Detection and characterization of naturally acquired West Nile virus infection in a female wild turkey

An adult female wild turkey exhibiting disorientation and failure to flee when approached was submitted to the Mississippi Veterinary Research and Diagnostic Laboratory. Gross pathologic examination revealed evidence of dehydration and the presence of modest numbers of adult nematodes in the small intestine. Histologic examination revealed extensive multifocal perivascular lymphocytic infiltration in brain, marked heterophilic hyperplasia in bone marrow, and multifocal interstitial lymphocytic infiltration in heart, pancreas, ventriculus, and skeletal muscles. West Nile virus (WNV) was isolated from the brain, lung, and kidney tissues using cultured Vero cells. Higher copies of viral RNA were detected from brain, lung, and kidney than from heart, liver, or spleen by quantitative real-time reverse transcription-polymerase chain reaction (RRT-PCR) analysis. Immunohistochemical (IHC) analysis detected WNV antigen in various tissues including neurons, kidney, respiratory tract epithelium, heart, and bone marrow. On the basis of the data from this investigation, it is concluded that WNV caused encephalitis along with many other pathologic changes in the affected wild turkey.

Washout of [99mTc] sestamibi in predicting response to chemotherapy in patients with multiple myeloma

AIM

Technetium-99m 2-methoxy-isobutyl-isonitrile ([99mTc] MIBI) has been successfully used to study patients with multiple myeloma (MM). This tracer is also a substrate for P-glycoprotein (Pgp). Since Pgp overexpression is one of the primary mechanisms of multidrug resistance in MM, the aim of this study was to test whether [99mTc] MIBI could be an index of Pgp overexpression and function in MM and therefore predicts response to chemotherapy.

METHODS

Forty patients with MM (12 in stage I, 15 in stage II, and 13 in stage III) showing diffuse bone marrow [99mTc] MIBI uptake were included in the study. All patients underwent whole body scintigraphy at 10 and 60 minutes after i.v. injection of 555 MBq of [99mTc] MIBI. [99mTc] MIBI washout was measured, after decay correction, as: (10 minute counts/pixel minus 60 minute counts/pixel) divided by 10 minute counts/pixel, computed on a region of interest drawn on the thoracic spine (posterior projection), taking care of avoiding heart and splanchnic organs. Disease restaging was performed at a mean time of 32+/-20 months, and patients were considered to be in remission (complete or partial) or to show disease progression on the basis of a complete clinical and hematological evaluation.

RESULTS

Patients showing disease progression at restaging (n=26) had higher washout (19.3+/-9.8% vs 12.8+/-6.9%, p<0.05) than patients in remission (n=14). Disease free survival was significantly better in patients with lower washout of [99mTc] MIBI. No differences in therapeutic regimen and stage of disease at admission were found between the 2 groups. When patients treated with melphalan were excluded from the analysis, 87.5% of patients in remission had low washout.

CONCLUSIONS

The present study suggests a potential role of [99mTc] MIBI washout in predicting response to chemotherapy in patients with MM.

Increased levels of NF-kappaB inhibitors (IkappaBalpha and IkappaBgamma) in the intestinal mucosa of Crohn's disease patients during infliximab treatment

The treatment with infliximab is employed successfully in Crohn's disease (CD) but predictors of efficacy are lacking. Activation of the transcription factor NF-kB has been demonstrated in CD and its inhibition is one of the mechanisms by which anti-inflammatory agents exert their effects. We evaluated the production of TNFalpha by peripheral blood mononuclear cells (PBMC) and the levels of NF-kappaB family molecules in the intestinal mucosa during infliximab therapy in 12 patients. TNFalpha was assayed on supernatants of PBMC culture stimulated with PHA or LPS. Immunohistochemistry was also done on intestinal biopsies. In six patients, Western blot analysis of the NF-kappaB subunit Rel-A, and its inhibitors IkappaBalpha and IkappaBgamma was performed on intestinal biopsies and PBMC. The TNFalpha production by LPS stimulated PBMC showed mild changes, while it was increased by PHA-stimulated PBMC after treatment. The number of inflammatory cells in the intestinal mucosa was reduced (p<0.002) by the treatment. In five out of six cases we detected an increase of the IkappaBalpha and IkappaBgamma)inhibitor levels in intestinal biopsies after treatment. An increase of IkappaB inhibitors levels could be one of the mechanisms by which infliximab decreases NF-kappaB activity and exerts its anti-inflammatory effects.

