Longterm peripheral baroreflex and chemoreflex function after bilateral eversion carotid endarterectomy

Introduction The “eversion” technique for carotid endarterectomy (e-CEA), that involves the transection of the internal carotid artery at the carotid bulb and its eversion over the atherosclerotic plaque, has been associated with an increased risk of postoperative hypertension possibly due to a direct iatrogenic damage to the carotid sinus fibers. The aim of this study is to assess the long-term effect of the e-CEA on arterial baroreflex and peripheral chemoreflex function in humans. Methods A retrospective review was conducted on a prospectively compiled computerized database of 3128 CEAs performed on 2617 patients at our Center between January 2001 and March 2006. During this period, a total of 292 patients who had bilateral carotid stenosis ≥70% at the time of the first admission underwent staged bilateral CEAs. Of these, 93 patients had staged bilateral e-CEAs, 126 staged bilateral s- CEAs and 73 had different procedures on each carotid. CEAs were performed with either the eversion or the standard technique with routine Dacron patching in all cases. The study inclusion criteria were bilateral CEA with the same technique on both sides and an uneventful postoperative course after both procedures. We decided to enroll patients submitted to bilateral e-CEA to eliminate the background noise from contralateral carotid sinus fibers. Exclusion criteria were: age >70 years, diabetes mellitus, chronic pulmonary disease, symptomatic ischemic cardiac disease or medical therapy with b-blockers, cardiac arrhythmia, permanent neurologic deficits or an abnormal preoperative cerebral CT scan, carotid restenosis and previous neck or chest surgery or irradiation. Young and aged-matched healthy subjects were also recruited as controls. Patients were assessed by the 4 standard cardiovascular reflex tests, including Lying-to-standing, Orthostatic hypotension, Deep breathing, and Valsalva Maneuver. Indirect autonomic parameters were assessed with a non-invasive approach based on spectral analysis of EKG RR interval, systolic arterial pressure, and respiration variability, performed with an ad hoc software. From the analysis of these parameters the software provides the estimates of spontaneous baroreflex sensitivity (BRS). The ventilatory response to hypoxia was assessed in patients and controls by means of classic rebreathing tests. Results A total of 29 patients (16 males, age 62.4±8.0 years) were enrolled. Overall, 13 patients had undergone bilateral e-CEA (44.8%) and 16 bilateral s-CEA (55.2%) with a mean interval between the procedures of 62±56 days. No patient showed signs or symptoms of autonomic dysfunction, including labile hypertension, tachycardia, palpitations, headache, inappropriate diaphoresis, pallor or flushing. The results of standard cardiovascular autonomic tests showed no evidence of autonomic dysfunction in any of the enrolled patients. At spectral analysis, a residual baroreflex performance was shown in both patient groups, though reduced, as expected, compared to young controls. Notably, baroreflex function was better maintained in e-CEA, compared to standard CEA. (BRS at rest: young controls 19.93 ± 2.45 msec/mmHg; age-matched controls 7.75 ± 1.24; e-CEA 13.85 ± 5.14; s-CEA 4.93 ± 1.15; ANOVA P=0.001; BRS at stand: young controls 7.83 ± 0.66; age-matched controls 3.71 ± 0.35; e-CEA 7.04 ± 1.99; s-CEA 3.57 ± 1.20; ANOVA P=0.001). In all subjects ventilation (VÝ E) and oximetry data fitted a linear regression model with r values > 0.8. Oneway analysis of variance showed a significantly higher slope both for ΔVE/ΔSaO2 in controls compared with both patient groups which were not different from each other (-1.37 ± 0.33 compared with -0.33±0.08 and -0.29 ±0.13 l/min/%SaO2, p<0.05, Fig.). Similar results were observed for and ΔVE/ΔPetO2 (-0.20 ± 0.1 versus -0.01 ± 0.0 and -0.07 ± 0.02 l/min/mmHg, p<0.05). A regression model using treatment, age, baseline FiCO2 and minimum SaO2 achieved showed only treatment as a significant factor in explaining the variance in minute ventilation (R2= 25%). Conclusions Overall, we demonstrated that bilateral e-CEA does not imply a carotid sinus denervation. As a result of some expected degree of iatrogenic damage, such performance was lower than that of controls. Interestingly though, baroreflex performance appeared better maintained in e-CEA than in s-CEA. This may be related to the changes in the elastic properties of the carotid sinus vascular wall, as the patch is more rigid than the endarterectomized carotid wall that remains in the e-CEA. These data confirmed the safety of CEA irrespective of the surgical technique and have relevant clinical implication in the assessment of the frequent hemodynamic disturbances associated with carotid angioplasty stenting.

