Search

Synopsis: Maternal SARS-CoV-2 infection can present with or without symptoms at the time of birth. Symptomatic mothers are likely be associated with preterm births. However population studies, demonstrate a consistent association of SARS-CoV-2 infection and a reduction in preterm birth rate. Newborns with positive SARS-CoV-2 test results appeared to have minimal burden of illness that is directly associated with a viral infection. The reported incidence of positive neonatal SARS-CoV-2 PCR test ranges from 0.56 to 6.9%. Neonatal mortality directly related to SARSCoV-2 is extremely rare. Maternal vaccination in pregnant women leads to maternal antibody production and this can occur as early as 5 days after the first vaccination dose

Summary Background The risk of vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, which causes COVID-19), the most appropriate management, and the neonate's risk of developing COVID-19 during the perinatal period are unknown. Therefore, we aimed to elucidate best practices regarding infection control in mother–newborn dyads, and identify potential risk factors associated with transmission. Methods In this observational cohort study, we identified all neonates born between March 22 and May 17, 2020, at three New York Presbyterian Hospitals in New York City (NY, USA) to mothers positive for SARS-CoV-2 at delivery. Mothers could practice skin-to-skin care and breastfeed in the delivery room, but had to wear a surgical mask when near their neonate and practice proper hand hygiene before skin-to-skin contact, breastfeeding, and routine care. Unless medically required, neonates were kept in a closed Giraffe isolette in the same room as their mothers, and were held by mothers for feeding after appropriate hand hygiene, breast cleansing, and placement of a surgical mask. Neonates were tested for SARS-CoV-2 by use of real-time PCR on nasopharyngeal swabs taken at 24 h, 5–7 days, and 14 days of life, and were clinically evaluated by telemedicine at 1 month of age. We recorded demographics, neonatal, and maternal clinical presentation, as well as infection control practices in the hospital and at home. Findings Of 1481 deliveries, 116 (8%) mothers tested positive for SARS-CoV-2; 120 neonates were identified. All neonates were tested at 24 h of life and none were positive for SARS-CoV-2. 82 (68%) neonates completed follow-up at day 5–7 of life. Of the 82 neonates, 68 (83%) roomed in with the mothers. All mothers were allowed to breastfeed; at 5–7 days of life, 64 (78%) were still breastfeeding. 79 (96%) of 82 neonates had a repeat PCR at 5–7 days of life, which was negative in all; 72 (88%) neonates were also tested at 14 days of life and none were positive. None of the neonates had symptoms of COVID-19. Interpretation Our data suggest that perinatal transmission of COVID-19 is unlikely to occur if correct hygiene precautions are undertaken, and that allowing neonates to room in with their mothers and direct breastfeeding are safe procedures when paired with effective parental education of infant protective strategies. Funding None.

* Abbreviations: COVID-19 — : coronavirus disease 2019 CPAP — : continuous positive airway pressure DR — : delivery room PI — : premature infant PPE — : personal protective equipment PUI — : patient under investigation SARS-CoV-2 — : severe acute respiratory syndrome coronavirus 2 WBN — : well-baby nursery Since the initial report of a novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan in December 2019, there has been widespread dissemination of disease worldwide.1 The impact on the neonatal population has been reported almost exclusively from China.2–8 Our study goal is to characterize for the first time in the United States the delivery room (DR) management and early course of infants born to mothers positive for coronavirus disease 2019 (COVID-19) during 3 weeks at the peak of the pandemic in New York, New York, and to describe the challenges and approaches developed to meet these excessive needs. This is a prospective initiative of mothers admitted to labor and delivery, all of whom were tested, and is focused on those who tested positive for COVID-19 via SARS-CoV-2 polymerase chain reaction obtained from a nasopharyngeal swab only and their infants triaged to the well-baby nursery (WBN) or admitted to NICU at New York-Presbyterian Hospital Weill Cornell Medicine between March 22 and April 15th, 2020. A checklist developed during the process delineated DR … Address correspondence to Jeffrey Perlman, MB, ChB, Division of Newborn Medicine, Department of Pediatrics, 525 E 68th St, Suite N-506, New York, NY 10065. E-mail: jmp2007{at}med.cornell.edu

Objectives To describe the integration of home-based Medication Therapy Management (MTM) into the ambulatory care infrastructure of a large urban health system and to discuss the outcomes of this service. Setting Minnesota from September 2012 to December 2013. The health system has more than 50 primary care and specialty clinics. Eighteen credentialed MTM pharmacists are located in 16 different primary care and specialty settings, with the greatest number of pharmacists providing services in the internal medicine clinic. Practice innovation Home-based MTM was promoted throughout the clinics within the health system. Physicians, advanced practice providers, nurses, and pharmacists could refer patients to receive MTM in their homes. A home visit had the components of a clinic-based visit and was documented in the electronic health record (EHR); however, providing the service in the home allowed for a more direct assessment of environmental factors affecting medication use. Evaluation Number of home MTM referrals, reason for referral and type of referring provider, number and type of medication-related problems (MRPs). Results In the first 15 months, 74 home visits were provided to 53 patients. Sixty-six percent of the patients were referred from the Internal Medicine Clinic. Referrals were also received from the senior care, coordinated care, and psychiatry clinics. Approximately 50% of referrals were made by physicians. More referrals (23%) were made by pharmacists compared with advanced practice providers, who made 21% of referrals. The top 3 reasons for referral were: nonadherence, transportation barriers, and the need for medication reconciliation with a home care nurse. Patients had a median of 3 MRPs with the most common (40%) MRP related to compliance. Conclusion Home-based MTM is feasibly delivered within the ambulatory care infrastructure of a health system with sufficient provider engagement as demonstrated by referrals to the service.

Objective To study the backgrounds of women requesting hymen 'repair', to assess the effects of extensive counselling, and the effects of hymen reconstruction. Methods A two-centre qualitative study, consisting of a semi-structured interview, education, discussion of alternatives, and instructions for self-examination (first visit), educational examination (second visit), decision on operation or alternative (third visit), and follow-up (fourth visit). Results Eighty-two women were interviewed at first visit. Sixty-eight women were followed until their decision to be operated upon or not. Forty-eight percent of all subjects reported a history of sexual violence, and 37% had had one or more abortions. Only 29% eventually decided to be operated. Seventeen of the 19 women who submitted to an operation and attended the follow-up visit reported no blood loss at first marital intercourse. Conclusions Most women requesting hymen reconstruction had a history complicated by critical life events related to their request. All women were afraid they would not bleed and/or would not be 'tight' enough during the wedding night. For 75% of the women empowerment by means of extensive counselling resulted in a decision against operation. Hymenoplasty alone does not help women because most operated women will not bleed and because they often also have to prove to be 'tight' enough.

