Cardiac magnetic resonance in athletes with ventricular arrhythmias

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular arrhythmias in athletes represent an important issue in sport eligibility as they may be a marker of a concealed cardiomyopathy, potentially at risk of sudden cardiac death during sport activity.

Purpose

to assess the utility of cardiac magnetic resonance (CMR) to identify cardiac abnormalities in athletes with documented frequent premature ventricular beats (PVB) or complex ventricular arrhythmias (VA) undergoing competitive sport eligibility screening.

Methods

We enrolled 65 athletes with documented ventricular arrhythmias as follows: 1) frequent PVB at 24-hour ambulatory ECG monitoring (>100 PVB/24h); 2) polymorphic PVB; 3) repetitive PVB (couplets, triplets, or nonsustained ventricular tachicardia). All athletes were studied with rest ECG, exercise stress testing, 24-hour ambulatory ECG monitoring, transthoracic echocardiography and contrast-enhanced CMR.

Results

Sixty-five athletes (56 males, 9 females, age 30 ± 15years) underwent CMR with gadolinium contrast. In 55 patients (84.6%) CMR was normal, in 10 patients (15.4%) the following abnormalities were reported at CMR: four patients with isolated late gadolinium enhancement (LGE) of whom 3 patients with subepicardial LGE in the inferolateral wall and 1 patient with intramyocardial basal inferior LGE; 1 patient with hypertrophic cardiomyopathy with septal LGE; 1 patient with left ventricular non compaction; 3 patients with right ventricular abnormalities (a 13-year-old patient with dilated right ventricle and LGE located at the superior interventricular insertion point, 1 patient with a dilated and hypokinetic right ventricle, 1 patient with a focal right ventricular aneurysm). Transthoracic echocardiography was normal in 7/10 (70%) athletes with CMR abnormalities.

Conclusion

In athletes with frequent or complex ventricular arrhythmias cardiac magnetic resonance identifies cardiac abnormalities in a significant proportion of subjects and it may offer a diagnostic incremental value.

Diagnostic accuracy and interobserver agreement of Quasistatic Ultrasound Elastography in the diagnosis of thyroid nodules

PURPOSE

To assess the best technique and the diagnostic accuracy of Quasistatic Ultrasound Elastography (QUE) in thyroid nodules. Interobserver agreement was also evaluated.

MATERIALS AND METHODS

A preliminary study of 50 patients with 54 thyroid nodules was performed with quantitative software in order to define the best cut-off value of different imaging methods. All patients underwent total thyroidectomy and histopathology findings served as the standard of reference. Thereafter, 154 nodules in 137 consecutive patients were prospectively evaluated by three operators. Findings at fine-needle aspiration cytology and histopathology (N = 60) served as the standard of reference.

RESULTS

The most accurate technique was the axial peri-intranodular measurement method which achieved an area under the ROC curve of 0.961 (95 %CI 0.848 - 1.00) and had an optimal cut-off value of 3.00. QUE in the differentiation of thyroid nodules showed for operator 1: sensitivity 90 % (95 %CI 73.5 - 97.9 %), specificity 92.7 % (95 %CI 86.7 - 96.6 %), LR+ 12.40 (6.54 - 23.50), LR- 0.11 (0.04 - 0.32) and accuracy 91.4 % (95 %CI 85.4 - 97.3 %); for operator 2: sensitivity 86.7 % (95 %CI 69.3 - 96.2 %), specificity 87.1 % (95 %CI 79.9 - 92.4 %), LR+ 6.72 (4.16 - 10.80), LR- 0.15 (0.06 - 0.38) and accuracy 86.9 % (95 %CI 80.0 - 93.7 %); for operator 3: sensitivity 80 % (95 %CI 61.4 - 92.3 %), specificity 83.9 % (95 %CI 76.2 - 89.9 %), LR+ 4.96 (3.20 - 7.70), LR- 0.24 (0.12 - 0.49) and accuracy 81.9 % (95 %CI 74.0 - 89.9 %). Interobserver agreement values between operator 1 and operator 2 (k = 0.79) (p < 0.05, 95 %CI 0.684 - 0.904), between operator 1 and operator 3 (k = 0.73, 95 %CI: 0.607 - 0.854) and between operator 2 and operator 3 (k = 0.71, 95 %CI: 0.584 - 0.835) were significant.

