A.tti del I I Simposio Internazionale su

Aspetti medico - sociali della Cronobiologia

Proceedings of I I International Symposium on

Chronobiologic approach to social medicine

A cura di / Edited by F . H A L B E R G - L . R E A L E - B. TARQUINI

Promosso ed organizzato DALL'ISTITUTO ITALIANO D I MEDICINA SOCIALE

con i l patrocinio DELL'ASSESSORATO ALLA SANITA' DELLA REGIONE TOSCANA

DELL'UNIVERSITA' DI FIRENZE Ε DELLA SOCIETA' ITALIANA DI CRONOBIOLOGIA

con la collaborazione DELL'ISTITUTO D I CLINICA MEDICA I I

DELL'UNIVERSITA' DI FIRENZE

Firenze, 2 ottobre 1984

ISTITUTO ITALIANO D I MEDICINA SOCIALE E D I T O R E - ROMA

Circadian timing of serum Cortisol in patients with anorexia nervosa / Timing del ritmo circadiano del cortisolo sierico in pazienti con anoressia nervosa

Boguslawa Baranowska *, Maria Lazicka-Frelek *, Barbara Migdalska *, Stefan Zgliczynski*, Barnett Zumoff**, R.$. Rosenfeld**, Germaine Cornelissen***, Helmut Arbogast****, Elke Eckert***, Franz Halberg***

* Endocrinology Clinic, Medical Center of Postgraduate Education, Bielanski Hospital - Ceglowska 80 - 01-809 Warsaw, Poland

** Department of Medicine, Beth Israel Medical Center, New York, NY, USA *** University of Minnesota, Minneapolis, MN, USA **** Kinderzentrum, University of Munich, F R G

Introduction

The hypothalamic-pituitary-adrenal network in patients wi th ano­rexia nervosa (AN) appears to be unusually active. Time-unspecified fasting or other serum Cortisol concentrations are reported as elevated in virtually all studies investigating plasma Cortisol in patients wi th AN (3, 6, 8, 10, 11, 19, 36, 37). Elevated serum Cortisol has been regarded as a differential diagnostic feature distinguishing AN from Addison's disease. This elevated serum Cortisol has been associated wi th a decrease in the rate of Cortisol metabolism in the form of an increased, i f circa­dian stage-unspecified Cortisol half-life (3, 8), probably related to a re­duced capacity of the liver for ring A reduction of Cortisol.

Elevated serum Cortisol has also been associated wi th an increased

SUPPORT: Scientific Programme RMZ-VII /9 ; National Institute of General Medical Sciences (GM-13981); Medtronic Inc., Minneapolis, MN, USA

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rate of Cortisol production relative to body size (35). There is an in­crease in the excretion of unconjugated or « free » Cortisol in the urine, usually a very sensitive indicator of adrenal overactivity (3, 35). Adreno­cortical activity is not as readily suppressed in patients wi th AN (8, 12) as in clinical health (CH), a finding suggesting fhat the hypothalamic and pituitary centers coordinating adrenal activity have an altered sen­sitivity.

I t has been suggested (7, 29) that malnutrition in anorexia nervosa patients is responsible for alterations seen in Cortisol metabolism. A more recent review (35), however, has concluded that additional changes in AN are not accounted for by protein-calorie malnutrition (29).

There are differing reports concerning the circadian variation of circulating Cortisol in AN. Some authors report an absence of the usual circadian variation (10, 11, 18, 33, 36), suggesting a disturbance of the hypothalamic coordination of pituitary-adrenal function in patients wi th AN. Other authors report the usual circadian variation of Cortisol (3, 6, 8). Studies reporting usual (non-deviant) and deviant results in cir­cadian variation of serum Cortisol are listed in Table 1.

Materials and methods

We studied 22 women wi th AN, ranging in age from 17 to 29 years (mean: 23 years) wi th weight deficiency ranging from 24% to 57% (mean 39%), and 18 CH women, 19 to 58 years of age (mean: 35 years) whose body weights were wi th in accepted limits. AN was diagnosed based on criteria described elsewhere (9, 25):

1) a pattern of behavior aimed at inducing weight loss,

2) emaciation to a body weight at least 20% below standard,

3) cessation of menstruation for at least 3 months,

4) absence of other (overt) physical or psychiatric illness.

Ideal body weight was calculated in kg from the formula: height in cm - 100. The clinical data are presented in Table 2.

The subjects wi th AN or in CH were examined on the 4th day of their hospitalization. The subjects slept or rested from about 23°° unt i l 07°°. Meals were served at 08°°, 13°° and 17°°. No drugs were admi­nistered. Activity was limited to that compatible wi th standard hos-

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Table 1

C I R C A D I A N V A R I A T I O N O F S E R U M C O R T I S O L IN ANOREXIA N E R V O S A

Authors Studies reporting

Sampling deviant results

# Samples /24h

# of subjects

Age (yrs) °/o loss in body weight

Comment (% deviant)

•Frankel and Jenkins (10) 09°°, 000 0 2 4 16-28 23.3-34.6 kgx 50

0830, low 2 9 13-25 26-48XX Data regarded as Garfinkel et al. (11) Morning & insufficient by authors Hurd et al. (18) afternoon 2 101 11-61 0-59 53

33.6+10.5xx 55 Vigersky et al, (33) 0800, 17°° 2 11 23.7+8.1 15-54 48°/o deviant & 22% with Warren & Van de « reversal » of circadian Wiele (36) 0900, 1600 2 23 10-23 rhythm

Studies reporting non-deviant results

Boyar et al. (3) q 20 min 72 10 16-28 23.8 —40.1xx 0 Casper et al. (6) Ö830, 200 0 2 20 14-32 16 —48xxx 0 Doerr et al. (8) q 30 min 48 16 13-29 23 —49xx 0

x% loss not reported xx% loss from ideal body weight taken from the Metropolitan Life Insurance Co. Statistical Bullettin, 1959

xxx°/o loss from « normal »

Table 2

C L I N I C A L DATA O F P A T I E N T S W I T H ANOREXIA N E R V O S A (AN)

Case Age Height Body weight Deficit of body number (years) (cm) (kgQ weight* (%)

1 27 156 24 57 2 26 160 28 53 3 25 165 31 52 4 29 161 31 49 5 25 162 33 47 6 22 167 37 45 7 25 168 38 44 8 22 158 34 41 9 19 163 37 41

10 26 166 39 41 11 22 172 44 39 12 28 154 34 37 13 24 160 39 36 14 19 162 40 35 15 16 165 43 34 16 18 154 38 29 17 18 155 40 27 18 17 164 48 25 19 20 160 45 25 20 26 154 41 24 21 22 161 47 23 22 27 164 49 23

* in relation to ideal body weight in kg computed as height in cm -lOO

pital conditions. The patients did not exhibit any body weight gain prior to blood sampling for Cortisol determinations. Blood samples were taken from the antecubital vein at 08°°, 12°°, 16°° and 220 0. Serum Cortisol con­centrations were measured by a fluorometric method (30). The data were analyzed by the single cosinor procedure (15, 17). Time-specified reference intervals, notably prediction intervals, were computed, as no­ted elsewhere (13, 21, 22), from the data on CH women and also from a data base used for international reference standards (14). Calculations were made by computer (Mera 400 and PDP11/34) wi th Fortran IV programs.

