Elbow monoarthritis: an atypical onset of juvenile idiopathic arthritis.

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition in childhood and an important cause of short and long term disability. Oligoarthritis is defined as an arthritis that affects four o fewer joints during the first 6 months of disease. The large majority of patients within this category belongs to a quite well defined disease which is not observed in adults. It is characterized by an early onset (before 6 years of age), an asymmetric arthritis involving mainly large joints, a female predilection, a high frequency of positive antinuclear antibodies (ANA), a high risk for developing chronic iridocyclitis and consistent HLA associations. We describe 3 clinical cases who presented monoarthritis of the elbow as early sign of oligoarticular JIA. All patients showed inflammatory markers elevation and 2/3 were ANA positive. MRI showed the presence of synovial inflammation without bone involvement. Intraarticular triamcinolone hexacetonide, led to remission in one case, while in the other two there was a re-activation of the disease treated with NSAIDs and/or MTX. The reported cases represent 0.6% of 490 patients with JIA followed by our unit in the last 10 years. Cases of exclusive involvement of the elbow at onset of JIA in literature are rare. Therefore, we report 3 cases of monoarthritis of the elbow as initial sign of oligoarticular JIA, a very atypical onset of this disease.

One-Step Laparoscopic Management of a Female Adnexal Tumor of Wolffian Origin.

We report a case of female adnexal tumor of Wolffian origin (FATWO), a rare neoplasm arising from the mesonephric ducts. A 48-year-old woman came first to our center for a recent discovery of a pelvic mass. Transvaginal ultrasonographic findings suggested a solid right para-ovarian mass suspected to be malignant. After thorough counseling, the patient underwent operative laparoscopy for excision of the para-ovarian mass with frozen section (FS) examination resulting in the diagnosis of a poorly differentiated adenocarcinoma. In this case, FS results allowed performing a comprehensive oncological staging, through a totally laparoscopic extrafascial hysterectomy, bilateral adnexectomy, total omentectomy, pelvic wall peritonectomy, and pelvic, parasacral and para-aortic lymphadenectomy. Final pathological and immunohistochemical results confirmed the diagnosis of FATWO. To our knowledge, this is the first case of FATWO managed entirely by a minimally invasive laparoscopic approach in a single surgical session.

Role of fetal MRI in the diagnosis of cerebral ventriculomegaly assessed by ultrasonography.

PURPOSE: To evaluate the additional diagnostic value of fetal MRI to evaluate cerebral ventriculomegaly assessed by ultrasonography (US) for the possibility to change the diagnosis, the counseling and the management of pregnancy. MATERIALS AND METHODS: From february 2006 to october 2008, we studied 55 pregnant women by fetal MRI (mean age 28 years), 4 with twin pregnancy, for a total of 59 fetuses with mean gestational age of 27 weeks. The number of fetuses affected by ventriculomegaly assessed by US was 55. All fetuses had a US diagnosis of ventriculomegaly: 29 fetuses with isolated ventriculomegaly and 26 fetuses with ventriculomegaly associated with CNS (central nervous system) abnormalities (18) and with no CNS abnormalities (8). RESULTS: The findings showed that the two techniques are substantially in agreement in defining the degree of VM, with the exception of some cases in which the disagreement could be attributed to the possible progression of the dilatation between the US and MRI examinations, which sway between two days and two weeks. We proved a low correlation between US and MRI in the evaluation of ventriculomegaly associated either with CNS or non-CNS anomalies: in fact while fetal MRI detected 26/55 (47,3%) VM associated with CNS anomalies, US demonstrated only 18/55(32,7%). Referring to VM associated with non-CNS anomalies, MRI diagnosed 10/55 cases (18,2%) compared to 8/55 fetuses (14,5%) showed by US. CONCLUSIONS: Our experience demonstrated that fetal MRI has an important role as adjunctive tool to sonography in the evaluation of cerebral ventriculomegaly for the additional informations given to parents and for the possibility to change the diagnosis, the counseling and the management of pregnancy.

