Posterior wall as atypical localization of left atrial myxoma : Diagnosis and management.

Atrial myxomas are the most common benign cardiac neoplasms. Although the majority occur in the left atrium (LA) and are attached to the interatrial septum (75-80 % of cases), they can arise from any part of the LA and the cardiac chambers. We report the case of a 65-year-old woman who presented with features of worsening dyspnea and persistent headache. During transthoracic echocardiography, a suspected cardiac myxoma was found arising from the posterior wall of the LA.

Intra-abdominal versus free-loop portion Doppler analysis of the umbilical artery: the importance of the choice.

AIM: The aim of this study was to assess the variations in Doppler indexes along the length of the cord from the intra-abdominal portion (IAP) to the free loop portion (FLP) of the umbilical artery (UA). METHODS: UA blood flow velocities were measured at the IAP and FLP in 100 low-risk singleton pregnancies. The peak systolic velocity (PSV), end-diastolic velocity, pulsatility index (PI), resistance index (RI), PS/ED ratio and Delta value (Δ) were calculated. at each site of sampling and were compared. RESULTS: PI and RI of the IAP were greater versus the FLP. UA blood velocities increased with gestational age and the PSV at the IAP showed different development compared to other sites, increasing from 20 to 30-32 weeks and then decreasing until term. The PSV value was greater in the IAP from 20 until 36 weeks. There were not significant differences in EDV values between the two sites. The Δ PI in IAP remained constantly greater than ~0.2 at all gestational ages. CONCLUSION: UA Doppler parameters vary significantly at different locations, showing the greater value in the IAP. The IAP site is in a fixed anatomical position, therefore potentially reproducible. This potential advantage is very important in cases of severe growth restriction and in monoamniotic twins.

Can immune disorders influence therapeutic approaches in treatment of epilepsy among neurologists? A first cooperative national recognition in Italy.

Functional disturbances of the immune system have been detected more often among persons affected by epilepsy than in the general population. In the February-July period of 2007 a specific questionnaire on the relationship between epilepsy and immunological response was sent to 27 specialized Centres for Epilepsy in nine Italian regions. 15,388 epileptic patients attended twenty-seven Centers during this six-month period. 3.3 percent (n=502) of these patients suffered an immune disease. This is the first National survey on the relationship between epilepsy and immunological response in current clinical practice.

Intravenous IgG: biological modulating molecules.

Intravenous IgG has been adopted as treatment for various immune-related diseases, including immune thrombocytopenic purpura, autoimmune neuropathies, systemic lupus erythematosus, Guillain-Barré syndrome, myasthenia gravis, Kawasaki disease, skin blistering diseases. The intravenous administration of exogenously pooled human immunoglobulin was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies, but in the last thirty years, despite a current lack of institutional approval, off-label IVIgG treatment of a consistent number of disorders has shown to be a useful approach with good clinical results. The mechanism of action of IVIgG is complex and is not fully understood. The current understanding and development in the immune modulant action of IVIgG has three basic mechanisms: 1) F(ab')2 mediated actions; 2) interaction of IgGFc molecule with Fc receptors (FcgammaR); 3) actions mediated by complement fractions binding within the Fc molecular structure. The mode of action of IVIgG involves expression and function of Fc receptors, idiotype network, complement and cytokine network, T and B cell differentiation, modulation of antigen-presenting cells (APC). The therapeutic action of IVIgG is also related to natural antibodies in maintaining immune homeostasis. In addition, IVIgG interaction through V regions with complementary V regions of antibodies may provide a rational basis for selection of various immune repertoires. Since there is a significant gap between the institutional approval and the use of IVIgG in various clinical conditions, for which there is no adequate testing or for which a small number of records does not allow a rigorous statistical approach, several public and private institutions (mostly insurance companies) and research centres have developed guidelines for evaluating a rational and deontological approach in various pathological situations where IVIgG is used. Mathematical models based on non-linear differential equations may represent another potentially useful system to better understand an IVIgG targeted use in individual subjects.

[Pharmacological induction of labour: benefits and risks]. / Induzione farmacologica del travaglio di parto: vantaggi e rischi.

