[Duodenopancreatectomy with conservation of the pylorus]

The authors report on their initial experience with pylorus-preserving pancreatoduodenectomy. In the last three years 11 patients with neoplastic disease of the pancreatic head and ampullary region underwent the above mentioned procedure. The surgical technique carefully preserved the blood supply and innervation to the antro-pyloric region and duodenum was transected 2 cm distal to the pylorus. Postoperative mortality was 9%. Postoperative nasogastric suction was required for eight days (median). Long term results are quite good with a satisfactory restoration of intestinal function and a weight gain of 95% of pre-illness weight. At the present time preserving the pylorus appears an usefull modification of Whipple procedure.

[Unusual anatomo-clinical features of thyroid metastasis]

The authors report a case of metastatic tumor from clear cell carcinoma in the thyroid gland occurred in a patient who had his primary tumor previously treated with right nephrectomy. The time interval before the appearance of the metastasis was 6 years. The diagnosis was made preoperatively because of the peculiar biological behavior of the primary tumor. In fact, the metastasis and the primary presented with neoplastic invasion of the middle thyroid vein and the renal vein respectively. The ultrasound examination revealed the vein thrombus arising from the thyroid and reaching the internal jugular vein through the middle thyroid vein. Subsequent fine needle aspiration biopsy confirmed the diagnosis of metastasis from clear cell renal carcinoma. The low grade of malignancy of the primary from the clinical point of view and the absence of other metastatic locations influenced the therapeutic approach.

Frequency domain analysis of contrast echocardiographic images

Sequences of echocontrastographic images of the dog's myocardium are analysed in the frequency domain for the identification of underperfused areas. Owing to the fact that echo images are contaminated by noise and artifacts, we have applied filtering techniques based on Fourier's methods in sequences of raw frames recorded during perfusion with a contrast agent. Thus we have been able to assess correctly the spatial and temporal distribution of the contrast, i.e. the agent kinetics which parallel the distribution of coronary blood flow, in terms of the time necessary for the flow gradient to reach its maximum value, and to describe such a distribution by a functional image obtained by means of an original procedure.

Nonuniformity of the transmural distribution of coronary blood flow during the cardiac cycle. In vivo documentation by contrast echocardiography

This study was performed to examine the transmural (endocardial vs. epicardial) heterogeneity of myocardial blood flow during the cardiac cycle (systole vs. diastole). Twenty-four contrast echocardiographic injections were performed in seven open-chest anesthetized dogs either into left anterior descending or circumflex coronary artery or into the aortic root. Two-dimensional echocardiography in short-axis view was performed and was digitized off-line into a 256 x 256 pixel matrix with 256 gray levels/pixel. All end-diastolic and end-systolic frames before and to peak contrast were analyzed. A region of interest corresponding to the most intensely opacified myocardial segment was traced, the mean videodensity measured, and the frame of initial contrast appearance detected. The region of interest was divided into three equal parallel layers corresponding to the endocardial, midcardial, and epicardial myocardium. When the echocardiographic contrast effect initially appeared in diastole, the increment in videodensity was greater for the endocardium (131 +/- 48%) than for the epicardium (71 +/- 37% of the increment in videodensity of the entire wall) (p less than 0.05). This inhomogeneity subsequently disappeared in the following end-systolic frame. When the initial echocardiographic contrast effect appeared in systole, intensity was higher in epicardium (136 +/- 83%) than in endocardium (60 +/- 60%) (p less than 0.05). However, in the following diastole, intensity was not significantly different for the two layers. Thus, myocardial contrast echocardiography demonstrates that coronary blood flow is primarily subendocardial in distribution during diastole and subepicardial during systole.

Renal involvement in IgD myeloma

Nine patients affected from IgD myeloma were studied retrospectively in order to elucidate the incidence and peculiar traits of related nephropathy. Eight patients developed chronic renal failure, and as many as 5 were already suffering from renal failure since first admission to the hospital. In 3 cases acute renal failure was the major presenting symptom of the disease. Five patients underwent a regular dialytic treatment. We suggest that the high incidence of renal involvement found in IgD myeloma is related to the high incidence of Bence-Jones proteinuria observed in this disease. Presenting atypical symptoms, among which renal failure is the most important, are misleading and characteristic of the disease. Survival time seems to be negatively influenced by the presence of renal failure at the time of diagnosis.