CONCLUSION

QUE provides accurate quantitative evaluation of thyroid nodules with low interobserver variability.

Double ileo-ceco-colic invagination due to right colon carcinoma: clinical presentation and management

Intestinal intussusceptions represent a rare cause of intestinal obstruction in adults (about 1% of intestinal obstructions). The principle causes are benign or malignant tumors. In adults, the most frequent localizations of intestinal invaginations are the ileo-cecal segment, ileum and colon as exclusive localization. We report the case of a 56 year-old Caucasian male admitted in our Department complaining with diffuse abdominal pain and severe anemia. The colonoscopy revealed a vegetant, stenosing and ulcerated mass in the hepatic flexure. The computed tomography suggested the additional diagnosis of intestinal intussusception with no evidence of intestinal obstruction. In our experience, surgery is always indicated for the treatment of intussusceptions in adults, especially for the almost constant underlying neoplasm.

Transmesenteric hernia after right nephrectomy: diagnostic and therapeutic management

Internal abdominal hernias are a rare cause of intestinal obstruction (0.2-0.9%). Transmesenteric hernia is a rare type of internal hernia and usually in adult people is acquired. We report the case of a 44 year-old caucasian female with a small bowel occlusion after right nephrectomy for clear cell renal carcinoma caused by an acquired transmesenteric hernia. We emphasize the role of CT scanning for a prompt diagnosis and a quick surgical treatment in order to avoid intestinal gangrene.

Two-years follow-up of low-dose methotrexate and 6-methylprednisolone therapy in a patient with idiopathic retroperitoneal fibrosis

Retroperitoneal fibrosis (RPF), also known as Ormond's disease, is a rare fibroinflammatory disease with uncertain etiology. RPF is characterized by the presence of a particular retroperitoneal fibrotic tissue which is white, woody and involving retroperitoneal structures such as the great vessels, ureters and psoas muscle. The main complication of RPF is the obstruction of local structures such as the ureters due to the fibrosis and the treatment of this aspect represents the main challenge for this pathology. RPF medical treatment consists of corticosteroids or/and immunosuppressive therapy. We report a case of a patient affected by idiopathic RPF treated with low-dose methotrexate (MTX) and 6-methylprednisolone (6-MP) for two years, describing and confirming the effectiveness and safety of a long-term low-dose MTX and 6-MP treatment associated to ureteral Double-J stenting avoiding more invasive surgical approaches.

Randomised clinical trial: the effectiveness of Lactobacillus reuteri ATCC 55730 rectal enema in children with active distal ulcerative colitis

BACKGROUND

Intestinal microbiota manipulation, one of the pathogenetic components of inflammatory bowel disease (IBD), has become an attractive therapy for ulcerative colitis (UC).

AIM

To assess in children with active distal UC the effectiveness of Lactobacillus (L) reuteri ATCC 55730 enema on inflammation and cytokine expression of rectal mucosa.

METHODS

A total of 40 patients (median age: 7.2 years range 6-18) with mild to moderate UC were enrolled in a prospective, randomised, placebo-controlled study. They received an enema solution containing 10(10) CFU of L. reuteri ATCC 55730 or placebo for 8 weeks, in addition to oral mesalazine. Clinical endoscopic and histological scores as well as rectal mucosal expression levels of IL-10, IL-1β, TNFα and IL-8 were evaluated at the beginning and at the end of the trial.

