Oreste de Divitiis

Left ventricular mass and body size in normotensive children and adults: Assessment of allometric relations and impact of overweight☆

OBJECTIVES This study was designed to determine the most appropriate method to normalize left ventricular mass for body size. BACKGROUND Left ventricular mass has been normalized for body weight, surface area or height in experimental and clinical studies, but it is uncertain which of these approaches is most appropriate. METHODS Three normotensive population samples--in New York City (127 adults), Naples, Italy (114 adults) and Cincinnati, Ohio (444 infants to young adults)--were studied by echocardiography. Relations of left ventricular mass to body size were similar in all normal weight groups, as assessed by linear and nonlinear regression analysis, and results were pooled (n = 611). RESULTS Left ventricular mass was related to body weight to the first power (r = 0.88), to body surface area to the 1.5 power (r = 0.88) and to height to the 2.7 power (r = 0.84), consistent with expected allometric (growth) relations between variables with linear (height), second-power (body surface area) and volumetric (left ventricular mass and body weight) dimensions. Strong residual relations of left ventricular mass/body surface area to body surface area (r = 0.54) and of ventricular mass/height to height (r = 0.72) were markedly reduced by normalization of ventricular mass for height2.7 and body surface area1.5. The variability among subjects of ventricular mass was also reduced (p < 0.01 to p < 0.002) by normalization for body weight, body surface area, body surface area1.5 or height2.7 but not for height. In 20% of adults who were overweight, ventricular mass was 14% higher (p < 0.001) than ideal mass predicted from observed height and ideal weight; this increase was identified as 14% by left ventricular mass/height2.7 and 9% by ventricular mass/height, whereas indexation for body surface area, body surface area1.5 and body weight erroneously identified left ventricular mass as reduced in overweight adults. CONCLUSIONS Normalizations of left ventricular mass for height or body surface area introduce artifactual relations of indexed ventricular mass to body size and errors in estimating the impact of overweight. These problems are avoided and variability among normal subjects is reduced by using left ventricular mass/height2.7. Simple nomograms of the normal relation between height and left ventricular mass allow detection of ventricular hypertrophy in children and adults.

Plasma Leptin Level Is Associated With Myocardial Wall Thickness in Hypertensive Insulin-Resistant Men

Leptin, the product of the ob gene, has been shown to increase heart rate and blood pressure through a stimulation of cardiac sympathetic nervous system activity, a phenomenon also involved in the pathogenesis of left ventricular hypertrophy in hypertensives. Thus, we hypothesize that plasma leptin concentration is associated with left ventricular hypertrophy. Forty hypertensive males and 15 healthy male subjects underwent anthropometric and echocardiographic evaluations, assessment of insulin sensitivity through euglycemic glucose clamp combined with indirect calorimetry, and determination of fasting plasma leptin concentration. Fasting plasma leptin levels were higher in hypertensives than in controls (6.48+/-2.9 versus 4. 62+/-1.5 ng/mL, P<0.05); these results were unchanged after adjustment for body mass index (P<0.05). In the whole group of patients (n=55), fasting plasma leptin concentration was correlated with body mass index (r=0.46, P<0.001) and waist/hip ratio (r=0.50, P<0.001); independent of body mass index and waist/hip ratio, fasting plasma leptin concentration was correlated (n=55) with whole-body glucose disposal (r=-0.27, P<0.04), interventricular septum thickness (r=0.34, P<0.001), posterior wall thickness (r=0.38, P<0.003), and the sum of wall thicknesses (r=0.68, P<0.001). In a multivariate analysis (n=55), age, body mass index, fasting plasma leptin concentration, plasma Na(+) concentration, whole-body glucose disposal, and diastolic blood pressure explained 68% of the variability of the sum of wall thicknesses with fasting plasma leptin concentration (P<0.03), whole body glucose disposal (P<0.002), and diastolic blood pressure (P<0.001), which were significantly and independently associated with the sum of wall thicknesses. In conclusion, our study demonstrates that fasting plasma leptin levels are associated with increased myocardial wall thickness independent of body composition and blood pressure levels in hypertensives.

Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases.

OBJECTIVETuberculum sellae meningiomas represent 5 to 10% of all intracranial meningiomas. Such lesions are classically removed through a variety of well-standardized transcranial approaches. The extended endonasal transsphenoidal route, under either microscopic or endoscopic visualization, has only recently been proposed as a viable surgical technique for the management of such tumors. MATERIAL AND METHODSA total of 51 consecutive patients with tuberculum sellae meningiomas were treated at our institution during a 21-year period. Forty-four patients had transcranial surgery, and the last seven were treated via the extended endoscopic transsphenoidal approach. We also compared our data with those reported in the pertinent literature related to the surgical, ophthalmological, and endocrinological outcome. RESULTSThe significant difference among the transcranial and transsphenoidal series, both in our experience and in the reviewed literature, did not allow us to draw statistically significant results but rather a reporting of the outcomes. In the transcranial group, 86.4% had a gross total removal of the lesion, whereas the percentage was 83.3% in the transsphenoidal group. Concerning the visual outcome, we experienced postoperative improvement in 61.4% of the transcranial patients and a worsening of 13.6%, whereas improvement was reported in 71.4% of the patients in the transsphenoidal group; in the last group, we did not observe any postoperative worsening. The main drawback of the transsphenoidal approach still remains the difficulty in reconstructing the cranial base dural and bone defects, which expose patients to a greater risk of postoperative cerebrospinal fluid leakage (28.6% in our series) and related complications. CONCLUSIONWhen treating a patient with a diagnosis of tuberculum sellae meningioma, a neurosurgeon should know that, aside from the classical transcranial approach, the possibility of an extended transsphenoidal approach exists. Although it is still not a standardized procedure, in carefully selected cases (i.e., small midline lesions, without major vessel encasement, or parasellar extension) and in experienced hands, it could be considered a viable alternative, especially in overcoming the reconstruction-related problems.

Use of pulsed Doppler tissue imaging to assess regional left ventricular diastolic dysfunction in hypertrophic cardiomyopathy

In this study, regional diastolic patterns and their relations with transmitral Doppler inflow were investigated in hypertrophic cardiomyopathy (HC) by pulsed Doppler tissue imaging (DTI). Doppler echocardiography and DTI of basal septum and lateral wall (apical 4-chamber view) were performed in 20 patients (15 men and 5 women) with HC and in 10 healthy subjects (7 men and 3 women). Diabetes, hypertension, coronary artery and valvular disease, mitral regurgitation, New York Heart Association functional classes III to IV, sinus tachycardia, atrial fibrillation, and inadequate echocardiograms were exclusion criteria. Peak velocity and time-velocity integral of early and late waves and their ratios, and deceleration and isovolumic relaxation times were determined by standard Doppler and by DTI at the septal and lateral wall levels. The 2 groups were comparable for age, heart rate, blood pressure, and ejection fraction. Transmitral peak velocity and time-velocity integral E/A ratios were reduced (both p <0.05) and deceleration and isovolumic relaxation times prolonged (both p <0.00001) in HC. Septal DTI showed lower peak velocity and time-velocity integral e/a ratios (p <0.00001 and p <0.001, respectively) and lengthened regional deceleration (p <0.01) and isovolumic (p <0.001) relaxation times. DTI of the lateral wall showed a prolongation of deceleration and isovolumic relaxation times (both p <0.01). By dividing HC according to transmitral E/A, 8 patients with E/A <1 had lower DTI septal e/a ratio (p <0.01) and prolonged septal deceleration and isovolumic relaxation times (both p <0.01) but no changes in DTI pattern of lateral wall than 12 patients with E/A > 1. In conclusion, DTI is useful and complementary to standard Doppler imaging to characterize diastolic properties in HC, reflecting a typical pattern of intramyocardial impaired relaxation at the level of hypertrophied septum and also providing information about the degree of this regional impairment. The lateral wall presents minor changes in diastolic times, which indicate how diastolic asynchrony is not confined to the hypertrophied segment in HC.

Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions

OBJECT The extended transsphenoidal approach to the suprasellar region has the advantages of minimal invasiveness and brain manipulation in the surgical treatment of small to medium lesions. At the same time, however, it carries a higher risk of postoperative cerebrospinal fluid (CSF) leakage and related complications than those for the standard transsphenoidal approach. Effective reconstruction of large skull base defects is a major concern in such extended approaches and remains challenging. METHODS Between January 2004 and April 2006, 21 patients affected by different suprasellar lesions underwent the extended endoscopic endonasal transtuberculum-transplanum approach. Three different techniques were used for the skull base reconstructions. In all cases, dehydrated human pericardium (Tutoplast) for dural reconstruction and a copolymer of L-lactic acid and glycolic acid (LactoSorb) as a bone substitute were used. Collagen sponges, fibrin glue, and an inflated Foley balloon catheter were also used to fill the sphenoid sinus cavity. RESULTS Two cases of postoperative CSF leaks (9.5%) and one case of mycotic sinusitis (4.8%) occurred following the intradural (inlay) and intraextradural (inlay-overlay) graft positioning. No cases of postoperative CSF leakage occurred in cases in which the extradural-only reconstruction procedure was applied. No meningitis or other complications related to the closure were noticed. CONCLUSIONS The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.

Early abnormalities of cardiac function in non-insulin-dependent diabetes mellitus and impaired glucose tolerance

The aim of this study was to evaluate the role of diabetes and minor abnormalities of glucose homeostasis, such as impaired glucose tolerance, as determinants of cardiac function and structure in a working population. We studied a population-based sample of 64 telephone company employees (both sexes, mean age 58 years): 25 with normoglycemia, 15 with impaired glucose tolerance, and 24 with non-insulin-dependent diabetes mellitus (NIDDM) diagnosed by oral glucose tolerance test according to the recommendations of the World Health Organization. Subjects with myocardial ischemia were excluded. Left ventricular end-systolic dimension, indexed to body surface area, was greater in those with NIDDM (p < 0.05) and in those with impaired glucose tolerance (p < 0.05) with respect to normoglycemic persons. The ratio of the peak early diastolic velocity wave to the late diastolic wave was lower in those with NIDDM (p < 0.05) and in those with impaired glucose tolerance (p < 0.05) than in participants with normoglycemia. Body mass index and blood pressure were similar in the 3 groups. These results clearly indicate that early abnormalities of cardiac structure and function are observed not only in patients with NIDDM, but also in those with impaired glucose tolerance, independent of the confounding role of myocardial ischemia, body weight, and blood pressure.

Microsurgical Anatomic Features of the Olfactory Nerve: Relevance to Olfaction Preservation in the Pterional Approach

OBJECTIVE: The pterional approach represents the standard approach for most lesions of the anterior and middle cranial fossa. It requires some degree of frontal lobe retraction, which may result in temporary or permanent damage of olfaction because of nerve avulsion or mechanical compression. The purpose of this study, based on microanatomic dissection of human cadaveric specimens, was to review the microsurgical anatomic features of the nerve and suggest operative nuances that may contribute to reducing the rate of postoperative olfactory dysfunction. METHODS: Twenty olfactory nerves and tracts were examined in 10 human cadaveric heads obtained from three fresh and seven formalin-fixed adult cadavers. A standard pterional craniotomy was performed. The olfactory nerve was dissected from its arachnoidal envelopes and then mobilized for an average length of 30 mm (range, 25–35 mm). RESULTS: The possible retraction of the frontal lobe was 10 to 15 mm. More retraction invariably resulted in nerve disruption. CONCLUSION: The standard sylvian and basal cistern opening may be insufficient to guarantee preservation of olfactory function. Early identification and arachnoidal dissection of the nerve may reduce the rate of olfaction compromise. The opening of the subarachnoidal space should be performed in a proximal-to-distal manner to allow early visualization of the olfactory bulb and its dissection. The arachnoidal dissection should be performed with sharp instruments, avoiding any traction on the posterior portion of the olfactory tract. Any direct retractor compression should also be avoided to spare the microvasculature lying on the dorsal surface of the nerve.

