS levels.

CONCLUSIONS

Flutamide may have a beneficial effect on hirsutism. This effectiveness is mainly due to its peripheral antiandrogen action. However, an effect on the adrenal gland seems to be present.

[The treatment of myocardial infarction during the hospital stage and shortly thereafter: now and 10 years ago]

OBJECTIVE

Comparison between the early and the late eighties of the application of thrombolysis and revascularisation in the acute phase of a myocardial infarction.

LOCATION

University Hospital, Rotterdam.

DESIGN

Prospective with historical comparison.

METHODS

All patients admitted between May 1987 and May 1990 with a myocardial infarction and aged up to 71 years were included (n = 430). Numbers of procedures and survival during the following year were compared with data of patients admitted from 1981 to the end of 1983 (n = 706).

RESULTS

In 1981-1983 thrombolytics were administered to 9% of the patients, in 1987-1990 to 40%. Revascularisation procedures during the next year were performed in 17% and 50% of the patients respectively. Hospital mortality decreased from 14% to 10% (p < 0.05), one-year survival increased from 75% to 83% (p < 0.05). For patients from 1987-1990 one-year survival was higher after thrombolysis treatment: 90% versus 78% without (p < 0.01), and after revascularisation: 94% versus 87% without (p < 0.01).

CONCLUSION

Compared with 1981-1983 the treatment is at present more directed towards reperfusion and revascularisation of the ischaemic myocardium, resulting in invasive treatment in 50% of the patients now as opposed to 25% in the early eighties. The survival rate during the first year has improved.

The efficacy and tolerability of long-term cabergoline therapy in hyperprolactinaemic disorders: an open, uncontrolled, multicentre study. European Multicentre Cabergoline Study Group

OBJECTIVE

We assessed the efficacy and safety of the new, long-acting dopamine agonist drug cabergoline during long-term therapy of hyperprolactinaemia.

DESIGN

Open, prospective, multicentre study.

PATIENTS

One hundred and sixty-two females with either a microprolactinoma (n = 100), idiopathic hyperprolactinaemia (n = 54), empty sella syndrome (n = 7) or residual hyperprolactinaemia after surgery for a macroprolactinoma (n = 1). All had previously been treated with cabergoline or placebo for 4 weeks as part of a dose-finding study.

MEASUREMENTS

Menstrual pattern, adverse symptoms, blood pressure and pulse, serum PRL, blood count, liver and renal function were assessed after one month and subsequently at two-monthly intervals.

RESULTS

Treatment was started at doses of 0.25 mg (n = 3), 0.5 mg (n = 8), 1 mg (n = 150) or 2 mg (n = 1) per week, given either as a single weekly dose (n = 8) or divided into twice-weekly doses (n = 154), and was continued for at least 49 weeks in 123 patients. Final treatment doses ranged from 0.25 mg fortnightly to 2 mg twice weekly: most patients finished the study taking 0.5 mg once (n = 31) or twice (n = 77) weekly. Stable normalization of PRL levels was achieved in 138 subjects (85%), in 129 of whom the effective dose was < 1 mg per week. In the subset of 114 patients completing 49 weeks of therapy and having dose adjustments according to the protocol, the biochemical success rate was 92%. Fifty-nine of the 65 previously amenorrhoeic women (91%) and 44 of the 49 (90%) who were previously oligomenorrhoeic resumed regular menses and/or became pregnant during the study. Adverse events were reported in 64 patients (39.5%). In 84% of cases with adverse events, the symptoms were of mild or moderate severity and most occurred during the first few weeks of therapy; five patients (3%) discontinued treatment because of poor tolerance. The most frequent symptoms were dizziness (13% of patients), headache (13%), nausea (10%) and weakness and/or fatigue (10%). Of 27 patients who had previously been poorly tolerant of other dopamine agonists, 17 (63%) did not experience any side-effects and only one was intolerant of cabergoline. No adverse haematological or biochemical effects were detected except for a slight downward trend in haemoglobin which may have been related to the resumption of regular menses in previously amenorrhoeic or oligomenorrhoeic women. A mild hypotensive effect was observed, mean systolic and diastolic blood pressures falling by 5 and 4 mmHg respectively during treatment.

CONCLUSIONS

The results provide evidence for the long-term effectiveness and safety of cabergoline in the treatment of hyperprolactinaemia. Its ability to normalize PRL and restore gonadal function compares favourably with reported data on reference compounds while its tolerability profile and simple administration schedule offer potential advantages in terms of patient acceptability.

