Search

We describe a foetus with an interstitial deletion of 1q detected in amniotic fluid cells and we review the literature of similar pre- and postnatal cases, in order to identify prognostic factors useful for prenatal counselling. Foetal/parents karyotyping and FISH with whole chromosome 1 paint and BAC clone specific for 1q23-32 region were performed. Further 100 Kb resolution array-CGH analysis was executed after pregnancy termination on DNA extracted from foetal skin fibroblasts. Cytogenetic analyses revealed a de novo interstitial deletion involving the long arm of chromosome 1. FISH analysis confirmed that the deletion involves the intermediate 1q31.2 region. Foetal ultrasound (US), performed at 21 weeks of gestation, showed intrauterine growth restriction, shortening of the long bones, echogenic intracardiac focus and mild cerebral ventriculomegaly. Array-CGH localized the deletion in a DNA sequence of about 21 Mb in the 1q24.3-q31.3 region. Our findings, together with available data on patients with 1q deletion, suggest that the most severe phenotypes are not simply associated with larger deletion, and that the results of prenatal US assessment, rather than a fine molecular characterization of the deletion, should be taken into account for prognostic evaluation.

Objective. Enhancement of the subjective components, recognition of overall needs, and careful consideration of subjectively perceived quality of life among dialysis and/or transplanted patients appear to be key objectives to promote optimized adherence to treatment and active cooperation of the patient. This study explores the relationship between self-rated health among recipients of kidney transplantations from deceased marginal donors (age older than 55 years) in relation to gender, age, time on dialysis, years after transplantation, and donor age. Patients and Methods. Posttransplant quality of life was assessed with the Complete Form Health Survey (SF-36) in 70 recipients of kidney transplantations from marginal deceased donors. Results. Donor age did not negatively influence health status perceived by the subjects. The vitality and mental health seemed to increase with greater donor ages, but the status of perceived health, vitality, social activities, and mental health were negatively influenced by the age of the transplant. Conclusions. Our study shows that good general health and social well-functioning can be achieved also among recipients of organs from older donors. Thus, age alone should not be a barrier to organ donation, providing that the organ function is normal and that specific disease is absent in the organ.

Purified allergens are required to detect cross-contamination with other allergenic foods and to understand allergen interaction with other components of the food matrix. Pure allergens are also used for the diagnosis and treatment of food allergies. For example, serological methods are being developed to improve the quality of diagnosis, and to reduce the need for food challenge tests. In addition, recombinant allergens are being evaluated as candidate vaccines for safe and efficacious specific immunotherapy. Pure allergens are indispensable as reference materials for the calibration and standardization of methods between different laboratories and operators for risk assessment in the food industry. Therefore, there is a need for well-defined purified food allergens. In this context, a panel of 46 food allergens from plant and animal sources has been purified, from either the food sources or as recombinant forms, within the EU-funded EuroPrevall project. These allergens have been characterized by a battery of diagnostic tests demonstrating that they constitute an authentic, well-defined library of comparable quality. The review summarizes the applications, potentials and limitations of key techniques used for the characterization and authentication of these allergen preparations, with a special emphasis on protein purity and identity, folding, post-translational modifications and immunochemical properties. One key area identified is the development of powerful analytical techniques, such as mass spectrometry and nuclear magnetic resonance, to improve the authentication of allergens for routine applications in allergy management.

Hemorrhoidal disease is a frequent cause of morbidity among the general population with a reported incidence of 4.4%, but little is known about its incidence and clinical features in kidney transplant recipients. Among 116 patients who had undergone kidney transplantation and were evaluated for hemorrhoidal disease, 82 had no hemorrhoids (70.6%), 28 (24%) had grade I hemorrhoids, and 6 (5.4%) had grade II hemorrhoids at the pretransplantation evaluation. Twenty-seven out of 116 recipients (22.4%) developed grade III or IV hemorrhoids after transplantation and underwent surgery. Hemorrhoidal disease was more frequent in patients with a pretransplantation history of hemorrhoids, with a rapid weight increase in the posttransplantation period, or who were aged between 30 and 50 years. Immunosuppressive therapy may play an important role in the worsening of hemorrhoidal disease among kidney transplant recipients. A prompt diagnosis and surgical treatment, whenever necessary, is mandatory for patients with clinical signs of worsening of hemorrhoids.

Visceral leishmaniasis (VL) is a rare complication of kidney transplantation, with100 cases reported in the literature. It is a life-threatening condition and usually occurs as a late complication after transplantation, with a median delay of 18 months between transplantation and onset of disease. We report the clinical features and management of 5 kidney transplant recipients who presented with VL in the early post-transplant period. All patients were successfully treated with liposomal amphotericin B (L-AMB), but 2 patients experienced graft loss. VL should be considered in the differential diagnosis in kidney transplant recipients living in endemic areas, who present with unexplained fever and pancytopenia in the early post-transplant period. Leishmania serology should be included in the screening of all transplant recipients, in order to identify a group of patients who could benefit from preemptive anti-Leishmania therapy. Therapy with L-AMB is highly effective and well tolerated in kidney transplant recipients with VL.

Introduction Psychologic disturbances are becoming more common in kidney transplantation, owing to effects of immunosuppressive therapy. In this study, we explored the incidence and specifity of psychopathology among kidney transplant patients. Twenty kidney transplant recipients underwent the Machover Draw-A-person test to detect significant variables (V1=V6) hypothetically related to chronologic age, education, years from transplantation, and gender differences. Emotional coarctation (V1) in the sense of “mental rigidity,” “egocentrism,” and “hypercontrol” were present in all transplant recipients (100%), followed by difficulty in interpersonal relationships (V3; 70%) and anxiety (V5; 70%). This research confirmed the hypothesis that transplantation can display a potential risk to the psychologic balance of the patient. Psychologic evaluation may be a fundamental step together with surgical aspects and management of immunosuppression to achieve well-being of kidney transplant recipients.