538

Results

The mean 24-h Cortisol concentrations in the CH women ranged from 6.10 to 25.55 μg/dl (Table 3). The mean 24-h Cortisol concentra­tions of the AN subjects were higher, from 12.12 to 43.28 μg/dl (Ta­ble 4). The difference between the mean of serum Cortisol in AN patients of 20.9 as compared to 13.2 in CH subjects is 7.8 ± 2.1 (SE), the cor­responding t is 3.65 (p <0.01).

A group rhythm is demonstrated by the population-mean cosinor technique for AN and CH, as shown in Table 5. The P-values (<.01) in testing the zero-amplitude (no rhythm) assumption demonstrate the prominence of circadian rhythmicity.

The timing of the Cortisol rhythm in each individual is shown in Figure 1 by acrophases alone. These are plotted along a circular scale, irrespective of amplitude. The acrophases of the CH women (dots) ran­ged from 0624 to 1041 (hrs min) from local midnight. Acrophases similar to those of the healthy group are also found in 16 of the women wi th AN (triangles). The acrophases of the six remaining patients wi th AN lie far outside the range of CH women (15° = 1 h). I n these women (wi th outlying acrophases), the body weight deficit rangefj from 39% to 57% of ideal body weight. The weight deficits of those;AN patients wi th acrophases within or outside the CH limits averaged 33.4% and 48.8%, respectively, The difference of 15.4 + 3.8% (SE) i$ associated wi th a t of 4.06 and is significant below the 1% level. One may also use a reference prediction region (ellipse) or conservative prediction limits (i.e., the tangents drawn to the ellipse) instead of a range for inter­preting the acrophase. The institutional reference ellipse and the indi­vidual (A, 0 ) pairs for AN patients are shown in Figs. 2a and 2b. I n Fig. 2a, the amplitude is used in original units, whereas in Fig. 2b, i t is expressed as percent of MESOR. With either approach, the results are discriminating in that the difference in body weight loss of patients whose Cortisol (A, 0 ) pair lies inside or outside the reference prediction ellipse (or the prediction limits for 0 ) is statistically significant below the 1% level.

Both approaches are given (for completeness), but a priori , i t was decided to interpret results on the basis of the amplitude as percentage of the MESOR, since, earlier, such reference regions, as compared to those based on the amplitude expressed in original units, had been found to be more reliable and internationally valid (21). Figs. 2a and 2b allow

539

Table 3

R H Y T H M O M E T R I C SUMMARY O F S E R U M C O R T I S O L I N C L I N I C A L L Y H E A L T H Y W O M E N *

Subject ID M E S O R

teg/dl) Amplitude

Acrophase 360° ss 24 h 0° = midnight degrees hour minute

2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18

10.52 6.10

14.25 10.98 10.70 11.23 10.80 12.33 10.72 13.80 11.78 7.55

11.23 25.55 22.75 22.50 10.78 13.22

2.08 3.14 5.70 6.98 3.33 5.74 2.94 3.16 3.41 2.69 3.57 2.35 4.70 7.15 6.67 3.98 4.65 4.28

132 142 120 102 110 131 149 129 133 106 122 96

144 124 109 148 118 160

08 09 08 06 07 08 09 08 08 07 08 06 09 08 07 09 07 10

51 30 02 50 22 47 57 39 52 07 11 24 38 16 17 52 55 41

* Each subject contributed 4 samples at 0600, 1200; 1600 and 2200.

an examination of the AN subjects ranked in order of decreasing seve­rity of body weight loss. Most of the AN patients wi th the largest deficit (wi th the lowest numbers shown in Figs. 2a and 2b) are outside the 90% prediction region.

A Kruskal-Wallis test was performed to compare the body weight loss in AN patients ( in Warsaw) having their Cortisol (A, 0 ) pair inside or outside the reference, region. A statistically significant difference is thus demonstrated ( X 2

( D = 9.136; Ρ <.01). This result is in keeping wi th that of the Student t-test reported above. A linear regression of only borderline statistical significance (P = .065) was found between relative body weight loss and the extent of departure of the Cortisol rhythm from « normalcy » (di), as gauged by the euclidean distance between the patients' (Ai/Mi, 0i)s and the CH population rhythm estimate ( A / M , 0 ) :

A

Μ sin 0 .

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Table 4

R H Y T H M O M E T R I C SUMMARY O F S E R U M C O R T I S O L I N WOMEN W I T H A N O R E X I A N E R V O S A *

Case teg/dl) Acrophase 360°= =24 h, 0° = midnight # M E S O R Amplitude degrees hour minute

1 18.88 3.70 — 17 01 08 2 12.32 3.61 — 209 13 58 3 16.28 0.86 — 9 00 38 4 23.28 2.57 — 94 06 16 5 28.07 10.48 — 244 16 18 6 25.72 7.98 — 183 12 13 7 15.33 4.58 — 113 07 35 8 24.63 4.26 — 113 07 32 9 23.33 6.14 — 139 09 16

10 19.52 3.96 — 97 06 30 11 17.33 6.25 — 261 17 25 12 15.03 4.42 — 121 08 04 13 17.22 5.22 — 125 08 20 14 43.28 3.74 — 95 06 21 15 15.40 5.29 — 127 08 28 16 15.22 1.68 — 93 06 13 17 24.70 1.64 — 99 06 37 18 24.33 4.26 — 113 07 19 36.07 12.73 — 105 07 Ρ3

ί2 20 12.12 0.87 — 145 09 Ρ3 ί2

21 16.67 1.87 — 112 07 h 22 15.35 2.17 — 106 07 07

* Each subject contributed 4 samples at 0600, 1200, 1600 and 2200.

Table 5

POPULATION-MEAN COSINOR OF 24-h P R O F I L E OF S E R U M C O R T I S O L C O N C E N T R A T I O N I N C L I N I C A L H E A L T H AND ANOREXIA N E R V O S A *

Population Ν Ρ M ± S E A (95% C L ) 0 h r m i n ( 9 5 % C L )

Anorexia nervosa Clinically healthy women

subj. 22

18

.003

<.001

20.93 + 1.70

13.16+1.23

2.55 (1.04,4.06)

4.07 (3.29,4.86)

084 8 (07«\ 1152)

0823 (0748, 090 0)

* Ν subj. = number of subjects Μ = M E S O R A = amplitude 0 = acrophase 95°/o C L = confidence limits Ρ = P-value in testing zero-amplitude (no-rhythm) hypothesis

541

Figure 1

Acrophases from cosinor summaries of 24-h profiles of serum Cortisol concentration in clinical health ( · ) and anorexia nervosa ( ^ ) .

Until more data are available, one cannot say whether there may not be a gradual departure from « normalcy » as a function of body weight loss or, rather, that abnormality occurs more abruptly once body weight loss has reached a critical point.

With 4 samples, 4 to 8 hours apart, on 18 to 22 subjects, i t is tempting to ignore individual behavior altogether and to restrict one's attention to groups only, unless a reference group of more than 18 cli­nically healthy subjects (sampled sparsely) can be found as an additio­nal reference standard. Additional data for use as standards for women

542

Figure 2a

Circadian Amplitude (A)- Acrophase (0) Pair of Serum Cortisol in Women with

Anorexia Nervosa (0 in Relation to 90% Prediction Region for Clinically Healthy Women*

Computed with A in original units.

