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Background A careful and integrated follow up after hospitalization for heart failure (HF) may represent a feasible strategy to optimize the adherence to ESC guidelines and reduce the occurrence of adverse events (mortality, re–hospitalizations). Methods A strict integration between hospital and local health district proximity office cardiologist through an integrated clinical data sharing software has been implemented in Apulia region, Italy, in order to optimize the management of the HF patient after an hospitalization: the PONTE (PDTA FOR INTEGRATED FOLLOW–UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) (bridge) project. As until December 2021, 1200 patients with HF have been enrolled in the project, both with reduced (HFrEF) and preserved ejection fraction (HFpEF). Adherence to ESC HF guidelines in HFrEF patients before vs after December 2020 was compared. Results In the HFrEF population (56%) the mean age was 63 years, 38% were hypertensive, 15% diabetic, 40% had ischemic heart disease, 42% were previously treated with coronary angioplasty, 56% had an ICD/CRT, 22% had atrial fibrillation. Mean NYHA class was 2.2, mean LVEF 30%, mean NT–proBNP values 4027 pg/mL, mean serum creatinine 1 mg/dL, 91% were taking beta–blockers (BB), 86% mineral corticoid receptor antagonists (MRA), 98% ACE–inhibitors/angiotensin–receptor–antagonists/neprilysin and angiotensin receptor antagonists (ACE/ARB/ARNI), and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs 13%, p Conclusions The implementation the PONTE project shows an improved adherence to ESC HF guidelines.

Background Dual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. Nevertheless, the risk for bleeding often impact on the long–term administration of DAPT. The aim of this study was to evaluate the determinants of bleeding risk after ACS. Methods This was a subanalysis of the PONTE ACS study. The PONTE ACS study is a prospective, longitudinal, cohort study which enrolled patients who were discharged from HUB centres of ASL BARI after coronary revascularization and/or ACS. They underwent clinical evaluation at 30 days, 3, 6 and 1 year–follow–up. The data were collected after including the data in the electronic medical record of the PONTE ACS study. Anthropometric, clinical and pharmacological parameters, instrumental and laboratory examinations were included. Data were computed in order to evaluate the major determinants of all–cause bleeding at one–year follow–up. Results We finally enrolled 2476 patients (77.4% male, mean age: 67.2±12.0 years). Pharmacological treatments were optimized during the follow–up visits. According to anti–thrombotic therapies, 92.1% of patients persisted on DAPT at one–year follow–up. The number of patients on DAPT+anticoagulant were: 4.4%. All–cause bleeding occurred in 2.2% of patients. Anthropometric characteristics (height [β: –0.04594 ± 0.01610, p = 0.0044] and weight [β: –0.03043 ± 0.01035, p = 0.033]), male gender [β: –0.7008 ± 0.2818, p = 0.0129], and age [β: 0.02535 ± 0.01219, p = 0.0376] were the major determinants of all–cause bleeding at univariate regression analysis but they were not confirmed at multivariate regression analysis (p=ns). Kaplan Meier curve points out the impact of age on all–cause bleeding (Figure 1). Nor DAPT or triple therapy remained associated with all–cause bleeding at one year follow–up. Conclusions Long–term DAPT is not a predictor of all–cause bleeding in patients who suffered ACS and/or coronary revascularization.

Background Patients on chronic dialysis are less likely to receive percutaneous coronary intervention (PCI) for treatment of acute myocardial infarction (AMI). This is due to the lack of evidence from randomized trials, concerns about possible PCI–related side effects, and multimorbidity. Thus, routine use of PCI for treatment of dialysis patients with AMI remains an unresolved issue. Methods We analyzed data of patients on chronic dialysis hospitalized with AMI (both ST–elevation myocardial infarction [STEMI] and non–ST–elevation myocardial infarction [NSTEMI]) from 2003 to 2018, by using the administrative Lombardy Health Database (Italy). Patients were grouped according to whether they were treated or not with PCI during hospitalization. The primary outcome was in–hospital mortality while 1–year mortality was the secondary endpoint. Results During the study period, 265,048 patients were hospitalized with AMI in Lombardy. Of them, 3,206 (1.2%) were on chronic dialysis (age 71±11; 72% males). Among dialysis patients, 44% were treated with PCI, while 54% underwent PCI among non–dialysis patients (P Conclusions Our real–world data showed that in patients with AMI on chronic dialysis, PCI use is associated with a significant in–hospital and 1–year survival benefit. This work was partly financed by the Italian Ministry of Health and the Lombardia Region (Grant NET–2016–02364191; EASY–NET)

