Strengths of early physical rehabilitation programs in surgical breast cancer patients: results of a randomized controlled study.

BACKGROUND: In the immediate postoperative period surgical breast cancer patients can face many problems including functional limitation of the shoulder, edema, pain and depression. Although those symptoms can alleviate during the stages of the therapeutic route, most of the time concur significantly to the everyday life discomforts decreasing sharply the quality of life. Therefore, is essential to pay attention to the functional problems of breast cancer patients in order to ensure a quick and complete physical and psychosocial recovery. AIM: Aim of this study, comparing 2 groups of patients, one that underwent to early physical rehabilitation program (EPRP) and one as a control group, is to evaluate: functional improvements of the glenohumeral joint mobility, antalgic effect of EPRP, improvements and/or worsening of quality of life. DESIGN: Randomized controlled study. SETTING: Inpatient and outpatient clinic, Breast Unit, "San Giuseppe Moscati" Hospital, Avellino, Italy. POPULATION: Seventy women planned for Madden's modified radical mastectomy or for segmental mastectomy with axillary dissection in the period from March 2010 to February 2011. METHODS: Patients were randomly assigned to treated and control group. All participants were evaluated before surgery and postoperatively at fifth day, first, sixth and twelfth month. Patients of the treated group, underwent first, to assisted cautious mobilization of hand, wrist and elbow and after drainage removal, to twenty physiotherapy sessions under the guide of a physiotherapist. RESULTS: Within group statistical analysis evidenced that TG regained normal function at 1 year after surgery while CG was unable to do so for flexion, abduction and internal rotation movements. TG manifested general and statistically significative improvements in QoL. Improvements in the grade of pain perceived were observed starting from the first postoperative month. CONCLUSION: Postoperative early physical rehabilitation programme in surgical breast cancer patients surgically treated significantly improves glenohumeral joint mobility, reduces pain and widely improves the quality of life. CLINICAL REHABILITATION IMPACT: Early rehabilitation plays a key role in the physical and psycho-social recovery for breast cancer patients surgically treated with axillary dissection.

Ischemic necrosis with sigmoid perforation in a patient with Systemic Lupus Erythematosus (SLE): case report.

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory rheumatic disease which affects the connective tissue. Its etiology is as yet unknown, while its pathogenesis involves the immune system. Both genetic and environmental and hormonal factors play a key role in the impaired immune regulation. A correlation with estrogens is demonstrated by the fact that the greatest incidence is found in young women, when estrogen secretion is at its highest. The disease is also reported to worsen in women taking oral contraceptives. It is therefore believed that the components of oral contraceptives, estrogens (ethinyl estradiol) and progestins, can affect the immune profile. Of the various complications attributed to systemic lupus erythematosus, gastrointestinal disorders are less common but potentially by far the most serious. We report a case of ischemic necrosis with sigma perforation in a patient with SLE. Signs and symptoms of acute abdomen in patients with SLE are rare (0.2%), but serious. Most patients require an exploratory laparotomy, as the causes are often linked with vasculitis.

[Diagnostic and therapeutic guidelines for entero-cutaneous fistulas. Personal experience and literature review]. / Orientamenti diagnostico-terapeutici nel trattamento delle fistole enterocutanee: esperienza personale e review della letteratura.

The entero-cutaneous fistulas (ECF) are abnormal communications between intestine and abdominal skin. They can occur spontaneously, or after an injury or a surgical procedure. They are associated with a high rate of morbidity and mortality. Spontaneous fistulas can mainly occur in patients affected by cancer, inflammatory bowel disease, diverticulitis, appendicitis, as a result of radiotherapy or injuries. Surgical procedures, carried out in case of neoplastic diseases, inflammatory bowel disease, adhesions removal, represent the primary cause in the development of a postoperative fistulas. Malnourishment, poor general conditions of the patient, high output fistula along with anatomical site of development, and the presence of abscesses, represent the negative factors influencing the spontaneous healing of fistulas. The experience reported here is about three ECF cases occurred after surgery and treated only with medical therapy. The first case is a woman in good general conditions who underwent surgery to remove a recurrent retroperitoneal myxoid liposarcoma situated in the right lower quadrant. The patient had never undergone surgery for an intestinal resection. The other two patients analyzed were affected by sepsis and metabolic unbalance and had developed a fistula after colonic resection. Fluids and electrolytes adjustments and sepsis management have preceded any other kind of therapy. Continuous infusion with somatostatin, fast, proton pump inhibitors and loperamide have been taken up to decrease secretions and intestinal motility. Total parenteral nutrition has been essential to recover nutritional status and improve patients' general conditions. In order to heal and protect peri-fistula skin we have used sterile washing solutions, absorbable ionic exchange resin, silver and polyurethanes based medications and colostomy bags adhesive systems. Since surgical treatment of ECF is associated with high rates of morbidity and mortality, conservative treatment should always be taken into consideration. When conservative treatment fails, delayed surgical intervention has been related to a higher rate of success. The purpose of this study is to describe diagnostic and therapeutic guidelines to general surgeons, like ourselves, whenever they have to deal with ECF cases.

