The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias.

BACKGROUND: Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias. METHODS: Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD. RESULTS: Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation. CONCLUSIONS: Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.

Immunosuppressive therapy in virus-negative inflammatory cardiomyopathy.

While there is general agreement on the favorable impact of immunosuppression in eosinophilic, granulomatous, giant cell and lymphocytic myocarditis and with inflammatory myocardial disease associated with connective tissue disorders or with rejection of a transplanted heart, its therapeutic role in the treatment of lymphocytic inflammatory cardiomyopathy (ICM) is still debated. Previous retrospective studies reported a relevant (≥ 10% left ventricular ejection fraction) clinical benefit in 90% of patients with virus-negative ICM and no cardiac impairment in 85% of patients with virus-positive ICM following immunosuppression. Some studies identified cardiomyocyte HLA up-regulation as an additional indicator of ICM susceptibility to immunosuppressive therapy. Recently in a single-center randomized prospective double-blind trial using a combination of prednisone (1 mg/kg per day for 4 weeks followed by 0.33 mg/kg per day for 5 months) and azathioprine (2 mg/kg per day for 6 months) in addition to supportive treatment in 85 virus-negative ICM patients, a significant improvement of left ventricular ejection fraction and a significant reduction of left ventricular dimensions in 88% of 43 treated patients was reported when compared to 42 patients receiving placebo who showed a cardiac impairment initially in 83% of cases (TIMIC study). These data confirm the efficacy of immunosuppression in virus-negative ICM. The lack of response in 12% of cases suggests that the missing response might be due to the presence of viruses which were not screened for or to mechanisms of damage and inflammation not susceptible to immunosuppression. The recovery of cardiac function in responders to immunosuppression was associated with the inhibition of cardiomyocyte death, an increase of cell proliferation and with newly synthesized contractile material.

Effect of the Enveloppe Linguale Nocturne on atypical swallowing: surface electromyography and computerised postural test evaluation.

AIM: Swallowing is a neuromuscular mechanism regulated by many nervous reflex arcs. Persistence of child swallowing at the end of dental eruption is called atypical swallowing (AS). This condition is related to a dysfunction of vertical maxillary growth called open bite. The authors treated this malocclusion with the Enveloppe Linguale Nocturne (ELN), or tongue positioner, created by Dr. Bonnet. The aim of this work is to evaluate the effect of ELN on swallowing and the postural variation obtained by its use. MATERIALS AND METHODS: Seven patients affected by AS were evaluated. Surface Electromyography (sEMG) testing was performed on each patient with different tongue positions, and swallowing was evaluated with and without the ELN. A surface Electromyograph (Biopack) with 8 channels was used (4 channels for the right muscles and 4 for the left) on 4 groups of muscles: temporals, masseters (MM), submental (SUB) and sternocleidmastoids. On each patient a postural test using a computerised Postural test (Lizard) was also performed. Statistical analysis was done using the Graph pad Instat 3 both for sEMG activity and for computerised postural analysis. RESULTS: All seven subjects had different results in the sEMG and footrest tests. The sEMG test results indicated that muscle activation and swallowing duration varied greatly with the use of ELN, with a reduction of time of swallow act (p = 0.002) and variation in contraction of muscles. Mean MM activation was higher without ELN than in tests performed with the appliance (p = 0.002). Mean SUB activation was higher with than without ELN (p = 0.0033). ELN has a therapeutic effect on posture too. Computerised postural test without device showed in all patients an alteration of barycentre as well as an elevated oscillatory record (A mmq; V mms). With ELN footrest kilogram difference (p = 0.0110), Oscillatory Area (P = 0.0102) and velocity of oscillation (P = 0.0102) presented a great reduction in respect to patients record without ELN. CONCLUSION: With ELN the tongue reaches the physiologic position during the swallowing and it is possible to have a low dental contact without tongue interference. ELN has no dental retention or contact. For this reason sEMG swallowing test shows that ELN induces a Mm activation reduction compared to swallowing test without ELN (P = 0.002) and an increase of SUB activation (P = 0.0033). In the same way with ELN there is a significant reduction of time of swallowing (c.f. oral phase) (P = 0.002). Patients with ELN changed their posture with a complete modification of barycentre (Footrest unbalancing kg P = 0.0110), oscillatory movement area (Footrest Area difference P = 0.0102), and oscillatory Velocity (Footrest Velocity oscillation difference P = 0.0102). These data suggest that this appliance has a function in the rehabilitation of atypical swallowing. ELN produces a physiologic neuromuscular mechanism that induces the correction of tongue position.