For 0 in degrees 360°= 24 hours

Numbers accompanying outliers indicate rank in relation to decreasing severity of body weight loss, the loss itself being given in parentheses as percentage of ideal body weight.

Institutional elliptical reference region for acrophase-amplitude pair of serum Cortisol concentrations estimated for clinically healthy women against which individual values for patients with anorexia nervosa are shown. Numbers show ranks in order of decreasing severity of body weight deficit. Deficits also given in parentheses as percentage of ideal body weight. Reference region based on amplitude in original units (a), left, and on amplitude expressed in percentage of mesor (b), middle. Results shown against international reference standard (c), right.

Figure 2b

Circadian Amplitude (A)- Acrophase (0) Pair of Serum Cortisol in Women with

Anorexia Nervosa (*) in Relation to 90% %

Prediction Region for Clinically Healthy Women Computed with A as percentage of mesor.

For 0 in degrees 360°= 24 hours 0°=00 0 0

M e a l s

% of Mesor

Rest-Activity Schedule

Numbers accompanying outliers indicate rank in relation to

decreasing severity of body weight loss, the loss itself being given

in parentheses as percentage of ideal body weight.

544

in CH are indeed available from a study involving 134 series sampled at 20-minute intervals for 24 hours, Figure 3 (14). International validity has been documented for such a reference standard in the form of the 90% prediction region for the amplitude and acrophase pair, when the amplitude is expressed as a percentage of the MESOR. Such a Minneso-tan prediction region, computed to contain 90% of a population, contains the (anticipated) majority of amplitude-acrophase pairs from studies of clinically healthy individuals in Japan (23), Italy and Germany (13). Moreover, all 18 of the Polish women in CH fall within this interna­tional reference standard (not shown). By contrast, one-half of the Polish women wi th AN fall outside this international standard (Fig. 2c). Unti l proof is offered to the contrary, a local institutional reference region is preferred to an international one. I n our case, the results obtained wi th the use of an international standard support the infe­rences based upon the use of a local standard.

Whichever standard is used, certain AN patients, but not all of them, have atypical acrophase-amplitude pairs. I t is of interest to see whether such differences are due to amplitude only, to acrophase only, or to both characteristics. Student's t-tests for any difference in body weight loss between those wi th amplitudes inside and outside the (A, 0 ) prediction region or inside and outside the reference interval for A, computed on the basis of the amplitude in original units, or on the basis of the amplitude expressed as percent of MESOR, were all associated wi th a Ρ above the 10% level (the corresponding t-values are 0.98, 0.43, 1.39 and 0.99).

A procedure similar to that practiced for examining discrimination of extent of body weight loss by the use of acrophases as criterion was also applied to the mean 24-h Cortisol concentrations or MESORS. Four patients w i th AN had their rhythm-adjusted means outside the range of those of CH women by more than 1 μg/dl. These four subjects had a mean weight deficit of 38%, whereas the other AN patients, who had a Cortisol MESOR wi th in the range of MESORS for CH, had a mean weight deficit of 37.5% (t = 0.08; Ρ >0.50). Unti l proof is offered to the con­trary, the increase in mean Cortisol concentration seen in AN patients may be non-specific in reflecting a low body weight, while a change in acrophase is more specific in this context. I t is concluded, in the light of such results, that the best criterion among the three parameters ex­amined here- -MESOR, amplitude and acrophase- -is indeed the acrophase. The value of a combination of these indices and of the waveform (when denser data allow its assessment, e.g., by harmonics), however, remains

545

Figure 2c

Circadian Characteristics of Serum Cortisol in 11 of 22 Women with Anorexia Nervosa in Poland Lie Outside

90% Prediction Region for Clinically Healthy Minnesotans

to be investigated. For the time being, the finding of deviant Cortisol acrophases relative to body weight loss is based on sparse data, whereas the similarity of circadian Cortisol acrophases examined by objective cosinor methods throughout the year in women of different ages, in different populations, and on different continents (14), rests on dense data obtained every 20 minutes for 24 hours, Figure 3.

546

Figure 3

CIRCADIAN RHYTWS OF PLASMA CORTISOL IN CLINICALLY HEALTHY WOMEN:

AGREEMENT AMONG SUBJECTS*

Japanese and American Women ot Three Age Groups

• IT aaottsctar t a o u * . ι · ) » - · KWftBaOMlT t aOU' . IO t • WMHSO'*

aosT-a«ia>»«wsai *» O U * . I * I ι » w v « yv»

Results of fit of 24-h cosine curve to 24-h plasma Cortisol profiles aj 100-minute intervals. With data at 20-minute intervals, over 99% of series allow rejection of the no-rhythm assumption at the 1% level and all do so at the 10% level.

Discussion

With Rotable exceptions (3, 8, 37) (Table 1), much earlier discussion in the literature on Cortisol in AN vs. CH is based on samples that were even more) l imited than those in the present study. Sampling limited to a single time-unspecified determination described as «fas t ing» , wi th added determinations apparently stemming from response tests, can be cited (17). There is also a case when dense sampling is used only for computing a reliable mean (37). Others sampled twice a day, Table 1. I t is on that basis that some authors discuss a deviant circadian varia­tion, whereas still others feel that the variation is wi th in the expecta­tion for clinically healthy subjects. Hurd et al. (18) report that in 42% of their patients, serum corticosteroid concentration was elevated and circadian variation lost or reversed in 53%, and that weight loss was correlated w i t h the urinary excretion of ketogenic steroids: the greater the weight loss, the higher the systemic steroid excretion. These authors refer to a discrepancy in AN between the serum concentration and the urinary excretion of corticosteroids, on the basis of data limited to

547

serum samples from 2 timepoints, in keeping with the practice of others (Table 1).

I t is noteworthy that the most extensive sampling--every - 20 or every 30-minute sampling (3, 8}·-yielded the overall (macroscopic) im­pression of no deviant result. I t is possible that the unaided eye, seeking to interpret small differences in pattern of variation (macroscopically) in a time plot, may often be in the same position as the eye unaided by histologic microscopy, trying to find a cell (macroscopically) in a tissue. Rhythmometric (microscopic) procedures such as the cosinors used herein provide objective point and (confidence) interval estimates of rhythms when the data are sufficiently dense. When the data are relatively sparse (for a rigorous individualized assessment), an imputed characteristic in AN, such as the amplitude-acrophase pair, may be interpreted by reference to a prediction region established on the basis of institutional sampling, in Figures 2a and 2b, or on the basis of inter­national reference standards (Figure 2c).

I t is also possible that other factors account for the difference in outcome. Further analyses are needed before one can conclude that the sparser sampling discriminates better and, if so, to determine to what extent alterations of waveform may be involved.

Whereas the finding of a statistically significantly different behavior as a function of the extent of weight loss experienced by the AN patients (those wi th the deviant acrophases showing, on the average, a greater deficit) is apparently original, it complements earlier focus by Gerner and Gwirtsman (12) upon the extent of weight loss i n the light of dexamethasone suppression tests. The Cortisol concentration after dexa-methasone suppression was correlated with the percentage of ideal weight (r = .35); there was a trend for the Cortisol concentrations of the 11 women who were less than 65% of their ideal weight to be higher than the concentrations of the 5 women who were 74% —80% of their ideal weight (17.3 + 2.2 versus 9.5 + 2.1 μg/dl, t = 2.12, ρ ~ 0.05).

