A hand-carried cardiac ultrasound device in the outpatient cardiology clinic reduces the need for standard echocardiography.

OBJECTIVE: To assess the potential value and cost-effectiveness of a hand-carried ultrasound (HCU) device in an outpatient cardiology clinic. METHODS: 222 consecutive patients were prospectively enrolled in the study. When standard echocardiography (SE) was specifically indicated on the basis of clinical history, electrocardiogram and physical examination, the same cardiologist (level-2 or level-3 trained) immediately performed an HCU examination. The cardiologist then reassessed the clinical situation to confirm or cancel the SE request according to the information provided by HCU. The SE examination was performed by a sonographer and examined in a blinded fashion by a cardiologist expert in echocardiography. Findings from the two examinations were compared. RESULTS: HCU was performed in 108/222 patients, and a definite diagnosis was established in 34 of them (31%), making SE examination potentially avoidable. In the 74 patients with inconclusive HCU results and for whom SE was still indicated, the decision was mainly dictated by the lack of spectral Doppler modality in the HCU system. The overall agreement between HCU and SE for diagnosis of normal/abnormal echocardiograms was 73% (kappa = 0.4). On the basis of the potentially avoided SE examinations and the obviated need for a second cardiac consultation, a total cost saving of euro2142 per 100 patients referred for echocardiography was estimated. CONCLUSIONS: The use of a simple HCU device in the outpatient cardiology clinic allowed reliable diagnosis in one third of the patients referred for echocardiography, which translates into cost and time saving benefits.

[Emergency department ultrasonography: impact on patient management and cost effectiveness]. / L'ecografia nel Dipartimento di Emergenza: impatto sulla gestione del malato e analisi costo-efficacia.

AIM: Ultrasonography is the most common noninvasive method for the evaluation of body organs and systems. However, the feasibility and potential advantages of ultrasound scanning by emergency physicians have not yet been fully explored. We therefore wanted to determine the impact of ultrasound scanning by emergency physicians on patient management in the Emergency Department, length of hospital stay, and related costs. METHODS: From a data-base search at our hospital we selected 111 patients and divided them into 3 groups according to symptoms: right hypochondriac region pain (Group A), flank pain (Group B), abdominal pain and hemodynamic instability (Group C). Patients were further stratified into 3 subgroups according to whether they were treated by an emergency physician or a radiologist or did not undergo ultrasonography. For each group the mean length of stay in the emergency department, the complications rate, the recurrence rate (defined as return visit to the emergency department for the same pathology) and the related costs were calculated. RESULTS: Of the 111 patients, 76 received ultrasound scanning, of which 43 were treated by an emergency physician. The length of hospital stay for this group was shorter than that of the other 2 subgroups. The recurrence rate was highest in the group that did not undergo ultrasonography. The costs were lower for the group that received ultrasound scanning by an emergency physician than for the group treated by a radiologist (Euro 20 vs Euro 38). CONCLUSION: Ultrasound scanning by emergency physicians can shorten length of hospital stay for emergency patients, reduce recurrence rates for the same pathology and lower patient management costs.

Scurvy mimicking systemic vasculitis.

An 91 years old woman was hospitalized because of lethargy, shortness of breath and diffuse subcutaneous hemorrhage of legs. Clinical features were consistent with the diagnosis of vasculitis with systemic involvement. However dermatologic characteristics of the legs, in association with malnutrition, suggested vitamin C deficiency which was confirmed by laboratory test. Ascorbic acid supplement dramatically improved her clinical symptoms. This case remarks how scurvy may mimmick a systemic vasculitis.

Effect of early treatment with captopril and metoprolol singly and together on postinfarction left ventricular remodeling.