To address the frequency of identifying nonsolid nodules, diagnosing lung cancer manifesting as such nodules, and the long-term outcome after treatment in a prospective cohort, the International Early Lung Cancer Action Program.A total of 57,496 participants underwent baseline and subsequent annual repeat computed tomographic (CT) screenings according to an institutional review board, HIPAA-compliant protocol. Informed consent was obtained. The frequency of participants with nonsolid nodules, the course of the nodule at follow-up, and the resulting diagnoses of lung cancer, treatment, and outcome are given separately for baseline and annual repeat rounds of screening. The χ(2) statistic was used to compare percentages.A nonsolid nodule was identified in 2392 (4.2%) of 57,496 baseline screenings, and pathologic pursuit led to the diagnosis of 73 cases of adenocarcinoma. A new nonsolid nodule was identified in 485 (0.7%) of 64,677 annual repeat screenings, and 11 had a diagnosis of stage I adenocarcinoma; none were in nodules 15 mm or larger in diameter. Nonsolid nodules resolved or decreased more frequently in annual repeat than in baseline rounds (322 [66%] of 485 vs 628 [26%] of 2392, P.0001). Treatment of the cases of lung cancer was with lobectomy in 55, bilobectomy in two, sublobar resection in 26, and radiation therapy in one. Median time to treatment was 19 months (interquartile range [IQR], 6-41 months). A solid component had developed in 22 cases prior to treatment (median transition time from nonsolid to part-solid, 25 months). The lung cancer-survival rate was 100% with median follow-up since diagnosis of 78 months (IQR, 45-122 months).Nonsolid nodules of any size can be safely followed with CT at 12-month intervals to assess transition to part-solid. Surgery was 100% curative in all cases, regardless of the time to treatment.

We report our experience with a 9-month-old infant treated with intravenous polymyxin B for multidrug-resistant Klebsiella pneumoniae bacteremia. Serial blood samples were obtained at steady state and serum drug concentrations were determined using a validated liquid chromatography-mass spectrometry method. The elimination half-lives of polymyxin B1 and isoleucine-polymyxin B1 were found to be 3.1 and 4.7 hours, respectively.

Takayasu arteritis (TA) is a large-vessel vasculitis, most commonly presenting in young adults and more rarely in pediatric patients. An apparent association between TA and Mycobacterium tuberculosis has been noted previously, although this potential relationship is not yet understood. We present the case of a 16-year-old Haitian girl diagnosed with TA, originally presenting in the context of active tuberculosis. Our patient has been treated with antituberculosis therapy, corticosteroids, methotrexate, and rituximab to control her continued active vasculitis. With this case report, we seek to promote further exploration of the apparent association between TA and tuberculosis, as further clarification of the nature of this relationship may lead to the development of more targeted therapies and better outcomes for TA patients.

We describe in detail the current trend using monoclonal antibodies to diagnose ovarian cancer either in vitro or in vivo. The approach with such powerful reagents allows to differentiate in vitro tumor histotypes and to detect in peritoneal washings the presence of a few neoplastic cells which characterize the minimal disease. The detection of elevated sera levels of ovarian cancer-associated antigens, such as CA-125 and TAG-72, allows the monitoring, follow-up of these patients and the response to therapy with great accuracy. We focused our attention on the role in vivo of labelled monoclonal antibodies, mainly for diagnostic purposes. Radioimmunoscintigraphy has been found to be more reliable than CT and US to detect foci of disease mainly in patients already treated by surgery, overcoming all the problems usually encountered with these two procedures.

Mycoplasma pneumoniae is one of the causative agents of atypical community-acquired pneumonia. Tigecycline belongs to a new class of glycylcycline antimicrobials that have activity against a wide range of microorganisms, including in vitro activity against M. pneumoniae . We investigated the effect of tigecycline on microbiologic, histologic, and immunologic indices in a murine model of M. pneumoniae pneumonia. BALB/c mice were inoculated intranasally with M. pneumoniae and treated subcutaneously with tigecycline or placebo for 6 days. Outcome variables included quantitative bronchoalveolar lavage (BAL) M. pneumoniae culture, lung histopathologic score (HPS), BAL cytokine and chemokine concentrations (tumor necrosis factor alpha [TNF-α], gamma interferon [IFN-γ], interleukin 1β [IL-1β], IL-2, IL-4, IL-5, IL-6, IL-10, IL-12 [p40/p70], granulocyte-macrophage colony-stimulating factor, MIP-1α, MIG, KC, MCP-1, and IP-10). BAL M. pneumoniae concentrations in mice treated with tigecycline (MpTige) tended to be reduced compared with mice treated with placebo (MpPl); however this did not reach statistical significance. The lung HPS was significantly lower, as well as the parenchymal-pneumonia subscore, in the MpTige mice than in the MpPl mice. MpTige mice had significantly lower BAL cytokine concentrations of IL-1β, IL-12 (p40/p70), IFN-γ, and TNF-α; of the chemokines, MIG, MIP-1α, and IP-10 were statistically lower in MpTige mice. While tigecycline treatment demonstrated a modest microbiologic effect, it significantly improved lung histologic inflammation and reduced pulmonary cytokines and chemokines.

UNLABELLED Alternative antimicrobial regimens are needed for treatment of methicillin-resistant Staphylococcus aureus (MRSA)-associated pulmonary exacerbations in children with cystic fibrosis (CF). There are no published pharmacokinetic (PK) and pharmacodynamic (PD) data for linezolid in children with CF. OBJECTIVES (1) To determine the PK and PD profile of linezolid among children with CF; (2) to characterize the effect of linezolid on MRSA infection; (3) to determine the effect of age and CF transmembrane regulator (CFTR) gene mutations on drug clearance. HYPOTHESES Linezolid clearance is enhanced in children with CF requiring a higher dosage regimen. Age and CFTR gene mutations affect drug clearance. METHODS This was a retrospective cohort study; medical records of children with MRSA-associated pulmonary exacerbations treated with linezolid (10 mg/kg/dose IV every 8h) were reviewed. Linezolid peak and trough concentrations in serum were determined by high performance liquid chromatography, PK profiles determined using standard noncompartmental method, and PD indices were evaluated. RESULTS 10 children (mean +/- SD, 10.2 +/- 5.5 years) received 14 courses of linezolid at 10 +/- 0.4 mg/kg/dose every 8h for 15.4 +/- 3.2 days. Seven had homozygous DeltaF508 CFTR mutation. Peak and trough linezolid concentrations varied widely (range, 8.4-20.5 and 0.1-11.5 mcg/mL respectively). The PK profile of children or=10 years). The PK indices of children with homozygous DeltaF508 differed marginally from those with heterozygous CFTR mutations, but there were too few subjects to allow separation of age and CFTR mutations effect. No patient achieved the target PD ratio of AUC/MIC >80. MRSA persisted in sputum or throat culture after treatment with linezolid. CONCLUSIONS Additional PK and PD data are needed to optimize linezolid therapy in children with cystic fibrosis; it is likely that higher doses will be needed.

Free radicals have been found in high concentrations within inflammatory multiple sclerosis (MS) lesions. The superoxide anion (O2–) reacts rapidly with nitric oxide (NO), producing peroxynitrite (ONOO–). Glatiramer acetate (GA) is a specific MS immunomodulator that induces the synthesis of Th2 cytokines, and reduces the frequency of relapses and the formation of active brain lesions. Proinflammatory cytokines could play a role in free radicals production in the peripheral immune system as well as in the central nervous system (CNS). The effect of GA on iNOS, superoxide radicals (O2–) and 3-nitrotyrosine production by peripheral blood adherent mononuclear cells (PBAMs) was assessed. Our findings demonstrate that in vitro GA reduced spontaneous and LPS-induced iNOS, 3-nitrotyrosine, NO and O2–production, and that similar inhibition can be demonstrated ex vivo in mononuclear cells obtained from GA-treated patients. The inhibition of the production of free radicals in PBAMs may represent a new therapeutic mechanism against inflammation during MS.