Introduction. The objective of this study was to evaluate the efficacy of an analgesic regimen based on levobupivacaine continuous infusion into the surgical wound of living kidney donors (LKDs). Patients and Methods. Fifty adult LKDs (mean age, 53.1 ± 5.3 years; age range, 52―68 years) were retrospectively assigned to a no wound infusion (NWI) group (n = 25) or a wound infusion (WI) group (n = 25). At the end of surgery, patients in the WI group received 10 mg intramuscular morphine; a peridural catheter was placed 10 cm between the intercostal muscles fibers close to the lower rib extremity, and a solution of levobupivacaine, 150 mg/100 mL, was started at 5 ml/h-1 . Patients in the NWI group received intramuscular morphine, 10 mg, every 8 hours; intravenous tramadole, 100 mg, was planned as a rescue drug for incidental pain. Pain was measured using a visual analog scale (VAS) ranging from 1 (no pain) to 10 (maximum pain) in both the basal condition (VASb) and during coughing (VASc) at 1 hour after leaving the operating room and 6, 12, and 24 hours thereafter. Results. At 1, 6, 12, and 24 hours, VASb values in the NWI vs the WI group were 5.2 vs 3.1, 6.8 vs 4.1, 5.8 vs 4.9 (all p < .01), and 5.4 vs 5.1, respectively, and VASc values were 8.2 vs 6.3, 8.8 vs 5.9, 7.1 vs 5.3, and 6.8 vs 5.1 (all p < .01). Mean VAS score was significantly higher between 1 and 6 hours in the NWI group for all VASb measurements vs VASc values. Tramadole consumption was higher in the NWI group than in the WI group. Conclusions. Continuous wound infusion with 5 mL/h ―1 levobupivacaine, 1.5 mg/mL ―1 , resulted in a safe and effective analgesic protocol in LKDs both in the immediate postoperative period and in the first day after surgery, a result that was more effective than a morphine-tramadole regimen. No adverse effects were recorded, which confirmed the safety of the technique. It is probable that better results could be achieved with dedicated administration devices.

Introduction Development of cancer after transplantation has rapidly became one of the leading causes of death in kidney transplant recipients with functioning grafts. Anogenital malignant neoplasms may occur with a 14-fold increased incidence, and human papilloma virus (HPV) infection has been recently identified as the leading cause of cervical carcinoma. We report the preliminary findings of a prospective study that evaluated the incidence of HPV infection and cervical carcinoma in a population of kidney transplant recipients. Patients and Methods The study included 35 female recipients of a deceased donor kidney with at least 6 months of follow-up. All patients underwent a cervicovaginal brushing, an HPV DNA test, and a Papanicolaou test. Results Twenty-two patients (62.8%) were positive for HPV DNA. Thirteen of 22 HPV DNA–positive recipients (59%) demonstrated a high-risk HPV genotype. No cytologic anomalies were detected in Papanicolaou smears. Conclusions These preliminary data demonstrated a high incidence of HPV infection in renal transplant recipients. Most of our recipients exhibited a high-risk HPV genotype, which suggests higher aggressiveness of such infection in immunosuppressed patients. The HPV test is useful to monitor patients at higher risk of anogenital malignant neoplasms by identifying the cytologic anomalies at an earlier stage. This ongoing study will investigate the rate of progression of HPV infection and the clinical patterns of HPV-positive cytologic anomalies in renal transplant recipients.

Introduction Renal vein thrombosis (RVT) has an incidence of 0.55% to 3.4% and accounts for as many as one-third of early allograft losses. Rarely, RVT may be a consequence of an extension of ipsilateral iliac vein thrombosis. We present a rare case of iliocaval thrombosis as a consequence of inferior vena cava compression by a large-for-size kidney transplant. Case Report A 20-year-old woman with spina bifida and kidney failure received a living donor kidney from her 52-year-old father. On postoperative day 8, the patient had right lower quadrant abdominal pain associated with oliguria. Graft duplex ultrasonography examination revealed venous thrombosis arising in the right femoral vein and extending to the iliac vein. An urgent second laparotomy was performed, and the kidney was finally placed in the peritoneal cavity. Conclusions The eventuality of an inferior vena cava compression by a transplanted kidney should be considered in any recipient with sudden leg swelling and acute graft dysfunction. An early diagnosis and prompt intervention may reduce the progression to RVT and subsequent graft nephrectomy. When planning a kidney transplantation with a supposed size discrepancy between donor and recipient, positioning the kidney on the left side or in the peritoneal cavity may be preferred.

Introduction Successful renal transplantation strictly depends on good control of rejection and better prevention and treatment of infections, which remain serious threats. Methods This retrospective, observational study of 245 renal allograft recipients who underwent transplantation between January 2002 and December 2005 included a 21 ± 10 months follow-up. Results A total of 110 (44.9%) patients developed an infective process during the posttransplantation period, namely, 232 infective processes. Eighty patients developed at least 1 episode of urinary tract infection (UTI) 11 patients (4%) had a wound infection, and 30 patients (12%) had pneumonia. We diagnosed 35 cases of bacteremia (35%), whereas cytomegalovirus (CMV) infection was demonstrated in 40 patients (16%). Conclusions Immunosuppressive therapy, necessary to avoid acute and chronic rejection, exposes patients to a higher rate of infectious complications. The immunosuppressive protocols led to a relatively low incidence of infectious complications, mainly of little clinical significance. The highest incidence was evident by the sixth month after transplantation, when the immunosuppressive regimen exercised its most depressive effects on patient immune systems.

