[Follow-up of the kidney donor]. / Il follow-up nel donatore.

Kidney transplant from a living donor is known to be the best renal replacement therapy. While not as common as in northern Europe and the USA, living donor transplants are on the rise in Italy. Although there is a large body of evidence in the literature about the safety of the surgical procedure, the risk of long-term complications for the donor has not been clearly defined because of the lack of studies with adequate follow-up and a sufficient number of subjects involved. The main questions concern the development of chronic kidney disease in the donor, expressed as a GFR decline or the presence of microalbuminuria. The physiopathological basis of GFR decline and proteinuria development may differ from the model of nephropathy in patients with two kidneys, and this could involve prognostic differences too, particularly with regard to the cardiovascular risk. Detailed and prolonged follow-up programs are needed to monitor and, if necessary, treat long-term complications in kidney donors.

[A case of Kaposi's sarcoma in the rapamycin era]. / Un caso di sarcoma di Kaposi nell'era della Rapamicina.

We report a case of Kaposi's sarcoma in a patient who received a double kidney transplant in 2005. Immunosuppression was induced with rapamycin and antilymphocyte serum while maintenance therapy consisted of rapamycin, corticosteroids and mycophenolic acid. The patient developed delayed graft function but no rejection. In November 2006 and March 2007 two graft biopsies were taken because of a significant rise in serum creatinine; they revealed chronic allograft nephropathy and polyomavirus infection. Meanwhile a skin biopsy of the leg was performed to determine the nature of a discolored lesion. The morphohistological diagnosis was Kaposi's sarcoma. For this reason rapamycin was stopped and steroid treatment gradually reduced. Specific therapy with doxorubicin was started; radiological and endoscopic examination excluded disseminated disease while serological tests were positive for antibodies to HHV-8, a virus known to cause Kaposi's sarcoma. Unfortunately, withdrawal of antirejection therapy caused loss of the graft, so the patient had to start dialysis. In this report we stress the possible development of malignancy in transplanted patients who are given rapamycin. Rapamycin is known to be an antirejection drug and to have antineoplastic activity; the major risk of malignancy is probably related to immunosuppression rather than the type of drugs used to obtain it.

[Neuronal plasticity and neuropathic pain]. / Neuroplasticità e dolore neuropatico.

The authors have analysis the physiopathology of neuropathic pain, focusing in particular on the plastic phenomena at the level of the central nervous system. Plastic phenomena take the form of anatomic and neurochemical alterations. In relation to the former, excitatory amino acids play a fundamental role, causing a state of hypersensitivity of N-menthyl-D aspartate (NMDA) receptors (excitation toxicity) which in turn cause the degeneration of inhibitory interneurons localised in the I-III laminae of the dorsal cornu. This hyperactivation is responsible for the presence of a discharge input that lasts for minutes after a nociceptive stimulus, a phenomenon known as long-term potentiation (LTP) on long term depression (LTD). The authors also analysed the role of other neurotransmitters and their possible interactions. Neurochemical alterations are coupled with anatomic modifications, like sprouting, at the level of the dorsal cornu laminae and dorsal root ganglia. These neuroplastic phenomena lead to an alteration in the central mechanisms of pain, for A-fibre mediated mechano-allodynia, a clinical phenomenon that differs from thermal hyperalgesia in both physiopathology and clinical prognosis. The role played by the sympathetic system in neuropathic pain is also discussed. The authors also raise a number of clinical considerations regarding the different nature of spontaneous pain, allodynia and hyperalgesia. New physiopathological knowledge is a useful tool for pharmacological and clinical research, as well as for treatment of syndromes secondary to neuropathic pain.

[Preemptive analgesia or balanced periemptive analgesia?]. / Preemptive analgesia o balanced periemptive analgesia?

"Preemptive analgesia" means that analgesia given before the painful stimulus prevents or reduces subsequent pain. The concept of preemptive analgesia originates from basic science and experimental studies. However, in some clinical studies preemptive effect is not always present. The authors think that it happens for: differences among experimental models and clinical reality, wrong use of some pharmacological knowledges, some methodological errors in clinical research. The authors analyze these factors and review in a critical manner clinical studies on preemptive analgesia. In some operations, only one administration of an analgesic drug, before surgery, is not sufficient to produce an evident preemptive effect. Postoperative pain can be reduced making a pharmacological treatment before surgery, for the whole time of painful stimulus. For this reason, the term "preemptive analgesia", like "analgesia given before surgery" is not adequate. The authors suggest that the concept of prevention of postoperative pain is well defined by the term of "balanced periemptive analgesia"; it is a new approach that use many modalities of analgesia in different times to prevent and control painful stimulus for the whole time of its origin: before and/or during operation and, if necessary, in the postoperative period for the residual pain.