Three women aged 17, 12 and 13 years presented with intermittent abdominal pain. Secondary sexual characteristics, i.e. mammae and pubic hair, were developed, but menarche had not occurred. All were found to have imperforate hymen. After incision, the symptoms disappeared. Imperforate hymen causes clinical symptoms from the time of menarche. Pubertal girls presenting with abdominal symptoms must be examined, including observation of secondary sexual characteristics and inspection of the external genitalia. This examination is often omitted because the patient and the physician are embarrassed. However, it is essential and should be carried out in a considerate manner. Excision of the hymen must be performed under general anaesthesia using a technique that will prevent secondary stenosis.

Mycoplasma pneumoniaeis a leading cause of pneumonia and is associated with asthma. Evidence linksM. pneumoniaerespiratory disease severity with interleukin-12 (IL-12) concentrations in respiratory secretions. We evaluated the effects of IL-12 therapy on microbiologic, inflammatory, and pulmonary function indices ofM. pneumoniaepneumonia in mice. BALB/c mice were inoculated withM. pneumoniaeor SP4 broth. Mice were treated with intranasal IL-12 or placebo daily for 8 days, starting on day 1 after inoculation. Mice were evaluated at baseline and on days 1, 3, 6, and 8 after therapy. Outcome variables included quantitative bronchoalveolar lavage (BAL)M. pneumoniaeculture, lung histopathologic score (HPS), BAL cytokine concentrations determined by enzyme-linked immunosorbent assay (tumor necrosis factor alpha [TNF-α], gamma interferon [IFN-γ], IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, and granulocyte-macrophage colony-stimulating factor), and plethysmography, both before and after methacholine treatment.M. pneumoniae-infected mice treated with IL-12 (MpIL12 mice) were found to have significantly higher BALM. pneumoniaeconcentrations than those ofM. pneumoniae-infected mice treated with placebo (MpP mice) (P< 0.001). MpIL12 mice had higher BAL concentrations of IL-12, IFN-γ, TNF-α, and IL-6, with differences in IL-12 and IFN-γ concentrations reaching statistical significance (P< 0.001). Airway obstruction was statistically elevated in MpIL12 mice compared to that in MpP mice (P= 0.048), while airway hyperreactivity was also elevated in MpIL12 mice but did not reach statistical significance (P= 0.081). Lung parenchymal pneumonia subscores were significantly higher in MpIL12 mice (P< 0.001), but no difference was found for overall HPS, even though a strong trend was noticed (P= 0.051). Treatment of experimentalM. pneumoniaepneumonia with intranasal IL-12 was associated with more severe pulmonary disease and less rapid microbiologic and histological resolution.

AIM: The aim of this study is to evaluate the accuracy of multidetector row CT angiography (MDCTA) of the abdominal aorta and lower extremities arteries in patients with peripheral arterial occlusive disease who did not receive any prior treatment whether interventional or surgical. METHODS: Twenty-two patients with peripheral vascular occlusive disease (16 male, 6 female, age range 44-85 years) underwent MDCTA of the abdominal aorta and lower extremities. Digital subtraction angiography (DSA) of the same districts was performed within 3 months. Images were blindly interpreted by 2 interventional radiologists and compared with the results of digital subtraction angiography. RESULTS: Sensitivity and specificity of MDCTA were 92% and 94%, respectively, with positive and negative predictive values of 93% and 95%. Overall diagnostic accuracy was 93%. Normal arterial segments and 100% occlusions were correctly identified in all cases by MDCTA. Moderately stenotic segments interpretation in the calves appeared to be more controversial, but no statistical difference in accuracy in this district was noted with respect to accuracy in more proximal arteries. CONCLUSION: MDCTA of the abdominal aorta and lower extremities is a feasible, accurate imaging modality in clinical practice when compared to DSA

We examined 1020 dry clavicles from cadavers of Italian origin to determine the prevalence of the coracoclavicular joint (ccj), a diarthrotic synovial joint occasionally present between the conoid tubercle of the clavicle and the superior surface of the horizontal part of the coracoid process. Five hundred and nine clavicles from individuals of different ages were submitted to X-ray examination. Using radiography, we measured the entire length and the index of sinuosity of the anterior lateral curve, on which the distance between the conoid tubercle and the coracoid process depends. We also used radiography to record the differences in prevalence of arthritis in two neighbouring joints, the acromioclavicular and sternoclavicular joints. Of the 1020 clavicles, eight (0.8%) displayed the articular facet of the ccj. No statistical correlation was found between clavicular length and the index of sinuosity of the anterior lateral curve. The prevalence of arthritis in clavicles with ccj was higher than that revealed in clavicles without ccj. The prevalence of ccj in the studied clavicles is lower than that observed in Asian cohorts. Furthermore, ccj is not conditioned by either length or sinuosity of the anterior lateral curve of the clavicle. Finally, the assumption that ccj is a predisposing factor for degenerative changes of neighbouring joints is statistically justified.

Adult GH deficiency (GHD) is associated with increased cardiovascular morbidity and mortality due to unfavorable lipid profile, hyperfibrinogenemia, and impairment of cardiac performance. This prospective controlled cohort study evaluated the effects of 12-month GH replacement on lipid profile, fibrinogen levels, cardiac mass by echocardiography, and performance by equilibrium radionuclide angiography. To this end we studied 20 patients (11 men and 9 women, aged 19-40 yr), 10 with childhood-onset (co-) and 10 with adult-onset (ao-) disease, and 20 sex- and age-matched healthy subjects. At study entry, insulin-like growth factor I (IGF-I; P0.0001) and high density lipoprotein (HDL) cholesterol (P0.0001) levels, left ventricular mass index (LVMi; P0.0001), ejection fraction (LVEF) at rest (P = 0.001) and at peak exercise (P0.0001), peak ejection rate (P = 0.005), and exercise duration (P0.0001) and capacity (P = 0.002) were lower, whereas total cholesterol (P = 0.02), triglycerides (P = 0.003), and fibrinogen (P = 0.005) levels were higher in patients than in controls. After 12 months, increases in IGF-I (P0.0001) and HDL cholesterol levels (P = 0.04), LVMi (P0.0001), LVEF at peak exercise (P0.0001), and exercise duration (P = 0.009) and capacity (P = 0.003) and decreases in total cholesterol (P0.0001), low density lipoprotein cholesterol (P0.0001), triglycerides (P0.0001), and fibrinogen (P = 0.01) levels were found in all patients, without any difference between co- and ao-GHD. At the end of treatment, however, total cholesterol, triglycerides, and fibrinogen levels were still higher, and HDL cholesterol levels, IGF-I levels, and LVEF at rest and at peak exercise were lower in patients than in controls. In conclusion, GH replacement for 12 months significantly improved lipid profile, decreased fibrinogen levels, and increased LVMi and LVEF in young adults with co- or ao-GHD. However, lipid profile, fibrinogen levels, and systolic function remained abnormal compared with those in age- and sex-matched controls, suggesting that a longer period of GH replacement is necessary to normalize cardiovascular parameters and reverse the cardiovascular risk of these patients.