[The gold standard in the treatment of haemorrhoidal disease. Milligan-Morgan haemorrhoidectomy vs Longo mucoprolapsectomy: comparing techniques]. / Il gold standard nel trattamento della malattia emorroidaria. Emorroidectomia secondo Milligan-Morgan vs mucoprolassectomia secondo Longo. Tecniche a confronto.

AIM: Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease. METHODS: From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation. RESULTS: The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences. CONCLUSION: The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.

[Diagnosis and treatment of gallbladder and common bile duct stones: our experience]. / Diagnosi e trattamento della calcolosi colecisto-coledocica. Nostra esperienza.

AIM: The aim of this study was to verify the possibility to identify and treat common bile duct (CBD) stones by means of preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with a reduction of postoperative complications. METHODS: We have carried out a retrospective monocenter analysis of 104 consecutive patients who underwent a laparoscopic or open cholecystectomy performed by a single surgeon at the VII Division of General Surgery, Second University of Naples, between 2002 and 2006. Before the operation, we have performed highly selective studies like MRCP and ERCP to identify and treat CBD stones in patients affected by pancreatitis, jaundice, high liver function tests or in case of common bile duct dilation at the US examination, without intraoperative cholangiography. RESULTS: Of 104 patients with indication for a cholecystectomy, 22 patients (21.2%) presented high levels of cholestasis tests; 13 patients (12.5%) presented common bile duct dilation at the US examination (>6 mm diameter). Both groups underwent a MRCP which was positive in 8 patients (7.7%), confirming the diagnosis of common bile duct stones. For these reasons we removed CBD stones using preoperative ERCP. CONCLUSION: Preoperative ERCP and RMCP, without intraoperative cholangiography, is not associated with a significant increase in morbility/mortality associated with CBD stones before surgical treatment.

[Minilaparotomy versus laparoscopy in the treatment of cholelithiasis: our experience]. / Minilaparotomia versus laparoscopia nel trattamento della litiasi biliare: nostra esperienza.

The traditional biliary surgery has undergone some transformations to patient's advantage. Nowadays the open-surgery of cholelithiasis is inclined to reduce the incision to 5-6 cm and to perform a transverse one to respect the anatomy of abdominal wall. From July 2002 to April 2006, 82 cholecystectomy (53 minilaparotomy cholecystectomy, and 29 laparoscopic cholecystectomy) have been performed in our institution. The two groups are homogeneous for age, sex, BMI, ASA. Among the patients who underwent a minilaparotomy cholecystectomy we observed a quick recovery of normal activities already 24 hours from the operation, a hospital stay of 24-48 hours and an excellent esthetic result. The minilaparotomy approach is, in our opinion, similar to laparoscopic for short and long time results. Nevertheless, according to medical literature, our first choice is for laparoscopic approach and we prefer laparotomy approach in selected clinical conditions.

[Anastomotic configuration as a risk factor in the recurring onset after intestinal resection for Crohn's disease: our point of view]. / La configurazione anastomotica quale fattore di rischio nell'insorgenza di recidiva dopo resezione intestinale per morbo di Crohn: nostro punto di vista.

