The multifaceted spectrum of liver cirrhosis in older hospitalised patients: analysis of the REPOSI registry

BACKGROUND

Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce.

OBJECTIVES

To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties.

METHODS

A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed.

RESULTS

LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age-sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10-1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37-3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P < 0.05) compared to FIT. D&M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P < 0.01; post-discharge: 41% vs 12%/15%, P < 0.01) and less rehospitalisation (10% vs 32%/34%, P < 0.01) compared to PSS and FIT.

CONCLUSIONS

LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features.

NTproBNP in insulin-resistance mediated conditions: overweight/obesity, metabolic syndrome and diabetes. The population-based Casale Monferrato Study

Background and aims

NTproBNP and BNP levels are reduced in obese subjects, but population-based data comparing the pattern of this relationship in the full spectrum of insulin-resistance mediated conditions, overweight/obesity, metabolic syndrome and diabetes, are limited.

Methods

The study-base were 3244 individuals aged 45–74 years, none of whom had heart failure, 1880 without diabetes and 1364 with diabetes, identified as part of two surveys of the population-based Casale Monferrato Study. All measurements were centralized. We examined with multiple linear regression and cubic regression splines the relationship between NTproBNP and BMI, independently of known risk factors and confounders. A logistic regression analysis was also performed to assess the effect of overweight/obesity (BMI ≥ 25 kg/m²), diabetes and metabolic syndrome on NTproBNP values.

Results

Out of the overall cohort of 3244 people, overweight/obesity was observed in 1118 (59.4%) non-diabetic and 917 (67.2%) diabetic subjects, respectively. In logistic regression, compared to normal weight individuals, those with a BMI ≥ 25 kg/m² had a OR of 0.70 (95% CI 0.56–0.87) of having high NTproBNP values, independently of diabetes. As interaction between diabetes and NTproBNP was evident (p < 0.001), stratified analyses were performed. Diabetes either alone or combined with overweight/obesity or metabolic syndrome enhanced fourfold and over the OR of having high NTproBNP levels, while the presence of metabolic syndrome alone had a more modest effect (OR 1.54, 1.18–2.01) even after having excluded individuals with CVD. In the non-diabetic cohort, obesity/overweight and HOMA-IR ≥ 2.0 decreased to a similar extent the ORs of high NTproBNP [0.76 (0.60–0.95) and 0.74 (0.59–0.93)], but the association between overweight/obesity and NTproBNP was no longer significant after the inclusion into the model of HOMA-IR, whereas CRP > 3 mg/dl conferred a fully adjusted OR of 0.65 (0.49–0.86).

Conclusions

NT-proBNP levels are lower in overweight/obesity, even in those with diabetes. Both insulin-resistance and chronic low-grade inflammation are involved in this relationship. Further intervention studies are required to clarify the potential role of drugs affecting the natriuretic peptides system on body weight and risk of diabetes.

[The PRKAG2 cardiac syndrome with familial hypertrophic cardiomyopathy: an inherited burden. A case report. Review of the literature]

We report the case of a young man without prior medical history who presented with a left ventricular heart failure because of a new onset atrial fibrillation. The evolution is characterized by a sinus rythm dysfunction, a complete atrioventricular block, a non-sustained ventricular tachycardia (which required a dual-chamber defibrillator implantation) and an ischemic testicular necrosis treated by orchidectomy. After ruling out differential diagnosis we evoked an hypertrophic cardiomyopathy. Medical family anamnesis revealed an hereditary component, and we concluded to a PRKAG2 cardiac syndrome presenting as a familial hypertrophic cardiomyopathy. Two years later, he presented with a type B aortic dissection. We review the literature and differentials diagnosis.

Levels of N-terminal pro brain natriuretic peptide are enhanced in people with the uncomplicated metabolic syndrome: a case-cohort analysis of the population-based Casale Monferrato study

BACKGROUND

Both metabolic syndrome (MetS) and N-amino terminal fragment of the prohormone B-type natriuretic peptide (NT-proBNP) confer increased risk of cardiovascular diseases (CVD). We assessed if NT-proBNP levels were greater in people with uncomplicated MetS, who had neither CVD/chronic kidney disease (CKD) nor diabetes, as compared with subjects who met none of the defining criteria of the MetS.