Clinical and computerized evaluation in study of temporo-mandibular joint intracapsular disease.

AIM: In this work authors show a diagnostic criteria in study of TMID: neuro occlusal clinical evaluation (NOE), T-Scan 2 system and surface electromyography (sEMG). METHODS: Nine patients 25-30 years old with TMID problem and 9 healthy group control have been selected and examined. On each patients it has been performed NOE, T-Scan and sEMG test. NOE has been calculated on each patient photos lateral mandibular excursion angle called: masticatory functional angle (AFM). T-Scan System is a computerized occlusal analyzer that provide in-depth understanding of the overall balance of the occlusion. At the same time of T-Scan record sEMG tests, in resting position and in maximum clench, have been performed. RESULTS: In healthy control there were no AFM difference. In no healthy group there were difference between the two AFM greater than 6 degrees. T-Scan COF showed how in healthy group control there was never a difference of COF greater than 5%. In no healthy group the difference were greater than 5% P<0.05. T-scan showed difference of time force in maximum intercuspidation (MIFT) in healthy respect TMID patients. In healthy patients MIFT was higher than TMID patients P<0.05. sEMG test showed in non healthy group a great asymmetrical activation of masseter (MM). MM activation were greater on side affected by joint sound than the balance side P<0.001. sEMG show how in TMID patients maximum masseter activation is always lower than maximum masseter activation of healthy subjects P<0.001. CONCLUSION: Neuro occlusal clinical evaluation (NOE) in TMID patients is supported by instrumental evaluation.

Sella turcica and craniofacial morphology in patients with palatally displaced canines: a retrospective study.

BACKGROUND: The aim of the study was to evaluate the sella and craniofacial morphological features in growing patients with palatally displaced canines compared to controls. MATERIALS AND METHODS: Twenty-two subjects with palatally displaced canines were retrospectively selected and compared to 22 controls matched for age and gender. Lateral cephalograms were collected and sagittal and vertical cephalometric variables were measured, together with sella interclinoid distance, sella depth, and sella diameter. The independent samples T-test or Mann-Whitney U-test were used to compare all the variables between the two groups. A Pearson correlation was computed for the craniofacial and sella variables that differed significantly (p < 0.05) between the groups. RESULTS: Patients with palatally displaced canines showed a smaller interclinoid distance and a greater SNA angle than control subjects. The interclinoid distance and the SNA angle were negatively correlated (-0.52, p = 0.017) in the experimental group. CONCLUSIONS: Growing patients with palatally displaced canines had smaller sella interclinoid distances and a greater SNA angle than control subjects.

Alterations of energy metabolism and glutathione levels of HL-60 cells induced by methacrylates present in composite resins.

OBJECTIVES: Methacrylic compounds such as 2-hydroxyethyl methacrylate (HEMA), triethylene glycol dimethacrylate (TEGDMA) and bisphenol A glycerolate (1 glycerol/phenol) dimethacrylate (Bis-GMA) are largely present in auto- or photopolymerizable composite resins. Since the polymerization reaction is never complete, these molecules are released into the oral cavity tissues and biological fluids where they could cause local adverse effects. The aim of this work was to verify the hypothesis that the biological effects of HEMA, TEGDMA and Bis-GMA - at a non-cytotoxic concentration - depend on the interaction with mitochondria and exert consequent alterations of energy metabolism, GSH levels and the related pathways in human promyelocytic cell line (HL-60). METHODS: The biological effects of methacrylic monomers were determined by analyzing the following parameters: GSH concentration, glucose-6-phosphate dehydrogenase (G6PDH) and glutathione reductase (GR) activity, oxygen and glucose consumption and lactate production along with cell differentiation and proliferation. RESULTS: All monomers induced both cellular differentiation and decrease in oxygen consumption. Cells treated with TEGDMA and Bis-GMA showed a significant enhancement of glucose consumption and lactate production. TEGDMA and HEMA induced GSH depletion stimulating G6PDH and GR activity. CONCLUSIONS: All the monomers under study affect the metabolism of HL-60 cells and show differentiating activity. Since alterations in cellular metabolism occurred at compound concentrations well below cytotoxic levels, the changes in energy metabolism and glutathione redox balance could be considered as potential mechanisms for inducing clinical and sub-clinical adverse effects and thus providing useful parameters when testing biocompatibility of dental materials.

