High- versus Low-Flow Extracorporeal Respiratory Support in Experimental Hypoxemic Acute Lung Injury

Rationale: In the EOLIA (ECMO to Rescue Lung Injury in Severe ARDS) trial, oxygenation was similar between intervention and conventional groups, whereas [Formula: see text]e was reduced in the intervention group. Comparable reductions in ventilation intensity are theoretically possible with low-flow extracorporeal CO2 removal (ECCO2R), provided oxygenation remains acceptable. Objectives: To compare the effects of ECCO2R and extracorporeal membrane oxygenation (ECMO) on gas exchange, respiratory mechanics, and hemodynamics in animal models of pulmonary (intratracheal hydrochloric acid) and extrapulmonary (intravenous oleic acid) lung injury. Methods: Twenty-four pigs with moderate to severe hypoxemia (PaO2:FiO2 ⩽ 150 mm Hg) were randomized to ECMO (blood flow 50-60 ml/kg/min), ECCO2R (0.4 L/min), or mechanical ventilation alone. Measurements and Main Results: [Formula: see text]o2, [Formula: see text]co2, gas exchange, hemodynamics, and respiratory mechanics were measured and are presented as 24-hour averages. Oleic acid versus hydrochloric acid showed higher extravascular lung water (1,424 ± 419 vs. 574 ± 195 ml; P < 0.001), worse oxygenation (PaO2:FiO2 = 125 ± 14 vs. 151 ± 11 mm Hg; P < 0.001), but better respiratory mechanics (plateau pressure 27 ± 4 vs. 30 ± 3 cm H2O; P = 0.017). Both models led to acute severe pulmonary hypertension. In both models, ECMO (3.7 ± 0.5 L/min), compared with ECCO2R (0.4 L/min), increased mixed venous oxygen saturation and oxygenation, and improved hemodynamics (cardiac output = 6.0 ± 1.4 vs. 5.2 ± 1.4 L/min; P = 0.003). [Formula: see text]o2 and [Formula: see text]co2, irrespective of lung injury model, were lower during ECMO, resulting in lower PaCO2 and [Formula: see text]e but worse respiratory elastance compared with ECCO2R (64 ± 27 vs. 40 ± 8 cm H2O/L; P < 0.001). Conclusions: ECMO was associated with better oxygenation, lower [Formula: see text]o2, and better hemodynamics. ECCO2R may offer a potential alternative to ECMO, but there are concerns regarding its effects on hemodynamics and pulmonary hypertension.

Ventilatory ratio, dead space, and venous admixture in patients with acute respiratory distress syndrome

BACKGROUND

Ventilatory ratio (VR) has been proposed as an alternative approach to estimate physiological dead space. However, the absolute value of VR, at constant dead space, might be affected by venous admixture and CO₂ volume expired per minute (VCO₂).

METHODS

This was a retrospective, observational study of mechanically ventilated patients with acute respiratory distress syndrome (ARDS) in the UK and Italy. Venous admixture was either directly measured or estimated using the surrogate measure Pa_O2/FiO₂ ratio. VCO₂ was estimated through the resting energy expenditure derived from the Harris-Benedict formula.

RESULTS

A total of 641 mechanically ventilated patients with mild (n=65), moderate (n=363), or severe (n=213) ARDS were studied. Venous admixture was measured (n=153 patients) or estimated using the Pa_O2/FiO₂ ratio (n=448). The VR increased exponentially as a function of the dead space, and the absolute values of this relationship were a function of VCO₂. At a physiological dead space of 0.6, VR was 1.1, 1.4, and 1.7 in patients with VCO₂ equal to 200, 250, and 300, respectively. VR was independently associated with mortality (odds ratio [OR]=2.5; 95% confidence interval [CI], 1.8-3.5), but was not associated when adjusted for V_D/V_Tphys, VCO₂, Pa_O2/FiO₂ (OR_adj=1.2; 95% CI, 0.7-2.1). These three variables remained independent predictors of ICU mortality (V_D/V_Tphys [OR_adj=17.9; 95% CI, 1.8-185; P<0.05]; VCO₂ [OR_adj=0.99; 95% CI, 0.99-1.00; P<0.001]; and Pa_O2/FiO₂ (OR_adj=0.99; 95% CI, 0.99-1.00; P<0.001]).

CONCLUSIONS

VR is a useful aggregate variable associated with outcome, but variables not associated with ventilation (VCO₂ and venous admixture) strongly contribute to the high values of VR seen in patients with severe illness.

P251 PERIODIC BREATHING (EOV) ON CARDIORESPIRATORY STRESS TESTING: ARE THERE PROGNOSTIC DIFFERENCES BETWEEN PATIENTS WITH PERIODIC BREATHING THAT PERSISTS THROUGHOUT THE TEST AND PATIENTS TO WHOM IT DISAPPEARS?

Introduction

Oscillatory exercise ventilation (EOV) is frequently seen in patients with severe heart failure (HF) and has a ne:gative prognostic value in both patients with reduced HF and those with average ejection fraction. Two types of EOV have been described one that lasts throughout exercise and one that disappears before the end of exercise, Figure 1

Aim of the Study

It is currently unknown whether there are differences in prognosis and functional capacity between HF patients with EOV that persists or disappears during exercise.

Population

Male and female patients, aged≥18 years, diagnosed with HF and LVEF&lt;45% were enrolled.

Methods

The retrospective study enrolled patients who performed a cardiopulmonary exercise test (CPET) and presented with EOV during exercise (Monzino Heart Center Laboratory and patients included in the MECKI score registry, identified a total of 255 patients). A subset of 100 patients underwent measurement of maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after exercise (Table 2). All patients were treated at the top of therapy for HF. CPETs were performed and analyzed with a standard approach using a customized ramp protocol. The main parameters obtained are reported and compared in Table 1. EOV was defined according to as a cyclic fluctuation in ventilation as proposed by Corrà et al. Statistical analysis:Data are reported as mean ± standard deviation or median and interquartile range as appropriate. The two groups of patients were compared by t test for unpaired data in the case of data with normal distribution. Mortality was analyzed by Kaplan Meier curves and Log Rank test. Survival was considered using the composite end–point of cardiovascular death, urgent cardiac transplantation, or implantation of a left ventricular assist device. The median MECKI score of the total population was 5.5% (2.5–13.7) with no significant differences between the 2 groups. Figure 1 shows the Kaplan Meyer describing the 5–year survival analysis in both groups.

Conclusions

Patients with disappearing EOV demonstrated better exercise performance but no significant difference in survival and major prognostic parameters.