Background Complications related to posttransplantation immunosuppressive therapy remain common. New-onset diabetes mellitus after transplantation (PTDM) is a well-recognized complication associated with reduced graft and patient survival. The type of immunosuppression may be responsible for more than two thirds of PTDM. We retrospectively reviewed our experience in a population of 284 kidney transplant recipients, evaluating the incidence of PTDM with regard to the type of immunosuppression. Patients and Methods From January 2001 to December 2005, 284 kidney transplantations were performed using tacrolimus-based (TAC) immunosuppression in 192 patients and a cyclosporine-based (CyA) regimen in 62 patients, whereas 30 patients received sirolimus-based immunosuppression. Results The overall incidence of PTDM was 4.9%. Among the immunosuppression protocols, 8 patients (4.1%) received TAC and 6 patients (9.6%) received CyA, whereas no patients treated with sirolimus developed PTDM. Graft and patient survival rates were 93% and 100%, respectively. Conclusions The overall risk of PTDM with recent immunosuppressive protocols is low, but it is increased among calcineurin inhibitor (CNI)-treated kidney transplant recipients. Sirolimus did not increase the risk of PTDM, allowing potential clinical application in diabetic recipients and in patients affected by PTDM.

To investigate the release of atrial natriuretic factor (ANF) in mitral stenosis and the influence of the increase on the frequency of atrial contraction or atrial distention on ANF secretion, we studied 10 patients with symptoms of congestive heart failure (New York Heart Association classes II and III) in sinus rhythm, who were undergoing cardiac catheterization as part of an evaluation workup for mitral stenosis. Echocardiographic tracings, repeat determinations of mean pulmonary artery wedge pressure (MPAWP) and mean right atrial pressure, and blood sampling from the pulmonary artery for measurements of ANF were performed at baseline, during atrial pacing (pacing rate of 125 beats/min for 5 minutes), and 5 minutes after the pacing protocol was completed. Baseline ANF levels were closely related to right atrial pressure (r = 0.89; p less than 0.001) and increased markedly after atrial pacing from 205.6 +/- 39.8 (SEM) to 343.9 +/- 57.9 (SEM) pg/ml. A similar pacing-induced increase was shown for MPAWP and left atrial size. Our data indicate that pacing-induced increases in atrial distention and intracavitary pressure further stimulate release of ANF. However, an independent effect of frequency of atrial pacing on plasma ANF in humans could not be identified.

Background Aspergillosis and other invasive mold infections are severe complications in immunosuppressed patients, and in renal transplant patients it is the most common cause of systemic fungal disease with an incidence ranging from 0.4% to 2.4% with a high mortality of 56% to 100%. We present our experience with voriconazole in a population of kidney transplant recipients with invasive aspergillosis. Patients and Methods From January 2002 to December 2005, 245 kidney transplantations were performed. Results Four patients (1.6%) presented with clinical and laboratory findings of invasive aspergillosis. Three patients presented with pulmonary aspergillosis, while one patient presented with pulmonary and ocular aspergillosis. All patients underwent a therapy with voriconazole 200 mg twice a day, in combination with caspofungin in one patient. All patients are alive, with no clinical recurrence of aspergillosis at a median follow-up of 13 months. One patient lost her graft due to discontinuation of immunosuppression. Conclusions Voriconazole is a potent and well-tolerated antifungal drug that is extremely efficacious in the treatment of invasive aspergillosis in kidney transplant recipients. A careful monitoring of immunosuppressive drugs should be considered to avoid nephrotoxicity.

Background Dual kidney transplantation (DKT) offers a safe way to face the organ shortage with good short-term and medium-term renal function. However, its application is limited by the longer operating time and the risk of surgical complication. This study reviews our results with DKT performed with an ipsilateral technique in terms of graft loss, graft and patient survival rates, and surgical complications. Patients and Methods From January 2002 to March 2006, 23 patients underwent DKT through a monolateral Gibson incision with placement of both kidneys. Results One primary nonfunction occurred (4%). Delayed graft function was observed in 3 DKT (13.3%). Acute rejection rate was 4.3% (1 patient). All patients are alive at a mean follow-up of 28 months. One-year and 2-year graft survival rates were 100% and 96%, respectively. Mean serum creatinine level at 1-year posttransplantation was 1.3 mg/dL (range, 0.8–2.1 mg/dL). One DKG recipient lost 1 graft, retaining the second normal functioning graft due to ureteral necrosis. The mean hospital stay after transplantation was 15 days (range, 12–34 days). Conclusions Monolateral placement in DKT offers the advantage of a single incision, minimizing the surgical risk. Tailored immunosuppression and careful selection of potential recipients, by excluding those with severe cardiopulmonary pathologies, could significantly improve both patient and graft survival in this group of patients.

Background Infection is a common cause of morbidity and mortality in kidney transplant recipients. The incidence of esophageal and urogenital candidiasis in kidney and kidney-pancreas transplant recipients has not been well documented. Azoles are safe, effective agents to treat esophageal candidiasis. However, resistance to azoles is now becoming common. This study reports the use of caspofungin for the treatment of azole-resistant esophageal and urogenital candidiasis in kidney transplant recipients. Patients and methods The incidence of esophageal and urogenital candidiasis was evaluated among 140 kidney transplantations and four combined kidney-pancreas transplants performed over a 2-year period. Results Twenty-two patients (15.7%) presented with esophageal candidiasis, while seven patients (5%) showed urogenital candidiasis. Thirteen patients with esophageal candidiasis (59%) and four patients (57%) with urogenital candidiasis did not improve after a week of azole treatment. A regimen of caspofungin was started in these patients, who tolerated the treatment. Urogenital candidiasis recurred in two patients 2 and 3 months after the treatment. One patient with esophageal candidiasis did not improve with caspofungin and was switched to amphotericin B therapy. There were no other recurrences of candidiasis among patients treated with caspofungin for a median follow-up of 8 months. Conclusions Renal transplant patients remain at high risk for fungal infections. Although the number of patients was limited, the results of this study indicated that caspofungin is an effective, well-tolerated alternative for difficult-to-treat, azole-resistant candida infections in kidney and pancreas transplant recipients. The high costs of the drug limit the use of caspofungin as first-line antifungal therapy, reserving its use to recipients who had undergone unsuccessful azole therapy.

