Cardiopulmonary baroreflex stimulation and blood pressure-related hypoalgesia.

Results from both experimental animals and humans suggest that baroreflex stimulation may be involved in blood pressure-related hypoalgesia. However, most of this research, especially in the area of human experimentation, has focused on sinoaortic baroreceptors. Cardiopulmonary baroreflex stimulation may also be an important moderator of pain. Sixty-six healthy male undergraduates varying in risk for hypertension participated in an experimental protocol in which painful mechanical finger pressure was presented three times in a counterbalanced fashion. One pain stimulus was preceded by 6 min of supine rest, another by a period of rest interspersed with periodic Valsalva manoeuvres, and another by a period in which cardiopulmonary baroreceptors were stimulated by passive leg elevation. Significantly lower pain was reported by men with relatively elevated systolic blood pressure following leg elevation but not the other conditions. Cardiopulmonary baroreflex stimulation was documented by increased forearm blood flow and other data obtained via impedance cardiography. These results suggest that blood pressure related hypoalgesia may be at least partially related to cardiopulmonary baroreflex stimulation.

Reliability of visual and quantitative hepatobiliary scintigraphy in the follow-up of patients who have undergone cholecystectomy and transduodenal sphincteroplasty.

A noninvasive scintigraphic technique to assess the efficacy of a surgical procedure (e.g., cholecystectomy and transduodenal sphincteroplasty) depends on the development of reliable and accurate qualitative or quantitative diagnostic criteria that allow early recognition of the occurrence and site of complications. For this purpose, the authors divided biliary flow into a four-step progression process and analyzed transit times from the peripheral vein to the gallbladder, common bile duct, and duodenum and the transit time from the common bile duct to the duodenum. These quantitative parameters were assessed in nine healthy volunteers and 31 asymptomatic patients who had previous cholecystectomy to validate their reliability. The results indicate that the four-step Tc-99m HIDA progression analysis provides a reliable, noninvasive evaluation of biliary flow, so that it can be applied to patients who have had cholecystectomy.

Criterion-based validity of an intracarotid amobarbital recognition-memory protocol.

PURPOSE: We tested whether the behavioral components of an Intracarotid Amobarbital Protocol (IAP) had criterion validity. It was hypothesized that a recognition-memory test designed for intracarotid injections and used to predict the risk of global amnesia before an elective temporal lobectomy should also identify persons who are severely amnesic due to other neurologic causes. Divergent validity predicts that speech tasks would be unaffected by amnesia. Test-retest reliability also was measured. METHODS: Fifteen persons with severe amnesia were administered four alternate forms of a yes/no recognition-memory protocol and a speech protocol. No drug injection occurred. Standardized neuropsychological tests were used to divide the amnesic group into those with Global Amnesia (i.e., retain no ongoing memories), Severe Amnesia (i.e., memory impaired), and Amnesia Plus (severe amnesia plus other neuropsychologic deficits). RESULTS: Two persons with Global Amnesia obtained scores at or below chance (i.e., failed) on the memory protocol. Unexpectedly, 12 of 13 severely amnesic persons obtained near-perfect memory scores. Amnesia had no impact on the speech protocol. Pass/Fail outcomes were highly correlated across all four sets. CONCLUSIONS: A four-item IAP memory protocol showed good reliability and criterion validity in identifying the rare condition of Global Amnesia, but it was insensitive to other disabling, severe amnesic disorders. This IAP memory protocol might have validity in predicting a postsurgical Global Amnesic disorder, but it did not identify and therefore could not predict other more common severe amnesic disorders.

Parental history of hypertension and hostility moderate cardiovascular responses to interpersonal conflict.

A parental history of hypertension has been implicated in the development of hypertension, perhaps by virtue of an elevated cardiovascular response to stress. Similarly, hostility has been hypothesized to be linked to cardiovascular disease through cardiovascular hyperreactivity. The interaction of parental history and hostility in moderating cardiovascular response has been infrequently examined, though research suggests the two may be linked through familial factors. The present study examined the cardiovascular response of 98 healthy young adult males categorized as offspring of hypertensive subjects (PH+) or offspring of normotensive subjects (PH-) and as high or low hostile, based on Cook-Medley Hostility scores (HiHo vs. LoHo). Subjects were exposed to either an harassment or non-harassment stressor. Results indicated elevated cardiac output and forearm blood flow responses in PH+/HiHo subjects who were harassed as compared to any other harassed subject and all non-harassed individuals. This hemodynamic response pattern of elevated blood flow suggests a mechanism of hypertensive disease development.

