Francesco Bonechi

Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope ☆ ☆☆ ★

BACKGROUND Head-up tilt testing is extensively used to determine the vasovagal origin of syncope in patients with otherwise unexplained loss of consciousness, although issues remain regarding the method of the test. The diagnostic value of a shortened head-up tilt test potentiated with sublingual nitroglycerin was assessed in patients with unexplained syncope. METHODS Two hundred two patients (mean age 49+/-19 years) with syncope of unknown origin and 34 subjects in a control group (mean age 45+/-17 years) were studied. The patients and the subjects in the control group were tilted upright to 60 degrees for 20 minutes. If syncope did not occur, sublingual nitroglycerin (400 microg) was administered, and observation was continued for 25 more minutes. RESULTS During the unmedicated phase syncope occurred in 22 (11%) patients and in one member of the control group. After nitroglycerin was administered, syncope occurred in 119 (59%) patients and in 1 (3%) member of the control group. False-positive response (exaggerated response) was observed in eight (4%) patients and in four (12%) subjects in the control group. The total positivity rate of the test was 70% with a specificity rate of 94%. CONCLUSIONS Short-duration head-up tilt test potentiated with sublingual nitroglycerin provides an adequate specificity and positivity rate in patients with unexplained syncope.

Diagnostic accuracy of peak exercise echocardiography in coronary artery disease: Comparison with thallium-201 myocardial scintigraphy

To evaluate the accuracy of exercise two-dimensional echocardiography for the recognition of coronary artery disease, 53 patients (46 men and 7 women, age range 35 to 69 years) without either previous myocardial infarction or resting wall motion abnormalities, were studied. According to coronary angiography 26 had normal coronary arteries, 14 had one-vessel, seven had two-vessel, and six had three-vessel disease. After withdrawal of any therapy, all patients underwent a single exercise stress test with a stress table during which cine-loop digitized echocardiography was acquired and 74 MBq of thallium-201 (TI-201) were injected. Echocardiographic images were evaluated at rest and at peak exercise. Three-view planar scintigraphic images were collected immediately after exercise and 4 hours later. For the overall recognition of coronary artery disease, exercise electrocardiography had 77.8% sensitivity and 65.4% specificity; myocardial scintigraphy had 100% sensitivity and 92.3% specificity; and exercise echocardiography had 92.6% sensitivity and 96.2% specificity (both NS versus myocardial scintigraphy). Global accuracy was 71.7% for exercise electrocardiography, 94.3% for stress echocardiography, and 96.2% for myocardial scintigraphy. For the classification of the individual involved coronary arteries, the sensitivity of myocardial scintigraphy was 84.8% and that of exercise echocardiography was 63% (p less than 0.01); the related specificities were 98% and 98.2% respectively (NS). It may be concluded that exercise echocardiography is highly accurate for the recognition of coronary artery disease, whereas it appears less sensitive in the identification of the involved vessels, particularly in patients with multivessel disease.

Methodology of head-up tilt testing potentiated with sublingual nitroglycerin in unexplained syncope

Shortened head-up tilt testing (HUT) potentiated with sublingual nitroglycerin (60 degrees passive standing for 20 minutes followed, if negative, by 400 microg of sublingual nitroglycerin spray with the test continuing for another 20 minutes) differs from conventional nitroglycerin HUT for a shorter drug-free phase (20 vs 45 minutes). To compare the positivity rate of the 2 protocols, both tests were performed in a randomized sequence in 10 patients with unexplained syncope (study 1), and another 42 patients were randomly assigned either to conventional or to shortened nitroglycerin HUT (study 2). To evaluate the reproducibility of the shortened nitroglycerin HUT, another 38 patients with unexplained syncope underwent 2 consecutive tests within a 7+/-8 day interval (study 3). Finally, to evaluate the specificity of the test, 47 control subjects underwent shortened nitroglycerin HUT (study 4). Seven positive responses were observed during shortened nitroglycerin HUT, and there were 8 positive responses during conventional nitroglycerin HUT (p = NS) in the study 1 group. Fifteen positive (71%) responses, 5 negative responses, and 1 exaggerated response were observed during shortened nitroglycerin HUT; 16 positive (76%, p = NS vs. shortened nitroglycerin HUT), 3 negative, and 2 exaggerated responses were observed during conventional nitroglycerin HUT in the study 2 group. During the first test, 21 patients (55%) had a positive, 15 patients had a negative, and 2 patients had an exaggerated response in study group 3. During the second test, 15 positive (39%), 19 negative, and 4 exaggerated responses were observed. Thus, the reproducibility was 67% for a positive and 94% for a negative test. In control subjects, 2 positive (4%) responses, 38 negative, and 7 exaggerated responses were observed with a specificity of 96% in study group 4. In patients with unexplained syncope, shortened nitroglycerin HUT allowed a positivity rate similar to that of the conventional test. Moreover, the shortened test provided a high specificity and adequate reproducibility for both the positive and the negative responses.