MR findings in lipoma arborescens of the knee: our experience

PURPOSE

This paper describes the role of MR imaging in the identification of the different macroscopic patterns of lipoma arborescens.

MATERIALS AND METHODS

Between June 1995 and January 2004, a total of 6387 MR examinations of the knee were retrospectively assessed for the presence of lipoma arborescens. The MR examinations were performed using a superconductive 0.5 T MR unit with a transmitting/ receiving coil dedicated for the extremities. The MR images were acquired with SE T1-weighted, GE T2-weighted and STIR sequences in sagittal, coronal and axial planes with 3-mm thickness and 1-mm gap.

RESULTS

Lipoma arborescens was identified in 9 patients (mean age: 36 years). In 2/9 cases a localized lipoma arborescens was detected as a well-marginated single nodule on the suprapatellar bursa without irregularity or synovial hyperplasia. In the remaining 7 cases diffuse lipoma arborescens was identified on the wall of the suprapatellar bursa. In one case of diffuse lipoma arborescens there was involvement of both knees. In all cases the MR findings were verified at surgery and the final diagnosis was made by histological examination.

CONCLUSIONS

MR imaging shows a high accuracy in the identification and characterization of lipoma arborescens, due to its multiplanar capabilities and high contrast resolution. MRI allows correct evaluation of size and grade, accurate treatment planning and effective follow-up, avoiding the need for synovial biopsy.

Added value of CT colonography after a positive conventional colonoscopy: impact on treatment strategy

BACKGROUND

Conventional colonoscopy (CC) requires an experienced operator to avoid technical or interpretative errors, and an endoscopic error rate of 14% for tumor localization has been reported. We evaluated the impact of computed tomographic colonography (CTC) on surgical treatment strategy in patients with CC reported as having colorectal neoplasm.

METHODS

Fifty-three patients testing positive for colorectal neoplasm on CC underwent CTC: 32 patients had CC in our hospital (group A) and 21 had CC in area hospitals (group B). All CTC procedures were performed with a multidetector CT system. The results of CTC and CC were compared with that of surgery. The preoperative surgical planning evaluated on the basis of CC and CTC was compared with the actual surgical approach, and the percentage of patients in whom CTC modified the treatment strategy suggested by CC was calculated.

RESULTS

CTC changed the treatment strategy in four of 53 patients (7.5%) in whom CC showed technical or interpretative errors. Group analysis showed that CTC did not influence the surgical management in any patient in group A but did affect treatment strategy in four of 21 patients (19%) in group B. The effect of CTC on treatment strategy between groups was statistically significant (p < 0.05). CTC identified five adenomas and three adenocarcinomas localized proximally to an impassable stenosis.

CONCLUSION

CTC can be used to reevaluate the findings of a positive CC and can indicate a more correct therapeutic approach in patients with colorectal neoplasms who are candidates for surgery.

Sedation in gynaecologic oncology day surgery

Gynaecologic oncology day surgery deals primarily with the diagnosis of endometrial, cervical, vulvar and vaginal tumors. Conscious sedation is an important technique used in gynaecologic oncology day surgery. It is often associated with regional anaesthesia. The goals of conscious sedation are to provide effective pain control with complete safety, reduction of the recovery time, of the infection risk and cost. Since the consequences of the immunosuppressive effects of the opiates and the surgical stress could lead to an increased susceptibility to post-operative infections and a possible lack of immunological defence in the cancer patients, we investigated the possibility of eliminating the administration of opiates during minor operations in gynaecologic oncology day surgery. In this study, 400 patients, aged between 35 and 77 years, underwent surgery using sedation at the day hospital annexed to the Gynaecology and Obstetrics Department of the 2nd University of Naples, Italy. The patients were randomized into two equal study groups, according to a computer-generated randomised list. All patients were seen by the consultant anaesthetist three days before surgery. In all cases, during surgery, we monitored the main vital parameters such as ECG, HR and RR, BT, BP and SO. The drugs commonly used were: opioids, hypnotics and benzodiazepines, associated or not, with local anaesthetics. By using these drugs, pain and anxiety were reduced, sedation and amnesia were accomplished. In our experience, conscious sedation seems to be the best choice in gynaecologic oncology day surgery because it presents low toxicity, is short acting and readily reversible, has a low cost and, finally, because it is more comfortable for the patients. Moreover, it is possible to eliminate the administration of opiates during conscious sedation for less invasive surgical procedures.