METHODS

A case-cohort study from the non-diabetic population-based Casale Monferrato study was performed, after exclusion of all subjects with established CVD, CKD [estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m(2)], and CRP values ≥3 mg/L. Cases (n = 161) with MetS were compared with all subjects within the cohort (n = 124) who were completely free of any component of the MetS. Serum NT-proBNP was centrally measured by immunoenzymatic assay.

RESULTS

NT-proBNP levels were significantly higher in cases than in control subjects [35.4 (15.5-98.2) vs 24.4 (11.7-49.6) pg/mL, p = 0.014]. In logistic regression analysis, compared with NT-proBNP values in the lower quartiles (≤49.64 pg/mL), higher values conferred odds ratio 4.17 (1.30-13.44) of having the MetS, independently of age, sex, microalbuminuria, CRP, eGFR, and central obesity. This association was evident even after the exclusion of hypertensive subjects. Further adjustment for log-HOMA and diastolic blood pressure did not modify the strength of the association, while central obesity was a negative confounder.

CONCLUSIONS

Compared with people without any component of the MetS, those with uncomplicated MetS, who had neither CVD/CKD nor diabetes, had increased NT-proBNP values, even if they were normotensive and although absolute values were still in the low range. The insulin resistance state did not mediate this association, while central obesity was a negative confounder.

Breast cancer and primary systemic therapy. Results of the Consensus Meeting on the recommendations for pathological examination and histological report of breast cancer specimens in the Marche Region

Primary systemic therapy (PST) adds some practical problems to the pathologic examination of neoplastic breast tissue obtained from patients before and after chemotherapy. Pathologists, oncologists, breast surgeons, radiotherapists and radiologists in the Marche Region held a Consensus Meeting in Ancona on May 13, 2010, in which 15 statements dealing with neoadjuvant chemotherapy were approved by all participants. The first two statements are related to the pre-PST phase and concern the technical procedures and the histological report of the core biopsy. The other statements deal with similar issues of the post-PST surgical specimen.

[Granulicatella adiacens: an underestimated cause of endocarditis]

We report the case of an old man who was affected by an endocarditis related to Granulicatella adiacens, an uncommon bacteria, difficult to isolate and responsible for an important morbidity and mortality. Thus, it is mandatory to seek for endocarditis when this germ is demonstrated in order to start quickly an effective antibiotic treatment. Inversely, in the presence of unexplained endocarditis, further bacteriological investigations are needed to seek for this life nutrition deficient bacteria.

Exhaled nitric oxide as a marker of asthma control in smoking patients

Exhaled nitric oxide fraction (F(eNO)), which is a reliable marker of eosinophilic airway inflammation, is partially suppressed by tobacco smoking. Consequently, its potential as a biomarker in asthma management has never been evaluated in smoking patients. In the present study, the authors tested the validity of F(eNO) to predict asthma control in this population. F(eNO) and the Asthma Control Questionnaire (ACQ) were recorded at least once in 411 nonsmoking (345 with at least two visits) and 59 smoking (51 with at least two visits) asthma patients. Despite similar mean ACQ scores (1.5 versus 1.7), F(eNO) was reduced in smoking asthmatics (18.1 ppb versus 33.7 ppb). A decrease in F(eNO) of <20% precludes asthma control improvement in nonsmoking (negative predictive value (NPV) 78%) and in smoking patients (NPV 72%). An increase in F(eNO) <30% is unlikely to be associated with deterioration in asthma control in both groups of patients (NPV = 86% and 84% in nonsmoking and smoking patients, respectively). It is concluded that, even in smokers, sequential changes in F(eNO) have a relationship with asthma control. The present study is the first to indicate that cigarette smoking does not obviate the clinical value of measuring F(eNO) in asthma among smokers.

Exhaled nitric oxide and asthma control: a longitudinal study in unselected patients

Controlled studies have shown that monitoring of the exhaled nitric oxide fraction (F(eNO)) improves asthma management. However, the studies seldom consider the full range of patients seen in clinical practise. In the present study, the ability of F(eNO) to reflect asthma control over time is investigated in a regular clinical setting, and meaningful F(eNO) cut-off points and changes are identified. Answers to the Asthma Control Questionnaire and F(eNO) were recorded at least once in 341 unselected asthma patients. The whole population and subgroups were considered, i.e. both inhaled corticosteroid (ICS)-naïve and low or high-to-medium (</= or >500 mug beclomethasone dipropionate equivalents.day(-1)) ICS-dose groups. An F(eNO) decrease <40% or increase <30% precludes asthma control optimisation or deterioration, respectively (negative predictive value 79 and 82%, respectively). In the present study's low-dose group, a decrease >40% indicated asthma control optimisation (positive predictive value (PPV) 83%). In ICS-naïve patients, F(eNO) >35 ppb predicted asthma control improvement in response to ICS (PPV 68%). In most cases, forced expiratory volume in one second assessments were not useful. In conclusion, in a given patient, exhaled nitric oxide fraction was found to be significantly related to asthma control over time. The overall ability of exhaled nitric oxide fraction to reflect asthma control was reduced in patients using high doses of inhaled corticosteroids. Forced expiratory volume in one second had little additional value in assessing asthma control.

