Clinical profile and outcome of cardiomyopathies in infants and children seen at a tertiary centre

INTRODUCTION

Due to their rare prevalence and marked heterogeneity, pediatric cardiomyopathies (CMPs) are little known and scarcely reported. We report the etiology, clinical profile and outcome of a consecutive cohort of children diagnosed with CMP and followed at Meyer Children's Hospital over a decade.

PATIENTS AND METHODS

We retrospectively reviewed patients consecutively referred from May 2008 to May 2019 for pediatric onset CMP (<18 years). Heart disease caused by arrhythmic disorders, toxic agents, rheumatic conditions and maternal disease were excluded.

RESULTS

We enrolled 110 patients (65 males), diagnosed at a median age of 27 [4-134] months; 35% had an infant onset (<1 year of age). A positive family history was more often associated with childhood-onset (38.8%). Hypertrophic cardiomyopathy (HCM; 48 patients) was the most frequent phenotype, followed by dilated cardiomyopathy (DCM; 35 patients). While metabolic and idiopathic etiologies were preponderant in infants, metabolic and sarcomeric diseases were most frequent in the childhood-onset group. Major adverse cardiac events (MACE) occurred in 31.8% of patients, including hospitalization for acute heart failure in 25.5% of patients, most commonly due to DCM. Overall, the most severe outcomes were documented in patients with metabolic diseases.

CONCLUSIONS

In a consecutive cohort of pediatric patients with CMP, those with infantile onset and with a metabolic etiology had the worst prognosis. Overall, MACE occurred in 41% of the entire population, most commonly associated with DCM, inborn errors of metabolism and genetic syndromes. Systematic NGS genetic testing was critical for etiological diagnosis and management.

Clinical course and outcome of pregnancy in patients with hypertrophic cardiomyopathy

Background

Hypertrophic Cardiomyopathy (HCM) is the most common genetic cardiomyopathy. However, few studies have systematically investigated the clinical course of pregnancy in HCM.

Purpose

To determine whether pregnancy is well tolerated in HCM.

Methods

Women consecutively referred to our Tertiary Clinic for Cardiomyopathies from 1969 to

2019 were retrospectively reviewed. Only women with complete data regarding pregnancy and with a follow up (FU)&gt;1 year were included in the study. Overall, of the 647 women followed at our center, 378 (58%) fulfilled our inclusion criteria. Demographic, clinical and instrumental records were retrieved. The peripartum period was defined as the timeframe from −1 to 6 months after delivery.

Results

There were 433 pregnancies in 239 (63%) women with 132 (62%) having &gt;1 pregnancy. By contrast, 139 (37%) reported no pregnancy or miscarriages: in 6 cases pregnancy was discouraged due to advanced disease stage. Twenty-eight (12%) women had 39 pregnancies after HCM diagnosis and were followed by the obstetrics department: this subset was significantly younger at diagnosis (age at diagnosis: 21 [13–29] vs 56 [47–66] vs 45 [24–62] years, p&lt;0.001, in women with a pregnancy after diagnosis vs women diagnosed after the pregnancy vs women with no pregnancy, respectively). Instrumental characteristics were comparable among women. Thirty percent presented with obstructive physiology at baseline. Among the 39 pregnancies in women who had a pregnancy after the diagnosis, there were 3 reported episodes of paroxysmal atrial fibrillation, one sustained ventricular tachycardia with pulse and three episodes of non-sustained ventricular tachycardia in the peripartum period. In this cohort, prevalence of intra-uterine growth delay and miscarriage was 8%. Only 3 women experienced a worsening clinical profile requiring hospitalization during the peripartum period: 2 were hospitalized for acute heart failure (AHF) and 1 was experienced a resuscitated cardiac arrest. Of note, 2/3 of patients were carriers of a (likely)pathogenic troponin mutation.

Long-term (FU: 5±3 years), nulligravida women were more symptomatic at last evaluation (NYHA III/IV: 25 vs 17, p&lt;0.05), reported a higher incidence of ICD appropriate shocks (26 vs 12%p=0.02) but had similar rates of heart transplant (2.1 vs 0.5%, p=0.143) and episodes of AHF (12 vs 14%, p=0.193). Eighteen patients (8.2%) died: incidence of cardiovascular mortality was 4.8%, with a lower rate in patients who reported a pregnancy (0.8%/year vs 2.8%/year, p=0.01).

Conclusions

Women with HCM tolerate pregnancy well. Rare complications occurred in the peripartum period which were manageable. In the long-term, pregnancy, even when multiple, did not influence the long-term course of the disease nor its outcome. Strategies to support appropriate counselling and antenatal care should be implemented to identify those at greater risk of disease progression.

Funding Acknowledgement

Type of funding sources: None.

Hidden familial cardiomyopathies in children: Role of genetic testing

Pediatric cardiomyopathies harbour significant phenotypic and genetic heterogeneity. Genetic testing is essential for the initial evaluation and the ongoing care of child and family, although challenges remain regarding its appropriate clinical implementation in minors. We here discuss the key role of genetic diagnosis in the clinical management of two patients.

Prevalence of adverse cardiovascular events in pediatric cardiomyopathies: an analysis of 110 patients followed at a long-standing tertiary care paediatric centre

Introduction

Pediatric cardiomyopathies (CMP) are disorders of the morphology and function of the heart, with a greater heterogeneity concerning etiology and clinical presentation than adult CMP. The assessment of etiology and genetic status is of paramount importance for prognosis, family screening, and therapeutic choices.

Purpose

To report clinical presentation, etiology, and outcome of a cohort of children diagnosed with CMP followed at tertiary care pediatric referral centre.

Methods

We retrospectively reviewed clinical, laboratory and imaging data of all patients referred to our cardiomyopathy centre from May 2008 to May 2019 for pediatric CMP (&lt;18 years). CMP due to arrhythmic disorders, toxic agents' exposure, rheumatic conditions and maternal disease (i.e. maternal diabetes) were excluded. Primary endpoint was a composite of major adverse cardiovascular events (MACE: cardiovascular death, heart failure [HF] hospitalization, arrhythmic events, need for surgery or heart transplant referral).

Results

We enrolled 110 patients (65 males, age at diagnosis 67±71 months). Hypertrophic cardiomyopathy (HCM, N=48, 44%) was most frequent, followed by dilated cardiomyopathy (DCM, N=35 32%) and left ventricular non-compaction phenotype (LVNC, N=12, 11%). Mixed phenotype (N=7, 6%) and restrictive cardiomyopathy (RCM, N=3, 3%) were less common. No cases of arrhythmogenic right ventricular cardiomyopathy (ARVC) were detected. Five genotype-positive patients presented with negative clinical phenotype. A diagnosis was confirmed in all patients; the most common was sarcomere disease (30%, N=33) followed by metabolic (28%,N=31) disease, genetic syndromes (11%, N=12), neuromuscular (7,3%, N=8) diseases, and post-myocarditis cases (4,5%,N=5). Twenty-one patients (19%) were identified as idiopathic. At referral, 4,5% of children presented with NYHA class III/IV.