Fetal MRI of the cardiovascular system: role of steady-state free precession sequences for the evaluation of normal and pathological appearances.

PURPOSE: This study aimed to evaluate the feasibility of fetal magnetic resonance imaging (MRI) with steady-state free precession (SSFP) sequences to visualise the normal and pathological appearances of the cardiovascular system. MATERIALS AND METHODS: This is a prospective observational study of 83 pregnant women who underwent fetal cardiac MRI: 43 patients (cases) had echocardiographic suspicion of congenital heart disease; 40 patients (controls) did not. Fetal cardiac MRI consisted of a static phase with multiplanar SSFP sequences and a dynamic phase with real-time SSFP sequences. Two radiologists evaluated the diagnostic quality of the SSFP images in both the controls and cases, the MRI morphological and functional features in the controls and the MRI signs of congenital heart disease in the cases. RESULTS: In both groups, SSFP sequences produced goodquality MR images and good visualisation of morphological features. Functional data appeared to be unavailable due to the current small temporal resolution and the technical impossibility of fetal cardiac triggering. MRI detected direct signs of congenital heart disease in 21 fetuses, indirect signs in six and both signs in 15. CONCLUSIONS: SSFP sequences are effective in demonstrating the morphological features of the cardiovascular system, whereas dynamic SSFP cine-MRI sequences may provide adjunctive albeit suboptimal functional information.

Fetal MRI with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) assessment in the evaluation of renal development: preliminary experience in normal kidneys.

PURPOSE: The study aimed to investigate the correlation between apparent diffusion coefficient (ADC) and gestational age by applying diffusion-weighted imaging (DWI) in the study of normal fetal kidneys. MATERIALS AND METHODS: We performed magnetic resonance (MR) imaging on 88 fetuses (gestational age range 17-40 weeks) after ultrasound had ruled out urinary system malformations. A multiplanar study of the urinary system was obtained by using conventional T2-weighted sequences and echoplanar imaging (EPI). DW sequences with ADC maps were subsequently acquired, and kidney ADC values were correlated with gestational age by diving the fetuses into six groups according to age. RESULTS: We found a correlation between ADC values and gestational age. The ADC values, ranging from 0.99 to 1.62x10(-3) mm(2)/s [mean 1.22; 95% confidence interval (CI) 1.19-1.25, standard deviation (SD) 0.147], showed a tendency to decrease with increasing gestational age. The relationship between ADC values and gestational age was expressed by a linear regression equation: ADC (mm(2)/s)=1.69-0.0169 (GA) (R(2)=37.7%, R(2) ADJ=37.0%, p<0.005, Pearson correlation=-0.614). CONCLUSIONS: DWI with ADC mapping provides functional information on fetal renal parenchyma development and may thus become a useful tool in the management of pregnancy and treatment of the newborn child.

Infertility in women: combined sonohysterography and hysterosalpingography in the evaluation of the uterine cavity.

PURPOSE: To evaluate the diagnostic effectiveness of combined hysterosalpingography (HSG) and sonohysterography (SHG) in the study of infertile women. MATERIALS AND METHODS: 208 women affected by primary (184) or secondary sterility (24) were divided in two random groups. Group 1 underwent only HSG and group 2 underwent simultaneous HSG and SHG. The results obtained in the two groups were correlated with the results of hysteroscopy or laparoscopy, considered Gold Standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratio (LR) of HSG alone and combined HSG/SHG were calculated. Results were evaluated with t-test, Pearson's Chi square or Fisher exact test when appropriate and ROC analysis. RESULTS: In group 1, hysteroscopy revealed no pathology in the uterine cavity in 70/104 patients, but evidenced 47 abnormalities related to the uterine cavity in 34 women. HSG outcome was in accordance with hysteroscopy in 27/34 cases of abnormalities, and in 64/70 cases of normal outcome. Sensitivity 0.79, specificity 0.91, PPV 0.82, NPV 0.90, LR+ 9.26. In group 2, hysteroscopy revealed no pathology in the uterine cavity in 64/104 patients but 52 abnormalities related to the uterine cavity in 40 women. HSG and SHG outcomes were confirmed by hysteroscopy in 39/40 cases of abnormalities of the uterine cavity and in 60/64 cases of normal uterine cavity. Sensitivity 0.97, specificity 0.94, PPV 0.91, NPV 0.98, LR+ 15.60. Statistical analysis showed that combined HSG and SHG yielded elevated specificity and LR+ and therefore few cases of false positive outcome. CONCLUSION: Combined performance of HSG and SHG can shorten diagnostic investigation time and reduce the discomfort to the patient as the injector is fed into the cervix only once. This may also reduce the patient's anxiety level as one of the causes of infertility.

