Electrocardiogram analysis in Anderson-Fabry disease: a valuable tool for progressive phenotypic expression tracking

Background

Electrocardiogram (ECG) has proven to be useful for early detection of cardiac involvement in Anderson-Fabry disease (AFD); however, little evidence is available on the association between ECG alterations and the progression of the disease.

Aim and Methods

To perform a cross sectional comparison of ECG abnormalities throughout different left ventricular hypertrophy (LVH) severity subgroups, providing ECG patterns specific of the progressive AFD stages. 189 AFD patients from a multicenter cohort underwent comprehensive ECG analysis, echocardiography, and clinical evaluation.

Results

The study cohort (39% males, median age 47 years, 68% classical AFD) was divided into 4 groups according to different degree of left ventricular (LV) thickness: group A ≤ 9 mm (n = 52, 28%); group B 10-14 mm (n = 76, 40%); group C 15-19 mm (n = 46, 24%); group D ≥ 20 mm (n = 15, 8%). The most frequent conduction delay was right bundle branch block (RBBB), incomplete in groups B and C (20%,22%) and complete RBBB in group D (54%, p < 0.001); none of the patients had left bundle branch block (LBBB). Left anterior fascicular block, LVH criteria, negative T waves, ST depression were more common in the advanced stages of the disease (p < 0.001). Summarizing our results, we suggested ECG patterns representative of the different AFD stages as assessed by the increases in LV thickness over time (Central Figure). Patients from group A showed mostly a normal ECG (77%) or minor anomalies like LVH criteria (8%) and delta wave/slurred QR onset + borderline PR (8%). Differently, patients from groups B and C exhibited more heterogeneous ECG patterns: LVH (17%; 7% respectively); LVH + LV strain (9%; 17%); incomplete RBBB + repolarization abnormalities (8%; 9%), more frequently associated with LVH criteria in group C than B (8%; 15%). Finally, patients from group D showed very peculiar ECG patterns, represented by complete RBBB + LVH and repolarization abnormalities (40%), sometimes associated with QRS fragmentation (13%).

Conclusions

ECG is a sensitive tool for early identification and long-term monitoring of cardiac involvement in patients with AFD, providing "instantaneous pictures" along the natural history of AFD. Whether ECG changes may be associated with clinical events remains to be determined.

Electrocardiographic findings in Anderson-Fabry patients on disease specific therapy: can treatment prevent ECG changes?

Background

Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder that have gained attention due to the availability of therapeutic options. Disease specific therapy (DST), either by enzyme replacement therapy or oral pharmacological chaperone, is the mainstay for AFD treatment. Although its widespread use, few data are available on the electrocardiographic variations associated with DST.

Purpose

To evaluate ECG findings and variations in AFD according to time duration of DST, comparing patients under long-term therapy with naïve patients starting therapy during follow-up.

Methods

One-hundred-seventy-nine AFD patients, ≥18 years old, with 2 readable ECGs, were recruited in the present multicentre study cohort. Two patients were excluded due to pacemaker (PM) implantation. Only patients on DST (n=107) were considered for final cohort and divided into 2 groups according to therapy duration: Group A (n=42) included patients treated for ≥12 months at the time of first evaluation, whereas Group B patients (n=65) started therapy during follow-up.

Results

Group A and Group B had no significant difference in terms of age at presentation (48 [39–60] vs 48 [36–56] years; p=0.856) and maximal wall thickness (13 [11–15] vs 13 [11–18] mm; p=0.090) whereas they differed for male prevalence (61% vs 38%; p=0.029) and classic phenotype (86% vs 29%; p&lt;0.0001). At baseline, more than half of both groups had ECG abnormalities (61% vs 61%; p=1.000). The prevalence among Group A and Group B of atrial fibrillation (AF, 5% vs 6%; p=1.000), first degree atrioventricular block (AVB, 7% vs 5%; p=0.677), right bundle branch block (RBBB, complete 7% vs 8%; p=1.000; incomplete RBBB 14% vs 12%; p=0.776), left anterior fascicular block (LAFB, 10% vs 9%; p=1.000) and repolarization abnormalities (48% vs 38%; p=0.423) was not significantly different. Conversely, left ventricular hypertrophy (LVH) was more prevalent in Group A (64% vs 37%; p=0.010).

