Hemodynamics of volume loading compared with dobutamine in severe right ventricular infarction.

To compare the hemodynamic effect of volume loading with that of dobutamine infusion in severe ischemic right ventricular (RV) dysfunction, 11 patients with inferior and RV infarction complicated by low cardiac output syndrome and important hemodynamic derangement (systolic blood pressure < 100 mm Hg, cardiac index < 2.0 liters/min/m2, right atrial pressure > 10 mm Hg) were prospectively studied within 48 hours of symptom onset. After right heart catheterization, volume loading (mean 400 ml saline solution) and dobutamine infusion (5 and 10 micrograms/kg/min over 10 minutes) were performed according to a randomized, crossover design. Volume loading resulted in increased right atrial (from 15 +/- 2 to 19 +/- 3 mm Hg, p < 0.05) and pulmonary capillary (from 15 +/- 2 to 19 +/- 3 mm Hg, p < 0.05) pressures, without increasing cardiac index, heart rate, aortic pressure, or right and left ventricular stroke work index. Dobutamine (5 micrograms/kg/min) increased cardiac index (from 1.5 +/- 0.3 to 1.9 +/- 0.5 liters/min/m2, p < 0.05), incrementing both heart rate (from 61 +/- 12 to 70 +/- 13 beats/min, p < 0.05) and stroke volume index (from 25 +/- 6 to 27 +/- 5 ml/beat/m2, p < 0.05), as well as right (from 1.4 +/- 1.6 to 2.3 +/- 2.2 g.m/m2, p < 0.05) and left (from 21 +/- 7 to 27 +/- 10 g.m/m2, p < 0.05) stroke work indexes; right and left ventricular filling pressures did not decrease. Dobutamine (10 micrograms/kg/min) significantly improved myocardial performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Syncope caused by cardiac asystole during dobutamine stress echocardiography.

Syncope caused by cardiac asystole during dobutamine stress echocardiography occurred in a 60 year old woman presenting with chest pain and a non-diagnostic exercise test. Cardiac asystole was not associated with myocardial ischemia and was attributed to a powerful cardioinhibitory vagal reflex elicited by the stimulation by the drug of cardiac and aortic mechanoreceptors. Cardiac asystole was promptly reversed by the administration of atropine with no significant sequelae.

Comparison of dobutamine stress echocardiography with dipyridamole stress echocardiography for detection of viable myocardium after myocardial infarction treated with thrombolysis.

OBJECTIVE: To compare the ability of dobutamine and dipyridamole stress echocardiography to detect functional recovery of stunned but viable myocardial regions early after acute myocardial infarction, and to predict late functional recovery of the reperfusion salvaged myocardium within the infarct area. METHODS: Within 10 d of acute myocardial infarction, 51 patients--30 anterior and 21 inferior, 44 Q wave and seven non-Q-wave infarction--were submitted to a dobutamine echocardiography test at low dose (5-10 micrograms/kg/min over 5 min) and high dose (20-40 micrograms/kg/min over 3 min) and to dipyridamole echocardiography test (0.56 mg/kg over 4 min + 0.28 mg/kg over 2 min) on different days and in random order, after interruption of any vasoactive drug. Resting echocardiography was repeated at two months in 41 of 51 patients (80%). Regional wall motion of the left ventricle was analysed in a semiquantitative manner on a 14-segment model. Viability was defined as improvement of one grade or more of at least two basally asynergic segments in the infarcted area. RESULTS: Regional functional recovery was detected by low dose dobutamine in 38/51 patients (75%) and in 147/308 (48%) of basally asynergic segments, compared to 25/51 patients (49%; P < 0.001) and 78/308 segments (25%; P < 0.001) only identified by dipyridamole. Late spontaneous functional recovery was detected in 24/41 patients (59%) and in 78/254 basally asynergic segments (31%). The sensitivity of dobutamine and dipyridamole echocardiography for predicting spontaneous functional recovery was 72% and 51% respectively (P < 0.001), specificity 68% and 82% (P < 0.001), positive predictive value 50% and 56%, and negative predictive value 85% and 79%. CONCLUSIONS: In comparison with dipyridamole in patients with thrombolysed myocardial infarction, dobutamine induces regional functional recovery. This suggests that dobutamine is more sensitive in showing the presence of viable myocardium within the infarct zone, though it has a lower specificity in predicting delayed spontaneous functional recovery of non-contractile but still viable areas.

Family studies and HLA typing in ankylosing spondylitis and sacroiliitis.