AIM: Induction of labour is a very common practice in modern obstetrics. The most used method is based on the use of topical prostaglandins. In this study we aimed to analyse the results of pharmacological induction of labour through the use of dinoprostone, comparing the intracervical gel (Prepidil 0.5 mg) and the vaginal insert (Propess 10 mg). METHODS: An observational longitudinal study was conducted, in which all patients treated with prostaglandins from January 1, 2003 to June 30, 2006 were included, for a total of 852 cases. The intracervical gel was applied on 32.5% of pregnant women (277 patients) while the vaginal insert to 56.2% (479 patients); in 11.3% of the cases (96 patients) both preparations were administered, one after the other. RESULTS: In 2/3 of the total (568 patients), the induction led to vaginal delivery, in contrast to 284 cases in which the practice showed negative results: in 270 women (31.7%) a cesarean section was practiced. Adverse events occurred only in 1.8% of cases (16 patients); the most frequent adverse reaction was uterine hypertonus in 1.8% of cases, which was in any case resolved with removal of the vaginal insert or injection of a tocolytic drug (atosiban). CONCLUSION: Induction through prostaglandins is an effective and safe method to get cervical maturation. Its success is influenced by Bishop score. In the case of unfit cervix, vaginal insert seems to get better results than intracervical gel. The relation between risks and benefits is certainly better in the latter.

Detection of particle motion using image processing with particular emphasis on rolling motion.

Image-processing has been used in granular systems for detecting particle positions and motion near optically accessible surfaces like sediment flow and bedload transport. We review the image-processing techniques used for single and multiple particles. To enhance reliability in particle recognition, tools like Canny edge and Hough transform are intensively used. We show exemplarily how they can be applied to detect not only particle positions but also rotatory motion. The different steps are described in detail and the algorithm is applied to different examples, which are discussed in view of the obtained accuracy.

Immune-derived cytokines in the nervous system: epigenetic instructive signals or neuropathogenic mediators?

The investigation of the effects of inflammatory cytokines (IC) on the growth and differentiation of neural cells has provided new insights on the role of such soluble mediators in nervous system development and/or plastic remodeling as well as in the pathogenesis of inflammatory neurodegenerative disorders, which are characterized by chronic IC dysregulation in the central nervous system (CNS). Thus, the study of the interaction between CNS and immune-derived soluble signals in physiological or pathological conditions is of increasing interest. This review first discusses experimental evidence supporting the instructive/permissive role of immune-derived cytokines on CNS development and plasticity. Next, we focus on human neurological disease states such as multiple sclerosis and the neurodegeneration associated to the acquired immune deficiency syndrome in which different inflammatory cytokines have been proposed as potential neuropathogenic mediators.

Plasma viraemia in seronegative HIV-1-infected individuals.

It has been reported that the period of latency between HIV-1 infection and the production of antibodies against the virus is sometimes prolonged for greater than 6 months. However, the data supporting this are still controversial and it is not known whether these individuals are actually infectious, especially through body fluids. We have performed a prospective study of 65 high-risk HIV-1-antibody-negative individuals who were followed-up for a period of at least 1 year. Twelve of these individuals were shown by polymerase chain reaction (PCR) to be carriers of HIV-1 proviral sequences. The virus was isolated from lymphocytes in five out of 10 PCR-positive subjects and from cell-free plasma in two. Our data indicate that in some cases delayed seroconversions may be associated with productive infection, suggesting that mechanism(s) other than viral latency may be responsible for the absence of antibody responses to HIV-1 proteins.

Parvovirus infection in children with AIDS: high prevalence of B19-specific immunoglobulin M and G antibodies.