Introduction The success of renal transplantation as a treatment for end-stage renal disease has created a chronic shortage of donor organs. We present our experience in transplanting kidneys from donors with hepatitis B virus (HBV) or hepatitis C virus (HCV) among matched serology-positive recipients. Materials and Methods From January 2002 to November 2005, 44 patients with end-stage renal disease and HCV seropositivity underwent kidney transplantation. In 28 transplants in HCV+ recipients, the donor was HCV+ (DC+/RC+) and in 16 of these cases the donor (one living donor) was HCV− (DC−/RC+). In the same period 14 patients with HBV infection and HbsAg seropositivity underwent kidney transplantation: eight received their graft from a cadaveric HbsAg-positive donor (DB+/RB+), while six patients received their graft from an HbsAg-negative donor. Results Viral reactivation was higher among DC+/RC+ (21.4%) than DC−/RC+ patients (6%). Graft survivals were 90% and 88% for DC+/RC+ and DC−/RC+, respectively; patient survivals were 100% for DC+/RC+ and 94% for DC−/RC+. Among the group of DB+/RB+, all the patients developed an HBV-DNA positivity in the early postoperative period. Patient and graft survivals were 100% in both groups. Conclusions Our results suggest that HBV- and HCV-positive donors can be considered as an alternative donor source, because their kidneys are allocated to the matched serology-positive recipients, shortening their time on the waiting list.

Galaxy hierarchical formation theories, numerical simulations, the discovery of the Sagittarius Dwarf Elliptical Galaxy (SagDEG) in 1994 and more recent investigations suggest that the dark halo of the Milky Way can have a rich phenomenology containing non thermalized substructures. In the present preliminary study, we investigate the case of the SagDEG (the best known satellite galaxy in the Milky Way crossing the solar neighbourhood) analyzing the consequences of its dark matter stream contribution to the galactic halo on the basis of the DAMA/NaI annual modulation data. The present analysis is restricted to some WIMP candidates and to some of the astrophysical, nuclear and particle Physics scenarios. Other candidates such as e.g. the light bosonic ones, we discussed elsewhere, and other non thermalized substructures are not yet addressed here., 17 pages, 10 figures, to appear in Eur. Phys. J. C

Introduction. The demand for kidney transplants and the improvement in recipient outcomes over the last years have stimulated surgeons to expand the criteria for usable donor organs, by accepting older patients to expand their donor pool. We herein report our experience with kidney transplants from donors aged older than 60 years, who have been declined by other transplantation centers. Patients and Methods. Sixty kidney transplantations were performed with grafts procured from donors aged older than 60 years. Forty-five patients received a single kidney graft (SKG) and 15 received a dual kidney graft (DKG). Mean donor age was 62 years for SKG and 64 years for DKG. Double kidney transplantations were performed with the ipsilateral allocation of both grafts. Results. No primary graft nonfunction occurred. Delayed graft function was observed in 22 SKG (48.8%) and in 7 DKG (46.6%). Acute rejection rates were 9% for SKG and 0% for DKG. One-year patient survival rates were 95% and 100% for SKG and DKG, respectively. Mean serum creatinine levels at 1-year posttransplantation were 1.9 mg/dL for SKG and 1.3 mg/dL for DKG. There were no surgical postoperative complications and mortality. Death censored 1-year graft survival rate was 88% for SKG and 94% for DKG. Conclusions. Our experience with marginal donors who have been declined by other transplantation centers has demonstrated that such organs, with accurate selection criteria, could be safely allocated to elderly recipients with no increase in postoperative complications, guaranteeing satisfactory results in the short and medium term, allowing a significant improvement in the number of transplants.

Introduction The success of renal transplantation as a treatment for end-stage renal disease has created a chronic shortage of donor organs. We present our initial experience in transplanting kidneys from hepatitis B surface antigen (HbsAg)–positive donors into HbsAg-positive recipients. Material and Methods From January 2002 to March 2004, 5 patients with end-stage renal disease, hepatitis B virus (HBV) infection, and HbsAg seropositivity underwent a kidney transplantation from a cadaveric HbsAg-positive donor. The median time on the waiting list was 8 months, compared with the median of 3 years on the national waiting list. Results One patient experienced an acute rejection; 1 patient had an increase in serum level of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) with no signs of recurrence of hepatits. Graft and patient survival at a median follow-up of 12 months was 100%. Conclusions Although the number of patients is small and the follow-up is short, our results suggest that HbsAg-positive donors can be considered as an alternative donor source because their kidneys are allocated to the matched serology-positive recipients, shortening their time on the waiting list.

The effects of practice schedule and amount of practice on the development of the generalized motor program (GMP) and on parameter estimation were investigated. Participants (N = 108) practiced the same relative timing but different absolute durations of a multisegment timing task. Practice schedules (constant, blocked, or serial) were crossed with amounts of practice (low and high). Inclusion of a constant practice condition allowed the authors to investigate the variability of practice prediction. Participants practiced the same proportional durations in a serial or a blocked schedule, which enabled the authors to examine contextual interference. A constant practice schedule enhanced GMP performance when task parameters remained the same, but varied practice schedules were beneficial when task parameters changed. A serial as opposed to a blocked practice schedule was superior when the performance of a task governed by a different GMP was required. Increased practice led to a consolidated task representation that was unavailable for updating.

The discovery of conjunctive "if-then" classification rules may be intractable when enumerating all possible conjunctions of terms. Various algorithms, notably C4.5 and CART, adopt a univariate strategy which reduces the process to a one-at-a-time best variable type of approach. While computationally feasible, such an approach may lead to unexplored portions of the database which may contain valuable nuggets. On the other hand, an exhaustive evaluation of all possible conjunctions may be intractable even for relatively small datasets. We propose a general approach to reduce the size of the search space of conjunctive "if-then" rule discovery algorithms by exploiting value-based data dependencies existing among the independent variables.

