[Coronary thrombosis and cannabis abuse: a case report]

Marijuana consumption is growing up becoming very common especially between young people. 9-THC, the main psychoactive compound in cannabis, acts on the endocannabinoid system having different cardiovascular effects, including arrhythmias, acute coronary syndrome, and sudden cardiac death. We present the case of a young man from Gambia with no cardiovascular risk factors, marijuana consumer, presenting to the emergency department with ST-elevation myocardial infarction. At coronary angiography, thrombotic left anterior descending coronary artery subocclusion was documented. We also describe the association between acute coronary syndrome and cannabis abuse.

[Caseous calcification of the mitral annulus: case report and review of the literature]

Caseous calcification of the mitral annulus is an uncommon variant of mitral annular calcification. It appears as a round echodense mass containing central areas of echolucencies resembling liquefaction and with no flow in the central zone on color Doppler. In most cases it involves the posterior mitral annulus region, particularly in female subjects. The pathogenesis remains unclear: hypercholesterolemia and the dissolution of lipid-rich macrophages may be implicated in liquefaction necrosis. Transthoracic and transesophageal echocardiography represents the most reliable technique for diagnosis, whereas cardiac magnetic resonance imaging is the choice in doubtful cases. We report the case of an 82-year-old female patient describing different aspects of this particular clinical condition.

Climate change and air pollution: Translating their interplay into present and future mortality risk for Rome and Milan municipalities

Heat and cold temperatures associated with exposure to poor air quality lead to increased mortality. Using a generalized linear model with Poisson regression for overdispersion, this study quantifies the natural-caused mortality burden attributable to heat/cold temperatures and PM₁₀ and O₃ air pollutants in Rome and Milan, the two most populated Italian cities. We calculate local-specific mortality relative risks (RRs) for the period 2004-2015 considering the overall population and the most vulnerable age category (≥85 years). Combining a regional climate model with a chemistry-transport model under future climate and air pollution scenarios (RCP2.6 and RCP8.5), we then project mortality to 2050. Results show that for historical mortality the burden is much larger for cold than for warm temperatures. RR peaks during wintertime in Milan and summertime in Rome, highlighting the relevance of accounting for the effects of air pollution besides that of climate, in particular PM₁₀ for Milan and O₃ for Rome. Overall, Milan reports higher RRs while, in both cities, the elderly appear more susceptible to heat/cold and air pollution events than the average population. Two counterbalancing effects shape mortality in the future: an increase associated with higher and more frequent warmer daily temperatures - especially in the case of climate inaction - and a decrease due to declining cold-mortality burden. The outcomes highlight the urgent need to adopt more stringent and integrated climate and air quality policies to reduce the temperature and air pollution combined effects on health.

From single to multivariable exposure models to translate climatic and air pollution effects into mortality risk. A customized application to the city of Rome, Italy

This study presents an approach developed to derive a Delayed-Multivariate Exposure-Response Model (D-MERF) useful to assess the short-term influence of temperature on mortality, accounting also for the effect of air pollution (O₃ and PM₁₀). By using Distributed, lag non-linear models (DLNM) we explain how city-specific exposure-response functions are derived for the municipality of Rome, which is taken as an example. The steps illustrated can be replicated to other cities while the statistical model presented here can be further extended to other exposure variables. We derive the mortality relative-risk (RR) curve averaged over the period 2004–2015, which accounts for city-specific climate and pollution conditions.

Key aspects of customization are as follows:

This study reports the steps followed to derive a combined, multivariate exposure-response model aimed at translating climatic and air pollution effects into mortality risk.

Integration of climate and air pollution parameters to derive RR values.

A specific interest is devoted to the investigation of delayed effects on mortality in the presence of different exposure factors.

Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study

Objectives

Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands.

Design

Multi‐country, 5‐year mixed methods study on barriers to legal abortion and travel for abortion.

Setting

UK, the Netherlands and Spain.

Population or Sample

We present quantitative data from 204 surveys, and qualitative data from 30 in‐depth interviews with pregnant people who travelled to the UK, the Netherlands and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits.

Methods

Mixed‐methods.

Main outcome measures

GA when presenting at abortion clinic, primary reason for abortion‐related travel.

Results

Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care.

Conclusions

Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary but not sufficient to meet people’s reproductive health needs.

Funding

This study is funded by the European Research Council (ERC).

Tweetable abstract

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

This study shows that GA limits drive women from EU countries where abortion is legal to seek abortions abroad.