Paradoxical worsening of tuberculosis in a heart?lung transplant recipient

We report on a heart-lung transplant recipient who presented with pulmonary tuberculosis (TB) 2.5 months after transplantation and then developed a paradoxical reaction after 4 months of adequate anti-TB treatment. She eventually recovered with anti-TB and high-dose steroid treatments.

METHODS

Using sequential bronchoalveolar lavages, we assessed the inflammatory response in the lung and investigated the alveolar immune response against a Mycobacterium tuberculosis antigen.

RESULTS

The paradoxical reaction was characterized by a massive infiltration of the alveolar space by M. tuberculosis antigen-specific CD4(+) T cells and by the presence of a CD4(-)CD8(-) T lymphocyte subpopulation bearing phenotypic markers (CD16(+)/56(+)) classically associated with NK cells.

CONCLUSION

This case report illustrates that even solid organ transplant recipients receiving intense triple-drug immune suppression may be able to develop a paradoxical reaction during TB treatment. Transplant physicians should be aware of this phenomenon in order to differentiate it from treatment failure.

Beneficial effects of atorvastatin on sd LDL and LDL phenotype B in statin-naive patients and patients previously treated with simvastatin or pravastatin

BACKGROUND

The presence of increased levels of small dense (sd) LDL (phenotype B) is associated with a substantial increase of cardiovascular disease risk. Since lowering of plasma low-density lipoprotein-cholesterol (LDL-C) by statins involves an up-regulation of the LDL receptor, we questioned whether LDL lowering by atorvastatin affects different LDL subfractions equally.

METHODS

Fifty-four hypercholesterolemic patients, requiring treatment for prevention of coronary heart disease received atorvastatin (10, 20 or 40 mg/day), either as initial therapy (n=33), or as replacement therapy (n=21) for pravastatin or simvastatin (both at 40 mg/day). In addition to plasma lipid measurements, cholesterol LDL subfractions were separated and analysed before and after 3 months of treatment.

RESULTS

In addition to the expected LDL-C decrease (-34%; p<0.0001), a major reduction in sd LDL occurred after atorvastatin therapy (-38.2%; p<0.0001). Interestingly, sd LDL decreased as much in patients previously treated with other statins (-36%; p<0.002). A close correlation (r=0.89, p<0.001) was found between reduction of sd LDL and that of LDL-C, in patients with phenotype B. Although high-density lipoprotein-cholesterol (HDL-C) was not affected by atorvastatin treatment, plasma triglycerides decreased by 27.4% (p<0.0001). Only a weak correlation (r=0.35, p<0.01) was found between the reduction of plasma triglycerides and the decrease of sd LDL after atorvastatin treatment.

CONCLUSION

These results show that the reduction of LDL-C by atorvastatin largely reflects a lowering of sd LDL. Our data also suggest that triglyceride lowering plays only a partial role in sd LDL reduction.

Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome

OBJECTIVES

To evaluate an early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome (ACS).

METHODS

All consecutive patients admitted with a diagnosis of non-ST elevation ACS from June 2002 to February 2004 were enrolled in this registry. Clinical outcome was assessed at 30 days and in long term follow up.

RESULTS

An early invasive strategy was followed for 439 patients, of whom 159 (36%) were elderly and had a higher clinical risk profile and greater extent of coronary artery disease (CAD) than the younger patients. Coronary revascularisation was conducted in 133 (83%) elderly patients and 239 (85%) younger patients (not significant). At a mean (SD) follow up time of 10.7 (5.2) months overall mortality, cardiac death, and death plus myocardial infarction were significantly higher among elderly patients than among younger patients (9.4% v 2.1%, p < 0.001; 6.8% v 1.8%, p < 0.01; 11.3% v 5%, p = 0.02, respectively). The significant difference in cardiac death between the two groups was related more to elderly patients being treated by coronary artery bypass grafting (19.3% v 4.9%, p = 0.05) than by percutaneous coronary intervention (PCI) (2.9% v 1.1%, p = 0.3). Cox regression analysis showed age, serum creatinine > 115 micromol/l, no previous history of CAD, left ventricular ejection fraction > 45%, and the absence of diabetes to be independent predictors of the occurrence of major adverse cardiac events.