Assessment of congenital heart disease (CHD): is there a role for fetal magnetic resonance imaging (MRI)?

PURPOSE: To review our experience with fetal magnetic resonance imaging (MRI) to evaluate congenital heart disease (CHD). METHODS: We performed fetal MRI in 32 fetuses with an echocardiographically assessed CHD. Both direct and indirect signs of CHD were investigated. Direct signs considered were: morpho-volumetric abnormalities of the heart; malrotations; ventricular and atrial septal defects; anomalies of the origin, size and course of the great arteries. Indirect signs considered were: difficulty to recognize a "normal" anatomical structures in the reference projections; increase of the vascular size before a stenosis; hypertrophy of the papillary muscles; cardiomegaly and pericardial effusion. All MRI findings were compared with postnatal or autoptic findings. RESULTS: MRI allowed the CHD to be visualised by direct signs in 17 fetuses, indirect signs in 5 and both direct and indirect signs in 9 fetuses, excluding the prenatal echocardiographic suspect of hypoplastic left heart syndrome in 1 fetus. Postnatal echocardiograms or autoptic findings confirmed a normal heart in 1 fetus and CHD in 31 fetuses including a single cardiac anomaly or syndrome in 19 fetuses, 2 associated cardiac abnormalities in 11 and 3 cardiac anomalies in 1 fetus. However, in 2 fetuses MRI detected a ventricular septal defect successively disclosed by gold standard. CONCLUSIONS: MRI is a promising method for further assessment of the cardiovascular pathologies diagnosed by echocardiography, and may be a valuable tool in assessing associated extracardiac anomalies.

Magnetic resonance imaging versus ultrasonography in fetal pathology.

PURPOSE: This paper describes our experience with magnetic resonance imaging (MRI) in the assessment of fetal anatomical structures and major fetal pathologies. MATERIALS AND METHODS: The retrospective study included 128 pregnant women between the 22nd and 38th week of gestation. We used the following imaging protocol: T2-weighted single-shot fast spin-echo sequences for all foetuses and, in selected cases, gradient echo with steady-state free precession (SSFP), T1-weighted spoiled gradient echo [fast low-angle shot (FLASH)] with and without fat saturation, and T2 thick-slab sequences with multiplanar technique. In 32 cases, we performed diffusion-weighted sequences with apparent diffusion coefficient (ACD) maps on the brain, the kidneys and the lungs. RESULTS: We achieved diagnostic-quality images in 125 of 128 patients; MR image quality was unsatisfactory in three cases only. In 16 cases with previous negative ultrasound (US) findings, MRI confirmed the US diagnosis. MRI confirmed the positive US diagnosis in 67 of 109 cases (61.5%); in 11 cases it changed the US diagnosis, and in 31/109 the examination was negative. In addition, MRI identified other anomalies not recognised during US examination. CONCLUSIONS: With its ultrafast sequences, fetal MRI provides good detail of normal fetal anatomy and allows characterisation of suspected anomalies.

Role of breast magnetic resonance imaging (MRI) in patients with unilateral nipple discharge: preliminary study.