At 35 [14–72] months, 4 (3.7%) patients required ICD implantation, 8 (7.4%) underwent cardiac surgery, and 1 (1%) underwent heart transplant. Furthermore, 28 (26%) patients required hospitalization due to acute HF, with DCM patients being at higher risk (p&lt;0.01), 7 (6.8%) experienced arrhythmic events and 4 (3.9%) had syncope. Overall, 13 (12%) died (7 with metabolic disorders, 3 with genetic syndromes, 1 with a sarcomeric mutation, 1 post myocarditis, and 1 idiopathic).

Conclusions

In our cohort, HCM was the most common cause of pediatric CMP followed by DCM and non-compaction. MACE were present in 41% of patients. While HCM had a less severe phenotype (characterized by a higher arrhythmic burden), DCM was characterized by a higher prevalence of HF hospitalizations. DCM, inborn errors in metabolism and genetic syndromes had the worst outcome in terms mortality and heart failure long term.

Widespread availability of genetic testing provides several benefits to the clinician, confirming diagnosis in ambiguous cases and defining etiology in order to guide management and identifying relatives at risk.

Figure 1

Funding Acknowledgement

Type of funding source: None

Pulmonary atresia or critical pulmonary stenosis with intact interventricular septum diagnosed in utero: echocardiographic findings and post-natal outcome

BACKGROUND

Survival of neonates with critical pulmonary obstruction depends on cardiac morphology and function but also on proper perinatal management.

METHODS

Postnatal outcome of five neonates with critical pulmonary stenosis or pulmonary atresia detected in utero is reported.

RESULTS

Right ventricular morphology and ratio between tricuspid and mitral annulus at Fetal Echocardiography were the most important prognostic parameters. Increasing severity of obstruction and of right ventricular hypoplasia was documented in two fetuses.

CONCLUSION

Prenatal diagnosis was useful for planning delivery; we hypothesize that it can be of benefit on postnatal outcome. In selected cases, earlier delivery and relief of obstruction could have beneficial effect on prognosis.

[Kawasaki disease: clinical characteristics and cardiovascular involvement in a cohort of 121 patients]

Kawasaki disease is an acute generalized self-limiting vasculitis of small and medium size arteries of unknown ethiology, mostly affecting children younger then 5 years of age. Coronary arteries may be involved with aneurysms lesions, thrombotic occlusion, acute coronary syndrome and sudden death. The mortality rate has been significantly reduced by combined therapy of intravenous immunoglobuline (IVIG) and acetil salicylic acid (ASA) from 3% to 0.2%. From February 1986 to November 2001, 121 children, 76 male and 45 females with Kawasaki disease, have been observed at the Paediatric Department, University of Florence. Coronary changes (i.e. coronary ectasia and coronary aneurysms) have been observed in 22.3%. In only one 3-months old child, giant aneurysms of coronary arteries and myocardial necrosis have been detected. In 26 of 27 children at 2D echo a remodelling of the coronary changes within 12 months from the onset of the illness was observed. The mean follow-up has been five years (range 6-138 months) and in no patient further cardiac manifestations have been observed; however, as little is known about the progression of vascular damage, a more protracted follow-up is needed.

Cardiac contusion in blunt chest trauma: a combined study of transesophageal echocardiography and cardiac troponin I determination

BACKGROUND

The role of cardiac troponin I (cTnI) is well established in acute myocardial ischemia. However, its role in myocardial contusion remains to be clarified. Since transesophageal echocardiography (TEE) appears, at present, to be the best method for the diagnosis of myocardial contusion, the aim of this study was to measure the concentration of cTnI in patients with blunt chest trauma studied using TEE.

METHODS

Thirty-two patients (27 males, 5 females, mean age 44+/-20 years), admitted to the Trauma Center of our Institution with clinical and/or radiological signs of acute blunt chest trauma, underwent biplane TEE within 24 hours of injury; serial blood samples were taken to measure cTnI levels (normal values < 0.4 ng/ml), using fluorimetric enzyme immunoassay.

RESULTS

Abnormal levels of cTnI were found in 17 patients (53%): 7 patients had levels of cTnI between 0.4 and 1 ng/ml, whereas 10 patients had levels > 1 ng/ml. Segmental wall motion abnormalities consistent with myocardial contusion could be identified by echocardiography in 6/10 patients with cTnI levels > 1 ng/ml (60%) but in no patients with normal cTnI levels or with titers between 0.4 and 1 ng/ml; mean cTnI levels showed a significant difference between the two groups of patients with and without echocardiographic signs of myocardial contusion (2.6+/-1.6 vs 0.6+/-1.4 ng/ml, p < 0.001).

CONCLUSIONS

Abnormal titers of cTnI suggesting myocardial contusion may be found in more than half of patients with blunt chest trauma; however, myocardial injury can be detected by TEE only for cTnI levels > 1 ng/ml; cTnI concentrations ranging between 0.4 and 1 ng/ml might be indicative of myocardial microlesions, not detectable by echocardiography, even if TEE is used; cTnI assay could therefore be suggested as a screening test before performing TEE after blunt chest trauma.

"Natural histories" of mitral valve prolapse. Influence of patient selection on cardiovascular event rates

BACKGROUND

In previous studies the reported incidence of cardiovascular events among mitral valve prolapse patients has differed more than 10 fold. We endeavored to determine the relation between the clinical features and mode of ascertainment of mitral valve prolapse and the resulting event rate.

METHODS

Between January 1979 and August 1996, 275 patients (129-47% men, 146-53% women, mean age 43 +/- 19 years), were followed for a mean of 98 months after evaluation in a referral center for valvular heart disease. Comparative data were obtained from a separate, less selected population consisting of 316 patients.

RESULTS

A total of 65 events occurred (2.9/100 patient-years): 46 (2.0/100 patient-years) mitral surgery, 12 cardiac deaths (0.5/100 patient-years), 6 neurologic ischemia (0.26/100 patient-years), and 1 infective endocarditis (0.04/100 patient-years). The overall event rate varied significantly according to demographic, clinical and echocardiographic variables (all p < 0.0001). It was higher among males (odds ratio-OR 2.1), subjects > or = 45 years of age (OR 14.7), those with a holosystolic murmur (OR 25.9), an enlarged left ventricle (OR 13.5) or left atrium (OR 34.9) and those with 3-4+ mitral regurgitation at color Doppler echocardiography (OR 40.0). It was lower in those with an audible mid-systolic click (OR 0.05). These ORs closely resembled those we reported previously in a less selected population. At multivariate analysis, male gender (p = 0.013), severe Doppler mitral regurgitation (p = 0.0048), and left atrial enlargement (p = 0.046) were all independent predictors of events.

CONCLUSIONS

In a population of mitral valve prolapse patients, including many with significant mitral regurgitation at baseline, we identified similar predictors of events but an overall event rate nearly 3 times higher than that we previously reported for relatively unselected patients or family members in New York City (1/100 patient-years). Therefore, the impact of patient selection on the prevalence of mitral regurgitation, older age and male gender strongly affects the adversity of the "natural history" of mitral valve prolapse.

