Preterm birth after loop electrosurgical excision procedure (LEEP): how cone features and microbiota could influence the pregnancy outcome

OBJECTIVE

In the last years, the mean age of women who underwent cervical treatment for high-grade cervical intraepithelial neoplasia (CIN 2-3) is similar to the age of women having their first pregnancy. The aim of this study was to evaluate the risk of preterm birth in subsequent pregnancies after loop electrosurgical excision procedure (LEEP).

PATIENTS AND METHODS

From January 2013 to January 2016 the study identified a total of 1435 women, nulliparous, who underwent LEEP for CIN 2-3, and who wished to have their first pregnancy. Before surgery, the lengths of the cervix were calculated by transvaginal sonography. After the treatment, the dimension of the removed tissue was evaluated. During the pregnancy, all women carried out periodic transvaginal sonography and vaginal-cervical swabs.

RESULTS

The average age of patients was 31.96±5.24 years; the interval between the surgical procedure and pregnancy was 12.04±4.67 months; the gestational age at births was 37.53±2.91 weeks. The first vaginal and cervical swab performed during pregnancy was negative in 81.8% of patients. The most prevalent infections were related to C. Albicans, G. Vaginalis, and Group B Streptococcus (GBS). The rate of preterm delivery was significantly higher in women with a minor cervical length.

CONCLUSIONS

The length and the volume of cervical tissue excised have been shown to be directly related to the risk for preterm birth. Furthermore, vaginal infections and their persistence during pregnancy in women with a history of LEEP may be associated with an increased risk for preterm birth, compared with women with no history of LEEP.

Cervicovaginal bacteria and fungi in pregnant diabetic and non-diabetic women: a multicenter observational cohort study

OBJECTIVE

We evaluated the prevalence of cervicovaginal Bacteria, group B Streptococcus (GBS), Gardnerella vaginalis (GV), Candida spp., Chlamydia trachomatis (CT), Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in pregnant women with and without diabetes mellitus (DM).

PATIENTS AND METHODS

Cervicovaginal swabs were gathered from 473 pregnant patients divided into 127 diabetic and 346 non-diabetic. The results were correlated to gestational age, parity and glycemic control.

RESULTS

A higher prevalence of MH/UU (p=0.012) was found in the diabetic patients. After the 28th week of pregnancy, the prevalence for all investigated microorganisms appeared similar except for MH/UU (p=0.014). In multigravida, there were statistical differences between two groups in testing for Bacteria (p=0.015) and for MH/UU (p=0.037). The diabetic condition correlated to the state of multigravida in cases positive for Candida spp. (p=0.049) and in those testing positive for at least one microorganism (p=0.043). Pregnant with a blood glucose > 92 have twice the risk of being positive to a single microbiological test than those with better glycemic control.

CONCLUSIONS

The higher prevalence of MH/UU after the 28th weeks can be explained with the physiologically reduced insulin tolerance characteristic of this gestational period. Among the diabetic testing positive to Candida spp. the statistically significant association was observed only in multigravida condition. These data suggest that diabetic multigravida women are at increased risk for Candida spp. infection in relation to the improper glycemic control.

Laparoendoscopic single site surgery in pediatric urology: does it require specialized tools?

PURPOSE

To describe our experience utilizing Laparoendoscopic single site (LESS) surgery in pediatric urology.

MATERIALS AND METHODS

Retrospective chart review was performed on LESS urologic procedures from November 2009 through March 2013. A total of 44 patients underwent 54 procedures including: nephrectomy (23), orchiopexy (14), varicocelectomy (9), orchiectomy (2), urachal cyst excision (3), and antegrade continence enema (3) (ACE).

RESULTS

Median patient age was 6.9 years old. Estimated blood loss (EBL), ranged from less than 5cc to 47cc for a bilateral nephrectomy. Operative time varied from 56 mins for varicocelectomy to a median of 360 minutes for a bilateral nephroureterectomy. Incision length ranged between 2 and 2.5cm. In our initial experience we used a commercial port. However, as we progressed, we were able to perform the majority of our procedures via adjacent fascial punctures for instrumentation at the single incision site. One patient did require conversion to an open procedure as a result of bleeding. Three complications were noted (6.8%), with two Clavien Grade 3b complications. Two patients required additional procedures at 1-year follow-up.

CONCLUSIONS

The use of LESS applies to many pediatric urologic procedures, ideally for ablative procedures or simple reconstructive efforts. The use of adjacent fascial puncture sites for instrumentation can obviate the need for a commercial port or multiple trocars.

Robotic Intracorporeal Orthotopic Neobladder: Urodynamic Outcomes, Urinary Function, and Health-related Quality of Life

BACKGROUND

Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required.

OBJECTIVE

To evaluate urodynamic features of iONB and bladder cancer-specific and general health-related quality-of-life (HRQOL) outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score.

RESULTS AND LIMITATIONS

The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p<0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p<0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm(3) (range 339-1001). BCI mean scores for urinary function (p=0.58) and urinary bother (p=0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs. 19%; ≤2 pads 84% vs. 79%), as reflected by total pad usage (p=0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group.