The families of 21 ankylosing spondylitis (AS) and 16 sacroiliitis (SI) patients were investigated and typed for HLA markers. The association of HLA B27 with AS was confirmed, but no strong evidence for the same or other HLA markers being associated with SI was found. Inheritance patterns in families were analyzed according to the multifactorial and monofactorial models. It is proposed that a major gene associated or interacting with the B27 product controls the susceptibility to AS, and that this gene behaves as a dominant with incomplete penetrance. The problem as to whether linkage disequilibrium maintained by selective pressure, or functional epistasis between the "disease gene" and the B27 antigen may be the acting mechanism of association, remains to be elucidated.

Indirect post-implant lesions of the inferior alveolar nerve. Radiological and biomechanical findings.

THE AIM OF THE WORK.: The mandibular canal, if it is affected by different illnesses, often shows typical radiological changes, made up of widespread hypodensity, an increase in its diameter and disappearing walls. This study aims to verify the reliability of such radiological signs in the cases of later post-operative lesions of the mandiblular canal. MATERIALS AND METHOD.: The study includes 16 patients, 9 males and 7 females, with an average age of 54 years, who underwent an operation to rehabilitate the mandible with a prosthetic implant for a total of 37 implants. All the subjects underwent an Orthopantograph due to the appearance of painful radicular symptoms some time after the operation. RESULTS.: In 36 cases out of 37 we found, with the Orthopantograph, a slight increase in the calibre of the mandibular canal compared to the controlateral. In 10 subjects we observed hypodensity of the canal itself, while in 6 subjects the canal passages were no longer recognisable. CONCLUSION.: The radiological indications of damage of the inferior alveolar nerve (IAN) are reliable even in the case of indirect post-implant lesions.

Screening of HLA-A, -B, -C and HLA-DR seric antibodies in blood donor married women. II. Study of two particular aspects of the HLA-DR immunization.

This note contains considerations about two aspects of the immunization against HLA-DR specificities. Such considerations were made during the study of the results obtained by a previous screening of the sera of 1,312 blood donor married women for the presence of HLA-A, -B, -C and -DR antibodies and by a previous collection of data about deliveries, abortions and received blood transfusions for each donor. The following techniques were used: density gradient lymphocytes separation from peripheral venous blood, C.d.L. according to N.I.H. standard technique, S.R.B.C. rosetting to obtain "B" lymphocytes, C.d.L. according to N.I.H. long incubation technique. Two observations are reported: 1) seven donors with no delivery, no abortion and no received blood transfusion (and, obviously, with no surgical transplantation) had seric antibodies against HLA-DR specificities; 2) among the donors positive for the presence of seric HLA-A, -B, -C or/and HLA-DR antibodies, the great majority (15/17) of those having three characteristics (named altogether "condition" in this note) had HLA-DR antibodies without HLA-A, -B, -C antibodies (i.e. "pure" HLA-DR antibodies). It may be the HLA-DR immunization happens in different circumstances, or happens even in different circumstances in respect to HLA-A, -B, -C immunization. Are HLA-DR antibodies synthesized, or may they be synthesized too, against spermatozoa or neo-formed zygote DR specificities?

[Screening for anti-HLA-A, -B, -C and anti-HLA-DR antibodies in the blood of married female blood donors. I. Influence of : a) some immunizing events on antibody production; b) time factors on their permanence in the circulation]. / Ricerca di anticorpi anti -HLA-A, -B, -C ed anti-HLA-DR nel siero di donatrici di sangue coniugate. I. Studio dell'influenza: a) di alcuni eventi immunizzanti sulla produzione di tali anti-: corpi; b) del tempo sulla loro permanenza in circolo.

Sera of 1,312 blood donor married women were screened for the presence of anti-HLA-A,-B, -C and -DR antibodies. Presence of HLA-A, -B, -C circulating antibodies seemed to be independent from the number of immunizing events (deliveries, abortions, received blood transfusions) when these events were more than zero; presence of HLA-DR circulating antibodies seemed to be independent from the number of immunizing events; presence of both HLA-A, -B, -C and HLA-DR circulating antibodies seemed to be independent from the time elapsed from the last immunizing event to the bleeding. Susceptibility of a pregnant woman to 1) produce or not produce and 2) produce during a short or long time antibodies against HLA-A, -B, -C and -DR structures of her child seems to depend mainly from her genetic constitution, possibly in relation with the genetic constitution of the child. It is spontaneous to think to human immune response (Ir) genes.