PURPOSE: This study was performed to assess the role of magnetic resonance imaging (MRI) in patients with unilateral nipple discharge. MATERIALS AND METHODS: Forty-four patients with bloody or serosanguineous nipple discharge and negative mammographic findings (35/44 cases) underwent MRI for evaluation of breast ducts. Ultrasonography, negative in 18 patients, identified 26 cases of ductal ectasia (12 simple, nine with solid intraductal echoes and wall thickening, five with inhomogeneous parenchyma). Galactography was negative in three patients and positive in nine. Nineteen patients were followed up by clinical examination, ultrasonography, and cytological evaluation of nipple discharge (6-12 months); three patients underwent excisional biopsy, ten core biopsy and 12 cytological biopsy (followed by excisional biopsy). RESULTS: MRI identified 25 enhancing lesions Breast Imaging Reporting and Data Systems (BI-RADS) 3 or 4) and confirmed the galactographic findings (ductal ectasia, intraluminal filling defects). Five papillomatoses appeared as patchy, homogeneous enhancing areas, 15 intraductal papillomas as areas with well-defined margins and type II time-intensity curves, and two atypical ductal hyperplasias as diffuse nodular enhancement. One micropapillary ductal carcinoma in situ (DCIS), one papillary carcinoma and one infiltrating ductal carcinoma (IDC) were visualised as two segmental areas of enhancement and one mass-like enhancement with poorly defined margins (BI-RADS 4). The follow-up was negative, showing no pathological enhancement (BI-RADS 1) in 12 patients and benign enhancement (BI-RADS 2) in seven. CONCLUSIONS: Breast MRI can be considered a valuable examination in the diagnosis of suspected ductal disease and an alternative to galactography when the latter cannot be used.

Tamoxifen in women with breast cancer and mammographic density.

PURPOSE OF INVESTIGATION: To evaluate the effect of tamoxifen on mammographic density using a qualitative and a semiquantitative method. METHODS: Mammograms from 148 women treated for breast cancer before and after surgery were reviewed: 68 were administered tamoxifen; 80 did not receive tamoxifen. The mammograms were classified in one of the four BIRADS density categories by two radiologists blinded to the treatment and by a computer-assisted method after digitizing images. RESULTS: At mammographic one-year-follow-up density was reduced in both groups and remained stable in the following years. A comparison of mammograms performed before surgery and after one year showed a statistically significant difference in density reduction between the tamoxifen and the non-tamoxifen-treated group. Good agreement was obtained between the qualitative and semiquantitative method. CONCLUSION: Breast density reduction observed in women treated with tamoxifen may help in the detection of small tumors in dense breasts by means of reducing the masking effect of parenchyma.

Phenotypes, genotypes and disease susceptibility associated with gene copy number variations: complement C4 CNVs in European American healthy subjects and those with systemic lupus erythematosus.

A new paradigm in human genetics is high frequencies of inter-individual variations in copy numbers of specific genomic DNA segments. Such common copy number variation (CNV) loci often contain genes engaged in host-environment interaction including those involved in immune effector functions. DNA sequences within a CNV locus often share a high degree of identity but beneficial or deleterious polymorphic variants are present among different individuals. Thus, common gene CNVs can contribute, both qualitatively and quantitatively, to a spectrum of phenotypic variants. In this review we describe the phenotypic and genotypic diversities of complement C4 created by copy number variations of RCCX modules (RP-C4-CYP21-TNX) and size dichotomy of C4 genes. A direct outcome of C4 CNV is the generation of two classes of polymorphic proteins, C4A and C4B, with differential chemical reactivities towards peptide or carbohydrate antigens, and a range of C4 plasma protein concentrations (from 15 to 70 mg/dl) among healthy subjects. Deliberate molecular genetic studies enabled development of definitive techniques to determine exact patterns of RCCX modular variations, copy numbers of long and short C4A and C4B genes by Southern blot analyses or by real-time quantitative PCR. It is found that in healthy European Americans, the total C4 gene copy number per diploid genome ranges from 2 to 6: 60.8% of people with four copies of C4 genes, 27.2% with less than four copies, and 12% with more than four copies. Such a distribution is skewed towards the low copy number side in patients with systemic lupus erythematosus (SLE), a prototypic autoimmune disease with complex etiology. In SLE, the frequency of individuals with less than four copies of C4 is significantly increased (42.2%), while the frequency of those with more than four copies is decreased (6%). This decrease in total C4 gene copy number in SLE is due to increases in homozygous and heterozygous deficiencies of C4A but not C4B. Therefore, it is concluded that lower copy number of C4 is a risk factor for and higher gene copy number of C4 is a protective factor against SLE disease susceptibility.