We describe the role of abciximab in unstable angina due to small vessel disease in a 58-year-old patient who was submitted to percutaneous transluminal coronary angioplasty and stenting of an occluded venous graft.

The increasing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led to most transplant centers developing protocols that allow safe utilization from donors with special clinical situations which previously were regarded as contraindications. Deceased donors with previous hepatitis C infection may represent a safe resource to expand the donor pool. When allocated to serology-matched recipients, kidney transplantation from donors with hepatitis C may result in an excellent short-term outcome and a significant reduction of time on the waiting list. Special care must be dedicated to the pre-transplant evaluation of potential candidates, particularly with regard to liver functionality and evidence of liver histological damage, such as cirrhosis, that could be a contraindication to transplantation. Pre-transplant antiviral therapy could be useful to reduce the viral load and to improve the long-term results, which may be affected by the progression of liver disease in the recipients. An accurate selection of both donor and recipient is mandatory to achieve a satisfactory long-term outcome.

Gaucher disease (GD) type I (McKusick 230800), the most prevalent lysosomal storage disorder, is due to β-glucocerebrosidase (EC 3.2.1.45) deficiency. It is characterized by the storage of uncleaved β-glucocerebroside in the cells of the reticuloendothelial system, leading to bone marrow infiltration, hepatosplenomegaly and skeletal lesions. Other clinical features include haematological changes with anaemia and thrombocytopenia (Beutler and Grabowski 1995). Enzyme replacement therapy has become available and is effective in reversing hepatosplenomegaly and haematological abnormalities (Charrow et al 1998). Patients with GD type I have a bleeding tendency partially due to thrombocytopenia; a combined deficiency of clotting factors and inhibitors has also been reported (Billet et al 1996; Hollak et al 1997). We undertook this study to gain further insight into the pathophysiology of haemostatic abnormalities associated with Gaucher disease. The effect of enzyme replacement therapy on haemostasis was also monitored in comparison with changes of other laboratory parameters reflecting the status of the disease.

The diagnostic value of exercise electrocardiography (ECG) in patients with complete right bundle block (cRBBB) remains controversial. The aim of this study was to investigate the diagnostic accuracy of exercise ECG for predicting ischemia in the presence of cRBBB.From a series of 1300 consecutive patients attending for exercise ECG and 99mTc-tetrofosmin single photon emission computed tomography (SPECT), we identified 38 male patients with cRBBB and 38 matched controls with normal intraventricular conduction. Patients with left ventricular hypertrophy or previous revascularization were excluded. Exercise ECG (modified Bruce protocol) was considered positive ator = 1 mm ST horizontal or downsloping depression inor = 2 adjacent leads. SPECT imaging at rest and post-exercise was performed at least 48 hours apart.The odds ratio for ischemia comparing patients with positive and negative exercise ECGs was 11.0 (95% confidence interval 2.49-48.64, p = 0.002) in controls and 2.49 (95% confidence interval 0.64-9.08, p = 0.32) in cRBBB. The prior probability of ischemia was 0.37 in controls and 0.58 with cRBBB. The posterior probability after a positive test was 0.65 in controls and 0.68 in cRBBB. Thus, the utility of the test (posterior probability minus prior probability) was greater in controls (+0.28) than in cRBBB (+0.1). This difference was most pronounced in the anterior leads V1-V4 (controls +0.63 vs cRBBB +0.01) but less significant in the lateral leads V5-V6 (controls +0.26 vs cRBBB +0.21). Similar analysis also indicated reduced diagnostic value of negative exercise ECGs in cRBBB patients.The diagnostic value of exercise ECG is reduced in patients with cRBBB, although ST-segment changes in the lateral ECG territory provide superior predictive accuracy to those in the anterior leads. The use of SPECT as a first-line investigation may be justified in patients with cRBBB.

Intracoronary stent implantation during percutaneous transluminal coronary angioplasty (PTCA) has shown favorable results, reducing acute complications associated with PTCA, such as coronary artery dissection and abrupt or threatened vessel closure. However, treatment of lesions with a complex morphology and diffuse disease, requiring long or multiple coronary stents, is still associated with a poorer outcome. We investigated the hypothesis that abciximab might lead to a different outcome in patients with complex coronary lesions, which require long or multiple stent implantation.One hundred and six patients were randomized to receive either a combination of abciximab (bolus and 12 hour infusion) and weight-adjusted low-dose heparin or weight-adjusted heparin alone and followed up to 30 days.The procedural success rate was 100% in both groups of patients. In the control group a composite rate of major adverse events such as any death irrespective of cause, Q wave or non-Q wave myocardial infarction, acute or subacute stent thrombosis and urgent revascularization of 15.3% was shown at 30-day follow-up. The use of abciximab reduced the composite adverse event rate to 3.7% (76% absolute reduction, p0.05).The use of abciximab during high risk stenting is safe and reduces the risk of cardiac events at 30-day follow-up as compared to standard treatment with heparin. A longer follow-up period is warranted to confirm the beneficial effects observed at 30 days with abciximab in this setting.