During the follow-up period (57 [60–28] months for Group A vs 70 (37–85) months for Group B; p=0.152), both groups developed electrocardiographic alterations (38% vs 23%; p=0.127). In particular, in Group A, 4 (10%) patients presented AF, 1 (2%) AVB, 7 (17%) complete or incomplete RBBB, 4 (10%) LAFB, 1 (2%) LVH and 8 (19%) repolarization abnormalities. In Group B, 2 (3%) developed AF, 1 (2%) AVB, 7 (11%) complete or incomplete RBBB, 2 (3%) LVH and 11 (17%) repolarization abnormalities; none developed LAFB.

Conclusions

In this AFD cohort, both patients on chronic DST (Group A) and patients who started treatment during follow-up (Group B) developed ECG alterations. ECG changes during the follow-up were more frequent in Group A (38% vs 23%), mainly composed by classic phenotype and male patients, suggesting a prompt start of therapy at an early stage.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic pathways leading to arrhythmogenic left ventricular cardiomyopathy in a single center cohort

Background

Despite major advances, the recognition of arrhythmogenic left ventricular cardiomyopathy (ALVC) remains challenging, since this clinical entity is often concealed in different clinical settings both in terms of clinical onset and imaging phenotype, resulting in significant delays in diagnosis with prognostic implications.

Purpose

To describe a single Center cohort of ALVC patients, focusing on the spectrum of clinical presentation and diagnostic pathways.

Methods

Patients were retrospectively evaluated between January 2012 and January 2022. Diagnosis was based on 1) ≥3 contiguous segments with subepicardial/midwall LGE in the LV at cardiac magnetic resonance (CMR) plus a likely pathogenic/pathogenic arrhythmogenic cardiomyopathy (ACM) associated genetic mutation and/or familial history of ACM and/or red flags for ALVC (i.e, negative T waves in V4–6/aVL, low voltages in limb leads) or 2) pathology examination of explanted hearts/autoptic cases suffering from sudden cardiac death (SCD). Patients with significant right ventricular involvement were excluded.

Results

Sixty-six patients were evaluated for suspected ALVC: 8 phenocopies were excluded (6 acute myocarditis and 2 sarcoidosis) after a comprehensive clinical and multi-modality instrumental evaluation. The final study cohort was composed by 56 patients (55% males, median age 45 years), from 36 families. Diagnostic pathways leading to diagnosis were: SCD in 4 (7%), ventricular arrhythmias in 11 (20%), chest pain in 9 (16%), heart failure in 7 (12%), and familial screening in 25 (45%) (Figure 1). An echocardiogram was available for all but 2 patients with SCD: 25 (46%) had normal phenotype, 17 (32%) had a hypokinetic non dilated cardiomyopathy, and 12 (22%) had a dilated cardiomyopathy (DCM). Of the 49 tested patients, 31 (63%) had a pathogenic/likely pathogenic DNA variant: desmoplakin (DSP, N=21), filamin C (FLNC, N=4), SCN5A (N=3) were the most frequently involved genes; 8 patients had a double gene mutation. Twenty-four patients (43%) had previously received a diagnosis other than ALVC: 10 idiopathic DCM, 9 acute myocarditis, 4 post-myocarditis DCM, 2 acute myocardial injury/non-ST elevated myocardial infarction. In 13 patients ALVC was diagnosed with the introduction of CMR in the diagnostic work-up of a DCM, in 2 cases the diagnosis was done with the pathology examination after heart transplantation. The median diagnostic delay was of 8 years, with a maximum of 20 years. It is worth nothing that patients from the same family might have different diagnostic pathways and phenotypes of ALVC (Figure 2).