OBJECTIVE: Investigation of the prevalence and pathogenic role of parvovirus B19 infection in Italian and Rumanian children with AIDS, compared with age-matched HIV-negative children (controls) with various recurrent infections of unknown aetiology. DESIGN: Detection of B19-specific immunoglobulin (Ig) M and IgG antibodies as the most indicative markers of past or current B19 infection. METHODS: B19 antibodies were detected by two enzyme immunoassays using synthetic peptide or recombinant protein, which corresponded to different B19 epitopes, as coating antigens. RESULTS: B19 IgM and IgG were seen in 10 out of 20 (50%) Italian and in 20 out of 51 (39.2%) Rumanian children with AIDS, in contrast to none out of 17 Italian and one out of 22 Rumanian controls (P less than 0.001). In addition, two Italian controls (11.8%), two Rumanian children with AIDS (3.9%), and two Rumanian controls (9.1%) had B19 IgM alone. Specific IgG alone was detected in eight (40%) Italian and 14 (27.5%) Rumanian children with AIDS, and in seven (41.2%) Italian and four (10.2%) Rumanian controls. CONCLUSIONS: While it is possible to attribute some B19 infections in Rumanian children to blood transfusion, the source was unknown for Italian children. However, in three of the Italian children who had B19 IgM and IgG persistently for 15-22 months, and in a 2-month-old Italian infant with B19 IgM and IgG, HIV might have activated a congenital or perinatally-acquired B19 infection.

Frequency of provirus-bearing CD4+ cells in HIV type 1 infection correlates with extent of in vitro apoptosis of CD8+ but not of CD4+ cells.

Lymphocytes from HIV-1-infected subjects undergo massive apoptosis when cultured in vitro, and this phenomenon might reflect pathogenetic mechanisms leading to immune dysfunction in vivo. However, (1) lymphocyte death is not restricted to CD4+ cells but seems to involve predominantly CD8+ cells, and (2) the same phenomenon occurs in other viral infections. Furthermore, it is not known whether a relationship exists between the HIV-1 burden and this type of cell death. In this work we sought to determine whether the HIV-1 provirus load correlates with the propensity to apoptosis of CD4+ and CD8+ cells. We studied 10 HIV-1-infected patients with CD4+ cell counts above 500/mm3 and free of concomitant infections. We correlated the frequency of HIV-1-infected CD4+ cells with the extent of culture-induced apoptosis as well as with the phenotype of the apoptotic lymphocytes. We found that the magnitude of apoptosis correlated with the frequency of HIV-1-infected CD4+ cells (p = 0.0007), and that increasing viral load and apoptosis were associated with a shift to the selective death of CD8+ cells. Our data support the view that, in addition to CD4+ cell killing, another immunopathogenic effect of HIV might be that of priming CD8+ cells to apoptosis. In vivo, this could eventually lead to the exhaustion of the cytotoxic T cell compartment.

Risk factors of incomplete distribution of cardioplegic solution during coronary artery grafting.

Myocardial distribution of cardioplegic solution infused by combined antegrade/retrograde routes was assessed with myocardial contrast echocardiography in 18 patients with chronic stable angina and three-vessel disease undergoing elective coronary artery bypass grafting. Overall myocardial opacification was significantly greater in retrograde than in antegrade cardioplegia (77.7% +/- 13.4% versus 59.1% +/- 15.7%; p = 0.0009). The difference was affected by collateral circulation, as pointed out by the significant interaction between coronary collateral circulation and percent of myocardial opacification after antegrade and retrograde cardioplegia (p = 0.002). When we performed multiple comparisons, in patients with good collaterals the opacification difference between antegrade and retrograde cardioplegia was not statistically significant (66.4% +/- 10.2% versus 76.0% +/- 15.2%; p = not significant), whereas in patients with poor collaterals myocardial opacification during retrograde cardioplegia was significantly greater (44.3% +/- 15.0% versus 81.2% +/- 9.0%; p < 0.02). During antegrade cardioplegia, patients with poor collaterals showed a lower degree of myocardial opacification than patients with good collaterals (44.3% +/- 15.0% versus 66.4% +/- 10.2%; p < 0.01). Our results show that retrograde cardioplegia in patients undergoing elective coronary artery bypass grafting offers no advantage over antegrade cardioplegia when collateral circulation is well developed. On the other hand, conventional aortic root infusion may not provide adequate myocardial protection in the subset of patients with significantly narrowed or occluded coronary arteries and poor collaterals.

Detection of IgM antibodies to human herpesvirus 6 in Romanian children with nonprogressive human immunodeficiency virus disease.