Capture-recapture methods to size alcohol related problems in a population

STUDY OBJECTIVE

To investigate the utility of capture-recapture methods to estimate prevalence of subjects with alcohol related disorders using multiple incomplete lists.

DESIGN

This was a cross sectional study of alcohol related disorders in a large community.

SETTING

During 1997 identified cases with known alcohol related disorders were independently flagged by four sources (self help volunteering groups; psychiatric ambulatory; public alcohology service; hospital discharges).

PATIENTS

381 records were flagged, corresponding to 349 individual cases from a target population resident in a northern Italy area.

MAIN RESULTS

The two sample capture-recapture estimates were clearly biased because of dependencies among sources. Estimates based on log-linear models showed prevalent counts ranged from 2297 (95% confidence intervals: 1524, 3794) to 2523 (95% confidence intervals: 1623, 4627) after adjustment for dependence among sources only or also for heterogeneity in catchability among age categories (< 50 and >/= 50 years), respectively.

CONCLUSIONS

The study suggests that capture-recapture is an appropriate approach for estimating prevalence of subjects with alcohol related problems who seek or need treatment and assistance when different lists of alcoholics can be obtained from different types of agencies involved with problematic use of alcohol. Critical factors are the complexity in case definition and the analysis of heterogeneity among people. Accurate estimates are needed to plan and evaluate public health interventions.

[Should the patient with an interatrial defect recognized in adulthood always be operated on?]

BACKGROUND

Atrial septal defect (ASD) can be recognized in adult age, mostly in asymptomatic or scarcely symptomatic patients. These patients differ from patients in "historical" clinical series, in whom diagnosis was done on the basis of clinical evidence, and their natural history is probably different.

AIM OF THE STUDY

Our aim was to verify retrospectively results of surgery versus medical follow-up in an adult population with ASD with age at first diagnosis > or = 30 years.

PATIENTS AND METHODS

Seventy-two patients with ASD, 52 females (72%), observed at our Institution since 1978, were considered. Mean age at diagnosis was 48 +/- 12 years (range 30-79); 36 patients (50%, group A) are still on medical therapy, 36 patients (group B) were operated. As groups A and B did not differ significantly in any demographic, clinical or echocardiographic parameter, they were compared for the incidence of complications.

RESULTS

During follow-up (100 +/- 70 months, range 12-240), the incidence of major clinical events showed no significant differences in the two groups, as cardiac death or cardiovascular complications (cerebral ischemic events, severe mitral insufficiency, reoperation) occurred in 4 patients in group A (11%) and in 4 patients in group B (11%). Worsening of NYHA class was observed in 3 patients from group A (8%) and 2 patients from group B (5.5%; p = ns). New onset of supraventricular arrhythmias occurred more frequently in group B (14 patients, 39%) than in group A (5 patients, 14%) (p = 0.01; OR = 3.9; CI 95%: 1.2-12.6).

CONCLUSIONS

In an adult population affected with asymptomatic or mildly symptomatic ASD and age at first diagnosis > or = 30 years, surgical closure of the defect did not modify morbidity and mortality at a mid-term follow-up. We suggest that, mostly in older asymptomatic patients, surgery should not be a routine choice and clinical decision-making should be individualized in each case.

[Verapamil-responsive ventricular tachycardia in small children: a case report and review of the literature]

A case of verapamil-responsive incessant ventricular tachycardia in a 4-year-old girl is reported. Oral verapamil alone failed in maintaining stable sinus rhythm. With association of oral verapamil and betablockers (nadolol) the patient remained asymptomatic without recurrence of ventricular tachycardia over a follow-up of 1 year. In case of failure of monotherapy with verapamil or betablockers alone, an association of both can be effective and safe also in pediatric age. Radiofrequency catheter ablation should be reserved, especially in pediatric age, only to patients with impaired ventricular function who are not responsive to medical therapy.

[The prevalence and characteristics of persistent pulmonary hypertension of the newborn. A multicenter study. The Study Group of the Società Italiana di Cardiologia Pediatrica (SICP)]

BACKGROUND

Persistent pulmonary hypertension of the newborn (PPHN) is a rare syndrome with a severe prognosis, in which a prompt diagnosis can be life-saving. The aim of our study was to verify its prevalence in a neonatal population, define clinical and echocardiographic criteria for the diagnosis of PPHN and discuss therapeutic choices.

METHODS

The following clinical and echocardiographic criteria for the diagnosis of PPHN were defined: 1. cyanosis and hypoxemia non-responsive to O2 therapy; 2. right to left shunt at an atrial or ductal level. All neonates fulfilling these criteria referred to the neonatal units of seven pediatric or general hospitals over a two-year period were enrolled.

RESULTS

From January 1995 to December 1996, thirty neonates with PPHN (8%) were observed. Birth was pre-term in 5 out of 30. Ten (33%) had experienced chronic and/or fetal asphyxia (FA). Death occurred in 7 (22%), four of whom with FA. Echocardiography showed tricuspid insufficiency in 18 (60%); mean pulmonary systolic pressure was 67 +/- 16 mmHg (range 41-95). In 23 surviving neonates, normalization of clinical and echocardiographic parameters occurred in 8 +/- 5 days.

THERAPY

In most neonates, vasodilators (tolazoline, prostacyclin) and/or nitric oxide were employed.

CONCLUSIONS

PPHN is confirmed to be a rare pathological condition; prognosis is severe, particularly in neonates with FA. Echocardiography is a reliable non-invasive method for a prompt diagnosis and follow-up. Subsequent studies are needed to assess therapeutic choices.

[Syncope at pediatric ages: evaluation with head-up tilt]

Syncope is a common medical problem with multiple potential causes and it is very frequent in pediatric population . Neurocardiogenic syncope has been increasingly recognized with the introduction of head-up tilt test (HUTT). The study investigates the clinical utility of HUTT in the evaluation and management of children with recurrent syncope and structurally normal heart. Two-hundred-forty-three consecutive young patients with recurrent unexplained syncope, 100 males and 143 females (mean age 11.4 years, range 5 to 20) underwent HUTT using a 60 degree tilt for 45 min. The test was considered positive when it provoked symptoms of syncope with hypotension and/or bradycardia. Twenty-six patients (10.7%) were positive for neurocardiogenic syncope. Of the 26 patients with the positive tilt, 5 (19.2%) had cardioinhibitory response, 5 (19.2%) mixed response and 16(61.6%) vasodepressive response. Nineteen of 143 females (13.3%) and 7 of 100 males (7%) resulted positive (NS). Among patients < 10 years of age 3/41 (9.8%) were positive and among > 10 years 22/202 patients (10.9%) resulted positive (NS). The cardioinhibitory response is more frequent in males (p = 0.01), and the vasodepressive in females (p = 0.05). In our study, concerning a non selected pediatric population a positive test resulted in a lower percentage than previously reported; moreover, the tilt test has appeared a promising method of identifying patients requiring pharmacotherapy. Additional randomized controlled studies are necessary to better define the prognosis and treatment of neurocardiogenic syncope in children and adolescents with positive tilt test. Finally, an assessment of the outcome of young patients with syncope and a negative tilt test is needed.