Myocardial cell death in human diabetes.

The renin-angiotensin system is upregulated with diabetes, and this may contribute to the development of a dilated myopathy. Angiotensin II (Ang II) locally may lead to oxidative damage, activating cardiac cell death. Moreover, diabetes and hypertension could synergistically impair myocardial structure and function. Therefore, apoptosis and necrosis were measured in ventricular myocardial biopsies obtained from diabetic and diabetic-hypertensive patients. Accumulation of a marker of oxidative stress, nitrotyrosine, and Ang II labeling were evaluated quantitatively. The diabetic heart showed cardiac hypertrophy, cavitary dilation, and depressed ventricular performance. These alterations were more severe with diabetes and hypertension. Diabetes was characterized by an 85-fold, 61-fold, and 26-fold increase in apoptosis of myocytes, endothelial cells, and fibroblasts, respectively. Apoptosis in cardiac cells did not increase additionally with diabetes and hypertension. Diabetes increased necrosis by 4-fold in myocytes, 9-fold in endothelial cells, and 6-fold in fibroblasts. However, diabetes and hypertension increased necrosis by 7-fold in myocytes and 18-fold in endothelial cells. Similarly, Ang II labeling in myocytes and endothelial cells increased more with diabetes and hypertension than with diabetes alone. Nitrotyrosine localization in cardiac cells followed a comparable pattern. In spite of the difference in the number of nitrotyrosine-positive cells with diabetes and with diabetes and hypertension, apoptosis and necrosis of myocytes, endothelial cells, and fibroblasts were detected only in cells containing this modified amino acid. In conclusion, local increases in Ang II with diabetes and with diabetes and hypertension may enhance oxidative damage, activating cardiac cell apoptosis and necrosis.

Immunosuppressive treatment of chronic non-viral myocarditis.

Inflammatory cardiomyopathy defined as myocarditis associated with cardiac dysfunction, represents a main cause of heart failure. Despite the improvement of diagnostic techniques, a specific standardized treatment of myocarditis is not yet available. The immunohistochemical detection of myocardial HLA up-regulation has been demonstrated useful in the identification of a sub-group of autoimmune inflammatory dilated cardiomyopathy (DCM) in part susceptible to immunosuppression. Recently, in a retrospective study, we defined the virologic and immunologic profile of responders and non-responders to immunosuppressive therapy of active lymphocytic myocarditis and chronic heart failure in patients who had failed to benefit from conventional supportive treatment. Non-responders were characterized by high prevalence (85%) of viral genomes in the myocardium and no detectable cardiac autoantibodies in the serum. Conversely, 90% of responders were positive for autoantibodies, while only 3 (15%) of them presented viral particles at PCR analysis on frozen endomyocardial tissue. With regard to the type of virus involved in non-responders, enterovirus, adenovirus, or their combination was associated with the worst clinical outcome. Hepatitis C virus (HCV) was the only viral agent of our series associated with detectable cardiac autoantibodies, suggesting a relevant immunomediated mechanism of damage by HCV and explaining the relief of myocardial inflammation after immunosuppressive treatment. The assessment of virologic and immunologic features of patients with biopsy-proven inflammatory cardiomyopathy may allow us to identify a specific treatment leading to recovery of cardiac function.

In vitro comparison of the cytotoxicity of two orthodontic composite resins.

AIM: Several studies have reported that dental resin-based materials release substances with biological activity: for this reason in this study we evaluated the in vitro cytopathic effects of a self-curing and a light-curing orthodontic composite resins by a cytotoxicity test. METHODS: The cytotoxic potential of specimens, prepared according to the manufacturer instructions, was evaluated using the thiazolyl blue tetrazolium bromide (MTT) assay on the mouse fibroblast cell line (3T3 Swiss) with 2 cells-material contact systems: the 24 h extracts method and the indirect toxicity method. RESULTS: The results obtained in this study elicit a close agreement between the 2 procedures; from the data obtained in the reported experimental conditions, it was possible to establish that the examined chemical-cured material is more cytotoxic than the light-cured one. CONCLUSIONS: From a clinical point of view, the photo-polymerizable resins are undoubtedly more useful in the daily practice, because of the larger precision of the bonding obtainable by the greater period available for setting the brackets before their lock. The results obtained in this study, even considering the limits of the in vitro tests, represent a further favourable feature of the light-curing composite resins. However, further investigations about the influence of polymerization methods of the materials on the biological effects are suggested to contribute to the determination of the best clinical operative conditions.