Effetti degli accordi Euro-Mediterrani sul comparto dell'ortofrutta fresca

In 1995, the European Union (EU) Member States and 12 Mediterranean countries launched in Barcelona a liberalization process that aims at establishing a free trade area (to be realized by 2010) and at promoting a sustainable and balanced economic development by the adoption of a new generation of Agreements: the Euro-Mediterranean Agreements (EMA). For the Mediterranean partner countries, the main concern is a better access for their fruit and vegetable exports to the European market. These products represent the main exports of these countries, and the EU is their first trading partner. On the other side, for the EU the main issue is not only the promotion of its products, but also the protection of its fruit and vegetables producers. Moreover, the trade with third countries is the key element of the Common Market Organization of the sector. Fruit and vegetables represent a very sensitive sector since their high seasonality, high perishability, and especially since the production of the Mediterranean countries is often similar to the European Mediterranean’s countries one. In fact, the agreements define preferences at the entrance of the EU market providing limited concessions for each partner, for specific products, limited quantities and calendars. This research tries to analyze the bilateral trade volume for fresh fruit and vegetables in the European and Italian markets in order to assess the effects of Mediterranean liberalization on this sector. Free trade of agricultural products represents a very actual topic in international trade and the Mediterranean countries, recognised as big producers of fruit and vegetables, as big exporters of their crops and actually significantly present on the European market, could be high competitors with the inward production because the outlet could be the same. The goal of this study is to provide some considerations about the competitiveness of mediterranean fruit and vegetables productions after Barcelona Process, in a first step for the European market and then also for the Italian one. The aim is to discuss the influence of the euro-mediterranean agreements on the fruit and vegetables trade between 10 foreign Mediterranean countries (Algeria, Egypt, Israel, Jordan, Libya, Lebanon, Morocco, Tunisia, Syria, and Turkey) and 15 EU countries in the period 1995-2007, by means of a gravity model, which is a widespread methodology in international trade analysis. The basic idea of gravity models is that bilateral trade from one country to another (as the dependent variable) can be explained by a set of factors: - factors that capture the potential of a country to export goods and services; - factors that capture the propensity of a country to imports goods and services; - any other forces that either attract or inhibit bilateral trade. This analysis compares only imports’ flows by Europe and by Italy (in volumes) from Mediterranean countries, since the exports’ flows toward those foreign countries are not significant, especially for Italy. The market of fruit and vegetables appears as a high heterogeneous group so it is very difficult to show a synthesis of the analysis performed and the related results. In fact, this sector includes the so called “poor products” (such as potatoes and legumes), and the “rich product”, such as nuts or exotic fruit, and there are a lot of different goods that arouse a dissimilar consumer demand which directly influence the import requirements. Fruit and vegetables sector includes products with extremely different biological cycles, leading to a very unlike seasonality. Moreover, the Mediterranean area appears as a highly heterogeneous bloc, including countries which differ from the others for economic size, production potential, capability to export and for the relationships with the EU. The econometric estimation includes 68 analyses, 34 of which considering the European import and 34 the Italian import and the products are examined in their aggregated form and in their disaggregated level. The analysis obtains a very high R2 coefficient, which means that the methodology is able to assess the import effects on fruit and vegetables associated to the Association Agreements, preferential tariffs, regional integration, and others information involved in the equation. The empirical analysis suggests that fruits and vegetables trade flows are well explained by some parameters: size of the involved countries (especially GDP and population of the Mediterranean countries); distances; prices of imported products; local production for the aggregated products; preferential expressed tariffs like duty free; sub-regional agreements that enforce the export capability. The euro-mediterranean agreements are significant in some of the performed analysis, confirming the slow and gradual evolution of euro- Mediterranean liberalization. The euro-mediterranean liberalization provides opportunities from one side, and imposes a new important challenge from the other side. For the EU the chance is that fruit and vegetables imported from the mediterranean area represent a support for local supply and a possibility to increase the range of products existing on the market. The challenge regards the competition of foreign products with the local ones since the types of productions are similar and markets coincide, especially in the Italian issue. We need to apply a strategy based not on a trade antagonism, but on the realization of a common plane market with the Mediterranean countries. This goal could be achieved enhancing the industrial cooperation in addition to commercial relationships, and increasing investments’ flows in the Mediterranean countries aiming at transforming those countries from potential competitors to trade partners and creating new commercial policies to export towards extra European countries.