[Role of photon absorption densitometry of the bone in uremic osteodystrophy]

The aim of this investigation is to evaluate the role of bone photonic densitometry in uremic osteodystrophy. Bone mineral content (BMC) and bone density (BD) have been measured in 80 hemodialyzed patients by double photonic emission densitometry. Photonic densitometry shows an higher sensibility to quantitative changes in bone mineral content than metacarpal index (IM). Photonic densitometry is unable to differentiate osteoporosis from osteomalacia; this differential diagnosis can be obtained by radiological analysis: low BD and low IM means osteoporosis, low BD and resorptive changes in cortical bone means osteomalacia and/or hyperparathyroidism. Photonic densitometry is particularly suitable for uremic osteodystrophy follow-up because of its easy repetitiveness and innocuousness and for its close correlation with iPTH variations.

Oral isosorbide 5-mononitrate can protect from myocardial ischemia induced by ergonovine test and by isometric effort. Preliminary results from an echocardiographic acute study in anginal patients

Isosorbide 5-mononitrate (IS 5-MN) has favourable pharmacodynamic properties, such as the specific half-life (close to 5 h) and the bioavailability (100% after oral ingestion). The efficacy of IS 5-MN (20 mg t.i.d.) in the treatment of stable angina has been documented in previous studies. In the present acute study, two subsets of patients were evaluated: the first group consisted of 10 patients with coronary vasospasm in whom oral IS 5-MN was effective in preventing myocardial ischaemia due to an abrupt reduction in coronary blood flow; the second group regarded 8 patients with a mixed form of angina, where the responsible mechanism for ischaemia can be considered a combination of increased myocardial oxygen demand and reduction of coronary blood flow due to vasoconstriction of large vessels. In all these patients, IS 5-MN was able to protect against transient myocardial ischaemia induced by isometric test. In conclusion, from the data available in our studies, IS 5-MN appears to be a useful drug in anginal patients: the beneficial effect is likely based on its capability both to prevent the abnormal vasoconstriction of diseased coronary vessels and to reduce myocardial oxygen demand.

Echocardiography in the study of myocardial ischemia in man: the clinical model of Prinzmetal's angina

Standard echocardiography was employed to study the clinical model of myocardial ischemia with ST-segment elevation, well known as Prinzmetal's angina. Ultrasonic monitoring was performed during the appearance of ST-segment elevation, from onset of pain, during an ergonovine maleate test, hemodynamic monitoring, radioisotopic studies and, occasionally, during routine examinations, when spontaneous episodes occurred. Reliability of findings was supported by two important conditions: each patient acted as his own control, since recording was carried out from basal state to basal state, throughout ischemia, or from ischemia to basal state; behaviour of ischemic walls was compared with that of non-ischemic ones. Echocardiographic findings in acute myocardial ischemia were similar both in spontaneous and in induced episodes and were mainly characterized by: decrease in contractility indices of the ischemic segment, such as wall motion and percent systolic thickening; increase in left ventricular end-systolic and end-diastolic diameter, with a decrease in percent fractional shortening; distorted shape of ventricular cavity, transiently deformed as in a "functional" aneurysm; a sharp demarcation between ischemic and non-ischemic adjacent segment, "step sign", was present only in severe cases. Taking ST-segment elevation as a reference the time sequence of events was studied, correlating mechanical, electric and clinical markers of ischemia. At least three different echocardiographic phases were identified in the evolution of ischemic attacks: Pre-electrocardiographic phase, when mechanical impairment is detected by ultrasounds in the absence of both ST-segment changes and pain; Electrocardiographic phase, when echocardiographic signs of ischemia co-exist with obvious electrocardiographic signs.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic documentation of myocardial ischemia in presence of angina pectoris without ST-T changes

A frequent clinical problem is to document the elusive entity of electrocardiographically silent myocardial ischemia. Since echocardiography offers a practical tool to detect reversible mechanical changes due to ischemia, 32 patients with angina on effort, and coronary artery disease, and 15 patients with angina at rest were studied. In all 47 patients electrocardiographic changes during effort or rest pain were inconclusive. Combined 12 lead electrocardiographic and 2-Dimensional echocardiographic monitoring were performed: during ergonovine testing in the 15 patients with angina at rest; during dipyridamole testing in the 32 patients with effort angina and a non diagnostic stress test. Interpretable echocardiograms were obtained in all the patients studied. Positivity of both the Ergonovine-Echocardiographic test and the Dipyridamole-Echocardiographic test was based upon the detection of regional transient asynergy. Of the 15 patients who had chest pain at rest in the absence of diagnostic electrocardiographic changes, Ergonovine-Echocardiographic test was positive in 6 (40%). Of the 32 patients who had chest pain in absence of diagnostic electrocardiographic changes during exercise stress testing, the Dipyridamole-Echocardiographic test was positive in 18 (56%). Echocardiographic monitoring in combination with provocative testing (ergonovine and dipyridamole) may be a practical, non invasive, inexpensive tool which is feasible in all patients with good basal echocardiograms and is able to unmask electrocardiographically silent myocardial ischemia by providing objective mechanical evidence of the ischemic event.