Scope. The aim of the study was to evaluate how the Covid–19 state of emergency affected the activity of the Syncope Unit (SU). During the lockdown, the outpatient activities of the SU were suspended(1). Materials. From March 2020 to March 2021, approximately 95 patients booked for the Tilt–up test were medically evaluated by teleconsultation and televiewer. Vasovagal syncope (VVS) (61%), orthostatic hypotension (OH) (5%) was diagnosed. The patients were trained, through television and video tutorials, in the use of counter pressure maneuvers (PCM) and tilt training, while dietary indications were provided and the importance of adequate oral hydration and the need to take, as recommended by the guidelines, 2–3l of water per day. We retrospectively observed the result at the end of the lockdown period: patients with VVS and OH called by the SU no longer needed to perform tilt up tests because they had obtained a significant reduction in syncope in 90% of cases. Discussion Reflex syncope is the most frequent, representing 21% of all types of syncope (2). Accurate history and physical examination are necessary for the diagnosis, sometimes a guided path in the SU in the unexplained forms. The indicated therapy is non–pharmacological (increase the salt and water content in the diet, avoid triggers, tilt training)(2) and, especially in young people, has been shown to prevent recurrences(2). Back pressure maneuvers (PCM) are effective in preventing syncope(3); oral hydration increases blood volume and improves symptoms(4). Conclusions The Covid–19 state of emergency, through the use of telemedicine tools, has made it possible to reach the diagnosis of reflex syncope through an accurate anamnestic evaluation, has allowed patients to be reassured about the benignity of the events and has motivated patients to implement the recommended non–pharmacological therapies. This has made it possible to reduce the number of tilt tests to be performed when the SU reopens.

Chronic hypoxia (CH)-induced pulmonary hypertension (PH) results, in part, from T helper-17 (TH17) cell-mediated perivascular inflammation. However, the antigen(s) involved is unknown. Cellular immunity to collagen type V (col V) develops after ischemia-reperfusion injury during lung transplant and is mediated by naturally occurring (n)TH17 cells. Col5a1 gene codifies for the α1-helix of col V, which is normally hidden from the immune system within type I collagen in the extracellular matrix. COL5A1 promoter analysis revealed nuclear factor of activated T cells, cytoplasmic 3 (NFATc3) binding sites. Therefore, we hypothesized that smooth muscle NFATc3 upregulates col V expression, leading to nTH17 cell-mediated autoimmunity to col V in response to CH, representing an upstream mechanism in PH development. To test our hypothesis, we measured indexes of PH in inducible smooth muscle cell (SMC)-specific NFATc3 knockout (KO) mice exposed to either CH (380 mmHg) or normoxia and compared them with wild-type (WT) mice. KO mice did not develop PH. In addition, COL5A1 was one of the 1,792 genes differentially affected by both CH and SMC NFATc3 in isolated intrapulmonary arteries, which was confirmed by RT-PCR and immunostaining. Cellular immunity to col V was determined using a trans vivo delayed-type hypersensitivity assay (Tv-DTH). Tv-DTH response was evident only when splenocytes were used from control mice exposed to CH but not from KO mice, and mediated by nTH17 cells. Our results suggest that SMC NFATc3 is important for CH-induced PH in adult mice, in part, by regulating the expression of the lung self-antigen COL5A1 protein contributing to col V-reactive nTH17-mediated inflammation and hypertension.

The pressure tubes in CANDU reactors have been operating for times up to about 25 years. The in-reactor performance of Zr–2.5Nb pressure tubes has been evaluated by sampling and periodic inspection. This paper describes the behaviour and discusses the factors controlling the behaviour of these components in currently operating CANDU reactors. The mechanical properties (such as ultimate tensile strength, UTS, and fracture toughness), and delayed-hydride-cracking properties (crack growth rate V c , and threshold stress intensity factor, K IH ) change with irradiation; the former reach a limiting value at a fluence of 25 n m −2 , while V c and K IH reach a steady-state condition after a fluence of about 3 × 10 25 n m −2 and 3 × 10 24 n m −2 , respectively. At saturation the UTS is raised by about 200 MPa, toughness is reduced to about 40% of its initial value, V c increases by about a factor of ten while K IH is only slightly reduced. The role of microstructure and trace elements in these behaviours is described. Pressure tubes exhibit elongation and diametral expansion. The deformation behaviour is a function of operating conditions and material properties that vary from tube-to-tube and as a function of axial location. Semi-empirical predictive models have been developed to describe the deformation response of average tubes as a function of operating conditions. For corrosion and, more importantly deuterium pickup, semi-empirical predictive models have also been developed to represent the behaviour of an average tube. The effect of material variability on corrosion behaviour is less well defined compared with other properties. Improvements in manufacturing have increased fracture resistance by minimising trace elements, especially H and Cl, and reduced variability by tightening controls on forming parameters, especially hot-working temperatures.