CONCLUSIONS

iONB had adequate UDS characteristics and comparable bladder cancer-specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up.

PATIENT SUMMARY

We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group.

ST segment elevations: always a marker of acute myocardial infarction?

Chest pain is one of the chief presenting complaints among patients attending Emergency department. The diagnosis of acute myocardial infarction may be a challenge. Various tools such as anamnesis, blood sample (with evaluation of markers of myocardial necrosis), ultrasound techniques and coronary computed tomography could be useful. However, the interpretation of electrocardiograms of these patients may be a real concern. The earliest manifestations of myocardial ischemia typically interest T waves and ST segment. Despite the high sensitivity, ST segment deviation has however poor specificity since it may be observed in many other cardiac and non-cardiac conditions. Therefore, when ST-T abnormalities are detected the physicians should take into account many other parameters (such as risk factors, symptoms and anamnesis) and all the other differential diagnoses. The aim of our review is to overview of the main conditions that may mimic a ST segment Elevation Myocardial Infarction (STEMI).

A retrospective review of factors associated with vasovasostomies in United States military members

BACKGROUND

Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal.

METHODS

All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed.

RESULT

A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy.

CONCLUSION

Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

Demographics of Men Receiving Vasectomies in the US Military 2000-2009

BACKGROUND

We hypothesize that there is a higher incidence of vasectomy within the military at a younger age based on this equal access health care system.

MATERIALS AND METHODS

A review of the CHAMPS military database was conducted for men receiving vasectomies from 2000 to 2009. Age at vasectomy, number of children, race, religion, and marital status were recorded and incidence was computed.

RESULTS

Total of 82,945 vasectomies was performed. The overall incidence to have a vasectomy was approximately 7.10 per 1000 men. The highest rate of occurrence was 14.4 per 1000 men in men 30-34 years old. Whites had a higher rate than blacks at 10.03 per 1000 men compared to 6.27 per 1000 men. Protestants had the highest rate at 8.44 per 1000 men, and Jewish people had the lowest at 1.86 per 1000 men. Married men had a rate of 12.3 per 1000 men, whereas single men were 1.03 per 1000 men.

CONCLUSIONS

The incidence to have a vasectomy in the military was 7.10 per 1000 men, with an age adjusted rate at 8.66 per 1000 men. This information may assist primary care providers in discussing vasectomies as a permanent form of contraception.

Castleman's disease in the left suprarenal region, mimicking an adrenal neoplasm

We present a rare case of a 16-year-old male patient with Castleman's disease (CD) manifest by a suspicious mass within the left suprarenal region abutting the left adrenal gland, mimicking an adrenal neoplasm. CD is an uncommon and poorly understood lymphoproliferative disorder that, when observed, typically occurs as a mediastinal mass. Two percent of cases reportedly occur in the pararenal region. Although rare, Castleman's disease should be considered in the differential diagnosis of a retroperitoneal mass.

[Computerized follow-up cards for ambulatory patients with implanted pacemaker or defibrillator]

The follow up of pacemaker and defibrillator dependent patients has a significant role for both the evaluation of pacing effectiveness and check of hemodynamic advantages about patient's quality of life. The bulky paper archives are often inaccurate, hampering the consultation. At present the paper card is the only document which can be utilized to record some data concerning the implant and patient clinical story. Therefore, there is the necessity for a card that can include all patient's data, and the implant and programming pacemaker/defibrillator data during follow up. This new pacemaker card has portable file or data-base including shared data with safety mechanism, which can be utilized in several controls by different users (physicians, hospital ward, primary care units, insurance companies). The pacemaker card includes a chip that permits to store a considerable amount of data; it can be update in every further medical control, in observance of laws. The card Chip Operating System (C.O.S.) consists of a microchip with a memory completely managed by the operating system inside the chip itself. The card can be read by means of a GCR-200 modem linked with a PC IBM-compatible computer and the data can be updated during the follow up. The pacemaker-defibrillator card will appear immediately on screen, and it can be printed, updated and/or modified by a Microsoft Windows operating programme. With this pacemaker card we are able to ensure serviceable medical work, particularly in terms of cost/benefit ratio giving to patient more and more reasoning and safe service.

Subacute cardiac rupture complicating myocardial infarction. A case report

The authors have focused this study on the emergence of subacute ventricular free wall rupture in a seventy-six-year-old patient admitted to hospital for inferior acute myocardial infarction. After six days he showed clinical signs of bradycardia and hypotension evolving to electromechanical dissociation. Given an adequate pharmacologic therapy, the patient was submitted to echocardiography, which was believed to be consistent with myocardial rupture, showing a moderate to large pericardial effusion. Pericardiocentesis of 150 mL of bloody fluid resulted in a further improvement in his hemodynamics. The patient underwent cardiac surgery with repair of the myocardial rupture through a large diaphragmatic infarction by a Dacron polyester fiber graft and pacemaker placement. In conclusion the authors confirm the relevant role of clinical data such as persistent chest pain and hemodynamic instability and the value of echocardiography in identifying subacute myocardial free wall rupture after an episode of acute myocardial infarction.