Conclusions

ALVC is a challenging diagnosis, hidden in different clinical scenarios. Five main clinical pathways leading to ALVC diagnosis may be identified: ventricular arrhythmias, chest pain, heart failure, SCD at first presentation, and clinical/instrumental familial screening.

Funding Acknowledgement

Type of funding sources: None.

Electrocardiographic evolution in Anderson-Fabry disease patients on and off specific therapy: a potential marker to study the therapeutic cardiac goal

Background

Anderson Fabry disease (AFD) is an X-linked lysosomal storage disorder leading to a deficiency in α-galactosidase A and globotriasylceramide (Gb3) deposition in different organs, including the heart. In AFD patients electrocardiogram (ECG) represents an important tool to detect cardiac involvement. AFD specific therapy (enzyme replacement or chaperon therapy) has shown to modify the natural history of the disease and to decrease Gb3 levels, but so far there are no data on its influence on ECG evolution.

Purpose

To assess the progression of ECG features in AFD patients on and off specific disease therapy and to evaluate the potential role of ECG in studying the cardiac specific response to therapy.

Methods

We recruited 170 patients with an established AFD diagnosis, ≥18 years old (64 males 38%, median age 46±15 years) in a multicentre study cohort. We analysed their ECG evolution for a median follow-up of 64±48 months in patients off (group A, N=63) and on (group B, N=107) specific therapy.

Results

AFD patients off specific disease therapy (group A) had similar age at baseline compared to those on therapy (47±14 vs 44±12 years; p=0,171), however significantly differed for males prevalence [13 (21%) vs 51 (48%); p≤0,001], classic phenotype [36 (57%) vs 82 (77%); p&lt;0,001)] and maximal wall thickness [11±3 vs 13±4 mm; p≤0,0001]. As regards ECG features at baseline, group A showed a lower prevalence of repolarization anomalies [16 (25%) vs 51 (48%), p=0,005], left ventricular hypertrophy [14 (22%) vs 51 (48%), p=0,001], pseudo necrosis [4 (6%) vs 18 (17%) vs, p≤0,060] and short PR [2 (3%) vs 12 (11%), p=0.0845]. During the follow-up ECG progression was observed in 9 patients in group A (14%), characterized by the development of repolarization anomalies (N=5; 8%), incomplete right bundle block (N=4; 6%), shortening of PR interval (N=2; 3%), left ventricular hypertrophy (N=2; 3%), left atrial enlargement (N=2; 3%) and complete right bundle block (N=1; 2%). Differently, in group B an ECG evolution was observed in 31 patients (29%) characterized by the development of repolarization anomalies (N=19; 18%), left atrial enlargement (N=12; 12%), complete right bundle block (N=8; 8%), left anterior fascicular hemiblock (N=4; 4%), left bundle block (N=4, 4%) and left ventricular hypertrophy (N=3; 3%). Among patients off therapy we observed an improvement of ECG in 1 patient characterized by regression of repolarization anomalies, which could be explained with the presence of transient overload anomalies.

Conclusion

In AFD patients off and on specific disease therapy, ECG evolution was detected in 14% and 29% respectively, consistently with the more advanced cardiac involvement in patients on therapy (higher prevalence of male sex, classic phenotype and higher maximum wall thickness). The fact that one third of the patients showed ECG changes progression despite being on specific disease therapy could be relevant to better defined the therapeutic cardiac goal.

Funding Acknowledgement

Type of funding sources: None.

ECG as a storytelling of cardiac involvement evolution in Anderson Fabry disease

Background

Cardiac involvement in Anderson-Fabry disease (AFD) is related to a progressive glycosphingolipid storage over time and is characterized by left ventricular hypertrophy (LVH), conduction abnormalities and myocardial fibrosis. ECG is useful for early recognition of AFD, however evidence is limited on the association between ECG alterations and disease stage.