Hereditary Haemorrhagic Teleangiectasia (HHT) is a vascular disorder of angiogenesis transmitted in an autosomal dominant pattern, characterised by heterogeneity in clinical manifestations. One of the most important organ involved is lung, including pulmonary arteriovenous malformations (PAVM). PAVM occur in 20 to 30% of the HHT population and recently are considered a marker of disease. PAVM are direct artery-to-vein connections with low pressure and without an interveining capillary bed. PAVM are classified as simple (supplied by one feeding artery) or complex (receiving blood supply from two or more feeding artery). According to the international reports, treatment it's recommendable for all PAVM with feeding vessels 3mm or larger, in order to reduce the risk of cerebral ischaemia and neurologic manifestations frequently attributed to paradoxical embolisation. Transcatheter embolotherapy of PAVM is a form of treatment based on occlusion of the feeding artery to a PAVM by using platinum coils or detachable balloons. The technique of coil embolisation involves the exact localisation of PAVM by pulmonary angiography followed by superselective percutaneous caheterisation of feeding artery obtained by using a dedicated 7F guiding catheter, which coaxially allocates a 5F hydrophilic catheter advanced in order to perform both superselective angiography of feeding artery and embolisation itself. Inside the 5F catheter the platinum coils are advanced using a .035'' guide-wire and released until an optimal occlusion of feeding artery is achieved. At the end of the procedure angiographic control is performed in order to verify the occlusion of feeding artery. The use of platinum coils is preferable over detachable balloons when feeding artery are greater than 7 mm in diameter and have irregular anatomical configuration. On the other hand, the principal advantage of using detachable balloons is that the balloon itself can be deflated and repositioned if necessary. Transcatheter embolotherapy is technically safe and clinically effective and may represent the primary choice of treatment in HHT patients. On the other hand the most common complications of this treatment (pleurisy and air embolism) can be prevented by using some tips during the embolisation procedure like "anchor technique," "scaffold technique" and "balloon assisted technique." Cerebral arteriovenous malformations (CAVM) are present in 10-20% of patients with HHT and multiple in 50% of cases. Cortical surface is the most frequent localisation. Angiography is needed to diagnose all CAVM and to clarify the angioarchitecture of the lesion. In HHT CAVM are usually either micro-AVM, with a nidus not bigger than 1 cm, or small AVM, with a nidus between 1 and 3 cm. Quite frequently there are lesions characterised by arteriovenous fistulas. In the three patterns of CAVM usually found in HHT, small AVM are the most risky for bleeding although the risk is lower than that associated with sporadic ones. It is estimated from 0.38 to 0.69% per year in spite of the general incidence of bleeding in sporadic CAVM that ranges from 2 to 4% per year. In HHT patients, at present, the precise indications and timing of treatment are not established. Trend is to treat small AVM and AVF and to follow-up micro-AVM with MRI and angiography. As for sporadic CAVM, treatment of small AVM is usually referred to stereotactic radiosurgery. Endovascular embolisation is proposable if the lesion is easily reachable by microcatheterism and the position of the microcatheter is safe. Glue is used for embolisation and the technique is briefly discussed.

We describe our experience based on 177 fetal MRI examinations performed in the last ten years, focusing on fetal brain anatomy and fetal brain anomalies, namely oloprosencephaly, agenesis of corpus callosum and Chiari II malformation. Magnetic resonance imaging (MRI) has been proposed as an alternative technique when an expert sonologist requires an in-depth morphological approach. However, there were few literature reports in the 1980s and early 1990s because of both the invasive technique of fetal curarization and later the technical difficulties of MRI “breath holding” sequences. Interest in fetal MRI increased in the late 1990s and many papers appeared after the introduction of MRI ultrafast sequences. Ultrasonography remains the first choice for investigation in pregnancy and technological progress in this diagnostic area with overall 3D ultrasound imaging has led to more accurate indications for fetal MRI in cerebral malformations. The main contribution of fetal MRI imaging is a clear “educational” demonstration of classic malformative patterns of the major pathologies, thanks to spectacular images. We conclude that fetal MRI examination is impressive but substantially unnecessary in the three malformative pathologies considered and in all major malformations. Current use of fetal brain MRI should be reserved for more subtle malformations like neuronal migration disorders, ventriculomegaly of the early second trimester of pregnancy and similar conditions where ultrasound is still ineffective.

Objectives To report, in a population of fetuses diagnosed with partial agenesis of the corpus callosum (PACC), the sonographic characterization, incidence of cerebral, extracerebral and chromosomal anomalies, and outcome. In addition, in some of our cases a comparison was made between findings on ultrasound and fetal magnetic resonance imaging (MRI). Methods This was a retrospective study of all cases of PACC seen at two referral centers for prenatal diagnosis of congenital anomalies over a 10-year period. The following variables were assessed: indication for referral, additional cerebral and extracerebral malformations, chromosomal abnormalities, and pregnancy and fetal/neonatal outcome. Results Among 54 cases of fetal agenesis of the corpus callosum detected in the referral centers during the observation period, PACC was diagnosed at prenatal sonography in 20 cases and confirmed at pre/postnatal MRI and necropsy examinations in 19 cases (35%). These 19 constituted the study group. The diagnosis was made in the sagittal planes and in 12 cases it was made prior to 24 weeks. In most cases the indication for referral was the presence of indirect signs of callosal anomalies, such as colpocephaly. In 10 cases PACC occurred in association with other anomalies and in nine it was isolated. MRI was particularly useful for demonstrating some additional cerebral anomalies such as late sulcation, migrational pathological conditions and heterotopia. Regarding pregnancy outcome, of those diagnosed before 24 weeks which had associated anomalies, all except two were terminated. Of the nine cases with isolated PACC, all were liveborn. Follow-up was available in eight, and two of these (25%) showed evidence of significant developmental delay. In our series the outcome of isolated PACC was not better than that of complete agenesis of the corpus callosum reported in other series. Conclusions PACC can be diagnosed reliably and characterized in prenatal life. The sonographic sign present in most cases is colpocephaly. Prenatal MRI can be performed to confirm the diagnosis. It is particularly useful to demonstrate some additional cerebral anomalies such as late sulcation, migrational pathological conditions and heterotopia. The relatively poor survival rate is due to the high rate of terminations and associated major anomalies. Copyright  2006 ISUOG. Published by John Wiley & Sons, Ltd.