[Radiofrequency catheter ablation of atrial tachycardia: technique, results and follow-up]

BACKGROUND

Recently radiofrequency (RF) catheter ablation (CA) of atrial tachycardia (AT) showed to be highly effective with a low incidence of compliance. Aim of our study was to report the results and follow-up of RFCA of drug-refractory AT in 59 consecutive patients (pts).

METHODS

Two mapping techniques were used to localize the ablation site of AT: the earliest atrial activation and the pace-mapping. Traumatic interruption of AT was used to verify the ablation site identified by the previous procedures. Moreover we evaluated the sensitivity, specificity and the positive predictive value of the three mapping techniques.

RESULTS

AT was successfully treated in 55/59 (93.2%) pts with a mean of 4.0 +/- 3.8 (range 1-16) RF pulses for patient. The mean procedure time was 185.2 +/- 48.5 min with a mean rx-time of 41.5 +/- 21.3 min. An interval between the onset of the intracavitary atrial deflection and the onset of the P-wave, during atrial tachycardia, (AP interval) > or = 30 ms and pace-mapping concordant sequence were highly sensitive (90.9% and 89.1%) but less specific (49.2% and 33.9%) in identifying the site of ablation. By using atrial tachycardia traumatic interruption combined with the AP interval > 30 ms or the pace-mapping concordant sequence we obtained a specificity of 78.7% and 77.0% respectively and a positive predictive value of 48.0% and 46.8% respectively. Four recurrences (7.3%) were observed during a mean follow-up of 23.4 +/- 13.3 months. In the 22 (37.3%) pts with dilated cardiomyopathy, chest Xr and echocardiography showed a significant decrease of cardiothoracic index (0.56 +/- 0.08 pre ablation, 0.43 +/- 0.07 post ablation, p < 0.001) and end-diastolic diameter (64 +/- 8 mm pre ablation, 52 +/- 8 mm post ablation, p < 0.001) and a significant improvement of left ventricular ejection fraction (37 +/- 9% pre ablation, 48 +/- 11% post ablation, p < 0.05).

CONCLUSION

The RFCA of AT was effective and safe. Moreover we observed a hemodynamic improvement in patients with reduced ejection fraction and increased cardiac volumes. An AP interval > or = 30 ms and the pace-mapping concordant sequence were reliable features to predict the outcome of the ablation procedure. Traumatic ablation of atrial tachycardia improved the specificity and the positive predictive value of these two mapping techniques and was able to predict the response to radiofrequency with a high specificity.

[Atrioventricular conduction before and after the radiofrequency catheter ablation of a nodal reentry tachycardia circuit]

Aim of our study was to retrospectively evaluate atrioventricular conduction 24 hours after selective radiofrequency catheter ablation of the fast pathway or after selective ablation of the slow pathway of the atrioventricular nodal reentrant tachycardia circuit. Electrophysiologic modifications were retrospectively analyzed in 47/48 patients successfully submitted to fast pathway ablation and in 90/93 patients successfully submitted to slow pathway ablation. The atrioventricular conduction intervals (P-Q and A-H), both anterograde and retrograde Wenckebach point, the effective refractory period of atrioventricular node and the atrioventricular node function curve were evaluated before and after selective radiofrequency catheter ablation of slow and fast pathway. We identified the fast pathway ablation potential as: A:V ratio > or = 2:1, His electrogram < or = 150 microV. The slow pathway potential was identified as the widest, sharpest and latest atrial electrogram recorded during sinus rhythm in the posteroseptal region of the atrioventricular junction or as the widest, sharpest and earliest observed during retrograde conduction. We observed a significant increase in the P-Q and A-H intervals in patients submitted to fast pathway ablation, while no significant modification of these parameters was appreciated in patients submitted to slow pathway ablation. No significant modification of anterograde Wenckebach point (NS) was observed in patients submitted to successfully ablation of fast pathway while a statistically significant increase in anterograde Wenckebach point (p = 0.03) was observed in patients submitted to slow pathway ablation. After selective fast pathway ablation, retrograde conduction was absent in 82.9% of patients submitted to ablation; in the remaining 17.1% a significant increase of retrograde Wenckebach point was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ablation of paroxysmal tachycardia in Wolff-Parkinson-White syndrome]

Surgical or catheter ablation of accessory pathways by means of high energy shock has been substantial associated with morbidity and mortality. On the contrary radiofrequency current, an alternative energy source for ablation, has a low incidence of complications and a very high success rate. Aim of this study was to relate about the results using catheter ablation of accessory pathways by radiofrequency current in our Electrophysiologic laboratory. Radiofrequency current (20-40 W) was delivered between a large-tip catheter electrode positioned against the mitral or tricuspid anulus and a standard adhesive electrosurgical dispersive pad applied to the left chest wall. When possible radiofrequency delivery was guided by catheter recordings of accessory pathway activation. Ablation was attempted in 181 patients with 191 accessory pathways. We obtained successful ablation of 187/191 accessory pathways and accessory pathway conduction was eliminated in 177/181 patients. During a mean follow-up of 14 +/- 10 months preexcitation returned in 7 patients (3.9%). All underwent a second successful ablation. In 1 patient, during the procedure, we observed a transient ischemic attack, with no complications. In accordance to other reports we conclude that radiofrequency ablation is highly effective in ablating accessory pathways, with low morbidity and no mortality.