Purpose

To assess the relationship between ECG characteristics and progressive cardiac involvement, from the pre-hypertrophic phase to phenotypes with increasing degree of LVH.

Methods

In a multicenter cohort, 183 AFD patients (40% male, age 47±12 years, 60% affected by “classical AFD”) underwent ECG and transthoracic echocardiography. Patients were divided into 4 groups according to the different degree of LV thickness measured in parasternal short axis view: group A ≤9 mm (N=46, 25%), group B 10–14 mm (N=77, 42%), group C 15–19 mm (N=45, 25%) and group D ≥20 mm (N=15, 8%). Patients with pacemaker and under 18 years of age were excluded.

Results

A normal ECG was present in 89% in group A, 59% in group B, 11% in group C and it was absent in group D. Short PR (&lt;120 ms) was more frequent in group A, whereas with LVH increasing, median PR interval duration significantly prolonged among the 4 groups (136 [125–150]vs 141 [130–160] vs 160 [130–180] vs 170 [130–180] ms, p=0.002 respectively). Median P-wave duration was shorter in group A and B compared to group C and D (80 m vs 100 ms, p&lt;0.001), while both QRS and QTc gradually increased. Median Sokolow-Lyon voltage criteria statistically augmented among the groups (22 [18–26] vs 27 [20–33] vs 32 [25–45] vs 35 [18–40] mm, p&lt;0.001 respectively), along with right ventricular hypertrophy (0%, 1%, 11%, 8%, p=0.02). Right bundle branch block (RBBB) had a higher frequency in advanced stages (0%, 34%, 34%, 40%, p&lt;0.001), with a prevalence of complete RBBB of 46% in group D. Similarly, left anterior fascicular block (0%, 7%, 18%, 46%, p&lt;0.001) and QRS fragmentation (2%, 11%, 25%, 23%, p=0.009) were more common in advanced stages. No differences were found in left bundle branch block (LBBB), in low QRS voltages or in LV pre-excitation prevalence. According with the wall thickness increase, negative T waves were more frequent in lateral (4%, 21%, 70%, 77%, p&lt;0.001) and inferior leads (6%, 15%, 32%, 46%, p 0.001), as well as their association with ST-T depression (4%, 17%, 64%, 46%, p&lt;0.001). Giant negative T waves were present only in group C and D (16% and 31%) mainly representing a LVH distribution toward the apex.

Conclusions

ECG is a very useful tool to stage cardiac involvement evolution in AFD. Peculiar ECG characteristics evolve together with LV wall thickness: incomplete and progressively complete RBBB usually associated (preceding or following) LVH and/or typical repolarization abnormalities in inferior or lateral leads and giant negative T waves in the more advanced stages are the most frequent and typical ECG patterns.

Funding Acknowledgement

Type of funding sources: None.

Tactile and Kinesthetic Stimulation (TKS) intervention improves outcomes in weanling rat bone in a neonatal stress model

OBJECTIVES

Preterm infants are born with low bone mineral. Neonatal stress further impedes bone mineralization. Clinical evidence suggests that tactile and kinesthetic stimulation (TKS) improves bone phenotype and decreases stress response. Clinical and translational studies indicate the IGF-1 axis, responsible for postnatal growth and bone mineralization, is a key player. We hypothesized that TKS would attenuate the negative impact of neonatal stress on bone phenotype and the IGF-1 axis in weanling rats.

METHODS

Neonatal stress (STRESS) or TKS (STRESS + 10min TKS) was administered from D6 to D10. Control animals received standard care. Tissue was harvested on D21. Dual energy x-ray absorptiometry (DXA) and bone morphometry were performed and serum osteocalcin, type I procollagen N-terminal propeptide (PINP), tartrate-resistant acid phosphatase (TRAP), and bone and liver mRNA levels of IGF-1, IGF-1 receptor (IGF-1R), and growth hormone receptor (GHR) were measured.