BACKGROUND: beta-Blockers improve clinical outcome after acute myocardial infarction (AMI), but few data are available on their effectiveness in preventing left ventricular remodeling. The aim of the study was to assess the relative effects of captopril, metoprolol, and their combination on left ventricular remodeling after uncomplicated AMI. METHODS: Two hundred fifty consecutive patients with a first AMI were randomly allocated to receive for 6 months captopril (up to 75 mg/d, group 1), metoprolol (up to 200 mg/d, group 2), or both (group 3) starting within 24 hours from symptom onset. Of these, 130 patients (group 1, 46; group 2, 47; group 3, 37) completed the study; all patients underwent 2-dimensional echocardiography at baseline and after 2 weeks and 3 and 6 months from AMI. RESULTS: At 6 months, in comparison with baseline values, left ventricular end-diastolic area index (LVEDI) significantly increased in group 3 (P =.013) and wall motion score index significantly decreased in group 1 (P =.038). At any follow-up evaluation, the covariance analysis showed significantly greater interval changes in LVEDI in group 3 than in group 1 (P =.0077 at 2 weeks, P =.0108 at 3 months, and P = 0.0155 at 6 months). No significant differences were observed between group 1 and group 2 and between group 2 and group 3. CONCLUSIONS: After uncomplicated first AMI, early and long-term treatment with captopril alone attenuates left ventricular remodeling better than its combination with metoprolol. In the head-to-head captopril versus metoprolol therapy strategy comparison, captopril alone seems more effective in reducing postinfarction enlargement, but a definite difference was not demonstrated.

Two distinct populations of tumor necrosis factor-stimulated gene-6 protein in the extracellular matrix of expanded mouse cumulus cell-oocyte complexes.

After the luteinizing hormone surge, the cumulus cell-oocyte complexes (COCs) in the preovulatory follicles produce a viscoelastic extracellular matrix, a process that requires the synthesis of hyaluronan as well as the incorporation of some components of the inter-alpha-trypsin inhibitor (IalphaI) family. In this study we report, that a hyaluronan-binding protein, the translated product of tumor necrosis factor-stimulated gene-6 (TSG-6), is also specifically accumulated in this matrix. TSG-6 mRNA expression is quickly upregulated and peaks at approximately 1500 copies/cell 4 h after the ovulatory stimuli as assessed by quantitative reverse transcription-polymerase chain reaction. Immunohistochemistry reveals the colocalization of the TSG-6 protein and hyaluronan around the cumulus and granulosa cells. The TSG-6 protein exists in two distinct populations in the COC matrix as demonstrated by Western-blot analysis. One population is a monomer that is anchored to the matrix by a noncovalent interaction. The second population is a covalent complex with either of the heavy chains of IalphaI and is bound to hyaluronan through a strong interaction that is resistant to denaturing conditions. The specific incorporation of the TSG-6 protein into the COC matrix suggests a structural role for this molecule.

Constrictive pericarditis after cardiac surgery.

Constrictive pericarditis is an infrequent complication of cardiac surgery. We report the case of a young woman who developed dyspnea and ascites 3 years after surgical closure of an atrial septal defect, and the findings at chest X-ray, computed tomographic scan and Doppler echocardiography are described. Epidemiology of the disease, new pathophysiologic concepts, diagnostic features, and therapeutic targets are reviewed.

Control of mouse cumulus cell-oocyte complex integrity before and after ovulation: plasminogen activator synthesis and matrix degradation.

During the preovulatory period, cumulus cells (CCs) form a hyaluronan-protein extracellular matrix (cumulus expansion) that positively influences oocyte fertilization. Degradation of this matrix and CC-oocyte complex (COC) dissociation occurs within a few hours of ovulation and parallels the aging of oocytes. Modulation of CC proteolytic activity by gonadotropins and oocyte soluble factors has been hypothesized to determine such cumulus matrix changes. In the present study, we investigated plasminogen activator (PA) synthesis by COCs during the expansion and disassembly processes. Our results show that the secretion of tissue type PA and urokinase type PA (uPA) by oocytes and CCs, respectively, does not change significantly during expansion but dramatically increases thereafter. Compact COCs were isolated from immature mice, primed 48 h earlier with 5 IU PMSGs, and were induced to expand in vitro with 100 ng/ml FSH in the presence of 1% FCS. Full expansion was achieved at 16 h, when hyaluronan synthesis ceased. Release of hyaluronan and CCs from the COC matrix began between 18 and 20 h of culture, which indicates that matrix degradation started at this time. PA activities in culture media were determined by SDS-PAGE, followed by a zymography at various time intervals between 4 and 32 h of culture. Secreted tissue type PA and uPA activity abruptly increased between 16 and 20 h after FSH stimulation. Slot blot hybridization of CC messenger RNA showed that uPA messenger RNA levels correlated with the increase in uPA activity. Similar temporal patterns of PA synthesis and matrix degradation were found in COCs induced to expand in vivo by injection of 5 IU human CG into PMSG-primed mice. Cultures of CCs, both in the presence and absence of oocytes, revealed that uPA synthesis is repressed in FSH-stimulated CCs by an oocyte-soluble factor for the first 16 h of culture, whereas CC responsiveness to this factor is lost thereafter. In conclusion, the data show that a sophisticated interplay between oocyte and CCs causes the two cell types to simultaneously secrete PA activity after ovulation. The fact that matrix degradation parallels PA production strongly supports the hypothesis that these enzymes may destabilize the expanded COC matrix.