A major involvement of the cardiovascular system in patients affected by Marfan syndrome: novel mutations in fibrillin 1 gene

The aim of our study was to characterize the molecular defect in Italian Marfan patients, thus contributing to the effort of correlating the genotype with the phenotype. In particular, our ultimate goal was to identify the region(s) of the fibrillin 1 (FBN1) gene mainly involved in the health of the heart and of the aorta in terms of the cardiovascular system. We searched for a molecular defect in three patients with classic Marfan syndrome (MFS). The mutations were detected applying heteroduplex analysis to each of the 65 exons of the FBN1 gene amplified by polymerase chain reaction (PCR). Exons containing heteroduplex bands were sequenced directly from PCR products. This study reports the detection of three unique missense mutations in the FBN1 gene in three Italian patients: a 44-year-old adult male and 36-year-old female affected by classic MFS (with all the cardinal manifestations in the cardiovascular, ocular and skeletal systems), and an 11-year-old male affected by infantile (earlier onset) classic MFS. The first two are sporadic cases and present a Cys-->Arg amino acid substitution (T-->C substitution at nucleotide 7729) in exon 62 and a Cys-->Tyr amino acid substitution (G-->A substitution at nucleotide 6695) in exon 54. The third is a familial case which presents a Cys-->Trp aminoacidic substitution (C-->G substitution at nucleotide 3546) in exon 28. Our data confirm that cysteine substitutions in calcium binding epidermal growth factor (cbEGF)-like domains cause severe Marfan phenotype. Exon 24-32 cluster seems to produce an even more severe phenotype. The early characterization may be of clinical relevance for prevention and early surgical treatment of aortic aneurysm or dissection.

[Long-term follow-up on ventricular pre-excitation in pediatric age]

AIM

Little is known yet about the clinical aspects of ventricular pre-excitation in pediatric age. In order to define clinical course, assess the risk of malignant arrhythmia and evaluate indications for ablative therapy, we studied 82 consecutive pediatric patients (pts) with this affection (61 males-21 females; mean age at diagnosis 5.1 years, range 1 day-15 years).

RESULTS

Mean follow-up time was 66 months (range 3-252). Fifty-six pts (68.3%) were asymptomatic. One patient, who was affected with hypertrophic cardiomyopathy and died suddenly when she was 2 while her cardiac rhythm was being monitored, had an EKG pattern of asystolia. In 28 pts (19 m - 9 f, 34.1%), episodes of reentrant atrio-ventricular tachycardia, ranging from 160 to 320 beats/minute, were documented. Five pts, four of whom were less than 1 year old, had syncope or cardiac failure due to tachyarrhythmia. As far as maximum incidence of symptoms is concerned, two peaks were observed: within the first year and between 14 and 16 years of age. A transesophageal electrophysiologic study was performed in 22 pts, tachyarrhythmias were induced in 15, and risk criteria were satisfied in 3/22 (13.6%). Five pts underwent catheter ablation of an accessory pathway and this was successful in three of them.

CONCLUSIONS

The clinical course in this series of patients has been benign. Nevertheless, during the first year of life cardiac failure or syncope may occur because of high heart rates. The transesophageal electrophysiologic study, which is also easy to perform in pediatric patients, has been sensitive in assessing the risk of malignant arrhythmia, but it shows low predictive accuracy. Lastly, ablative therapy has shown lower efficacy in children than in adult patients.

Prognostic factors for long-term survival in cirrhotic patients after the first episode of liver decompensation

BACKGROUND/AIMS

Prognostic studies on cirrhosis are needed, since several attempts to obtain better survival predictors than the empirically derived Child-Pugh's score have failed.

METHODS

Four hundred and ninety-four consecutive in-patients with cirrhosis at the first episode of decompensation (ascites, jaundice, encephalopathy) and/or of digestive haemorrhage from ruptured oesophageal varices were followed from admission (1983-1989) to 1993, studying the relationship between 26 prognostic variables and survival. Three prognostic models were constructed using Cox's regression model and the Receiver Operating Characteristic (ROC) analysis was used to compare their predictive ability.

RESULTS

During follow-up 351 patients died (median cumulative survival 1.82 years). Child-Pugh's score (explicative variable of the first Cox's model), albumin and encephalopathy among the 5 Child-Pugh variables (second model), and oesophageal varices haemorrhage and 3 biochemical indexes among the 7 significant variables on univariate analysis (third model) correlated with survival. The area under the ROC curve of the first model did not significantly differ from that for the other 2 models.

CONCLUSIONS

The Child-Pugh's score is still the best and simplest index for assessing the prognosis of liver cirrhosis.

Renal resistive index and left ventricular hypertrophy in essential hypertension: a close link

The aim of this study was to evaluate renal Doppler resistive index in patients with mild to moderate essential hypertension (EH) and to correlate its changes with the presence of left ventricular hypertrophy assessed by echocardiography. Twenty-eight EH patients (19 males, 9 females, mean age 56.2 +/- 8.6 years) and 13 normotensive subjects (7 males, 6 females, mean age 57.6 +/- 7.9 years) were studied; all patients underwent a complete echocardiographic study (M-mode, two-dimensional and Doppler) and a color Doppler echography of renal and intrarenal arteries. After the renal Doppler waveform was obtained, resistive index was calculated by peak systolic velocity (S) and lowest diastolic velocity (D) with the formula S-D/S. EH patients were divided into two subgroups on the basis of left ventricular mass (LVM): Group EH1 with normal LVM (15 patients) and Group EH2 with increased LVM (13 patients). All patients evidenced normal renal morphology and function and received no therapy throughout the entire observation period. Renal resistive index was significantly higher in EH patients than in controls; however, the maximum difference was observed between normotensive subjects and the EH patients with increased LVM (p < 0.00001). At univariate analysis, significant correlations were found between renal resistive index and age, body mass index, left ventricular relative wall thickness and LVM. However, when multiple regression analysis was used, only age (p < 0.01) and LVM (p < 0.05) remained significant predictors of resistive index. In conclusion, our data show that in EH patients resistive index, which is considered an expression of arterial impedance, is well correlated with the presence of left ventricular hypertrophy, presently considered the best index of the severity of hypertensive disease. This correlation may be the expression of the involvement of two target organs in hypertension.

[Efficacy of steroid therapy in a case of hepatic hemangioendothelioma in childhood]

Multiple hepatic hemangioendothelioma are vascular lesions of the liver that generally appear in the infancy with hepatomegaly, high output congestive heart failure and cutaneous hemangiomas. Many plans for management (steroid, radiation, hepatic artery ligation, embolization, cyclophosphamide) have been proposed. We report a case in two months old boy of hepatic hemangioendothelioma with arteriovenous shunts and heart congestive failure, successfully treated with steroid.