The prevalence of human herpesvirus 6 (HHV-6) infection and the course of human immunodeficiency virus (HIV) disease were investigated in 25 Romanian children with nosocomial HIV-1 infection. HHV-6 IgM and IgG antibodies were detected by enzyme immunoassay (EIA) and immunofluorescence assay (IFA) at the beginning of the study and after 18 months, concomitantly with collection of virologic, immunologic and clinical data. The initial HHV-6 seropositivity was 92% by EIA and 76% by IFA, whereas final testing showed 100% positivity by EIA and 84% by IFA. Positive HHV-6 IgM antibodies were detected in 10 children (40%) by EIA and IFA. Of these 9 children (36%) by EIA and 6 (24%) by IFA had both initial and final IgM antibodies. Children with HHV-6 IgM antibodies had a higher prevalence of pneumonitis than those without (100% vs. 53.3%; P < 0.01). In addition they more frequently showed positive p24 antigen detection (67% vs. 40%) and positive HIV-1 culture (80% vs. 69%). Nevertheless the patients with HHV-6 IgM antibodies showed a slight increase in the final mean CD4+ T cell count (from 1.140 to 1.185 x 10(6)/liter), whereas those with HHV-6 IgG alone showed a statistically significant (P = 0.01) decrease (from 1.395 to 968 CD4+ T-cells x 10(6)/liter). Therefore current or recent HHV-6 infection, as revealed by positive HHV-6 IgM antibodies, appeared to be associated with the development of pneumonitis but not with progression of HIV disease. A possible competitive inhibition of HIV-1 by HHV-6 or a stimulating effect of HHV-6 on CD4+ T-cell production may be suggested.

Screening patients affected by common variable immunodeficiency.

Chronic immunoglobulin administration decreases the incidence of bronchial and pulmonary infections in patients affected by chronic variable immunodeficiency (CVI). In this study, an ENT screening was carried out in 22 patients affected by chronic variable immunodeficiency and treated with chronic immunoglobulin administration. All the patients underwent ENT physical examination, nasal endoscopy by fiberoptics, mucociliary transport test (MTT), anterior rhinorheomanometry (RRM), nasal provocation test with cold water (ANPT), audiometry and impedentiometry, olfactory evaluation, and paranasal sinus X rays. Dysphagia was present in 91% of the patients, nasal secretion and obstruction in 77%, and hypoacusia, tinnitus, and otodinia in 57%. Rhinitis and pharyngitis were observed in 86% of the patients, and serous middle ear effusion in 50%. Confirmed maxillary sinusitis was observed in five patients. Hyposmia was observed in 50% of the patients. MTT was significantly longer in the patients than in the controls (18.0 +/- 10.5 vs. 11.2 +/- 2.4 min; p < .05). Nasal resistance was lower in patients than in controls (0.46 +/- 0.32 vs. 1.11 +/- 0.22 Pa/L.s-1; p < .001). ANPT was positive in 9 patients out of 25 versus 1 control out of 15 (p < .05). Finally, seven patients were affected by transmissive hypoacusia, and one patient by neurosensorial hypoacusia. Our results suggest that chronic immunoglobulin administration in CVI patients is not effective against ENT disorders, probably because of the important role played by nasal hyperreactivity. Frequent ENT examination and early treatment of ENT disorders are therefore suggested in order to prevent chronic disease.

Acute myeloblastic leukemia secondary to myelodysplasia (MDS-AML): a comparison of remission induction with three drugs versus standard two-drugs induction.

To evaluate the addition of a third drug to standard induction chemotherapy in patients with MDS-AML, 23 patients (males/females 13/10, median age 54.3 years, range 24-74 years, median MDS duration 9.8 months, range 2-39 months) who received a standard 2-drugs induction were compared with 23 patients (males/females 11/12, median age 45.6 months, range 21-60 years, median MDS duration 8.3 months, range 2-29 months) who received an intensified 3-drugs induction with etoposide. CR rate, median CR duration and median OS were similar in both groups (48% vs 56%, 4.8 vs 5.9 months, 6.5 vs 7.0 months respectively). Among responding patients, all but one, who underwent allogeneic bone marrow transplantation, relapsed. In conclusion, addition of a third drug (etoposide) does not seem to significantly improve the poor prognosis of MDS-AML patients.

Hodgkin's Disease in 50 Intravenous Drug Users with HIV-Infection.