Crohn's disease is an inflammatory chronic intestinal disease characterized of an high level of postoperative recurrence. Actually surgical treatment is not decisive; patients can undergo several operations during their lives, running the risk of coming up against the syndrome of short bowel. The main disease frequently appears in the segment ileo-caecal, while the site more often affected by the recurrence seems to be the stump close to the anastomosis. General, local and not specific factors should influence the recurrence level. Among the general factors, cigarette smoking would have a leading role in the recurrences onset. Giving up smoking and a treatment with 5-ASA (amino-salicylic acid) help to reduce the risk of Crohn's recurrences after surgery. During the treatment of this pathology the wide intestinal resections are not justified because the anastomotic recurrence after resection seems to be influenced not by the presence of remaining lesions but by the type of realized anastomosis. Although they disagree about the type of anastomosis to adopt, the authors agree identifying the anastomotic stenosis as the main factor which determines the recurrences. Stenosis, in fact, determining fecal stasis and, therefore, the increase of the pressure at the intestinal wall level, causes ischemia of this same wall. Ischemia puts up the risk of fistulas and anastomotic dehiscence. The mechanical or manual ileo-colic side-to-side anastomosis, assuring a wide lumen, drops to the minimum the risk of stenosis compared with the end-to-end and end-to-side configurations. And then, the side-to-side ileo-colic anastomosis avoiding the intestinal compartmentation between ileo and colon, guarantees less reflow in the small bowel of bacteria and colic metabolite. In this way the inflammatory process which brings to the fresh outbreak of the disease on the mucosa of the near anastomotic head faints. In the light of this thesis, most of the authors, including the writer, agree about making the side-to-side anastomoses in the intestinal resections for the Crohn's disease.

Carcinoid of the vermiform appendix. Description of three clinical cases and review of the literature.

Carcinoids of the appendix represent a separate class of tumours with characteristics that vary between benign (adenomas) and malignant (carcinomas) neoplasias. A recent nomenclature identifies them as diffuse neuroendocrine system (DNS) and/or, parallely, as neuroendocrine tumours (NET): the gastroenteric tract is the site of about 64.3% of carcinoids, followed by the respiratory tract with 25.3%. Among the gastrointestinals, tumour of the small intestine is the one with the highest incidence with 28.5%, followed by the appendix with 4.77%, the rectum with 13.6% and the stomach with 4.6%. Carcinoid of the colon has an incidence of 8.62%, with the caecum which alone represents 34.5% of colic localisations. The 3 cases described are an example of the behavioural unpredictability of intestinal carcinoids. The first case is that of a female patient in whom the primary tumour was only discovered after liver metastasis was documented. The second case regards a girl who, at admission, presented a picture of acute abdomen with the symptomatological characteristics of acute appendicitis. She was submitted to an appendicectomy. Subsequent investigations carried out in the postoperative period documented the presence of liver metastasis at the V and VI liver segments. The last case, similar to the second from certain points of view, shows the need to carry out a right hemicolectomy with removal of locoregional lymphnodes in the event of an appendicular carcinoid >2 cm. Both laboratory and instrumental examinations contribute to the diagnosis of intestinal carcinoid. The main laboratory examinations are based on the measurement of serotonin and urinary 5-hydroxy-indolacetic acid. First level instrumental examinations for the diagnosis of intestinal carcinoid are represented by CT with and without contrast medium, diagnostic endoscopy and, to better highlight the presence of locoregional metastases, scintigraphy with octreotide and PET. An alternative treatment of liver metastases other than surgery is most certainly chemoembolisation. This latter treatment has also proved very effective as a neoadjuvant treatment for liver metastases before subjecting the patient to liver resection. Treatment with somatostatin, on the other hand, proved effective in controlling tumour secretion, so attenuating the inconveniences of carcinoid syndrome.

[Nearly total thyroidectomy: versus total thyroidectomy: our experience]. / Tiroidectomia quasi totale versus tiroidectomia totale. Nostra esperienza.