Hostility, sodium consumption, and cardiovascular response to interpersonal stress.

OBJECTIVE: Previous studies have reported poorer health behaviors in high vs. low hostile subjects. The role of stress in these observed differences has not been explored although interpersonal stress does increase cardiovascular response in high hostiles. Given evidence that stress may induce increased salt-intake, this study examined the role of hostility and interpersonal stress in increasing sodium consumption in addition to cardiovascular reactivity. METHOD: Sixty-nine male undergraduates were categorized into high (HiHo) and low hostile (LoHo) groups based on Buss-Durkee Hostility Inventory scores. Subjects engaged in either a math task with harassment, math task without harassment, or a control/rest condition. Sodium intake was assessed posttask by having subjects ingest a sodium-free soup that was presented with a saltshaker without any comments. Cardiovascular measures were also recorded. RESULTS: HiHo subjects consumed more salt than LoHo subjects irrespective of experimental condition. HiHo subjects who were harassed also exhibited greater cardiac output, systolic blood pressure, and forearm blood flow than did HiHo nonharassed, HiHo control, or LoHo subjects. CONCLUSION: HiHo subjects exhibited increased salt-intake, although evidence for stress-induced salt-intake was not obtained. Nonetheless, the combination of salt and stress may contribute to the cardiovascular hyperreactivity and risk for cardiovascular disease in hostile individuals.

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

OBJECTIVE: The authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair. SUMMARY BACKGROUND DATA: The authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals. METHODS: Eighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured. RESULTS: Early and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location. CONCLUSIONS: High biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.

[Non-resectable neoplasms of the biliary duct: palliative surgery vs non-surgical management]. / Neoplasie non resecabili della confluenza biliare: palliazione chirurgica versus trattamento non chirurgico.

A retrospective analysis comparing the results of biliary enteric anastomoses and non-operative management in unresectable bile duct carcinomas was carried out. Twenty-four patients underwent surgical drainage (Group A), and 29 were managed with transhepatic or endoscopic stent (Group B). Concomitant medical diseases were more frequent in group B patients (16.6% vs 48.2%, p < 0.03). Group A and group B were comparable in morbidity (29.1% vs 41.3%), mortality (12.5% vs 13.7%) and 1-year survival rate (21% vs 17%). Median survival was 4.2 months in group A and 2.6 in group B. Jaundice relief was achieved in 70.8% of group A patients and in 68.9% of group B. Group B patients experienced more cholangitis (p = 0.001) and required more hospital readmission (p = 0.0015). Quality of life was better in group A patients, however difference did not reach statistical significance. Therefore, low risk patients with unresectable hilar bile duct tumor and yet good life expectancy may benefit from surgical palliation.

Dimensions of hostility and cardiovascular response to interpersonal stress.

Emerging research suggests that hostility is a multidimensional construct with different dimensions conferring different cardiovascular disease risk. This study examined two dimensions of hostility, expressive and neurotic, and their hemodynamic response patterns upon exposure to interpersonal stress. Fifty-seven male undergraduates were categorized into high and low expressive hostility (HiEH, LoEH) and high and low neurotic hostility (HiNH, LoNH) groups based on their Buss-Durkee Hostility Inventory scores. Subjects engaged in a mathematical subtraction task, with half of the subjects harassed through anger-provoking statements. Separate analyses were conducted for the expressive and neurotic hostility groupings. For expressive hostility, results indicated that HiEH/harassed subjects exhibited greater systolic blood pressure, heart rate, and cardiac output responses than did HiEH/nonharassed subjects or LoEH subjects irrespective of harassment. Neurotic hostility analyses revealed elevated forearm blood flow in HiNH/harassed subjects as compared to HiNH/nonharassed subjects or LoNH subjects in either harassment condition. The hemodynamic response pattern of expressive hostiles is consistent with their risk for heart disease. The response pattern of neurotic hostiles may indicate risk for hypertension, though this remains to be established.

Estradiol, progesterone and cardiovascular response to stress.