FSH: urinary and recombinant

Infertility affects approximately 10-15% of couples. To enhance the chances of conception, assisted reproductive techniques (ART) have been improved and, in the last 5 years, thousands of babies have been delivered after IVF or ICSI procedures. To obtain an appropriate and controlled ovarian hyperstimulation (COH), clinicians have introduced many drug protocols based on GnRH agonists or antagonists for pituitary down-regulation and FSH or HMG for ovarian stimulation. Currently FSH is the most common drug used for ovulation induction. It is a glycosylated protein with a molecular weight of 28000-30000Da, normally secreted by the anterior pituitary gland. The recombinant preparations of follicle stimulation hormone (r-FSH) are characterized by a higher level of purity, reduced batch to batch variability and no risk of infection. The purpose of this review was to establish the efficacy of different trials based on the use of r-FSH and urinary FSH (u-FSH) comparing published data from randomised studies on the ovulation induction for assisted reproductive techniques. Unfortunately, we did not find any paper with sufficient power to detect a clinically significant difference in pregnancy rates, however, recent meta-analysis among homogeneous trials indicates that the use of r-FSH is to be preferred to u-FSH because more oocytes were collected in cycles with better embryo quality and with more pregnancies. Recombinant FSH has a higher cost per ampoule than urinary FSH, but also a higher effectiveness. A recent cost-effectiveness analysis on follitropin alfa compared to urinary FSH-HP, using a Markov model, confirmed other previous studies that, considering the ongoing pregnancies beyond 12 weeks gestation, r-FSH is the most effective therapy for ovulation induction in ART.

Sympathetic nervous function in patients with hypertrophic cardiomyopathy assessed by [123I]-MIBG: relationship with left ventricular perfusion and function

AIM

The aim of the present study was to evaluate [123I] MIBG uptake and clearance in patients with hypertrophic cardiomyopathy (HCM) and to assess their relationships with left ventricular function (systolic and diastolic) and perfusion.

METHODS

Eleven consecutive patients with HCM (8 men and 3 women; mean age 38+/-12 years, none in the dilated phase) underwent (in separate days, in random order) [123I]-MIBG scintigraphy, [(99m)Tc]-MIBI SPET at rest, and echocardiography. All patients were studied in fasting condition, and all medications were discontinued. [(99m)Tc]-MIBI SPET study was performed 1 hour after tracer injection. [123I]-MIBG study was acquired 5 minutes (planar) and 4 hours (planar and SPET) after the i.v. injection of [123I]-MIBG. Heart to mediastinum ratio (H/M) was computed at 4 hours. Wash out rate (WOR) was computed as: (H early - H delayed)/(H early), after decay correction. Both [123I]-MIBG and [(99m)Tc]-MIBI SPET were analyzed on 3 short axis views (apical, middle, and basal). Left ventricular outflow tract gradient (LVOTG), ejection fraction, volumes, septum thickness, and left atrial fractional shortening (LAFS) were evaluated on echocardiography.

RESULTS

[123I]-MIBG WOR showed a positive relationship with LVOTG (r=0.84, p<0.001) and septum thickness (r=0.76, p<0.01), while a negative one was found with LAFS (r= -0.66, p<0.05). The study group was divided into: Group A (n=5) with higher, and Group B (n=6) with lower WOR than the median value (i.e. 11%). Group A patients had significantly lower LAFS (17.6+/-4.8 vs 26.8+/-7.2%, p<0.05), higher LVOTG (49+/-35 vs 3+/-3 mmHg), and thicker septum (21+/-2 vs 17+/-2 mm) than Group B patients. Inferior and septal wall [123I]-MIBG uptake on 4 hour SPET was significantly lower in Group A than in Group B. On the other hand, no differences were found in (99m)T-MIBI SPET rest regional uptake between the 2 subgroups of patients.

CONCLUSION

These results suggest that cardiac sympathetic activity correlates to cardiac anatomy (i.e. degree of hypertrophy) and diastolic function in patients with HCM.

