Central olfactory processing in patients with disorders of consciousness.

BACKGROUND AND PURPOSE: Previous studies have demonstrated that individuals suffering from disorder of consciousness (DOC) maintain some minor neural processing of percepts mediated by senses that early in their pathway intersect the thalamus, a key dysfunctional area in DOC patients. Here the degree of sensory preservation within the olfactory system, a system that lacks an obligatory thalamic relay, and its relationship to the consciousness level in DOC patients of various etiologies was assessed. METHODS: Clinical Coma Recovery Scale - Revised (CRS-R) as well as cerebral responses to odors by means of functional magnetic resonance were obtained in a group of vegetative state/unresponsive wakefulness syndrome (n = 26) patients, minimally conscious state (n = 7) patients and healthy controls (n = 25). RESULTS: A majority of vegetative state/unresponsive wakefulness syndrome patients (58%) and 100% of minimally conscious state patients demonstrated a significant preservation of olfactory neural processing, manifested by activation within the piriform cortex, an area considered as a primary olfactory region. Degree of preservation of olfactory processing differed linearly in line with the patients' etiologies where groups demonstrating greater conscious awareness demonstrated more significant processing. Viewed over all DOC patients, there was a significant negative association between odor-related activity in the orbitofrontal cortex and CRS-R scores. CONCLUSIONS: It is demonstrated that DOC patients exhibit a significant preservation of olfactory neural processing with a clear relationship to etiopathologies and clinical measures even years after of chronification of DOC.

Resting state fMRI in cluster headache: which role?

The pathophysiology of cluster headache (CH) is not well-known. For several years, the most widely accepted theory was that CH was triggered by hypothalamus with secondary activation of the trigeminal-autonomic reflex. However, it was recently suggested that the posterior hypothalamus might be an actor of the pain modulating network more involved in terminating rather than triggering attacks. To investigate this hypothesis, resting state fMRI could provide valuable information on functional connectivity between brainstem and hypothalamus, as well as other brain structures that could be involved in CH pathophysiology. In this framework, here we review recent studies investigating functional connectivity by means of resting state fMRI. Despite the important findings of these studies, we suggest that important steps in the comprehension of CH pathophysiology will be done when the scientific community will use the new methodological approaches recently suggested to study functional connectivity in the brainstem.

[Pilot study: Apricena Marble District quarry workers and COPD]. / Studio pilota: addetti alle cave di pietra nel distretto del Marmo di Apricena e BPCO.

The aim of the present article was to verify the Chronic Obstructive Pulmonary Disease (COPD) prevalence in a cohort of quarry workers who belong to the Apricena Marble District. We studied 70 workers. They received a questionnaire about the disease and confounding factors. The spirometry showed that the FEV1 was normal in 95% of workers, instead 5% showed values lower than former (Average: 73%). TNF alpha and IL-1 Beta in Exhaled breath condensate (EBC) were lower than the method limit in all workers. Our cohort is limited, but we could retain that the lung disease is not present in workers taken into consideration. Our results are in according to Rushton who demonstrated that only a prolonged occupation, higher than thirty years, is able to induce lung disease.

Assessment of flow velocity reserve by transthoracic Doppler echocardiography and venous adenosine infusion before and after left anterior descending coronary artery stenting.