AIM: Generally, the classification of thyroidectomy as benign pathology is: multinodular toxic goitre, simple goitre, toxic adenoma, Base-dow disease, Hashimoto's tyroiditis Subtotal thyroidectomy provides for the removal of the gland except for a bilateral residue of about 6-10 g, near total thyroidectomy provides for the near total removal of the gland except for a residue inferior to 5 grams. Near total thyroidectomy has taken the place of the subtotal thyroidectomy. METHODS: In two years, in our institute, there have been exeuted: 96 near total thyrodectomies, 96 total thyroidetomies, 8 lobectomies ad two revues for recurrencies. RESULTS: In 2 cases there have been haemorrhagies after nearly total thyroidetomy. Only in 1 case we practiced tracheotomy for follicular carcinoma infiltering thiroidic cartilage. In 2 cases treated with nearly total thyroidetomy and in 4 cases treated with total thyroidetomy, there has been temporary hypoparathyroidism. In no case treared wih nearly total thyroidetomy and in 2 cases treated with total thyroidetomy, there has been permanent hypo-parathyroidism. In 5 cases treated with total thyroidetomy and in no case treated with nearly total thyroidetomy, there has been, monolateral, temporary paralysis of the inferior laryngeal nerve that solved in 6 months for 3 patients and in 2 months for 2 patients. CONCLUSIONS: There has not been permanent paralysis of the mono or bilateral inferior laryngeal nerve. Even if the surgical approach to the benign disease is now orientated to the total thyroidectomy, a more conservative surgery is, in our opinion, justified when a malignant pathology is excluded and considering also the low effect of recurrencies and hypothyroidism.

Long-term follow-up of right ventricular monomorphic extrasystoles.

OBJECTIVES: The purpose of this study was to verify in a long-term follow-up whether frequent monomorphic right ventricle extrasystoles may progress to arrhythmogenic right ventricular dysplasia (ARVD). BACKGROUND: Frequent monomorphic right ventricle extrasystoles are generally considered benign. However, in patients with this pattern, cardiac magnetic resonance (MR) has recently shown anatomical and functional abnormalities of the right ventricle. METHODS: Sixty-one patients who had been classified by noninvasive examinations as having frequent idiopathic right ventricle ectopy were contacted after 15 +/- 2 years (12 to 20) and submitted to clinical examination, electrocardiogram (ECG), Holter monitoring, stress test, signal averaged ECG, echocardiography and, in 11 patients, cardiac MR. The primary end point was to ascertain the presence of cases of sudden death or progression to ARVD. RESULTS: At the end of the follow-up, 55 patients were alive; six died, none of sudden death; eight stated to be well but refused further examinations. The 47 patients examined had normal ECG; in 24 patients (51%), extrasystoles were no longer present at Holter monitoring; late potentials were present in up to 15% of the patients; the right ventricle was normal at echocardiography. In 8 of 11 patients (73%), cardiac MR showed focal fatty replacement and other abnormalities of the right ventricle. CONCLUSIONS: In this long-term follow-up study, no patient died of sudden death nor developed ARVD; two-thirds of the patients were asymptomatic, and, in half of the patients, ectopy had disappeared. Focal fatty replacement in the right ventricle was present in most.

Comparison of defibrillation thresholds using monodirectional electrical vector versus bidirectional electrical vector.

BACKGROUND: Currently, two main lead configurations are used for implantable cardioverter-defibrillators (ICD). One generates a monodirectional electrical vector by using the can surface as an active part (hot can) together with a right ventricular defibrillation coil. The other one (TRIAD) produces a bidirectional electrical vector by adding a proximal defibrillation electrode on the same lead. The purpose of this prospective study was to determine whether there is a difference between these configurations in terms of the acute defibrillation threshold (DFT). The secondary objective was to evaluate the possible sequential effect of successive arrhythmia induction and defibrillation shocks on the final DFT value. METHODS: In 44 patients (37 males, 7 females, mean age 59.18 +/- 12.05 years; mean ejection fraction 35.21 +/- 11.69%), a Hot Can Ventak family ICD (Guidant, St. Paul, MN, USA) was implanted in a left pectoral pocket. During the implant procedure, step-down to failure DFT testing was performed twice in each patient using the two different above-mentioned configurations: the bidirectional and the monodirectional. The first configuration to be tested was determined by a 1:1 randomization by center. RESULTS: The step-down DFT protocol was followed in 35 patients. The average DFT was 8.6 +/- 4.0 J for TRIAD and 10.4 +/- 4.3 J for the monodirectional (p = 0.009) lead configuration; this represents a 16.3% decrease in the DFT using a bidirectional configuration. Furthermore, no relationship between the final DFT and the number of ventricular fibrillation inductions and shocks received was observed, confirming the secondary objective. CONCLUSIONS: Compared to the monodirectional electrical vector, the bidirectional electrical vector is clearly more beneficial for the patient.