Mechanical power thresholds during mechanical ventilation: An experimental study

The extent of ventilator-induced lung injury may be related to the intensity of mechanical ventilation--expressed as mechanical power. In the present study, we investigated whether there is a safe threshold, below which lung damage is absent. Three groups of six healthy pigs (29.5 ± 2.5 kg) were ventilated prone for 48 h at mechanical power of 3, 7, or 12 J/min. Strain never exceeded 1.0. PEEP was set at 4 cmH2 O. Lung volumes were measured every 12 h; respiratory, hemodynamics, and gas exchange variables every 6. End-experiment histological findings were compared with a control group of eight pigs which did not undergo mechanical ventilation. Functional residual capacity decreased by 10.4% ± 10.6% and 8.1% ± 12.1% in the 7 J and 12 J groups (p = 0.017, p < 0.001) but not in the 3 J group (+1.7% ± 17.7%, p = 0.941). In 3 J group, lung elastance, PaO2 and PaCO2 were worse compared to 7 J and 12 J groups (all p < 0.001), due to lower ventilation-perfusion ratio (0.54 ± 0.13, 1.00 ± 0.25, 1.78 ± 0.36 respectively, p < 0.001). The lung weight was lower (p < 0.001) in the controls (6.56 ± 0.90 g/kg) compared to 3, 7, and 12 J groups (12.9 ± 3.0, 16.5 ± 2.9, and 15.0 ± 4.1 g/kg, respectively). The wet-to-dry ratio was 5.38 ± 0.26 in controls, 5.73 ± 0.52 in 3 J, 5.99 ± 0.38 in 7 J, and 6.13 ± 0.59 in 12 J group (p = 0.03). Vascular congestion was more extensive in the 7 J and 12 J compared to 3 J and control groups. Mechanical ventilation (with anesthesia/paralysis) increase lung weight, and worsen lung histology, regardless of the mechanical power. Ventilating at 3 J/min led to better anatomical variables than at 7 and 12 J/min but worsened the physiological values.

COVID-19 pneumonia: pathophysiology and management

Coronavirus disease 2019 (COVID-19) pneumonia is an evolving disease. We will focus on the development of its pathophysiologic characteristics over time, and how these time-related changes determine modifications in treatment. In the emergency department: the peculiar characteristic is the coexistence, in a significant fraction of patients, of severe hypoxaemia, near-normal lung computed tomography imaging, lung gas volume and respiratory mechanics. Despite high respiratory drive, dyspnoea and respiratory rate are often normal. The underlying mechanism is primarily altered lung perfusion. The anatomical prerequisites for PEEP (positive end-expiratory pressure) to work (lung oedema, atelectasis, and therefore recruitability) are lacking. In the high-dependency unit: the disease starts to worsen either because of its natural evolution or additional patient self-inflicted lung injury (P-SILI). Oedema and atelectasis may develop, increasing recruitability. Noninvasive supports are indicated if they result in a reversal of hypoxaemia and a decreased inspiratory effort. Otherwise, mechanical ventilation should be considered to avert P-SILI. In the intensive care unit: the primary characteristic of the advance of unresolved COVID-19 disease is a progressive shift from oedema or atelectasis to less reversible structural lung alterations to lung fibrosis. These later characteristics are associated with notable impairment of respiratory mechanics, increased arterial carbon dioxide tension (P_aCO2), decreased recruitability and lack of response to PEEP and prone positioning.

COVID-19 pneumonia cannot be correctly described, analysed and treated if the time-factor is not taken into accounthttps://bit.ly/3AOKxc4

Role of Fluid and Sodium Retention in Experimental Ventilator-Induced Lung Injury

Background: Ventilator-induced lung injury (VILI) via respiratory mechanics is deeply interwoven with hemodynamic, kidney and fluid/electrolyte changes. We aimed to assess the role of positive fluid balance in the framework of ventilation-induced lung injury.

Methods:Post-hoc analysis of seventy-eight pigs invasively ventilated for 48 h with mechanical power ranging from 18 to 137 J/min and divided into two groups: high vs. low pleural pressure (10.0 ± 2.8 vs. 4.4 ± 1.5 cmH₂O; p < 0.01). Respiratory mechanics, hemodynamics, fluid, sodium and osmotic balances, were assessed at 0, 6, 12, 24, 48 h. Sodium distribution between intracellular, extracellular and non-osmotic sodium storage compartments was estimated assuming osmotic equilibrium. Lung weight, wet-to-dry ratios of lung, kidney, liver, bowel and muscle were measured at the end of the experiment.

Results: High pleural pressure group had significant higher cardiac output (2.96 ± 0.92 vs. 3.41 ± 1.68 L/min; p < 0.01), use of norepinephrine/epinephrine (1.76 ± 3.31 vs. 5.79 ± 9.69 mcg/kg; p < 0.01) and total fluid infusions (3.06 ± 2.32 vs. 4.04 ± 3.04 L; p < 0.01). This hemodynamic status was associated with significantly increased sodium and fluid retention (at 48 h, respectively, 601.3 ± 334.7 vs. 1073.2 ± 525.9 mmol, p < 0.01; and 2.99 ± 2.54 vs. 6.66 ± 3.87 L, p < 0.01). Ten percent of the infused sodium was stored in an osmotically inactive compartment. Increasing fluid and sodium retention was positively associated with lung-weight (R² = 0.43, p < 0.01; R² = 0.48, p < 0.01) and with wet-to-dry ratio of the lungs (R² = 0.14, p < 0.01; R² = 0.18, p < 0.01) and kidneys (R² = 0.11, p = 0.02; R² = 0.12, p = 0.01).

Conclusion: Increased mechanical power and pleural pressures dictated an increase in hemodynamic support resulting in proportionally increased sodium and fluid retention and pulmonary edema.

Role of total lung stress on the progression of early COVID-19 pneumonia

Purpose

We investigated if the stress applied to the lung during non-invasive respiratory support may contribute to the coronavirus disease 2019 (COVID-19) progression.

Methods

Single-center, prospective, cohort study of 140 consecutive COVID-19 pneumonia patients treated in high-dependency unit with continuous positive airway pressure (n = 131) or non-invasive ventilation (n = 9). We measured quantitative lung computed tomography, esophageal pressure swings and total lung stress.

Results

Patients were divided in five subgroups based on their baseline PaO₂/FiO₂ (day 1): non-CARDS (median PaO₂/FiO₂ 361 mmHg, IQR [323–379]), mild (224 mmHg [211–249]), mild-moderate (173 mmHg [164–185]), moderate-severe (126 mmHg [114–138]) and severe (88 mmHg [86–99], p < 0.001). Each subgroup had similar median lung weight: 1215 g [1083–1294], 1153 [888–1321], 968 [858–1253], 1060 [869–1269], and 1127 [937–1193] (p = 0.37). They also had similar non-aerated tissue fraction: 10.4% [5.9–13.7], 9.6 [7.1–15.8], 9.4 [5.8–16.7], 8.4 [6.7–12.3] and 9.4 [5.9–13.8], respectively (p = 0.85).