OBJECTIVES: We sought to evaluate whether coronary flow velocity reserve (CFR) (the ratio between hyperemic and baseline peak flow velocity), as measured by transthoracic Doppler echocardiography during adenosine infusion, allows detection of flow changes in the left anterior descending coronary artery (LAD) before and after stenting. BACKGROUND: The immediate post-stenting evaluation of CFR by intracoronary Doppler has shown mixed results, due to reactive hyperemia and microvascular stunning. Noninvasive coronary Doppler echocardiography may be a more reliable measure than intracoronary Doppler. METHODS: Transthoracic Doppler echocardiography during 90-s venous adenosine infusion (140 microg/kg body weight per min) was used to measure CFR of the LAD in 45 patients before and 3.7 +/- 2 days after successful stenting, as well as in 25 subjects with an angiographically normal LAD (control group). RESULTS: Adequate Doppler spectra were obtained in 96% of the patients. Pre-stent CFR was significantly lower in patients than in control subjects (diastolic CFR: 1.45 +/- 0.5 vs. 2.72 +/- 0.71, p < 0.01; systolic CFR: 1.61 +/- 1.02 vs. 2.41 +/- 0.68, p < 0.01) and increased toward the normal range after stenting (diastolic CFR: 2.58 +/- 0.7 vs. 2.72 +/- 0.75, p = NS; systolic CFR: 2.43 +/- 1.01 vs. 2.41 +/- 0.52, p = NS). Diastolic CFR was often damped, suggesting coronary steal in patients with > or =90% versus <90% LAD stenosis (0.86 +/- 0.23 vs. 1.69 +/- 0.43, p < 0.01). Coronary stenting normalized diastolic CFR in these two groups (2.45 +/- 0.77 and 2.64 +/- 0.69, respectively, p = NS), even though impaired diastolic CFR persisted in three of four patients with > or =90% stenosis. Stenosis of the LAD was better discriminated by diastolic (F = 49.30) than systolic (F = 12.20) CFR (both p < 0.01). CONCLUSIONS: Coronary flow reserve, as measured by transthoracic Doppler echocardiography, is impaired in LAD disease; it may identify patients with > or =90% stenosis; and it normalizes early after stenting, even in patients with > or =90% stenosis.

BioEnterics Intragastric Balloon: The Italian Experience with 2,515 Patients.

BACKGROUND: The temporary use of the BioEnterics Intragastric Balloon (BIB) in morbidly obesity is increasing worldwide. The aim of this study is the evaluation of the efficacy of this device in a large population, in terms of weight loss and its influence on co-morbidities. METHODS: Data were retrospectively recruited from the data-base of the Italian Collaborative Study Group for Lap-Band and BIB (GILB). After diagnostic endoscopy, the BIB was positioned and was filled with saline (500-700 ml) and methylene blue (10 ml). Patients were discharged with diet counselling ( approximately 1000 Kcal) and medical therapy. The BIB was removed after 6 months. Positioning and removal were performed under conscious or unconscious sedation. Mortality, complications, BMI, %EWL, BMI loss and co-morbidities were evaluated. RESULTS: From May 2000 to September 2004, 2,515 patients underwent BIB (722M/1,793F; mean age 38.9+/-14.7, range 12-71; mean BMI 44.4+/-7.8 kg/m(2) ; range 28.0-79.1; and mean excess weight 59.5+/-29.8 kg, range 16-210). BIB positioning was uncomplicated in all but two cases (0.08%) with acute gastric dilation treated conservatively. Overall complication rate was 70/2,515 (2.8%). Gastric perforation occurred in 5 patients (0.19%), 4 of whom had undergone previous gastric surgery: 2 died and 2 were successfully treated by laparoscopic repair after balloon removal. 19 gastric obstructions (0.76%) presented in the first week after positioning and were successfully treated by balloon removal. Balloon rupture (n=9; 0.36%) was not prevalent within any particular period of BIB treatment, and was also treated by BIB removal. Esophagitis (n=32; 1.27%) and gastric ulcer (n=5; 0.2%) presented in patients without a history of peptic disease and were treated conservatively by drugs. Preoperative co-morbidities were diagnosed in 1,394/2,471 patients (56.4%); these resolved in 617/1,394 (44.3%), improved (less pharmacological dosage or shift to other therapies) in 625/1,394 (44.8%), and were unchanged in 152/1,394 (10.9%). After 6 months, mean BMI was 35.4+/-11.8 kg/m(2) (range 24-73) and %EWL was 33.9+/-18.7 (range 0-87). BMI loss was 4.9+/-12.7 kg/m(2) (range 0-25). CONCLUSIONS: BIB is an effective procedure with satisfactory weight loss and improvement in co-morbidities after 6 months. Previous gastric surgery is a contraindication to BIB placement.

Inhibin alpha-subunit (INHA) gene and locus changes in paediatric adrenocortical tumours from TP53 R337H mutation heterozygote carriers.