The present study examined the relationship between endogenous estradiol and progesterone levels and cardiovascular activity at rest and during stress in healthy young women. Subjects were tested in both the follicular and luteal phases of the menstrual cycle. Results indicated that, during the luteal phase, higher levels of estradiol were associated with lower levels of cardiac output responses to the combined video game and speech tasks, and lower levels of heart rate and systolic blood pressure responses to the cold pressor; estradiol levels were also associated positively with PEP responses to the cold pressor but only under high levels of progesterone. Additionally, during the luteal phase, higher levels of progesterone were associated with higher TPR and lower stroke volume responses to the cold pressor. In contrast, during the follicular phase, higher levels of progesterone were associated with lower vascular resistance responses to the cold pressor. Consistent with data from studies using exogenous estrogens, these results suggest that estradiol may contribute to a lowering of cardiovascular responses to stress.

Is there a causal connection between bile acids and colorectal cancer?

Bile acid composition was assessed in 50 patients with colorectal cancer as compared to that in a control group of 50 subjects. The two groups were age- and sex-matched. The overall bile acid values were similar in both groups, while the relative concentrations of primary and secondary bile acids were different, a significant increase in the patients with colorectal cancer being observed. This finding thus seems to confirm the existence of a link between colorectal cancer and cholelithiasis. Both conditions share common risk factors, such as alterations in cholesterol metabolism and bile acid composition.

[Biliary calculi in liver cirrhosis. Clinical, epidemiologic & therapeutic aspects]. / Litiasi biliare in corso di cirrosi epatica. Considerazioni clinico-epidemiologiche e di terapia.

BACKGROUND: Incidence of cholelithiasis in cirrhotic patients is twice of threefold that in non cirrhotic one. Cholelithiasis is often asintomatic, however, when complications occur, emergency surgery is burden by high rates of morbidity and mortality. Purpose of the current study is to state the clinical features and to assess the outcome of elective surgery in these patients. METHODS: Sixtyseven consecutive patients with liver cirrhosis (Group A) who underwent elective surgery for biliary stones were retrospectively reviewed. Preoperative clinical features, surgical procedure, postoperative morbidity and morality were recorded and compared with those of the 3291 non cirrhotic patients (Group B) observed in the same period and submitted to elective surgery for biliary stones. RESULTS: Stone involvement of the biliary tract (A vs B:31.3% vs 20.5%), cholangitis (A vs B:23.8% vs 13.0%) and acute biliary pancreatitis (A vs B:4.4% vs 0.7%) were found to be more frequent among cirrhotic patients. In Group A postoperative morbidity and mortality in Child-Pugh A and B were found to be not statistically different from those of Group B patients. CONCLUSION: Authors conclude that definitive biliary surgery may be considered as a successful and safe indication in the treatment of cirrhotic patients in Child-Pugh A and B grade. Conservative approaches are considered as more suitable in Child-Pugh C patients, and definitive elective procedures should be considered for these patients only when an improvement of their liver function can be achieved.

Parental history of hypertension, sodium loading, and cardiovascular response to stress.

Parental history of hypertension, dietary sodium, and psychological stress have all been implicated in the development of essential hypertension and may interact in elevating disease risk. The mechanism by which this might occur is unclear, but it may be related to changes in the peripheral vasculature. The present study examined the effects of parental history and sodium on cardiovascular responses to an extended stressor. Eighteen normotensive offspring of hypertensives and 18 offspring of normotensives were exposed to a 1-hour shock-avoidance video-game procedure after 14 days of sodium loading (10 1-g tablets/day) and again after 14 days of placebo tablets. Order of sessions was counterbalanced between subjects in a double-blind design. In offspring of hypertensives, sodium loading elevated total peripheral resistance and norepinephrine responses to stress relative to placebo conditions and compared with offspring of normotensives. These increases were accompanied by decreases in stroke volume and cardiac output, which may explain the absence of familial differences in blood pressure responses to stress and sodium. Sodium loading had no effect on offspring of normotensives. The elevated resistance in offspring of hypertensives may suggest the initiation of pathological processes. The absence of sodium effects on resting values indicates the importance of research under conditions of stress.

[Mirizzi syndrome. Diagnostic and therapeutic considerations on 27 cases]. / La sindrome di Mirizzi. Considerazioni di diagnosi e terapia su 27 casi osservati.