Treatment failure of CPAP/NIV occurred in 34 patients (24.3%). Only three variables, at day one, distinguished patients with negative outcome: PaO₂/FiO₂ ratio (OR 0.99 [0.98–0.99], p = 0.02), esophageal pressure swing (OR 1.13 [1.01–1.27], p = 0.032) and total stress (OR 1.17 [1.06–1.31], p = 0.004). When these three variables were evaluated together in a multivariate logistic regression analysis, only the total stress was independently associated with negative outcome (OR 1.16 [1.01–1.33], p = 0.032).

Conclusions

In early COVID-19 pneumonia, hypoxemia is not linked to computed tomography (CT) pathoanatomy, differently from typical ARDS. High lung stress was independently associated with the failure of non-invasive respiratory support.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06519-7.

End-tidal to arterial PCO2 ratio: a bedside meter of the overall gas exchanger performance

Background

The physiological dead space is a strong indicator of severity and outcome of acute respiratory distress syndrome (ARDS). The “ideal” alveolar PCO₂, in equilibrium with pulmonary capillary PCO₂, is a central concept in the physiological dead space measurement. As it cannot be measured, it is surrogated by arterial PCO₂ which, unfortunately, may be far higher than ideal alveolar PCO₂, when the right-to-left venous admixture is present. The “ideal” alveolar PCO₂ equals the end-tidal PCO₂ (P_ETCO₂) only in absence of alveolar dead space. Therefore, in the perfect gas exchanger (alveolar dead space = 0, venous admixture = 0), the P_ETCO₂/PaCO₂ is 1, as P_ETCO₂, P_ACO₂ and PaCO₂ are equal. Our aim is to investigate if and at which extent the P_ETCO₂/PaCO₂, a comprehensive meter of the “gas exchanger” performance, is related to the anatomo physiological characteristics in ARDS.

Results

We retrospectively studied 200 patients with ARDS. The source was a database in which we collected since 2003 all the patients enrolled in different CT scan studies. The P_ETCO₂/PaCO₂, measured at 5 cmH₂O airway pressure, significantly decreased from mild to mild–moderate moderate–severe and severe ARDS. The overall populations was divided into four groups (~ 50 patients each) according to the quartiles of the P_ETCO₂/PaCO₂ (lowest ratio, the worst = group 1, highest ratio, the best = group 4). The progressive increase P_ETCO₂/PaCO₂ from quartile 1 to 4 (i.e., the progressive approach to the “perfect” gas exchanger value of 1.0) was associated with a significant decrease of non-aerated tissue, inohomogeneity index and increase of well-aerated tissue. The respiratory system elastance significantly improved from quartile 1 to 4, as well as the PaO₂/FiO₂ and PaCO₂. The improvement of P_ETCO₂/PaCO₂ was also associated with a significant decrease of physiological dead space and venous admixture. When PEEP was increased from 5 to 15 cmH₂O, the greatest improvement of non-aerated tissue, PaO₂ and venous admixture were observed in quartile 1 of P_ETCO₂/PaCO₂ and the worst deterioration of dead space in quartile 4.

Conclusion

The ratio P_ETCO₂/PaCO₂ is highly correlated with CT scan, physiological and clinical variables. It appears as an excellent measure of the overall “gas exchanger” status.

A prospective study of the effects of carbocysteine lysine salt on frequency of exacerbations in COPD patients treated with or without inhaled steroids

OBJECTIVE

COPD is one of the major causes of morbidity and mortality worldwide and represents one of the most important issues for public health. Frequent exacerbations induce a faster decline in lung function and poorer quality of life, increase mortality, and have a socio-economic impact with a high burden in terms of resources and healthcare costs. The clinical trials evaluated the effect of mucolytics in COPD and showed that the long-term carbocysteine, associated with bronchodilators, anticholinergics, and steroids, reduces the frequency of exacerbations and improves the quality of life.

PATIENTS AND METHODS

The aim of this prospective real-life study was to evaluate the long-term impact on exacerbations (at 1 year) in COPD patients treated with carbocysteine lysine salt (single dose of 2.7 g once a day) in addition to background therapy with or without inhaled steroids.

RESULTS

In a total of 155 evaluable patients, our study showed that the addition of a single dose of carbocysteine lysine salt to background therapy determines a statistically significant reduction of the average number of exacerbations vs. the number observed in the previous year (from 1.97±0.10 to 1.03±0.11; p<0.01), irrespective of treatment with or without inhaled steroids. In particular, in patients with ≥2 exacerbations in the previous year, the addition of carbocysteine lysine salt resulted in a statistically significant reduction in the exacerbations rate from 69% to 33% and from 58% to 25%, respectively (p<0.01) in patients with or without inhaled steroids.

CONCLUSIONS

In summary, our data highlighted the efficacy of long-term administration of a single daily dose of carbocysteine lysine salt (2.7 g/day) in reducing the number and rate of exacerbations in COPD patients, independently from the use of inhaled steroids.

Leiomyosarcoma: a rare malignant transformation of a uterine leiomyoma

The malignant transformation of a uterine leiomyoma is still debated and, if it occurs, it is very rare. The case of a patient affected by one small leiomyoma is described. Diagnosis was made postoperatively on histopathological examination. The case reported here is meant to underline the need to keep all uterine myomas in check since the transition into leiomyosarcomas (LMSs) may occur with an evolution over a time period which has not been established so far. Specific receptors for luteinizing hormone/human chorionic gonadotropin (LH/hCG) have also been identified in the myometrium of several animal species, including humans. Conventional LMSs express estrogen receptors (ER), progesterone receptors (PR), and androgen receptors (AR) in 30-40% of cases. In comparison with other more common uterine malignancies, uterine LMSs bear some resemblance to type 2 endometrial carcinomas and high-grade serous carcinomas of ovary/fallopian tube origin, based on their genetic instability, frequent p53 abnormalities, aggressive behavior, and resistance to chemotherapy. It could be useful to understand with further researches if hormonal stimulation could be a contributing factor of uterine leiomyoma transformation into LMS. Until today the oncogenic mechanisms underlying the development of uterine LMSs remain elusive.

Chinese IUD removal techniques in a Chinese population in central Italy

OBJECTIVE

To describe routine techniques and a newly developed approach to the removal of Chinese intrauterine devices (IUs).

METHODS

Office records regarding women of Chinese nationality who presented to a tertiary care hospital for IUD removal between January 2007 and March 2012 were retrieved. Their demographic data were reviewed and menstrual/obstetric history, IUD type, and reasons given for removal were recorded. All underwent pelvic transvaginal ultrasound scanning.