The intergeniculate leaflet, but not the visual midbrain, mediates hamster circadian rhythm response to constant light

Several studies have demonstrated a variety of effects of intergeniculate leaflet (IGL) lesions on circadian rhythm regulation. Recent studies have suggested the possibility that certain rhythm functions attributed to the IGL are actually controlled by retinorecipient midbrain nuclei or other brain areas connected to the IGL. The present investigations evaluated whether midbrain lesions previously shown to block the phasic actions of benzodiazepine would also reduce or eliminate the period-lengthening effect of constant light (LL), a function that has been attributed to the IGL. Experiment 1 established that the circadian period of controls lengthened by about 0.57 h when the animals were transferred from constant dark (DD) to LL, but the magnitude of change was attenuated by about 50% in animals with IGL lesions caused by the neurotoxin N-methyl-D-aspartate (NMDA). In experiment 2, controls were compared to groups receiving either NMDA lesions of the pretectum or tectum or knife cuts designed to sever connections between the IGL and more medial retinorecipient nuclei. As in experiment 1, there were no differences between groups with respect to circadian period in DD. However, unlike experiment 1, all groups lengthened period equally in LL (overall mean increase = 0.57 h). Thus, the effect of LL on circadian period appears to be a joint result of photic information arriving at the circadian clock directly from the retinohypothalamic tract and indirectly through the IGL via the geniculohypothalamic tract, without involvement of visual midbrain. The results may have implications for the anatomical basis of Aschoff's rule.

Diagnostic accuracy of low-dose dobutamine echocardiography in predicting post-revascularisation recovery of function in patients with chronic coronary artery disease: relationship to thallium-201 uptake

It is known that contractile reserve may be blunted if perfusion and coronary flow reserve are reduced. Thus, it is conceivable that the predictive accuracy of dobutamine echocardiography may differ according to perfusion tracer uptake. The aim of this study was therefore to assess the relationship between the level of thallium-201 uptake and the accuracy of dobutamine echocardiography in identifying reversible dysfunction. Sixty-nine patients (age 59+/-8 years, ejection fraction 40%+/-11%) with chronic coronary artery disease scheduled for coronary revascularisation were studied. All patients underwent rest 201Tl single-photon emission tomography and two-dimensional echocardiography at rest and during low-dose dobutamine infusion on the same day before revascularisation and repeated echocardiography at least 30 days thereafter. At follow-up, recovery of function was observed in 49% of 339 dysfunctional segments. The percentage of segments with post-revascularisation recovery of function and the percentage with contractile reserve increased in parallel with 201Tl uptake both in the total group of segments (chi2=35.5, P<0.0001 and chi2=35.9, P<0.0001, respectively) and among the 183 akinetic segments (chi2=44.4, P<0.0001 and chi2=14.6, P<0.05, respectively). The dysfunctional segments were divided into three groups according to 201Tl uptake: (a) uptake <65%, (b) uptake between 65% and 79%, (c) uptake >80%. The positive predictive value increased significantly with the level of 201Tl uptake, and was suboptimal (46%) in akinetic segments with severely reduced 201Tl uptake. The negative predictive value decreased significantly with 201Tl uptake, and it was less than suboptimal (29%) in akinetic segments with normal tracer uptake. Sensitivity was lower in the subset of akinetic segments (42%-63%) than in all dyssynergic segments (63%-76%), whereas specificity was very high in akinetic segments (80%-84%). It is concluded that the accuracy of low-dose dobutamine echocardiography in predicting reversibility of regional dysfunction varies considerably according to 201Tl uptake at rest and to the severity of regional dysfunction.

[Pregnancy in women with thalassaemia]

Women with transfusion dependent thalassaemia suffer from failure of pubertal growth and delayed onset of menarche with amenorrhea, anovulation and infertility. With improved pediatric and hematological care is now possible, for patients with b thalassaemia, to achieve a pregnancy. Pre-pregnancy assessment included checks for hypothyroidism and diabetes, for hepatitis B and C, human immunodeficiency virus, Rubella, cardiac functions, liver functions by estimating aspartate and alanine aminotransferases, gamma-glutamyl transpeptidase, alkaline phospatase, and total plasma proteins. The frequency of blood transfusion needed to be increased in order to maintain the hemoglobin concentration above 10 g/dl. Desferroxamine must be stopped as soon as pregnancy is diagnosed continuing the administration of the folic acid supplements throughout pregnancy. Desferroxamine will be resumed after delivery. The safety of iron chelation with desferroxamine during the periconceptional period and pregnancy has not yet been established. Some animal studies have shown skeletal anomalies; other published studies report seven women with b thalassaemia major who became pregnant while taking desferroxamine: all the women had normal babies. The mode of delivery is usually vaginal, while Cesarean section is performed in those cases with pre-eclampsia, fetal distress, cephalopelvic dysproportion, slow progression of labor, as in women without thalassaemia. In conclusion, with the advent of regular blood transfusion associated with iron chelation therapy, pregnancy in b thalassaemia can be safe for mothers and their babies with appropriate care.

