Migraine, cortical blindness, multiple cerebral infarctions and hypocoagulopathy in celiac disease.

We describe the case of a female patient affected by migraine and untreated adult celiac disease who presented with a state of acute migraine accompanied by multiple neurological deficits, including transient cortical blindness with ischemic CT and MRI alterations, and hypocoagulation due to factor VII deficiency. She was receiving estroprogestin therapy. There was a prompt response to cortisone therapy followed by a state of complete well-being, which also led to the disappearance of migraine attacks after five years of dietary treatment alone.

Prevalence of intestinal metaplasia in the distal oesophagus, oesophagogastric junction and gastric cardia in symptomatic patients in north-east Italy: a prospective, descriptive survey. The Italian Ulcer Study Group "GISU".

BACKGROUND: Incidence of adenocarcinoma of distal oesophagus and gastric cardia, probably arising from areas of intestinal metaplasia, has been increasing rapidly. AIMS: To define prevalence of intestinal metaplasia of distal oesophagus, oesophagogastric junction and gastric cardia and to evaluate potential associated factors, by means of a prospective multicentre study including University and teaching hospitals, and primary and tertiary care centres. PATIENTS: Each of 24 institutions involved in study enrolled 10 consecutive patients undergoing first-time routine endoscopy for dyspeptic symptoms. METHODS: Patients answered symptom questionnaires and underwent gastroscopy Three biopsies were taken from distal oesophagus, oesophago-gastric junction and gastric cardia, and were stained with haematoxylin and eosin. Specimens were also evaluated for Helicobacter pylori infection. RESULTS: A total of 240 patients (124 male, 116 female; median age 56 years, range 20-90) were enrolled in study. Intestinal metaplasia affected distal oesophagus in 5, oesophago-gastric junction in 19 and gastric cardia in 10 patients. Low-grade dysplasia was found at distal oesophagus and/or oesophago-gastric junction of 3/24 patients with intestinal metaplasia vs 2/216 without intestinal metaplasia (p<0.05). A significant association was found between symptoms and presence of intestinal metaplasia, regardless of location, and between Helicobacter pylori infection and intestinal metaplasia at oesophago-gastric junction. CONCLUSIONS: Intestinal metaplasia of distal oesophagus, oesophagogastric-junction and gastric cardia is found in a significant proportion of symptomatic patients undergoing gastroscopy and is associated with dysplasia in many cases. Although prevalence of dysplasia seems to decrease when specialized columnar epithelium is found in short segment, or even focally in oesophago-gastric junction, these small foci of intestinal metaplastic cells may represent source of most adenocarcinomas of cardia.

Cure of Helicobacter pylori-positive active duodenal ulcer patients: a double-blind, multicentre, 12-month study comparing a two-week dual vs a one-week triple therapy. GISU (Interdisciplinary Group for Ulcer Study).

AIMS: To compare a two-week dual therapy to a one-week triple therapy for the healing of duodenal ulcer and the eradication of the Helicobacter pylori infection. PATIENTS AND METHODS: A total of 165 patients with active duodenal ulcer were enrolled in the study. At entry, endoscopy, clinical examination and laboratory tests were performed. Histology and the rapid urease test were used to diagnose Helicobacter pylori infection. Patients received either lansoprazole 30 mg plus amoxycillin 1 g bid for two weeks (two-week, dual therapy) or lansoprazole 30 mg plus amoxycillin 1 g plus tinidazole 500 mg bid for one week plus lansoprazole qd for an additional week (one-week, triple therapy). Two and twelve months after cessation of therapy, endoscopy and clinical assessments were repeated. RESULTS: Duodenal ulcer healing and Helicobacter pylori eradication were both significantly greater (p<0.0001) in the triple therapy group (healing: 98.6%; Helicobacter pylori cure rate: 72.6%) than in the dual therapy group (healing: 77.3%; Helicobacter pylori cure rate: 33.3%). Ulcers healed more frequently in Helicobacter pyloricured than in Helicobacter pylori-not cured patients (94.9% vs. 77.2%; p<0.0022). After one year, Helicobacter pylori eradication was re-confirmed in 46/58 patients previously treated with the triple therapy and in 10/40 patients treated with the dual therapy [p<0.0001]. Only three duodenal ulcer relapses were observed throughout follow-up: all were in Helicobacter pylori-not cured patients. CONCLUSIONS: Triple therapy was more effective than dual both in curing Helicobacter pylori infection and healing active duodenal ulcers. The speed of ulcer healing obtained after only 7 days of antibiotics and 14 days of proton pump inhibitors confirmed that longer periods of anti ulcer therapy were not necessary. Helicobacter pylori -not cured patients had more slowly healing ulcers which were more apt to relapse when left untreated.