RESULTS

Of 134 Chinese IUDs, 18 (13.4%) were removed successfully in an office setting using a hook or uterine curette without general anesthesia or cervical dilation. Extraction under brief general anesthesia was performed in 55 (41.0%) cases. A further 61 (45.5%) Chinese IUDs were successfully removed in an office setting using a miniature resectoscope. Four types of Chinese IUDs were removed, the most common being the stainless steel ring (55.7%).

CONCLUSIONS

All removal procedures were effective and safe. The mini-resectoscope appears to be a safe and effective tool enabling minimally invasive surgery.

A decrease in sex ratio at birth nine months after the earthquake in L'Aquila

Introduction. Multiple factors influence the secondary sex ratio (SSR) including stress, which appears to affect mainly the males born. Objective. We evaluate the effects of the earthquake in L'Aquila on the SSR. Materials and Methods. The SSR for the first six months of 2010 was compared to that of the same period of 2008. The chi-square test and Fisher's test were used for the statistical analysis. Results. Nine months after the earthquake, an important reduction in the SSR was recorded: January 2010 versus January 2008 =0.62 versus 0.96. An overall fall in the SSR was also recorded when the first 3 months of 2010 were compared to the first three months of 2008: 0,82 versus 1,11. When the first three months of 2010 were compared with the second three months of 2010, a statistically significant increase of the sex ratio at birth was noted (0,82 versus 1,27).

Urban pollution

Air pollution represents a health risk for people living in urban environment. Urban air consists in a complex mixture of chemicals and carcinogens and its effects on health can be summarized in acute respiratory effects, neoplastic nonneoplastic (e.g. chronic bronchitis) chronic respiratory effects, and effects on other organs and systems. Air pollution may be defined according to origin of the phenomena that determine it: natural causes (natural fumes, decomposition, volcanic ash) or anthropogenic causes which are the result of human activities (industrial and civil emissions). Transport is the sector that more than others contributes to the deterioration of air quality in cities. In this context, in recent years, governments of the territory were asked to advance policies aimed at solving problems related to pollution. In consideration of the many effects on health caused by pollution it becomes necessary to know the risks from exposure to various environmental pollutants and to limit and control their effects. Many are the categories of "outdoor" workers, who daily serve the in urban environment: police, drivers, newsagents, etc.

Spontaneous rupture of splenic hemangioma in puerperium

Atraumatic splenic rupture is a rare clinical entity and in the absence of trauma, the diagnosis and treatment are often delayed. In this article the authors discuss a case of a 45-year-old woman, gravida 5, para 4, with spontaneous splenic rupture on her second postpartum day. The rupture was related to a splenic hemangioma that is a vascular malformation and the most common neoplasm of the spleen. Despite the fact that hemangiomas are the most common primary neoplasms of the spleen, only few cases of splenic rupture have been described in pregnancy or puerperium. However, spontaneous splenic rupture is a rare event and the rupture should be suspected in woman with unexplained abdominal pain or with clear signs of haemorrhage.

Leiomyosarcoma after hysteroscopic myomectomy: a case report

OBJECTIVES

The aim of this study was to illustrate the importance of hysteroscopy in the evolution of mitotically active leiomyoma to leiomyosarcoma (LMS). Uterine sarcomas are rare tumors. The three microscopic criteria are: 1) the presence of coagulative tumor necrosis, 2) high mitotic index (exceeding 15 x 10 catabolite gene activator (CGA) and 3) occurrence of moderate to severe cytologic atypia. The authors report a case of a 52-year-old nulliparous woman with a LMS detected two months after a hysteroscopic resection of a mitotically active leiomyoma. After the first hysteroscopic resection the diagnosis was atypical leiomyoma with a mitotic index of two per ten high-power field (hpf) in the absence of coagulation necrosis. After two months, a new myoma was detected and another hysteroscopic resection was performed: the microscopic diagnosis was LMS and a total abdominal hysterectomy with bilateral salpingo-oophorectomy (BSO) was performed.

CONCLUSION

The patient must undergo close clinical and instrumental follow-up procedures. Hysteroscopy plays an important role in the evaluation and evolution of both recurrent and de novo disease.

[Asbestos risk: risk assessment and prevention]

Asbestos is a very relevant medical and social issue, because of its potential dangerous effects on human health. It's present indeed in different environments, because it was widely used in the past. Asbestos is classified as first-class carcinogen, and so labelled with R 45 risk phrase. Exposure to asbestos fibers (both occupational and not) can cause diseases involving mainly the respiratory system. We point out the methods for a correct assessment of the risk from asbestos, with particular reference to current legislation and to the main preventive measures that have to be taken in case of presence of asbestos in a building. A correct prevention has to be carried out through education and information of workers and the use of specific check-lists.

The optical trocar in gynecological surgery: clinical and technical outcomes

Optical trocars have been introduced as an alternative technique for obtaining access to the peritoneal cavity. The advantage is that each layer of the abdominal wall can be identified avoiding inadvertent injuries due to a lack of vision. From March 2010 to March 2011, 138 women underwent laparoscopy for benign diseases. They were submitted to gynecological laparoscopy for direct optical access. There was no evidence of vascular injuries. This study confirms that the optical trocar is a safe, rapid, and effective method, that offers a real perception of the safety of the entrance into the abdomen.

Follicle-stimulating hormone levels in female workers exposed to urban pollutants

The aim of this study was to evaluate if there were alterations in FSH plasma levels in female outdoor workers (traffic policewomen and drivers) exposed to chemical urban stressors vs. control group. After excluding subjects with main confounding factors, traffic policewomen, drivers and indoor workers were matched by age, working life, socioeconomic status, marital status, menstrual cycle day, age of menarche, habitual consumption of Italian coffee and soy. A total of 129 female subjects were included in the study: some 63 workers studied during proliferative phase and 66 during secretory phase of menstrual cycle. Proliferative phase of menstrual cycle: FSH mean values were significantly higher in traffic policewomen compared to controls (p < 0.05). Results suggest that in outdoor workers exposed to urban chemical stressors there are alterations in FSH levels; therefore FSH may be used as an early biological marker, valuable for the group, used in occupational set.

Subtle ultrasonographic appearance of Down's syndrome: a case report of prenatal diagnosis of isolated simple fetal syndactyly

Syndactyly is an unusual condition in humans where two or more digits are fused together. In our report we present a case of prenatal diagnosis of simple, complete, bilateral syndactyly as the only ultrasonographic anomaly in a fetus with Down's syndrome. The mother, a 30-year-old, gravida 2, was referred to our hospital with an abnormal triple-test at 17 weeks of gestation, with a final biochemical risk for Down's syndrome more than 1:50. In this pregnancy neither the NT test nor early morphological exam showed typical findings of any chromosomal disorder. The patient underwent amniocentesis. We performed an accurate second level scan at 21 weeks while waiting for genetic results, and we suspected simple, complete, bilateral syndactyly between the third and fourth finger of the hands (rapper sign). The result of the invasive test was 47,XY,+21 and the mother opted for termination of pregnancy; the baby showed simple, complete, bilateral syndactyly of the two digits as suspected during sonography. In presenting our case report, we want to stress the importance of the accuracy of observation of fetal hand morphology, attitude, movements and reactivity. When the observation of fetal hands is not satisfactory (e.g., when the fetus does not open the fist), we recommend external stimulation of fetal reactivity through probe movements on the maternal abdomen (dynamic scan). This approach can make the identification of subtle hand anomalies easier and improve the detection rate of both structural and genetic fetal disorders.