Differences in the circadian and circannual timing of the periodic production of aldosterone, Cortisol, dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEA-S) are noteworthy; they suggest the periodic ope­ration of a 4-way switch in the pathway of adrenocortical steroid bio­synthesis preferred at a given stage. Thus, in human beings, along the 24-hour scale, high values of aldosterone precede those of Cortisol, with the latter preceding high DHEA, wi th high DHEA-S concentrations lag­ging behind all of these. Although the concentrations of these hormones

548

i n blood are vastly different, their time relations, notably of DHEA-S, along the scale of a year as well as of a day may be important markers of enzymatic adrenocortical activities. The pineal may contribute to this t iming, since i t is already known that i t rhythmically modulates (attenuates, leaves unaffected or amplifies) a pituitary tropic hormone (ACTH) effect upon adrenal corticosterone production (26-28). This mo­dulation may be impaired i f not absent in some patients wi th AN.

Deviant acrophases, such as those here noted for AN, can also be seen in our analyses of data obtained wi th a sampling similar to that here practiced on 3 out of 4 children wi th AN in Munich, Federal Re­public of Germany (13), as well as in very young CH children (less than 1 year of age) in M i k i , Japan (23). I n CH children two years of age or older, the amplitude-acrophase pair is within the international reference standard for Cortisol, computed wi th the amplitude as a percentage of the MESOR. I t seems pertinent that a statistically significantly higher Cortisol concentration in anorexia nervosa found earlier (3, 6, 8, 10, 11, 19, 36, 37) was shown by Zumoff et al. (37) to be associated wi th a lowering of adrenal androgen (p < 0.05). The DHEA-to-cortisol ratio representing the relative activities of pathways from 17-hyroxy^regne-nolone to DHEA vs. Cortisol averaged less than half of the reference value in AN, while in relapse, whereas in partial remission, theffe was an increase in DHEA-to-cortisol ratio. The failure of DHEA concentra­tions to rise in response to ACTH in AN patients resembles the picture seen in pre-adrenarcheal children and is probably due to low activity of 17, 20 - lyase. What is physiological in pre-adrenarche may be patho­logical i n A N . The lowered DHEA-to-cortisol ratio then, constitutes a hormonal parameter of ontogenic regression (34). Even earlier evidence that AN may represent a regression to pre-puberty was found by Boyar et al. (4), who report that the 24-h plasma luteinizing hormone secre­tory pattern was similar to that seen in pre-pubertal children.

Along the same line of thought, our analyses of systematic data from Japan by Onishi et al. (23) show that in the first year of life as compared to later in life, the timing of the circadian variation i n Cortisol is drastically different. One could postulate that some of the patients w i t h AN might be regressed into the circadian pattern of very early childhood.

More than serum and even urinary Cortisol w i l l have to be deter­mined for those who wish to look at the mechanisms of AN. I n view of the failure of the mean to discriminate (in this study and in those of others) between patients wi th large and small deficits in body weight,

549

any endocrine focus upon AN w i l l have to include an objective measure of timing, since an alteration of timing, established wi th the cosinor method herein, is also implied macroscopically by others, referring, e.g., to a reversed pattern, Table 1.

The data herein, limited to four samples a day, have served pri­marily for the comparison of patients wi th AN and subjects in CH, but they also achieve subgroupings as a first step by weight deficit. The question whether a change in Cortisol acrophase, the discriminant found, and perhaps some change in a rhythm characteristic of another hormone (yet to be demonstrated) is an unspecific concomitant of AN, or rather an important co-determinant of the condition, is a topic for further research, to be planned in the light of this work. Our findings are in keeping wi th an alteration of cephalo-adrenal interaction (16). A direct pineal effect upon pituitary-adrenal interactions, rather than necessarily a hypothalamically-mediated pineal effect, has recently been demonstrated as a so-called feed-sideward (16, 26-28), apart from any feedbacks from the adrenal to the pituitary or hypothalamus. The pineal, in a rhythmic sequence, attenuates, leaves unaffected or amplifies the pituitary (or the ACTH) effect upon the adrenal in vitro (and thus in the absence of the hypothalamus) (16, 26-28). What is particularly per­tinent to the findings of this study, under certain conditions, the pineal shifts a rhythm that, for one reason or another, is out of phase (26). Could this aspect of pineal modulation be deficient in AN? This possi­bil i ty is a matter for further consideration to be explored wi th frequent sampling on the several variables that reflect not only the Cortisol pathway but also competing pathways coordinating electrolyte and sex hormone metabolism in the adrenal itself and also in its superimposed and juxtaposed coordinators, the pituitary, hypothalamus and pineal, now known to interact in a time-dependent fashion and wi th important consequences in terms of body defense and behavior (1φ, 26-28).

Since the hormones involved in CH as a reference standard for AN exhibit a set of rhythmic changes with several frequencies, the work herein may be used to suggest that rather than being 3 vexing source of variability, the study of circadian, circannual and other rhythms can yield novel and useful parameters that thus far have discriminated between AN patients wi th large or small body weight deficit, pointing to mechanisms of cephaloendocrine interactions and suggesting the need to test in particular a possible alteration of a pineal feed-sideward upon pituitary-adrenal interaction. Answers to whether cephaloadrenal inte­ractions constitute a determinant of AN w i l l have to be explored with

550

strategically-placed cost-effective sampling (14) on the several variables implicated by the new finding of a quantitative change in timing of the Cortisol rhythm, here interpreted in the light of the voluminous litera­ture on adrenocortical function and steroids more broadly in AN, wi th only a citation (1 , 2, 5, 20, 24, 31, 32, 34, 35, 38) to some other pertinent endocrine and metabolic studies.

Conclusion

Reliance in this paper, of necessity rather than choice, upon a less specific fluorometric method, as compared to a radioimmunoassay, fo­restalls definitive inferences. A set of radioimmunoassays on much den­ser data but on a different population (37) warrants the inference that serum Cortisol in patients wi th anorexia nervosa and a certain extent of body weight loss, and in healthy subjects, is similarly timed. Whether or not this inference is to be extended to data from Warsaw, the present study, by being fluorometric and thereby picking up additional fluorogens, should prompt focus upon rhythms in substances other than Cortisol that may also exhibit deviant characteristics in anorexia nervosa.

1 Institutional in relation to reference limits, in the context of this paper, specifies 1) a population of women studied in Warsaw, 2) the fluorometric me­thod used for Cortisol determination and 3) a certain approach in determining body weight status for the diagnosis of anorexia nervosa. The Varsovian institu­tional reference standard differs from that in New York, also discussed in this paper, by all three criteria, i.e., geography and methodologies for Cortisol determi­nation and for assessing body weight loss. Whether any one or several of the three differences in possibly contributing to the results here found remains to be elucidated.