New insights into regional systolic and diastolic left ventricular function with tissue Doppler echocardiography: from qualitative analysis to a quantitative approach.

Tissue Doppler echocardiography is a variation of conventional Doppler flow imaging. This modality allows quantification of the Doppler shift within the range of myocardial tissue motion. The velocity at a variety of myocardial sites can be determined and distinguished very rapidly by using Doppler techniques. The velocity of moving tissue can be studied with pulsed wave tissue Doppler sampling, which displays the velocity of a selected myocardial region against time, with high temporal resolution. In addition, the velocities can be calculated with time-velocity maps and displayed as color-encoded velocity maps in either an M-mode or 2-dimensional format. This review will focus on the technical aspects and the different methods of tissue Doppler echocardiography for the analysis of regional systolic and diastolic left ventricular function. Whereas pulsed wave tissue Doppler echocardiography allows measurements of velocities of a selected myocardial region, color tissue Doppler gives the best overview of cardiac dynamics because the entire scanned color data are displayed simultaneously. However, there is an increasing need for objective evaluation of tissue Doppler information. Digital images and postprocessing of the data allow for quantitative off-line analysis, and the different approaches and parameters proposed from different centers are discussed.

Paracrine actions of oocytes in the mouse pre-ovulatory follicle.

In mammals, ovulation requires a tight control of extracellular matrix modifications, within both the follicle wall and the inner mass of granulosa cells surrounding the oocyte, namely the cumulus cells. During the pre-ovulatory period, mural granulosa cells promote selective degradation of perifollicular matrix, resulting in the formation of a follicle rupture site. Conversely, cumulus cells synthesize a large amount of a muco-elastic matrix that plays an essential role in the extrusion of the oocyte from the follicle and in the subsequent fertilization process. Formation of such matrix by cumulus cells in the pre-ovulatory follicle appears to be controlled by a paracrine influence by the oocyte. We have shown that mouse oocytes modulate the response of cumulus cells to an ovulatory gonadotropin stimulus by promoting the synthesis and preventing the degradation of cumulus matrix. Therefore, although gonadotropins are essential for triggering the complex events involved in ovulation, the oocyte appears to have an active role in this process. In the present review current data and hypotheses concerning molecular mechanisms involved in the organization and synthesis of cumulus matrix are discussed.

[Tissue Doppler: the physical principles, representational and analytical modalities and clinical applications]. / Il Doppler tessutale: principi fisici, modalità di rappresentazione e di analisi ed applicazioni cliniche.

Tissue Doppler imaging or myocardial velocity imaging is a variation of conventional Doppler. This modality allows the quantification of the Doppler shift within the range of myocardial tissue motion. The velocity of motion at a variety of myocardial sites can be determined and distinguished very rapidly using Doppler techniques. The velocity of moving tissue can be studied with pulsed wave tissue Doppler sampling, which displays the velocity of a selected myocardial region against time, with high temporal resolution. In addition, the velocities can be calculated with time velocity maps and displayed as color coded velocity maps in either M-mode or two-dimensional format. This review will focus on the technical aspects and the different methods of tissue Doppler for regional systolic and diastolic left ventricular function analysis. While pulsed wave tissue Doppler allows us to measure the velocities of a selected myocardial region, color tissue Doppler gives the best overall view of cardiac dynamics because the whole scanned color data are displayed simultaneously. However, there is an increasing need for objective evaluation of tissue Doppler information. Digital images and data post-processing allow for quantitative off-line analysis, and the different approaches and parameters proposed from different centers are discussed. In recent years, tissue Doppler imaging has been applied for accurate evaluation of diastolic function, quantifying regional function particularly during stress, pre-excitation syndrome, and left ventricular hypertrophy. The results of these experiences indicate that tissue Doppler imaging is a promising technique for quantifying the response of the myocardium and endocardium during both normal and abnormal function. Again, there is a significant learning curve concerning its application, but with experience it will be a useful and reproducible technique.