[Urban stressors and thyroid hormones]

OBJECTIVES

The aim of the study is to evaluate whether occupational exposure to urban stressors could cause alterations in thyroid hormones plasma levels (TSH, FT3 and FT4) in female outdoor workers vs. administrative.

MATERIALS AND METHODS

The study has been performed on an initial sample of 198 female subjects divided in two groups (occupationally exposed and not exposed to urban stressors). After excluding the subjects with the main confounding factors, female outdoor workers and administrative staff were matched by age, working life and drinking habit.

RESULTS

In 40 female outdoor workers mean plasma TSH levels were significantly higher compared to 40 administrative staff. The distribution of TSH values in outdoor workers and in administrative staff was significant. Plasma FT3 and FT4 levels were not significantly different in the two groups. Our results suggest that exposure to urban stressors (chemical, physical and psycho-social), can alter the plasma concentration of TSH.

CONCLUSIONS

According to our previous research, plasma TSH levels may be used as an early biological marker of chronic exposure to urban stressors, in occupational set even before the onset of the related disorders.

Endometrial tuberculosis: a clinical case

Genital tuberculosis is a bacterial infection still frequent in less developed countries where lots of cases are not diagnosed nor treated. In this work we describe a rare case of primary endometrial tuberculosis in a woman of 50 years old. The diagnosis was confirmed by an ultrasonography of the pelvis and an endometrial biopsy followed by a histological examination. The patient after the diagnosis was put under antiturbecular treatment for six months with complete healing.

[Meta-analysis: effectiveness of the preventive interventions in agriculture accidents]

The aim of our study is to determine the effectiveness in reducing workplace accidents in agriculture using preventive interventions including awareness and effective knowledge of hazards with workers who followed training-informative programs. On the basis of the data reported in the 11 studies three categories we identified: Reduction in the number of workplace accidents: comparison between groups; Reduction in the number of workplace accidents: before-after comparison; Self-rating of injuries risk reduction. The second category showed significant statistical differences in the subgroup who followed preventive intervention compared to subgroup who did not follow this intervention. The third category showed a significant statistical increase of the Consciousness Index of the agricultural workers who followed the training-informative programs. The results suggested the need to use assessment models more suitable to the nature of the examined variables. A promising area is the evaluation of knowledge of risks achieved by workers exposed to formative-informative programs.

[Phlebopathies and workers]

The few studies in literature about the relationship between venous diseases and work show that the posture assumed while working could promote the occurrence of venous disease in lower limbs. We compared male workers belonging to different occupational categories, matched for age, BMI and traditional risk factors for venous diseases, in order to assess the prevalence of venous disease and occupational and not-occupational postural risk factors. We found that maintaining a standing position for more than 50% of the shift appears the most important occupational risk factor in provoking the observed higher prevalence of venous disease in the workers studied. It can be assumed the venous diseases are often determined by occupational factors which could be main or concomitant causes. The identification of preventive measures to apply in workplaces, such as better organization of work, targeted examinations and therapeutic indications as the prescription of elastic stockings, is very important.

Pulmonary nodules in workers exposed to urban stressor

By multilayer spiral low-dose computed tomography (LD-CT) of the chest this study assesses the early detection of lung lesions on a sample of 100 traffic policemen of a big Italian city professionally exposed to urban pollutants and 100 controls non-occupationally exposed to urban pollutants matched by sex, age, length of service and cigarette smoking habit. Exposure to urban pollutants in traffic policemen was characterized using the annual average concentrations of PM(10), NO2 and benzene in the period 1998-2008 measured by fixed monitoring stations located in different areas of the city. A significant and increasing number of suspicious lung nodules with diameters between 5 and 10 mm was observed: in traffic policemen (including smokers and non-smokers) vs. controls (including smokers and non-smokers); in total smokers (including traffic policemen and controls) vs. total non-smokers (traffic policemen and controls); in smoker traffic policemen vs. smoker controls and vs. non-smoker traffic policemen; in non-smoker traffic policemen vs. non-smoker controls. The RR of finding cases with at least one lung nodule with diameters between 5 and 10mm in traffic policemen (including smokers and non-smokers) compared to controls (including smokers and non-smokers) is 1.94 (CI 1.13-3.31); in total smokers vs. non-smokers the RR is 1.96 (CI 1.20-3.19). The comparison between the interaction exposure and smoking shows an increase in smoker traffic policemen than in smoker controls (RR=2.14; CI 1.02-4.52). The RR for smoker traffic policemen was higher than in non-smoker traffic policemen (RR=2.09; CI 1.19-3.66). The results of our study show that: (1) while smoker workers have a higher risk for developing solid suspicious lung nodules, the simple routinely exposure to urban pollutants is unable to produce the same kind of increased risk; (2) the interaction of smoking and exposure to urban pollutants greatly increases the risk for the development of solid suspicious lung nodules. In conclusion, the use of chest LD-CT in workers at risk helps identify suspicious solid lung nodules at early stage.

[Cardiovascular parameters in workers exposed to urban pollutions]

The aim of the study is to evaluate if "outdoor" workers exposed to chemical, physical and psycho-social urban stressors could have alterations of systolic and diastolic blood pressure at rest and heart disease investigated by electrocardiogram compared with a group of "indoor" workers not exposed. Among non-smoking, the mean values of systolic blood pressure at rest were significantly higher in exposed compared to non exposed (p = 0.002) and frequency of electrocardiographic abnormalities was significantly higher in exposed (20.8%) than not exposed (10.4%, p = 0.02). Among exposed, the values of systolic blood pressure at rest were significantly higher in smokers than non-smokers (p = 0.002). Among non-exposed, the frequency of electrocardiographic abnormalities was significantly higher in smokers than non-smokers (p = 0.002). The study results suggest that chronic exposure to chemical, physical and psycho-social stressors can be a cardiovascular risk factor in addition to cigarette smoking in a manner determined by the categories of outdoor workers.