Tamoxifen treatment and pulmunary embolism: a case report and literature review

Breast carcinoma is becoming a spread disease that needs a specif teraphy. Tamoxifen is the first line treatment in patients with positivity of expression of estrogen receptors. The risk of thromboembolism is high in patients treated with tamoxifene indipendent from the neoplastic disease. This work focuses the attention on tamoxifen mechanism of thrombosis.

[Intramyocardial bridges: anatomo-pathological characteristics, diagnosis, and therapeutic strategies]

Intramyocardial bridge is defined as the segment of a major epicardial coronary artery that runs within the cardiac muscle wall (coronary tunneling). Usually, this kind of anatomic variant is asymptomatic but sometimes it may lead to acute coronary syndrome and/or arrhythmias, and more rarely to sudden cardiac death. Treatment for symptomatic patients is pharmacological, using beta-blockers.

Kounis syndrome: inferior ST-segment elevation myocardial infarction following a bumblebee sting

The Kounis syndrome was first described in 1991 as'the allergic angina syndrome'which could progress to acute myocardial infarction which was named'allergic myocardial infarction. There are several causes underlying this syndrome including drugs, various conditions and a variety of environmental exposure factors such as animal stings. Hymenoptera stings can induce Kounis syndrome because hymenoptera venom contains allergenic proteins and peptides. The following case report describes a patient who experienced an anaphylactic shock associated with coronary artery ischaemia (inferior ST-segment elevation myocardial infarction) after a bumblebee sting.

Stem cells and repair of the heart: cell-releasing epicardial scaffolds

Cell transplantation represents the last frontier within the treatment of cardiac diseases. From the first paper published in 1992 that has documented the potentials of the transplantation of autologous skeletal muscle cells to treat the damage induced by acute myocardial infarction, innumerable techniques of implantation and types of cells used has been reported, greatly expanding this innovative and appealing field of search in cardiovascular medicine. Despite original promises and expectations, current evidences of stem cell transplantation are still weak and controversial. Therefore, alternative line of research are being explored, particularly in the field of techniques of cell implantation and engraftment. Besides direct implantation or myocardial colonization by bone marrow stimulation, epicardial application of cell-delivering systems (scaffold and patches) have gained popularity due to the possibility to apply selectively a cell-containing device which may gradually release the chosen cell type, alone or in combination with trophic substances. The scaffolds have proven to be successful in this respect and may represent a valid alternative to coronary, intra-myocardial, or venous injection of stem cells, or to stem cell stimulating factors. Finally these systems may be applied through minimally invasive procedures and act as external constraint to enhance ventricular reverse remodelling or limit further cardiac dilatation.

Giant asymptomatic left atrial myxoma

The classic triad of myxoma clinical presentation is characterized by intracardiac obstruction, embolisms, and constitutional symptoms with fever, weight loss, or symptoms resembling connective tissue disease. Giant myxoma without symptoms are very rare. We present a case of a 30-year-old female with a giant asymptomatic myxoma in the left atrium, discovered by echocardiography. The patient was asymptomatic.

Boerhaave's syndrome - a difficult differential diagnosis of chest pain

Boerhaave's syndrome is a very rare disease characterised by a spontaneous rupture of the oesophagus. It is often misdiagnosed and there is no consensus as to the best treatment. We describe a case of a 61 year-old man without significant previous medical history presenting in the emergency room with acute chest and back pain. Despite objective and laboratory tests negative for chest pain screening, computed tomography showed the presence of mediastinal air and pneumothorax consistent with oesophagus rupture. Urgent surgical intervention saved the patient.

Tricuspid valve myxoma in a patient with congestive heart failure

Myxomas are the most frequent benign primary cardiac tumours (50% of benign heart tumours). This kind of tumour is most likely to be localized in the left atrium, followed by the right atrium, right ventricle and left ventricle. Quite exceptional is the presence of a myxoma originating from the tricuspid valve or from the Eustachian valve. We describe the case of a woman with moderate dyspnoea of unknown origin and the presence of tricuspid myxoma who underwent tricuspid valve curettage.

Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome

AIMS/OBJECTIVES

This review examines the 'tako-tsubo-like' syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome.

METHODS

We have evaluated the data from literature for a comprehensive consideration of multiple aspects of this syndrome.