RESULTS

Neonatal stress increased bone mineral content (BMC), area (BA), growth plate width, liver IGF-1 mRNA, and serum IGF-1. TKS maintained areal bone mineral density (aBMD) and bone specific IGF-1 and IGF-1R mRNA while STRESS decreased compared to controls.

CONCLUSIONS

Neonatal stress results in apparent accelerated growth response. TKS differed from STRESS with improved tibia aBMD and increased bone specific IGF-1 mRNA.

Mechanical-tactile stimulation (MTS) intervention in a neonatal stress model improves long-term outcomes on bone

OBJECTIVES

Neonatal stress impairs postnatal bone mineralization. Evidence suggests that mechanical tactile stimulation (MTS) in early life decreases stress hormones and improves bone mineralization. Insulin-like growth factor (IGF1) is impacted by stress and essential to bone development. We hypothesized that MTS administered during neonatal stress would improve bone phenotype in later life. We also predicted an increase in bone specific mRNA expression of IGF1 related pathways.

METHODS

Neonatal stress (STRESS) and MTS (STRESS+10 min of MTS) were given from D6 to D10 of rat life and tissue was harvested on D60 of life. Dual energy x-ray absorptiometry (DXA), bone morphometry, serum osteocalcin, type I procollagen N-terminal propeptide (PINP), tartrate-resistant acid phosphatase (TRAP), and bone and liver mRNA levels of IGF1, IGF1 receptor (IGF1R), and growth hormone receptor (GHR) were measured.

RESULTS

Stress resulted in reduced bone area and bone mineral content (BMC) compared to naive control (CTL). MTS intervention increased BMC and tibial growth plate width compared to STRESS. MTS also resulted in higher osteocalcin, and, in males, lower TRAP (p<0.05). MTS resulted in three-fold, two-fold, and six-fold higher bone specific IGF1, IGF1R, and GHR, respectively (p ≤ 0.001) compared to STRESS.

CONCLUSIONS

MTS in early postnatal life improves long-term bone mineralization. IGF1 and related pathways may explain improved BMC.

Role of hemochromatosis genes in chronic hepatitis C

PURPOSE

Hereditary hemochromatosis is commonly associated with iron overload and hepatitis C virus (HCV). Association between hemochromatosis C282Y or H63D mutation has been observed, although not uniformly, and iron overload is also commonly found in chronic HCV hepatitis. This study explored the contribution of genetic hemochromatosis to iron accumulation in hepatitis C.

DESIGN

Review of current literature.

RESULTS

The prevalence of increased serum iron stores in patients with HCV infection is 28% (patients having an elevated ferritin or transferrin saturation). Patients with elevated serum iron markers have more active chronic hepatitis with more liver fibrosis. In the opinion of the experts HFE mutations are not associated with a high hepatic iron content. No relation was detected between hepatic iron stores and HFE gene mutation. Significant iron deposition in the liver was uncommon and overall the quantity of iron that was detectable histologically and biochemically was unrelated to the grade and stage of HCV related liver injury. The mechanism by which liver iron accumulates in patients is unclear.

CONCLUSIONS

Carriage of HFE mutations does not have a role in the accumulation of iron or the liver disease in HCV. These findings do not support a role for iron depletion in patients with chronic HCV infection, including these with elevated serum studies.

Idiopathic chronic urinary retention in the female: Case report

Female urinary retention may present various etiological aspects. From reports in literature, the most frequent cause appears to be a neurological lesion (60%), while there is no clearly identifiable cause in the remaining 40%. The Authors report the case of a young woman who, following slight retention immediately after a gynaecological operation, returned after 5 months requiring first of all indwelling vesical catheterisation followed by clean intermittent authocatheterisation. Checks and clinical assessments produced negative results and the real cause of urinary retention was not clear. Clean intermittent autocatheterisation was the only feasible therapy, also allowing functional recovery of the vesico-sphincteric apparatus.