Follicle-stimulating hormone levels in male workers exposed to urban chemical, physical, and psychosocial stressors

The aim of this study is to evaluate whether occupational exposure to urban stressors could cause alterations in the follicle-stimulating hormone (FSH) levels in traffic policemen compared to a control group. After excluding the subjects with main confounding factors, traffic policemen and male controls were matched by age, working life, body mass index (BMI), drinking habit, cigarette smoking history, and daily consumption of Italian coffee, 166 traffic policemen and 166 controls were included into the study. FSH levels were significantly higher in traffic policemen compared to male controls ( P < 0.05). The distribution of FSH values in traffic policemen and controls was significant ( P < 0.05). Our results suggest that occupational exposure to low doses of chemical and psychosocial stressors may alter plasma levels of FSH in traffic policemen more than in the control group. If the results obtained are confirmed by further research, the plasma levels of FSH may be used as early biological markers, valuable for the group, used in occupational set even before the appearance of disorders of male fertility.

Luteinizing hormone (LH) levels in male workers exposed to urban stressors

The aim of the study is to evaluate if occupational exposure to urban stressors could cause alterations in luteinizing hormone (LH) plasma levels in male traffic policemen vs. administrative staff of Municipal Police.After excluding the subjects with the main confounding factors, male traffic police and administrative staff of Municipal Police were matched by age, working life, body mass index (BMI), alcohol drinking habit, cigarette smoking habit and habitual consumption of Italian coffee.In 166 male traffic police mean LH values were significantly higher compared to 166 male administrative employees. The distribution of LH values in traffic police and in administrative employees was statistically significant.Our results suggest that recent exposure to urban stressors (chemical, physical and psycho-social) can alter the plasma concentration of LH. In agreement with our previous research, levels of plasma LH may be used as early biological markers, valuable for the group, used in occupational set before the appearance of the disease.

[Night workers and plasmatic cortisol]

The aim of the study is to evaluate whether occupational exposure to night work could cause alterations in the levels of plasmatic cortisol. The interest toward this argument arises form several studies in scientific literature referring the presence of an alteration in the synthesis and release of cortisol in workers exposed to night work. We studied a population of workers employed in night security service and monitoring service of alarm systems in different museums compared to a control group not performing shift-work and/or night work. The exposed and control subjects were compared by age, length of service, smoking habit (n. cigarettes per day), habitual consumption of alcoholic drinks (n. glass of wine/beer per day). We evaluated the levels of plasmatic cortisol on 50 workers exposed to night work, all males of whom 30 smokers and 20 non-smokers and on 50 controls of whom 30 smokers and 20 non-smokers.

Management of ovarian cysts in pregnancy: a case report

According to recent epidemiological studies on ovarian cysts during pregnancy one out of 600 are, in most cases, benign neoformations. The most frequent histological type reported is mature cystic teratoma (50% of the cases), followed by functional cysts (13%), benign cystadenomas (20%) and ovarian cancer (0.6%). Most adnexal masses are asymptomatic and spontaneously resolve before the 16th week of amenorrhoea. On the other hand, some cases are persistent forms which can cause complications for the mother and fetus. The objective of this work was to review the existing literature from an epidemiological point of view, with an emphasis on diagnostic and therapeutic management. We have paid particular attention in our review to the use of diagnostic techniques and non surgical therapies such as laparoscopy, which in expert hands and adopting particular skills, can be considered as on approach to ovarian cysts in pregnancy. We present the case of a patient with an ovarian cyst during pregnancy that was a successfully treated with laparoscopy.

[Ectropion of the uterine cervix in adolescence. Study of a topical drug as an alternative to surgical treatment]

The Authors, studied the ectropion of the uterine cervix in the teen-agers (young ladies) and the effect of the desossiribonucleic acid therapy in topic way by 5 mg/die for 20 days in 80 patients with an ectropion of the I degree and the II degree portion of the uterine cervix. The patients were separated in two groups. 40 patients treated by desossiribonucleic acid therapy, 40 patients didn't take any medicament. In conclusion the results show that the desossiribonucleic therapy could be an alternative way for the treatment of the ectropion of the uterine cervix.

Does lung diffusion impairment affect exercise capacity in patients with heart failure?

OBJECTIVE

To determine whether there is a relation between impairment of lung diffusion and reduced exercise capacity in chronic heart failure.

DESIGN

40 patients with heart failure in stable clinical condition and 40 controls participated in the study. All subjects underwent standard pulmonary function tests plus measurements of resting lung diffusion (carbon monoxide transfer, TLCO), pulmonary capillary volume (VC), and membrane resistance (DM), and maximal cardiopulmonary exercise testing. In 20 patients and controls, the following investigations were also done: (1) resting and constant work rate TLCO; (2) maximal cardiopulmonary exercise testing with inspiratory O2 fractions of 0.21 and 0.16; and (3) rest and peak exercise blood gases. The other subjects underwent TLCO, DM, and VC measurements during constant work rate exercise.

RESULTS

In normoxia, exercise induced reductions of haemoglobin O2 saturation never occurred. With hypoxia, peak exercise uptake (peak O2) decreased from (mean (SD)) 1285 (395) to 1081 (396) ml/min (p < 0.01) in patients, and from 1861 (563) to 1771 (457) ml/min (p < 0.05) in controls. Resting TLCO correlated with peak O2 in heart failure (normoxia < hypoxia). In heart failure patients and normal subjects, TLCO and peak O2 correlated with O2 arterial content at rest and during peak exercise in both normoxia and hypoxia. TLCO, VC, and DM increased during exercise. The increase in TLCO was greater in patients who had a smaller reduction of exercise capacity with hypoxia. Alveolar-arterial O2 gradient at peak correlated with exercise capacity in heart failure during normoxia and, to a greater extent, during hypoxia.

CONCLUSIONS

Lung diffusion impairment is related to exercise capacity in heart failure.

Genital tuberculosis in a menopausal woman. A case report

We have analysed the role played by genital tuberculosis (TBC) in Italy today, and in particular in L'Aquila, in the light of a worrying recrudescence. We report the case of a 64-year-old patient, in menopause for the past 11 years or so, referred to the Gynecology and Obstetrics Clinic of the University of L'Aquila, with an anamnesis of menometrorrhagia since the age of 55. The patient was studied from a gynecological and internist profile including the following procedures: gynecological examination and pap-test, colposcopy, transvaginal scan, chest X-ray, abdominal and pelvic CAT, laboratory tests and Mantoux reaction. The uterus was found to be fibromatous during the gynecological examination and scan, whereas colposcopy revealed a small ectropion and the presence of very adherent yellowish mucus. The Mantoux test was positive. CAT showed cicatricial sequelae in the pulmonary parenchyma. It was decided to perform curettage, but this was prevented by the presence of pyometra. The patient was treated with specific chemotherapy and then underwent total laparohysterectomy with bilateral adnexectomy. The histological findings confirmed genital TBC. Genital TBC is now undergoing a worrying recrudescence. We need to have a full knowledge of the pathology, the diagnostic means with which to discover it and the correct therapeutic instruments to overcome it.