CONCLUSIONS

In unselected elderly patients presenting with non-ST elevation ACS an early invasive strategy is feasible and leads to coronary revascularisation in the majority of cases, resulting in encouraging immediate and long term clinical results, particularly among PCI treated patients.

[Cardiac magnetic resonance. Myth and reality]

The authors report their own experience and a review of the current literature in the field of cardiac MR (CMR). Latest technical improvements now allow obtaining both anatomical and functional imaging of the beating heart and great vessels in most pathological conditions. Established CMR indications such as cardiac tumors, pericardial diseases, operated congenital heart diseases, valvular diseases, arythmogenic right ventricular dysplasia, specific cardiomyopathies and great vessels of the thorax are reviewed and updated. Current applications in post myocardial infarction such as perfusion and viability imaging sequences are described. Moreover, CMR applications in syndrome X and myocarditis are evoked. Medical contra-indications and technical limitations of CMR are also discussed. Finally, the authors insist on the interest of a real partnership between radiologists and cardiologists for these procedures.

Otoplasty: anterior abrasion of ear cartilage with dermabrader

BACKGROUND

The international literature describes many different techniques for correcting prominent ears. Some of these techniques use weakening of the anterior surface in an "open or close" way. Others use suturing of the unfold antihelix. Still others suture the concha with mastoid, and some combine several of these procedures. There is thus no most widely accepted single method. Since 1993, the senior author has used the described technique on a group of 40 patients (35 bilateral and 5 monolateral cases). Before 1993, the senior author always used an "open" technique, but the anterior cartilage was weakened by the partial parallel incision procedure.

METHODS

In the current study, the surgical approach for cases with a normal or moderately deep concha consisted of open anterior otoplasty with cartilage abrasion by an electric burr alone. If the concha was severely hypertrophied, concha-mastoid suturing was combined with otoabrasion, as previously described.

RESULTS

The follow-up period was a minimum of 16 months and a maximum of 8 years. Complications were rare and rapidly resolved. The outcome was successful whether the burr alone or a combined method was used.

CONCLUSIONS

The authors believe that anterior abrasion of ear cartilage is a useful, simple technique that is not too time consuming by which an immediate postoperative aesthetic improvement is reached. It also is more precise and safe than the partial parallel incision procedure.

Mucocele-like tumour of the breast

Mucocele-like (ML) lesions of the breast are rare tumours and were reported as benign lesions that histologically resembled colloid carcinoma of the breast when first described about sixteen years ago. Only subsequent reports identified ML lesions associated with ductal hyperplasia or carcinoma. The Authors report an additional case of ML tumour of the breast and review the available medical literature. A young asymptomatic woman, without family history of breast cancer, presented with a palpable breast mass. As the radiological aspect was not typical of a simple cyst, the patient underwent a fine needle aspiration biopsy which showed a doubtful pathological pattern compatible with fibroadenoma. The patient underwent surgery and the gross examination of the surgically removed mass revealed multiple aggregated cysts containing mucinous material. Microscopic examination showed a ML tumour of the breast, with aspects of cribriform ductal hyperplasia.

Localized renal cell carcinoma of an unusually large size: case report

Renal cell carcinoma has a variable clinical course. Size is a prognostic factor correlated with venous invasion, lymph node or distant metastases. These are more often encountered when the size exceeds 10 cm. For 20 years, incidental renal tumours have represented the majority of diagnosed cases, as a result of more common use of imaging techniques. We report a case of renal cell carcinoma of an unusually large size, without metastatic or locally advanced disease. Histology revealed a pT2 clear cell renal cell carcinoma of 31 x 31 x 10 cm, which was totally resected. It is the first case reported of localized conventional renal cell carcinoma reaching such a size.

Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction

In case of soft-tissue injury to the distal third of the leg, a safe and effective repair technique should be adopted. The use of complex procedures such as free flaps and cross-leg flaps is not always advisable. The authors present two methods that have proved to be both reliable and effective in obtaining long-lasting satisfactory results: the reverse fasciosubcutaneous sural flap and the reverse fasciocutaneous island sural flap. Since 1992 the authors have operated on 25 patients affected by traumatic tissue loss of the distal third of the leg and the calcaneal region. They used the fasciosubcutaneous flap in 14 patients and the sural flap in 11. Both of these flaps are technically simple, safe, and effective, and cause minimal injury to the donor site. The sural flaps are more useful for moderate-size wounds, especially in the calcaneal region, whereas the fasciosubcutaneous flap is better for repairing larger lesions of the leg and the ankle.

Early effect of ultrarush venom immunotherapy on the IgG antibody response

BACKGROUND

We have previously shown in several allergy models that allergic and tolerance status with respect to allergens is associated with a somewhat different dominant specificity of IgG antibodies. The objective was to test this hypothesis in the compelling model of ultrarush venom immunotherapy (VIT), which induces clinical tolerance after only a few hours of treatment.

METHODS

Antibody titers and specificity were evaluated through solid-phase ELISA using streptavidin-biotin technology in 12 patients allergic to wasp venom before and during the ultrarush procedure (at 12 h, 24 h, and 15 days). The results were compared with those from another group of 20 patients treated with venom injections for at least 2 years.

RESULTS

No significant change was observed in IgG titers during the early phase of VIT. The capacity of individual sera to prevent the antigen binding of pooled IgG from allergic patients changed rapidly, with mean percentage inhibitions falling from 80+/-15%, before starting VIT, to 26+/-14%, 35+/-15%, and 34+/-5% after 12 h, 24 h, and 15 days of treatment, respectively (P<0.001 by one-way ANOVA). The capacity of individual sera to prevent the antigen binding of pooled IgG from patients receiving prolonged VIT changed, with mean percent inhibitions increasing from 47+/-8%, before starting VIT, to 76+/-7%, 83+/-6%, and 87+/-6% after 12 h, 24 h, and 15 days of treatment, respectively (P<0.001 by one-way ANOVA).

CONCLUSIONS

During the initial phase of ultrarush VIT, a change in IgG specificity, i.e., a change in the set of epitopes dominantly recognized by IgG on wasp-venom antigens, occurred concomitantly with early clinical tolerance and was already detectable a few hours after the onset of treatment. Although it may be an epiphenomenon, this change represents the earliest humoral modification described so far during this procedure. The mechanism is unknown, but it appears to be a selective depletion of the highest avidity antibody fraction by the venom injected in large doses at this stage of therapy. Finally, our data now show the previously documented association between a particular IgG specificity and the clinical status (allergy vs tolerance) to be true also with ultrarush VIT, a model in which the clinical ability to display allergic symptoms is rapidly reversed.

Absence of nitrate tolerance after long-term treatment with ramipril: an endothelium-dependent mechanism

To determine whether nitrate tolerance is attenuated on aortas isolated from rats treated in the long term with an angiotensin-converting enzyme (ACE) inhibitor, five groups of rats were studied in parallel. Group 1 received ramipril, 1 mg/ kg/day, p.o., for 6 weeks; group 2 received ramipril at the same dose for 4 weeks, and the last 2 weeks, a cotreatment with ramipril plus HOE 140 (a bradykinin B2 antagonist, 500 microg/ kg/day, s.c. injections); group 3 received losartan, 2 mg/kg/day, p.o., for 6 weeks; group 4 received losartan at the same dose, and the last 2 weeks, a cotreatment with losartan plus HOE 140; and group 5 served as control. Rings of thoracic aorta from these groups were studied in organ baths. After nitroglycerin preincubation (10 microM for 30 min) in vitro, the dose-response curves to nitroglycerin were significantly shifted to the right in the control group but not in group 1. This protective effect was partially present in group 3; it was completely abolished in groups 2 and 4. In groups 1 and 3, it also was abolished after nitric oxide synthase (cNOS) inhibition (L-NMMA incubation) or removal of the endothelium. Superoxide anion accumulation (assessed by lucigenin chemiluminescence) was increased by nitroglycerin incubation in the control group but not in groups 1 and 3. After in vivo exposure to nitroglycerin (50 mg/kg subcutaneously twice daily for 4 days), this protection against nitrate tolerance also was observed in groups 1 and 3. Thus long-term ACE inhibition prevents nitrate tolerance by an endothelium-dependent mechanism involving mainly an enhanced NO availability via B2-kinin receptor. This effect on the cNOS pathway seems to attenuate the superoxide anion accumulation induced by nitroglycerin exposure (probably via a downregulation of oxidative enzyme).