[A methodological approach to the transcatheter radiofrequency ablation of anomalous Kent-type pathways]

Aim of this study is to suggest our methodological approach for transcatheter ablation of Kent bundles by radiofrequency energy as to the potential ablation sites, the need in unipolar or bipolar recording mode, single catheter or multiple catheters mapping of anomalous pathways, the vascular approach for both left sited and right sited anomalous pathways, and finally the duration and power to supply. The recording of Kent potential and/or a Va-QRS interval > or = 0 ms have been considered significant predictors of success (respectively p < 0.001 and p < 0.05). The unipolar recording mode has been considered critical in the choice of ablation site in 47 (29.9%) patients. A 6-catheter approach for both diagnostic electrophysiologic studies and mapping allowed us to easily localize accessory pathways and to record either a probable or possible Kent potential in a high percentage of patients and to reduce the permanence of the ablation catheter in the left ventricle. By transaortic retrograde approach in ablating left sited anomalous pathways, we obtained a high success rate, while right sited accessory pathway were approached from the inferior vena cava. In right sited anomalous pathway we delivered radiofrequency energy for a longer time in order to avoid a relapse soon after the procedure. We performed ablation of 174/178 (97.7%) anomalous pathways in 165/169 (97.6%) patients. We observed a 3.8% relapse during a mean follow up of 13 +/- 9 months.

[Cardiac effects of GH]

To investigate cardiac effects of excess and deficiency of growth hormone (GH) we studied twenty acromegalic subjects and eleven adult patients with GH deficiency by means of a non invasive method, the Doppler echocardiography. The results obtained in the group of patients were compared with those of two groups of twenty and eleven normal subjects, respectively, age and sex matched. The age of the acromegalic patients ranged from 20 to 62 years. Nineteen patients were considered to have active acromegaly at the time of the study. Mean duration of disease since treatment was 12 +/- 5 years (range 5 to 24 years). The age of GH deficient adults ranged from 21 to 33 years. All these patients have been treated with extractive GH over nine years and the therapy withdrawal was performed at least three years before entering the study. In the group of acromegalic patients, a subgroup including nine patients with mild to moderate hypertension was considered. All subjects gave informed consent and the study protocol was approved by the Ethical Committee of the Medical School of Naples. Right ventricular free wall thickness resulted significantly increased in acromegalic patients (8 +/- 2 vs 4 +/- 1 mm; p < 0.001). Left ventricular mass index was augmented both in the whole group and in the subgroups of normotensive and hypertensive acromegalics as compared with normals (134 +/- 33 p < 0.001, 115 +/- 20 p < 0.01 and 156 +/- 31 p < 0.001 vs 80 +/- 18 g.m-2). Ejection phase indices were normal in patient group, while impaired left and right ventricular diastolic filling was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Platelet aggregability in patients with a VVI pacemaker

Several studies have suggested an increased incidence of thromboembolic events in patients with VVI pacemaker (VVI patients); furthermore, other authors have demonstrated that a treatment with anticoagulants or antiplatelet drugs may be effective in reducing thromboembolic events, thus suggesting an increased formation of platelet thrombi in these patients. In this respect, platelet aggregability was investigated in ten VVI patients and ten age- and sex-matched subjects. beta-thromboglobulin (beta-Tg) and platelet factor 4 (PF4) plasma levels were determined as well as platelet aggregation induced by ADP, collagen, epinephrine, and arachidonic acid. Plasma beta-Tg levels were increased in the patient group (86 +/- 24 vs 24 +/- 13 ng/mL; P < 0.001) in presence of normal PF4 values (14 +/- 11 vs 13 +/- 6 ng/mL; NS). Aggregation curves showed abnormal values of maximal amplitude, slope, and lag time. In particular, maximal amplitude was significantly higher in VVI patients as compared with controls (ADP P < 0.01, collagen P < 0.001, adrenaline P < 0.01, arachidonic acid P < 0.05). These findings strongly suggest an increase of platelet activity in VVI patients.