Background The Cochrane risk of bias (RoB) tool has been widely embraced by the systematic review community, but several studies have reported that its reliability is low. We aim to investigate whether training of raters, including objective and standardized instructions on how to assess risk of bias, can improve the reliability of this tool. We describe the methods that will be used in this investigation and present an intensive standardized training package for risk of bias assessment that could be used by contributors to the Cochrane Collaboration and other reviewers. Methods/Design This is a pilot study. We will first perform a systematic literature review to identify randomized clinical trials (RCTs) that will be used for risk of bias assessment. Using the identified RCTs, we will then do a randomized experiment, where raters will be allocated to two different training schemes: minimal training and intensive standardized training. We will calculate the chance-corrected weighted Kappa with 95% confidence intervals to quantify within- and between-group Kappa agreement for each of the domains of the risk of bias tool. To calculate between-group Kappa agreement, we will use risk of bias assessments from pairs of raters after resolution of disagreements. Between-group Kappa agreement will quantify the agreement between the risk of bias assessment of raters in the training groups and the risk of bias assessment of experienced raters. To compare agreement of raters under different training conditions, we will calculate differences between Kappa values with 95% confidence intervals. Discussion This study will investigate whether the reliability of the risk of bias tool can be improved by training raters using standardized instructions for risk of bias assessment. One group of inexperienced raters will receive intensive training on risk of bias assessment and the other will receive minimal training. By including a control group with minimal training, we will attempt to mimic what many review authors commonly have to do, that is—conduct risk of bias assessment in RCTs without much formal training or standardized instructions. If our results indicate that an intense standardized training does improve the reliability of the RoB tool, our study is likely to help improve the quality of risk of bias assessments, which is a central component of evidence synthesis. Electronic supplementary material The online version of this article (doi:10.1186/2046-4053-3-144) contains supplementary material, which is available to authorized users.

Lissencephaly (agyria) is a cortical dysplasia associated with a disturbance in the migration of neocortical neurons. Because of abnormal sonographic findings in the brain of a 24-week fetus, we carried out serial magnetic resonance imaging (MRI) examinations which raised the suspicion of isolated lissencephaly. In the second trimester, an area of damage depicted as low-intensity signals was identified by MRI inside the cortical parenchyma. In the same cortical area, agyria was detected later in pregnancy, and post-natally calcification was observed by computerized tomography (CT) scan. We believe that ultrasound and targeted MRI examination can improve our understanding of some disorders of neuronal migration and that earlier diagnosis is feasible if both methods are employed and interpreted by sound criteria. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

Resumen La deficiencia de piruvato cinasa es una causa rara de anemia hemolitica. Durante el embarazo, se ha tratado casos graves de esta deficiencia con transfusions profilacticas de concentrados de hematies para mantener unos valores de hemoglobina entre 7 y 8 g/dl. Caso clinico Se descubrio un caso de anemia hemolitica secundaria a deficit de piruvato cinasa durante el primer embarazo de una mujer de 32 anos. La anemia se trato con transfusiones de concentrados de hematies, y en la segunda gestacion fue necesario un mayor numero de ellas para mantener los valores de hemoglobina por encima de 7 g/dl. En ambos casos, los recien nacidos tuvieron pesos en el percentil adecuado para su edad gestacional. Conclusiones Este tipo de anemia es raro, y en ocasiones se descubre en situaciones especiales, como embarazo, infeccion o estres.

Acute hypoxia attenuates agonist-induced constrictor and pressor responses in conscious rats, and a recent report suggests that hypoxia may also diminish myogenic reactivity in isolated, perfused rat kidneys. Thus we hypothesized that the diminished responsiveness to pressor agents during hypoxia is caused by an impairment of myogenic reactivity. Male Sprague-Dawley rats were instrumented with a pulsed Doppler flow probe on the left renal artery, an aortic vascular occluder cuff immediately above the left renal artery to control renal perfusion pressure, and catheters were inserted to measure systemic arterial blood pressure and renal arterial pressure (RAP) and for administration of agents. Animals were studied under normoxic or acute hypoxic (fractional concentration of O2 in inspired gials = 0.12) conditions and were administered phenylephrine, arginine vasopressin, or angiotensin II. To determine the myogenic (pressure-dependent) component of agonist-induced vasoconstriction, renal vascular resistance was calculated during agonist infusion with RAP uncontrolled and with RAP controlled to preinfusion levels. Significant myogenic components of agonist-induced renal vasoconstriction were evident with all pressor agents used. However, hypoxia did not attenuate agonist-induced, pressure-dependent increases in renal vascular resistance. We conclude that the reduced vasoreactivity associated with acute hypoxia is not caused by diminished myogenic reactivity.

Two cases of fetal choroid plexus papillomas diagnosed by ultrasound at 21 weeks of pregnancy are reported. Dilatation of the cerebral lateral ventricle, unilateral in one case, made it possible to see the irregular profile of the choroid plexus that was confirmed, successively, by magnetic resonance imaging and anatomic pathological examination on the aborted fetuses.

