Endovascular and surgical approaches of ethmoidal dural fistulas: a multicenter experience and a literature review.

Ethmoidal dural arteriovenous fistulae are rare vascular malformations associated with a high risk of bleeding. We present a multicenter contemporary series of patients treated with microsurgical and endovascular techniques. Sixteen consecutive patients were evaluated and/or treated between 2008 and 2015 at four centers with large experience in the endovascular and surgical treatment of cerebrovascular diseases. We analyzed demographic and clinical data, risk factors for dural fistulas, treatment type, peri- and post-operative morbidity, clinical and radiological outcomes, rates of occlusion, and long-term neurological outcome. Sixteen patients (81 % men, mean age of 58 years) with ethmoidal dural fistulas were included in the analysis. Seven patients had suffered an intracranial hemorrhage; the remaining presenting with neurological signs and symptoms or the fistula was an incidental finding. Three patients were managed conservatively. Among patients who underwent intervention (n = 13), 46.1 % were treated with endovascular therapy and 53.9 % were treated surgically. Complete angiographic obliteration was achieved in 100 % immediately after treatment and at last follow-up evaluation. All patients experienced a favorable neurological recovery (mRS 0-2) at the last follow-up visit (12 months). Ethmoidal dural AVFs are found mostly in male patients. Nowadays, due to wider use of non-invasive imaging, AVFs are discovered with increasing frequency in patients with minimal or no symptoms. Traditionally, these fistulas were considered "surgical." However, in the modern endovascular era, selected patients can be effectively and safely treated with embolization although surgical ligation continues to have an important role in their management.

High serum resistin in chronic viral hepatitis is not a marker of metabolic disorder.

BACKGROUND/AIMS: The role of resistin, an adipocyte-secreted hormone, in insulin resistance and in inflammation is controversial. In chronic hepatitis C, insulin resistance, type 2 diabetes and liver steatosis are frequent and inconsistently correlated to circulating resistin levels. In this study we assessed if viral aetiology and host metabolic parameters influence serum resistin in patients with HCV- and HBV- related chronic hepatitis. METHODOLOGY: Serum resistin was measured by ELISA and correlated to viral aetiology, age, gender, BMI, HOMA-IR, liver steatosis, hepatitis staging and grading, blood glucose, triglycerides and cholesterol in 43 patients with chronic hepatitis C, in 16 with chronic hepatitis B and in 29 healthy controls. RESULTS: In both groups of patients resistin was significantly higher than in controls, with higher values in HBV- than in HCV-patients (p = 0.0007). Resistin levels were correlated to aetiology and, inversely, to age (p = 0.026), diabetes (p = 0.036) and steatosis (p = 0.029). Multiple regression analysis showed that resistin concentration was dependent only on the aetiology of liver disease (p = 0.001). CONCLUSIONS: In chronic viral hepatitis serum resistin levels are high and not associated with altered metabolic parameters or with the histological activity of the disease. The meaning of higher resistin in HBV- than in HCV- chronic hepatitis is unclear.

Endovascular treatment of pulmonary and cerebral arteriovenous malformations in patients affected by hereditary haemorrhagic teleangiectasia.

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.

Unexpected sudden death during acute myocardial infarction: role of primary electromechanical dissociation.

The causes of death during the acute phase of myocardial infarction were studied in 128 patients. Forty-three of these, who had no clear signs of cardiocirculatory failure, were considered to be cases of sudden and unexpected death. Thirty-two of these patients (74%) had electromechanical dissociation, defined as a sudden disappearance of an effective arterial pressure in the presence of adequate electrocardiographic complexes. Twenty-three patients who had been given this diagnosis were males and 9 females; 53% presented with anterior infarction, 31% with infero-posterior infarction, 3.5% with both anterior and infero-posterior and 12.5% with non-Q wave infarction. A previous episode of infarction was recorded in 31.2% of patients with electromechanical dissociation. Autopsy was performed in 84 patients, 23 of whom died with electromechanical dissociation. Half of the latter cases revealed cardiac rupture (secondary electromechanical dissociation), whereas in the other half death was due to primary electromechanical dissociation. The study stresses the relatively high incidence of this cause of death and the need to differentiate between the two different forms. Although at present the pathophysiology of primary electromechanical dissociation is not completely understood, we believe that recurrence of global or local ischemia may play a more important role than cardiovascular inhibitory reflexes.