[Detection of lymphocytotoxic HLA-A, B, C antibodies in the blood of married female blood donors. I. Serological study]. / Ricerca di anticorpi HLA-A, -B, -C linfocitotossici nel siero di donatrici di sangue coniugate. I. Studio sierologico.

Bleedings from 1.843 blood donors married women have been checked, according to NIH standard technique, against panels of 17-20 samples of lymphocytes from random healthy HLA-A, -B, -C typed individuals of the Turin population. Lymphocytotoxic activity has been found in 209 sera, but only 90 of them showed strong reaction(s) (at least 60-80% of killed lymphocytes) and 20 of these were HLA typing (or easily transformable in HLA typing) sera. Very few sera killed only 20-50% of lymphocytes in some samples and this cytotoxic activity remained even if dilutions as far as 1:16 and, sometimes, 1:32 were made. Bleedings from blood donors married women give a small yield (1%) of ;typing sera, but these sera are easily available and, practically, without problems of quantity.

[Detection of lymphocytotoxic HLA-A, B, C antibodies in the blood of married female blood donors. II. Population study of the relation between: a) the number of immunizing events and the presence of antibodies; b) time elapsed and presence of antibodies]. / Ricerca di anticorpi HLA-A, -B, -C linfocitotossici nel siero di donatrici di sangue coniugate. II. Studio popolazionistico della relazione tra : 1) il numero di eventi immunizzanti e la presenza di anticorpi; b) il tempo trascorso e la presenza di anticorpi.

Sera of 1.843 blood donors married women of the Turin population have been checked against random lymphocytes samples of the same population according to NIH standard technique. Positive (with cytotoxic antibodies) and negative (without cytotoxic antibodies) women have been, separately, distributed in classes: A) events number classes and B) time classes. "A-type" distributions were dealing with number of deliveries and, separately, with total number of immunizing events (deliveries, abortions, received blood transfusions); "B-type" distributions were dealing with number of years passed from last delivery to bleeding and, separately, from last immunizing event to bleeding. Differences between positive and negative women distributions were not significant. Number of events and time elapsed after last event do not affect presence or absence of antibodies significantly. Genetic individual constitution seems to affect not only presence or absence of antibodies, but also the duration of response.

[Echography of the oral phase of deglutition]. / L'ecografia nello studio della fase orale della deglutizione.

Neither cineradiography nor videorecording are satisfactory techniques for the dynamic study of the oral phase of deglutition. Therefore, oral swallowing was studied by means of real-time sonography (US) in 20 asymptomatic patients. Both anatomy and motility of the muscles of the mouth and tongue were clearly demonstrated. Real-time US proved thus to allow an accurate and dynamic visualization of the oral phase of deglutition.

[The echographic visualization of the lingual bolus. The reference point in a study of dysphagia]. / La visualizzazione ecografica del bolo linguale. Punto di riferimento nello studio delle disfagie.

The videotape recording of the cinefluorographic images obtained with barium swallowing, proved to be very useful in studying pharyngo-esophageal motility. On the contrary, the method failed to be exhaustive in the study of the oral phase of swallowing. In 1983 Shawker et al. were the first authors to suggest the use of US to record tongue motility and the upward movement of hyoid bone. In a previous paper the authors had reported on the value of US videorecording in the dynamic study of oral swallowing, and of lingual bolus development and shape. In the present paper, the authors investigated how frequently the formation of lingual bolus can be recorded by means of US in patients with no dysphagic disorders. Sagittal and transverse scans were acquired in all patients with US units with 5 MHz probes connected to a U-matic videorecorder. In 98% of 50 examined patients, US demonstrated the presence of a lingual bolus in the preparatory phase of oral swallowing. Since lingual bolus formation in the oral phase of swallowing can be considered quite a normal event, the authors believe this finding to be a reliable reference-point in the study of oral swallowing.

[Double-contrast esophagography in the diagnosis of esophagitis due to Candida. A study on HIV-seropositive patients]. / L'esofagografia a doppio contrasto nella diagnosi di esofagite da Candida. Studio su pazienti sieropositivi per HIV.