Recent studies from our laboratory have shown that acute and chronic hypoxic exposures are associated with attenuated systemic vasoreactivity in conscious rats. The present studies examined the role of adenosine triphosphate-sensitive potassium channels (KATP channels) in modulating the pressor and vasoconstrictor responses to phenylephrine (PE) in conscious instrumented rats 1) during acute hypoxia or 2) after chronic hypoxic exposure. Mean arterial pressure, mean cardiac output, and total peripheral resistance were assessed before and after graded infusions of PE in both groups of rats under normoxic or hypoxic conditions. Additionally, the role of KATP channels in attenuating vasoreactivity was determined by administration of glibenclamide (KATP channel blocker) before PE infusions. Acute hypoxia (12% O2) was associated with reduced pressor and constrictor responses to PE in control animals. Furthermore, acute return to room air did not restore the pressor and constrictor responses in the chronically hypoxic rats. Glibenclamide infusion did not influence the pressor or vasoconstrictor responses to PE in either group of animals during normoxia or acute hypoxia. Therefore, our data suggest that opening of KATP channels is not involved in the attenuated vasoreactivity associated with acute and chronic hypoxia in the conscious rat.

Lo studio si compone di due parti: una revisione accurata degli esami RM di 40 soggetti sani volontari suddivisi in quattro fasce di età e lo studio RM di 72 pazienti con patologia del sistema extrapiramidale. I dati di anatomia presentati concordano in larga misura con quelli della letteratura per quanto si riferisce alle caratteristiche morfologiche e di segnale dei centri extrapiramidali. Sono stati soprattutto analizzati i dati relativi al deposito di metalli pesanti, con specifico riferimento al ferro, a livello del nucleo rosso, della sostanza nigra mesencefalica, del globo pallido e del putamen, nelle differenti fasce di età considerate. I dati patologici sono stati esaminati raggruppando i singoli casi in base al reperto lesionale predominante. La diagnosi radiologica che ne risultava è stata poi confrontata con quella clinica. L'interessamento della pars compacta della sostanza nigra mesencefalica era documentabile in 34 pazienti con sindrome clinica ascrivibile a malattia di Parkinson. Il putamen risultava compromesso in modo prevalente in 12 casi con quadro clinico di Parkinson Plus. Tre casi presentavano una tipica atrofia dei collicoli superiori della lamina quadrigemina nell'ambito di una sindrome a tipo paralisi sovranucleare progressiva. In 4 casi era prevalente un'atrofia tronco-encefalica e cerebellare tipica della atrofia olivo-ponto-cerebellare. I pazienti coreici erano infine 19 e tutti presentavano la tipica atrofia della testa del nucleo caudato: in 6 casi con variante rigida giovanile era presente il segno RM caratteristico di iposegnale, nelle sequenze a lungo TR, del putamen. Alla luce dei risultati ottenuti si richiama l'attenzione sui reperti RM delle malattie extrapiramidali in ragione del loro contributo alla clinica.

La RM fetale si candida come metodica di approfondimento nella diagnostica per immagini prenatale, dopo il classico approccio ecografico entrato ormai nel depistage di massa delle anomalie fetali. Il ricorso alla RM fetale ha una storia breve ma l'interesse dei vari autori a questa metodica è risultato crescente nell'ultimo decennio. In questo lavoro viene presentata una breve revisione critica dei dati della letteratura con alcune annotazioni sulle diverse soluzioni tecniche proposte. Viene soprattutto discusso il problema legato ai movimenti fetali che tendono a degradare l'immagine RM dando particolare risalto alle manovre eco-guidate di curarizzazione fetale. Vengono quindi riportati i risultati su una casistica di 27 pazienti gravide in epoca gestazionale compresa tra il secondo ed il terzo trimestre, 22 delle quali sottoposte a curarizzazione fetale. In particolare sono presentati i diversi risultati RM in relazione al diverso dosaggio e al diverso agente curaro-simile impiegato e alcuni dettagli tecnici sull'esecuzione della RM fetale. In questa prima parte del nostro lavoro viene infine discussa l'anatomia normale del cervello fetale all'RM.

This paper reports 15 examinations by magnetic resonance imaging (MRI) performed in pregnant women whose fetuses had cerebral malformations identified by sonography. In all the cases the fetuses were immobilized by ultrasound-guided intravenous or intramuscular curarization. The diagnoses by MRI and ultrasound differed only in one case where an occipital meningocele had first been suggested. No cerebral abnormalities were demonstrated in this case by the MRI study, and this was confirmed at birth. In the remaining 14 cases, MRI confirmed the ultrasound diagnosis of cerebral malformation. In four of these cases, MRI added some additional information to the ultrasound diagnosis of ventriculomegaly by detecting agenesis of the corpus callosum in two fetuses, one Chiari malformation and one triventricular hydrocephalus. Another two ultrasound diagnoses of microcephaly actually proved to be semilobar holoprosencephaly with MRI. In the following cases, the MRI diagnoses concurred with those of ultrasound, and was therefore used unnecessarily despite providing further anatomical details of the lesions: two cases of agenesis of the corpus callosum, one case of anencephaly, a cystic hygroma of the neck, an alobar holoprosencephaly, a Dandy-Walker malformation and a mild isolated hydrocephalus associated with diaphragmatic hernia. In one case of iniencephaly, sonography offered closer approximation to the correct diagnosis. The results obtained unequivocally confirm the high sensitivity of ultrasound examinations in the prenatal screening of cerebral malformations and show that MRI proves to be complementary in uncertain cases or when more accurate anatomical detail is required.