Evaluation of normal brain development by prenatal MR imaging.

PURPOSE: The aim of this study was to describe the normal pattern of development and maturation of the foetal brain with respect to gestational age as assessed with magnetic resonance imaging (MRI) and to provide an overview of the possibilities of the technique. MATERIALS AND METHODS: Foetal cerebral MRI was performed on 56 pregnant women between 19 and 37 weeks of gestation. Half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady precession (FISP), T1-weighted fast low angle shot (FLASH) two-dimensional (2D) and diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) were obtained. Biometric parameters and developmental areas of the cerebral cortex were correlated to gestational age by using the Spearman rank correlation test. RESULT: We found a negative correlation between the germinal matrix/biparietal diameter ratio and gestational age and a positive correlation between the germinal and cortical matrix when expressed as external intraocular diameter ratio (R=0.452, p=0.02). The cortical mantle was correlated with biometric parameters, such as the biparietal diameter and the frontooccipital diameter, and with gestational age. The interhemispheric fissure, the parietooccipital fissure and the sylvian fissure were detectable by the 22nd week. In the grey matter, the mean ADC values varied from 1.76 x 10(-3) mm(2)/s (at week 19) to 0.89 x 10(-3) mm(2)/s (at week 37), whereas in the white matter, the values varied from 2.03 x 10(-3) mm(2)/s (at week 19) to 1.25 x 10(-3) mm(2)/s (at week 37). CONCLUSIONS: MRI provides a reliable valuation of brain maturation during pregnancy.

Adjunctive diagnostic value of ultrasonography evaluation in patients with suspected ductal breast disease.

PURPOSE: The purpose of this study was to evaluate the adjunctive diagnostic value of breast ultrasonography (US) in the study of benign ductal breast disease. MATERIALS AND METHODS: Fifty-two patients underwent US examinations for bloody nipple discharge, palpable retroareolar masses, retroareolar opacities or ductal pattern on mammography. US enabled visualisation of mammary-duct ectasia (simple or pseudocystic, retroareolar and/or peripheral) and focal masses (endoluminal or periductal, with ill-defined or regular margins). All patients with nipple discharge underwent cytological evaluation. After the US examination, all focal masses with ill-defined margins underwent fine-needle aspiration biopsy (FNAB), if necessary. The benign alterations were followed up. RESULTS: In 38/52 cases, US diagnosed mammary-duct ectasia and in 30/52 cases, the presence of focal masses (mean size 7 mm). In the nine women who underwent biopsy, histopathological evaluation diagnosed five solitary papillomas, one solitary papilloma with a focal area of ductal carcinoma in situ (DCIS), two multiple papillomas of the nipple and one papillomatosis. CONCLUSIONS: High-frequency US plays an important role in the detection of benign ductal disease both for the diagnosis and classification of focal masses and mammary-duct ectasia. US can be used as a complementary imaging method to galactography or as a valuable alternative when galactography is not available.

Diagnostic utility of combined ultrasonography and mammography in the evaluation of women with mammographically dense breasts.