Epidermoid cyst of the testis: Report of two cases and literature review

— Epidermoid cysts of the testis are very rare and their treatment is controversial. The lesion is benign but no reliable pre- or intraoperative examination can be achieved. We believe that the most correct treatment is orchiectomy through inguinal access. Conservative surgery can be considered in particular cases. We describe two cases.

[Multicenter comparative study of meropenem vs. imipenem in the intramuscular treatment of hospital infections of the urinary tract]

A clinical, multicentre, randomised, comparative study in 283 adult hospitalized patients was carried out to assess efficacy of meropenem in the treatment of complicated and non-complicated urinary tract infections, in comparison to imipenem/cilastatin. Both antibiotics were administered intramuscularly, at a dose of 500 mg bid. The two groups were homogeneous, as regards the distribution between male and female, the mean age of the patients, the severity of infections and the mean duration of treatment. Clinical results were assessed at the end of therapy and follow-up (4-6 weeks). Bacteriological results were assessed at 5-9 days post-treatment and at follow-up. As regards clinical and bacteriological results patients showing a satisfactory response rate were compared, at the end of the treatments using a Chi square test. With both treatments high satisfactory clinical and bacteriological response rates were seen. As regards clinical satisfactory responses (97% of meropenem assessable patients versus 90% of imipenem/cilastatin assessable patients), there was a statistically significant difference in favor of meropenem. The bacteriological outcome was successful (eradication) for 75% of assessable patients in each group. Most failures were seen in the complicated infections, even when pathogens usually sensitives to carbapenemics were initially isolated. Safety was good with both drugs; no withdrawals in any group of treatment was seen because of side effects. The local tolerance of meropenem was globally rated as good.

Testicular neoplasms and tumoral markers

The use of tumoral markers and especially of BHCG and AFP in the diagnosis, staging and follow-up of patients affected by testicle germinai neoplasms is now widespread. Nevertheless, controversies stili exist in each one of these fields. Especially for clinical staging, high percentages of understaging of stage I tumours are reported in literature with considerable effects on therapeutical indications and prognosis. The Authors attempt a criticai review on the use of markers for diagnosis and staging of testicular neoplasms based upon their own experience of 79 cases over a 14-year period.

Vesicovaginal fistulas: our experience and review of literature

Vesicovaginal fistulas (VVF) still represent a sad complication of surgery of the female genital system. In this article an extensive review of the literature was conducted, analyzing the etiological, pathological and clinical aspects, as well as the therapeutical problems. For this purpose, we have compared the many surgical techniques proposed for treatment of VVF and have also evaluated their results. Furthermore, we report on our series of 35 patients who had undergone treatment for VVF.

Bladder Instability

Bladder instability is undoubtedly a major cause of incontinence. The condition is reasonably well-defined and advances in the last 20 years in the urodynamic diagnosis of the condition have stimulated a number of leading clinicians and research workers to focus their attention on this problem. The aim of this paper is to produce a better understanding of the unstable bladder.

Diagnostic and therapeutic problems in multicentric renal angiomyolipoma

Multicentric renal angiomyolipoma is a rare form of benign tumor. However, its effective incidence as evaluated in autopsy studies may be as high as 8%. There are 2 main types of renal angiomyolipoma, that is isolated forms and those associated with other diseases, such as phakomatosis, polycystic kidneys and fibromuscular dysplasia. The tumor may also display malignant behavior with local invasiveness and regional lymph node involvement. However, the clinical course is benign and multicentricity is important for prognosis. Histopathological diagnosis often is difficult. Immunohistochemical analysis of surgical specimens using a panel of monoclonal antibodies, including HMB-45 and actin, enabled us to make a definitive diagnosis in 3 cases of multicentric renal angiomyolipoma.

[Clinical and instrumental evaluation of erectile impotence: a proposal of a diagnostic protocol]

There has been increasing interest in recent years in patients complaining of erectile dysfunction. This has prompted research and the development of diagnostic procedures aimed at allowing increasingly rapid characterization of the type of impotence involved (psychogenic or organic) and thus the most effective treatment. In this preliminary study, we present our study methodology in patients with erectile dysfunction, emphasising in particular the diagnostic procedures best suited to revealing the presence of an organic cause in the pathogenesis of impotence.