Inflammatory left ventricular microaneurysms as a cause of apparently idiopathic ventricular tachyarrhythmias.

BACKGROUND: We sought to investigate the arrhythmogenic role, incidence, treatment, and prognosis of inflammatory left ventricular (LV) microaneurysms in patients with apparently idiopathic ventricular tachyarrhythmias. Methods and Results-- We studied 156 consecutive patients (71 men, 85 women; mean age, 44.1+/-11.8 years) with severe ventricular arrhythmias and normal 2D echo cardiac parameters by coronary and ventricular angiography, biventricular endomyocardial biopsy, and electrophysiological study. Polymerase chain reaction was used to detect genomic sequences of enterovirus, adenovirus, Epstein Barr virus, cytomegalovirus, herpes simplex viruses, influenza A and B viruses, and hepatitis C virus in frozen endomyocardial samples. Of these patients, 15 (9.6%) showed angiographic evidence of single or multiple LV microaneurysms. All 15 patients had recurrent episodes of ventricular tachycardia with right bundle-branch block morphology, and the arrhythmias originated within or close to the aneurysms in those patients (n=6) undergoing ventricular mapping. A lymphocytic myocarditis was observed in LV biopsies of all patients and in the right ventricles of 3 patients. Polymerase chain reaction analysis was performed in 12 and viral genomes were found in 5 (42%): hepatitis C virus in 2, enterovirus in 2, and influenza virus A in 1. The patients were treated with antiarrhythmics, and cardiac function was preserved for the next 47+/-39.5 months of follow-up. No major clinical event was registered, and arrhythmias were successfully treated by antiarrhythmics. CONCLUSIONS: Inflammatory LV microaneurysms, often of viral origin, are a consistent cause of apparently idiopathic ventricular arrhythmias. Their prognosis so far has been benign, and aggressive therapeutic strategies have been unnecessary.

Role of different determinants of psychological distress in acute coronary syndromes.

OBJECTIVES: The aim of this study was to examine the prevalence of psychological distress and of its major determinants in acute coronary patients and in a control group. BACKGROUND: The prevalence and major determinants of psychological distress in acute coronary patients are not clear. METHODS: One hundred and thirty cardiac patients (110 men, age 56+/-9; 85 with acute myocardial infarction and 45 with unstable angina) and 102 controls hospitalized for acute trauma (70 men, age 55+/-9 years) were studied and the level of psychological distress estimated by a Modified Maastricht Questionnaire, self-ratings and ratings by a close relative. Major determinants of psychological distress were assessed by the Life Events Assessment, the Social Support Questionnaire and the Ways of Coping Checklist. RESULTS: The average level of psychological distress was significantly higher (p < 0.001) in coronary patients than in controls in all tests (self-evaluation=7.1+/-2.3 vs 4.3+/-2.4; relative-evaluation = 7.4+/-2.4 vs 4.2+/- 2.5; Modified Maastricht Questionnaire=91+/-32 vs 59+/-30). Cardiac patients reported significantly higher (p < 0.05) levels of social isolation (28.9+/-11.1 vs 23.4+/-8.8), self-blame (7.2+/-1.9 vs 5.8+/- 1.6) and avoidance (21.1+/-3.5 vs 18.9+/-3) and more painful life events (3.9+/-3.8 vs 2.6+/-2.2), than controls. However, not all patients had evidence of distress; indeed, cluster analysis identified a subgroup that comprised 75% of controls and 25% of cardiac patients with no determinants eliciting distress, while the other four subgroups, with one or more determinants of distress, comprised about 75% of patients and only 25% of controls. CONCLUSIONS: These results show that a high level of psychological distress is detectable in about 75% of patients with acute myocardial infarction or unstable angina and is related to one or more major determinants.

Marked elevation of myocardial trace elements in idiopathic dilated cardiomyopathy compared with secondary cardiac dysfunction.