Cardiac structure and function are affected both by acromegaly and hyperthyroidism. Whereas the former is mainly characterized by ventricular hypertrophy as well as diastolic and systolic impairment, the latter frequently leads to increased heart rate and enhancement of contractility and cardiac output. To further investigate this issue, we designed this two-arm study. In the first cross-sectional study, we compared echocardiography and radionuclide angiography results obtained in eight hyperthyroid acromegalic patients, eight hyperthyroid nonacromegalic patients, and eight healthy subjects. All acromegalic patients were receiving treatment for acromegaly at the onset of hyperthyroidism. In the second longitudinal study, performed in the group of acromegalic patients, we compared the cardiovascular results obtained during hyperthyroidism with the retrospective data obtained at the initial diagnosis of acromegaly and after 1-yr treatment for this disease and those prospective data obtained during the remission of hyperthyroidism. In the cross-sectional study, hyperthyroid acromegalic patients showed an increase in the left ventricular (LV) mass index (LVMi) compared to healthy and hyperthyroid controls (P0.05), with evidence of LVMi hypertrophy in five of them (62.5%). A significant correlation was found between LVMi and GH levels (r = 0.785; P0.05). The LV ejection fraction (LVEF) at rest was higher in the control hyperthyroid population than in healthy controls (P0.05), whereas the LVEF response to exercise was reduced in acromegalic patients (P0.05 vs. healthy controls). In acromegalics, the exercise-induced change in LVEF was significantly reduced compared to that in healthy controls (P0.001), but not to that in hyperthyroid controls (P0.07), being abnormal (5% increase vs. baseline values) in six patients. Four of these six patients (66%) had elevated GH and insulin-like growth factor I levels during the treatment of acromegaly. An inverse correlation between GH and LVEF at rest (r = -0.896;P0.05) and at peak exercise (r = -0.950; P0.001) was recorded. The peak filling rate was reduced in hyperthyroid acromegalic patients compared to those in both control populations (P0.05). In the longitudinal study, acromegalic patients showed an increased LVMi during hyperthyroidism compared to that observed after successful treatment of acromegaly (P0.05); resting LVEF was increased compared to both basal (P0.001) and posttreatment values (P0.05). However, the exercise-induced change in LVEF was reduced (P0.05 vs. previous follow-up values). Remission of hyperthyroidism led to significant reduction of LVMi (P0.05) and resting LVEF (P0.05) and an increase in exercise-induced LVEF (P0.05). In light of these findings, hyperthyroidism produces a detrimental effect on the cardiovascular system of acromegalic patients, particularly in those with uncontrolled disease. Thus, control of GH and insulin-like growth factor I should be a major objective, as cardiovascular risk persists in patients with ineffective hormonal suppression, and constant endocrine and cardiovascular surveillance remain crucial steps in patient follow-up.

The asynchrony of the left ventricle--i.e., its nonuniform contraction and relaxation--is an important factor for left ventricular function. Heart failure is often related to abnormal systolic function, sometimes associated with a diastolic dysfunction. We studied the relationship of left ventricular asynchrony to left ventricular function in patients with nonischemic heart failure.Radionuclide angiography at rest was performed in 25 patients with nonischemic heart failure and in 26 age and sex matched normal subjects. In addition to ejection fraction and peak filling rate, two indices of left ventricular asynchrony were calculated: the coefficient of variation of regional time to end systole and the coefficient of variation of regional time to peak filling rate. These factors indicate how disperse are the regional values of time to end systole and of time to peak filling rate. In fact, the higher the value, the greater the asynchrony.A significant (r = .46, p.05) inverse correlation was found between the ejection fraction and the coefficient of variation of regional time to end systole in both the normal subjects and the heart failure patients, while the ejection fraction correlated significantly (r = .46, p.05) with the coefficient of variation of regional time to peak filling rate only in the patients. Moreover, the peak filling rate was inversely correlated (r = .57, p.05) with the coefficient of variation of regional time to peak filling rate in the heart failure patients but not in the normal subjects.These results suggest that left ventricular systolic and diastolic asynchrony may contribute to impair left ventricular systolic and diastolic function in patients with nonischemic heart failure.

Magnetic Resonance Imaging (MRI) has been proposed as the diagnostic technique of choice to characterize adrenal tumors. However, the results of the current studies are controversial.Forty-nine patients with unilateral adrenal masses were submitted to MRI for lesion characterization on the basis of MR signal intensity. Cytology and/or histology demonstrated 14 pheochromocytomas (pheos), 11 adenomas, 3 cysts, 2 myelolipomas, 4 carcinomas, 3 metastases and 1 fibrosarcoma; a clinical diagnosis of adenoma was made in the remaining 11 patients. MR studies were performed using spin-echo (SE) sequences with T1 (TR/TE = 600/17 ms) and T2 (TR/TE = 2000/15-90 ms) weighting. T1-weighted images were also acquired after Gadolinium-DTPA (Gd-DTPA) administration. MR studies were integrated with in- and out-of-phase (TR/TE = 100/4-6 ms) chemical-shift (CS) sequences. MR signal intensity (SI) was analyzed qualitatively and quantitatively; MR results were correlated with tumor type and hormone secretion.The qualitative analysis of T2 images showed high signal intensity in the majority (80%) of adrenal lesions (14 pheos, 12 adenomas, 3 cysts, 2 myelolipomas and 8 malignancies). The quantitative analysis of post-Gd-DTPA T1 images permitted to distinguish adenomas, cysts and myelolipomas from pheos and malignancies. The qualitative analysis of post-Gd-DTPA T2 and T1 images permitted to distinguish pheos and cysts from adenomas and malignancies (p.05); however, pheos and cysts as well as adenomas and malignancies were not differentiated. MR SI was similar in secreting and nonsecreting adenomas from both a qualitative and a quantitative viewpoints. CS MRI permitted to distinguish adenomas (decreased signal intensity on out-phase relative to in-phase images) from other benign and malignant lesions (no signal change from out-phase to in-phase images).The qualitative analysis of MR SI on conventional T1 and T2 images does not permit to differentiate adrenal masses. The qualitative evaluation of T1 images after Gd-DTPA administration, the quantitative analysis and CS sequences are technical options improving lesion characterization.