RESULTS

Thirty-one patients accomplished the trial (17 males, median age 13 year, range 7-18). Mayo score (including clinical and endoscopic features) decreased significantly in the L. reuteri group (3.2 ± 1.3 vs. 8.6 ± 0.8, P < 0.01) compared with placebo (7.1 ± 1.1 vs. 8.7 ± 0.7, NS); furthermore, histological score significantly decrease only in the L. reuteri group (0.6 ± 0.5 vs. 4.5 ± 0.6, P < 0.01) (placebo: 2.9 ± 0.8 vs. 4.6 ± 0.6, NS). At the post-trial evaluation of cytokine mucosal expression levels, IL-10 significantly increased (P < 0.01) whereas IL-1β, TNFα and IL-8 significantly decreased (P < 0.01) only in the L. reuteri group.

CONCLUSIONS

In children with active distal ulcerative colitis, rectal infusion of L. reuteri is effective in improving mucosal inflammation and changing mucosal expression levels of some cytokines involved in the mechanisms of inflammatory bowel disease.

[Comparison of plasma matrix metalloproteases 2, 3, 9 in breast carcinomas and fibroadenomas]

Tumor cell infiltration causes the remodelling of peritumoral tissues, determined by an increased lytic activity of extracellular matrix exerted by the neoplastic invasive phenotype. Among the principal lytic enzymes produced by tumor cells and mainly involved in invasion process there are the matrix metalloproteases (MMPs). The Authors compared the plasmatic values of MMPs 2, 3, 9 from patients with breast carcinomas and fibroadenomas in order to evaluate whether there was a significant difference between the two groups of patients. MMPs 2, 3, 9 values were quantified by ELISA test from plasma collected 24 hours before surgery in 50 breast carcinomas and 30 fibroadenomas. MMP2 mean value from the patients with carcinomas resulted significantly higher as compared to that from the patients with fibroadenomas; while for MMP 3 and 9 mean values was not possible to find a significant difference between the two groups of malignant and benign breast tumors. These data confirm the main role played by MMPs during the tumor invasion process. Therefore, it is possible to propose the future inclusion of MMP2 test, together to other biological and clinical data, for prognostic evaluation of neoplastic breast lesions.

[Association between thyroiditis and cancer. Our experience]

We analyzed a homogeneous sample of 671 patients underwent total thyroidectomy for various pathologies evaluating the final histological diagnosis and seeking the association between thyroiditis and cancer. As is known to the literature the incidence of association between autoimmune disease and cancer is not exceptional. In our experience, we have shown it in 39 cases (18.6%). We also considered the genetic background RET/PTC which is more prevalent in cases of papillary carcinoma in an inflammatory environment; could be stimulant the study of specific molecular markers to identify targets to inhibit the inflammatory status in thyroid cancer prevention.

Feasibility of transradial approach in a hub and spoke cath lab network

AIM

Radial artery approach for coronary angiography presents advantages in terms of reduction of costs and complications. Opening a diagnostic-only cath lab is controversial in an era of interventional approach. The authors present the data of Carpi diagnostic-only cath lab (Spoke), satellite of the main cath lab situated in Modena (Hub) 20 Kms apart.

METHODS

Between January 2004 and December 2007, 1496 coronary angiograms were performed. The indication was ischemic heart disease in 1197 cases (80%), dilated cardiomiopathy in other 165 cases (11%) and valvular heart disease in the remaining 134 patients (9%). The procedure was performed percutaneously via radial artery in 95% (N=1421) of the cases, via brachial artery in 1% (N=15) and via femoral artery in the remaining 4% (N=60) of patients.

RESULTS

Among the 1197 patients undergoing coronary angiography for ischemic heart disease, an indication to medical therapy was given in 443 (37%), a surgical indication in 216 (18%) patients and an indication to percutaneous coronary intervention (PCI) in 538 (45%) cases. PCI was performed in the Hub centre the same day and via the same arterial approach of the diagnostic angiography, maintaining the sheath in situ during transport. In 6 patients only it was necessary to shift to a femoral approach.

CONCLUSIONS

This model presents many advantages: 1) a cath lab in a peripheral hospital allows a early carrying out of the hemodynamic examination with reduction of hospital stay; 2) transport to the Hub centre cath lab is undertaken only in patients who really need PCI; 3) the PCI is feasible the same day of the diagnostic examination; 4) this model relieves the hub centre congestion, ensuring motivation and professional competence for personnel of peripheral hospital.