Clinical experience with the transvenous Medtronic Pacer Cardioverter Defibrillator (PCD) System

We review our experience with the transvenous Medtronic Pacer Cardioverter Defibrillator System (Model 7217B), a multifunction implantable pacer defibrillator combined with a transvenous lead system (Transvene). From April 1991 to October 1992, we implanted this device in 19 consecutive patients (11 men and 8 women; average age, 56.5 years). Nine patients (47.4%), 5 with coronary artery disease and 4 with dilated cardiomyopathy, had an ejection fraction of < 30%. The average operative time was 129 minutes. In 18 patients (94.7%), the transvenous lead system provided effective sensing, pacing, and defibrillation during intraoperative testing. In each of these cases, the defibrillation threshold was less than 18 J. In 1 patient (5.3%), it was necessary to switch to epicardial leads, which were implanted through a left thoracotomy. All patients were extubated in the recovery room. The average hospital stay was 8 days. There was no early mortality or morbidity. During a maximum follow-up period of 17 months (mean, 9.2 months), no sudden death occurred. The implantable system terminated 245 ventricular tachycardia episodes in 14 patients (73.7%) and 82 ventricular fibrillation episodes in 13 patients (68.4%). Two hundred eleven (86.1%) of the ventricular tachycardia episodes were resolved by antitachycardia pacing alone. In 2 patients (10.5%), the caval electrode became dislocated; repositioning of the electrode was followed by repeat defibrillation threshold evaluation. Our experience shows that the transvenous Medtronic Pacer Cardioverter Defibrillator System provides safe, effective treatment of ventricular tachyarrhythmias. Because the perioperative mortality and morbidity are extremely low, use of this device may be particularly beneficial in patients with a high operative risk. Moreover, the lower number of unpleasant therapeutic shocks should increase patient a acceptance of the device.

Influence of atenolol on the relationship between heart rate and QT interval in patients with exercise-induced myocardial ischemia

The aim of this study was to analyze the relationship between heart rate and QT interval (HR-QT) during exercise in control subjects (Group A) and in patients with coronary artery disease (CAD) with effort angina and without previous myocardial infarction (MI) (Group B). The diagnosis of CAD was confirmed by coronarographic examination. The correlation HR-QT was significant (p < 0.001) in both groups on effort and at recovery. The analysis of the regression HR-QT was carried out separately, both on effort in upright position and at rest in supine position, to avoid the influence of posture on QT length. During effort, the regression line showed lower slope and intercept values in Group B (p < 0.001) than those for Group A. A similar behavior was also observed at rest. Thus, at the highest heart rate, where ECG signs of ischemia (ST depression > 1 mm) frequently occurred, a longer QT interval was present in Group B. Moreover, in Group B, the QT interval in the presence of ECG signs of ischemia was significantly longer (p < 0.01) than in Group A at comparable heart rates both on effort and at rest, thereby confirming the result obtained by comparing both regression lines. The same effort protocol was repeated in Group B patients after acute administration of atenolol 100 mg per os. After atenolol administration, the analysis of the regression HR-QT in Group B clearly showed a shorter QT interval than that obtained in washout period during the baseline test at the highest heart rates where the ECG frequently showed signs of ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of coronary artery disease with Tc 99m-methoxy isobutyl isonitrile and transesophageal pacing

Recently the use of a new radioactive agent with physical and biological properties more favorable than those of thallium 201, methoxy-isobutyl-isonitrile (MIBI) labeled with technetium 99m (Tc 99m), has permitted simultaneous performance of perfusion and function studies in ischemic cardiopathy. Transesophageal atrial pacing (TAP) technique has evolved as an alternative provocative test of ischemia. The authors compared the capability of Tc 99m-MIBI myocardial scintigraphy, combined with TAP, with that of Tc 99m-MIBI, combined with maximal stress test, in the diagnosis of ischemic cardiopathy. They studied 11 patients with a clinical history of angina pectoris. Myocardial scintigraphy was performed at rest, after stress test, and after TAP. Finally, all the patients underwent coronary angiography. The analysis of myocardial perfusion images on both Tc 99m-MIBI associated with TAP and with stress demonstrated, in 165 myocardial segments examined: 143 normal, 20 reversible defects, 2 irreversible defects. The concordance of localization between coronarographic data and scintigraphic reversible and irreversible defects was 85%. In conclusion TAP proves to be a valid and sensitive provocative test of ischemia when combined with myocardial scintigraphy and with Tc 99m-MIBI.

Pacemaker malfunction due to subcutaneous emphysema--a case report

The authors describe a cas of pacemaker malfunction due to a critical increase of impedance resulting from air entrapment in the pacemaker pocket.

Evaluation, by noninvasive methods, of the effects of acute loss of thyroid hormones on the heart

To evaluate the effects of the acute loss of thyroid hormones on the heart the authors studied 11 women with acute hypothyroidism. The cardiac study was performed by means of electrocardiography (ECG), radionuclide ventriculography (RNV) at rest and under effort, and monodimensional echocardiography (MD-echo) and was repeated with ECG and MD-echo after six months of thyroxine suppressive therapy. The ECG showed a significant prolongation of QT interval and flattening and inversion of T wave with normal heart rate. The MD-echo revealed left ventricular function in the normal range and normal left ventricular dimensions. RNV showed the ejection fraction in the lower normal range at rest, which increased to a smaller extent under effort in comparison with a control group. The ECG performed during suppressive therapy with L-thyroxine yielded normal findings with an increase of heart rate and of R wave amplitude, and the MD-echo showed no significant variations of cardiac function due to the increase of heart rate.