Italian experience with AutoCapture in conjunction with a membrane lead. Pacesetter Automatic Control of Energy and Membrane Automatic Threshold Evaluation (Pacemate) Study Group.

AutoCapture is a programmable feature of the Pacesetter Microny SR + 2425T VVIR pacemaker, which provides for the automatic capture verification, increase in output in the presence of noncapture and threshold searching, with adjustment of output settings. The effectiveness of this unit in conjunction with the Membrane models 1400T and 1401T bipolar endocardial leads was studied in 54 patients followed at 19 Italian Centers. The patients were randomized at the time of implantation to receive either the model 1400T or the 1401T lead. The electrodes in these leads are covered by a Nafion membrane, which was either impregnated (model 1400T) or not-impregnated (model 1401T) with steroid. This paper reports the data collected over the first six weeks postimplantation. The results of the automatic capture function was compared to the capture threshold measured using the Vario technique at the time of predischarge evaluations, and weeks 1,2, and 6 of postimplant follow-up. The reliability and effectiveness of the pulse generator-lead system allowed for consistent pacing at very low outputs and safety preserved at a programmed output only 0.3 V above the capture threshold.

[Idiopathic ventricular tachycardia with onset in the verapamil-sensitive left ventricle: the clinical characteristics and long-term follow-up of 37 patients]. / Tachicardia ventricolare idiopatica ad insorgenza dal ventricolo sinistro sensibile al verapamil: caratteristiche cliniche e follow-up a lungo termine di 37 pazienti.

BACKGROUND: Idiopathic verapamil-responsive left ventricular tachycardia (IVRLVT) is a rare, well known form of ventricular tachycardia. Issues concerning long-term prognosis, drug prophylaxis and non-pharmacological therapy are rarely reported in the literature. We report the long-term follow-up, the efficacy of various drugs in the prophylaxis and the role of catheter ablation in a large group of patients with IVRLVT. METHODS AND RESULTS: This retrospective study involves 37 patients with a mean age of 28.3 +/- 14.8 years at first IVRLVT episode. The tachycardia morphology was typically with a right bundle-branch block configuration in all cases, with left axis deviation in 33 and right axis deviation in 5 (one patient had the 2 morphologies). Four patients had a mitral valve prolapse; the remaining 33 patients had neither clinical nor echocardiographic signs of heart disease. Only sporadic ventricular extrasystoles were detected at Holter monitoring in 73% of cases; 30% of patients had positive criteria for the presence of late potentials at signal averaged ECG. During electrophysiologic study, the tachycardia could be easily induced in 91% of patients. Mean follow-up is 7.3 +/- 4.7 years; all patients are alive at the end of follow-up. A mean of 2.3 +/- 1.2 drugs was prescribed in 35 patients (94.6%); betablockers were effective in 66% of the cases, verapamil in 20%, class I drugs in 22%, class III drugs in 15%. Both the 2 patients, who never received prophylaxis, and the 4 who stopped medication, utilize verapamil in case of recurrences. Eight patients were submitted to catheter ablation, with DC shock the first 2 patients, with RF energy from the third on; all but one (with DC shock) were successfully cured. CONCLUSIONS: Long-term follow-up confirmed the good prognosis of this form of ventricular tachycardia; a new insight that has been addressed about prophylaxis is the high efficacy of betablockers in preventing relapse and the poor efficacy of verapamil per os in chronic prophylaxis. Radiofrequency catheter ablation is effective and safe, using the earliest ventricular potential and the pace-mapping reproducing the same morphology of the tachycardia in all the 12 leads as a marker to identify the site of RF application, and may be proposed to all patients suffering from frequent episodes of IVRLVT.

Idiopathic verapamil-responsive left ventricular tachycardia: clinical characteristics and long-term follow-up of 33 patients.