Endothelin-1 (ET-1) is an endothelium-derived mediator with vasoconstrictive and mitogenic activity which stimulates vascular smooth muscle cell proliferation. The aim of this study was to evaluate ET-1 production during percutaneous transluminal coronary angioplasty (PTCA) and elective stent implantation. We hypothesized that the additional vessel wall trauma induced by stent deployment might be associated with a greater production of ET-1. To this end, ET-1 levels were measured in 18 patients undergoing PTCA and stenting (12 with left anterior descending coronary artery stenosis and 6 with circumflex artery lesion). The sampling sites were the coronary ostium and coronary sinus in basal conditions (before the procedure), during first balloon inflation, and 5, 20, 60 min after the end of first balloon inflation. At baseline, ET-1 levels were higher in the coronary sinus than in coronary ostium (1.58 +/- 0.22 vs 1.29 +/- 0.20 pg/ml, p0.001). During first balloon inflation, ET-1 coronary sinus levels significantly diminished with respect to the basal levels (1.08 +/- 0.32 vs 1.58 +/- 0.22 pg/ml, p0.001). Further significant variations of ET-1 levels were not detected neither following the first balloon inflation nor after stent deployment. In conclusion, the culprit lesion seems to produce most of ET-1 circulating in the coronary tree. This is demonstrated by higher ET-1 levels in the coronary sinus compared to coronary ostium at baseline, and even more by the significant ET-1 reduction in the coronary sinus during first balloon inflation. Despite our expectations, we did not detect any significant ET-1 increase during stent deployment.

We observed the development of left ventricular outflow tract dynamic obstruction in some patients during dobutamine stress echocardiography. The purpose of this study was to identify the possible mechanisms and to consider the clinical implications. From 11/04/94 to 01/09/97 we studied 547 patients; 42 patients developed dynamic obstruction, defined as a late peak Doppler velocity profile that exceeded baseline outflow velocity by at least 1 m/s. The encountered mechanisms were: increased myocardial contractility; systolic anterior motion of the mitral valve; decreased venous return to the left ventricle, and peculiar characteristics of the left ventricular geometry. The results of this study show that the dynamic obstruction is mainly due to the first mechanism and secondarily to some characteristics of the left ventricular geometry. The hypotension observed in a few cases is not related to the dynamic obstruction but to beta 2 receptor hypersensibility to dobutamine. The symptoms, like dyspnea and chest pain, experienced by these patients are related to the dynamic obstruction rather than to the presence of coronary artery disease. In conclusion, we think that patients who develop dynamic obstruction, without wall motion abnormalities, during dobutamine stress echocardiography, may behave pathophysiologically as patients with obstructive hypertrophic cardiomyopathy, in whom diastolic dysfunction and outflow tract obstruction are responsible for symptoms. Therefore, these patients require a pharmacological treatment with beta blockers and/or non-dihydropyridine calcium channel blockers.

The angiostent is a single wire, flexible, highly radiopaque, balloon expandable stent. To evaluate the feasibility and safety of the deployment of this new stent, we report the clinical and procedural results of 70 procedures performed in 51 native coronary arteries of 48 patients, with objective evidence of ischemia. The target lesion was located in the left anterior descending artery in 18 (36%) cases, in the circumflex artery in 16 (31%) cases and in the right coronary artery in 17 (33%) cases. Mean reference vessel diameter was 3.2 +/- 0.4 mm and the minimal luminal diameter was 0.4 +/- 0.3 mm, with a mean diameter stenosis of 86 +/- 10%. Type B2 and C lesions were encountered in 56% of the cases. More than one angiostent was implanted in 14 vessels and multiple stenting was accomplished with the use of different stents in 8 coronary arteries. No major complications were reported. The post-procedural minimal luminal diameter was 3.2 +/- 0.4 mm with a mean diameter stenosis of 1.4 +/- 3.7%. In 25 cases (49%) major side branches raised from the stented segment and in all but one remained patent. In conclusion, the implantation of the angiostent is safe, feasible and effective, as it can be easily deployed at the lesion site, used for the treatment of complex lesions and preserves the patency of jailed side-branches.

Abciximab, REOPRO, a potent inhibitor of platelet aggregation via glycoprotein IIb/IIIa inhibition, has shown to be effective in the prevention of short and long-term complications of percutaneous coronary interventions. Very few reports on the role of this drug in the setting of acute stent thrombosis have been published. We report 1 case of the effectiveness of REOPRO in the complete lysis of stent thrombus with reperfusion of the coronary vessel and its collaterals. This case suggests an important role of platelets in the setting of acute stent thrombosis and a thrombolytic effect of REOPRO.

There is still some controversy whether ST segment depression during exercise testing might predict the location of myocardial ischemia. From a population of 1196 patients who underwent myocardial 99mTc-tetrofosmin exercise SPECT scintigraphy, 22 consecutive patients (20 males and 2 females, mean age 54 +/- 10 years) with no previous myocardial infarction, positive exercise testing (or = 1 mm ST segment depression) performed in pharmacologic wash-out and angiographically documented isolated single vessel coronary artery disease (or = 70% diameter stenosis in a main coronary artery) were selected. None of the patients showedor = 1 mm ST segment depression exclusively in inferior leads (II-III-aVF). Eight patients (36%) showedor = 1 mm ST segment depression exclusively in precordial leads (Group 1). The remaining 14 patients (64%) showedor = 1 mm ST segment depression in both inferior and precordial leads (Group 2). No differences between groups were observed regarding peak exercise test parameters such as heart rate (124 +/- 28 vs 135 +/- 21 b/min, NS), rate-pressure product (22592 +/- 5323 vs 23118 +/- 4197 mmHg x b/min, NS) and exercise time (14.5 +/- 3.9 vs 15.1 +/- 2.9 min, NS) and the number of stress-induced reversible and partially reversible defects (3.3 +/- 3.4 vs 4.6 +/- 2.8, NS). All reversible and partially reversible defects were seen in the related coronary artery stenosis region. Among Group 1, 5 patient (62.5%) showed aor = 70% stenosis of left descending coronary artery, 1 patient (12.5%) of left circumflex and 2 patients (25%) of right coronary artery. Similarly, among Group 2, 9 patients (64.3%) showed a significant stenosis of left descending coronary artery, 1 patient (7.1%) of left circumflex and 4 patients (28.6%) of right coronary artery. Thus, we were not able to show a relation between exercise ST segment depression and the location of myocardial ischemia as assessed by myocardial 99mTc-tetrofosmin SPECT scintigraphy in a population of patients selected on the basis of single coronary artery disease.