PURPOSE: To assess the diagnostic utility and additional cost of combined breast ultrasonography and mammography in the evaluation of asymptomatic women with mammographically dense breasts. MATERIALS AND METHODS: Of 5108 asymptomatic women, who underwent mammography, 1754 had dense breasts (BI-RADS 3 or 4) and negative mammographic outcome. They were divided in 4 subgroups according to their age (<40 yrs; 40-49 yrs; 50-59 yrs; >59 yrs). Breast ultrasonography was performed immediately after mammography. Lesions detected at ultrasonography were examined cytologically/histologically. Mammograms from women, who were diagnosed carcinoma at ultrasonography, were reviewed by an external radiologist. Costs per diagnosed carcinoma and per examined woman were calculated on the basis of current regional charges. RESULTS: Mammographies (5108) were performed, 67 cancers were detected (cancer detection rate 13.1‰): mammography identified 55 carcinomas and ultrasonography performed in women with dense breasts identified 12 cancers (17.9% of all cancers detected, overall cancer detection rate 6.8‰). Ultrasonography identified a benign condition in 1567 out of 1754 women (89.3%) (in 925 absence of focal lesions; 438 simple cysts; 56 ductal ectasia; 148 benign solid lesions); 97 complex cysts, 52 lesions that could not be differentiated as liquid or solid lesions, and 38 solid lesions suspicious for malignancy in the remaining 187 out of 1754 patients (10.7%). Cytology/histology confirmed carcinoma in 12 women (overall biopsy rate 26.2‰, benign biopsy rate 19.4‰). The additional costs were: € 6,123.45 per detected cancer, € 41.89 per examined woman. CONCLUSION: Breast ultrasonography immediately after mammography in women with dense breasts is useful to avoid diagnostic delays and inconvenient medico-legal implications even though this procedure involves increased costs.

Sonohysterography: is the hysterosalpingographic vacuum cup a valid alternative device for cannulation of the cervical Os?

PURPOSE: To determine whether sonohysterography (SHG) should be performed with Plexiglas hysterosalpingographic vacuum cups instead of standard catheters. MATERIALS AND METHODS: In a prospective setting, 226 women randomly classified into 2 groups underwent SHG. The method used for cervical cannulation was a two-way catheter in the first group (n = 108) and a Plexiglas hysterosalpingographic vacuum cup in the second one (n = 118). Diagnostic reliability, easy applicability for the physician, discomfort for the patients and cost of the instruments were assessed for both devices. RESULTS: 226/226 (100 %) complete sonohysterographic examinations were performed. As regards uterine cavity distension the same diagnostic reliability was reported for vacuum cups and two-way catheters. The standard catheter obscured the cervical canal because of the dilation of the balloon. Both methods were judged as easy to use, and no statistically significant difference was found as far as the time required for cervical cannulation (p > 0.05). A little more discomfort was recorded by women who underwent sonohysterography with standard balloon catheters but a greater interpersonal variability was noticed in this group (SD 3.65 vs. 1.13 in the vacuum cup group). Vacuum cups were by far the most economical devices (unit cost: 16.70 euro vs. catheter unit cost 46.20 euro). CONCLUSION: Vacuum cups allow sonohysterography to be correctly performed. As they are inexpensive, easy to use, better tolerated by the patients and more helpful for visualisation of the lower third of the uterine cavity, vacuum cups should be considered a serious alternative to standard catheters in the performance of SHG.

Novel splicing and missense mutations in autosomal dominant polycystic kidney disease 1 (PKD1) gene: expression of mutated genes.

Autosomal dominant polycystic kidney disease (ADPKD) is a common disorder mostly characterized by cyst formation in kidney tubules. The majority of ADPKD cases is caused by mutations in the PKD1 gene, but no prevalent mutation has been reported. By heteroduplex analysis of the 3' single-copy region of the gene, we have searched for mutations in subjects from 40 ADPKD families of Northern Italy. Seven novel polymorphisms and three novel disease-associated mutations (R3718Q, L3851P and IVS45+56del25) were identified. Both missense mutations are located in the major extracellular loop of polycystin-1. The 25 bp deletion inside intron 45 did not affect 5' and 3' consensus splicing sites, but caused a 56 nucleotide out of frame-deletion due to activation of a cryptic 3' splice site in exon 46. The mutated RNA should produce a truncated polycystin 1 at the G binding peptide in the intracellular C-terminal end of the protein. RT-PCR analysis showed that the disease-associated mutations were present in transcribed sequences. In particular, RNA analysis of BHK cells transfected with PKD1 genomic DNA, including the deleted intron, showed that no normal transcript is produced by the deleted gene. This intronic mutation, found in a large pedigree, seems to be associated with a prevalence of cerebrovascular disease.