Fifty cases of Hodgkin's disease in intravenous drug users (IVDU) have been collected by the Italian Cooperative Group on AIDS-Related Tumors (G.I.C.A.T.). Ninety-two per cent of the patients were males; the median age was 26 years. Persistent generalized lymphadenopathy (PGL) at onset was present in 54% of patients, AIDS in 9%, ARC in 9% while 28% were simply HIV-positive. The initial median absolute number of CD4 lymphocytes was 264/mmc. Opportunistic infections were diagnosed in 20% of patients. In most patients the histological pattern was that of mixed cellularity and lymphocytic depletion (76%). In almost half the initial symptom was a persistent lymph node enlargement due to PGL. In the majority of patients (58%) only a clinical staging and bone marrow biopsy could be performed due to the presence of opportunistic infections, rapid disease progression or refusal of pathologic staging procedures. One patient presented with a Waldeyer's ring involvement, but no other unusual presentations were observed. After MOPP alternated or followed by ABVD or MOPP alone, 15/29 CR (52%) and 14/29 PR (48%) were observed. The median duration of CR was 14 months, while the median survival of CR has not been reached; the median survival of patients treated with chemotherapy with CD4 values at presentation {geq}400/mmc was significantly superior to that in those with CD4 < 400/mmc. The overall median survival was 16 months. Twenty-eight per cent of patients receiving chemotherapy + radiotherapy developed opportunistic as well as non-opportunistic infections (21%). Lethal hepatic toxicity was observed in 2 patients. In conclusion, Hodgkin's disease in IVDU was not found to be associated with unusual presentations, as previously reported for homosexuals. Complete remissions could be achieved in over 50% of patients, but in IVDU non-opportunistic infections in addition to opportunistic infections may also limit treatment administration. The presence of parenchymal functional impairment due to drug abuse, or drug abuse-related infections, such as pneumonia, endocarditis and hepatitis, should lead to the choice of antitumour agents with no or only minor potential liver, lung and cardiac toxicity.

Left ventricular aneurysmectomy; comparison between two techniques; early and late results.

OBJECTIVE: The aim of the present study was to evaluate early and late results of two different surgical techniques for left ventricular aneurysms repair. The conventional aneurysmectomy and direct closure of the ventricular wall and the endoventricular patch plasty. METHODS: We retrospectively reviewed 118 patients operated on for postinfarction left ventricular aneurysm from 1981 to 1994. Eighty-seven patients (Group A) were operated upon between 1981 and 1991 with the conventional technique and 31 patients (Group B) between 1992 and 1994 with the endoventricular patch plasty technique. Preoperative clinical, hemodynamic and echocardiographic evaluation with operative procedures and early postoperative results of all patients are reported. We also analyzed results of late clinical and echocardiographic controls of 34 patients of Group A and all patients of Group B after a mean follow-up of 42 and 28 months, respectively. RESULTS: Mean number of by-pass grafts was 1.9 in Group A and 2.6 in Group B (P = 0.01). The left anterior descending coronary artery was revascularized in 27 patients of Group A (34.6%) and 26 of Group B (89.7%) (P < 0.001); the left internal mammary artery was used in seven patients of Group A (8.9%) and 24 of Group B (82.8%) (P < 0.001). Hospital mortality in Group A was 10.3% (9/87), in Group B there was no hospital mortality (P > 0.05). Thirty-two patients of Group A (36.8%) and 3 of Group B (9.7%) suffered of low cardiac output syndrome (P = 0.01). At late control, improvements observed in NYHA and CCS classes, left ventricular ejection fraction (all P < 0.001 in both groups versus preoperative values) and left ventricular end-diastolic diameter (P > 0.05 in Group A and P < 0.001 in Group B) proved to be statistically higher in patients of Group B. CONCLUSIONS: Endoventricular patch plasty associated with a complete myocardial revascularization, in particular of the anterior descending coronary, and a larger use of the internal mammary artery, permits, by means of reconstruction of the left ventricular geometry, a better outcome for patients undergoing left ventricular aneurysmectomy.

The role of Doppler technology in the evaluation of fetal hypoxia.