The R337H TP53 mutation is a low-penetrance molecular defect that predisposes to adrenocortical tumour (ACT) formation in Brazilian and possibly other populations. Additional genetic defects may be responsible for the variable expression of ACTs in these cases. The inhibin alpha-subunit gene (INHA) on 2q33-qter has been implicated in mouse adrenocortical tumourigenesis. We studied 46 pediatric patients with ACTs from Brazil for INHA genetic alterations; 39 of these patients were heterozygous carriers of the R337H TP53 mutation. We first mapped the INHA gene by radiation hybrid analysis and determined 10 linked microsatellite markers in an area flanked by D2S1371 and D2S206 on 2q33-qter. These markers were then used for loss of heterozygozity (LOH) studies in nine paired germline and tumour DNA samples. Mapping placed the INHA gene in close proximity to D2S2848 (SHGC11864) with a log of odds (LOD) score of 5.84. LOH for at least one marker in the region was identified in 8/9 tumours (89%). Six patients were heterozygous for three INHA mutations: one in exon 1, 127C>G, and two in exon 2, 3998G>A and 4088G>A, all leading to amino acid substitutions (P43A, G227R, and A257T, respectively). A257T is located in a conserved INHA region, highly homologous to transforming growth factor-beta; both G227R and A257T change polarity, and, in addition, G227R changes the pH. We conclude that these sequence alterations and the detected 2q allelic changes suggest that INHA may be one of the contributing factors needed for ACT formation in pediatric patient carriers of the R337H TP53 mutation.

Electrocardiographic correlates with left ventricular morphology in idiopathic dilated cardiomyopathy.

The purpose of the present study was to verify whether the electrocardiographic pattern of patients with idiopathic dilated cardiomyopathy (IDC) might be useful in predicting measurements of left ventricular (LV) morphology. A total of 12 electrocardiographic criteria for LV enlargement were evaluated in 67 patients with IDC, aged 14 to 68 years (mean 48), and were correlated to LV wall thickness, volume and mass, as assessed at angiography (all patients) and echocardiography (50 patients). Linear regression analysis showed weak correlations between multiple electrocardiographic criteria and LV wall thickness, volume and mass. Multiple logistic regression analysis showed that total 12-lead QRS amplitude, voltage criteria of Sokolow and Lyon, overshoot and U-wave inversion were the variables significantly related to LV wall thickness, as assessed by angiography (r = 0.55, p less than 0.005) and echocardiography (r = 0.43, p less than 0.025). The sum of T/R-wave ratios, the RV6/RV5 ratio and the Romhilt-Estes score were predictors of LV end-diastolic volume, as determined by angiography (r = 0.83, p less than 0.001) and echocardiography (r = 0.77, p less than 0.005). Total 12-lead QRS amplitude and the sum of T/R-wave ratios were the only independent predictors of LV mass, either angiographically (r = 0.81, p less than 0.001) or echocardiographically measured (r = 0.71, p less than 0.025). It is concluded that a single electrocardiographic criterion for prediction of LV morphology in patients with IDC is barely effective. Multiple electrocardiographic criteria should be utilized to better predict LV mass and distinguish reliably between LV wall thickening and dilatation.

Acute hemodynamic effects of acebutolol and propranolol.

The acute hemodynamic effects of intravenous acebutolol, 50 mg, and propranolol, 10 mg, were evaluated in 12 patients undergoing diagnostic cardiac catheterization. Each patient received acebutolol or propranolol according to a list of randomization. Both acebutolol and propranolol depressed left ventricular function. There was a significant increase in left ventricular end-diastolic pressure at rest and after isometric exercise, with a concomitant decrease in cardiac index. Systemic vascular resistance was increased by both drugs. The increment after patients received acebutolol was not statistically significant; however, with propranolol it was statistically significant. The overall hemodynamic effects of acebutolol and propranolol are similar, but a quantitative difference exists in their effect on systemic vascular resistance. Acebutolol, a cardioselective agent, produces less of a peripheral vascular beta 2-blockade than does propranolol.

Coronary air embolism complicating accessory pathway catheter ablation: detection by echocardiography.

Percutaneous radiofrequency catheter ablation has been recently introduced for treatment of Wolff-Parkinson-White syndrome. Access to left free-wall atrioventricular accessory pathways can be obtained either via retrograde cardiac catheterization or via the transseptal procedure, which allows ablation of the accessory pathway at its ventricular or atrial insertion, respectively. We describe a patient with Wolff-Parkinson-White syndrome in whom coronary air embolism occurred as a complication of transseptal percutaneous radiofrequency catheter ablation. The diagnosis was made by two-dimensional echocardiography showing a marked echocontrast effect in the posterior wall and in the posterior half of the interventricular septum. A grossly evident breakage of the rubber seal of the vascular sheath was supposed to be the cause of air insinuation. This report suggests that the transseptal approach should be used with caution in performing percutaneous radiofrequency catheter ablation to avoid the risk of air embolization. Two-dimensional echocardiography is an ideal tool to detect this complication.