Gli autori analizzano alcuni fattori che possono determinare l'errore diagnostico. Le moderne tecniche neuroradiologiche, a fronte di una sensibilità generalmente elevata, offrono spesso, nei differenti quadri morbosi una specificità non altrettanto alta. Vengono analizzate alcune tappe fondamentali che compongono l'iter diagnostico e che possono notevolmente influire sulla diagnosi: la valutazione clinica, la scelta delle metodiche e tecniche d'esame, l'analisi dell'immagine, il referto. Per evitare o ridurre l'errore diagnostico restano indispensabili la capacità di revisione critica e la disponibilità al confronto quali elementi fondamentali nel lavoro quotidiano per una crescita professionale.

La risonanza magnetica rappresenta attualmente l'esame di prima scelta nello studio delle malformazioni della giunzione cranio-cervicale. Infatti essa permette la contemporanea visualizzazione delle strutture ossee, vascolari, nervose e degli spazi molli paravertebrali nei diversi piani dello spazio. In questo senso diviene fondamentale l'uso di sequenze di impulsi appropriate. In questo lavoro gli autori propongono una ridefinizione della patologia della cerniera cranio-cervicale alla luce dell'uso ormai routinario ed ottimale della RM.

Bacteraemias during burn wound manipulation are frequent, especially following burn wound excision. However, these bacteraemias seem not to have any clinical consequences, and their treatment is therefore controversial. Over a 20-month period 35 surgical debridement procedures were recorded prospectively in 18 burn patients. Blood culture samples were drawn before, during, and after surgical excision. Bacteraemias were found in ten out of the 35 patients (28%), and 16 of the 105 blood samples (15%) were positive. All three blood samples were positive in one case ("primary bacteraemia"), while others were "transient bacteraemia". Six positive blood cultures were considered to be "bacteraemias induced by wound manipulation" and seven "bacteraemias of unknown source". Bacteraemias of unknown source were not recorded at any time while "bacteraemias induced by wound manipulation" were recorded after day 5 post-burn. Patients with more than 40% TBSA had 4.3 times more bacteraemic risk than patients with less extensive TBSA. Blood pressure and white blood cell variations were observed in bacteraemic patients but without any clinical relevance. We conclude that bacteraemic rates were high and that there were two different patterns of bacteraemia- both transient and with no clinical relevance.

Thoracic electrical bioimpedance (TEB) is a non-invasive method used to evaluate beat-by-beat stroke volume (SV) and, when the heart rate (HR) is known, cardiac output (CO). Given the fact that in the electrical impedance signal it is easy to identify the start and end of systole, when an electrocardiographic signal is available this method can also be used for the beat-to-beat measurement of the left ventricular pre-ejection period (PEP), the left ventricular ejection time (LVET), and the PEP/LVET ratio (Weissler quotient), which is widely considered an excellent index for monitoring left ventricular contractility (Fig. 1).

Assessing the haemodynamic status of critical patients is undoubtedly one of the cornerstones of diagnostics and the ensuing therapy in intensive care units. The success of the Swan-Ganz catheter over the past 30 years is linked to the fact that it yields data such as cardiac output (CO), systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR), left and right ventricular stroke work (LVSW and RVSW, respectively), and the filling pressure of the left ventricle (WP) and of the right ventricle (CVP). However, the Swan-Ganz catheter also furnishes shaky information on cardiac preloading [1,2], and its use as a gold standard for comparisons with other methods of measuring CO raises several questions. Indeed, in 1990 the European Society of Cardiology pinpointed the dilution method using a dye such as indocyanine green, with spectrophotometric evaluation of serial assays, as the gold standard.

In recent years, there has been a rise in the number of reports of perioperative and postoperative cardiovascular complications that once went unobserved. The study by Badner et al. [1] demonstrated that in-depth analysis can reveal the presence of acute myocardial infarction (AMI) in the perioperative phase of major non-cardiac surgery to a much greater extent than is usually noted. Using multiple-lead electrocardiography (ECG) in the operating theater, repeated postoperative ECG, regular enzymatic checks (troponin T twice a day for the entire postoperative period), and myocardial scintigraphy with technetium- 99m pyrophosphate in case of doubt, the authors found 18 cases of AMI (5.6%) in 323 patients over the age of 50 years at risk for myocardial ischemia. Of these, most of these events (14) took place on the day surgery was performed or the next day. It is important to note that only 3 patients experienced precordial pain and that most (10) had a non-Q AMI. Consequently, it is clear that AMI is a complication that is anything but rare among risk patients undergoing major non-cardiac surgery. Given its characteristics, however, it may go unobserved and thus untreated.