[Correlations between acne and polycystic ovary. A study of 60 cases]

BACKGROUND

In this paper we correlated the clinical severity of the polycystic ovary with the clinical manifestation of acne. Acne is an inflammatory process of follicle sebaceous unites. Polycystic ovaries (PCOS) are characterized by several subcapsular cystic follicles with an increased production of androgens. Onset of polycystic ovaries in women with acne, ranges from 45 to 84% of cases.

METHODS

Sixty patients, aged from 19 to 28 years, with acne and polycystic ovaries were enrolled. The clinical severity of acne was appraised by millimetric macrophotography. This technique evaluated subsequent phases of acne like comedo, papules or pustules, nodular or scarring lesions. Polycystic ovaries were studied by ultrasound and hormonal assay. Sonora Logic 500 MD, by GE Echography, with 3.5 MHz convex probe, were employed. US examination was performed, in each patient, on day 6th, 10th, 15th and 22th of the menstrual cycle. The following US parameters were considered: dimension of the ovaries, thickness of albuginea and number of cysts. Serum levels of FSH, LH, 17-b-estradiol, progesterone, DHEA-S, testosterone and LH/FSH ratio were determined. Furthermore, the presence of premenstrual syndrome (PMS) was evaluated.

RESULTS

We found that in PCOS the increased levels of androgens can cause the onset of acne. Photographic score and ovaries ultrasonography may be useful in the assessment of the clinical association between acne and polycystic ovaries. We observed that the subsequent phases of acne were correlated with the clinical severity of polycystic ovaries and to the presence of Premenstrual Syndrome in 93% of the cases (56 of 60 patients).

CONCLUSIONS

US images, compared with visual score, established the clinical association between acne and PCOS in three phases with a progressive severity.

Predictive value of technetium-99m sestamibi in patients with multiple myeloma and potential role in the follow-up

Technetium-99m 2-methoxyisobutylisonitrile (99mTc-MIBI or setamibi) has recently been proposed for use in the evaluation of multiple myeloma (MM). The aims of this study were to investigate its potential predictive value in patients with MM and its possible role in the follow-up. Thirty patients with MM who had undergone two 99mTc-MIBI scintigraphic studies at least 2 months apart constituted the study group; 22 of them received chemotherapy in the interval between the two scans. The scans were classified as showing pattern N when only physiological uptake was present, pattern D when diffuse bone marrow uptake was observed, pattern F when areas of focal uptake of the tracer were evident, and pattern F + D when both D and F patterns were observed. Comparative 99mTc-MIBI scintigraphy was considered indicative of disease progression when there was a worsening of the pattern (i.e. from N to D, or from N or D to F or to F + D) or an increase in the pattern D semiquantitative score. It was considered indicative of disease improvement when the opposite trend was observed; otherwise, it was considered to document a stable condition. A significant association was observed between the baseline scintigraphic pattern and clinical status at follow-up in the group of patients evaluated after chemotherapy (chi 2 = 16.7, P < 0.05). A negative baseline 99mTc-MIBI scintigram showed a high predictive accuracy (100%) for remission, while the presence of pattern F or F + D was often associated with a less favourable outcome. A multivariate analysis showed that 99mTc-MIBI uptake pattern has an added value in relation to known prognostic variables such as C-reactive protein. 99mTc-MIBI scintigraphy patterns at follow-up were significantly associated with the clinical status evaluated after chemotherapy (chi 2 = 32.6, P < 0.0001). Considering pattern N as indicating remission, pattern D stable condition, and pattern F or F + D progressive disease, a high concordance between scintigraphic findings and clinical status was found in the 22 patients undergoing chemotherapy (91%). Variation in 99mTc-MIBI findings comparing baseline and follow-up evaluations was significantly associated with clinical status both in patients undergoing chemotherapy (chi 2 = 26.5, P < 0.0005) and in those not undergoing chemotherapy (chi 2 = 8.0, P < 0.005). In conclusion, the results of this study suggest a prognostic value of 99mTc-MIBI scintigraphy in patients with MM and a potential role during the follow-up.