Long-term prognosis, pharmacological prophylaxis and transcatheter ablation in a large group of patients with idiopathic verapamil-responsive left ventricular tachycardia (IVRLVT) are reported in this study. Thirty-three patients with a mean age of 27 +/- 16 years at their first IVRLVT episode, were studied retrospectively. Ventricular tachycardia was of the right bundle branch block morphology in all cases, with left axis deviation in 29 and right axis deviation in five (one patient had the two morphologies). Mitral valve prolapse was present in four patients; no heart disease was found in the remaining 29. Ventricular tachycardia could be electrophysiologically induced in 90% of the patients; Holter monitoring showed only sporadic ventricular extrasystoles in 76%; late potentials were found in 33% of the cases. At the end of a follow-up of 5.7 +/- 4.7 years, no patient had died. Thirty-one patients (94%) received a mean of 2.5 +/- 1.2 drugs; beta-blockers were effective in 71% of the cases, verapamil in 25%, class 1 drugs in 22%, class 3 drugs in 18%. Two patients who never received prophylaxis and four in whom it was stopped, were controlled with verapamil in case of recurrence. Six patients underwent catheter ablation; two with DC shock in whom it was successful in one, and four with radiofrequency energy, with a total success rate. The good prognosis of IVRLVT has been confirmed in a long-term follow-up; a new finding is the high efficacy of beta-blockers for prophylaxis. Radiofrequency transcatheter ablation is an effective and safe therapy for patients with symptoms not controlled by drug treatment.

Associated cardiac lesions in patients with radiation-induced complete heart block.

We investigated the clinical, electrophysiological, haemodynamic and angiographic aspects of four patients (two men and two women, aged 31-46 years) who developed complete heart block 13-20 years after therapeutic irradiation of the chest for Hodgkin's disease. The initial cardiac symptom was syncope in three, effort intolerance in one. The electrocardiogram recorded third-degree atrioventricular block in three patients, right bundle branch block and posterior fascicular block in one. The electrophysiological study, performed in three cases, showed that the block was infranodal in two. Three patients had significant coronary arterial stenoses, that involved the ostia in two. All patients had mild-to-moderate aortic and mitral regurgitation. One patient had haemodynamic signs of constriction. Another patient had recurrent pericardial effusions. All had echocardiographic evidence of a thickened pericardium. Cardiac involvement can be extensive in patient with radiation-induced heart block. Because coronary artery disease can be particularly severe, coronary angiography appears to be warranted in such patients.

Catheter ablation of accessory pathways in patients with Wolff-Parkinson-White syndrome.

PATIENTS: Fifty-two patients with Wolff-Parkinson-White syndrome underwent transcatheter ablation. All patients were symptomatic. Eighteen had documented episodes of atrial fibrillation, 14 of which also had reentrant tachycardias; the remaining 34 had only episodes of reentrant tachycardias. Forty-nine patients had both anterograde and retrograde conduction through the accessory pathway; 3 had retrograde conduction alone; 2 patients had 2 accessory pathways and 1 had 3. All patients were resistant or intolerant to at least 2 antiarrhythmic drugs. METHODS: All patients were treated with radiofrequency current. Ablation was considered successful if the anterograde and retrograde conduction were completely abolished. Ablation was considered unsuccessful if ablation of only 1 pathway in patients with 2 or more accessory pathways and/or modification of the accessory pathway conduction without interruption was achieved. RESULTS: Accessory pathway ablation was successfully performed in 46 out of 52 patients (88%). Fifty out of 56 accessory pathways were effectively ablated (89%). Thirty-eight required a single session of ablation and 8 additional patients were successfully ablated during a second session. The number of radiofrequency current applications ranged from 2 to 13 (mean 4.1 +/- 2.5). The mean duration of the sessions was 4.30 +/- 1.50 hours (range 2.30 to 9). The mean radiation exposure for session was 55 +/- 25 minutes (range 20 minutes to 2.30 hours). Complications were observed in 2 out of 52 patients. One patient had a transient II degree type 1 atrioventricular block; another patient with severe arterial hypertension had a mild hemorrhagic stroke with complete neurological remission. FOLLOW-UP. Forty-five out of the 46 patients in whom ablation was successful were asymptomatic for arrhythmias during a mean follow-up of 8 months (range 4 to 16), without antiarrhythmic treatment, and without reappearance of preexcitation. One patient showed reappearance of preexcitation at electrocardiogram one month after the ablation, followed by an episode of reentrant tachycardia; this patient underwent a second successful ablation session. CONCLUSIONS: Our results show that ablation techniques have high success rates with no serious complications.