551

RlASSUNTO

Variazioni del ri tmo circadiano del cortisolo plasmatico possono indicare alterazioni della regolazione cefalo-ipotalamo-ipofisi-surrenalica in corso di anoressia nervosa (A.N.). I I cortisolo plasmatico e stato do-sato con metodo fluorimetrico in 22 donne con A.N. e 18 donne clinica-mente sane ai tempi 06, 12, 16 e 22. Sulla base dei gruppi i livelli medi di cortisolo erano significativamente piü alti nel gruppo di A.N. in raf-fronto al gruppo di controllo, ma i l MESOR non differisce nei pazienti con A.N. con i l MESOR dei controlli sani. Un ri tmo circadiano significa-tivo e stato riscontrato in entrambi i gruppi con i l metodo del « single cosinor ». Sono stati valutati i l imi t i di riferimento istituzionale per le donne sane come regioni di predizione al 90% per le misure di ampiezza/ acrofase. Sei delle pazienti con A.N. hanno mostrato caratteristiche cir-cadiane del cortisolo fuori dei l imi t i istituzionali di riferimento per i l paio ampiezza/acrofase dei normali. Le pazienti con A.N. le cui acrofasi di cortisolo erano fuori dei l imi t i di riferimento istituzionale avevano i piü gravi deficit ponderali. I I tempo di deviazione, misurato con l'am-piezza/acrofase pesato, e in accordo con altr i comportamenti regres­siv! riscontrati nelle pazienti con A.N.

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R E F E R E N C E S

1. ARO Α., LAMBERG B.A., PELKONEN K . 1977: Hypothalamic endocrine dysfunction in anorexia nervosa. Acta Endocrinol. (Kbh) 85: 673.

2. B E U M O N T P.J.V. , GEORGE G . C . W . , P I M S T O N E B . L . , V I N I K A J . 1976: Body weight and the pituitary response to hypothalamic releasing hormone in patients with anorexia nervosa. J . Clin. Endocrinol. 43: 487.

3. BOYAR R . M . , H E L L M A N L . D . , ROFFWARG H . , K A T Z J . , Z U M O F F B., O'CONNOR J . , BRADLOW H . L . , F U K U S H I M E D.K. 1977: Cortisol secretion and metabolism in anorexia nervosa. N . Engl. J . Med. 296: 190.

4. BOYAR R . M . , K A T Z J . , F I N K E L S T E I N J . W . et al. 1974: Immaturity of the 24-hour luteinizing hormone secretory pattern. N . Engl. J . Med. 291: 861.

5. BRADLOW H . L . , BOYAR R . M . , O'CONNOR J . , Z U M O F F B„ H E L L M A N J . 1976: Hypo­thyroid - like alterations in testosterone metabolism in anorexia nervosa. J . Clin. Endocrinol. 43: 571.

6. CASPER R . C . , CHATTWRTON R . T . , D A V I S J.M. 1979: Alterations in serum Cortisol and its binding characteristics in anorexic nervosa. J . Clin. Endocrinol. Me-tab. 49: 406.

7. COOKE J .N .C . , J A M E S V . H . T . , LANDON J . , W Y N N V . 1964: Adrenocortical function in chronic malnutrition. Br . Med. J . 1: 662.

8. DOERR P., F I C H T E R M., P I R K E K.M., L U N D E . 1980: Relationship between weight gain and hypothalamic pituitary adrenal function in patients with anorexia nervosa. J . Steroid. Biochem. 13/5: 529.

9. F E I G H N E R S.P., ROBINS E . , G U Z E S.B., WOODRUFF R.A. , WINOKUR G., MUNOR G. 1972: Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychol. 26: 57.

10. FRANKEL R . J . , J E N K I N S J.S. 1975: Hypothalamic - pituitary function in anorexia nervosa. Acta Endocrinol. (Kbh) 78: 209.

11. G A R F I N K E L P.E. , BROWN G M . , STANCER H . C . , MOLDOFSKA H . 1975: Hypothalamic-pituitary function in anorexia nervosa. Arch. Gen. Psychiatry 32: 739.

12. GERNER R . H . , G W I R T S M A N H . E . 1981: Abnormalities of dexamethasone suppres­sion test and urinary MHPG in anorexia nervosa. 138: 659.

13. H A E N E . , H Ö L L E R W . , B I D L I N G M E I E R F . , KNORR D . F HALBERG F . 1983: Circadian amplitude (A) - acrophase ( 0 ) of serum Cortisol in Bavarian children and adolescents and pituitary dysfunction. Chronobiologia 10: 129.

14. HALBERG F . , C O R N E L I S S E N G , SOTHERN R . B . , WALLACH L . A . , HALBERG Ε . , A H L -GREN Α., K U Z E L Μ., RADKE Α., BARBOSA J . , GOETZ F . , B U C K L E Y J . , MANDEL J . , S C H U M A N L . , H A U S Ε . , LAKATUA D . , SACKETT L . , B E R G H . , KAWASAKI T . , UENO Μ., UEZONO Κ., MATSUOKA Μ., O M A E T . , TAROUINI Β., CAGNONI M., GARCIA S A I N Z M.,

553

G R I F F I T H S Κ . , W I L S O N D., WETTERBERG L . , DONATI L . , T A T T I P., VASTA M., LOCA-T E L L I I . , CAMAGNA Α. , LAURO R . , T R I T S C H G , WENDT H. 1981: International geographic studies of oncological interest on chronobiological variables. I n : Hans Kaiser (ed) Neoplasm—Comparative Pathology of Growth in Animals, Plants and Man, Williams and Wilkins Co., Baltimore, p. 553.

15. HALBERG F . , HALBERG E . , N E L S O N W., T E S L O W T., MONTALBETTI N. 1982: Chrono-biology and laboratory medicine in developing areas. In: N. Montalbetti (ed.) f

Proc. 1st. African and Mediterranean Congress oi Clinical Chemistry, p. 113.

16. HALBERG F . , SANCHEZ DE LA PENA S. , FERNANDES G. 1983: Immunochronophar-macology. In: J . Hadden, L . Chedid, P. Dukor, F . Spreafico, D. Willoughby (eds.). Advances in Immunopharmacology, Pergamon Press, Oxford, p. 463.

17. HALBERG F . , TONG Y . L . , JOHNSON E.A. 1967: Circadian system phase, an aspect of temporal morphology. Procedures and illustrative examples. In: H.V. Mayersbach (ed.). The Cellular Aspects of Biorhythms, Springer - Verlag, Ber­lin pp. 20-48.

18. HURD H.P., PALUMBO I I P.J., GHARIB H.: Hypothalamic-endocrine dysfunction in anorexia nervosa. Mayo Clin. Proc. 52: 711, 1977.

19. LONDON J . , GREENWOOD F . C . , S T A M P T.C.B. 1966: The plasma sugar, tree fatty acid, Cortisol, and growth hormone response to insulin and the comparison of this procedure with other tests of pituitary and adrenal function. II. In: patients with hypothalamic or pituitary dysfunction or anorexia nervosa. J . Clin. Invest. 45: 437.

20. MECKLENBURG R . S . , L O R I A U X D . L . , THOMPSON R . H . , ANDERSEN A.E. , L I P S E T T M.B. 1974: Hypothalamic dysfunction in patients with anorexia nervosa. Medicine 54: 147.

21. N E L S O N W., CORNELISSEN G . F HALBERG F . , H A U S Ε . 1983: Time-specified reference

intervals for plasma prolactin and Cortisol, based on hybrid sampling design. Chronobiologia 10: 143.

22. NELSON W., CORNELISSEN G., H I N K L E Y D., B I N G H A M C , HALBERG F . 1983: Construc­

tion of rhythm-specified reference intervals and regions, with emphasis on hybrid data, illustrated for plasma Cortisol. Chronobiologia 10: 179.

23. O N I S H I S., MIYAZAWA G., N I S H I M U R A Y . , SUGIYAMA S., YAMAKAWA T., INA-GAKI Η . , K A T O H T., ITOH S., ISOBE Κ . 1983: Postnatal development of circadian rhythm in serum Cortisol levels in children. Pediatrics 72: 399-404.