RESULTS/FINDINGS

Transient left ventricular apical ballooning typically affects women, and the clinical presentation is comparable to acute coronary syndrome with chest pain or sudden dyspnoea, changes in ECG and elevated cardiac enzymes in the absence of significant coronary stenosis, with complete resolution of wall-motion abnormalities in a period of days or weeks. This syndrome is triggered by marked psychological or physiological stress. Several pathophysiological mechanisms have been proposed, such as cathecolamine-mediated cardiotoxicity, abnormalities in coronary microvascular function and multivessel coronary vasospasm. The highest incidence of transient left ventricular apical ballooning is in the Japanese population, but it has been recently identified also in the USA and Europe. Treatment is empirical and supportive. The prognosis is generally favourable, although some deaths have been reported, usually the result of irreversible cardiogenic shock, refractory ventricular arrhythmias, or other catastrophic cardiovascular event.

CONCLUSIONS/INTERPRETATIONS

We conclude by emphasising the importance of a more deeper knowledge of this syndrome for general physicians and cardiologists and it should be often considered as a possible diagnosis occurring in emergency department and in patients admitted in the Chest Pain Units with a diagnosis of coronary acute syndrome.

Imaging of caseous calcification of the mitral annulus

Caseous calcification of the mitral annulus is a rare form of periannular calcification that generally appears as a calcified mass with a central echolucent area that may lead to diagnostic errors. The case is reported of a 65-year-old woman in whom a suspicious mass was detected with transthoracic echocardiography performed for dyspnea.

[Homocysteine: a casual link with heart failure?]

Several studies and recent patents have demonstrated that hyperhomocysteinemia (HHCY) is an independent risk factor for congestive heart failure (CHF); it is also correlated to the severity of the disease. In literature there are some data about effects of HHCY on myocardial structure and function in animal models. These studies indicate a direct effect of HCY in promoting reactive myocardial fibrosis and systolic dysfunction, promoting miocardial redox state, endothelial and mithocondryal dysfunction, negative inotropic effect. According to some authors the HHCY is a potential ethiological factor for heart failure while according to others it is just an epiphenomenon without direct effects on myocardium. Nevertheless the literature studies show the relevant involvement of HHCY in CHF and the strong relations between HHCY plasma levels and the severity and prognosis of the disease. Regarding the potential mechanistic role of HHCY in CHF, all of these studies do not provide any mechanistic insights because of their epidemiological nature. Future studies need to explore the exact pathomechanisms of HHCY in CHF.

A giant interatrial mass: an unusual presentation of primary amyloidosis

We report a patient with primary systemic amyloidosis who had a very unusual form of clinical and instrumental presentation.

High sensitivity C-reactive protein: a predictor for recurrence of atrial fibrillation after successful cardioversion

Atrial fibrillation (AF) is often associated, more or less indirectly, with an inflammatory acute or chronic process. So it is probable that the inflammation could contribute to the genesis and the perpetuation of this dysrhythmia. Phlogistic test indexes in patients (pts) with AF will be positive and have prognostic significance in patients treated with electrical cardioversion with restoration of a sinus rhythm. We evaluated 106 pts affected by AF of recent onset without known cardiovascular disease. We measured the plasma concentration of C-reactive protein (CRP) through a high sensibility method, in addition to routine blood samples. We performed an ECG 1 week and a Holter ECG monitoring 1 and 6 months after the electrical cardioversion. The CRP values were high (5.8 +/- 10.7 U/L), with values above the normal range in 60 pts. After electrical cardioversion, we obtained restoration of sinus rhythm in all the patients. One week after cardioversion, 85 pts (80%) were in sinus rhythm, while after 6 months 60 pts (56%) maintained a sinus rhythm. In total 46 (43%) patients had a recurrence of atrial fibrillation within 6 months, and 41 of these 46 patients (89%) had elevated values of CRP (P < 0.001 with respect to the patients who maintained a sinus rhythm). 18/21 patients (86%) with an AF relapse in the first week and 23/25 patients (92%) with AF recurrences at 6 months later had elevated values of CRP. The patients with AF may have elevated values of CRP, and the assessment of this increase may be predictive of early relapses of AF after electrical cardioversion.