The use of a new automated contour-detection system (CD) allows rapid quantification of the dimensions of coronary lumen and plaque in an entire three-dimensional set of intracoronary images (ICUS), obtained during an ECG-gated pull-back image acquisition. The aim of the study was to evaluate the reproducibility, feasibility and accuracy of this approach in the clinical setting. We examined 32 coronary stents implanted in 28 patients, mean age 59 +/- 16 years. The ICUS images were acquired during a motorized uniform-speed pull-back (0.5 mm/s) of the ultrasound catheter after angiographically guided stent optimization, recorded on videotape, and analyzed during a conventional two-dimensional ICUS examination. An ECG-gated pull-back was then performed and analyzed by a second operator using CD. The minimal lumen area and diameter of the stent and the lumen area of the reference segments were measured. Comparing the analysis on- and off-line, correlation coefficients (r) not less than 0.96, with a mean difference not higher than 0.3 +/- 1.5 were found. On the other side, the comparison between the two-dimensional analysis and the analysis performed on-line showed a good correlation between the two methods. The two-dimensional method revealed a systematic overestimation (delta = -1.3 +/- 2.3) of the area and diameter. The time required for the on-line three-dimensional analysis was 9 +/- 3 min, whereas the off-line analysis was performed within 35 +/- 10 min. Focal segments of stent underexpansion were seen in 4 cases by two-dimensional ICUS and in 3 more cases by three-dimensional ICUS, analyzed on- and off-line. In order to evaluate the reproducibility of the system, we examined ICUS images after an ECG-gated pull-back of 23 segments of coronary arteries in 20 patients. The intra and interobserver variability was evaluated. The mean relative difference between the area and volume measurements of intra and interobserver variability ranged from 0.14 to 1.51%, with a standard deviation not higher than +/- 7.17, a standard error of estimate not higher than +/- 4.85 and a correlation coefficient (r) not less than 0.98. Thus, the "contour detection" in ECG-gated three-dimensional ICUS is highly reproducible, suggesting the use of the system in studies of progression-regression of atherosclerosis. It is feasible for the on-line application as it can be performed rapidly and shows good agreement with measurements obtained by off-line CD.

Left bundle branch block does not permit an easy diagnosis of coronary heart disease (CAD) with provocative non-invasive test such as bicycle or treadmill stress test. Echocardiography allows the identification of segmental wall motion by evaluating the movement as well the thickness of the segment examined. Due to its agonist action on beta 1 receptors, dobutamine causes an increase in myocardial oxygen consumption and, as a consequence, may reveal myocardial ischemia; on this basis, we evaluated the sensibility, specificity and diagnostic accuracy of dobutamine stress-echo in identifying CAD in patients with left bundle branch block, and compared results with those obtained from coronary catheterization. From February 1994 to September 1995 we observed 25 patients with left bundle branch block (17 men, 8 women, mean age 61.8 +/- 8.4 years, range 43.75), affected or suspected for CAD. All patients underwent dobutamine stress-echo test and coronary arteriography. We divided patients into two groups: the first one (11 patients) with acute myocardial infarction, the second one (14 patients) without previous ischemic episodes. Diagnostic accuracy, specificity and sensibility of the stress-echo test were evaluated in order to identify significant stenosis of the left anterior descending (LAD), right coronary (RCA), and/or circumflex artery (CA). Dobutamine stress echocardiography showed in all patients, from basal to peak, an increase in blood pressure (from 121.2 +/- 17.4 to 141.8 +/- 23.6 mmHg), heart rate (from 81.3 +/- 10.9 to 140.7 +/- 8.9 b/min), and double product (from 9861.1 +/- 1898.1 to 19976.6 +/- 3603.6). In 8 (32%) patients who had typical chest pain, 7 had CAD. In 17 (68%) patients without chest pain, 5 had CAD and 12 had normal coronary arteries. Dobutamine stress echocardiography showed segmental wall motion variations only in 13 patients; 12 of them had a significant stenosis of coronary artery relative to the ischemic area, the other 1 was a false positive. Coronary arteriography showed stenosis of LAD in 10 and of RCA and/or CA in 12 patients, in both groups dobutamine stress-echo test had 1 false negative. Dobutamine stress echocardiography showed high diagnostic value as a provocative non-invasive test for CAD in patients with left bundle branch block. In conclusion, or study shows that no statistical difference exists in identifying ischemia in identifying ischemia in the LAD territory compared to RCA and/or CA. Further investigations are need to confirm the higher diagnostic accuracy in patients with left bundle branch block and to establish whether lower specificity in patients with a previous myocardial infarction is due to the smaller number of patients or to methodology.

Coronary artery disease (CAD) is one of the main causes of cardiovascular morbility and mortality. Actual research lines are directed towards the discovery of silent CAD before hard events as myocardial infarction and sudden death. Dobutamine stress echocardiography is an useful method to assess patients with suspected CAD who, are not able to stand an effort because of physical reasons. During the test, hypotension and/or bradycardia may occur and may cause interruption of the test. The aim of our study was to consider prevalence, meaning and clinical implications of hypotensive, sometimes associated to bradycardia, during dobutamine stress echocardiography. From April 1994 to June 1996, 363 consecutive patients (267 men and 96 women with an average age of 59.3 +/- 10 year) were examined because of suspected or known ischemic cardiopathy. All patients underwent dobutamine stress echocardiography and coronary arteriography. Neither hypotension nor bradycardia was noted in 285 of our patients (78.51%), while in the remaining 78 patients (21.48%) there was a pressure dropor = 20 mmHg; bradycardia appeared in 6 patients. The study shows that it does not exist a statistically significant difference between the percentage of the patients with CAD of the control group and those of the hypotensive group (91.9 vs 83.3%, NS). As for the changes in well motion score index, there was not a statistically significant difference between patients improved score index in the control group and in the hypotensive group (80 vs 74.3%, NS). The 6 patients with hypotension and bradycardia had normal coronary arteries. In the light of these results hypotension, alone or associated with bradycardia, should not be considered as a negative prognostic factor and should not induce to the interruption of the dobutamine stress echocardiography.