BACKGROUND: Osteoporosis is common in patients with Cushing's disease and is likely due to an imbalance between bone formation and resorption. Alendronate is an aminobisphosphonate that is able to increase bone mass mainly by inhibiting bone resorption. OBJECTIVE: We have evaluated the effect of chronic treatment with alendronate on bone mineral density (BMD) in patients with Cushing's disease. PATIENTS: 39 patients with Cushing's disease entered this study. 39 age-, sex- and BMI-matched normals served as controls for baseline evaluation. The 39 patients were divided into four groups: 1) 10 patients with active disease treated with alendronate and ketoconazole; 2) 11 patients with inactive disease treated with alendronate; 3) 8 patients with active disease treated with ketoconazole alone, 4) 10 patients with inactive disease received no treatment. TREATMENT PROTOCOL: Alendronate was given for 12 months in a dose of 10 mg orally once daily after fasting at 0800 h in the morning. Ketoconazole was given in a dose of 200-600 mg orally daily, when pituitary surgery was unsuccessful. STUDY DESIGN: Lumbar spine (L1-L4) and femoral neck BMD, serum osteocalcin (OC), urinary cross-linked N-telopeptides of type I collagen (Ntx) levels were evaluated at study entry, in patients and controls, and were repeated after 6 and 12 months in the 39 patients. RESULTS: BMD values were lower in patients with Cushing's disease than in controls at both L1-L4 (0.72 +/- 0.4 vs. 1.01 +/- 0.6 g/cm2, P < 0.05) and femoral neck (0.69 +/- 0.3 vs. 0.96 +/- 0.6 g/cm2, P < 0.05). In the 39 patients with Cushing's disease considered as a whole, serum OC levels were lower (1.1 +/- 0.1 vs 1.5 +/- 0.1 nmol/l, P < 0.01), while Ntx values were higher than in controls (168 +/- 25 vs. 61 +/- 31 nmol BCE/mmol creatinine, P < 0.01). In the alendronate-treated groups, serum OC levels increased, while Ntx levels significantly decreased after 6 and 12 months of treatment without any significant difference between the two groups. BMD values measured at L1-L4 and femoral neck significantly increased after 12 months of therapy. In patients of group 4, a significant increase of serum OC levels and a significant decrease of Ntx levels were observed together with a slight increase of BMD values after 12 months. No significant change in either biochemical markers or BMD values was found in patients of group 3. CONCLUSIONS: Patients with Cushing's disease have osteoporosis which needs to be rapidly reversed to limit the risk of fracture. The results of the present study show that a 12 month treatment period with alendronate induced an improvement in bone mineral density greater than in untreated patients.

It is still unclear whether in patients with chronic coronary artery disease (CAD) the improvements in myocardial perfusion and left ventricular (LV) function induced by revascularization persist in the long run. This study was planned to evaluate the 1-yr effects of successful revascularization on myocardial perfusion and LV function in patients with CAD and to assess the accuracy of thallium imaging in the prediction of functional recovery 1 yr after revascularization.Thirty-eight patients with chronic CAD who were revascularized (experimental group) underwent, while off drugs, 201Tl tomography, two-dimensional echocardiography and radionuclide angiography before and after a 1-yr follow-up. Twenty-nine patients with similar characteristics who were not revascularized (control group) and completed the 1-yr follow-up were also studied. Regional thallium activity was quantitatively measured in 13 segments per patient. Systolic function was assessed by echocardiography in corresponding segments.In the experimental group, at baseline, on the basis of regional LV function and thallium uptake, 276 segments were normal, 169 dysfunctional-viable and 49 nonviable. After revascularization, the majority (75%) of the dysfunctional-viable segments at baseline showed functional recovery at follow-up, whereas the majority (81%) of the nonviable segments at baseline did not. Simultaneously, LV ejection fraction increased 4 wk after revascularization (from 39% +/- 9% to 42% +/- 10%, p0.01) and remained unchanged after 1-yr (43% +/- 8%, p0.01 versus baseline study). LV wall-motion score index after 1 yr was reduced (from 1.68 +/- 0.4 to 1.42 +/- 0.3, p0.001) as compared with baseline. On the contrary, in the control group, no change in myocardial perfusion and LV function was detected after the 1-yr follow-up.In patients with chronic CAD, successful coronary revascularization induces a stable improvement in myocardial perfusion and LV function, which is still detectable after a 1-yr follow-up. Furthermore, preserved thallium uptake in dysfunctional regions is predictive of functional recovery after revascularization.

Functional assembly of the plasminogen-dependent proteolytic system on the cell surface requires multiple interactions involving urokinase (uPA), urokinase receptor (uPAR), plasminogen activator inhibitors, and other molecules that mediate cell migration and adhesion. We analyzed the in vitro interaction of uPAR-containing particulate cell fractions with the amino-terminal fragment (ATF) of human urokinase and the matrix-like form of vitronectin. Binding and cross-linking of 125I-labeled ATF to crude membrane extracts from LB6-19 mouse cells overexpressing human uPARs in the presence of 25 nM urea-denatured vitronectin led to the formation of Mr 137,000, 92, 000, and 82,000 covalent complexes. Immunoprecipitation of the preformed cross-linked 125I-labeled complexes with anti-vitronectin, anti-uPA, or anti-uPAR antibodies revealed that the Mr 82,000 and 92, 000 species do contain ATF and vitronectin and identified the Mr 137, 000 species as a ternary complex formed by ATF, uPAR, and vitronectin. A similar electrophoretic pattern was displayed by acid-pretreated membranes extracted from MCF-7 breast carcinoma or HT1080 fibrosarcoma cell lines, as well as a ductal breast carcinoma specimen; the latter exhibited complex formation at concentrations of vitronectin lower than 10 nM. Finally, uPAR-vitronectin interaction was further documented by the decreased reactivity of an anti-uPAR polyclonal antibody to acid-pretreated sections of 10 breast carcinomas that had been preincubated with vitronectin. Our findings highlight the ability of uPAR to interact simultaneously with vitronectin and uPA in breast cancer, supporting a dynamic coupling of the molecular mechanisms underlying plasminogen-dependent matrix degradation and cell adhesion.

Forty infants with suspected gastroesophageal reflux (GOR) underwent continuous 24 hour esophageal pH-metry and sonography of the gastroesophageal junction. In 29 out of 40 cases (72.5%) GOR was confirmed by the 24 hour pH-monitoring, because of a percentage of total time of reflux of 10% or more. The positive and negative predictive value of sonography versus the result of continuous 24 hour pH-monitoring was 80% and 50% respectively. Sonography cannot be considered a faithful diagnostic tool in screening for GOR in infants.

The aim of this study was to assess changes in left ventricular (LV) function during 6-min walk test and cardiopulmonary exercise by continuous radionuclide monitoring in patients with congestive heart failure (CHF).Seventeen patients with CHF and 10 normal subjects underwent monitoring of LV function (Vest) during 6-min walk test and during bicycle exercise with combined analysis of pulmonary gas exchange. During cardiopulmonary exercise, all parameters of LV function were measured at rest, at the anaerobic threshold (AT) and at peak oxygen uptake (peak VO2).In the normal subjects, during the walk test, heart rate (HR), ejection fraction (EF), end-diastolic volume (EDV), cardiac output (CO) and stroke volume (SV) significantly increased from rest to peak (all p0.001), while end-systolic volume (ESV) significantly decreased from rest to peak (p0.001). In patients with CHF, during the walk test, HR, EDV, ESV and CO significantly increased from rest to peak (p0.001), EF significantly decreased from rest to peak (p0.001) and SV did not show significant change. During cardiopulmonary exercise, normal subjects showed a significant increase in HR and CO, from rest to AT and from AT to the peak VO2 (p0.001). EF, EDV and SV significantly increased from rest to AT (p0.001), with no significant change from AT to peak VO2. ESV decreased from rest to AT (p0.001), showing no significant change from AT to peak VO2. In patients with CHF, HR, CO, ESV and EDV increased significantly from rest to AT (p0.001) and from AT to peak VO2 (p0.001). EF and SV did not show significant changes from rest to AT, showing a significant decrease from AT to peak VO2 (p0.001).Vest can be used to evaluate cardiac responses during 6-min walk test and cardiopulmonary exercise in patients with CHF. In such patients, significant impairment of LV function is already present during submaximal physical exercise becoming more evident during the anaerobic phases of bicycle exercise.