OBJECTIVES: We sought to investigate the possible pathogenetic role of myocardial trace elements (TE) in patients with various forms of cardiac failure. BACKGROUND: Both myocardial TE accumulation and deficiency have been associated with the development of heart failure indistinguishable from an idiopathic dilated cardiomyopathy. METHODS: Myocardial and muscular content of 32 TE has been assessed in biopsy samples of 13 patients (pts) with clinical, hemodynamic and histologic diagnosis of idiopathic dilated cardiomyopathy (IDCM), all without past or current exposure to TE. One muscular and one left ventricular (LV) endomyocardial specimen from each patient, drawn with metal contamination-free technique, were analyzed by neutron activation analysis and compared with 1) similar surgical samples from patients with valvular (12 pts) and ischemic (13 pts) heart disease comparable for age and degree of LV dysfunction; 2) papillary and skeletal muscle surgical biopsies from 10 pts with mitral stenosis and normal LV function, and 3) LV endomyocardial biopsies from four normal subjects. RESULTS: A large increase (>10,000 times for mercury and antimony) of TE concentration has been observed in myocardial but not in muscular samples in all pts with IDCM. Patients with secondary cardiac dysfunction had mild increase (< or = 5 times) of myocardial TE and normal muscular TE. In particular, in pts with IDCM mean mercury concentration was 22,000 times (178,400 ng/g vs. 8 ng/g), antimony 12,000 times (19,260 ng/g vs. 1.5 ng/g), gold 11 times (26 ng/g vs. 2.3 ng/g), chromium 13 times (2,300 ng/g vs. 177 ng/g) and cobalt 4 times (86,5 ng/g vs. 20 ng/g) higher than in control subjects. CONCLUSIONS: A large, significant increase of myocardial TE is present in IDCM but not in secondary cardiac dysfunction. The increased concentration of TE in pts with IDCM may adversely affect mitochondrial activity and myocardial metabolism and worsen cellular function.

Prognostic significance of left ventricular aneurysms with normal global function caused by myocarditis.

OBJECTIVES: To evaluate the prognosis of left ventricular (LV) aneurysms with normal global function caused by myocarditis. BACKGROUND: LV aneurysms may result from idiopathic or viral myocarditis. The prognosis of inflammatory LV aneurysms when associated with a normal cardiac function is unknown. METHODS: Among 353 patients with a histologic diagnosis of myocarditis, 12 (3.3%) had single or multiple localized LV aneurysms (length, 10.6 +/- 3.1 mm; width, 7.4 +/- 4.2 mm) with normal cardiac function. Presenting symptoms were ventricular tachycardia (VT) in nine patients and unexplained chest pain in three. All patients underwent laboratory tests and noninvasive and invasive cardiac examinations, including biventricular endomyocardial biopsy. RESULTS: In all patients, LV endomyocardial biopsy specimen showed a lymphocytic myocarditis with focal intense myocytolysis or damage of intramural vessels, whereas right ventricular biopsy was diagnostic for myocarditis only in three. Serologic study suggested a viral infection in 3 patients and an immunologic disorder in 2, although it was negative in 7. Treatment included antiarrhythmics in 9 patients with VT, ss-blockers in 1 with chest pain, and immunosuppression (prednisone and azathioprine for 5 months) in 4 with active myocarditis (2 with chest pain and 2 with VT). At intermediate-term follow-up (mean, 53 months; range, 12 to 120 months), LV function was persistently normal in all patients, with an LV aneurysm occlusion being observed in two patients. All patients were asymptomatic, with no VT recurrence or major clinical events. None required implantable electrical devices or a surgical intervention. CONCLUSIONS: LV aneurysms with normal global function caused by myocarditis are an uncommon benign entity in which major therapeutic regimens are usually unnecessary.

Idiopathic myocardial vasculitis presenting as restrictive cardiomyopathy.

A previously unreported case of small-vessel myocardial vasculitis presenting as restrictive cardiomyopathy and congestive heart failure is described. The hemodynamic study, showing severely increased and equalized diastolic pressures in atrial and ventricular chambers, and cardiac MRI, showing normal pericardium and ventricular endomyocardial biopsy, not including myocardial vascular component, were insufficient to make a diagnosis. This made a thoracotomy and surgical cardiac biopsy necessary. Steroids and cyclophosphamide, introduced after histologic evidence of necrotizing vasculitis, unassociated with a systemic disease, became available and improved the clinical profile and the diastolic dysfunction at two-dimensional echocardiographic Doppler analysis.

Right ventricular aneurysm associated with advanced hypertrophic cardiomyopathy.