This study was aimed at assessing the sensitivity of double-contrast esophagography in diagnosing Candida esophagitis. This condition accounts for 85% of all esophageal infections in the subjects suffering from AIDS. Thirty-nine HIV+ patients were evaluated: 19 of them had endoscopic diagnosis of Candida esophagitis. Our study confirmed the high sensitivity of esophagography (90%), as reported in the literature. Radiographic findings were edematous esophageal folds in the early stage and, subsequently, plaques and diffuse ulcerations. These patterns are suggestive of anatomical lesions: in the early stage, mucosal edema and erythema are observed, and later on pseudomembranes and ulcerations. None of our patients exhibited stenosis. All the subjects with Candida esophagitis had less than 250/mm3 of CD4 lymphocytes. In conclusion, double-contrast esophagography must be included in the periodic examinations performed on patients with AIDS, so as to allow an early diagnosis.

[Dynamic study of oro-pharyngeal deglutition]. / Lo studio dinamico della deglutizione oro-faringea.

Oropharyngeal swallowing is too fast and complex a motion for the human eye to seize its various phases and subsequently evaluate morphology and function of the anatomical structures involved. A chronological subdivision of the swallowing act is needed for a step-by-step analysis. Dynamic evaluation of oropharyngeal swallowing by means of fluoroscopic and US videorecording proved to be a reliable method. Echovideorecording allowed tongue movements to be depicted, together with bolus formation and propulsion. Fluorovideorecording (U-matic Sony unit, 25-30 images/sec) demonstrated pharyngeal and esophageal phases. A series of chronological and morphological reference points, which characterize oropharyngeal swallowing, were employed to analyze videorecorded images. Slow-motion mode, "freezed" images, and rewinding allowed an easy and accurate evaluation of swallowing details. Combined chronological and morphological pieces of information allow a comprehensive evaluation of the swallowing act.

[Lung tuberculosis in HIV positive patients. Clinico-radiologic correlations]. / La tubercolosi polmonare nei pazienti HIV positivi. Correlazioni clinico-radiologiche.

UNLABELLED: We investigated the radiologic features of pulmonary tuberculosis in HIV+ patients. SUBJECTS AND METHODS: 24 cases of pulmonary tuberculosis in HIV+ patients were studied (17 men and 7 women, average age: 38 years). The study includes 19 drug addicts, 3 homosexuals, 1 polytransfused subject and 1 patient not belonging to the categories considered at risk). Three subgroups were identified by the CD4/mm3 cell count (< 200, 200-500, > 500). RESULTS: In our 24 patients, we identified 37 radiologic manifestations (in 13 cases associated in the same patient), with 6 cases of bilateral pulmonary and 9 atypical localizations. In detail: 10 consolidations, 7 productive (miliary) cavitations, 8 mediastinal lymphadenitis, 3 extrapulmonary forms and 4 cases with no chest X-ray alterations. There is a major frequency of consolidations and cavitations in the patients with CD4 > 200 and a major frequency of productive forms, lymphadenitis and extrapulmonary localizations in the subjects with CD4 < 200. We observed no cases of tuberculosis in patients with CD4 > 500. The medical therapy is usually more effective in the more immunocompetent subjects and, anyway, in the exudative forms, improving in 35% of cases, than in the productive and disseminated forms improving in 6% of cases only. DISCUSSION AND CONCLUSIONS: Only the severely immunodeficient HIV+ patients (CD4 < 500) are affected with tuberculosis. There exists a significant rate of parenchymal consolidations and tisiogenic forms in subjects with CD4 > 200 and a high rate of miliary forms, lymphadenitis and extrapulmonary localizations in patients with low cell count (< 200). The medical therapy is more effective in the more immunocompetent subjects and, anyway, in the exudative forms, than in the productive and disseminated forms. Finally, atypical localization of pulmonary tuberculosis are frequent in HIV patients.

Results of dipyridamole plus atropine echo stress test for the diagnosis of coronary artery disease.