Failing intrauterine support to the fetus can lead to intrauterine growth retardation (IUGR) and hypoxia and it is associated with a high risk of perinatal morbidity and mortality. The main effects of moderate to severe hypoxia on the fetus are different degrees of blood flow redistribution and reduction of oxygen consumption to maintain oxygen delivery to the central organs at the expenses of peripheral organs. The redistribution results in a 'brain sparing' effect. Recently, a Doppler ultrasonic technology (continuous wave, pulsed wave and colour flow imaging) has been developed for the non invasive measurement of flow. Doppler velocimetry detects the flow velocity waveform (FVW) which reflects the cardiac output, the vascular compliance and the resistance to the flow in a defined point of the vessel. Velocity waveform indices or even simpler criteria, such as the presence or absence of diastolic flow or flow reverse during diastole, have been applied to a number of fetal vessels. A significant relationship exists between blood oxygen, systemic lactic acidosis (determined by cordocentesis) and increase PI values in umbilical artery (UA), thoracic aorta (TA) and renal artery (RA). Moreover, in experimental animals during steady state hypoxia, several cardiovascular parameters are affected (heart rate/cardiac output decreases and blood pressure increases) while placental flow don't show a significant variation thus suggesting a raise in placental vascular resistance. Redistribution of the flow may be reliably evaluated by the cerebroplacental ratio (i.e. ratio between PI of MCA and PI of UA, c/p).(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term effects of ritodrine, aminophylline and atropine on umbilical artery blood flow velocity waveform.

With the recent introduction of Doppler technology, a non-invasive methodology which enables to evaluate qualitative changes in circulatory vessels, it is possible to investigate the possible effects of various drugs on several parameters of utero-placental-fetal circulation. In the present study we evaluate the flow velocity waveform (FVW) of umbilical artery (UA) during and after administration of aminophylline, atropine and ritodrine to healthy pregnant women. In our study we did not observe any significant short-term variation of PI after the administration of these drugs. Slight variations were detected, and they may be interpreted on the basis of the mode of action of these drugs. Doppler technology may be a useful tool for monitoring some effects on the fetus of the maternal administration of therapeutic agents.

Arteriomegaly and inflammatory abdominal aortic aneurysm. Case report.

In this case report inflammatory abdominal aortic aneurysm (IAAA) was superimposed on an arteriomegaly condition complicated by bilateral aneurysm of the common iliac arteries. Obstruction of the right ureter, mild hydronephrosis of the left system and a slight impairment of renal function were also present. Preoperative cellular and humoral immunological parameters were within normal limits while the erythrocyte sedimentation rate (ESR) was elevated (74 mm). Histological analysis showed numerous scattered lymphoid cells or organized in follicles with germinal centers within the adventitial thickening of the IAAA wall. Immunohistochemical analysis on frozen sections demonstrated that dispersed and perivascular lymphoid cells were mainly composed of similar amounts of CD3+/CD4+ and CD3+/CD8+ T lymphocytes. Histological analysis of the common iliac artery aneurysm showed a mild intimal thickening will small aggregates of macrophages. After aneurysm repair all peripheral blood analysis normalized within one month after surgery. The IAAA observed in our patient with arteriomegaly as underlying arterial disease cannot be interpreted as an inflammatory variation of an atherosclerotic aneurysm. The histological pattern of the inflammatory reaction and its resolution after surgery give, in our opinion, more credit to the etiopathogenetic hypothesis of a reaction elicited by an antigen within the arterial wall of the infrarenal aorta which might be enhanced by the lymphatic stasis subsequent to aneurysm compression.

Immunoregulation of autoimmune disorders: the role of intravenous immunoglobulins.

Modified and intact immunoglobulin preparations are available for therapeutic use. The administration of intravenous immunoglobulins (IVI G) gave positive results in Primary Immunodeficiency Syndromes (PIS) (prophylaxis of viral and bacterial diseases), in treatment of secondary immunodeficiencies (hematologic malignancies, bone marrow transplantation), and in some infections. Adverse reactions have been reported during IVIG infusions, but they are rarely serious and do not represent limiting conditions for a short or long term therapy. After the original observation in thrombocytopenic purpura, IVIG have been used as immune modulators in various autoimmune related disorders. Various mechanisms of action are proposed: blockade and down regulation of phagocytic function via Fc receptor, regulation of idiotype-anti idiotype network, suppression of idiotype synthesis, T-B cell interference towards antigen presentation, increase in suppressor lymphocytes, IVIG-cytokine interaction.