Emergencies in the retroperitoneum: assessment of spread of disease by helical CT.

Acute pancreatitis, leaking abdominal aortic aneurysm, and renal trauma frequently occur in the setting of patients with abdominal nontraumatic and traumatic injury; it represents the most urgent conditions that may determine the presence of fluid collections or haematoma in the retroperitoneum. Single spiral CT and multidetector-row CT (MDCT) play an important role in diagnosis of retroperitoneal emergencies, providing useful informations on the type, site, extent and management of the fluid collections. An accurate CT assessment requires the awareness of the existence of dissectable retroperitoneal fascial planes. Fluid collections or haematoma tends to escape the retroperitoneal site of origin into planes extend from the diaphragm to the pelvic floor. We assess the multicompartimental anatomy of the retroperitoneum and the pathway of spread of the most frequent retroperitoneal fluid collections or haematoma by helical CT.

Pituitary adenomas: the role of 111In-DTPA-octreotide SPET in the detection of minimal post-surgical residues.

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.

Interferon retreatment of patients with chronic hepatitis C. A long-term follow-up.

BACKGROUND/AIMS: We retrospectively evaluated the long-term efficacy of interferon retreatment in patients with chronic hepatitis C, who did not have a sustained response to a 1st cycle of treatment. METHODOLOGY: Sixty-six patients, 43 non-responder and 23 relapser to alpha interferon treatment, were retreated with alpha interferon, 6 MU thrice weekly for 12 months. Response was defined as negative HCV viremia. Responders underwent long-term follow-up (27-43 months). RESULTS: The response rates were 14% and 35% at the end of retreatment, 7% and 22% at 6 months, and 2% and 13% at long-term follow-up in non-responders and relapsers respectively. The outcome of retreatment was not statistically influenced by age, cirrhosis, viral genotype, dose and duration of previous treatment. CONCLUSIONS: Interferon retreatment, for sustained viral eradication, is not effective in non-responders and useful in few relapsers. Whereas, retreatment could prove effective in slowing down the activity of the disease and reducing the incidence of hepatocarcinoma, since some relapses occur late during the follow-up. Therefore, retreatment should be confined to relapsers with contraindications to new more efficient therapeutic strategies.

Class I HLA antigens hepatic display and beta-2-microglobulin serum values in chronic hepatitis C: effect of treatment with recombinant alpha interferon.

BACKGROUND/AIMS: Enhanced hepatocellular display of class I HLA antigens together with rising serum beta-2-microglobulin (a subunit of class I HLA molecule) and transaminases is reported in patients with chronic hepatitis B during treatment with interferon as an index of immune lysis of virus infected cells. METHODOLOGY: We studied class I HLA antigens and beta-2-microglobulin display in the livers of 23 patients with chronic hepatitis C before and after a 12 month treatment with recombinant alpha interferon. Beta-2-microglobulin serum values were monitored. In all the patients before treatment, class I HLA antigens and beta-2-microglobulin were diffusely displayed in the bile duct epithelium, in the sinusoidal lining cells, in approximately 50% of the inflammatory cells and in the hepatocyte membrane with marked staining in the areas of periportal and lobular necrosis. RESULTS: At the end of the treatment, class I HLA antigens and beta-2-microglobulin were no longer or only faintly detectable in the hepatocytes of 12 patients who showed clinical and histological improvement. The immunohistochemical pattern was unchanged in the 11 patients who did not respond to the therapy. Baseline serum beta-2-microglobulin values were high in all the patients and decreased significantly only in the group of responders. No peaks of transaminases were registered. CONCLUSIONS: The disappearance or reduction of HLA hepatocellular display without acute increase of serum beta-2-microglobulin values and transaminases during successful treatment with interferon in chronic hepatitis C suggests a clearance of the virus due to direct antiviral rather than immunologically mediated mechanism.