Bone marrow uptake of 99mTc-MIBI in patients with multiple myeloma

In a previous study, we showed the ability of technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) scan to identify active disease in patients with multiple myeloma (Eur J Nucl Med 1998; 25: 714-720). In particular, a semiquantitative score of the extension and intensity of bone marrow uptake was derived and correlated with both the clinical status of the disease and plasma cell bone marrow infiltration. In order to estimate quantitatively 99mTc-MIBI bone marrow uptake and to verify the intracellular localization of the tracer, bone marrow samples obtained from 24 multiple myeloma patients, three patients with monoclonal gammopathy of undetermined significance (MGUS) and two healthy donors were studied for in vitro uptake. After centrifugation over Ficoll-Hypaque gradient, cell suspensions were incubated with 99mTc-MIBI and the uptake was expressed as the percentage of radioactivity specifically retained within the cells. The cellular localization of the tracer was assessed by micro-autoradiography. Twenty-two out of 27 patients underwent 99mTc-MIBI scan within a week of bone marrow sampling. Whole-body images were obtained 10 min after intravenous injection of 555 MBq of the tracer; the extension and intensity of 99mTc-MIBI uptake were graded using the semiquantitative score. A statistically significant correlation was found between in vitro uptake of 99mTc-MIBI and both plasma cell infiltration (Pearson's coefficient of correlation r=0.69, P<0.0001) and in vivo score (Spearman rank correlation coefficient r=0.60, P<0.01). No specific tracer uptake was found in bone marrow samples obtained from the two healthy donors. Micro-autoradiography showed localization of 99mTc-MIBI inside the plasma cells infiltrating the bone marrow. Therefore, our findings show that the degree of tracer uptake both in vitro and in vivo is related to the percentage of infiltrating plasma cells which accumulate the tracer in their inner compartments.

Scintimammography with 99mTc-MIBI versus dynamic MRI for non-invasive characterization of breast masses

Although mammography remains the technique of choice for the early detection of breast cancer, several imaging techniques, including scintimammography and magnetic resonance imaging (MRI), have recently been proposed as adjuncts for this purpose and included in many diagnostic protocols. This study was undertaken to assess the clinical accuracy of scintimammography with technetium-99m methoxyisobutylisonitrile (MIBI) and contrast-enhanced MRI in the detection of primary breast carcinoma in patients with equivocal mammographic findings. Forty-nine patients with a suspicious breast mass detected either by physical examination or by mammography and ultrasound (US) were studied. All patients underwent scintimammography and dynamic contrast-enhanced MRI 1 week apart. The results of the two techniques were compared and correlated to the final diagnoses. Two independent readers reported the scans using a four-point confidence scale. The areas under the receiver operator characteristic (ROC) curves were obtained. Scintimammography showed an accuracy for tumour detection of 84%, with a sensitivity of 80% and a specificity of 88%. MRI showed an accuracy of 86%, with a sensitivity and specificity of 96% and 75%, respectively. Comparison of the two areas under the ROC curves showed no significant differences between MRI, 0.91+/-0.05 (mean+/-SD), and scintimammography, 0.88+/-0.05 (P=0.9). It is concluded that dynamic MRI and scintimammography possess comparable accuracy in the diagnosis of primary breast carcinoma in patients with equivocal mammographic or US findings.

Prediction of improvement in global left ventricular function in patients with chronic coronary artery disease and impaired left ventricular function: rest thallium-201 SPET versus low-dose dobutamine echocardiography

Accurate assessment of myocardial viability permits selection of patients who would benefit from myocardial revascularization. Currently, rest-redistribution thallium-201 scintigraphy and low-dose dobutamine echocardiography are among the most used techniques for the identification of viable myocardium. Thirty-one consecutive patients (all men, mean age 60 +/- 8 years) with chronic coronary artery disease and reduced left ventricular ejection fraction (31% +/- 7%) were studied. Rest 201Tl single-photon emission tomography (SPET), low-dose dobutamine echocardiography and radionuclide angiography were performed before revascularization. Radionuclide angiography and echocardiography were repeated after revascularization. An a/dyskinetic segment was considered viable on 201Tl SPET when tracer uptake was >65%, while improvement on low-dose dobutamine echocardiography was considered a marker of viability. Increase in global ejection fraction was considered significant at > or = 5%. In identifying viable segments, rest 201Tl SPET showed higher sensitivity than low-dose dobutamine echocardiography (72% vs 53%, P<0.05), while specificity was not significantly different (86% vs 88%). In 17 patients, global ejection fraction increased > or = 5% (group 1) while in 14 it did not (group 2). A higher number of a/dyskinetic segments were viable on 201Tl SPET in group 1 than in group 2 (2.6 +/- 1.9 vs 0.6 +/- 1.2, P < 0.005), while no significant differences were observed on low-dose dobutamine echocardiography (1.7 +/- 1.6 vs 1.1 +/- 1.6). A significant correlation was found between the number of a/dyskinetic segments viable on 201Tl SPET and post-revascularization changes in ejection fraction (r = 0.52, P < 0.05), but such a correlation was not observed for low-dose dobutamine echocardiography. Using as the cut-off the presence of at least one viable a/dyskinetic segment, rest 201Tl SPET had a higher sensitivity (82% vs 53%, P = 0.07) and showed a trend towards higher accuracy and specificity (77% vs 58%, and 71% vs 64%, respectively) as compared with low-dose dobutamine echocardiography. In conclusion, these findings suggest that when severely reduced global function is present, rest 201Tl SPET evaluation of viability is more accurate than low-dose dobutamine echocardiography for the identification of patients who will benefit most from revascularization.