Prediction of improvement of ventricular function after first acute myocardial infarction using low-dose dobutamine stress echocardiography.

This study was performed to assess the prevalence of spontaneous improvement of regional left ventricular function in patients after acute myocardial infarction, and to evaluate the role of low-dose dobutamine stress echocardiography for its prediction. In 57 patients with a first acute myocardial infarction (thrombolysis, n = 27; Q-wave, n = 49), regional wall motion was evaluated with 2-dimensional echocardiography at rest, during a low-dose dobutamine stress test performed within 1 week after hospital admission, and at 3-month follow-up. Myocardial viability was considered if there was an improvement of > or = 1 grade in dyssynergic segments from rest to low-dose dobutamine infusion; recovery of regional function was defined as an improvement of > or = 1 grade between rest and follow-up echocardiograms. Wall motion score index decreased from rest to low-dose dobutamine echocardiography (1.46 +/- 0.29 to 1.39 +/- 0.30, p < 0.0001), and this change persisted at follow-up study (1.37 +/- 0.30). No differences were found between patients who did and did not undergo thrombolyis, or between those who had Q-wave and non-Q-wave infarction. At baseline echocardiography, 189 of 627 segments were dyssynergic (85 hypokinetic, 104 akinetic). Viability at low-dose dobutamine stress echocardiography was more frequent in hypokinetic than in akinetic segments (30 of 85 vs 12 of 104, odds ratio 4.18, 95% confidence interval [CI] 1.87 to 9.48).(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral valve prolapse. Age and sex incidence, echocardiographic diagnosis and clinical and electrocardiographic correlations]. / Prolasso della mitrale. Incidenza per età e sesso, diagnosi ecocardiografica e correlazioni cliniche ed elettrocardiografiche.

The paper reports an electrocardiographic and M and B-mode echocardiographical study in 3682 non-selected patients among which a total of 241 were identified with mitral valve prolapse. In males the highest frequency was found during the second decade of life with a tendency to decrease with increasing age. In females, who were found to be the most severely affected (2:1 in relation to males), two peaks of incidence were observed during the third and fifth decade, with a greater frequency in the latter and a marked absence of cases in the fourth decade. Many echocardiographically diagnosed mitral prolapses were both clinically and electrocardiographically silent; moreover it was observed that the risks of this complication increased in parallel to the thinness and redundance of the mitralic flap affected by prolapse and the dilation of the valvular ring.

Circadian rhythm of sinoatrial conduction time assessed by 24 hours ECG monitoring.

SACT was evaluated in 50 subjects during 24 hours ECG monitoring. All of these subjects presented frequent atrial beats with no evidence of bradyarrhythmias. SACT was measured in accordance with Strauss' formula (SACT = P2P3 - P1P1/2). Twenty-four hours recording were divided in to 4 time intervals, 6 hour each, starting 7 o'clock. The SACT is higher during nighttime than during daytime. The phenomenon is, presumably, attributable to predominance of the para-sympathetic tone during the night.

Experimental study on the correlation between cardiac function and ovarian hormones.

Results of the study of cardiac function carried out on young women during various phases of the menstrual cycle were correlated to those obtained after acute administration of progesterone. In all cases systolic time intervals reveals a reduction of mechanical systole and of preejection. Direct action progesterone on cardiac function by an unknown mechanism was confirmed.

Cardiovascular effects induced by progesterone administration.

The Authors have studied cardiovascular effects induced by progesterone administration. The results obtained in the present investigation reveal a significant reduction in O-S2 and PEP in the absence of modifications in the values of the other parameters of systolic time intervals. The results confirm the hypothesis that progesterone exerts an adrenergic effect upon cardiac function.

[Study of left ventricular function using systolic time intervals in a group of patients with polycythemia vera (Vaquez-Osler disease)]. / Lo studio della funzione del ventricolo sinistro mediante l'uso dei tempi sistolici in un gruppo di pazienti affetti da policitemia vera (morbo di Vaquez-Osler).