[Case of cardiac amyloidosis associated with IgG-K multiple myeloma in the framework of restrictive myocardiopathy]

Primary amyloidosis, due to amassing of fragments of light chains of IgG, often causes cardiac involvement. We describe a 65-year-old woman with multiple myeloma efficaciously treated with chemotherapy. Amyloidosis had been supported by myelic biopsy. The patient came to our observation because of right heart failure, hypotension and syncope: she was treated with a dopamine i.v. and was in cachectic status. She had a moderate pericardial effusion. ECG showed reduction of QRS amplitude, I degree atrioventricular block, posterior fascicular and right bundle branch block. Right cardiac catheterization showed a restrictive situation. After 1 week exitus occurred by asystole. In this case, there were other involvements by amyloidosis, besides the cardia one: that of autonomic nervous system and, probably, surrenal.

Modified antigenic reactivity of anti-phospholipase A2 IgG antibodies in patients allergic to bee venom: conversion with immunotherapy and relation to subclass expression

BACKGROUND

We have previously reported that, in addition to modifying IgG levels and subclass distributions, wasp venom immunotherapy (VIT) rapidly changes IgG antibody specificity.

OBJECTIVES

We investigated whether such a change can be documented in the IgG response to the major bee venom allergen, phospholipase A2 (PLA2), from patients allergic to bees treated with VIT; whether it is coupled to the shift in IgG subclass distribution (IgG4 predominance) usually observed during VIT; and whether it restores the specificity displayed by IgG antibodies from nonallergic individuals.

METHODS

Antibody specificity was evaluated in 17 patients allergic to bee venom in competitive ELISAs by using streptavidin biotin technology. Patients were tested before and during specific immunotherapy (at 15 days and 6 months) and compared with another group of 17 patients treated with venom injections for at least 2 years (VIT patients) and 30 healthy individuals.

RESULTS

The capacity of individual sera to prevent PLA2 binding of pooled IgG from allergic patients changed rapidly with mean percentage inhibitions falling from 84% +/- 14% before starting VIT to 27% +/- 13% and 28% +/- 7% after 15 days and 6 months of treatment, respectively (p < 0.001 by one-way analysis of variance [ANOVA]). IgG titers were only slightly increased. The capacity of individual sera to prevent the binding of pooled IgG from patients receiving VIT changed rapidly with mean percentage inhibition increasing from 60% +/- 12% before starting VIT to 85% +/- 6% and 82% +/- 6% after 15 days and 6 months of treatment, respectively (p < 0.001 by one-way ANOVA). Similar results were found regardless of whether pooled IgG1 or pooled IgG4 were used.

CONCLUSION

VIT results in a rapid change in the antigenic reactivity of anti-PLA2 IgG antibody of human allergic sera, restoring, although not completely, the specificity peculiar to lgG from healthy individuals. This suggests that allergic status and immunoprotection correlate with the preferential expression of distinct IgG specificities, which appear equally distributed over the IgG1 and IgG4 antibody subclasses. It is, however, not known whether the shift in IgG specificity is one of the operative mechanisms of VIT.

Color Doppler sonography

The authors report the results obtained with color Doppler sonography in the study of breast conditions. Color Doppler allows to detect the following main features in breast conditions: the presence of blood flow, vessel arrangement, vascularization extent, the number of vascular poles. To investigate slow flows, it is better to use low PRF values (not above 1 KHz) and low filters, while amplification should be set immediately above the system's noise threshold; the size of color Doppler box should be adjusted as small as possible to maximize sensitivity and minimize flash artifacts. In May 1992 to September 1997, 252 patients with solid breast masses were examined with mammography, B-mode, color Doppler and power Doppler sonography (only 57 cases). We identified histologically (176 cases) or cytologically (77 cases) 141 carcinomas and 112 benign solid lesions. The diameter of the 141 carcinomas ranged 0.4-4 cm (mean 1.7), while the diameter of benign lesions ranged 0.7-3 cm (mean 1.5). The malignancy pattern was characterized by hypervascularity (92.9%), irregular and abundant (54.2%) vascularization and more than one vascular pole. Benign lesions were avascular (43.4%) with poor and peripheral vascularity (90%) and mostly showed only one vascular pole. The avascular cancers (10 cases) were three mucoid, five in situ and two small (0.7 and 0.9 cm) invasive ductal carcinomas. The six benign lesions with irregular and abundant vascularization and more than one vascular pole were proved to be two proliferating and three juvenile fibroadenomas and one phylloid tumor. These results are encouraging and suggest that this technique can be a useful adjunct to mammography and sonography in the differential, diagnosis of breast nodules.