Noncommutative Instantons on the 4-Sphere¶from Quantum Groups

Abstract: We describe an approach to the noncommutative instantons on the 4-sphere based on quantum group theory. We quantize the Hopf bundle ?7→?4 making use of the concept of quantum coisotropic subgroups. The analysis of the semiclassical Poisson–Lie structure of U(4) shows that the diagonal SU(2) must be conjugated to be properly quantized. The quantum coisotropic subgroup we obtain is the standard SUq(2); it determines a new deformation of the 4-sphere ∑4q as the algebra of coinvariants in ?q7. We show that the quantum vector bundle associated to the fundamental corepresentation of SUq(2) is finitely generated and projective and we compute the explicit projector. We give the unitary representations of ∑4q, we define two 0-summable Fredholm modules and we compute the Chern–Connes pairing between the projector and their characters. It comes out that even the zero class in cyclic homology is non-trivial.

Determinants of exercise tolerance after acute myocardial infarction in older persons.

OBJECTIVES: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age‐related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI.

Exponential Mixing and \(\) Time Scales¶in Quantized Hyperbolic Maps on the Torus

Abstract:We study the behaviour, in the simultaneous limits , of the Husimi and Wigner distributions of initial coherent states and position eigenstates, evolved under the quantized hyperbolic toral automorphisms and the quantized baker map. We show how the exponential mixing of the underlying dynamics manifests itself in those quantities on time scales logarithmic in . The phase space distributions of the coherent states, evolved under either of those dynamics, are shown to equidistribute on the torus in the limit , for times t between and , where γ is the Lyapounov exponent of the classical system. For times shorter than , they remain concentrated on the classical trajectory of the center of the coherent state. The behaviour of the phase space distributions of evolved position eigenstates, on the other hand, is not the same for the quantized automorphisms as for the baker map. In the first case, they equidistribute provided t→∞ as , and as long as t is shorter than . In the second case, they remain localized on the evolved initial position at all such times.

Poisson Sigma Model on the Sphere

We evaluate the path integral of the Poisson sigma model on the sphere and study the correlators of quantum observables. We argue that for the path integral to be well-defined the corresponding Poisson structure should be unimodular. The construction of the finite dimensional BV theory is presented and we argue that it is responsible for the leading semiclassical contribution. For a (twisted) generalized Kähler manifold we discuss the gauge fixed action for the Poisson sigma model. Using the localization we prove that for the holomorphic Poisson structure the semiclassical result for the correlators is indeed the full quantum result.

Controlling strong scarring for quantized ergodic toral automorphisms

We show that in the semi-classical limit the eigenfunctions of quantized ergodic symplectic toral automorphisms can not concentrate in measure on a finite number of closed orbits of the dynamics. More generally, we show that, if the pure point component of the limit measure has support on a finite number of such orbits, then the mass of this component must be smaller than two thirds of the total mass. The proofs use only the algebraic (i.e. not the number theoretic) properties of the toral automorphisms together with the exponential instability of the dynamics and therefore work in all dimensions.

On the Noncommutative Geometry of Twisted Spheres

We describe noncommutative geometric aspects of twisted deformations, in particular of the spheres of Connes and Landi and of Connes and Dubois Violette, by using the differential and integral calculus on these spaces that is covariant under the action of their corresponding quantum symmetry groups. We start from multiparametric deformations of the orthogonal groups and related planes and spheres. We show that only in the twisted limit of these multiparametric deformations the covariant calculus on the plane gives, by a quotient procedure, a meaningful calculus on the sphere. In this calculus, the external algebra has the same dimension as the classical one. We develop the Haar functional on spheres and use it to define an integral of forms. In the twisted limit (differently from the general multiparametric case), the Haar functional is a trace and we thus obtain a cycle on the algebra. Moreover, we explicitly construct the *-Hodge operator on the space of forms on the plane and then by quotient on the sphere. We apply our results to even spheres and compute the Chern–Connes pairing between the character of this cycle, i.e. a cyclic 2n-cocycle, and the instanton projector defined in math.QA/0107070.

Decrease in frequency of anginal episodes by control of thrombin generation with low-dose heparin: A controlled cross-over randomized study

Increased thrombin generation is frequently associated with an increase in anginal activity. A cross-over, single-blind, completely randomized study was planned in order to evaluate whether the control of thrombin generation affected the increase in anginal activity. After discharge from the hospital, 24 patients (18 men and 6 women, aged 40 to 69 years) suffering from spontaneous angina were followed up to 12 months and were alternatively treated during two consecutive 6-month periods with calcium heparin, 12,500 IU by the subcutaneous route, or with placebo by the intramuscular route, in addition to the usual antianginal medications. Thrombin generation and clinical activity of angina were assessed every 15 days by measuring fibrinopeptide A (FPA) plasma levels and by grading in three classes (symptomless, mildly symptomatic, and severely symptomatic) the anginal activity on the basis of the number and the time concentration of the ischemic attacks and ECG changes. Low-dose heparin treatment significantly reduced both the FPA plasma level (from 4.1 +/- 3.7 to 2.3 +/- 1.8 ng/ml, p less than 0.001) and the clinical activity of angina. During heparin treatment, the frequency of the observations in the severely and mildly symptomatic classes decreased, respectively, by 53% and by 30%, whereas that in the symptomless class increased by 23% (p less than 0.001) in comparison with the period on placebo. Present results indicate that the control of thrombin generation obtained by low-dose heparin treatment favorably affects the degree of anginal activity in patients with spontaneous angina.