24. R E I C H L I N S. 1968: In: Williams R . H . E d . Textbook of Endocrinology Saunders. Philadelphia p. 103.

25. R U S S E L L C .F .M. 1979: Anorexia nervosa: its identity as on illness and its treatment. In : Price J .H. (ed.) Modern Trends in Psychological Medicine. 131, Butterwoth, London.

26. SANCHEZ DE LA PENA S., HALBERQ F . , UNGAR F . 1982: Pineal chronomodulation

the feed-sideward. Clin. Chem. Newsletter 2: 191.

554

27. SANCHEZ DE LA PENA S. , HALBERG F . , HALBERG E . , UNGAR F . , CORNFXISSEN G., SANCHEZ Ε . , BROWN G., S C H E V I N G L . E . , Y U N I S E . G . , V E C S E I P. 1983: Pineal modulation of ACTH 1-17 effect upon murine corticosterone production. Brain Res. Bull . 11: 117.

28. SXNCHEZ DE LA PENA S. , HALBERG F . , UNGAR F . , H A U S Ε . , LAKATÜA D., S C H E V I N G L . E . , SANCHEZ Ε . , V E C S E I P. 1983: Circadian pineal modulation of pituitary effect on murine corticosterone in vitro. Brain Res. Bull. 10: 559.

29. S M I T H S .R. , BLEDSOE T . , C H H E T R I M.K. 1975: Cortisol metabolism and the pituitary - adrenal axis in adults with protein calorie malnutrition. J . Clin. Endocrinol. Me tab. 40: 43.

30. STEENBURG R.W., THOMASSON B . H . 1964: Fluorometric determination of corti­costeroids in human blood. J . Clin. Endoer. 24: 875.

31. TRAVAGLINI P., BECKJPECCOZ P., FERRARI G. , AMBROSI B., PARACCHI Α. , SEVERGNINI Α . , SPADA Α . , FAGHLIA G. 1976: Some aspects of hypothalamic-pituitary function in patients with anorexia nervosa. Acta Endocrinol. (Kbh) 81: 252.

32. V A N L U C H E N E E . , AERTSENS W., VANDECKERCKHOVE D. 1979: Steroid excretion in anorexia nervosa patients. Acta Endocrinol. 90: 133.

33. V I G E R S K Y R.A., ANDERSEN A.E. , THOMPSON R . H . , LORIAUX D . L . 1977: Hypothalamic dysfunction in secondary amenorrhoea associated with simple weight loss. N. Engl. J . Med. 297: 1141.

34. W A L S H B . T . , K A T Z J . L . , L E V I N J . , K R E A M J . , F U K U S H I M A D . K . , W E I N E R H „ Z U -M O F F H . , ZuMOFF.p. 1981: The production rate of Cortisol declines during recovery from anorexia nervosa. J . Clin. Endocrinol. Metab. 53: 203.

35. W A L S H B . T . , K A T Z J.L. . . L E V I N J . , K R E A M D.K., F U K U S H I M A L „ H E L L M A N D . , W E I N E R H . , Z U M O F F B . 1978: Adrenal activity in anorexia nervosa. Psychosom. Med. 40: 499.

36. WARREN M.P., V A N DE W I E L E R . L . 1973: Clinical and metabolic features of ano­rexia nervosa. Am. J . Obstet. Gynecol. 117: 435.

37. Z U M O F F B., W A L S H B.T., K A T Z J . L . , L E V I N J . , ROSENFELD R . S . , K R E A M J . , W E I ­NER IJ , : Subnormal plasma dehydroisoandrosterone to Cortisol ratio in ano­rexia nervosa: a second hormonal parameter of ontogenic regression. J . Clin. Endocr. Metab. 56: 668, 1983.

38. Z U Z E W I C Z K . , K W A R E C K I K . , M E L L E R H . 1979: Analiza matematyczno staty-styczna wskaznikow fizjologicznych w aspekcie rytmow dobowych. Acta Phy­siol. Pol. 30: 179.

555

D E D I C A T I Ö N / D £ D / C A Pag. 5

P R E F A Z I O N E / P J R J E F A C E LORIO R E A L E » 8

L E T T U R A M A G I S T R A L E PLENARY LECTURE

FRANZ HALBERG, ERHARD H A U S , E R N A HALBERG, G E R M A I N E CORNELISSEN, PAOLO

SCARPELLI, BRUNETTO TARQUINI, MARIO CAGNONI, DOUGLAS W I L S O N , K E I T H

G R I F F I T H S , H U G S I M P S O N , E S T E R BALESTRA, LORIO R E A L E : Chrono-

biologic challenges in social medicine: illustrative tasks in cardio­logy and oncology / Sfide cronobiologiche in medicina sociale: enunciazione di compiti in cardiologia e oncologia . . . . » 1 3

P R I M A S E S S I O N E FIRST SESSION Cronobiologia clinica Clinical chronobiology

UGO MANZOLI, ANTONIO G . R E B U Z Z I , M I C H E L E L U C E N T E : Aspetti cronobio-

logici della cardiopatia ischemica / Chronobiological features of the ischemic heart disease » 4 5

P.T . SCARPELLI, L . SCARPELLI , R . L I V I , E . CROPPI, M . CAGNONI, M . PAMPA-

LONI, V. G I A C H E T T I , A. SEMERARO, G . FANGHI: Utilizzazione delle au-tomisure multiple della pressione arteriosa e del polso nella dia-gnosi e nel trattamento dell'ipertensione / Utilization of multiple blood pressure and heart rate self-measurement in diagnosis and treatment of hypertension » 6 5

CHRISTIAN BARTSCH - E L L A BARTSCH: The link between the pineal gland and cancer an interaction involving chronobiological mechanimsms / Correlazioni tra epifisi e cancro: una interazione che coinvolge meccanismi circadiani » 1 0 5

BRUNETTO TARQUINI, FRANZ HALBERG: Altered circannual prolactin and T S H and circadian melatonin rhythm and risk of developing breast cancer / Alterazioni del ritmo circannuale della prolattina e del TSH e del ritmo circandiano della melatonina e rischio di sviluppo del cancro della mammella » 1 2 7

MAURIZIO C E C C H E T T I N , ANGELO CARIDDI, DONATELLA CALVANI, LAURA M A S I ,

BRUNETTO TARQUINI: Aspetti cronobiologici di alcuni markers cir-colanti di patologia ossea / Marker rhythms in bone diseases . . » 149

786

SERGIO S E N S I , MARIA T E R E S A GUAGNANO, FABIO CAPANI: Meal-timing and

circadian time structure / Ritmo di assunzione dei pasti e struttura temporale circadiana Pag. 171

G E R M A I N E CORNELISSEN, FRANZ HALBERG, R U D O L F E N G E L , E R N A HALBERG,

P I E R R E PASSOUANT: Chronobiology of paroxysmal central nervous system disorders / Aspetti cronobiologici in affezioni parossistiche del Sistema Nervoso Centrale » 1 8 5

BRUNETTO TAROUINI: L'ulcera peptica: cronobiologia da costrizione / Peptic ulcer: forced chronobiology » 195