[Cardiac troponin I and T in unstable angina: incidence, correlation, kinetics of release and prognostic value]. / Troponina i cardiaca e troponina T cardiaca nell'angina instabile: incidenza, correlazione, cinetica di rilasciamento e valore prognostico.

BACKGROUND: The aim of this study was to ascertain the incidence of altered serum cardiac Troponin-T (cTnT) and cardiac Troponin I (cTnI) in patients with unstable angina, the concordance between findings for the two proteins, their release kinetics and their utility in predicting coronary events. METHODS: We studied 32 consecutive patients (pts) admitted to the Coronary Unit with a diagnosis of unstable angina; following Braunwald classification criteria, 5 pts were in class I, 4 class II, 23 class III. A blood sample was taken on admission to hospital and subsequently every 8 hours for two days, a total of 7 samples being obtained per pt. Cardiac-TnT values ranging from 0-0.17 mugr/L (Boehringer Mannheim) were considered normal, as were cTnI values ranging from 0 to 0.7 mugr/L (Stratus-Dade). RESULTS: Among 218 samples, altered cTnT values (0.18-0.68 mugr/L) were found in 19 (3 pts), and 13 of these samples were positive for cTnI (0.8-5.5 mugr/L), while the remaining 6 showed borderline values for cTnI (0.5-0.7 mugr/L). No cTnT negative samples were found to be positive for cTnI. The release kinetics of cTnT and cTnI were comparable in all three cases, with a "plateau" pattern, unlike the kinetics in the course of acute myocardial infarction (AMI). The mean follow-up was 13 months on average (range 1-19). In two pts with altered cTnT and cTnI values, symptoms were controlled with medical therapy, while the remaining patient failed to respond to medical therapy and therefore underwent PTCA. Fifteen months later, they are alive and have not had myocardial infarction. Of the 29 pts with normal cTnT and cTnI values, three developed AMI, which in two cases was fatal. Seven pts were submitted PTCA, seven to aorto-coronary bypass surgery, two were subsequently rehospitalized for a recurrent angina symptoms. In 13 pts complete control of symptoms was achieved with medical therapy. CONCLUSIONS: Our findings demonstrate that the incidence of altered cTnT and cTnI values in pts with unstable angina is low; there is close agreement between findings for the two proteins; in cases of angina, the cTnT and cTnI release kinetics are different from those in AMI. The finding of altered cTnT and cTnI values in the serum of our pts with unstable angina does not appear to be of prognostic value for future coronary events.

[Cardiac troponin I in unstable angina]. / La troponina I cardiaca nell'angina instabile.

BACKGROUND: Unstable angina implies high risk of myocardial infarction and sudden death. Increased levels of cytoplasmatic enzymes and proteins (creatine phosphokinase, MB creatine phosphokinase troponin T, etc.) were described in unstable angina, providing information about incoming major coronary events. Cardiac troponin I (cTn-I) is a structural protein inhibiting the actinomyosine ATPase; it is only found in myocardial cells. Serum titration of cTn-I has been recently introduced into clinical practice as a sensitive and specific marker of myocardial cellular necrosis. OBJECTIVES: The aim of our prospective study was to assess the presence of cTn-I in blood samples of patients with unstable angina and no signs of myocardial necrosis. Furthermore we intended to test the possible use of cTn-I in unstable angina as a prognostic marker of major coronary events on short and middle term. METHODS: We studied 33 consecutive patients admitted to our CCU for unstable angina. According to unstable angina Braunwald's classification, 6 patients were included in the first class, 4 patients in the second class and 23 patients in the third class. We excluded patients with acute or recent myocardial infarction. Blood samples of all patients were obtained at the time of CCU admission and every eight hours in the first and second day. Serum cTn-I titration was performed with the sandwich immunoenzymometric method, recently introduced by Diagnostic Pasteur. Two months follow-up was carried out in order to survey major coronary events and revascularization procedures, either angioplasty or coronary artery bypass surgery. RESULTS: No patients with unstable angina exhibited cTn-I in their blood samples; accordingly, cTn-I was not found in the first blood sample of a patient who underwent myocardial infarction during hospitalization. During the follow-up 2 patients died of myocardial infarction, 9 patients had surgical revascularization and 5 patients angioplasty. CONCLUSIONS: CTn-I is a sensitive and specific marker of myocardial necrosis. It is not found in patients with unstable angina; therefore it has no role as a prognostic marker of major coronary events.