The recent implantation of intravascular devices (stents), during percutaneous transluminal coronary angioplasty (PTCA), has shown favourable results, decreasing acute occlusion and restenosis during follow-up as compared to PTCA alone. The aim of the study was to assess in a single center the efficacy of the implantation of a Palmaz-Schatz stent in a homogeneous group of patients and to assess the incidence of angiographic restenosis. Fifty-four consecutive patients (mean age 57 +/- 12 years) with single vessel coronary disease at angiography and with objective evidence of myocardial ischemia were studied. According to the duration of angiographic follow-up, patients were divided into two groups: Group I (mean 6 +/- 3 months) and Group II (mean 29 +/- 5 months). Stent implantation was performed electively in 43 patients (80%) while in the remaining 11 (20%) as "bail out" in a failed PTCA. Sixty-five stents were implanted in 54 patients of whom 1 stent in 47 patients (87%), 2 stents in 3 patients (6%) and 3 stents in the remaining 4 patients (7%). The stents were placed in the anterior descending of the left coronary artery in 32 patients (59%), left circumflex coronary artery in 8 patients (15%) and right coronary artery in 14 patients (26%). Mean diameter stenosis before stent implantation was 88 +/- 6% and decreased significantly to 4 +/- 7% after stent implantation (p0.0001). No major complications such as death, Q wave myocardial infarction, emergency coronary artery bypass graft or stroke occurred during the procedure. Minor complications such as wrong positioning of the stent, non occlusive acute thrombosis, non Q wave myocardial infarction and transient vessel occlusion occurred in 9% of treated patients. At follow-up, in Group I, 8 patient of 43 (18%) showed aor = 50% restenosis and 10 patients50% restenosis; in the remaining 25 patients no variations in the caliber of the vessel were observed. In Group II, 2 patients of 11 (18%) showed aor = 50% restenosis and 1 patient50% restenosis; in the remaining 8 patients no variations in the caliber of the vessel were observed. Complications during medium and long-term follow-up included total vessel occlusion in 1 patient. In conclusion, these data confirm that the Palmaz-Schatz stent may be implanted with high success and low complication rate. The percentage of restenosis, occurring in near 20% of the cases, remains an unresolved problem, despite the implantation of such intravascular devices.

We have analyzed the immediate and mid-term (1 and 2 years) results of percutaneous mitral valvuloplasty (PMV) by Inoue's catheter in 97 patients60 years (Group A) compared with 34 patients60 years (Group B). In 61% Group A the patients were in NYHA functional class II, 36% in III, and 3% in I; in Group B, 56% of the patients were in NYHA functional class III, 38% in II, and 6% in IV. Mean mitral valve area was 1.1 cm2 before dilatation in both groups, and a significant (p0.0001) increase was obtained in both Group A (0.9 +/- 0.3 cm2) and Group B (0.8 +/- 0.3 cm2). No significant differences were observed between the two groups. Mean transvalvular gradient decreased significantly (p0.0001) from 13.6 +/- 5.7 to 7.2 +/- 3.1 mmHg in Group A, and from 9.9 +/- 4 to 6.5 +/- 2.3 mmHg in Group B (A vs B: p0.02). Optimal result was obtained in 94% and 88% of Group A and Group B patients, respectively. Suboptimal result was obtained in 2% and 6% of Group A and Group B patients, respectively. These differences were not significant. Failure of PMV occurred in 4% and 6%, respectively. At 1-year follow-up Group A 7 patients and 5 Group B patients showed restenosis; at 2-year follow-up one more restenosis was present in Group A (A vs B at 1 and 2 years: NS). We conclude that PMV is a safe and effective technique in young patients and in patients60 years.

Atherosclerosis is the most common cause of arterial disease and presently occupies a position of heightened interest. It is the most frequently lethal disease of modern western society. Chronic occlusive arterial disease is a “high risk” pathology affecting population from 40 to over 70 years old, in a various percentage (5%–60%) with prevalence of male gender.

Percutaneous mitral valvuloplasty (PMV) was performed with Inoue's catheter, by anterograde approach, in 19 patients (2 males and 17 females, mean age of 56 +/- 13 years) with restenosis after surgical commissurotomy. Mean valvular area increased from 1.2 +/- 0.2 to 1.9 +/- 0.2 cm2 while mean transvalvular gradient decreased from 13 +/- 6 to 7 +/- 4 mmHg. All but 2 patients reached optimal results; one had a suboptimal result (final valvular area1.5 cm2, percentage of increase less than 25%), and 1 was sent to the surgeon for a significant increase in mitral regurgitation ( ). At 1 year follow-up, (available for 11 patients), mean valvular area was 1.7 +/- 0.3 cm2 and transmitral gradient was of 5.4 +/- 2 mmHg. Four patients showed a restenosis; 1 of them underwent surgical mitral valve replacement after a second unsuccessful PMV; 2 showed good clinical conditions, while the fourth patient was sent to the surgeon for the high echocardiographic score. At 2-year follow-up, available for 4 patients, the mean gradient was of 5.5 +/- 2.5 mmHg and the mitral valve area was 1.8 +/- 0.2 cm2. NYHA functional class progressively improved after the procedure in all patients but those undergoing mitral valve replacement. In conclusion, despite the occurrence of restenosis, PMV seems to be feasible in patients who already underwent surgical commissurotomy; this procedure can avoid the risks of a second surgery, and should be considered the first choice treatment in these patients.