[Erythropoietin: a new perspective in cardiovascular therapy]

Erythropoietin is a hormone produced by the kidney, which regulates proliferation, differentiation and maturation of red cells. Recombinant human EPO (rH-EPO) is well known to correct anaemia in patients with chronic renal failure in terminal stage. However, recent studies showed the existence of several not haematopoietic effects of erythropoietin. EPO receptors have been found to be expressed in several tissues, included the cardiovascular system. An increase in cardiac systolic function has been observed in patients with chronic heart failure treated with EPO. Other beneficial effects appear to be related to the pro-angiogenic properties on endothelial cells and could be useful for treatment of ischemic heart disease. These findings suggest that EPO could provide potential therapeutic benefits in the management of cardiovascular diseases beyond anaemia correction. This review focuses its attention on the pleiotropic effects of EPO and its future promising applications in cardiovascular pathology.

Thrombus or tumor? a case of fibroelastoma as indicated during the submission process

We describe the case of a 50-year-old woman who was admitted to a pheriferal department for heart failure. The echocardiography revealed a small mass measuring about 1.3 x 1.0 cm adhering to the non-coronary cusp of the aortic valve, mild dilated cardiomiopathy and severe biventricular dysfunction. This mass had erroneously been considered a thrombotic lesion, so the patient was treated with thrombolysis and heparin e.v. Only after a transoesophageal echocardiography a tumour cardiac mass was suspected. The diagnosis of fibroelastoma was confirmed by MRI and then from the anatomic and histoligical definition after surgery.

Acute thrombosis in mitralic mechanical prosthesis: a case report

We describe a case of a man, 42 years old, submitted to successful fibrinolitic strategy with rTPA in acute mitralic prosthesis valve thrombosis and ipomobility of one emidisk. There aren't a consensus agreement in therapeutic strategy but we may support the approach of some authors that employ fibrinolisis in patients without absolute or relative controindications and if thrombus dimension is less than 1 cm otherwise they make use of heparin therapy in non obstructive thrombosis with successive transesophageal echocardiography evaluation for the efficacy and the later indication for thrombolisis or surgery treatment.

[Diabetes and ischemic heart disease: specific treatment]

Diabetes mellitus is a worldwide epidemic whose incidence and prevalence have significantly increased in recent decades. Diabetic patients have an increased mortality and morbidity related to ischemic heart disease and are more likely to develop multivessel coronary artery disease than non-diabetic patients. An acute coronary event is the leading cause of death among diabetics. These patients have an increased risk of complications after an acute coronary syndrome both during the acute phase and in the post-infarction period. Experimental evidences showed an increased prevalence of atherosclerosis as well as platelet and coagulation abnormalities in patients with diabetes, even after data adjustment for other risk factors. Both hyperglycemia and insulin resistance play a role in the pathogenic link between diabetes and atherosclerosis. Diabetic patients, therefore, could derive a greater benefit from therapies shown to be effective in treating and preventing ischemic heart disease. An aggressive correction of cardiovascular risk factors and accurate risk stratification of patients with diabetes are needed.

[Peripartum cardiomyopathy]

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in the first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.

Out-of-hospital cardiac arrest caused by transient left ventricular apical ballooning syndrome

We describe a case of out-of-hospital cardiac arrest due to ventricular fibrillation in a patient with transient left ventricular apical ballooning syndrome. Our report confirms that left ventricular apical ballooning may have the same complications of myocardial infarction, adding the early ventricular fibrillation to the previous findings of left ventricular wall rupture, ventricular arrhythmias during hospitalization and complete atrio-ventricular block. Moreover, left ventricular apical ballooning may have different and unusual clinical onsets, including sudden cardiac death due to ventricular tachyarrhythmias in the absence of associated symptoms. Therefore, in our opinion left ventricular apical ballooning may be considered as a possible cause of sudden death in otherwise healthy women.

Dynamic mild subaortic left ventricular obstruction caused by an accessory mitral valve attached to the anterior mitral valve in a young pregnant woman

Accessory mitral valve tissue is an extremely rare congenital cardiac anomaly of embryologic development of the endocardial cushion. This anomaly is often associated with left ventricular outflow tract obstruction (LVOTO). A 26-year-old pregnant female was referred to our Department of Cardiology with exertional shortness of breath and tachycardia. Transthoracic and transesophageal echocardiography revealed a flexible circular (1.3 x 1.4 cm), mobile structure attached to the ventricular side of anterior mitral valve leaflet, with chordal attachments structure from anterior papillary muscle. This picture is compatible with a parachute-like accessory mitral valve tissue. We performed an echocardiographic exercise test that shows a systolic flow turbulence starting immediately proximal to this structure, resulting in a small increase in left ventricular outflow tract (LVOT) gradient (30 mmHg). Therefore we started low dose of beta-blocker therapy in order to decrease heart frequency and reduce the future risk of a worsening of an LVOT dynamic obstruction. Transthoracic and transesophageal echocardiography is critical for the differential diagnosis of LVOT and in the management of accessory mitral valve tissue. In patients without rest and only an exertional mild LVOTO and no other cardiac malformations, prophylactic removal of mitral accessory tissue excision is not required; antibiotic prophylaxis for endocarditis can be indicated and a regular follow-up is recommended to identify any progression in LVOTO entity.