[Clinical course of hypertrophic cardiomyopathy in a non selected population. The Experience of the Italian Multicenter Cardiomyopathy Study]

BACKGROUND

Most of the information available on the clinical course and prognosis of hypertrophic cardiomyopathy (HCM) is based on data generated from international referral centres and as a result, it constitutes a potentially biased perspective of the disease process in this complex and diverse condition. A multicentric study was therefore set up with the aim of providing information on unselected patient populations with HCM.

METHODS

The study group comprised 330 patients from 5 non-referral hospitals (mean age 42 +/- 16 years, M/F 226/104, 74-22%-obstructive, 299-91%-in NYHA class I-II) who were followed up regularly for 9.5 +/- 5.6 years.

RESULTS

The vast majority of patients (n = 272, 82%) remained asymptomatic or mildly symptomatic during the follow-up period, whereas the remaining patients (n = 58, 18%) experienced clinical deterioration or died. Of the 18 patients (5%) who died of cardiovascular causes related to hypertrophic cardiomyopathy, 14 had progressive congestive heart failure and only 4 died suddenly. The annual mortality rate for cardiovascular disease was 0.57%, while the mortality rate due to sudden cardiac death was only 0.1%. The cumulative survival rate was 98, 95 and 93%, at 5, 10 and 15 years of follow-up respectively. Atrial fibrillation proved to be a relatively common (n = 81, 24%) and particularly unfavourable clinical feature, with higher mortality rate for cardiovascular causes related to hypertrophic cardiomyopathy. Syncope occurred in 47 patients (14%) but did not appear to have prognostic significance.

CONCLUSIONS

In an unselected population, hypertrophic cardiomyopathy had a relatively benign prognosis that was inconsistent with its prior characterization as a generally progressive disorder, based primarily on the experience of selected referral institutions. Sudden unexpected cardiac death was distinctly uncommon, although a sizable proportion of patients, particularly the subset prone to atrial fibrillation, did experience clinical deterioration.

[Nonpalpable lesions of the breast. Diagnostic potentials of the stereotaxic-guided radiogram]

PURPOSE

To investigate the diagnostic capabilities of the stereotaxic technique in characterizing suspicious mammographic findings for which stereotaxic FNAB is indicated.

METHOD

January, 1990, through December, 1992, 871 patients underwent stereotaxic mammograms preliminary to FNAB; in 12 of them (1.4%) mammography could rule out the malignant nature of the lesions, thus making FNAB useless.

MATERIAL

Stereotaxic images were acquired with a conventional mammographic unit (Senographe 500 or 600T CGR-GE). An average 34 months' mammographic follow-up confirmed the absence of malignancy in the above patients. The most common glandular structure in these patients was investigated, together with the type of nonpalpable lesions found on conventional mammograms (opacity, local distortion or scar, microcalcification without a mass) and the reasons why FNAB was unfeasible, or useless. In our patients FNAB was unfeasible mostly in fatty breasts (9/12), while lesion type was not relevant for screening. The lesions were 5/12 distortion, 5/12 small opacities and 2/12 clusters of small microcalcifications. In 9/12 patients FNAB was not performed because the image observed on conventional exams had disappeared, in 2/12 patients with microcalcifications because they were scattered on a large glandular area and in 1/12 patients because vascular sinuosity was diagnosed.

Il trattamento chirurgico delle ipospadie nelle differenti età evolutive. Parte 1a: Età infantile:Hypospadias treatment in different ages of development. Part 1: Infancy

The Authors describe their diagnostic protocol for hypospadias in childhood, including the evaluation of associated malformations and degree of intersexuality. Treatment usually consists of a single-stage operation, except for perineo-scrotal hypospadias, and must be performed before the child is two years old.