Stones in horseshoe kidney treated by ESWL

In this report the Authors present their experience regarding 11 patients (in all 12 renal units) with stones in horseshoe kidney treated by ESWL. Horseshoe kidney is a frequent malformation that in about one out of five cases is complicated by lithiasis with a marked tendency to recurrence. In these cases, because of anomalous seat, rotation and vascularization, percutaneous lithotripsy appears to be dangerous. 66.6% of treated renal units were stone-free after one or more treatments (maximum 3). The lithotriptor was a Dornier MFL 5000. On the basis of these data ESWL represents the treatment of choice for stones with dimensions less than 25 mm in horseshoe kidney.

Ureteral multiple diverticulosis associateci with cystic ureteritis. Etiopathogenetic hypothesis

Ureteral diverticulosis is an uncommon pathology whose etiopathogenesis is not clear yet. The most reliable etiopathogenetic hypothesis for multiple diverticuli is the inflammatory one. We report a case of ureteral multiple diverticulosis associated with cystic ureteritis: it can be supposed that both pathologies were caused by a common inflammatory stimulus. We submitted the patient to follow-up by urinalysis, urinary citology and urography. At present the appearance of the ureteral lesions is unchanged.

Hemorrhagic pseudocysts of the adrenal gland: Case description

Cysts of the suprarenal gland, classified as parasitical cysts, epithelial cysts, endothelial cysts and pseudocysts are uncommon. We report a case of pseudocysts of the suprarenal gland. Clinical signs consisted of flank pain and palpable mass. Urography, ultrasonography and computed tomography were essential for diagnosis. Treatment consisted of surgical extirpation, as percutaneous needle aspiration entails high rate of recurrences.

[Spermatic cord torsion]

Torsion of the spermatic cord constitutes a surgical emergency. Morphologically and functionally, the fate of the compromised testis largely depends on the time elapsed between the acute episode and surgical intervention. Patients who had been treated for testicular torsion by our group from 1976 to 1989 were requested to return for outpatient evaluation. These patient were divided into two groups according to the time elapsed between the diagnosis and surgical intervention. We observed that surgical correction within 12 hours following presentation permitted testicular salvage. Testicular volume was generally preserved and remained normal or slightly diminished. However, when the time elapsed was over 12 hours, testicular atrophy was observed in 46% of the patients. We can conclude, therefore, that detorsion must be performed as soon as possible. Vaginalis testis eversion will generally achieve stable and lasting fixation.

[Continuous monitoring of nocturnal penile tumescence and rigidity in the evaluation of erection disorders. Preliminary data]

Nocturnal penile tumescence measurements continues to be an important step in the diagnosis of impaired erectile function. We present our experience with this technique employed on 65 patients who consulted at our andrologic center. Our results corroborate the importance of the NPR-R test with the Rigi-Scan in the evaluation of this pathology to ensure these patients receive the most appropriate treatment.

[Conservative surgical treatment of bilateral renal neoplasms]

Surgery seems to be the only effective treatment for bilateral kidney neoplasms as shown by the better survival rate of operated patients compared with those otherwise treated or untreated at all. The best conservative treatments, regarding radicality and security required by these neoplasms, are the enucleation and the partial in situ nephrectomy. Our study is based on 11 patients affected by bilateral kidney neoplasms; 8 of them, in which there were no signs of metastatization, have undergone surgical treatment. In 2 patients (18%) a bilateral enucleation was performed and in 6 (55%) monolateral enucleation together with a controlateral radical nephrectomy. All tumors developed simultaneously have been operated in the same session. No postoperative complications were observed except in 2 patients which developed a transient renal insufficiency. The follow up was from 2 to 66 months. All patients were examined with echotomography or CT scan at least once a year and are, up today, in good health condition and tumor free.