Angina and normal epicardial coronary arteries: radionuclide features and pathophysiological implications at long-term follow-up.

BACKGROUND: The aim of this study was to identify specific characteristics associated with modifications of symptoms and to evaluate the presence of a pathophysiological link between radionuclide abnormalities and delayed run-off of coronary contrast dye in patients with angina and normal coronary arteries. METHODS: We followed up 53 patients (21 men and 32 women, mean age: 52 +/- 10 years) with angina and angiographically normal epicardial coronary arteries, 21 of whom (40%) displayed a pattern of slow contrast dye run-off from coronary vessels, on visual assessment using a semiquantitative empirical score. Exercise tests showed ECG abnormalities in 29 patients (55%). RESULTS: All patients were alive 92 +/- 44 months after catheterization (140 +/- 79 months after beginning of symptoms). However, 30 patients (57%), who reported worsening or no change of symptoms, presented with a non-significant higher prevalence of conduction abnormalities at rest ECG (27 versus 17%), pathological exercise tests (57 versus 52%), and delayed run-off (47 versus 30%). Regional left ventricular function and perfusion were then simultaneously assessed at rest and peak exercise with 99mTc-sestamibi. Exercise-induced radionuclide abnormalities were detected in 27 patients (51%), who also presented with a non-significant higher prevalence of pathological exercise tests (63 versus 43%) and no improvement of symptoms (63 versus 46%). However, exercise-induced functional and perfusional abnormalities were simultaneously present in 29 out of 42 (69%) coronary territories supplied by vessels with delayed run-off, versus 21 out of 117 (17%) normal territories (P = 0.00032). CONCLUSIONS: Despite a good prognosis, some patients with angina and normal coronary arteries presented no improvement of symptoms at follow-up, and had functional and perfusional abnormalities in coronary territories supplied by vessels showing delayed contrast dye run-off.

Correlation between angiographic success and functional improvement assessed by exercise test following percutaneous transluminal coronary angioplasty.

Sixty-one consecutive patients with stable effort angina and single vessel disease underwent successful (reduction of coronary stenoses by greater than or equal to 20%) percutaneous transluminal coronary angioplasty (PTCA). Anatomical results were analysed on the basis of functional evaluation obtained by exercise test (ET) 1 week before (pre-PTCA) and within 1 month after (post-PTCA) PTCA. Total exercise duration and maximal double product significantly increased after PTCA (4.5 +/- 1 min vs 6.9 +/- 1.5 min, p less than 0.001 and 14.1 +/- 3.6 x 1000 mmHg x bpm vs 18 +/- 4.2 x 1000 mmHg x bpm, p less than 0.001). Pre-PTCA ET was positive in 43 patients (70%) and post-PTCA ET in 15 (24%). In patients with post-PTCA positive ET, mean stenosis diameter reduction was significantly lower than that obtained in patients with negative post-PTCA ET (29.6 +/- 8.9% vs 61.1 +/- 18.8%, p less than 0.001). In conclusion, PTCA improved exercise tolerance in the majority of patients with myocardial ischemia, however the definition of anatomical success used in this study appears to be poorly correlated with functional improvement as assessed by ET.

Treatment of homozygous and double heterozygous familial hypercholesterolemic children with LDL-apheresis.