[Mitral valve prolapse: the clinical and echocardiographic characteristics in a hospital outpatient population]

BACKGROUND

Mitral valve prolapse (MVP) is generally regarded as a benign condition, but serious complications (including severe mitral insufficiency, cerebral ischemia, infective endocarditis, complex arrhythmias and sudden death) have been described in a minority of patients and have been correlated to demographic, clinical and echocardiographic characteristics. Both a lack of standardized definition of MVP in earlier studies and the different ways of recruitment of MVP patients may explain the variability in reported complication rates.

METHODS

As an offspring of a larger prospective study this paper focuses on the profile of patients who were found to have MVP by M-Mode and two-dimensional echocardiography in several outpatient hospital departments. A total of 8252 consecutive subjects, examined since March 1990 to February 1991 in the Echo laboratories of the Florence area are considered; according to the presence or absence of structural changes (anterior mitral leaflet thickness > 5 mm, leaflet redundancy and/or anulus dilatation) two groups of patients with MVP (A and B) were identified.

RESULTS

A MVP was diagnosed in 288 subjects (3.5%), 170 females (59%) and 118 males (41%), mean age 41 +/- 18 years (range 7-84). 110 (38%) were in Group A, 178 (62%) in Group B. The following parameters differed significantly in the two groups: age (45 +/- 17 vs 39 +/- 17 years; p < 0.003); male gender (50% vs 35%; p < 0.01); auscultatory findings (midsystolic click: 31% vs 68%; p < 0.00001; holosystolic murmur: 22% vs 3%; p < 0.00001); left ventricular diameter (53 +/- 7 vs 48 +/- 5 mm; p < 0.00001) and left atrial diameter (38 +/- 8 vs 33 +/- 5 mm; p < 0.00001). Among patients with mitral regurgitation detected by Color Doppler Echocardiography 65% were in Group A (p < 0.00001).

CONCLUSIONS

These patients with MVP are obviously selected by the modality of recruitment; hence there is a higher prevalence of subjects with morphologic abnormalities and mitral regurgitation who are older and more likely to be male if compared to individuals with MVP who are found in the general population. A long-term follow-up of these patients is ongoing: owing to the data of the literature about prognostic predictors, a higher incidence of complications with a different prognosis between the two groups (with or without structural changes of the mitral valve) is expected.

[Congenital arterio-venous malformations: an unusual cause of heart failure at birth and during the first months of life]

BACKGROUND

Congenital arteriovenous malformations represent a rare cause of heart failure in neonates.

MATERIALS

Four neonates with arteriovenous malformations (cerebral in one, hepatic in two and pulmonary in one) are reported.

RESULTS

In the first three cases Color Doppler echography was able to image the arteriovenous malformations, to identify the afferent and efferent vessels and to quantify the arteriovenous shunt. In the neonate with pulmonary malformation, a cardiac cause of heart failure was excluded by echocardiography, and the diagnosis was stated by selective angiography. The neonate with cerebral great arteriovenous malformation died at 4th day of life. The two neonates with hepatic malformations improved both with medical therapy; in the last neonate, with multiple arteriovenous pulmonary fistulae, selective embolization was performed, but the child died a few months later.

CONCLUSION

Congenital arteriovenous malformations are rare, and an early diagnosis is the base for a correct therapy; Color Doppler echography represents the gold standard for cerebral and hepatic malformations, while selective angiography should be reserved to patients who might profit of embolization or surgical resection.

Natural history of mitral valve prolapse

To assess the rate and predictors of complications in patients with mitral valve prolapse (MVP), 316 subjects (mean age 42 +/- 15 years) with echocardiographic MVP were followed prospectively for a mean of 102 months: 220 (70%) were women, 225 (71%) had clinically recognized MVP, and 91 (29%) were detected in family studies. During follow-up, 11 patients (0.4/100 subject-years) required mitral valve surgery, 6 died of cardiac causes (0.2/100 subject-years), 7 developed cerebral ischemia (0.3/100 subject-years), and 2 developed active infective endocarditis (0.1/100 subject-years). The overall rate of fatal and nonfatal complications (1/100 patient-years) was higher in men than in women (odds ratio [OR] 3.2, p < 0.003), in subjects aged > 45 than < or = 45 years (OR 3.4, p = 0.002), in clinically recognized patients than in affected family members (OR 3.8, p < 0.02), and in those with a holosystolic murmur (OR 26.9, p < 0.00005); the overall rate was lower in those with a midsystolic click (OR 0.3, p < 0.002). Echocardiographic left ventricular or atrial diameter > or = 6.0 or > or = 4.0 cm, respectively, was associated with a 16.7- and 15.1-fold higher likelihood, respectively, of subsequent complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias in mitral valve prolapse: relation to anterior mitral leaflet thickening, clinical variables, and color Doppler echocardiographic parameters

Atrial and ventricular arrhythmias have been reported with variable incidence in symptomatic patients with mitral valve prolapse (MVP). The role of clinical and echocardiographic parameters as predictors for arrhythmias still needs to be clarified. One hundred nineteen consecutive patients (56 women and 63 men, mean age 40 +/- 17 years) with echocardiographically diagnosed MVP were examined. A complete echocardiographic study (M-mode, two-dimensional, and Doppler) and 24-hour electrocardiographic monitoring were performed in all patients. Complex atrial arrhythmias (CAAs) included atrial couplets, atrial tachycardia, and paroxysmal or sustained atrial flutter or fibrillation. Complex ventricular arrhythmias (CVAs) included multiform ventricular premature contractions (VPCs), VPC couplets, and runs of three or more sequential VPCs (salvos of ventricular tachycardia). The relation between complex arrhythmias and clinical parameters (age and gender) and echocardiographic parameters (left atrial and left ventricular dimensions, anterior mitral leaflet thickness [AMLT], and presence and severity of mitral regurgitation) was evaluated by multiple logistic regression analysis. CAA were present in 14% of patients and CVA in 30%. According to multiple logistic modeling, CAA correlated separately in the univariate analysis with age, presence of MR, and left ventricular and left atrial diameters; age was the only independent predictor (p < 0.001). CVA, in the univariate analysis, correlated with age, female gender, left ventricular end-diastolic diameter, and AMLT; only female gender and AMLT were independent predictors in the multivariate analysis (p < 0.01). The incidence of mitral regurgitation (59%) was higher than expected in a general population of MVP patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[An echocardiographic study of the left ventricular functional indices in pediatric patients on hemodialysis and in treatment with recombinant human erythropoietin (r-HuEPO)]

Recombinant human erythropoietin (r-HuEPO) is efficient in the treatment of anaemia in chronic renal failure on hemodialysis. We investigated the changes in cardiac function under r-HuEPO therapy using echocardiography. Seven patients with severe renal anaemia (Ht 19%) were treated with 50 U/kg r-HuEPO EV three times/week. Echocardiographic studies were performed in the anemic state and when hematocrit values were stable at levels (Ht 30%). Left ventricular function as showed by fractional shortening (D%) improved, the thickness of the interventricular septum and left ventricular hypertrophy were reduced. Our data indicate that the correction of renal anaemia by r-HuEPO can improve myocardial function in patients on maintenance hemodialysis.