From digital image processing of colour Doppler M-mode maps to noninvasive evaluation of the left ventricular diastolic function: a dedicated software package.

Noninvasive estimation of diastolic pressure gradients has recently been validated using the space-temporal velocity distribution available from colour Doppler M-mode (CDM). However, the methods currently applied for analysing CDM patterns of left ventricular (LV) filling have limitations, such as lack of automation, subjective variability and limited use of digital velocity map. For this reason, we have developed software able to acquire and process the CDM maps; thus, providing an easily interpretable graphical and numerical display. The pressure field is obtained by approximating the derivatives with centred finite differences via the incompressible Navier-Stokes equations. After digital filtering of the noise and the removal of the colour black spots, the velocity field is utilised to compute the pressure gradient field and the pressure values by spatial integration. It is concluded that automatic quantification of colour CDM patterns is feasible and will be a strategic tool in the investigation of one of the most intriguing topics in cardiology.

Three-dimensional echocardiography: where we are, where we are going.

Three-dimensional reconstruction of the heart has been an important research goal ever since the introduction of two-dimensional echocardiography. Several directions have been followed. Most approaches towards three-dimensional echocardiography are off-line and are based on the sequential rotational scanning and acquisition of multiple cross-sectional images together with their spatial position and orientation using internal coordinate reference systems. From the reconstructed volumetric data set electronic slicing can be performed which allows any-plane and paraplane echocardiography. The availability and versatility using the volumetric data set permits the retrieval of an infinite number of cardiac cross-sections which allow more accurate and reproducible measurements of valve areas, masses and cavity volumes by obviating geometric assumptions. The application of algorithms based on light reflection to the grey scale data provides tissue-depicting information allowing for dynamic volume-rendered display in projection, up till now unavailable in cardiology. This capability decreases variability both in the quality and interpretation of complex pathology among investigators. Emerging clinical experience indicates the strong potential of three-dimensional echocardiography in qualitative and quantitative diagnostic appraisal of various cardiac problems. While the technique is ready for clinical applications, its widespread use can be facilitated by a number of improvements. Advances in computer technology can be applied to three-dimensional echocardiography offering an exciting opportunity to employ virtual reality and simulation of interventional and surgical procedures, to predict results and plan appropriate therapy. In the future new physiologic parameters will provide additional information and will allow us to address new clinical questions.

Hyaluronan and proteoglycans in ovarian follicles.

Proteoglycans are macromolecules formed by a protein backbone to which one or more glycosaminoglycan side chains are co-valently attached. They can be secreted by the cells, retained at the cell surface, or stored in intracellular vacuoles. Hyaluronan is an extremely long glycosaminoglycan which, at variance with other glycosaminoglycans, is released into the extracellular matrix as a free polysaccharide not co-valently linked to a core protein. Both proteoglycans and hyaluronan influence many aspects of cell behaviour by multiple interactions with other molecules. They are involved in matrix formation, cell-cell and cell-matrix adhesion, cell proliferation and migration, and show co-receptor activity for growth factors. Both proteoglycan and hyaluranon synthesis change significantly during ovarian follicle development and atresia. This review describes the structure of these molecules and their possible function in ovarian physiology.

Prediction of cardiac events after uncomplicated acute myocardial infarction by clinical variables and dobutamine stress test.