Within the framework of a seven-year clinical experience on treatment of severe hyperlipoproteinemia with/without associated coronary heart disease, with therapeutic plasmapheresis (APO B-100-containing lipoprotein-apheresis), we focused the present report on two young patients aged 7 and 11 years, respectively. The older patient is a boy treated since 1990 by plasma-exchange, cascade filtration-low density lipoprotein apheresis (LDL-apheresis), and dextrane sulphate-LDL apheresis. Over the treatment period the patient was submitted to three consecutive coronary angiographies. The second is a girl first submitted to a coronary angiography and then treated with dextrane sulphate-LDL apheresis. Up to now, a total of one-hundred therapeutic plasmaphereses have been performed. The interval of treatment was of fifteen days, and a volume of 2-3000 ml of plasma was processed at each session. The systems used were the following: DIDECO Vivacell BT 798-A, DIDECO Vivacell BT 798-A + BT 803, DIDECO BT 985 (Dideco, Mirandola, Italy), KANEKA MA-01 (Kanegafuchi, Osaka, Japan). Mean (SD) plasma apo B-100-containing major lipoprotein-LDL, Lp(a)-levels during treatment, are reported below: [table: see text] The treatment was very well tolerated. Rare, moderate hypotensive events occurred. Nevertheless, all procedures were regularly completed. A mild hypochromic anemia, regressed using drug treatment, was observed in the boy. Along with the improvement of plasma atherogenic profile, a regression of skin xanthomas and unchanged favourable coronary angiograms, were obtained in the above mentioned patient.

Evidence for improved cardiac performance after beta-blockade in patients with coronary artery disease.

The study was undertaken to investigate the acute haemodynamic effects of bunitrolol (0-2-hydroxy-3-(tert.butylamino)-propoxy)-bity. Right and left heart catheterization was performed in eleven patients with documented coronary artery disease. After bunitrolol (10 mg i.v.), there was a statistically significant decrease in left ventricular and aortic systolic pressures left ventricular end-diastolic pressure, aortic diastolic and mean pressures, pressure-rate product and compliance index (delta P/delta V). Left ventricular dp/dt, left ventricular dp/dt over isovolumic pressure, systemic resistance and heart rate tended to decrease, stroke volume and left ventricular stroke work index tended to increase, without statistical significance. Cardiac index showed individual variations, the mean values for the group being unchanged. Correlation of left ventricular end-diastolic pressure and left ventricular stroke work index showed a shift toward improved ventricular function curve in most cases, deterioration in no instance. Supine exercise was performed in ten patients. Angina occurred in nine patients; in five only before and in four before and after beta-blockade. Post-drug exercise heart rate, pressure-rate product and left ventricular end-diastolic pressure were significantly lower, the latter also in the four patients who still presented exercise angina. It is concluded that certain beta-blockers can improve cardiac performance at rest and during exercise in patients with coronary artery disease. This is explainable on the basis of a more favourable balance between oxygen supply and demand, together with a less marked negative inotropic effect due to the partial agonist activity of the agent used in the study.

Iliac arteriovenous fistula complicating lumbar laminectomy.

An iliac arteriovenous fistula may rarely complicate lumbar laminectomy, particularly at the L4-L5 level. We present such a complication in a 45-year-old man who presented in our institution with a postlaminectomy iliac arteriovenous fistula and severe congestive heart failure. Repair of the fistulous orifice and tubular reconstruction of the iliac artery were successfully performed.

[The ocular fundus in ischemic cardiopathy]. / Ruolo del fondo dell'occhio nella cardiopatia ischemica.

BACKGROUND: This work aims to correlate retina vessel alteration with the possible presence of coronary alteration in the same patient. METHODS: For this purpose 103 patients have been studied. Of these, 63 had symptoms of coronary heart disease while the remaining 40 were used as a control. 29 patients, out of the 63, were also afflicted with angine while 34 had previously had myocardial infarction. Eye fundus tests and coronarography have been carried out, and risk factors such as high cholesterol, high blood pressure, diabetes and smoking have been investigated. RESULTS AND CONCLUSIONS: This work shows that there is a close correlation between a positive eye fundus and coronarography alteration whereas a negative one is not incompatible with organic lesions. A positive eye fundus due to alteration of retina microcirculation can be indicative of atherosclerosis in symptomatic patients.

Woven coronary artery: differential diagnosis with diffuse intracoronary thrombosis.

Woven coronary malformation is characterized by the branching of a major epicardial coronary artery into thin channels which then merge again in a normal conduit. The angiogram can suggest a filling defect instead of a malformation and an undue coronary angioplasty could be performed determining some damage to the arterial wall. In this case report we describe a patient with a stenosis on the left anterior descending coronary artery and a woven coronary artery on the right coronary artery. In 1995 a coronary angioplasty was performed on the left anterior descending coronary artery. Four years later a coronary angiogram did not show any changes in the right coronary artery. In this patient the malformation did not induce any reduction in the coronary reserve as shown at cardiac scintigraphy. We need more information about the natural history of such a malformation.