Resting 99mTc-MIBI cardiac imaging may be poorly accurate in identifying the presence of viable myocardium in patients with chronic coronary artery disease (CAD). In this study, we directly compared the results of resting 99mTc-MIBI SPECT with initial (1 hr) and delayed (5 hrs) images with those of 99mTc-MIBI SPECT after nitroglycerine (NTG) administration in 31 patients with chronic CAD. All patients also underwent rest-redistribution thallium-201 (201Tl) SPECT. In 8 patients, echocardiography was performed before and after coronary revascularization (Rev). Of 682 myocardial segments, 197 showed a marked reduction (50% of peak) in MIBI uptake on initial images. MIBI uptake (or = 10%) was increased in 47 (24%) segments on delayed images (from 43 +/- 8% to 60 +/- 8%, p0.001) and in 54 (27%) segments after NTG (from 42 +/- 8% to 60 +/- 8%, p0.001). The results of delayed and NTG MIBI images were in agreement in most segments (n = 160, 81%). The results of delayed and NTG MIBI images were in disagreement in the remaining 37 (19%) segments. In particular, 15 segments showed reversible defects on delayed, but not on NTG MIBI images, while 22 on NTG, but not on delayed MIBI images. All the segments with reversible MIBI defects on delayed and/or NTG images were identified as viable on TI-201. In the 8 pts examined before and after Rev. 83% of segments with reversible MIBI defects on delayed images and 87% of those with reversible defects after NTG showed functional recovery after Rev; furthermore, in these patients a significant improvement in global left ventricular function was observed after Rev, as shown by ejection fraction values (from 42 +/- 7% to 47 +/- 7%, p0.01). These comparative results show that resting delayed and NTG MIBI imaging provide similar information to identify viable myocardium and to predict functional recovery after coronary Rev in chronic CAD.

The aim of this study was to investigate the accuracy of quantitative one-day exercise-rest 99mTc tetrofosmin tomography in the identification of patients with suspected coronary artery disease (CAD) and in the detection of single stenosed coronary vessels. Sixty-one patients with suspected CAD and submitted to coronary angiography were examined. All patients were given 2 i.v. injections of 99mTc tetrofosmin, one at peak exercise (370 MBq) and the other (1110 MBq) at rest 3 hours after exercise (images 15-30 min after injection for both studies). All patients with CAD (or = 50% luminal stenosis) (n = 50) had abnormal 99mTc tetrofosmin tomogram (100% sensitivity). Only one patient without CAD had abnormal 99mTc tetrofosmin tomogram (91% specificity). Overall sensitivity, specificity, and diagnostic accuracy in the detection of single stenosed vessels were 77%, 93% and 85%, respectively. No significant differences among single vascular areas were observed. Sensitivity and diagnostic accuracy in the identification of single stenosed coronary vessels were significantly higher (p0.05) in the patients with single-vessel disease (n = 21) than in those with multivessel disease (n = 29). Sensitivity, specificity and diagnostic accuracy in detecting single diseased vessels were similar in the patients without (n = 26) and in those with previous myocardial infarction (n = 35). The results of this study demonstrate that quantitative one-day exercise-rest 99mTc tetrofosmin SPECT imaging is a suitable and accurate technique to identify patients with suspected CAD and to detect single stenosed coronary vessels.

The purpose of this study was to evaluate whether an additional redistribution image after a rest 99mTc-MIBI injection enhances detection of viable myocardium and predicts functional recovery after coronary revascularization in patients with chronic coronary artery disease (CAD).Thirty-one patients (29 men, mean age 55 +/- 10 yr) with proven CAD and left ventricular (LV) dysfunction (ejection fraction 39% +/- 9%) underwent resting 99mTc-MIBI tomography with initial (1 hr) and delayed (5 hr) images. Within 1 wk of MIBI imaging, all patients underwent rest-distribution 201Tl imaging. Eight patients also underwent two-dimensional echocardiography before and 5 +/- 3 mo after coronary revascularization.On the initial 99mTc-MIBI images, 302 myocardial segments were normal, 183 showed moderate and 197 severe reduction of tracer uptake. Of these 197 segments, 47 (24%) demonstrated increased tracer uptake (or = 10% versus initial) on delayed images (from 43% +/- 8% to 60% +/- 8%, p0.001) and were considered as showing 99mTc-MIBI redistribution. These 47 segments were observed in 20 (65%) patients in whom 201Tl images detected viable myocardium in the same segments. In the eight patients studied before and after revascularization, 83% of segments with 99mTc-MIBI redistribution and abnormal LV function showed functional recovery after revascularization, while 96% of segments without 99mTc-MIBI redistribution did not show functional recovery.Resting 99mTc-MIBI redistribution frequently occurs in patients with chronic CAD. Acquisition of 99mTc-MIBI redistribution images enhances detection of viable myocardium and predicts functional recovery after revascularization.

The aim of this study was to assess whether nitrate administration improves the imaging capabilities of 99mTc-MIBI tomography in detecting viable myocardium in coronary artery disease (CAD).Thirty-one patients with angiographically proven CAD and chronic LV dysfunction (ejection fraction 39% +/- 9%) underwent two 99mTc-MIBI studies on separate days: one under rest conditions and the other after nitroglycerine (0.005 mg/kg per os) administration. Within 1 wk, all patients also underwent rest-redistribution 201Tl imaging. Eight patients were also studied by echocardiography before and 5 +/- 3 mo after coronary revascularization.On resting 99mTc-MIBI images, 302 segments had normal uptake, 183 segments had moderately reduced uptake and 197 had severely reduced uptake. Of the segments with severely reduced uptake, 54 (27%) had increased uptake after nitroglycerine and were viable on 201Tl images. Of the 143 (73%) segments with severely reduced 99mTc-MIBI uptake and no change after nitroglycerine, 81% were nonviable on 201Tl images. In the eight patients studied before and after revascularization, 87% of segments with reversible 99mTc-MIBI defects and abnormal LV function demonstrated functional recovery after revascularization, whereas 89% of segments with irreversible 99mTc-MIBI defects did not.In patients with chronic ischemic LV dysfunction, nitrate administration improved the detection of severely hypoperfused but still viable myocardium on 99mTc-MIBI images.

Forty patients (38 men and 2 women, mean age 56 +/- 9 years) with angiographic evidence of coronary artery disease underwent 201Thallium myocardial scintigraphy and two-dimensional echocardiography. 201Thallium uptake and echocardiographic regional ventricular function were studied in corresponding myocardial segments. On exercise-redistribution 201Thallium imaging, 308 segments (51% of the total) had normal Thallium uptake, 48 (8%) exhibited reversible defects and 244 (41%) irreversible defects. Of the latter 244 segments with irreversible defects, 114 (47%) exhibited increased tracer uptake (Re+) and 130 (53%) remained unchanged (Re-) after 201Thallium reinjection at rest. Regional ventricular function was significantly better in the segments with normal Thallium uptake than in the segments with reversible or irreversible defects (p0.001). Furthermore, the segments with irreversible defects Re- had impaired regional function compared to the segments with irreversible defects Re+ (p0.001). Coronary artery stenosis was significantly more severe in the segments with irreversible defects Re- (93 +/- 16%) than in those with reversible defects (81 +/- 20%) and with irreversible Re+ defects (80 +/- 20%) (both p0.001). In conclusion, in coronary artery disease patients, exercise-redistribution 201Thallium cardiac imaging with reinjection at rest can identify severely ischemic but still viable myocardium and may be particularly useful in the prognosis of such patients.