Mirizzi's syndrome is characterized by compression and/or stenosis of the common bile duct as a consequence of a stone impaction in the cystic duct or in the gallbladder neck. Clinical outcome, diagnostic pathway and operative management in 27 patients are presented. Ultrasound is referred as the first screening method, while E.R.C.P. and/or percutaneous transhepatic cholangiography allow to confirm the diagnosis. Surgical approach is considered to be of choice and technical expedients are suggested to prevent intraoperative damage and to repair defects of the common bile duct.

Parental history of hypertension, menstrual cycle phase, and cardiovascular response to stress.

The present study examined whether inconsistent findings for elevated cardiovascular response to stress in female offspring of hypertensives might be a function of 1) lack of control for menstrual cycle phase, and 2) stressor type employed. Thirty healthy women (18-35 years), half of whom were offspring of hypertensives, were tested in both the luteal and follicular phases of the menstrual cycle. Order of testing was counterbalanced between subjects and cycle phase was confirmed by measurement of serum sex hormone levels. In each session, subjects were exposed to four tasks: the cold pressor test, interpersonal speech, shock-avoidance video-game, and reading. The most consistent menstrual cycle effect was for offspring of normotensives who exhibited higher diastolic blood pressure and state-anger responses to the speech task in the follicular compared with the luteal phase. Though menstrual cycle had no consistent effect on offspring of hypertensives, their luteal phase diastolic blood pressure and state-anger responses to the speech task were elevated compared with controls. Potential limitations of the observed familial differences in luteal phase response are discussed.

[Cancer of the distal pancreas: comments on its diagnosis and therapy]. / Il cancro del pancreas distale: considerazioni su diagnosi e terapia.

The authors report 14 cases of neoplasms involving the pancreatic body and tail. Duration and characteristics of symptoms at outbreak, diagnostic work-up, resection rates, morbidity and operative mortality are statistically analysed and compared with those found in the same period in patients with cancer of the pancreatic head. A number of important differences between these two locations are detected and analytically discussed.

The impact of ultrasonography on the prognosis of pancreatic cancer.

The authors review 207 consecutive patients admitted for pancreatic cancer from 1960 to 1989 to the 1st Department of Surgery of the University of Rome "La Sapienza", in order to ascertain whether ultrasonography contributes to achieving the ideal goal of early diagnoses. The results achieved show a higher number of early diagnoses (< 1 month from first symptoms) performed by means of US, and a concurrent increase of cases amenable to radical surgery during the period 1975-1989, and basically from 1985 to 1989. Diagnostic imaging, namely US, is therefore deemed to provide earlier diagnoses and higher rates of pancreatic resectability.

[The impact of technology on the diagnosis and treatment of pancreatic carcinoma]. / L'impatto tecnologico sulla diagnosi e sul trattamento del carcinoma pancreatico.

Between 1960 and 1989, 207 patients with cancer of the head of the pancreas were diagnosed in the 1st Surgical Department of the University of Rome "La Sapienza". While in the first period (1960-'74) diagnosis was performed on the basis of clinical signs and traditional radiological findings, imaging and endoscopy became progressively the main diagnostic tools in the second one (1975-'89). The authors analyse how the different diagnostic approach has influenced the therapeutical outcome. Earlier diagnosis, increased resectability, proper surgical indication, decreased morbidity and mortality, improvement of survival are the achieved results.

[Biliary tract surgery in patients of 70 and older: an assessment of our experience with 100 consecutive cases]. / La chirurgia delle vie biliari nei pazienti di 70 anni ed oltre: bilancio di una esperienza su 100 casi consecutivi.

A series of 100 consecutive patients aged 70 years and older having biliary tract lithiasis observed over a 19-year period (1970-1989) at the 1st Surgical Department of the University of Rome was analyzed in an effort to define morbidity and mortality. Eighty-eight patients underwent surgical treatment. Three patients died postoperatively (3.4%); 12 patients had local and 13 general complications. The highest incidence of complications occurred in patients with associated diseases and bacteriobilia. A long-lasting symptomatology involved a more frequent exploration of the common bile duct. Morbidity and mortality were not significantly related to the type of surgical procedure performed. Elective biliary tract surgery is a safe procedure even in aged patients.