Is High Pulse Pressure a Marker of Preclinical Cardiovascular Disease

This study tests the hypothesis that high brachial pulse pressure might constitute preclinical cardiovascular disease, rather than a risk factor. We studied 1250 subjects (472 nonobese normotensive [<135/80 mm Hg] and 778 untreated hypertensive). Central pulse pressure was estimated from brachial pulse pressure and age and divided by stroke volume (PP/SV). Brachial pulse pressure was considered high when >63 mm Hg, and peripheral resistance high when >90th percentile of normal distribution. Among hypertensive subjects, 34% had high resistance; among them, 33% had high brachial pulse pressure, as opposed to 147 of 516 patients (28.5%) with normal resistance (P=not significant). After adjusting for age, sex, race, body mass index, heart rate, and center, left ventricular (LV) internal dimension and mass were lower with high resistance, and higher when brachial pulse pressure was high. PP/SV was 36% higher with high resistance than with normal resistance, and higher when brachial pulse pressure was high (all P<0.0001). Factorial analysis demonstrated that associations of high brachial pulse pressure with both higher PP/SV and LV mass were independent of other pressure components. Thus, because of these associations, our hypothesis is that in hypertension, pulse pressure may be considered as a marker of preclinical cardiovascular disease, similar to LV mass and PP/SV, rather than a cardiovascular risk factor.

Impact of ambulatory blood pressure on left ventricular diastolic dysfunction in uncomplicated arterial systemic hypertension

To determine the relations of 24-hour blood pressure (BP) and its different phases with left ventricular (LV) diastolic filling, 125 subjects (mean age 46 years) not taking cardiac drugs were studied by Doppler echocardiography and ambulatory BP recording. Subjects (excluding those with coronary artery or valvular heart disease, heart failure, or diabetes) were classified into 2 groups according to the level of Doppler-derived ratio of peak early to atrial velocity (E/A ratio): 59 had E/A >1 (normal diastole), 62 had E/A <1 (impaired diastole), and 4 had E/A = 1. Patients with E/A <1 were older and had higher LV mass indexed for height, average 24-hour BP, average nighttime BP, and lower day-night BP decrease, whereas average daytime BP did not differ significantly between the 2 groups. Negative correlations of E/A were found with age, heart rate, office, average 24-hour and average nighttime systolic and diastolic BP, and LV mass index. In a multivariate model that included potentially confounding factors, only age (standardized beta coefficient = -0.52, p<0.00001), nighttime BP (beta = -0.28, p<0.0001), and heart rate (beta = -0.22, p<0.001) were independent predictors of E/A in the pooled population. In conclusion, LV diastolic function is more closely related to ambulatory, rather than to clinic, BP measurements, and high average nocturnal diastolic BP is a powerful marker of LV filling impairment.

A double-blind comparison of nicorandil and metoprolol in stable effort angina pectoris

SummaryThe antianginal activities of nicorandil, 10 and 20 mg bid, and metoprolol, 100 mg bid, were compared in patients with stable effort angina pectoris in a randomized, double-blind parallel group study lasting 7 weeks. Twenty patients were enrolled into the trial and 16 patients completed the study. To evaluate the antiischemic effects of the two drugs, a treadmill exercise test was performed after a 1-week placebo run-in period and 6 weeks of treatment. On the same occasions, weekly sublingual nitroglycerine consumption and the number of anginal attacks were also recorded in the patients diary. The total duration of exercise increased significantly with both nicorandil, 10 and 20 mg, and metoprolol (p<0.01). Similar improvements were observed in the time to onset of ischemia with both treatments (p<0.01). The double product at maximal comparable workload (MAX 1) was reduced with the two drugs (p<0.05 for nicorandil and p<0.01 for metoprolol), while at the maximal exercise time (MAX 2) it was reduced with metoprolol (p<0.01) and slightly but not significantly increased with both doses of nicorandil. Weekly sublingual nitroglycerine consumption and anginal attacks were also significantly reduced a similar manner by both treatments (p<0.01). In conclusion, nicorandil, 10 and 20 mg bid, exerted an antiischemic effect comparable with that of metoprolol in patients with stable effort angina pectoris.