[Magnetic resonance versus traditional breast imaging in solid nodular diseases of the breast]

We report and compare the results obtained with conventional imaging (mammography and US) and MRI in the study of 46 solid nodular breast lesions verified with histologic, cytologic and/or instrumental follow-up examinations for 12-34 months. The variables we compared were relative to the identification, nature and size of the lesions. MRI, which was performed on the basis of previous mammographic and US findings, detected all the lesions but never modified the diagnosis of conventional imaging methods. Questionable MR diagnoses were fewer than mammographic and US ones (2 versus 11), but its role in correcting the questionable diagnoses of conventional imaging methods was controversial. Particularly, of 11 such cases on mammographic and US images, MRI made 8 correct diagnoses but exhibited 2 false positives and 1 false negative for carcinoma. Such MR mistakes are likely to be related to the non-use of contrast medium. As for size, US was more accurate than mammography and MRI; yet, very few misdiagnoses were make on the whole.

[Echography of the operated breast]

Aim of the present study is to evaluate the results of quadrantectomy by means of mammography and sonography (US). A hundred and thirty-five quadrantectomized patients bearing a carcinoma were investigated; 97 of them are now undergoing TCT. Mammographic examinations were performed with last-generation units; US studies employed high-frequency probes greater than or equal to 7.5 MHz. Ten relapses (7.4%) were observed, all of them around the scar: clinical examination correctly detected 3 cases, mammography 8, and US 6; the latter technique identified in 1 further case a pathologic finding which had not been previously assessed as a neoplastic lesion. Our results suggest that clinical examination has poor diagnostic value, while mammography has high value (8/10 cases), especially in detecting neoplastic microcalcifications (3/10 cases). The structural opacity of the breast caused 2/10 mammographic false negatives; US correctly detected 6/10 relapses, but failed to identify 3 microcalcifications. The combined use of the two techniques allowed the respective mistakes to be amended. US has proven to be especially useful not only to integrate mammography in the diagnosis of tumor recurrences, but also to study postoperative fluid collections, which are usually missed by mammography.

[Dynamic imaging with magnetic resonance in the diagnosis of breast disease]

MR imaging was employed for the identification and tissue characterization of nodular lesions in the breast. The study had poor outcome, but the clinical introduction of a paramagnetic contrast medium, Gd-DTPA, allowed better results to be obtained. This study was aimed at evaluating the possibilities of Gd-DTPA enhanced MRI in differentiating benign from malignant breast nodules and in staging cancer. Final diagnosis was made by means of either histology, in the patients who underwent surgery, or cytology. Sixty-one patients with nodules at mammography and US were examined with MRI. The results of US, mammography, and MRI were blindly evaluated and proved that combined mammography and US, together with Gd-DTPA enhanced MRI, correctly identified all nodular lesions. Moreover, enhanced MRI allowed benign lesions to be distinguished from malignant nodules. MRI with Gd-DTPA correctly assessed both T parameter and pectoral muscle infiltration. MRI cannot replace mammography, which is a quick and inexpensive examination, but it should be performed as an adjunct in the cases of questionable radiographic and US findings and to stage breast cancer.

[Two mammographic periods compared]

The authors report the results obtained in two different series of cases examined by means of mammography in 1968/74 and in 1987/89. All patients had histologically proven breast cancer. The first series of cases included 183 patients who were examined with a mammographic unit with fixed anode, 0.6 x 0.6 mm focal spot, and 25-40 cm FFD. The second series included 152 patients who were examined with a last-generation mammographic unit with turning anode, 0.3 x 0.3 mm focal spot, 50-65 cm FFD, and radiographic magnification. Lesion staging in the first group went as follows: 10% of patients were T1, and 90% were in more advanced stages; in the second series, 42% were T1 and 52% were in more advanced stages. Mammographic accuracy was 83% in the first series and 84.8% in the second series. The main mammographic features of the lesions and their incidence were analyzed. In 11 patients examined with a last-generation unit, breast cancer was diagnosed for the presence of indirect signs which had not been demonstrated with the older unit. In conclusion, last-generation mammographic units allow an earlier diagnosis to be made, and most signs of breast cancer to be promptly demonstrated.

[The clinical utility of stereotaxic x-ray guided cytological biopsy in nonpalpable neoplastic pathology of the breast]

The authors report the initial results of the combined use of stereotaxic X-rays and fine-needle aspiration biopsy in 83 patients with nonpalpable breast lesions. The stereotaxic system employed is a simple accessory of conventional mammographic equipment. Cytologic diagnosis (94 biopsies) had 90% sensitivity and 97% specificity; the percentage of acellular/insufficient cytologic samples was 10.8%. To assess the clinical value of this technique, the obtained results were compared with both mammographic findings and US-guided aspiration biopsy data.