Sensitivity of dipyridamole stress echocardiography (DIP-E) has been reported to be less than ideal in particular subsets of patients such as those with less severe extent of coronary artery disease (CAD). To verify if sensitivity could be improved, ATRO (1 mg in 2 minutes) was added at the end of a negative high-dose (0.84 mg/kg over 10 minutes) DIP-E in 61 consecutive patients (58 men, aged 53 +/- 7 years) evaluated for chest pain (33%) or for detection of residual ischemia after acute myocardial infarction (AMI) or previous MI (67%). DIP-E was positive in 28/61 (46%) and negative in 33/61 (54%) patients. Additional echo positivity was obtained in 18/33 (54%) patients after ATRO. Coronary arteriography was normal in 6 patients (10%); 1-vessel CAD was diagnosed in 28 (46%), 2-vessel CAD in 16 (26%) and 3-vessel CAD in 11 (18%) cases. The sensitivity for CAD diagnosis was 49% (27/55) for DIP-E and 84% (46/55) for DIP-E+ATRO (p < 0.001). Specificity was 83% and 80%, respectively. Diagnostic accuracy increased from 52% to 83% (p < 0.001). The better diagnostic accuracy of DIP-E was mainly related to the significant increase in sensitivity of the combined test in patients with 1-vessel CAD (from 46% to 75%) (p < 0.005). At quantitative coronary evaluation, compared to patients with positive DIP-E+ATRO or negative DIP-E+ATRO test, patients with positive DIP-E had a higher mean % diameter stenosis: 80 +/- 13% vs 72 +/- 24% and 65 +/- 36%, respectively. Peak heart rate was significantly higher after the addition of ATRO vs basal and DIP alone in patients with a positive DIP-E+ATRO test. The addition of ATRO to DIP increases diagnostic accuracy of DIP-E particularly in patients with less severe extent of CAD; ATRO may be considered as a useful routine procedure for increasing diagnostic value of DIP-E test.

HLA antibodies cytotoxic only for B lymphocytes.

Of 28 unabsorbed sera from polytransfused individuals or multiparous women, which were not cytotoxic for total peripheral blood lymphocytes, 13 were found to react positively against B cell-enriched suspensions. These 13 sera were further characterized after platelet absorption-elution, as well as by pretreatment with turkey anti-human-beta2-microglobulin serum. Different patterns were found: five sera behaved as pure anti-B cell reagents; four seemed to contain different antibody populations, directed against both B cell determinants and HLA-A, -B or -C antigens; four only contained antibodies directed against HLA-A, -B or -C specificities. Absorption experiments with purified T and B lymphocytes, showed that these last sera, although noncytotoxic for T cells, can be absorbed by them. It was concluded that not all sera reacting only with B lymphocytes recognize specifities absent from T cells, and that all sera should be exhaustively absorbed with platelets before being tested as anti-B cell-specific reagents.

HLA and psoriasis (with or without arthropathy).

30 probands affected by psoriasis, with or without arthropathy, and their relatives were typed for HLA-A, -B and -C antigens. Association of HLA-B16 and HLA-B17 with psoriasis was confirmed. One third of probands was without any known HLA-A, -B, -C marker. Considering probands with at least one HLA-B marker, we found that 50% of their sibs carrying marker is affected and the remaining 50% is healthy. To explain the weak association observed, an attempt to propose a model is made: such a model postulate a gene interaction between the HLA marker gene and an hypothetic "Ps (Psoriasis susceptibility) gene". The model, described in detail in this work, tries to explain why a large part (1/3) of probands is affected even if they do not carry any HLA marker and why 50% of marker positive sibs of marker positive probands are healthy.

[Diagnostic imaging of current pulmonary tuberculosis. Clinical significance of the presentation patterns and particular aspects in HIV-positive and HIV-negative subjects]. / Diagnostica per immagini della tubercolosi polmonare attuale. Significato clinico dei quadri di presentazione e aspetti particolari nei soggetti HIV positivi e HIV negativi.

PURPOSE: We compared two groups of risk patients to try to identify different radiologic patterns in pulmonary tuberculosis. MATERIALS AND METHODS: 74 subjects, divided into two groups (HIV+:27; HIV-:47) were included since 1993. The patients were examined with chest X-ray (CXR) and CT. RESULTS: In the HIV+ group we observed 40 radiologic alterations, with 6 cases of bilateral lung involvement and 9 of atypical localizations; particularly: 11 consolidations, 8 cavitations, 5 miliary diseases, 9 hilar or mediastinal adenopathies, 3 extrapulmonary localizations and 4 negative CXRs. In the HIV- group we found 53 radiologic alterations, with 6 cases of bilateral lung involvement and 3 of atypical localizations; particularly: 12 consolidations, 25 cavitations, 5 nodular patterns, 1 miliary disease, 5 nodal disease, 4 pleural diseases and 1 negative CRX. DISCUSSION AND CONCLUSIONS: In HIV- patients lung consolidations and tysiogen patterns are significantly prevalent, while miliary diseases, mediastinal diseases and atypical localizations and negative CRXs are more frequent in HIV+ patients. We found miliary diseases, mediastinal diseases and extrapulmonary localizations also in HIV- patients with heavily impaired social, economic and sanitary conditions. This alterations indicate compromised host resistance, independent of the causes and modalities of immunodeficiency. The distinction between primary and secondary tuberculosis is currently not mandatory.