[Spectral analysis and color-coded Doppler study of the changes in aortic regurgitation induced by vasodilators in asymptomatic patients with severe aortic insufficiency]. / Studio Doppler ad analisi spettrale e a codice di colori delle modificazioni del rigurgito aortico indotte da vasodilatatori in pazienti asintomatici affetti da insufficienza aortica grave.

The acute effects of 20 mg of sublingual nifedipine in 12 patients with chronic severe aortic regurgitation were evaluated with M-mode echocardiography, continuous wave and colour Doppler. After nifedipine, heart rate increased from 68 +/- 8 to 82 +/- 11 beats/m' (p less than 0.001); arterial systolic and diastolic pressures decreased from 143 +/- 16 to 129 +/- 9 mmHg (p less than 0.01) and from 61 +/- 11 to 53 +/- 17 mmHg (p less than 0.01) respectively. Left ventricular systolic and diastolic diameters also decreased from 50 +/- 4 to 46 +/- 4 mm (p less than 0.01) and 76 +/- 6 to 72 +/- 6 mm (p less than 0.01) respectively; the slightly increase in fractional shortening which occurred was not significant. The aortic systolic and diastolic velocity integrals decreased from 38 +/- 9 to 34.7 +/- 8 cm (p less than 0.01) and from 203 +/- 41 to 163 +/- 29 cm (p less than 0.001); the diastolic slope of the velocity curve increased a little but significantly: from 334 +/- 70 to 394 +/- 70 cm/sec2 (p less than 0.01). With colour Doppler, protodiastolic jet areas decreased by 19% in the long parasternal view (p less than 0.01), by 28% in the apical view (p less than 0.001), by 26% in the short-axis view (p less than 0.01); the length of the jets in the long parasternal view decreased by 14% (p less than 0.001), but the height did not change significantly. Positive changes from acute nifedipine administration are present in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Joubert syndrome. Review of the fifty-three cases so far published.

Joubert's syndrome (JS) is an autosomal recessive disorder, which is characterised by a variable combination of central nervous, respiratory and eye anomalies. We review the clinical characteristics of the 53 so far reported children with Joubert's syndrome, stressing the importance of recognising the syndrome in the neonatal period, in order that specific and effective therapeutic measures be started as soon as possible.

[Doppler study of porcine bioprosthesis at the mitral site]. / Studio Doppler di bioprotesi porcine in sede mitralica.

Twenty-nine asymptomatic patients with porcine (9 Liotta, 8 Carpentier, 8 Hancock and 4 Xenomedica) mitral prosthesis without clinical findings of prosthetic dysfunction and with normal M-mode and two-dimensional echocardiography were studied with pulsed and continuous wave Doppler. The following parameters of prosthetic function were evaluated: 1) maximum velocity (Vmax); 2) mean pressure gradient; 3) pressure half-time (P 1/2 t); 4) functional prosthetic area or Doppler orifice area (DOA); 5) mitral prosthetic regurgitation (MR); 6) tricuspid regurgitation (TR), if associated. P 1/2 t reproducibility was tested. For the study of the bioprosthetic function the transducer was located in apical position with the best alignment between ultrasonic beam and flow direction in the apical four-chamber view. The best acoustic signal was the guide to an optimal Doppler recording, analyzed for calculations. In 26 patients without MR at Doppler examination Doppler data were as follows: Vmax 1.6 +/- 0.2 m/sec (1.2-2 m/sec); mean pressure gradient: 4.4 +/- 2.7 mmHg (1.4-13 mmHg); P 1/2 t = 94.2 +/- 19.8 msec (55-140 msec); DOA = 2.4 +/- 0.6 cm2 (1.5-4 cm2). Mild unsuspected MR was detected in 3 patients, but the other parameters did not differ from those of the other 26 patients. TR was found in 10 patients. The degree of reproducibility of P 1/2 t was 0.92. Only the P 1/2 t value was longer among Hancock and Liotta or Xenomedica bioprosthesis (p = 0.005). Furthermore P 1/2 t was longer in the patients with longer follow-up periods than in the others (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and electrocardiographic features and long-term results of electrical therapy in patients with isolated His bundle disease.