Left ventricular performance has been studied in 50 patients affected by primary polycythemia (P.V.) by determining systolic time intervals. 50 normal subjects were used as control group. All cases underwent a pharmacodynamic test with Amyl Nitrite. The results indicate that patients with P.V. present an abnormal behaviour of left ventricular performance after Amyl Nitrite; this alteration is more evident in patients with arterial hypertension. Amyl Nitrite, through its pharmacological action, causes changes in systolic time intervals and reveals a state of latent cardiac failure.

[Systolic ejection murmur in the differential diagnosis of isolated aortic insufficiency and its association with stenosis]. / Il soffio sistolico da eiezione nella diagnosi differenziale tra insufficienza aortica isolata e associata a stenosi.

As assessment of the value of systolic ejection murmur in the differentiation of valvular insufficiency with and without stenosis was carried out by means of ECG, polycardiography and M-mode echocardiography in 60 patients with aortic valve disease divided into 35 subjects with and 25 without stenosis. Attention was directed to the configuration of the murmur, with particular reference to the proto-, meso- or telesystolic location of its acme and the Q-acme distance. It was found that the acme was meso or telesystolic in all cases where stenosis was present, whereas it was proto- or very initially mesosystolic in its absence.

[Use of systolic times and electrocardiography for the evaluation of left ventricle involvement in aortic valve diseases]. / L'uso dei tempi sistolici e dell'elettrocardiogramma per la valutazione dell'impegno del ventricolo sinistro nelle valvulopatie aortiche.

75 patients suffering from aortic valvulopathy without signs of left ventricular insufficiency have been examined. Left ventricular function is studied by determining systolic times with polygraphic examination (Q-S2, LVET and PEP). The ECG findings were assessed with a myocardial hypertrophy criterion based on a point-score system. Finally, the time of total carotidogram ascent, the 1/2 T and the distance between Q wave and acme of the systolic murmur (Q-acme) were measured. It is concluded that: 1) The most meaningful increases in LVET are associated with the most evident shortenings in PEP only in the phase of the disease in which left ventricular hypertrophy is at its height. 2) The delay in systolic wave ascent should be considered indicative of the functional haemodynamic importance of aortic stenosis, whereas the earliness or otherwise of systolic murmur acme is an expression of the anatomic extent of the stenosis in question.

[Problems of acid-base equilibrium of the organism]. / Alcuni problemi sull'equilibrio acido-base dell'organismo.

The physiopathology, clinical aspects and diagnosis of changes in Acid-Base balance are reviewed. Balance depends on diet, metabolism and efficiency of the emunctory organs (intestinal, renal and respiratory). Changes in Acid-Base balance are more frequent than is commonly thought and are also seen in out-patients whose general condition is not serious. Specific diagnosis is based exclusively on blood measurement of pH, PCO2 and HCO3. It is necessary and sufficient for the physician to remember to carry out these studies more often. It is thus possible to identify and correct initial situations of altered A-B balance which, if ignored, may aggravate general condition to a sometimes fatal extent.

[Some cardiological problems in high mountains. Correlation with humans in flight]. / Alcuni problemi di cardiologia in alta montagna. Correlazioni con l'uomo in volo.

A number of cardiology problems connected with altitude are discussed. Dietetic and pharmacological measures of service to heart patients in high mountain environments are suggested. It is concluded that the more serious patients (belonging to the IVth and Vth N.Y.H.A. functional classes), those suffering from myocardial infarction in the acute phase or from serious pulmonary hypertension, should not go higher than 1.000-1.500 metres above sea level. All other patients (with angina, hypertension, non-serious aortic and mitral arteriosclerotic cardiopathy) can go as far as 3.000 metres without inconvenience, providing the outlined dietetic and pharmacological measures are respected.

[Neurovegetative regulation of the heart and use of beta-adrenergic blocking agents]. / La regolazione neurovegetativa del cuore e l'uso dei farmaci bloccanti beta-adrenergici.

Dynamic adaptation of cardiac activity to respond to various physiological and pathological situations involves the autonomic nervous systems by means of negative feed-back. Beta-blocking drugs are very effective in changing cardiocirculatory regulation equilibria by altering the intensity of the negative feed-back mechanism, or by converting positive feed-back into negative feed-back. A strict and specific indication for the use of these powerful drugs is therefore required. Treatment should also take the form of courses, and be limited in terms of time wherever possible.

[Purpose, organization and structure of the coronary unit]. / Finalità, organizzazione e struttura dell'unità coronarica.

The purposes of the coronary unit are: 1) monitoring of fatal arrhythmias; 2) monitoring of shock and decompensation; 3) protection of the ischaemic myocardium. The structure and organization that a coronary unit should have to fulfil its purposes are described.