Clinical effects of plasmapheresis in acute Guillain-Barré syndrome

5 consecutive cases of acute GBS were treated by plasmapheresis (PP). Clinical features and results of therapy have been compared with those of 10 consecutive acute GBS cases untreated by PP. PP treatment, applied early during the phase of deterioration, seemed to stop deficit progression, thus eliminating the stationary stage and triggering recovery immediately. Complete recovery seemed to occur comparatively faster than in the untreated group.

Short and long-term clinical effects of plasma-exchange in 33 cases of myasthenia gravis

The authors examine the results of plasma exchange (PE) treatment in 33 patients with myasthenia gravis, who underwent a total of 49 cycles of treatment. On the basis of clinical response, evaluated in relation to a modification of the functional state and to the duration of improvement after PE, we selected a group of 20 responsive patients ("responders" = 60.6%) and 13 non-responsive patients ("non-responders" = 39.4%). Positive effects, some only short-lasting, were observed in 24 patients (72.7%) after 32 cycles of a total of 49 cycles (65.3%). Out of the 11 most critical patients, 7 (63.6%) were considered responders, given the importance and duration of the improvement they presented, while 2 other patients had clear but short-lasting improvements; in these 9 patients, the positive effects amounted to 81.2%. Factors presumably responsible for therapeutic failure in the non-responders are discussed.

Effect of chronic anticonvulsant monotherapy on lymphocyte subpopulations in adult epileptic patients

Sixty-five patients undergoing long-term monotherapy for at least 3 months with phenytoin, carbamazepine or phenobarbital were screened for lymphocyte and immunoglobulin abnormalities. In 57% of patients the duration of therapy was longer than 12 months. The control subjects were matched for sex and age and none of them was taking drugs. The average serum immunoglobulin (IgG, IgA, IgM) values did not differ in control and patient groups. A significant decrease of OKT4+ cells was seen with all drugs, while other lymphocyte subpopulations were differently affected depending on the drug used. It is concluded that long-term single-drug treatment with phenytoin, carbamazepine and phenobarbital exhibits immunosuppressant effects through a complex action which involves more than one lymphocyte subpopulation. Moreover, the possible interference of the disease state with the immune functions of epileptic patients is discussed.

[Computerized tomography in the diagnosis of a herniated cervical disk ]

A total number of 117 cervical herniated disks was observed in 103 patients. Among these, 30 underwent surgical treatment. A comparison is made between CT findings and myelographic and surgical data. Purpose of the investigation is to define the reliability of CT in the diagnosis of cervical herniated disk. The morphology, level and tomographic localization into the vertebral canal are described. Moreover the possible association with spondylosis and "narrow canal" is stressed. The diagnosis was correct in all operated cases (100%). The topographic description too was correct in all cases. In 3 patients the level-diagnosis was mistaken. CT shows a higher degree of sensibility and specificity than myelography in the diagnosis of herniated disk in the cervical spine.

Lymphocyte populations in patients with myasthenia gravis. Influence of thymectomy and immunosuppressive drugs

The T/B peripheral blood lymphocyte ratio was evaluated in 51 patients with myasthenia gravis by means of the rosette test and HTLA. Total T cells and T gamma and Tmu were decreased while B lymphocytes were increased. E-active rosettes were also above the normal range. The previous thymectomy and/or immunosuppressive treatment restored the T lymphocytes identified by HTLA to normal range while those identified by E rosettes were still reduced. This difference may be due to the different stages of T lymphocyte maturation.

EEG findings in 118 cases of myasthenia gravis

We examined 148 EEG recordings from 118 patients affected with myasthenia gravis (35 males and 83 females, aged 17-82, with illness durations between 1 month and 24 years). The cases were clinically evaluated according to Ossermann's classification at the time of EEG recording. EEG patterns were subdivided into normal, diffuse or focal slow abnormalities, or epileptiform patterns. Of the 118 patients, 104 had normal EEG recordings and 14 had at least one abnormal recording (8 diffuse slow abnormalities, 6 focal slow abnormalities). The EEG findings were not correlated with clinical parameters (thymic pathology, respiratory incidents, drug treatment, etc.). One patient (whose EEG recordings were normal) showed an isolated epileptic fit and another patient was affected by epilepsy. A possible relationship between the two diseases is discussed.