Scintigraphy with 111In-DTPA-octreotide (111In-octreotide) enables the localization of tumours with somatostatin receptors on their cell membranes, of which pituitary adenomas are an example. Trans-sphenoidal excision of such tumours is sometimes incomplete and the detection of post-surgical residues is a difficult diagnostic task. In this study, we used 111In-octreotide SPET to visualize pituitary adenomas and their minimal residues. In positive cases, the indirect demonstration of the presence of somatostatin receptors may be decisive for the planning of treatment. 111In-octreotide SPET was able to visualize adenomas in 21 of 27 patients (77.7%) (10 GH-secreting, 10 PRL-secreting and 1 non-secreting). Repeat SPET after the recurrence of clinical symptoms and hormone hypersecretion revealed intense 111In-octreotide uptake by residues in 8 of 10 patients (4 GH-secreting and 6 PRL-secreting). Magnetic resonance imaging was positive in only 3 of these 10 patients. Our results suggest that 111In-octreotide SPET, in combination with other imaging modalities, is useful in the diagnosis and follow-up pituitary adenomas. It ensures better selection of patients for treatment with somatostatin analogues, both pre- and post-operatively, and assists in the development of personalized treatment plans.

Objective: To assess the diagnostic potential of Magnetic Resonance Imaging (MRI) in the management of ultrasonically diagnosed congenital anomalies. Patients and Methods: Ninety-two patients were included into the study after the ultrasonic diagnosis of an abnormality. Sixty-three of these patients were affected by an abnormality of the central nervous system (CNS) and 29 by abnormalities in other apparatuses. The GRE technique was used to obtain T1 and T2 starweighted images. Results and Discussion: Satisfactory imaging was obtained in all but one case. In order to define the reliability of MRI for a given condition, a diagnostic score was designed and separately given by the obstetrician and the radiologist involved in the case. MRI scored less than ultrasonography for abnormalities of the fetal contour and for large and complex distortion of the CNS as holoprosencephaly. For subtle midbrain anomalies, as well as for neuronal migration disorders, MRI definitely was superior to sonography. For other anomalies, as for example congenital diaphragmatic hernia, MRI was better than conventional techniques in assessing prognosis and outcome, but less reliable in assessing associated anomalies. MRI seems to be a valuable adjunct to us for prenatal diagnosis of only selected fetal anomalies and requires precise guidelines in a multidisciplinary approach to prenatal pathology.

Diagnostic and prognostic value of the assessment of respiratory mechanics in patients with adult respiratory distress syndrome (ARDS) has been extensively investigated and clearly defined [1–3]. Most studies have investigated the role of compliance and resistance of the total respiratory system in ARDS patients, but only few studies separately considered the relative contributions of the lung and the chest wall. Partitioning of the respiratory mechanics into its lung and chest wall components, in fact, needs the use of an esophageal balloon which is considered, by the majority of physicians, a waste of time and a tedious technique. However, it may allow better definition of the pathophysiology of ARDS in order to improve the consequent clinical management.

General anesthesia deeply influences the behavioral state, altering consciousness and sensation by the direct or indirect effects of various anesthetic drugs. However, these drugs may cause additional effects, sometimes undesirable on other organ systems. In particular, the effects on respiratory function seem to be significant. Although several studies investigated the effects of general anaesthesia on respiratory function, they were specifically performed in healthy young people, and did not include patients with different ages or anthropometric characteristics. Moreover, general anaesthesia may be performed in different positions or surgical conditions (i.e. during laparoscopy), which may further influence the respiratory function compared to the supine position. In this chapter we will discuss the effects of general anaesthesia on respiratory system mechanics in different categories of patients and surgical conditions, as well as the possible clinical implications of these findings and some therapeutic approaches.

Lissencephaly (agyria) is a cortical dysplasia associated with a disturbance in the migration of neocortical neurons. Because of abnormal sonographic findings in the brain of a 24-week fetus, we carried out serial magnetic resonance imaging (MRI) examinations which raised the suspicion of isolated lissencephaly. In the second trimester, an area of damage depicted as low-intensity signals was identified by MRI inside the cortical parenchyma. In the same cortical area, agyria was detected later in pregnancy, and postnatally calcification was observed by computerized tomography (CT) scan. We believe that ultrasound and targeted MRI examination can improve our understanding of some disorders of neuronal migration and that earlier diagnosis is feasible if both methods are employed and interpreted by sound criteria.

A total of 78 pregnant patients who had previously been studied by ultrasound (US) underwent magnetic resonance (MRI) because of suspected fetal abnormality. The first 20 cases were performed using fetal curarization. Even in the 27 cases in which the MR examination concerned other body regions, a brain study was always performed to analyze the normal anatomy at different gestational ages. There is a brief discussion on normal MRI anatomy of the fetal brain. There were 45 studies that concerned central nervous system pathology, and the most frequent malformative and neoplastic disorders were revealed. A comparison between MRI and US is proposed for each. In conclusion, MRI can be regarded as a complementary method that can be helpful in the rare cases when the US diagnosis is doubtful.

Two cases of fetal choroid plexus papillomas diagnosed by ultrasound at 21 weeks of pregnancy are reported. Dilatation of the cerebral lateral ventricle, unilateral in one case, made it possible to see the irregular profile of the choroid plexus that was confirmed, successively, by magnetic resonance imaging and anatomic pathological examination on the aborted fetuses.