[Role of echocardiography in the treatment of heart failure with permanent electric stimulation]

Permanent cardiac pacing has been proposed for the treatment of atrioventricular and intraventricular conduction defects and related hemodynamic alterations which may worsen the performance of the failing heart. The initial positive results of right sided atrioventricular synchronous pacing have not been confirmed in later studies involving a larger number of patients with different clinical characteristics. The reason of these conflicting results may be related to the poor understanding of the complex interaction between the adopted pacing mode and the different type, grade and hemodynamic significance of conduction defects. The negative hemodynamic effects of the altered sequence and synchrony of ventricular activation during right sided pacing may outweigh the benefits of an optimal atrioventricular synchrony. Biventricular stimulation has been proposed to improve the electromechanical activation of the left ventricle in patients with left bundle branch block. Ongoing prospective studies are evaluating the potential benefits of biventricular stimulation versus alternative treatments. Although there are no standard indications to cardiac pacing in heart failure it seems that this therapeutic tool may be of value in selected patients with conduction defects which unfavorably affect the cardiac function and that are amenable to be corrected by an appropriate pacing modality. Doppler echocardiography, in its different applications, emerges has a key technique for the selection of patients who may benefit from permanent pacing and for the selection of the best pacing modality. Doppler echocardiography criteria may also be useful in the selection of homogeneous groups of patients to be enrolled in prospective studies aimed at assessing the potential benefits of permanent pacing versus alternative treatments.

Cardiomegaly as a possible cause of lung dysfunction in patients with heart failure

BACKGROUND

Our hypothesis is that an enlarged heart may compete for space with the lungs, causing a restrictive pattern that is often seen in patients with chronic heart failure.

METHODS

Eighty patients with stable congestive heart failure in New York Heart Association classes II and III participated in the study. We measured cardiothoracic index (chest radiography), FEV1, vital capacity, alveolar volume, lung diffusion capacity for carbon monoxide (DLCO), and its 2 subcomponents alveolar-capillary membrane diffusion (DM), and pulmonary capillary blood volume.

RESULTS

Reliable measurements were obtained in 72 of 80 participants enrolled. Cardiothoracic index averaged 57% +/- 7%. FEV1, vital capacity, alveolar volume, DLCO, and DM were inversely related to the cardiothoracic index (r = -0.514, -0.557, -0.522, -0.475, and -0.480, respectively). However, the relations of DLCO and DM with the cardiothoracic index were lost when DLCO and DM were adjusted for alveolar volume. A significant correlation (P < .01) was found between alveolar volume and vital capacity, FEV1, and DLCO (r = 0.799, 0.705, and 0.614, respectively). At multivariate analysis, cardiothoracic index, FEV1, and pulmonary capillary blood volume were independent predictors of DLCO, whereas alveolar volume, FEV1, and left ventricular ejection fraction were independent predictors of DM.

CONCLUSIONS

Cardiac enlargement in chronic heart failure appears to be involved in causing restrictive lung pattern and a reduced alveolar volume that disturbs carbon monoxide diffusion.

Lack of improvement of lung diffusing capacity following fluid withdrawal by ultrafiltration in chronic heart failure

OBJECTIVES

We sought to investigate the possibility that lung diffusing capacity reduction observed in chronic heart failure is reversible in the short term.

BACKGROUND

Mechanical properties of the lung usually ameliorate with antifailure treatment including drugs, ultrafiltration and heart transplantation, whereas lung diffusion rarely improves.

METHODS

We studied the mechanical properties of the lung (pulmonary function tests with determination of alveolar volume, extravascular lung fluids and lung tissue), lung diffusion for carbon monoxide (DLco), including membrane diffusing capacity (Dm), pulmonary capillary blood volume (Vc) and pulmonary hemodynamics, in 28 patients with stable chronic heart failure, before a single session of extracorporeal ultrafiltration (3,973 +/- 2200 ml) and four days thereafter. Lung mechanics and diffusion were also evaluated in 18 normal subjects.

RESULTS

Vital capacity, forced expiratory volume (1 s) and maximal voluntary ventilation were lower in patients when compared with normal subjects, and increased after ultrafiltration from 2.1 +/- 0.7 to 2.5 +/- 0.7(1)*, 1.7 +/- 0.5 to 2.0 +/- 0.6(1)* and 67 +/- 25 to 79 +/- 26 (1/min)*, respectively (* p < 0.02 vs. pre-ultrafiltration). Post-ultrafiltration alveolar volume was augmented, while lung tissue, body weight (approximately 6 kg), chest X-ray extravascular lung water score and pulmonary vascular pressure were reduced. Heart dimensions (echocardiography) remained unchanged. DLco, Dm and Vc were 29.0 +/- 5.0 ml/min/mm Hg, 47.0 +/- 11.0 ml/min/mm Hg, 102 +/- 20 ml in normal subjects and 17.1 +/- 4.0#, 24.1 +/- 6.5#, 113 +/- 38 and 17.0 +/- 5.0#, 24.8 +/- 7.9#, 100 +/- 39 in patients before and after ultrafiltration, respectively (# = p < 0.01 vs. controls).

CONCLUSIONS

In chronic heart failure, ultrafiltration improves volumes and mechanical properties of the lung by reducing lung fluids. Diffusion is unaffected by ultrafiltration, suggesting that, in chronic heart failure, the alveolar-capillary membrane abnormalities are fluid-independent.

[Antibiotic prophylaxis of infective complications after cesarean section. Our experience]

BACKGROUND

The efficacy of a single dose of antibiotic vs multiple doses of the same drug, in reducing maternal infections following the cesarean section, is evaluated.

METHODS

A total of 206 pregnant women undergoing elective or emergency cesarean section from 1st June 1998 to 30 June 1999, at the Department of Obstetrics and Gynecology of the University of L'Aquila, were included in a randomized study to compare the efficacy of prophylaxis with a single dose of piperacillin sodium (2 g i.v. after the umbilical cord clamping; group A) vs triple doses of the same antibiotic (2 g i.v. at 6 hourly intervals, beginning from the umbilical cord clamping; group B).

RESULTS

The incidence of infective morbidity in group A was 7.3%, with a 2% wound infections, 1% urinary infections and 4.16% febrile morbidity. The incidence of infective morbidity in group B was not much higher (9%), with 2.7% wound infections, 1.8% urinary infections and 4.5% febrile morbidity.

CONCLUSIONS

In order to obtain a useful antibiotic prophylaxis in cesarean sections, the single-dose seems to be preferable to the multiple-doses, since the single-dose not only has equal efficacy, but also less cost, smaller risk of super-infections by resistant organisms and it involves smaller care from the-medical and nursing staff.