[Relationship between rheumatic disease and mitral valve prolapse: an etiopathogenetic connection or the result of a semiologic confusion?]

The term mitral valve prolapse is used to describe either one of the pathophysiological mechanisms of mitral regurgitation or a distinct biological condition with a defined inherited basis, with or without mitral incompetence. In the former case, association with rheumatic fever is implied by the definition itself; in the latter it's questionable (rheumatic fever could act as an environmental factor in the expression of a genetically determined mitral valve prolapse). Three hundred and twenty patients with mitral valve prolapse, diagnosed as a primary one, were studied in order to assess the prevalence of a well-documented history of rheumatic fever: this resulted higher versus a control population (5.6% vs 0.9%-p < 0.01). The retrospective nature of the study does not allow a definite conclusion. Familial as well as long-term follow-up studies are necessary to better define the association between rheumatic fever and mitral valve prolapse; a potentially different prognosis, mainly accounting to the development of a clinically relevant mitral regurgitation in patients with mitral valve prolapse and previous rheumatic fever, has to be searched.

[The cardiac changes in thalassemia major: their assessment by Doppler echocardiography]

Dilated cardiomyopathy with impaired left ventricular function is the most common cause of death in patients (pts) with Thalassemia Major (TM) undergoing multiple transfusions. To assess the cardiac status in a young population with TM, 25 pts (mean age 15.8 +/- 5.7 years) and 25 controls (sex and age matched), underwent clinical, echocardiographic and Doppler evaluation. Thirteen pts who received a correct chelation therapy had serum Ferritin (F) below, and nine pts up to 1300 ng/ml. Three out of 9 pts with F > 1300 ng/ml were symptomatic for heart failure, and echocardiography showed a dilated cardiomyopathy. All pts with F < 1300 ng/ml had a normal systolic function. Mean left ventricular (LV) diastolic dimension and LV mass index were significantly increased in pts with TM versus controls (respectively: 37.2 +/- 7.9 mm vs 30.5 +/- 4.3 mm--p < 0.001; 78.6 +/- 16.7 g vs 65.2 +/- 19.4 g--p < 0.05). Moreover, LV end-diastolic dimension was significantly increased in patients with TM having normal systolic function versus controls (36.1 +/- 7.5 mm vs 30.5 +/- 4.3 mm). No difference was found between patients with TM and controls for wall thickness nor for Doppler diastolic indexes obtained from analysis of transmitral flow. Our study suggests that a correct chelation therapy may protect pts with TM from early development of a dilated cardiomyopathy. The first echocardiographic abnormality in pts still asymptomatic and with normal systolic function seems to be an increased end diastolic LV dimension. In our experience, left ventricular filling is not altered in asymptomatic patients.

[The sports fitness of patients operated on for aortic coarctation: assessment by exercise Doppler echocardiography]

BACKGROUND

The aim of this study was to assess the utility of Doppler echocardiography both at rest and during isotonic exercise in evaluating competition eligibility of patients with repaired coarctation of the aorta (CoAo).

METHODS

Seventeen young patients (11 male, 6 female; mean age 17.1 +/- 7.9 years) with previous surgical repair of CoAo were examined. Mean follow-up after repair was 10.3 +/- 3.5 years. All patients underwent complete Echocardiographic examination (M-mode, 2D and Doppler) and an exercise test on an ergometric bicycle, with continuous wave Doppler monitoring of flow velocity in descending aorta, with a transducer positioned in the suprasternal notch. Peak and mean Doppler gradients in descending aorta were measured both at rest and during exercise, using the simplified Bernoulli equation. According to peak Doppler gradient at rest, patients were divided into two subgroups: Group IA = patients with peak gradient lower than 25 mmHg; Group IB = patients with peak gradient greater than 25 mmHg. Finally, 17 healthy subjects (Control Group), matched for age and body surface area, were examined.

RESULTS

Systolic and diastolic blood pressure both at rest and during exercise were not significantly different in the 3 groups. Patients of Group IB showed a significant increase of left ventricular mass (124.0 +/- 24.4 vs 85.8 +/- 24.1 g/m2, p < 0.01), and during exercise, a significant increase of peak gradient (68.3 +/- 27.2 vs 23.5 +/- 9.0 mmHg, p < 0.0001) and mean gradient (34.8 +/- 11.5 vs 11.9 +/- 5.0 mmHg, p < 0.0001) at the level of the descending aorta. In patients of Group IA, echocardiographic parameters were not different in comparison with the Control Group, whereas Doppler gradients during exercise were only slightly greater than those observed in the Control Group (peak gradient 36.9 +/- 13.0 vs 23.5 +/- 9.0 mmHg, p < 0.05; mean gradient 19.6 +/- 6.0 vs 11.9 +/- 5.0 mmHg, p < 0.05). However, 4 patients of Group IA showed a peak gradient during exercise greater than 40 mmHg (this value was equivalent to the mean value plus 2 Standard Deviations, observed in the Control Group) with the presence of diastolic flow, whereas exercise systolic blood pressure was lower than 200 mmHg.

CONCLUSIONS

Thus, as a result of this study aimed at evaluating competition eligibility in patients with repaired CoAo, two subgroups of patients have to be distinguished according to Doppler echocardiography results: a) patients with peak Doppler gradient at rest greater than 25 mmHg, for whom competition is forbidden; b) Patients with peak gradient lower than 25 mmHg who must be investigated with exercise Doppler echocardiography to exclude an abnormal increase of Doppler gradients, even if exercise blood pressure is within normal limits.

[The usefulness of Doppler echocardiography in the diagnosis of neonatal Marfan's syndrome. A clinical case report]

Marfan syndrome is very rarely diagnosed in the neonate, and specific pathological and clinical findings are described in this age; cardiac involvement occurs very often, carrying severe prognosis in most patients. In the presented case the diagnosis was suspected according to clinical findings; bidimensional echocardiography showed that the most important lesion was tricuspid dysplasia and prolapse; Doppler echocardiography has contributed to explain the clinical severity, showing regurgitation of all cardiac valves and a pattern of functional tricuspid atresia. Autoptic examination has later confirmed all these findings.

[Use of integrated echocardiography in the evaluation of neonatal asphyxia]

Perinatal asphyxia provides a dramatic example of vulnerability of the cardiovascular system during adaptation to the extrauterine life. The clinical picture is variable, depending upon the severity of perinatal stress and the individual response of pulmonary vascular bed and myocardium. Doppler Echocardiography is a reliable and noninvasive method which allows both the ruling out of congenital heart disease and the making of an early diagnosis in these neonates.