OBJECTIVES: We sought to determine the relative prognostic power of several clinical and dobutamine stress test variables in patients after a first uncomplicated acute myocardial infarction (AMI). BACKGROUND: The value of dobutamine echocardiography (DE) for determining prognosis after AMI is not yet defined. In particular, the influence of dobutamine stress test response on the outcome of these patients is unknown. METHODS: A graded predischarge DE (from 5 to 40 microg/kg/min, plus atropine if needed) was performed in 245 patients (mean age 60 +/- 10 years) with a first uncomplicated AMI. RESULTS: At follow-up (17 +/- 13 months), an adverse outcome occurred in 40 patients: cardiac death in 7, nonfatal myocardial infarction in 9 (hard events = 16) and unstable angina requiring hospital readmission in 24. Significant predictors of adverse outcome by univariate analysis were positive DE, ischemic wall motion score index (WMSI), angina during DE and diabetes for all events, and positive DE, ischemic WMSI and age for hard events. At multivariate analysis, the only independent predictors of adverse outcome were positive DE, diabetes and angina during DE for all events, and positive DE and age for hard events. The presence of both age >60 years and a history of diabetes identified patients at high risk of cardiac events (event rate 37%), compared with patients <60 years and no diabetes (event rate 11%). In patients with intermediate risk (only one clinical risk factor, event rate 18%), DE added prognostic information (event rate 10% in the negatives, 25% in the positives and 35% in the positives with angina). CONCLUSIONS: After uncomplicated AMI, dobutamine stress test variables offer additional prognostic information to clinical data.

Effects of early treatment with captopril and metoprolol singly or together on six-month mortality and morbidity after acute myocardial infarction. Results of the RIMA (Rimodellamento Infarto Miocardico Acuto) study. The RIMA researchers.

UNLABELLED: The RIMA (Rimodellamento Infarto Miocardico Acuto) study was designed to assess the relative effects of angiotensin-converting enzyme (ACE) inhibition by captopril, beta-blocker therapy by metoprolol, and their combination in patients with a first acute myocardial infarction on: 1. echocardiographically detected left ventricular remodeling; 2. prognosis. The second goal will be the argument of the present paper. Two-hundred fifty < or = 75 years consecutive patients (mean age: 58 yrs, males = 203) with acute myocardial infarction were randomly allocated to receive for > or = 3 months captopril (up to 75 mg/day, Group 1), metoprolol (up to 200 mg/day, Group 2) or captopril + metoprolol (Group 3) starting in the first 24 hours after the onset of symptoms. Intravenous beta-blockers in the acute phase of myocardial infarction and all other cardioactive drugs were allowed. The effect of the randomized therapy at six months from admission to the coronary care unit was considered in relation to: 1. recurrence of spontaneous cardiac events and of elective revascularization procedures; 2. adverse reactions (hypotension, atrioventricular block, cough, allergy, need of beta-blockers in Group 1, need for ACE inhibition in Group 2) requiring treatment modification based on physician's decision. RESULTS: Definite follow-up data were available in 226 patients and 195/226 patients (86%) had a complete treatment period. In these patients (per protocol analysis), 37 spontaneous cardiac events occurred: cardiac death = 6, non-fatal reinfarction = 9, unstable angina requiring hospitalization = 16, congestive heart failure = 6. Moreover, seven patients received a coronary revascularization procedure. Events occurred in 11/67 patients from Group 1, 16/63 patients from Group 2, 10/65 patients from Group 3 (16% vs 25% vs 15%, p = 0.28). The multiple logistic regression analysis demonstrated an increased odds ratio (OR) for spontaneous cardiac events in patients from Group 2 (OR = 2.82, 95% Cl: 1.16-6.87: p < 0.05). Elective revascularization procedures were statistically less frequent in patients treated with metoprolol (Group 1 = 9%, Group 2 = 1.6%, Group 3 = 0%; Group 1 vs Groups 2 and 3; p = 0.03). The intention-to-treat analysis on the overall population (226 patients) confirmed the presence of a trend towards a higher risk in patients from Group 2 (OR = 2.1, 95% Cl: 0.96-4.59; p = 0.06). Adverse reactions were observed in 16 patients from Group 1, 6 patients from Group 2 and 15 patients from Group 3 (22% vs 10% vs 23%; Group 2 vs Groups 1 and 3; p = 0.08). At the multivariate regression analysis, a trend towards less adverse reactions in patients assigned to the beta-blocker therapy alone was confirmed (OR = 0.41, 95% Cl: 0.15-1.13; p = 0.07). CONCLUSIONS: In a randomized early post-infarction treatment strategy, ACE inhibition with captopril alone or in combination with metoprolol demonstrated an increased protection against spontaneous cardiac events at six months in comparison with metoprolol alone. On the other hand, the beta-blocker treatment was associated with a lower number of elective revascularization procedures and appeared better tolerated than ACE inhibition.