Scintigraphy, using small, thrombus-avid, synthetic peptides labeled with gamma-emitting nuclides is an innovative approach to the noninvasive detection of acute deep venous thrombosis (DVT). The goal of this study was to evaluate clinically 99mTc-P280 for imaging DVT. The peptide P280 is a 26 amino acid dimer that binds with high affinity to the GPIIb/IIIa receptor expressed on activated platelets and can be labeled with 99mTc.Scintigraphy with 99mTc-P280 (10-22 mCi) was performed in nine patients with clinical suspicion and diagnostic evidence of DVT. Planar and tomographic images of the legs, abdomen/pelvis, chest and head were obtained immediately, 1, 2, 4 and 24 hr after injection.No adverse effects were noted after 99mTc-P280 administration in any patient. Positive visualization of thrombi occurred in eight of nine cases with confirmed DVT within 1 hr of tracer injection. The majority of the patients had recent onset of DVT symptoms (less than 3 wk), while the only negative case was diagnosed 42 days earlier and was likely related to an accident 7 mo earlier. Thrombi-to-background ratios were essentially constant over the study. Technetium-99m-P280 accumulation was also discernible in two patients with pulmonary embolism, while in a third patient the radiotracer concentrated in a cerebellar hemangioblastoma.These human studies indicate that 99mTc-P280 is a potentially safe and sensitive procedure for diagnosing DVT and pulmonary embolism. It also may have substantial utility in monitoring active venous thrombosis.

Forty-three patients (40 men and 3 women, mean age 54 +/- 9 years) with coronary artery disease underwent 99mTc methoxy isobutyl isonitrile (sestamibi) myocardial scintigraphy and coronary arteriography. Sestamibi uptake and wall thickening index (WTI) were quantitatively evaluated in each myocardial segment. Segments were divided into group 1 (normal coronary arteries, no. = 94), group 2 (coronary artery stenosis 50-99%, no. = 79), and group 3 (coronary artery stenosis 100%, no. = 42). Group 3 segments were subdivided into group 3A (with collaterals, no. = 18) and group 3B (without collaterals, no. = 24) segments. Both sestamibi uptake and WTI were significantly lower (p0.01) in group 3 than in groups 1 and 2. However, only WTI was significantly reduced (p0.01) in group 3B vs group 3A. Diagnostic capabilities (i.e. identification of segments supplied by stenosed coronary arteries) of sestamibi uptake, WTI, and a combination of both variables with a discriminant function were compared by analysis of receiver operator characteristic curve (ROC) areas. The diagnostic capabilities of sestamibi uptake (ROC area = 0.65 +/- 0.04) were significantly lower (p0.05) than those of WTI (ROC area = 0.81 +/- 0.03) and discriminant function (ROC area = 0.83 +/- 0.03). In conclusion, our data suggest that combined analysis of myocardial perfusion and regional ventricular function may increase the diagnostic accuracy of sestamibi myocardial scintigraphy in identifying myocardial segments supplied by stenosed coronary arteries.

In order to evaluate 131I metaiodobenzylguanidine (MIBG) uptake in patients with benign or malignant paragangliomas, 28 patients (14 men and 14 women, mean age 37 +/- 10 years) with benign (no. = 15; group 1) or malignant (no. = 13; group 2) tumors underwent MIBG scintigraphy. A total of 110 lesions (20 benign and 90 malignant) were studied. In all patients histologic disease confirmation was obtained. MIBG uptake was quantified on 48 hours' images (Kodak NMC-1 films) using a photographic densitometer. The optical densities of tumor and adjacent or contralateral normal tissue were used to calculate the MIBG uptake intensity ratio for each lesion. In group 1, all patients exhibited 1 or 2 lesions with abnormal MIBG uptake. In group 2, all patients had 1 to 28 abnormal foci of MIBG uptake. In the patients with 2 or more lesions, the average MIBG uptake intensity ratio was calculated. MIBG uptake intensity ratio was significantly higher in malignant than in benign paragangliomas (5.2 +/- 2.4 vs 2.9 +/- 1.4, p0.01). Since MIBG uptake in paragangliomas reflects the intratumoral concentration of catecholamines, higher MIBG uptake in malignant lesions suggests a greater amount of stored catecholamines in these tumors. In conclusion, 131I MIBG scintigraphy may be useful to distinguish benign from malignant paragangliomas.

We report the successful diagnosis of thyroid involvement by histiocytosis X due to accurate evaluation of nuclear medicine results. METHODS: A total thyroidectomy specimen from our patient was initially suggestive of medullary thyroid carcinoma. However, histologic reevaluation was performed on the basis of nuclear medicine findings which were incompatible with the original histologic diagnosis. RESULTS: Immunohistochemical and light microscopy studies were performed to obtain the correct diagnosis. Diffuse thyroid involvement by histiocytosis X was demonstrated. CONCLUSION: Thyroid scintigraphy was helpful in successfully diagnosing thyroid involvement by histiocytosis X. Because tracer uptake is related to increased cellularity and metabolism, none of these tracers reported here is specific for defining histiocytosis X.

In order to assess the clinical role of Magnetic Resonance (MR) imaging in patients with benign or malignant pheochromocytomas, the MR signal intensity ratios of benign and malignant tumors were evaluated. Eighteen patients (9 men and 9 women, mean age: 37 +/- 8 years) with benign (n = 10) or malignant (n = 8) pheochromocytomas were studied. A total of 27 lesions (12 benign and 15 malignant) were analyzed. In all patients, histology confirmed the disease. MR studies were performed using a 1.5-T superconducting magnet system. Sequences were used to obtain T1-weighted (TR/TE 300/12 ms) and T2-weighted (TR/TE 2000/80 ms) images. On both T1- and T2-weighted MR images, the mean absolute signal intensity values of tumor lesions, of liver, muscle and fat tissues, and of image background were measured to obtain the corresponding signal intensity ratios for each lesion. Our results exhibited no statistically significant differences in both T1 and T2 MR signal intensity ratios between benign and malignant lesions. In conclusion, our results suggest that MR imaging cannot differentiate benign from malignant lesions in patients with pheochromocytoma.