Non-invasive assessment of coronary flow velocity reserve before and after angioplasty in a patient with mammary graft stenosis.

We report the diagnosis of mammary artery graft dysfunction by high-resolution transthoracic Doppler and venous adenosine infusion. The patient was treated by percutaneous balloon angioplasty, with optimal angiographic results. Coronary flow reserve in the distal left anterior descending artery was abnormal before angioplasty, and recovered soon after the procedure. The utility of this new non-invasive technique in the diagnosis of flow-limiting stenoses and follow-up of coronary angioplasty is described.

Rheumatic fever recurrence: a possible cause of restenosis after percutaneous mitral valvuloplasty.

BACKGROUND: We evaluated the occurrence of a rapid process of restenosis after percutaneous mitral valvuloplasty (PMV), initiated by the recurrence of acute rheumatic fever. Restenosis after PMV has been mainly related to a high echocardiographic score (> or = 8) indicating a severely compromised mitral valve apparatus. METHODS: From 1986 to 1996, 120 patients underwent PMV by the transseptal approach at our Institution. The mean follow-up time was 58 +/- 32 months (range 3 months to 9 years). RESULTS: Restenosis occurred in 10 patients (8.3%): in 4 restenosis was found within a relatively short period of time (1 to 3 months) following a documented recurrence of acute rheumatic fever; in the other 6 patients there was a gradual loss of the initial gain in the mitral valve area. CONCLUSIONS: These data suggest two potential mechanisms of restenosis: 1) a more common slow process, due to turbulent flow-trauma on the mitral valve; 2) a rapid process that relates to valvulitis consequent to a recurrence of acute rheumatic fever. In consideration of the second possibility, after PMV prophylactic treatment may be warranted at least in those patients who are at high risk of streptococcal infection.

População de protozoários ruminais em novilhos zebuínos alimentados com ou sem volumoso / Population of Protozoa in zebu steers fed with or without bulk

This study aimed to quantify and identify the profile of the rumen protozoa population of beef steers fed with or without roughage. Nellore crossbred steers raised in extensive system on lignified tropical pastures with mineral supplementation and steers confined for 60 days only receiving pelletized concentrate and whole corn kernels were evaluated. After slaughter, rumen fluid was collected and one ml aliquots were diluted in nine ml formaldehyde solution at 10%. The counts of small, medium and large protozoa were held in Sedgewick Rafter chambers and identification of genus was possible after staining lugol and optical microscope with a 40X objective. The concentration of rumen protozoa positively correlated with pH ruminal. Cattle fed without roughage had significantly lower rumen protozoa population (P<0.05). Animals fed roughage had higher occurrence of Dasytrichia genus, Charonina, Entodinum, Diplodinium, Ostracodinium and Epidinium while those fed without bulk, the Buetschilia, Isotricha, Eodinium, Polyplastron, Elyplastron, Metadinium and Enoploplastron were the most frequent genus.(AU)

População de protozoários ruminais em novilhos zebuínos alimentados com ou sem volumoso / Population of Protozoa in zebu steers fed with or without bulk

This study aimed to quantify and identify the profile of the rumen protozoa population of beef steers fed with or without roughage. Nellore crossbred steers raised in extensive system on lignified tropical pastures with mineral supplementation and steers confined for 60 days only receiving pelletized concentrate and whole corn kernels were evaluated. After slaughter, rumen fluid was collected and one ml aliquots were diluted in nine ml formaldehyde solution at 10%. The counts of small, medium and large protozoa were held in Sedgewick Rafter chambers and identification of genus was possible after staining lugol and optical microscope with a 40X objective. The concentration of rumen protozoa positively correlated with pH ruminal. Cattle fed without roughage had significantly lower rumen protozoa population (P<0.05). Animals fed roughage had higher occurrence of Dasytrichia genus, Charonina, Entodinum, Diplodinium, Ostracodinium and Epidinium while those fed without bulk, the Buetschilia, Isotricha, Eodinium, Polyplastron, Elyplastron, Metadinium and Enoploplastron were the most frequent genus.(AU)