Ten year follow-up of patients with chronic hepatitis C treated with interferon.

BACKGROUND/AIMS: The impact of the treatment with interferon (IFN) on the natural history of chronic hepatitis C is not defined. The aim of this study was to evaluate the long term effect of the treatment in patients with chronic hepatitis C. METHODOLOGY: In 31 patients with chronic hepatitis C (9 with cirrhosis) consecutively treated with recombinant alpha 2a interferon (r alpha 2a IFN), the evolution of the disease at 10 years from the therapy was evaluated by means of upper endoscopy, liver ultrasonography (US), liver function tests and hepatitis C virus (HCV) viremia. RESULTS: Among 10/31 patients previously classified as responders, only 1 has signs of evolution to cirrhosis; HCV-RNA is still present in 2. Among 21 non-responder patients, 5 developed hepatocarcinoma (HCC) and 4 died during the follow-up; HCV-RNA is present in all the patients still alive. The 6 patients already cirrhotic when treated have clinical signs of progression to Child class B and C. The biochemical, ultrasonographical and endoscopical evaluation shows onset of cirrhosis in 7 of the others. CONCLUSIONS: Patients with chronic hepatitis C who respond to treatment with interferon have good outcome and rare evolution to cirrhosis. The treatment does not seem to influence the natural history of the disease in non-responders.

Clinical improvement and serum amino acid levels after mud-bath therapy.

Spa therapy is an ancient approach to degenerative diseases such as osteoarthritis, but until today this tradition has been predominantly empiric and intuitive and few studies have focused on the biological changes derived from this treatment. We assessed the clinical efficacy and variations in amino acid concentrations in serum samples from patients with knee osteoarthritis who underwent spa therapy and put forward an explanation of their role in clinical improvement. Thirty-one patients with knee osteoarthritis who underwent spa therapy underwent a clinical evaluation, and serum amino acid levels were assayed before and after a cycle of balneotherapy and mud-pack therapy. The thermal treatments were carried out in Sciacca. Analysis of the data showed a significant reduction in pain and improvement in joint motility. Serum concentrations of tryptophan, cysteine and citrulline were significantly higher than at baseline. No significant differences were observed in serum levels of the remaining free amino acids. The results of this study confirm the efficacy of spa therapy in the treatment of osteoarthritis. A possible role for changes in serum amino acid concentration is discussed.

[Alcohol consumption and coronary disease in men]. / Consumo di alcol e malattia coronarica nell'uomo.

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.

[Behavior of anti-HBc IgM in acute and chronic hepatitis]. / Comportamento degli anti-HBc IgM nelle epatiti acute e croniche.

Anti-HBV core IgM antibodies (anti-HBc IgM) were tested by RIA in the sera from 269 patients with acute viral hepatitis (AVH), from 39 patients with chronic HBSAg+ hepatitis (CH) at various stage of evolution, in 41 asymptomatic HBsAg carriers and in 30 healthy volunteers. Anti-HBc IgM were found in 100/108 HBsAg+ AVH, in 6/161 HBsAg--AVH, in 9/39 with CH and only 1 asymptomatic HBsAg carrier. Among the chronic patients with anti-HBc IgM, 3 were HBeAg+ and 6 were anti-HBe+. The test of anti-HBc IgM results useful in the early aetiological diagnosis of acute hepatitis since it is always positive in HBV acute hepatitis even in the subjects who early seroconvert to anti-HBs; the absence of anti-HBc IgM in the HBsAg+ acute hepatitis suggests other overinfecting agents. The presence of anti-HBc IgM in CH seems not to be related to an active viral replication.

[Pharmacologic induction of fetal immobilization for prenatal diagnostic-therapeutic procedures]. / Induzione farmacologica della paralisi del feto per procedure diagnostico-terapeutiche prenatali.

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.