Coronary artery fistula: diagnostic role of transthoracic and transesophageal echocardiography

Congenital coronary artery fistulas (CAFs) are rare. Some patients develop symptoms of congestive heart failure secondary to a large left-to-right shunt or myocardial ischemia from coronary artery steal in the first few years after birth. After the second decade the frequency of symptoms and complications increase. We report a case of CAF originating from the circumflex artery and draining into the coronary sinus, associated with left main coronary aneurysm. Transtho-racic and transesophageal echocardiography approach showed the origin, course, and drainage site of the CAF. This case represents a typical sample of this rare anomaly and puts into evidence the essential role of echocardiography to define and complete the angiographic diagnosis.

[Urocortin: molecular biology and cardiovascular effects]

Urocortins and the corticotropin releasing hormone have a long evolutionary history. In the nervous system the corticotropin releasing hormone is responsible of anxiogenic effects associated with stress, while urocortins are concerned with adaptive behavior. Urocortins are also expressed in the heart, where they may play an autocrine/paracrine role binding to corticotropin releasing hormone-R2 receptors. The expression of endogenous cardiac urocortin is increased by in vitro ischemia-reperfusion damage, and the addiction of exogenous urocortins is associated with reduction of myocardial cell death during ischemia-reperfusion damage in vitro, ex vivo and in vivo. In isolated perfused heart urocortin enhances cardiac contractility and decreases high energy phosphates reduction after ischemia-reperfusion damage. Urocortin is also associated with peripheral and coronary vasodilation and with positive inotropic effect. There are experimental data which suggest a beneficial effect of urocortins in subjects with heart failure and a possible beneficial role of urocortin in preventing the iatrogenic ischemia-reperfusion damage caused by cardioplegic arrest during cardiac surgery. These early observations suggest that assessment of the clinical use of urocortin in heart failure and for the prevention of ischemia-reperfusion damage in cardiac surgery should be actively pursued.

Diagnostic value of the head-up tilt test and the R-test in patients with syncope

The diagnostic value of the head-up tilt test (HUTT) in discovering vasovagal syndrome depends on the pre-test probability. An accurate anamnesis and clinical examination screens the patients indicated for the HUTT. In patients with unexplained syncope, the R-test is an alternative procedure to discover its cause. In our study, we evaluated the diagnostic significance of the HUTT in a group of 211 patients and of the R-test in a subgroup of 45 patients with negative HUTT results and with negative traditional Holter ECG monitoring (24 hr).

Percutaneous coronary angioplasty in a patient with anomalous single coronary artery arising from the right sinus of Valsalva

We describe a 74-year-old female patient with unstable angina. The coronary angiogram showed the presence of a single coronary artery arising from the right sinus of Valsalva, which is a very uncommon congenital anomaly, with subocclusive atherosclerotic plaques at the proximal and distal right coronary artery. The stenoses were treated through percutaneous coronary angioplasty and insertion of taxol-eluting stents, with complete relief of symptoms and without evidence of myocardial ischemia at 6-months follow up. Single coronary artery is a rare congenital coronary anomaly, which may be asymptomatic and occasionally detected in patients with myocardial ischemia due to atherosclerotic coronary artery disease. In these cases, percutaneous coronary angioplasty with stent insertion may be a successful therapeutic option; however, accurate morphologic identification of anomalous arteries is mandatory before planning these interventions, in order to recognize other possible mechanisms of myocardial ischemia (e.g. vascular compression) and to choose the most appropriate type of pharmacological, percutaneous or surgical intervention.