PAOLA GALVAN, ALFONSO GRANATI, RENATO L E N Z I , GUSMANO POGGINI, SERGIO

SQUARCIALUPI, BRUNETTO TAROUINI: II lavoro a turni: un modello cronobiologico sociale / Shift-Work: α social chronobiological model » 209

PIETRO C U G I N I : Cronobiologia e senescenza / Chronobiology and se­nescence » 229

SECONDA S E S S I O N E SECOND SESSION Aspetti di Metodologia Workshop on Chronobiological Cronobiologica Methodology

G E R M A I N E CORNELISSEN/ FRANCA CARANDENTE, FRANZ HALBERG: Circadian and circaseptan periodicity in differential skin surface temperature automatically monitored by polychronor / Periodicita circadiana e circasettana nella temperatura differenziale cutanea registrata auto-maticamente con polychronor » 271

MARCO CAVALLINI , FRANZ HALBERG, TAO L I U , GUIDO MAGNUS: Coordinated

optimization of device, administration pattern, route and time scale for (e.g., cyclosporine) chronotherapy / Ottimizzazione coordinata degli strumenti, schemi di somministrazione, vie e tempo per una cronoterapia (ciclosporina) » 289

RAMON C. HERMIDA DOMINGUEZ, ROBERT B . SOTHERN, FRANZ HALBERG, TODD

R . LANGEVIN: Variability of circadian acrophase of urinary potas­sium excretion as a potential marker for cancer chronotherapy / Variabilitä dell'acrofase circadiana nelVescrezione di potassio uri-nario come marker Potenziale nella cronoterapia del cancro . . » 3 1 3

RAMON C. HERMIDA DOMINGUEZ, FRANZ HALBERG, TODD R . LANGEVIN:

Serial whthe blood cell counts and chronochemiotherapy according to highest values (macrophases*) or by model character­istics (acrophases) / Conta seriata dei Globuli Bianchi e cronoche-mioterapia in funzione dei valori piü alti (macrofasi) ο delle carat-teristiche del modello (acrofasi) » 327

P . T . SCARPELLI , S . ROMANO, Μ . CAGNONI, R . L I V I , L . SCARPELLI , E . CROPPI,

F . B I G I O L I , W . MÄRZ, F . HALBERG: Blood pressure self-measurement as part of instruction in the Regione Toscana / Automisurazione della pressione arteriosa come parte dell'istruzione scolastica η ell a Regione Toscana Pag. 345

K A T H L E E N L . JOHNS, FRANZ HALBERG, G E R M A I N E CORNELISSEN, WOLFGANG

M Ä R Z : Chronobiology at the American international school in Lisbon, Portugal / La cronobiologia nella Scuola Internaz'ionale Americana di Lisbona » 367

VITTORIO DE LEONARDIS, MAURIZIO D E S C A L Z I , PIERO C I N E L L I : Lautoritmo-

metria come guida indispensabile alia cronoterapia deH'ipertensione arteriosa / Autorhythmometry as an essential guide to chrono-therapy of hypertension » 385

ROBERT Β. SOTHERN, FRANZ HALBERG: Circadian and infradian blood pres­sure rhythms of a man 20 to 37 years of age / Ritmi circadiani e infradiant della pressione sanguigna in tin uomo, da 20 a 37 anni dL.pta » 395

NELSON MARQUES, M I R I A N D . MARQUES, FRANZ HALBERG, ROBERT Β. SOTHERN:

Ambulatory cardiovascular monitoring by an adult man for 16 days after transequatorial-transmeridian flight / Monitoraggio car­diovascular e ambulatoriale di un uomo adulto per 16 giorni dopo un volo transequatoriale-transmeridiano » 417

G . SLOVER, R . B . SOTHERN, L . E . SCHEVING, T . S . T S A I , F . HALBERG: Urinary

and self-measured circadian and circatrigintan rhythms before and after a human manic episode / Ritmi circadiani e circa-trigintani urinari, automisurati, prima e dopo un episodio mania-cale nell'uomo » 427

SALVATORE ROMANO: Alcuni metodi cronobiologici di analisi statistica utili in fase diagnostica e terapeutica / Some chronobiological me­thods of statistical analysis usefull in diagnostic and therapeutic approaches » 4 4 5

MARCO B O S S I N I : Le applicazioni del personal computer in cronobiologia / The personal computer in chronobiology » 5 1 1

T E R Z A S E S S I O N E THIRD SESSION a) Comunicazioni a) Communications

BOGUSLAWA BARANOWSKA, MARIA L A Z I C K A - F R E L E K , BARBARA MIGDALSKA.

STEFAN Z G L I C Z Y N S K I , BARNETT Z U M O F F , R . S . ROSENFELD, G E R M A I N E COR­

NELISSEN, H E L M U T ARBOGAST, E L K E E C K E R T , FRANZ HALBERG: Circadian

timing of serum Cortisol in patients with anorexia nervosa / Timing del ritmo circadiano del cortisolo sierico in pazienti con anores-sia nervosa » 5 3 5

PlETRO CüGINI, PlERNATALE LUCIA, GlULIA MüRANO, CLAUDIO LETIZIA, DO-MENICO SCAVO: Contributo cronobiologico clinico alio studio dei determinanti del ritmo circadiano della pressione arteriosa / A chronobiologic contribution to the scrutiny of determinants for blood pressure circadian rhythmicity Pag. 557

P A U L J . M E I S , FRANZ HALBERG, FRANCE B O Y E T T E - K O U R I : Hyperbaric index

guages excess blood pressure during pregnancy / La misurazione dell'indice iperbarico sovrastima la pressione sanguigna in gra-vidanza » 569

RICHARD DOE, H E L E N H R U B Y , P H I L I P GOLDMAN, FRANZ HALBERG: Circannual

rhythm in glucocorticoid receptors of circulating polyomorpho-nuclears in clinically healthy adults / Ritmo circannuale dei ricet-tori dei glicocorticoidi nei polimorfonucleati in soggetti adulti cli-nicamente sani » 575

M A U R I Z I O D E S C A L Z I , VITTORIO DE LEONARDIS, FRANCO SALVATORE FABIANO,

MAURO GUICCIARDI , PIERO C I N E L L I : Elettrocardiografia dinamica e

fattori di rischio per la cardiopatia coronarica: un approccio cro­nobiologico / 24 - Hour electrocardiogram monitoring in the assessment of the influence on chrono electrocardiographic para­meters by risk factors for coronary heart disease . . . . » 5 8 1

VINCENZO ESPOSITO, MARIA ROSARIA CAFARO, SERGIO D E ANGELIS , ALDO ERAMO,

G I U S E P P E L O I U D I C E , BRUNO D'ALESSANDRO: Variazioni circadiane della secrezione di L H ed F S H in pazienti affetti da ipogonadismo ipo-gonadotropo « isolato » ( I H H ) / Twenty four hours rhythm of LH and FSH release in patients with « isolated» hypo gonadotropic hypogonadism (IHH) * 589

VINCENZO ESPOSITO, G I U S E P P E L O I U D I C E , M A U R I Z I O LOMBARDI, C A R M I N E

M A Z Z E L L A , ANNUNZIATA OFFICIOSO, CARMELA R I S P O L I , BRUNO D ' A L E S ­

SANDRO: Variazioni circadiante della secrezione di T S H , Prolattina e Cortisolo in pazienti affetti da ipogonadismo ipogonadotropo « isolato » ( I H H ) / Circadian variations of TSH, proclactin (PRL), Cortisol secretion in patiens with « isolated» hypo gonadotropic hypogonadism (IHH) » 595