[Double ileo-ileal and ileo-cecocolic intussusception due to submucous lipoma: case report]

Intestinal intussusception is a rare pathology in adults and counts for approximately 5-16% of all invaginations, according to literature. We report the case of a 54 years-old male affected by a double ileo-ileal and ileocecocolic invagination secondary to a submucosal intestinal lipoma. Because of a bowel obstruction symptomathology, the diagnosis was based on abdomen X-rays, abdominal ultrasound and multislice CT scan that showed a probable pre-operative diagnosis of intestinal intussusception. The diagnosis of double invagination was confirmed intraoperatively and was therefore performed a right colectomy extended to a long tract of ileum. Opening the specimen demonstrated the evidence of a submucosal lipoma on the head of the intussusceptum. After the description of this case, we proceed with review of the literature of adult intestinal invagination.

[Modern orientation in parotid surgery]

The choice of the surgical approach is very relevant in parotid surgery because of the extreme anatomic variability of the parotideal district and the functional importance of the branches of facial nerve. The aim of this paper is to prove how an accurate knowledge of the anatomy and a careful execution of surgery permit radicality in case of tumors and respect of nerves and other structures of the region. We studied anatomy of the different intra- and periparotideal structures to compare two different approaches in parotidectomy, proving how the orthograde technique is safer and more effective in preventing hyatrogenous nerve injuries and other major complications.

Experimental results on the recognition of embryos in human assisted reproduction

The recognition of embryos suitable for transfer in human assisted reproduction is important, and there is evidence that the morphology of the cells may influence the results achievable. A procedure for this recognition problem has been formulated based on morphological attributes of the images of the embryos, and it is therefore useful to compare the recognition of experts with that of a machine programme. The aim of this paper is to compare the precision in the recognition of viable embryos by a group of experts to that of a machine recognition procedure, both for a basic set of embryos and a blind set. Experts were asked to classify the images of 249 embryos transferred to 73 patients, indicated as the training set and another set of 103 embryos transferred to 35 patients called the blind set. A machine programme was used for the same classification. For all the experts the results were statistically not significantly different from independence, which means that viable embryos are not recognized as such for both data sets. Instead, the machine algorithm recognizes in a statistically significant way, the membership class for the embryos submitted. Cell morphology is important for IVF, but differences do not appear to be discernable by the senses, clinical insight, experience and/or training, while classification by machine methods provides more accurate results, which could be improved by enlarging the training set.

Testosterone enhances flow-mediated brachial artery reactivity in men with coronary artery disease

Acute administration of high-dose testosterone in men with coronary artery disease improves endothelial function.

The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy

STUDY OBJECTIVE

To determine whether the pain and discomfort of routine hysteroscopy with endometrial biopsy to diagnose infertility and endometrial pathology can be minimized by topical application of mepivacaine.

DESIGN

Prospective, randomized, double-blind study.

SETTING

The Department of Obstetrics and Gynecology at a teaching hospital in Rome, Italy.

PATIENTS

Eighteen women undergoing diagnostic hysteroscopy.

INTERVENTIONS

Hysteroscopy and endometrial biopsy were performed after transcervical injection of 5 ml 2% mepivacaine or 5 ml saline solution into the uterine cavity.

MEASUREMENTS AND MAIN RESULTS

Difficulty introducing the hysteroscope was rated by the operator on a scale of 1 to 3. An observer scored visible signs of each woman's distress using a three-point scale. The patients reported their pain 15, 30, 60, 120 minutes after the procedure on a visual analog scale. Mepivacaine was more effective than placebo according to all measurements.

CONCLUSIONS

Topical mepivacaine reduced the pain experienced during and after hysteroscopy and endometrial biopsy.

Reduplication of nuclear membranes in tissue-culture cells infected with guinea-pig cytomegalovirus

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