[Long-term clinical assessment of single-lead VDD electric stimulation]. / Valutazione clinica a lungo termine dell'elettrostimolazione VDD monocatetere.

BACKGROUND: During the last decade single lead VDD pacing has been progressively affirmed as an electrotherapy of choice in patients with advanced atrioventricular block without alterations of the sinus function. It combines the benefits of P-synchronous ventricular pacing with an easy implant procedure when compared to the conventional DDD approach. The aim of this study was to evaluate the validity of such an approach in a large population of patients, all implanted in a single center. METHODS: From 1987 up to now, 317 patients, all affected by advanced atrioventricular block and without sinus node dysfunction, were implanted in our center with a single lead VDD pacemaker. During follow-up the persistence of a proper atrioventricular synchronization was assessed and evaluated. RESULTS: The mean follow-up was 3.9 +/- 2.7 years/patient (range 6-138 months). The 94.6% of implanted systems maintained the normal VDD pacing function. Permanent reprogramming in VVI mode was necessary in 17 patients (5.36%); in 12 (3.78%) because of chronic atrial fibrillation and in 5 (1.63%) for loss of atrial sensing. The percentage of atrial synchronization was optimal (> 98%) and acceptable (> 95%) in 81% and 19% of patients, respectively. Episodes of paroxysmal atrial fibrillation occurred in 3 patients. Neither inhibition by myopotentials nor occurrence of sinus node disease was observed during follow-up. These results are in accordance with those reported by previous studies, performed on a smaller population or on a multicenter basis, and are comparable with the results reported for conventional DDD pacemaker. CONCLUSIONS: Our results confirm the high reliability of the single lead VDD pacing system concerning the long-term persistence of a proper atrioventricular synchronization. Data showed above enforce our opinion that this pacing approach should be considered the treatment of choice in patients with advanced atrioventricular block and preserved sinus node function.

Multi response biomarker approach in the crab Carcinus aestuarii experimentally exposed to benzo a pyrene, polychlorobiphenyls and methyl mercury.

The aim of this study was to test a multi response biomarker approach for evaluating toxicological risk due to some of the main contaminants in the Mediterranean benzo a pyrene, polychlorobiphenyls and methyl mercury, using the Mediterranean crab Carcinus aestuarii as bioindicator organism. Forty crabs were injected with different doses of these contaminants. Several molecular, biochemical and genotoxic biomarkers were tested in different tissues and biological materials. The main conclusions were: 1 hepatopancreas, gills, haemolymph and excreta seem to be useful for biomarker studies in this species; 2 several biochemical, molecular and genotoxic biomarkers were found suitable for testing in these tissues; 3 several biomarkers were found suitable for evaluating chemical stress due to different Mediterranean contaminants.

Bifascicular block complicating blunt cardiac injury. A case report and review of the literature.

A thirty-five-year-old horse trainer presented to the emergency room of the authors' hospital with minimal nonpenetrating chest injury after having been kicked by a horse. No rib or sternum fractures were demonstrated. The admission ECG demonstrated a right bundle branch block and a left anterior hemiblock that were previously absent. The authors are aware of only two similar reports, but analogous conduction disturbances might have been classified as intraventricular conduction defects. The rarity of these defects may be explained by the anatomic pathways of the bundle of His and its bifurcations.

Average life expectancy of heterozygous beta thalassemic subjects.

In order to define the lifespan of heterozygous beta thalassemic subjects as compared to non thalassemic subjects, the authors prospectively studied all patients deceased during a period of 76 months at St. Camillo Hospital of Comacchio (Ferrara), located in the Po delta, a region with high prevalence of thalassemia minor. No statistically significant differences were found in the average life expectancy between the thalassemic and non thalassemic groups.