ETTORE FERRARI, P I E R ANGELO BOSSOLO, ALBERTO V A I L A T I , L U I G I MAGNANI,

G I U S E P P E M A R E L L I , E M I L I A MARTIGNONI, G I U S E P P E M I C I E L I , G I U S E P P E

NAPPI, F E L I C E PETRAGLIA, ANDREA R . GENAZZANI: Crono-patologia en-

docrina e neuro-vegetativa nelle cefalee primarie / Endocrine and autonomic chrono-pathology in primary headache syndromes . . » 603

FRANK W . FINGER: The effect of age on circadian pattern of activity / Effetto delVetä sul comportamento circadiano delVattiviia . . » 619

K A L V A SHANKARAIAH, FRANZ HALBERG, EDMOND Y U N I S , ADA L . M . WATSON:

Alternate-day feeding alters the circadian system, reduces breast cancer incidence and prolongs life / La nutrizione a giorni alterni

789

modified il sistema circadiano, riduce la incidenza del cancro della mammella e allunga la vita, nel ratio Pag. 633

E R N A HALBERG, FRANZ HALBERG, SHAHID RAMAM, S H I R I N I . R A M , DEVENDRA P. D U B E Y , FRANCA CARANDENTE: Circadian rhythmic aspects of gastric ulcerogenesis in rats / Aspetti ritmici circadiani nell'ulcerogenesi gastrica nel ratio » 649

M O R T I M E R L I P S E T T , GEORGE CHROUSOS, FRANZ HALBERG: Alteration of circa­

dian serum Cortisol rhythm characteristics in a father and son / Alterazioni delle caratteristiche del ritmo circadiano del cortisolo serico nel padre e nel figlio » 657

G I U S E P P E L O I U D I C E , VINCENZO ESPOSITO, PASOUALINA FEDERICO, BIANCA

PERNA, ADA ROMANO, BRUNO D'ALESSANDRO: Comportamento nelle 24

ore della tiroxina libera e della frequenza cardiaca in pazienti con adenoma tiroideo funzionante e eutiroidismo / The 24-hour plasma free thyroxine and heart rate profile in euthyroid patients with functioning adenoma of the thyroid » 6 7 1

GIOVANNI MURIALDO, ANDREA D E MARIA, MARIA L U I S A BONURA, PAOLA MA-

STURZO, ALESSANDRO P O L L E R I : L a periodicitä secretoria degli adenomi ipofisari / The secretory periodicity of pituitary adenomas . . » 679

G A B R I E L E N E N C I , ANGELO CARIDDI, PAOLA GALVAN, MARIA B E N V E N U T I , jyiAU-

RIZIO C E C C H E T T I N , BRUNETTO TARQUINI: Valutazione della gastrina e del pepsinogeno sierico in turnisti / Serum gastrin and pepsinogen in shift-workers » 693

ALESSANDRO PANCONESI, BRUNO A N S E L M I , CARLO CURRADI, P I E R L U I G I D E L BIANCO, GIANCARLO FRANCHI, FEDERICO S I C U T E R I , BRUNETTO TARQUINI: Bioritmi della reattivitä vasculare alia serotonina nell'uomo / Biological rhythms of vascular reactivity to serotonin in man . . » 701

PAOLO PASQUALETTI, P I E R L U I G I A C I T E L L I , R A F F A E L E CASALE, DOMENICO CO-

LANTONIO, VITTORIO F E S T U C C I A , LAURA NATALI: Ritmi circannuali della

prolattina e del testosterone in soggetti sani anziani ed in pazienti con ipertrofia prostatica benigna prima e dopo adenomiomectomia / Circannual rhythms of prolactin and testosterone in healty elderly subjects and in patients whit benign prostatic hypertrophy before and after removal of adenoma » 7 1 5

R E N E RYBA, FRANZ HALBERG, ROBERT B . SOTHERN, OLGA PETRE-QUADENS,

P . J . WALTER, F . LOSKOT: Chronobiologic cardiovascular and other monitoring before and after coronary bypass surgery / Monito-raggio cardiovascolare cronobiologico e non, prima e dopo bypass coronarico 9 » 729

ROBERTO S A L T I , FIORELLA G A L L U Z Z I , GIANNA C H I T I , CARMELO L A CAUZA,

ANGELO CARIDDI, ANTONIO P I E R I , BRUNETTO TARQUINI, SALVATORE S E M I -

NARA: Variazioni circannuali del T S H sierico in un gruppo di bam-

790

bini obesi / Circannual variations in serum TSH of obese children Pag. 741

T E R Z A S E S S I O N E b) Intervent!

THIRD SESSION b) Short Reports

MARY C. GANNON, FRANK Q. N U T T A L L , FRANZ HALBBRG: Circannual changes in murine cardiac glycogen, glycogen synthase, phosporylase, plasma insulin and glucose and body weight / Variazioni circannuali del glicogeno, della glicogeno-sintetasi e della fosforilasi cardiaci, del-Vinsulina e glucosio plasmatici e del peso corporeo nel topo .

H. ARBOGAST, R. SOTHERN, F . HALBERG : Cosinor assessment of differences in M E S O R and acrophase of plasma luteinizing hormone (LH) in teenagers with Stein-Leven thai syndrome (S) and clinically healthy (H) girls / Valutazione con il cosinor delle differenze nel MESOR e nella acrofase deU'ormone luteinizzante (LH) nel plasma in giovani con sindrome di Stein-Leventhal (S) ed in ragazze clinicamente sane (H)

J A I M E I G L E S I A S , ROBERTO V I L L A E S C U S A , V I C E N T E GOYANES, LORENZO OTERO,

C A M I L L O V E I R A S , JOSE" OTERO R A I C E S , FRANZ HALBERG: Comparison of

circadian variation in blood of patients with cancer and in appa­rent clinical health / Confront ο fra variazioni circadiane di alcuni parametri circolanti in pazienti con cancro e pazienti clinicamen­te sani

P . L I S S O N I , O. M A R E L L I , R. M A U R I , M. R E S E N T I N I , P . FRANCO, D . E S P O S T I , G . E S P O S T I , F . FRASCHINI , F . HALBERG: Chronomodulatory sequence of stimulation and inhibition of human N K cell activity by melato­nin given in the afternoon to nocturnally resting subjects / Sequenza cronomodulatoria della stimolazione e dell'inibizione dell'attivitä delle cellule NK umane da parte della melatonina data nel pomerig-gio a soggetti che riposano di notte

K R I S T I N A ORTH-GOMER, G E R M A I N E CORNELISSEN, FRANZ HALBERG, ROBERT B.

SOTHERN, TORBJÖN AKERSTEDT: Relative merits of chronobiologic vs. conventional monitoring of ventricular ectopic beats ( V E B ) / Van-taggi del monitoraggio cronobiologico nei confronti di quello con-venzionale nella valutazione dei battiti ventricolari ectopici .

SALVADOR SANCHEZ DE LA PENA, NELSON MARQUES, FRANZ HALBERG: Inf ra­

dian modulation of corticosterone production by hamster adrenals in vitro / Modulazione infradiana della produzione di corticosterone nella surrenale di criceto in vitro

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C O N C L U S I O N I CONCLUSIONS

BRUNETTO TAROUINI

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