Pretreatment plasma levels of fibrinopeptide-A (FPA), D-dimer (DD), and von Willebrand factor (vWF) in patients with operable cervical cancer: influence of surgical-pathological stage, tumor size, histologic type, and lymph node status

The preoperative plasma levels of fibrinopeptide A (FPA), D-dimer (DD), and von Willebrand Factor (vWF) were measured in 38 patients with cervical cancer undergoing radical hysterectomy with pelvic lymphadenectomy. The surgical-pathological stage of disease was Ib in 17 patients, IIa in 9 patients, and IIb in 12 patients. The tumor size was < or = 4 cm in 20 patients and > 4 cm in 18 patients. The histologic type was squamous cell carcinoma in 32 patients and adenocarcinoma in 6 patients. Positive pelvic lymph nodes were found in 10 patients. When compared to controls, FPA, DD, and vWF levels were significantly raised in patients with surgical-pathological stage IIb disease but not in patients with stage Ib or IIa disease. The values of FPA, DD, and vWF were related to surgical-pathological stage (stage IIb vs stage Ib-IIa: P < 0.005, P < 0.001, and P < 0.001, respectively) and tumor size (> 4 cm vs < or = 4 cm: P < 0.05, P < 0.005, and P < 0.02, respectively), but not to histologic type. vWF values were also related to lymph node status (positive vs negative lymph nodes: P < 0.02). FPA and DD levels were higher in patients with positive lymph nodes than in patients with negative lymph nodes, but the difference did not reach the statistical significance even due to the small number of patients involved. In conclusion, increased fibrin production and degradation seem to occur in patients with stage IIb cervical cancer. The biological meaning of this hemostasis activation deserves further investigation.

Serum soluble interleukin-2 receptor (sIL-2R) assay in cervical and endometrial cancer. Preliminary data

Pretreatment serum levels of soluble interleukin-2 receptor (sIL-2R), CA 125, and SCC were measured in 183 patients with malignant or benign uterine diseases. Serum sIL-2R levels were higher in the 46 patients with cervical cancer (p < 0.05) or in the 35 patients with endometrial cancer (p < 0.05) than in the 102 patients with benign uterine diseases. Raised serum concentrations of sIL-2R (> or = 50 U/mL), CA 125 (> or = 35 U/mL) and SCC (> or = 2 ng/mL) were found in 50.0%, 15.0% and 67.5% of 40 patients with squamous cell carcinoma of the cervix, respectively. Serum sIL-2R values were > or = 50 U/mL in 83.3% of 6 patients with cervical adenocarcinoma. Elevated serum levels of sIL-2R, CA 125 and SCC were detected in 51.4%, 11.3% and 14.3% of 35 patients with endometrial cancer, respectively. The sensitivity of SCC for squamous cell carcinoma of the cervix was better than that of sIL-2R. On the other hand, we observed that sIL-2R was the most sensitive antigen for endometrial cancer; therefore it could represent a new tumor marker for the management of patients with this malignancy.

Effects of ipriflavone administration on bone mass and metabolism in ovariectomized women

The aim of the present study was to assess the effects of ipriflavone administration in the prevention of the rapid bone loss that follows ovariectomy in women. After 10-30 days from bilateral ovariectomy, patients received either the sole calcium supplementation (500 mg/day, n = 16) or ipriflavone (600 mg/day, n = 16) in addition to the same daily calcium supplement for 12 months. In calcium-treated subjects urinary hydroxyproline excretion, serum alkaline phosphatase and plasma bone Gla protein levels showed a substantial (p < 0.01) increase, while radial bone density significantly (p < 0.01) decreased 6 months after surgery. In ipriflavone treated group the patterns of biochemical markers indicated that ipriflavone can restrain the bone remodeling processes and radial bone density showed no significant modification during the 12 month study period. These results demonstrate that ipriflavone administration prevents the rapid bone loss that follows ovariectomy. Thus, ipriflavone can represent an attractive alternative for the prevention of osteoporosis in postmenopausal women who present contraindications to the estrogen replacement therapy.

Lipid-independent therapeutic properties of transdermal 17 B-estradiol on cardiovascular diseases

A low dose of transdermally administered 17 B-estradiol promptly improved a severe, treatment-unresponsive, cardiac arrhythmia initiated after the menopause in a woman with type-II familial hyperlipoproteinemia. The same treatment normalized the hypertension initiated after ovariectomy, in a woman who was only poorly controlled by anti-hypertensive drugs. These two cases are the first clear report of cardiovascular therapeutic properties of transdermal estradiol via mechanisms independent of lipoprotein modifications.

Dose-dependent suppression of serum prolactin by cabergoline in hyperprolactinaemia: a placebo controlled, double blind, multicentre study. European Multicentre Cabergoline Dose-finding Study Group

OBJECTIVE

Dopamine agonists have a well established place in the treatment of hyperprolactinaemic disorders but their use is associated with a high incidence of adverse effects. We have investigated the biochemical efficacy and side-effect profile of a range of doses of the novel, long-acting dopamine agonist, cabergoline, in suppressing prolactin (PRL) in hyperprolactinaemic women.

DESIGN

Multicentre, prospective, randomized, placebo controlled and double blind.