[Colchicine in the treatment of idiopathic recurrent pericarditis. Report of a case]. / La colchicina nel trattamento della pericardite idiopatica recidivante. Descrizione di un caso clinico.

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.

Contrast materials with low iodine concentration and intra-arterial digital subtraction angiography.

Intra-arterial digital subtraction angiography was performed in 25 patients, using Iopamidol in three different iodine concentrations: 50, 75, and 100 mg I/ml and comparing the results obtained with each concentration. The following vessels were explored: the aortic arch, the common carotid artery, the internal and external carotid arteries and the vertebral artery. The contrastographic effect was satisfactory when lower iodine concentrations were used in very selective catheterizations while greater concentrations of iodine were needed in less selective procedures.

[Prevalence of non A - non B hepatitis in childhood (author's transl)]. / Incidenza di epatiti non A - non B in soggetti dell'età evolutiva.

Little is known from the literature about the epidemiology of non A - non B hepatitis (NANB/H) in childhood. Aim of this study was to assess the prevalence of NANB/H in a consecutive series of children with acute viral hepatitis hospitalized over an one year's period. Thirty children, 9 females, aged 3-12 years, were studied. Serial blood samples were tested for HBsAg, anti-HBs, anti-HBc, anti-HAV (Abbott RIA), anti-HAV-IgM (Absorption Staph. aureus protein A), anti-EBV (Immunofluorescence), anti-CMV, anti-Herpes s. virus (complement fixation). The diagnosis of NANB/H was based on the absence of these markers. Nineteen patients (63,3%) had type A, and 5 (16,6%), had type B hepatitis. One child showed antibodies anti-Herpes with rising titer and 5 (16.6%), 2 females, were considered suffering from NANB/H. None of these patients had been injected or haemotransfuded; all but one came from rural ambient and two from the same family. Two children had an anicteric course. The illness lasted less than 30 days in all but one, who showed three peaks of transaminases and recovered after 70 days. These data show a prevalence of NANB/H in childhood greater than that elsewhere reported, while the absence of injections suggests a way of infection other than parenteral.

[Prostaglandins and gastric cancer: a preliminary study]. / Prostaglandine e cancro gastrico: studio preliminare.

As high levels of Prostaglandins E2 were observed in several gastric diseases, the Authors determined the PGE2 levels in gastric cancer patients without recurrences, in pre and post-operative period. PGE levels were correlated with cancer progression and their significance as tumoral markers was also assessed.

Insulin-like growth factor-II is a useful marker to detect hepatocellular carcinoma?

BACKGROUND: Hepatocellular carcinoma (HCC) is a typical hypervascular tumor. The utility of serum alpha-fetoprotein (α-FP) in its detection is questionable. Over-expression and high circulating levels of insulin-like growth factor-II (IGF-II) were reported in tissue and in serum of patients with HCC. We investigated the diagnostic application of IGF-II in the diagnosis of HCC. METHODS: Serum IGF-II and α-FP levels were measured in 178 patients (82 with HCC and 96 with liver cirrhosis) and in 30 healthy controls. Spearman test, non parametric combination test and confidence interval analysis were used for statistical evaluation of data. RESULTS: The best cut-off values selected by ROC curves were 796 ng/ml for IGF-II and 132 ng/ml for α-FP. IGF-II mean values were higher in patients with HCC than in those with liver cirrhosis (LC) (p=0.0001) but lower in LC than in controls (p=0.0001). Serum IGF-II levels above cut-off were found in 22% of patients with HCC, in 9.3% of those with cirrhosis and in 20% of controls. α-FP serum levels >132 ng/ml were observed in 48% of HCC, in 3.1% of LC and in none of control group. By correlation study, serum IGF-II levels were significantly correlated with serum α-FP levels (r=0.427, p=0.0001) and with nodules' diameter (r=0.252, p=0.0130) but not with nodules' number (p>0.050). Finally, IGF-II showed lower sensitivity, specificity and predictive values than α-FP. CONCLUSION: Circulating IGF-II is not a useful marker for HCC. Further researches are however needed to evaluate its diagnostic accuracy before and after nutritional adjustment.