Comparison between exercise and trans-oesophageal atrial pacing in patients with coronary artery disease: technetium-99m methoxy isobutyl isonitrile simultaneous evaluation of ventricular function and myocardial perfusion

In this study we compared the results of exercise and trans-oesophageal atrial pacing (TAP) technetium-99m methoxyisobutyl isonitrile (99mTc-SESTAMIBI) cardiac imaging in the evaluation of left ventricular (LV) function and myocardial perfusion in patients with angiographically proven coronary artery disease. Ten patients (8 men and 2 women, mean age 59 +/- 6 years) were submitted to 3 separate injections of 99mTc-SESTAMIBI, one under control conditions, one after exercise and one after TAP. LV ejection fraction, as measured by electrocardiogram (ECG) gated first pass, decreased from 49 +/- 5% under control conditions to 42 +/- 6% during exercise (P less than 0.05 versus control) and to 43 +/- 8% during TAP (P less than 0.05 versus control and insignificant change versus exercise). Segmental myocardial perfusion analysis was performed on a total of 150 myocardial segments. On both exercise and TAP 99mTc-SESTAMIBI studies, 103 segments (69% of the total) were normal, 32 (21%) had reversible, and 15 (10%) irreversible, perfusion defects. Relative regional tracer uptake was not statistically different between exercise and TAP in normal regions (91.1 +/- 9.1% versus 90.7 +/- 8.5%, respectively), in regions with reversible (61.9 +/- 12% versus 62.4 +/- 10.4%, respectively) and irreversible perfusion defects (55.8 +/- 7.8% versus 58.8 +/- 9.5%, respectively). Our results demonstrated that 99mTc-SESTAMIBI TAP cardiac imaging shows similar results to 99mTc-SESTAMIBI exercise myocardial scintigraphy in the assessment of LV function and myocardial perfusion in patients with coronary artery disease.

Follow-Up of a Respiratory Rate Modulated Pacemaker

The efficacy of 27 respiration sensitive rate modulated pacemakers (Biorate RDP-3 Biotec) implanted in the left pectoral area was evaluated every 3 months during a mean follow-up period of 29 months (range 10-50 months). Rate modulation function was unchanged other than for three patients in whom the auxiliary leads became displaced. Two implants lost ventricular sensing in this nonprogrammable model. In all but the three patients, Holter monitoring demonstrated pacing rate variation corresponding to daily activity. Stress test duration increased from 8.2 +/- 1.5 minutes (in fixed rate VVI rate) to 12.83 +/- 2.0 minutes (in the VVIR mode) (P less than 0.05). Right arm movement increased the pacing rate by 5 +/- 3 beats/min (NS), while the left arm movement increase was 30 +/- 5 beats/min (P less than 0.05). Mental, arithmetic, and nifedipine tests did not change the rate modulated pacing rate. The system responded to a change in respiratory rate by an increase in stimulation rate. A satisfactory response in sensitivity and velocity was present only with medium-high workloads. Interference with rate modulation occurred with movement of the arm ipsilateral to the implanted pulse generator.

Fourier analysis in patients with different pacing modes

The purpose of this study was to evaluate the usefulness of phase analysis in detecting the altered activation sequence induced by different pacing modes. Radionuclide ventriculography and planar gated blood pool scintigraphy were performed at rest in 56 patients with different pacemakers. This method permitted us to localize the pacemaker impulse site in the right ventricle and its diffusion in the heart. In patients with VVI pacemaker, this technique showed an evident asynchronism of contraction and relaxation of each ventricle and the standard deviation of phase angle (sigma), calculated by computer, is greater during pacing than sinus rhythm for left (LV) and right (RV) ventricles (LV sigma: 17 degrees +/- 4 vs 11 degrees +/- 3, less than 0.001; RV sigma: 31 degrees +/- 7 vs 14 degrees +/- 4, P less than 0.001). In the patients with VVI rate responsive pacemakers, the LV sigma changed from 18.5 +/- 3 under pacing to 11 degrees +/- 3 in sinus rhythm, P less than 0.001, while the RV sigma changed from 30 degrees +/- 8 to 14 degrees +/- 4, P less than 0.001. Instead in the patients with DDD pacemakers, the LV sigma changed from 15.5 degrees +/- 2 under pacing to 11 degrees +/- 3 in sinus rhythm, P less than 0.05, while the RV sigma changed from 29.1 degrees +/- 6 to 14 degrees +/- 4, P less than 0.001.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac function (angiocardioscintigraphic evaluation) and plasma catecholamine levels in non-insulin-dependent diabetics]