[Nonpharmacological therapy of supraventricular arrhythmia]. / Terapia non farmacologica delle aritmie sopraventricolari.

Between 1985 and 1990, 1242 patients with supraventricular arrhythmias were followed-up at our Institution. Six hundred and twenty patients had atrial fibrillation or flutter; 7 of them (1%) underwent modulation of atrioventricular conduction. Four hundred and twenty-eight patients had ventricular preexcitation; in 23 (5%) surgical or transcatheter ablation of an accessory pathway were performed. Atrioventricular node reentrant tachycardias were diagnosed in 111 patients; 8 patients (7%) underwent antitachycardia pacemaker implantation. Surgical and catheter ablative techniques eliminate the substrate of the tachycardia; death and complete A-V block (paraseptal pathways) are at this moment rarely reported. Antitachycardia pacemakers do not offer a definitive therapy. For their safeness and effectiveness they are still indicated in patients with A-V node reentrant tachycardias, until technological development will reduce the risks of ablative techniques.

[A case of pericarditis in acute brucellosis]. / Su di un caso di pericardite in corso di brucellosi acuta.

A case of brucellosis pericarditis in a patient affected with acute brucellosis hospitalized in the Infectious Disease Department of Asti Hospital is described. During the hospitalization, the patient revealed (in addition to the classical symptoms and signs), a modest shooting pain in the chest and typical electrocardiographic alterations confirmed by an echocardiography that revealed slight pericardial effusion at both front and rear, subsequently and by steroid and specific antibiotic therapies. The real possibility of finding this complication, considered so rare in the literature, in cardiovascular brucellosis is pointed out as is the capacity of modern echocardiographic research to confirm and reinforce diagnosis and consequently also the description of modest pericardial effusions with unclear symptoms and electrocardiographic signs that were once practically ignored when the pericardial involvement often escaped a clinical identification, being concealed by the most important signs of the primary infection.

No evidence of platelet activation during atrial pacing in subjects with stable angina.

Platelet behaviour (activation) in ischemic heart disease (stable angina) during pacing-induced tachycardia was studied. ECG was recorded during the trial. Ischemic heart disease (IHD) subjects had 75% or more narrowing of the luminal diameter of a coronary artery, demonstrated by coronary angiography. Eight subjects needing cardiac catheterism because of supraventricular rhythm disturbances with no evidence of IHD were studied as controls. Beta-thromboglobulin (beta-tg) and platelet factor 4 (PF4) were studied as platelet activation markers; beta-tg and PF4 were evaluated before atrial pacing in peripheral venous blood and, by catheterism, before and at maximum pacing rate in coronary venous sinus (CVS) and in ascending aorta (AA). Catheterism and blood withdrawals were performed in order to reduce platelet activation in vivo. No significant difference in platelet activation between IHD patients and control group in peripheral venous blood were found. No trans-myocardial gradient neither in IHD subjects nor in controls were observed. In conclusion, no platelet activation in IHD patients during pacing-induced tachycardia could be observed.

Platelet arachidonic acid metabolism in patients with cardiovascular disorders.

There is increasing evidence that prostaglandins (PG) and thromboxane (Tx) play a major role in the pathogenesis of coronary artery disease. The regulation of arachidonic acid (AA) metabolism through cyclooxygenase (COx) pathway and the AA-dependent Ca2+ influx were investigated in platelets from 10 patients with unstable angina and 10 controls. The activation of the hexose monophosphate shunt (HMS), a sensitive index of the flux through the PGG2 to PGH2 step of the COx pathway, in response to AA was significantly enhanced in platelets from patients. AA-induced malonyldialdehyde (MDA) production as well as AA-evoked Ca2+ flux and glutathione-dependent peroxidase activity resulted significantly increased. Moreover, platelet sensitivity to prostacyclin (PGI2), measured as inhibition of Ca2+ flux, was highly decreased. Thus far, evidence is presented for intrinsic platelet hyperactivity (at the PG-peroxidase reaction of the COx pathway) in patients with unstable angina: the resulting increase in PGH2 and TxA2 synthesis, alone or in combination with decreased PGI2 sensitivity, may account for a facilitated thrombus formation.