[Influence of ovarian cysts during controlled ovarian hyperstimulation]

BACKGROUND

The use of gonadotrophin-releasing hormone agonist and purified follicular stimulating hormone increases the incidence of ovarian cysts during in vitro fertilization-embryo transfer cycles. The aetiopathogenesis and the effects of ovarian cysts on controlled ovarian hyperstimulation is unclear; most authors observed no-detrimental influence of ovarian cysts in controlled ovarian hyperstimulation cycles for IVF. The aim of this study was the evaluation of the real incidence and effects of ovarian cysts during in vitro fertilization-embryo transfer cycles.

METHODS

DESIGN

retrospective study.

SETTING

reproductive medicine units.

PATIENTS

130 women.

INTERVENTIONS

r-FSH--225 U.I. was administered to 130 women i.m. after a long protocol of down regulation with GnRH-a (Triptoreline 3.75). The drug administration was personalized on the basis of: pre-existent patients pathologies; E2 blood levels; ultrasound evaluation of the follicular development.

MAIN OUTCOME MEASURES

E2 levels, number and quality of oocytes retrieved, fertilization rate, number of embryos developed, pregnancy rate.

RESULTS

At the end of stimulation ovarian cyst was observed in eighteen cases. There was no difference, between the cycles with or without cysts, in the follicular development, number and quality of eggs retrieved, fertilization rate, number and quality of the transferred embryos, pregnancy and miscarriage rate.

CONCLUSIONS

The conclusion is drawn that the incidence of ovarian cysts during COH can be reduced observing some simple rules like: to exclude from the stimulation protocols patients with follicles of more than 12 mm diameters as observed at the preliminary ultrasound control; to personalize the therapeutic regime with the pre-existent patients pathologies; ultrasound evaluation of the follicular development; determination of the E2 serum levels, every two days.

Regulatory role of extracellular matrix proteins in neutrophil respiratory burst during aging

Neutrophil respiratory burst was assessed on plates coated with fibronectin (FN) or laminin (LM), both used at dosages inhibiting polystyrene-triggered cell activation in young healthy volunteers. Under these conditions, a low, yet significant, spontaneous superoxide anion (O(2)(-)) production, matching with enhanced levels of basal adherence, was detected in FN-plated neutrophils of elderly donors. In contrast, although neutrophil stimulation with tumor necrosis factor (TNF)-alpha, granulocyte macrophage-colony stimulating factor (GM-CSF), fMLP or phorbol myristate acetate (PMA) gave rise to a massive and prolonged FN-primed O(2)(-) release, a significant impairment of oxidative response occurred in the aged group as a result of GM-CSF or fMLP cell challenge. Such an effect was not associated to an age-related imbalance of stimulant-triggered neutrophil adhesiveness to FN, even though a larger contribution of CD18-dependent versus CD18-independent pathways was observed in old as compared to young individuals. Notably, within the aged group, anti-CD18 monoclonal antibody cell pretreatment resulted in a higher suppression of FN-primed O(2)(-) release following TNF-alpha with respect to GM-CSF stimulation, thus implying that an agonist-related defect of the coupling between beta2 integrin-dependent adhesive and oxidative events is likely to occur as a feature of age. All physiological mediators failed to activate the respiratory burst of neutrophils plated on LM-coated wells in both young and aged donors. This effect appears to be the result of an active process, since neutrophils from either group of subjects adhered to LM-coated surfaces and LM inhibited in a dose-dependent manner the FN-priming effect on neutrophil O(2)(-) production. All together the findings provide additional evidence for an imbalance of neutrophil-mediated functions in the elderly.