Acute myocardial infarction in a young woman with antiphospholipid syndrome and occasional cocaine abuse

We describe a case of acute myocardial infarction in a 19-year-old woman reporting a history of occasional cocaine abuse with last exposure 4 days before symptom onset, otherwise at low cardiovascular risk. Coronary angiography showed thrombotic occlusion of anterior descending coronary artery without atherosclerotic plaques, and complete recanalization of the vessel after anticoagulation with enoxaparine. Hypercoagulability evaluation revealed the presence of antiphospholipid antibodies. We suppose that cocaine abuse may have had a delayed effect as trigger of acute myocardial infarction. This action may be due to cocaine-induced endothelial activation and to a synergic prothrombotic activity of cocaine and antiphospholipid antibodies.

An evaluation of particle deposition fluxes to cultural heritage sites in Florence, Italy

The pernicious effects of deposition of airborne particles on monumental stones have been widely demonstrated, but estimates of deposition fluxes on historic buildings remain a hard task because of the lack of careful experiments and modelling. AERBOX is a new box model developed by ENVIROWARE and ENEA, simulating the whole life cycle of aerosols. AERBOX takes into account all the relevant chemical and physical processes involved: emission, chemical reactions in gas and in gas-liquid phases, deposition, entrainment, condensation and nucleation. Concentration and deposition rates of 52 species of gaseous pollutants and 14 species of particulate pollutants are calculated on hourly basis. A modelling system composed by AERBOX and the emission pre-processor Tool for Hourly Speciation of CORINAIR Annual Emissions (THOSCANE) has been applied to estimate the flux of particulate matter deposited on the monumental area of Florence downtown starting from a CORINAIR emission inventory developed by the Tuscany Region including the industrial and mobile sources in the area of Florence and Prato counties. The time and chemical profiles of the emissions have been adapted to the Tuscany region from the reference profiles given by both the California Air Resource Board and EPA and meteorological inputs were given by the Tuscany Meteorological Centre. Concentrations and deposition fluxes were compared with field measurements available in the open literature.

Autoimmunity and malaria: what are they doing together?

A common feature of autoimmunity is the presence of autoantibodies (AAb). Two types of AAb have been described: the 'pathogenic' AAb, associated with autoimmune diseases (AID), and the so-called 'natural' AAb. The latter are present in all normal individuals and have been postulated to play a major role as a first defensive barrier of the organism. Both the 'pathogenic' and the 'natural' AAb can be detected at higher frequencies among individuals exposed to viral, bacterial and parasitic infections. The malaria associated AAb do not seem to result from a generalised polyclonal B-cell activation (PBA), have specificities that may differ according to the degree of clinical immunity and do not seem to be pathogenic. Malaria may offer a protective effect against AID, by diminishing its severity or by either preventing or retarding its expression. AAb could also participate in the immune protection against malaria, and this could happen in several ways: (i) AAb directed to modified Ag expressed on the red blood cell (RBC) membrane during parasitisation and (ii) AAb reactive with crypto- or neo-Ag revealed on both normal and infected RBC membranes, by destroying infected, and also normal, erythrocytes; (iii) anti-idiotype AAb specific of the binding site of anti-merozoite Ab, which would mimic the parasite ligand for the RBC receptor, by competing with parasites and blocking RBC invasion; (iv) AAb cross-reactive with parasite material - such as nuclear or cytoskeleton Ag - having a direct parasiticide activity; (v) the natural AAb network, through its 'anti-bacterial first defense barrier'; and finally (vi) anti-phospholipid (PL) AAb, by neutralizing the pathogenic properties of parasite-derived PL. Finally, in view of currently available knowledge, it is concluded that, since AAb are not always pathogenic, the price for an 'autoimmunity-mediated' protection in malaria would not necessarily be immunopathology and clinical autoimmunity, and a protective role of AAb could be exerted with no danger to the host.

The physician-patient relationship in amyotrophic lateral sclerosis

The principal models of the physician-patient relationship are analysed in terms of their historical development. An outline is given of the clinical, psychological and ethical particularities of the approach to patients with amyotrophic lateral sclerosis. The peculiarities of this disease are so exclusive that they do not resemble other progressive diseases with a negative prognosis, and therefore require an equally exclusive approach to the physician-patient relationship. This approach should not only be informative, scientific and interpretative-deliberative, but must simultaneously be founded on a solid therapeutic alliance aimed at seeking the best interests of the patients while respecting their autonomy as well as their "good" (not only in the sense of physical well-being, but also in terms of respect for their personal values). This is the only way to confront the conflicts that inevitably arise (especially in advanced stages of the disease) without the risks associated with a desire to escape or to adopt extreme solutions (such as euthanasia and therapeutic insistence) and without the risk of burn-out.