Cardiac mortality is more frequent in diabetic patients than in normal subjects and particularly heart failure occurs 4-6 times more frequently in these patients than in normals also excluding diabetics with coronary artery disease (CAD). To study cardiac function, 20 patients with type II diabetes mellitus (11 M and 9 F, mean age 48 +/- 9 years), and 13 normal subjects (6 M and 7 F, mean age 48 +/- 13 years), were submitted to radionuclide ventriculography with technetium 99m to evaluate some indices of cardiac function at rest and during effort. The diabetic patients were on good metabolic control testified by a satisfactory fasting and post prandial glycaemia, absence of glycosuria in the last 3 monthly controls and a normal value of glycosylate haemoglobin; they had no vascular or neurological complications; CAD was excluded submitting these patients to a maximal effort ECG on an ergometer. The normal subjects were comparable to diabetic patients for age, sex, mean arterial pressure, body mass index and body surface area. At rest, stroke volume, peak filling rate, cardiac output, ejection fraction (EF), were significantly lower in diabetic patients than in normal subjects. Systemic vascular resistances (SVR) were higher in diabetics than in normal subjects (p less than 0.01). Mean EF during effort increased in both normals and diabetics but 30% of diabetic patients showed no increase in EF during effort (less than 5%). Preload, represented by end-diastolic volume or blood volume, did not differ in the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anaerobic threshold in the evaluation of heart function in patients with rate-responsive pacemaker]

It is very difficult to evaluate the ability of carrying out physical exercise in patients with rate responsive (RR) pacemaker (PM). However, the anaerobic threshold (AT) proved to be a useful parameter in the evaluation of cardiac function. The AT can be easily reproduced and not influenced from emotional aspects of both the patient and the physician, moreover being under maximum and then easy to achieve. Aims of our study were: to evaluate if the cardiopulmonary stress test can represent a method to be used for a more correct rate responsive pacemaker programming; to compare the data obtained of 3 rate responsive pacemakers steered by different sensors. We have studied 24 patients, of whom 10 with Activitrax (A), 8 with Meta (M), and 6 with Phymos MPT (P) pacemakers. Patients were submitted to symptoms limited cycloergometer stress test at 2 different settings: fixed rate at 70 b/min; increasing rate at until 85% of maximum heart rate for each patient, with range 0 + 10 W/min. Gas exchange data were continuously collected using an automated system (Medical Graphic System 2001) based on Whipp and Wasserman's method.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of ticlopidine in the prevention of thromboembolic events in patients with VVI pacemakers

This study was designed to evaluate whether long-term treatment with ticlopidine reduces the incidence of thromboembolic episodes in patients with a VVI pacemaker. One hundred eleven patients with a VVI pacemaker were randomly assigned to two groups: group A (52 patients) was treated with ticlopidine at the dose of 250 mg a day; and group B (59 patients) was not treated and served as a control group. The primary analysis of efficacy of ticlopidine was based on the occurrence of thromboembolic episodes and of cardiovascular and cerebrovascular deaths. The mean follow-up period was 66 months. In group A, there was a significant reduction in the incidence of thromboembolic episodes (P less than 0.05) with a smaller incidence of total cardiovascular and cerebrovascular deaths (8 in group A and 18 in group B; P = 0.05) as compared with group B. Twelve percent of patients had moderate side effects with 1 dropout (epistaxis). Our data confirm the high incidence of thromboembolic events in patients with a VVI pacemaker and demonstrate the efficacy of ticlopidine in preventing them.

[Heart function (angioscintigraphic evaluation) and sympathetic tone in insulin-dependent diabetes mellitus]

Cardiac failure is a frequent feature in diabetic patients and it often causes their death. But how and when cardiac disease begins in this kind of patient is still debatable. For example, cardiac failure can be present even in the absence of atherosclerotic involvement of coronary arteries in young diabetics. The aims of our study were to evaluate the cardiac function and sympathetic tone of 16 young type 1 diabetic patients (8 M and 8 F, mean age: 27 years, SD +/- 5) in comparison with 10 normal subjects (4 M and 6 F, mean age: 30 years, SD +/- 7). Diabetic patients were choose from a large population because of the following features young age, absence of clinical and instrumental evidence of micro- or macroangiopathy, clinical evidence of diabetic autonomic neuropathy, proteinuria or arterial hypertension. They were in good metabolic control on daily insulin therapy of two or three administrations. Cardiac function was evaluated at rest and during submaximal exercise on a cycloergometer in supine position using radionuclide ventriculography with technetium 99m. Sympathetic tone was checked using the five clinical tests according to Ewing and the plasmatic level of catecholamines at rest was evaluated using high pressure chromatography. The ejection fraction, cardiac output, stroke volume of diabetics were comparable with those of normal subjects even in the presence of comparable systemic vascular resistance. The increase in ejection fraction during effort was normal. Only in one diabetic patient (incidentally the oldest one) did ejection fraction decrease (7%) during effort. The peak ejection and filling rates were significantly higher (p less than 0.001) in diabetic patients compared to those of normal subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

[HR/QT ratio during ergometric test: influence of ischemia and beta blocking therapy]