The clinical, ECG, and electrophysiologic findings of 35 consecutive patients with second- and third-degree intra-His block with normal QRS complexes were examined. The follow-up period varied between 12 and 120 months (mean 45). Seventy-seven per cent of the patients were women. Underlying heart disease was present in 43% of the patients. ECGs were characterized by both second-degree type I and type II atrioventricular block, normal or slightly prolonged PR interval of the conducted beats or of the first conducted beat of a Wenckebach sequence, and by subtle changes in the initial forces of the QRS complexes of the escape beats. Electrophysiologic study showed normal sinus and atrioventricular node function and normal infra-His conduction in all patients. In four patients repetitive bradycardia-dependent intra-His block was induced. Thirty-two patients were permanently paced soon after the initial evaluation and three during the follow-up period. Total long-term mortality rate was 23%. None of the patients developed bundle branch block.

[Aortic regurgitation: evaluation by pulsed Doppler echocardiography]. / Entità del rigurgito aortico: valutazione mediante eco-Doppler pulsato.

Ninety-one consecutive patients with aortic regurgitation, either isolated (23 subjects) or associated with other valvular diseases (68 subjects), were studied with pulsed Doppler echocardiography and subsequent aortography, and the results were compared in order to assess the value of the noninvasive technique for a semiquantitative evaluation of the degree of the aortic regurgitation. Both the noninvasive and invasive estimations were graded on a four-point scale. In the long-axis parasternal view, the outflow tract of the left ventricle was divided in four areas going from the aortic valve to the apex. Echo-Doppler grading (from + 1 to +4) was obtained by assessing the area where the abnormal diastolic flow could still be recorded. In the group as a whole, concordant degrees of the aortic insufficiency were obtained in 73 of 91 patients (r = .93; p less than .001); the degree of the aortic regurgitation was overestimated in 8 cases (9%) and underestimated in 10 cases (11%). Most of the discrepancies between the Doppler and the aortographic evaluation were found in patients with intermediate degree (+2, +3) of aortic regurgitation; the degree of discordance was never more than +1 or -1. Correlation between Doppler and aortography was higher in the subjects with pure aortic regurgitation (r = .94, p less than .001) and lower in the subgroup of the subjects with associated mitral stenosis (r = .87, p less than .001). Two-dimensional pulsed Doppler echocardiography is a simple and little time consuming technique that in selected groups of patients can be relied upon for the semiquantitated evaluation of the degree of aortic regurgitation.

[Conduction disorders and sites of calcification of the mitral ring: 2-dimensional echocardiographic study]. / Disturbi di conduzione e sede delle calcificazioni dell'anello mitralico: studio ecocardiografico bidimensionale.

The association between a calcified mitral annulus and impairment of cardiac impulse transmission is well known. However informations on the relations between the site of mitral calcification and conduction disturbance are still scanty. Twenty-nine patients (22 women and 7 men, mean age 64.4 +/- 13.1 years) with M-mode and two-dimensional echocardiographic evidence of mitral annulus calcifications were studied. The "annulus" was subdivided in 4 segments: antero-medial, antero-lateral, postero-medial and postero-lateral. Conduction disturbances were present in 15 patients (51.7%). Atrio-ventricular or intra-ventricular conduction defects were found in 12 out of 15 patients with calcifications of the antero-medial segment and only in 3 of 14 subjects without antero-medial calcifications (P less than .01). The presence of conduction defects therefore seems to be significantly increased when calcium deposition is located near the conduction system.

[Reflux esophagitis: clinico-endoscopic aspects]. / Esofagite da reflusso: aspetti clinico-endoscopici.

Though long well known, reflux oesophagitis is as yet poorly understood in terms of both incidence and physiopathology. These aspects of gastrooesophageal reflux were studied in a group of patients subjected to endoscopic examination. The 13.6% incidence of the condition was very similar to the encountered incidence of ulcers. In two thirds of the cases, anamnesis is sufficient for correct diagnosis. In its more severe forms, reflux oesophagitis is associated with hiatus hernia and overindulgence in tobacco or alcohol. Routine radiology is practically or completely useless for the diagnosis of reflux oesophagitis. The use of the Savary classification system facilitates endoscopic diagnosis and staging.