[Relationship between exercise capacity and left ventricular function at rest in patients with heart insufficiency: radionuclide continuous monitoring of left ventricular function]

PURPOSE

To evaluate the relationship of systolic and diastolic function at rest to exercise capacity.

MATERIAL AND METHODS

Seventeen patients with ischemic heart failure were included in the study. Ambulatory left ventricular monitoring at rest and during upright exercise with combined analysis of pulmonary gas exchange was performed. Ejection fraction, end-diastolic volume, end-systolic volume, stroke volume, cardiac output, and peak filling rate were measured.

RESULTS

Significant positive correlations were found between rest ejection fraction and peak oxygen consumption (r = .60, p < .01), peak cardiac output (r = .77, p < .0001), peak stroke volume (r = .67, p < .005), and peak ejection fraction (r = .69, p < .005). On the other hand, peak filling rate at rest showed a significant inverse correlation with peak end-diastolic (r = -.48, p < .05) and end-systolic (r = -.66, p < .005) volumes. The patients were then subgrouped into two groups according to their rest ejection fraction (lower or higher than 40%). In the group with ejection fraction less than 40% a significant correlation was observed between rest ejection fraction and both peak stroke volume (r = .66, p < .05) and peak ejection fraction (r = .69, p < .05). In the same group of patients an inverse correlation was found between peak filling rate and both end-diastolic (r = -0.65, p < .05) and end-systolic (r = -.82, p < .005) volumes.

CONCLUSIONS

The results of the present study suggest that exercise capacity is related to left ventricular function at rest and that rest diastolic function might be a determinant of left ventricular function during exercise in patients with heart failure.

Quantitative thallium-201 and technetium 99m sestamibi tomography at rest in detection of myocardial viability in patients with chronic ischemic left ventricular dysfunction

BACKGROUND

This study was designed to determine the most effective quantitative threshold for thallium-201 and technetium 99m sestamibi uptake on tomographic imaging after rest injection for the detection of myocardial viability in patients with chronic myocardial infarction.

METHODS AND RESULTS

Thallium and sestamibi cardiac tomography at rest was performed in 43 patients with chronic myocardial infarction and impaired left ventricular (LV) function undergoing coronary revascularization. In all patients, echocardiography and radionuclide angiography were performed at baseline and repeated 12 months later to evaluate recovery of regional LV function and LV ejection fraction, respectively. Optimal threshold cutoff points to separate reversible from irreversible dysfunction were determined by receiver operating characteristic analysis. When all dysfunctional segments were considered, the best cutoff point in the identification of reversible LV dysfunction for both thallium and sestamibi activity was 67%. When only akinetic or dyskinetic segments were considered, the best cutoff point in the identification of reversible LV dysfunction was 58% for thallium and 55% for sestamibi. In these segments, the area under the receiving operating characteristic curves constructed for thallium and sestamibi activity were 0.74+/-0.05 and 0.75+/-0.04, respectively (P = not significant). LV ejection fraction was 33%+/-7% at baseline and increased to 37%+/-7% after revascularization (P<.0001). A significant relation between the number of akinetic or dyskinetic but viable myocardial segments and revascularization-induced changes in LV ejection fraction was observed for both thallium (r = 0.60, P<.0001) and sestamibi (r = 0.64, P<.0001) imaging.

CONCLUSIONS

In patients with chronic myocardial infarction, quantitative analysis of thallium and sestamibi activity on tomographic imaging at rest predicts recovery of regional and global LV dysfunction after revascularization procedures. The most effective quantitative threshold for detecting reversible LV dysfunction is comparable for thallium and sestamibi tomographic imaging. However, the optimal cutoff point is different for both tracers when all dysfunctional segments are considered or when the analysis is focused only on segments with more severe functional impairment (i.e., akinetic or dyskinetic segments).

[Autoimmune hemolytic anemia in chronic hepatitis C virus infection treated with alpha-interferon: a therapy-related event or extra-hepatic immunologic manifestation?]

We report a case of Coombs' positive autoimmune haemolytic anaemia occurring in a patient with chronic hepatitis C virus infection, after five months of alpha-interferon administration. Prednisolone treatment induced a complete remission of both clinical and hematological findings after two months, while Coombs' tests became negative after three months. This points out the possibility of an additional unusual extrahepatic autoimmune feature during the course of hepatitis C virus infection.