A previously undescribed case of right ventricular aneurysm (RVA) associated with hypertrophic cardiomyopathy in an advanced stage is reported. The diagnosis was established by noninvasive (cardiac two-dimensional echocardiogram and nuclear MRI) and invasive (cardiac catheterization, angiography, and biventricular endomyocardial biopsy) cardiac examinations, which documented hypertrophied, dilated and hypokinetic biventricular chambers associated with typical histologic findings (histologic hypertrophic cardiomyopathy index of 66%). A prominent narrowing of myocardial arterioles, extended to the right ventricular myocardium, has been identified and has been hypothesized as being responsible for RVA formation.

Giant cell myocarditis responding to immunosuppressive therapy.

An unusual case of giant cell myocarditis presenting with cardiogenic shock that dramatically responded to conventional dose of steroids and azathioprine is reported. Cardiac recovery was rapid, complete (left ventricular ejection fraction rose to 55% from 10%), and was accompanied by the disappearance of the inflammatory infiltrates including giant cells in the control endomyocardial biopsy. Maintenance of the recovery at 16 months of follow-up on a low dose of azathioprine suggests that giant cell myocarditis might be a heterogeneous disease having either a negative untreatable trend necessitating cardiac transplantation, or a curable substrate responding to immunosuppressive drugs.

Coronary angiodysplasia of epicardial and intramural vessels.

A case of coronary angiodysplasia combining large aneurysms of epicardial arteries with diffuse malformation of intramural vessels is reported. Clinical presentation may mimic a vascularized cardiac tumor. Although leaking of the aneurysms in the pericardial space may occur, this entity seems to have a benign prognosis not requiring surgical repair.

Necrotizing myocardial vasculitis in Churg-Strauss syndrome: clinicohistologic evaluation of steroids and immunosuppressive therapy.

Treatment of cardiac dysfunction associated with Churg-Strauss syndrome (CSS) is empiric since the histologic findings provided by endomyocardial biopsy are rare and often nondiagnostic. Myocardial necrotizing vasculitis presenting as restrictive cardiomyopathy has not been reported before. A case of CSS, presenting with fever and progressive heart failure due to pericarditis, eosinophilic endomyocarditis, and myocardial necrotizing vasculitis, is reported. Cardiac involvement assessed by noninvasive (cardiac two-dimensional echocardiogram and nuclear magnetic resonance [NMR] imaging) and invasive (cardiac catheterization, angiography, and biopsy) studies showed a moderate degree of pericardial effusion and left ventricular (LV) dysfunction (ejection fraction 0.40), severe diastolic dysfunction (increased right and LV filling pressure with a dip and plateau pattern) and a severe reduction of cardiac index (1.6 L/min/m2). Histologic characteristics showed marked eosinophilic infiltration of the endocardium and myocardium with myocitolysis and fibrinoid necrosis of arterioles, venules, and capillaries. Combination therapy of steroids and cyclophosphamide resulted in both a clinical (regression of pericardial effusion, normalization of systolic and diastolic dysfunction, and increase of cardiac index to 2.8 L/min/m2) and histologic (sequential endomyocardial biopsies at 1, 3, and 6 months of follow-up) resolution of cardiac involvement. No recurrences were registered at 12-month follow-up with the patient receiving a maintenance drug regimen.

Five-year follow-up of Le Fort I osteotomies.

The outcome of a five-year radiographic follow-up study of 150 patients with maxillo-mandibular malformations who had undergone Le Fort I osteotomy of the maxilla is reported. A superimposition technique made possible an exact evaluation of the adjustments effected. The results confirm the validity of a study conducted in 1977 and the five-year stability of the maxilla. The importance of the relationship between the Frankfort plane, occlusal plane and the osteotomy line is emphasized. In operations in which Le Fort I osteotomy of the maxilla is combined with a sagittal osteotomy of the mandible the maxilla undergoes minute displacements in the weeks following surgery, which can easily be predicted and allowed for at the planning stage. The long-term stability of the maxilla is assured.

[Biomechanical aspects of the space gaining therapy according to Cetlin]. / Aspetti biomeccanici nella terapia di recupero di spazio secondo Cetlin.

The non extraction technique according to N. Cetlin for the treatment of crowded and protrusive dentitions in class I and class II malocclusions is assessed. The intent of this article is to outline the approach to non extraction treatment with the following major clinical objectives: 1) space gaining in both maxillary and mandibular arches; 2) anchorage preservation throughout treatment and 3) intrusion of the maxillary incisors.