The aim of this study was to analyze the HR/QT relation during exercise in a group of patients with effort angina (Group B) in comparison with the same relation obtained in a group of normal subjects (Group A) comparable for age and sex. The regression analysis was carried out separately during effort in upright position and during rest in clinostatic position to avoid influences on QT by the patient's posture. During effort in patients of the Group B the regression shows a lower value of the slope and of the intercept (p less than 0.001) than those obtained in the subjects of the Group A. A similar behaviour is shown also from the regressions obtained during rest in the same groups. Thus at the highest HRs we observed a longer QT in the Group B. Moreover QT of ischemic patients in the presence of ECG signs of ischemia (ST less than or equal to 1 mm) resulted significantly longer (p less than 0.01) either during effort and at rest, respect to that obtained in Group A at comparable HRs. The analysis of the regression HR/QT after administration of atenolol 100 mg per os in a subgroup of patients of Group B clearly shows a less prolonged QT at the highest HRs where ECG ischemia frequently appears. This fact is demonstrated by the presence of a higher slope (p less than 0.05) respect to that obtained in the same group without therapy. In conclusion, myocardial transient ischemia provokes a longer QT in patients with ischemic heart disease in comparison with normal subjects. Acute therapy with atenolol per os is able to condition the regression HR/QT showing a relative shortening of QT at the highest HRs respect to that carried out in the same patients in absence of therapy.

[Cardioscintigraphic evaluation of obese subjects with or without arterial hypertension]

A group of normotensive obese subjects (group A), a group of hypertensive obese subjects (group B) and a group of control subjects (group C) were submitted to radionuclide ventriculography using 99mTc to investigate cardiac function and haemodynamic situation in the presence of an increased preload (group A), preload and afterload (group B). Results show a significant reduction in ejection fraction and systolic blood pressure/end systolic volume in group A. Group B shows better cardiac function probably for the presence of cardiac concentric hypertrophy. Left ventricle work either in a minute and for each beat is greatest in patients of group B. Thus the simultaneous presence of obesity and hypertension can cause a worse prognosis in such patients for cardiac ischaemia and/or sudden death.

Cardiac function and sympathetic activity in young diabetics

This study was aimed at evaluating cardiac function, both systolic and diastolic, in young type 1 diabetics with a mean duration of the disease of 10.9 +/- 6 years and without evidence of cardiac autonomic neuropathy and micro- or macroangiopathy. Thirteen diabetics, with good metabolic control, and 10 normal matched subjects were studied by echocardiography at rest and by radionuclide ventriculography both at rest and during effort. The level of plasma catecholamines was also determined. The echocardiographic data were comparable in the two groups. Scintigraphic data showed an increased peak ejection and peak filling rate (P less than 0.001) in diabetics while the other indices of cardiac function were comparable. Norepinephrine (P less than 0.01) and epinephrine (P less than 0.001) were higher in diabetics. A hypothesis is formulated that the higher indices of flow velocities in type 1 diabetics are supported by a sympathetic overactivity.

[Hemodynamic adaptation in severe obesity with or without arterial hypertension]

Hypertension and obesity are 2 common pathological conditions that have been directly related. The incidence of hypertension in an obese population is far greater than in otherwise normal people. Nevertheless, a causal relationship between the 2 disorders has not been established. But their coincidence in the same patient carries increased risk of cardiovascular morbidity and mortality. In the present study we have studied a group of normotensive obese patients (21 patients, Group A), a group of hypertensive obese patients (19 patients, Group B) and a group of normal subjects (11 patients, Group C) by radionuclide ventriculography with Tc 99m to visualize the different hemodynamic adaptation to these different conditions. Overweight causes an increased preload while hypertension causes an increased afterload. In response to the increase in preload the heart of obese patient undergoes eccentric hypertrophy; when an increase in afterload is present at the same time, the left ventricle develops concentric hypertrophy. We found an increased preload in both the obese groups (A and B) testified by increased blood volume and end diastolic volume. Heart rate was higher in the 2 populations of obese patients. As a result, cardiac output was significantly increased in Group A and B. But the stroke index is decreased in Group A and B with respect to Group C. The ejection fraction is reduced in Group A with respect to Group B and C. The contractility index (systolic blood pressure/end systolic volume) is higher in Group B in comparison with Group A. Thus, hypertensive obese patients seem to have a better cardiac performance respect to the normotensive obese patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Exercise electrocardiogram in the evaluation of coronary atherosclerosis: correlations between electrocardiographic signs of ischemia and a coronarographic study]

We divided 51 patients (Group C) with stable effort angina into 2 groups: Group A of 30 patients without previous myocardial infarction, Group B of 21 patients with previous myocardial infarction. The aim of this study was to test the relation between some ECG signs of ischemia and coronary artery disease (CAD) severity and to propose a new simple angiographic score of CAD. The patients, after a pharmacological wash-out period, were submitted to a treadmill effort test and to a coronarography. Stenoses were quantified using a score system recently proposed in the literature and a new simple score obtained summing the coronary stenosis in percent. Significant correlations between the time to the onset of ischemia (TSI) and the recovery time (TR) with the CAD severity in Groups A, B, and C using both scores were observed. The total stress time and the new index obtained summing the total effort time and the time to the onset of ischemia were related to the severity of CAD in Groups A and C using both scores. The multivariate discriminant analysis suggested that the TSI is the most sensitive variable to predict CAD severity in our patients. A good correlation between the 2 scores was also observed.