The recent development of an ambulatory radionuclide detector (VEST) to assess left ventricular (LV) function may enhance the detection of ischemia during routine daily activities in patients with coronary artery disease (CAD). The aim of this study was to evaluate the usefulness of VEST in monitoring LV ejection fraction (EF) responses to daily activities and sustained handgrip test (HG) in patients with CAD.13 patients (12 men and 1 woman) with angiographically proven coronary artery disease were studied by VEST (mean 162 min, range 120 to 250 min). LV responses to different daily activities (walking and climbing stairs) and to HG were evaluated.Walking on a level surface and climbing stairs did not induce significant change in mean LVEF. However, a transient decrease in EF was observed in 4 (31%) and in 5 (38%) of the 13 patients during walking and climbing stairs, respectively. HG induced a significant (p0.01) reduction in mean EF. In particular, during HG, EF decreasedor = 5% in 11 (85%) of the 13 patients. A transient spontaneous decrease in LVEF lastingor = 1 min was observed on 18 occasions in 11 patients with CAD; 5 episodes were symptomatic and 13 asymptomatic. ECG ST segment depression was recorded in 4 of the 5 symptomatic and in 5 of the 13 asymptomatic episodes.These results suggest that simultaneous monitoring of LV function and ECG may permit a better understanding of the incidence and severity of ischemic symptomatic and asymptomatic episodes.

The recent development of new radionuclide detectors allows noninvasive outpatient monitoring of left ventricular function. This study was aimed at describing a new radionuclide technique useful to monitor cardiac function and at evaluating its potential clinical applications. We studied 14 normal subjects, 30 patients with coronary artery disease and 25 patients with dilated cardiomyopathy. Left ventricular function was continuously monitored in control conditions at rest, during daily physical activity of different intensity (walking on a level surface and climbing stairs), and during bicycle exercise. Left ventricular ejection fraction (EF) variability during recording in control conditions at rest was 0.2 +/- 1.8%. A significant relationship between outpatient EF at rest and conventional equilibrium radionuclide angiography was observed (r = 0.97, n = 69, p less than 0.001). In normal subjects both daily physical activity and exercise stress test induced an increase in heart rate and EF. In patients with coronary artery disease and in patients with dilated cardiomyopathy a heterogeneous EF response was observed during physical activity and exercise stress test. Our results demonstrate that this technique can be used for the ambulatory monitoring of left ventricular function in both normal subjects and patients with different types of cardiomyopathies.

In spite of their important impact on populations, a number of diseases--all types of cancer and coronary heart disease in women--are "rare" events for statistical analysis and often analyzed in designs affected by selection and information biases, such as case-control studies. Large cohort studies based on the storage of biological specimens appear to be the most suitable solution for identifying risks for those diseases. Progetto ATENA, a study on the etiology of major chronic diseases in women is based on this design. Ten thousand women, aged 30-69 years, living in the area of the city of Naples, free of cancer and cardiovascular disease, are being recruited over a four-year period. Ten per cent of the cohort is being randomly selected from the electoral roles, the rest will be volunteers. Information on dietary habits, reproductive history, familiarity for chronic disease, active smoking habits and passive smoking exposure, physical activity, and socio-demographic data are being collected. Clinical data such as blood pressure, anthropometry, and electrocardiogram are also taken. All the participants provide biological samples of blood (fasting drawing) and urine (timed morning spot). The biological samples are processed in order to explore the main areas under study (nutritional markers, metabolism, endocrinology, genetics, environmental exposure markers, thrombogenesis). The samples are stored in liquid nitrogen (-196 degrees C) as soon as the blood and urine processing have been finished. An appropriate follow-up information system on the health status of the participants is being set up to estimate incidence and mortality rates.

Technetium-99m methoxy-isobutyl-isonitrile (MIBI) myocardial scintigraphy has been proposed as an alternative to Thallium 201 myocardial imaging in the evaluation of patients with coronary artery diseases. We studied 39 patients (37 men, mean age 56 +/- 9 years) with suspected coronary artery disease. All patients underwent 99mTc MIBI myocardial scintigraphy after stress and at rest. Coronary arteriography, performed within 1 month, showed significant (greater than or equal to 50%) stenosis of at least 1 epicardial coronary artery in 36 subjects. 99mTc MIBI myocardial scintigraphy exhibited 94% sensitivity (34/36 patients) and 100% specificity (3/3 subjects with normal coronary arteries). Sensitivity for individual vessel stenosis was 81% (96% for the left anterior descending artery, 65% for the circumflex artery and 79% for the right artery). Our data show that 99mTc MIBI myocardial scintigraphy is capable of evaluating patients with coronary artery diseases.

Three methods of cervical Pap smear have been studied: the classical spatula, the combination of spatula and cytobrush, and the Cervex-Brush. Thirty-two percent of the spatula smears did not provide endocervical cylinder cells. Significantly better results can be achieved by performing the smear with a combination of spatula and cytobrush (11% without cylinder cells), or with Cervex-Brush (15% without cylinder cells). Cervical smears using a spatula alone are therefore discouraged.

Renovascular hypertension is the most important and common cause of secondary hypertension. We studied 10 patients with arterial hypertension and different degrees of renal artery stenosis to assess the usefulness of dynamic radionuclide renography in evaluating renal perfusion and function, and to compare functional radionuclide results to the morphological findings of renal angiography. Computer-assisted dynamic renal imaging with 99mTc diethylenetriaminepentaacetic acid (DTPA) and 131I ortho-iodohippurate (OIH), and renal arteriography were also employed in all patients. In all patients, radionuclide results matched angiographic findings in quality. In particular, 3 patients with hemodynamically insignificant renal artery stenosis exhibited normal perfusion and function at dynamic radionuclide renography. Seven patients had significant renal artery stenosis and associated functional changes at dynamic radionuclide renography. Quantitative comparison of all patients showed a significant correlation (r = 0.866, p less than 0.001) between the degree of renal artery stenosis, quantified as the percentage of narrowing as compared to adjacent/contralateral normal vessel diameter, and the results of split renal function, as assessed during OIH studies and expressed per kidney as a percentage of the net total counts of both kidneys. In conclusion, our results demonstrated dynamic radionuclide renography to be a valuable tool in the assessment of functional changes secondary to renal artery stenosis in hypertensive patients, providing complementary results to arteriography.

This paper reports the clinical features of 2 patients affected by mixed transcortical aphasia. Both of them had extensive damage of the left hemisphere. Cerebral blood flow measurement showed a marked decrease in left-hemisphere flow. In particular, speech areas were found to be morphologically and functionally damaged. The present findings, together with a critical review of the literature, served as a starting point for a discussion of linguistic features, diagnostic criteria and classical neuroanatomical interpretation of mixed transcortical aphasia. The possible contribution of the right hemisphere in determining this aphasic syndrome is suggested.

The results of 131I metaiodobenzylguanidine (MIBG) and Computed Tomography (CT) scans in a group of patients with clinically suspected pheochromocytoma were evaluated and compared with biohumoral parameters. We studied 24 consecutive patients (7 M and 17 F; age range 20-66 years). 131I-MIBG scintigraphy and CT were in agreement in 19 patients (79%): of them 7 cases were true positive, and 12 were true negative. Disagreement between the two imaging techniques was observed in 5 patients (21%). In this group, one patient, with positive CT scan, had false negative MIBG study, while 4 patients with negative MIBG scan, had false positive CT. MIBG showed significantly higher (p less than 0.05) specificity (100%), positive predictive value (100%), and accuracy (96%) than CT (75%, 67%, and 83%, respectively). 131I-MIBG scintigraphy is an accurate, noninvasive technique for localizing pheochromocytoma and providing direct tissue characterization, while CT provides more accurate spatial information. In conclusion, CT and MIBG studies are complementary in the evaluation of patients with suspected pheochromocytoma.