It has been recently suggested by many epidemiological studies, and emphasized by a nonspecialistic press, that a moderate alcohol intake may exert a protective role in coronary heart diseases. In our study, by means of a questionnaire, the consumption of alcohol in 100 male patients, less than 70 years old, affected by myocardial infarction and/ or angina pectoris, has been evaluated during a period before and after the admission to our Coronary Care Unit. On the basis of their alcohol intake, patients were divided into five categories: abstainers (8%), daily intake lower than one drink (7%), between one and two drinks (8%) between three and four drinks (46%) and equal or higher than five drinks (31%). In the light of these results, we suggested that, in our region (a country area in the north-east of Italy), there are higher levels of ethanol intake compared to those reported by other authors, that these parameters are only slightly modified by the occurrence of coronary heart diseases and that alcohol consumption, although low and moderate, must be therefore emphasized with extreme caution.

Previous studies from our laboratory indicate that acute but not chronic hypoxia decreases the hemorrhage volume required to elicit reflex hypotension. Furthermore, chronically hypoxic animals exhibit an elevated hypotensive threshold during both normoxia and hypoxia compared with control animals. Because reports suggest that opioid and serotonergic mechanisms may be involved in mediating the sympathoinhibition that occurs with hemorrhage, we hypothesized that opioid and/or serotonergic systems are stimulated during hemorrhage under conditions of acute hypoxia and suppressed after chronic exposure to hypoxia and are thus responsible for the altered cardiovascular responses to hemorrhage under each condition. Control and chronically hypoxi rats were administered either the opioid receptor antagonist naltrexone (1 mg/kg), the selective 5-hydroxytryptamine receptor subtype 3 (5-HT3) serotonergic receptor antagonist MDL-72222 (0.5 mg/kg), or their respective vehicles intravenously before hemorrhage was initiated during normoxia or hypoxia (FIO2 = 0.12). In control animals, pretreatment with naltrexone increased the hemorrhage was initiated volume required to achieve hypotension in hypoxic but not normoxic conditions. Naltrexone had no effect on hypotensive threshold in chronically hypoxic animals under conditions of either normoxia or hypoxia. In addition, MDL-72222 had no effect on hypotensive threshold in either control or chronically hypoxic animals in either normoxic or hypoxic conditions. We conclude that endogenous opioids may contribute to the reflex hypotension that occurs during hypoxic hemorrhage in control rats, while no such involvement is evident in chronically hypoxic animals. Furthermore, peripheral 5-HT3 receptors are not likely involved in this response during either normoxic or hypoxic hemorrhage in control or chronically hypoxic rats.

Treatment of recurrence, which is one of the major complications of pericarditis, is often difficult. After three recurrences of idiopathic acute pericarditis, over a period of four months, despite therapy with acetylsalicylic acid, indomethacin and methilprednisolone, a patient, 37 years old, responded favorably to colchine treatment. No recurrences, no side effects were observed, after a prolonged low dose treatment. Our report suggests, therefore, that colchinine may be beneficial in acute attacks of idiopathic pericarditis and may be useful in avoiding recurrent episodes of pericarditis.

Neuro-muscular blocking agents are currently administered to the fetus during intrauterine procedures, in order to freeze fetal movements and to avoid traumatic effects. The authors have evaluated three drug regimens (Pancuronium, Vecuronium, Atracurium), both via the intramuscular and the intravascular route of administration to the fetus. The time lapse between injection and disappearance of movements and the duration of paralysis have shown no significant differences for each group. The duration of fetal immobilization, on the other hand, has resulted excessively long for the necessity of the procedure. The authors speculate that immaturity of fetal metabolism can be responsible for the prolonged action of the drug. No side effect related to paralysis have been recorded at birth and after two years follow-up.

This paper reports 15 examinations by magnetic resonance imaging (MRI) performed in pregnant women whose fetuses had cerebral malformations identified by sonography. In all the cases the fetuses were immobilized by ultrasound-guided intravenous or intramuscular curarization. The diagnoses by MRI and ultrasound differed only in one case where an occipital meningocele had first been suggested. No cerebral abnormalities were demonstrated in this case by the MRI study, and this was confirmed at birth. In the remaining 14 cases, MRI confirmed the ultrasound diagnosis of cerebral malformation. In four of these cases, MRI added some additional information to the ultrasound diagnosis of ventriculomegaly by detecting agenesis of the corpus callosum in two fetuses, one Chiari malformation and one triventricular hydrocephalus. Another two ultrasound diagnoses of microcephaly actually proved to be semilobar holoprosencephaly with MRI. In the following cases, the MRI diagnoses concurred with those of ultrasound, and was therefore used unnecessarily despite providing further anatomical details of the lesions: two cases of agenesis of the corpus callosum, one case of anencephaly, a cystic hygroma of the neck, an alobar holoprosencephaly, a Dandy-Walker malformation and a mild isolated hydrocephalus associated with diaphragmatic hernia. In one case of iniencephaly, sonography offered closer approximation to the correct diagnosis. The results obtained unequivocally confirm the high sensitivity of ultrasound examinations in the prenatal screening of cerebral malformations and show that MRI proves to be complementary in uncertain cases or when more accurate anatomical detail is required.