PATIENTS

One hundred and eighty-eight women with hyperprolactinaemia secondary to microprolactinoma (n = 113), idiopathic disease (n = 67), empty sella syndrome (n = 7) or following failed surgery for a macroprolactinoma (n = 1).

MEASUREMENTS

Weekly assessment of adverse symptoms, blood pressure and pulse, serum PRL, blood count, liver and renal function.

RESULTS

Patients received either placebo (n = 20) or cabergoline 0.125 (n = 43), 0.5 (n = 42), 0.75 (n = 42) or 1.0 mg (n = 41) twice weekly for 4 weeks. The five treatment groups were comparable in age (mean 31.8, range 16-46 years), diagnosis, previous therapy, and pretreatment serum PRL. PRL was suppressed to below half the pretreatment level in 5, 60, 90, 95 and 98% and normalized in 0, 30, 74, 74 and 95% of patients taking placebo or cabergoline 0.125, 0.5, 0.75 or 1.0 mg twice weekly respectively (Armitage's test, chi 2 = 39.3, P < 0.01). Cabergoline therapy (all doses) restored menses in 82% of the amenorrhoeic women not previously treated with dopamine agonists. Adverse events were recorded in 45% of patients in the placebo group and in 44, 50, 50 and 58% of those taking 0.125, 0.5, 0.75 and 1.0 mg cabergoline twice weekly (Armitage's test, P > 0.05). Over 95% of reported symptoms were relatively trivial, most frequently transient nausea, headache, dizziness, fatigue and constipation. More severe adverse events, interfering significantly with the patients' lifestyle, occurred in 13 (7.7%) patients taking cabergoline; treatment withdrawal was necessary in only one case. No adverse effects were detected on blood pressure or haematological or biochemical parameters.

CONCLUSIONS

We have shown a linear dose-response relationship for cabergoline in the treatment of hyperprolactinaemia in the range 0.125-1.0 mg twice weekly, with normalization of PRL in up to 95% of cases and acceptable tolerability throughout the dose range.

Effects of continuous and cyclic nasal calcitonin administration in ovariectomized women

The aim of the present study was to assess the effects of continuous and cyclic salmon calcitonin (sCT) administration in the prevention of the rapid bone loss that follows ovariectomy in humans. Patients who had undergone bilateral ovariectomy 10-30 days previously received either calcium supplementation alone (500 mg/day, n = 12) or such supplementation together with nasal sCT (200 IU/day) according to a continuous (n = 20) or a cyclic (3 months on, 1 month off) regimen (n = 16) for 2 years. In the calcium-only-treated subjects urinary hydroxyproline excretion, serum alkaline phosphatase and plasma bone Gla protein levels showed a substantial increase (P < 0.01) 6 months after surgery, while radial bone density was found to have decreased significantly (P < 0.01). The patterns of biochemical markers in the sCT-treated groups indicated that nasal sCT can positively uncouple the two bone remodelling processes without inducing any significant change in radial bone density over a 2-year period. No differences were observed between the two sCT-treated groups. These results demonstrate that the rapid bone loss that follows ovariectomy can be prevented by either cyclic or continuous nasal sCT administration. Thus, cyclic nasal sCT represents an attractive alternative for the prevention of osteoporosis in postmenopausal women with contraindications to oestrogen replacement therapy.

Lack of any estrogenic effect of ipriflavone in postmenopausal women

Estrogen replacement therapy (ERT) has been demonstrated to prevent osteoporosis in postmenopausal women (PMW). However, several contraindications exist for ERT and many PMW cannot be treated. It has also been shown that too low doses of ERT are able to exert therapeutical effects on some climacteric symptoms but not on bone and compounds exerting synergic actions with ERT on bone without effects on other organs could be useful. The isoflavone derivative, ipriflavone, seems to have this effect but data are lacking on its endocrine effect in humans; thus, this study was undertaken to clarify in PMW whether ipriflavone exerts estrogenic activity. Evaluation of LH and FSH secretion during a 24-h period was performed in a group of 15 PMW after a single oral dose of 600 or 1,000 mg of ipriflavone or placebo, and after 7, 14 and 21 days of oral treatment with ipriflavone 600 mg and 1,000 mg/daily, administered in three divided doses. LH secretion was also evaluated during naloxone infusion before and after 21 days of ipriflavone, placebo or conjugated estrogen treatment (0.625 mg/day; CE). LH response to NAL treatment was absent during ipriflavone and placebo such as it was observed before treatments. By contrast, a significant increase of LH plasma levels was measured during naloxone infusion in CE-treated women. This result demonstrates that ipriflavone is unable to exert the same effects that estrogens do in PMW. In addition, no changes like in placebo group were seen on vaginal cytology in this group of subjects after 21 days, whereas a significant increase of superficial vaginal cells was observed after 21 days of CE treatment.(ABSTRACT TRUNCATED AT 250 WORDS)