Statistical analysis in andrology

The authors began a statistical study on a file group of 9384 records of semen analyses and anamnestic data (P-1). From this file, they selected a group of 5191 patients having undergone analysis at least one time (P-2) and a file of 850 patients having undergone analysis at least three times (P-3). Finally a new group, derived from P-3, of 203 patients followed by their medical team was created (P-4). Two control groups-composed of 20 sperm-bank donors (DON) and 740 prevasectomy subjects (VAS)-were also created. Frequency distributions and cluster analyses were carried out. The multivariate statistical analysis allows a distinction to be made between fertile and infertile subjects regarding a patient's clinical condition. The most discriminating parameters appear to be sperm concentration and, above all, forward motility and sperm morphology.

[Usefulness of pulsed doppler echocardiography in the diagnosis and medical therapy of patent ductus arteriosus in the newborn with respiratory distress]

In preterm infants patent ductus arteriosus (PDA) may worsen the clinical course of Respiratory Distress Syndrome (RDS). Indomethacin is usually effective in producing duct closure in the first days of life, but clinical diagnosis is often difficult to perform in these patients. In recent years Pulsed Doppler Cross-Sectional Echocardiography (PD-CSE) has made it possible to identify the duct and to assess noninvasively the characteristics of blood flow within it. The aim of this study was to verify the utility of PD-CSE in the early diagnosis of PDA and to provide the basis for a more effective drug therapy. Among 51 patients with RDS, a significant PDA was evidenced in 20 with PD-CSE and in only 8/20 with physical and E-TM examination (p less than 0.01). Indomethacin administration produced duct closure in 19/20 patients (95%). In this study PD-CSE has been more sensitive than the other noninvasive procedures in the diagnosis of PDA; moreover, the success with drug therapy demonstrates the utility of this procedure in providing the basis of a more effective treatment of the duct.

[Evaluation with Doppler echocardiography of the Bjork-Shiley Monostrut prosthesis in the mitral position]

The Doppler characteristics of Björk-Shiley Monostrut prostheses in mitral position were studied in 53 patients (35 women; 18 men; mean age 53.8 yrs). Valvular function was considered normal on the basis of clinical and echocardiographic evaluation. Mean follow-up after surgery was 23.9 +/- 12.0 months (range 9-53). M-mode, two-dimensional and colour flow mapping echo were performed in each patient. Transvalvular blood flow characteristics were examined by colour flow imaging whereas peak and mean gradient through the valve, pressure half-time and prosthetic area were calculated using continuous wave Doppler. In 84% of patients, colour flow mapping showed a transprosthetic flow with 2 jets; in 78% the jets were different: the main one was directed towards the free wall of left ventricle in 52% and towards the interventricular septum in 48%. Thus, the main jet direction was dependent on the spatial position of the prostheses and the orientation of the disc. In 16% a single jet flow was present during the whole diastole. CW Doppler showed the following parameters: peak velocity 1.6 +/- 0.3 m/s; peak gradient 10.7 +/- 3.9 mmHg; mean gradient 3.8 +/- 2.3 mmHg; pressure half-time 83.3 +/- 16.6 msec; prosthetic area 2.7 +/- 0.51 cm2. No statistically significant difference was found between different size prostheses. Our data show the excellent long term hemodynamic parameters of Björk-Shiley Monostrut mitral prosthesis and confirm the value of colour flow mapping in identifying normal transprosthetic flow profile.

[Familial pulmonary stenosis: considerations on genetic aspects]

A family with 4 cases of pulmonary valvular stenosis with under-developed or normal right ventricle, is reported. The father and his three daughters were affected. In two of the girls, who were twins, a prenatal diagnosis was made using 2D-echo. The importance of genetic counseling and prenatal diagnosis in the families at risk are underlined.

[Mitral valve prolapse. A prevalence study using bidimensional echocardiography in a young population]

The results of many studies on the prevalence of mitral valve prolapse have been greatly influenced by the diagnostic methods and criteria adopted as well as by population selection. The method of choice today is 2d-echocardiography because of its ability to highlight both movement anomaly (i.e. functional prolapse) and any eventual morphological variations of the mitral valve (i.e. anatomic prolapse). The latter (chordae lengthening, thickening and overabundance of the leaflets, dilation of the valvular ring) are, nowadays, considered especially important even as predictive factors of complications. Therefore we studied the prevalence of these two types of prolapse in a population of 420 university students. Functional mitral valve prolapse was found in 27/420 (6.4%) and anatomical prolapse in 2 cases (0.5%). No auscultatory finding was present in 24/27 patients with functional prolapse. There was no correlation between the two types of mitral valve prolapse and the body mass index, the fractional shortening of the left ventricle and symptoms (dyspnea, palpitations, precordial pain, dizziness). We think that the distinction between the two types of mitral valve prolapse should prove very useful for the comparison of results in future epidemiological studies. Follow-up of both groups of patients will hopefully clarify the usefulness of such distinction from the clinical point of view.

[Echocardiographic study of heart rhabdomyoma in tuberous sclerosis]

In order to study the prevalence of cardiac rhabdomyoma in tuberous sclerosis using non invasive methods, 11 consecutive patients affected by tuberous sclerosis (age: 3 months-22 years, mean 6 years) were examined between January 1984 and April 1987. In each patient clinical examination, 12 lead electrocardiogram, M-mode and two-dimensional echocardiogram were performed: on 7 of them a 24-hour ambulatory electrocardiogram was also performed. Clinical examination revealed a systolic murmur (grade 3/6) in two cases. In one of them it was associated with cyanosis and cardiac failure. None of other patients showed signs or symptoms related to the heart during clinical examination. ECG was abnormal in 3 cases (ventricular pre-excitation in 2 cases and left ventricular strain in 1). Two-dimensional echocardiogram showed single or multiple intracardiac masses suggestive of cardiac rhabdomyoma in 8 cases; in 3 of them masses were isolated, intramural, and in the interventricular septum, from 5 to 16 mm in diameter; in the other 5 cases they were multiple, intramural and endoluminal, in the interventricular septum, in the right or left ventricle, from 7 to 20 mm in diameter. Ambulatory electrocardiogram revealed only isolated ectopic supraventricular and ventricular beats in 2/7 cases. Each patient was clinically controlled every six months using ECG standard and two-dimensional echocardiogram. The mean follow-up period was 32 months (range 9-53). This study confirms the usefulness of the two-dimensional echocardiography to visualize intramural or intracavitary masses due to cardiac rhabdomyoma in patients with tuberous sclerosis, especially when they appear clinically asymptomatic. Two-dimensional echocardiography is probably the ideal method to use in order to evaluate potential increase in cardiac rhabdomyoma, when prolonged follow-up studies are performed.