Non-invasive measurement of stroke volume during exercise in heart failure patients

The objective of the present study was to determine the variability of the arterio-venous O(2) concentration difference [C(a-v)O(2)] at anaerobic threshold and at peak oxygen uptake (VO(2)) during a progressively increasing cycle ergometer exercise test, with the purpose of assessing the possible error in estimating stroke volume from measurements of VO(2) alone. We sampled mixed venous and systemic arterial blood every 1 min during a progressively increasing cycle ergometer exercise test and measured, in each blood sample, haemoglobin concentration and blood gas data. Ventilation, VO(2) and CO(2) uptake were also measured continuously. We studied 40 patients with normal haemoglobin concentrations and with stable heart failure due to ischaemic or idiopathic cardiomyopathy. Mean values (+/-S.D.) for C(a-v)O(2) were 7.8+/-2.6, 13.0+/-2.4 and 15. 0+/-2.7 ml/100 ml at rest, anaerobic threshold and peak VO(2) respectively. The patients with heart failure were divided into classes according to their peak VO(2). Classes A, B and C contained patients with peak VO(2) values of>20, 15-20 and 10-15 ml.min(-1). kg(-1) respectively. At anaerobic threshold, C(a-v)O(2) was 12.3+/-1. 3, 13.1+/-2.7 and 13.5+/-2.6 ml/100 ml for classes A, B and C respectively (class A significantly different from classes B and C; P<0.05). At peak exercise C(a-v)O(2) was 13.6+/-1.4, 15.6+/-2.5 and 15.4+/-3.2 ml/100 ml for classes A, B and C respectively (class A significantly different from classes B and C; P<0.05). Stroke volume was estimated for each subject using the mean values of the measured C(a-v)O(2) in each functional class and individual values of VO(2) and heart rate using the Fick formulation. The average difference between the stroke volume estimated from mean C(a-v)O(2) and that obtained using the patient's actual C(a-v)O(2) value was 9.2+/-9.7, 1.0+/-8.8 and -0.2+/-6.1 ml at anaerobic threshold, and -1.9+/-11.3, 0.9+/-10.0 and -2.3+/-8.5 ml at peak exercise, in classes A, B and C respectively. Among the various classes, the most precise estimation of stroke volume was observed for class C patients. We conclude that stroke volume during exercise can be estimated with the accuracy needed for most purposes from measurement of VO(2) at the anaerobic threshold and at peak exercise, and from population-estimated mean values for C(a-v)O(2) in heart failure patients.

Preterm delivery: predictive value of cervico-vaginal fetal fibronectin

OBJECTIVE

This study aimed to evaluate the risk of preterm delivery in the asymptomatic obstetric population of L'Aquila by means of fetal fibronectin immunoassay in cervicovaginal secretions.

METHODS

In this prospective study, 60 asymptomatic pregnant women at low-risk for preterm delivery were followed-up. Fetal fibronectin cervical swabs from the esocervix and posterior vaginal fornix were obtained every second week from 24 to 36 weeks of gestation. Fetal fibronectin concentrations were measured by an enzyme-linked immunosorbent assay with a cutoff level set at 50 ng/ml.

RESULTS

Twelve patients (20%) had at least one positive fetal fibronectin test result. Six women in our study group (10%) were delivered spontaneously < 37 weeks; 4 of these (66%) had at least one positive fetal fibronectin test result (positive predictive value: 33%; sensitivity: 66%) and 3 of these women (75%) had a positive test result between 24 and 26 weeks. The remaining 8 patients with at least one positive fetal fibronectin test were delivered at term or post-term. Forty-eight women always had negative tests and 46 (95.8%) of these were delivered at term (specificity 82%), whereas 2 (4.2%) were delivered prematurely. The negative predictive value of fetal fibronectin as a predictor of term delivery in this low-risk population in 95% with odds ratio = 11.5 (95% confidence interval 1.44 to 110.4), relative risk = 8 (95% confidence interval 1.38 to 59.2) and Fisher Exact Test p < 0.024.

CONCLUSION

In a population of asymptomatic patients at low risk for prematurity, the occurrence of a positive cervical or vaginal fetal fibronectin test result defines a subgroup at increased risk for preterm delivery, mostly at low gestational age.

Synergistic efficacy of enalapril and losartan on exercise performance and oxygen consumption at peak exercise in congestive heart failure

Oxygen consumption at peak exercise (peak VO2) is a strong independent predictor of the outcome in congestive heart failure (CHF). Renin-angiotensin system inhibition with either ACE or AT1 receptor blockers is effective on peak VO2. We evaluated whether mechanisms are similar for the 2 categories of drugs and whether their combination is able to produce a synergistic effect. Twenty CHF patients were randomized to receive, in a double-blind fashion, placebo + placebo (P+P), enalapril (20 mg/day) + placebo (E+P), losartan (50 mg/day) + placebo (L+P), and enalapril + losartan (E+L) or the same preparations in a reverse order, each for 8 weeks. Two patients did not complete the trial. Pulmonary function, cardiopulmonary exercise test, plasma neurohormones, and quality of life were assessed at the end of each treatment. Compared with P+P, E+P, and L+P similarly (16% and 15%, respectively) and significantly (p <0.01) augmented peak VO2. Enalapril improved lung function (reduced slope of ventilation vs carbon dioxide production and dead space to tidal volume ratio, and increased alveolar membrane conductance and tidal volume). Losartan likely activated the exercising muscle perfusion (raised delta VO2/delta work rate, which is a measure of aerobic work efficiency). In combination, they further increased peak VO2, 10% from E+P (p <0.05) and 11% from L+P (p <0.05). Compared with run-in, E+P and L+P significantly reduced plasma norepinephrine by 70 +/- 14 pg/ml and 100 +/- 16 pg/ml and aldosterone by 1.6 +/- 0.7 ng/dl and 1.6 +/- 0.8 ng/dl. These changes were significantly greater when the drugs were combined (140 +/- 20 pg/ml for norepinephrine, and 5.6 +/- 0.9 ng/dl for aldosterone). Quality-of-life score did not improve significantly at each treatment step. Thus, lorsartan and enalapril similarly increased peak VO2 in CHF patients, but mediators of this effect were, at least in part, different therapeutic targets that may be synergistic when the 2 drugs are combined.

Oxygen consumption

It gets more and more frequent to use oxygen consumption (VO2) to evaluate exercise capacity and response to treatment in heart failure patients. The amount of VO2 is due to ventilation, oxygen transport and muscle activity. No one of these single steps can define by itself VO2, but all these physiological functions are integrated each other. In this paper we examine the modifications of cardiac output, arteriovenous oxygen content difference, and the temporal behavior of their variations during exercise in heart failure. We specifically describe changes in VO2 during simulated altitude; we also contemplate mechanisms governing oxygen diffusion from capillary bed to mitochondria and critical capillary PO2 concept.