Clinical evaluation of a monophasic ethinylestradiol/desogestrel-containing oral contraceptive

A multicenter trial was conducted in 267 centers in Italy to evaluate the efficacy, acceptability and safety of a monophasic oral contraceptive containing 30 micrograms ethinyl estradiol and 150 micrograms desogestrel (Marvelon) 13,290 women were followed up for a total of 74,967 cycles. No pregnancies due to method failure were reported and only three because of patient failure. Cycle control was good. There was a decrease in the occurrence of irregular cycles and in the duration and amount of menstrual bleeding; the incidence of breakthrough bleeding and spotting was low. No severe side-effects occurred and the incidence of minor complaints was generally lower during treatment than in the pre-treatment cycle. Body weight and blood pressure were not significantly altered.

[Role of two-dimensional echocardiography in the diagnosis of embolic cardiopathy in patients with transient cerebral ischemia attacks]

Cardiac sources of emboli have been frequently described in patients with Transitory Ischemic Attacks (TIAs). The aim of our study was to assess the value of two-dimensional echocardiography (2D-E) in the investigation for possible cardiac aetiology of TIAs. As an offshoot of a larger epidemiologic study which aimed at determining the period prevalence of TIAs in 6.504 subject(s) of the general population aged between 40-65, fifty subjects with TIA (group A) and 66 controls (group B) were studied. A heart disease was found in 20/50 s. (40%) in group A (coronary artery disease: 5; hypertensive heart disease: 4; mitral valve prolapse: 5; left ventricular aneurysms: 2; aortic valve disease: 2; aortic valve prosthesis: 1; atrial fibrillation: 1) and in 5/66 s. (7.5%) in group B (p less than 0.01) (coronary disease: 2; hypertensive heart disease: 1; mitral valve prolapse: 2). A potential source of emboli was present in 11 s. in group A (22%) and in 2 s. in group B (3%) (p less than 0.01). In 4/50 s. in group A and in 1/66 in group B the diagnosis was obtained by means of 2D-E only, because other clinical signs and ECG data were negative. 2D-E could only confirm the diagnosis in the remaining cases, with no additional information (i.e., no intracavitary masses were seen). In conclusion there is a high prevalence of heart disease in patients with TIA over 40 years of age. A cardiac source of emboli may be suspected in a substantial number of cases. Nevertheless the value of routine 2D-E in disclosing an otherwise undetected source of emboli is rather low.

[Pulmonary atelectasis and massive pleural effusion. Echocardiography]

Pulmonary atelectasis can be detected by Two Dimensional Echocardiography (2D-E) when massive pleural effusion is present. A triangular mass, base toward the mediastinum and apex moving freely in the pleural cavity, is shown by 2D-E either in an apical modified view in left pleural effusions or in a subcostal modified view in right pleural effusions. The texture of the mass is liver-like. Three cases are reported by way of example. Differential diagnosis with other masses, such as pleural or pericardial metastasis, is discussed.

Diastolic time intervals before and after nadolol in patients with hypertrophic cardiomyopathy

In 9 patients with hypertrophic cardiomyopathy, diastolic function was evaluated by noninvasive measurements of diastolic time intervals before and after nadolol administration. No significant variation of the intervals was observed after therapy. The method therefore appears scarcely useful in the evaluation of beta-blocker therapy in these patients.

[Correlations between electrocardiographic findings and echocardiographic patterns in 116 patients with hypertrophic cardiomyopathy]

To evaluate the correlation between electrocardiographic and echocardiographic m-mode (E-TM) and two-dimensional (E-2D) patterns, 116 patients with hypertrophic cardiomyopathy (HCM) were studied by these two methods. Patients were classified into four types, according to Maron et al's E-2D classification of HCM. In addition a subgroup (IIIb) of 15 patients in types III, had typical left ventricular concentric hypertrophy. Twelve per cent of the study patients had a normal ECG, and most often those patients showed types I-II and IIIb. Left ventricular hypertrophy by ECG was most frequent (46%) and was found mostly in type III (P less than 0.02). Abnormal Q waves, suggestive but not diagnostic of HCM, were found in 22 of 116 (18%) patients, and were present in equal proportion in each morphologic type. Isolated ST-T changes were found in the same percentage of patients. Six of 7 patients with giant negative T waves had apical left ventricular hypertrophy, but 4 other patients with apical hypertrophy had no such ECG findings. Mean left atrial dimensions at E-TM, although larger in patients with atrial fibrillation, with statistical significance (P less than 0.001), were not predictive of this arrhythmia. ECG is still useful in the diagnosis of HCM, although there is no abnormal pattern specific for the disease, and even a normal ECG can be found in these patients.

[Usefulness of 2-dimensional echocardiography in emergency surgical treatment. Description of a case of metastatic sarcoma of the right ventricle]

A case of metastatic tumor, occupying a large part of right ventricular cavity, is reported. An accurate diagnosis was allowed by 2-D echocardiography and the patient was immediately sent to cardiac surgery. 2-D echo was also useful in the postoperative evaluation of surgical results.

[Hepatitis B in hospital workers: analysis of the relation between occupational risk and locale]

In this paper it has been studied the prevalence of subject positives for the markers of infection of hepatitis B virus in operators of two hospitals. The authors have examined the reports between profession and endemic level of infection in the afferent population.

Echocardiographic features of right ventricular infarction

In a series of 75 consecutive patients with transmural acute myocardial infarction (AMI) a right-to-left ventricular filling pressure ratio equal to or greater than 0.65 (RVFP/LVFP greater than or equal to 0.65) was assumed to be indicative of associated right ventricular infarction (RVI). Out of 45 patients with inferoposterior myocardial infarction, 11 (24%) had such hemodynamic evidence of right ventricular infarction (group A). The remaining 34 patients with inferoposterior myocardial infarction (group B) and the 30 patients with anterior myocardial infarction did not. Time-motion and two-dimensional echocardiographic examinations were performed 7-10 days after admission in the 62 patients who survived. Right ventricular wall asynergy was found in six of eight group A patients. In three of these, right ventricular dilatation was also present. No patient in group B with inferior infarction or with anterior infarction showed abnormal right ventricular wall motion. While hemodynamic monitoring seems presently the most specific diagnostic method and it is of invaluable help in the choice of the best pharmacological therapy of right ventricular failure due to RVI, two-dimensional echocardiography is probably highly sensitive and specific for the diagnosis of RVI, by detecting RV wall motion and thickening abnormalities. Due to advantages, such as noninvasivity and repeatibility, two-dimensional echocardiography can be used in the selection of patients who deserve hemodynamic monitoring and in follow-up studies.

Concentrations of nitrates in drinking water and incidence of gastric carcinomas: first descriptive study of the Piemonte Region, Italy

A descriptive epidemiological research, within the Piemonte Region was carried out, to consider whether there is an association between concentrations of nitrates in drinking water and the incidence of gastric carcinomas. The results indicate that an association does exist, but also that concentrations of nitrates higher than 20 mg/l in drinking water are a risk factor for people exposed.

Bioavailability of flufenamic acid in hard and soft gelatin capsules

The biological availability of flufenamic acid after oral administration of the drug in both hard and soft gelatin capsules was studied in dogs and humans. The soft gelatin capsules produced consistently higher plasma concentration-time curves.