[Transcatheter approach in patients with severe aortic stenosis and concomitant severe mitral regurgitation]

Patients with severe aortic valve stenosis who are candidates for transcatheter aortic valve replacement represent a high-risk population for the presence of frequent comorbidities (reduced left ventricular ejection fraction, associated valve insufficiency, right ventricular dysfunction and/or pulmonary hypertension). Aortic valve stenosis can be associated with any other valve defects but among these mitral regurgitation is the most commonly associated valve disease. The simultaneous presence of severe mitral regurgitation in patients with aortic stenosis is a negative prognostic factor, resulting in increased mortality and a high diagnostic complexity, in particular in the accuracy of the evaluation of the two valve defects and therapeutic management which, at present, are not supported by strong scientific evidence.

Vestibular evoked myogenic potentials in multiple sclerosis: clinical and imaging correlations

Patients with multiple sclerosis (MS) frequently report symptoms related to vestibular disorders in the course of their disease. At present, the fundamental tests assessing vestibulospinal involvement are posturography and vestibular evoked myogenic potentials (VEMPs). While posturography cannot be performed in every subject requiring minimal stance control, VEMPs do not require any specific skill on the part of the subjects and they may be investigated in all patients able to sit. VEMPs were recorded for 40 patients (17 men, 23 women; mean age 38 years, range 17-71 years) fulfilling diagnostic criteria of clinically defined MS, by means of rarefaction clicks, recording modulation of sterno-cleido-mastoideus tonic contraction saccule-mediated modulation. VEMPs were found to be abnormal in 28 of 40 patients. In 18 of the cases the VEMPs were asymmetric, i.e., had a prolonged latency on one side. In six cases latency was increased on both sides (mean delay 4.1 ms). In four subjects VEMPs were absent on one side. C oncordance with clinical findings of presence/absence of brainstem involvement was found in 55% and with MRI findings in 65% of the cases. A bnormal VEMPs indicated brainstem dysfunction in four patients (10%) with normal MRI and no specific clinical signs.

Endothelial progenitor cells as factors in neovascularization and endothelial repair

Endothelial progenitor cells (EPCs) are a heterogeneous population of cells that are provided by the bone marrow and other adult tissue in both animals and humans. They express both hematopoietic and endothelial surface markers, which challenge the classic dogma that the presumed differentiation of cells into angioblasts and subsequent endothelial and vascular differentiation occurred exclusively in embryonic development. This breakthrough stimulated research to understand the mechanism(s) underlying their physiologic function to allow development of new therapeutic options. One focus has been on their ability to form new vessels in injured tissues, and another has been on their ability to repair endothelial damage and restore both monolayer integrity and endothelial function in denuded vessels. Moreover, measures of their density have been shown to be a better predictor of cardiovascular events, both in healthy and coronary artery disease populations than the classical tools used in the clinic to evaluate the risk stratification. In the present paper we review the effects of EPCs on revascularization and endothelial repair in animal models and human studies, in an attempt to better understand their function, which may lead to potential advancement in clinical management.

Coronary microvascular dysfunction in diabetes mellitus: A review

The exploration of coronary microcirculatory dysfunction in diabetes has accelerated in recent years. Cardiac function is compromised in diabetes. Diabetic patients manifest accelerated atherosclerosis in coronary arteries. These data are confirmed in diabetic animal models, where lesions of small coronary arteries have been described. These concepts are epitomized in the classic microvascular complications of diabetes, i.e. blindness, kidney failure and distal dry gangrene. Most importantly, accumulating data indicate that insights gained from the link between inflammation and diabetes can yield predictive and prognostic information of considerable clinical utility. This review summarizes the evidence for the predisposing factors and the mechanisms involved in diabetes, and assesses the current state of knowledge regarding the triggers for inflammation in this disease. We evaluate the roles of hyperglycemia, oxidative stress, polyol pathway, protein kinase C, advanced glycation end products, insulin resistance, peroxisome proliferator-activated receptor-γ, inflammation, and diabetic cardiomyopathy as a "stem cell disease". Furthermore, we discuss the mechanisms responsible for impaired coronary arteriole function. Finally, we consider how new insights in diabetes may provide innovative therapeutic strategies.

Role of EDHF in type 2 diabetes-induced endothelial dysfunction

Endothelium-derived hyperpolarizing factor (EDHF) plays a crucial role in modulating vasomotor tone, especially in microvessels when nitric oxide-dependent control is compromised such as in diabetes. Epoxyeicosatrienoic acids (EETs), potassium ions (K+), and hydrogen peroxide (H2O2) are proposed as EDHFs. However, the identity (or identities) of EDHF-dependent endothelial dilators has not been clearly elucidated in diabetes. We assessed the mechanisms of EDHF-induced vasodilation in wild-type (WT, normal), db/db (advanced type 2 diabetic) mice, and db/db mice null for TNF (dbTNF-/dbTNF-). In db/db mice, EDHF-induced vasodilation [ACh-induced vasodilation in the presence of N(G)-nitro-L-arginine methyl ester (L-NAME, 10 micromol/l) and prostaglandin synthase inhibitor indomethacin (Indo, 10 mumol/l)] was diminished after the administration of catalase (an enzyme that selectively dismutates H2O2 to water and oxygen, 1,000 U/ml); administration of the combination of charybdotoxin (a nonselective blocker of intermediate-conductance Ca2+-activated K+ channels, 10 micromol/l) and apamin (a selective blocker of small-conductance Ca2+-activated K+ channels, 50 micromol/l) also attenuated EDHF-induced vasodilation, but the inhibition of EETs synthesis [14,15-epoxyeicosa-5(Z)-enoic acid; 10 mumol/l] did not alter EDHF-induced vasodilation. In WT controls, EDHF-dependent vasodilation was significantly diminished after an inhibition of K+ channel, EETs synthesis, or H2O2 production. Our molecular results indicate that mRNA and protein expression of interleukin-6 (IL-6) were greater in db/db versus WT and dbTNF-/dbTNF- mice, but neutralizing antibody to IL-6 (anti-IL-6; 0.28 mg.ml(-1).kg(-1) ip for 3 days) attenuated IL-6 expression in db/db mice. The incubation of the microvessels with IL-6 (5 ng/ml) induced endothelial dysfunction in the presence of l-NAME and Indo in WT mice, but anti-IL-6 restored ACh-induced vasodilation in the presence of L-NAME and Indo in db/db mice. In db(TNF-)/db(TNF-) mice, EDHF-induced vasodilation was greater and comparable with controls, but IL-6 decreased EDHF-mediated vasodilation. Our results indicate that EDHF compensates for diminished NO-dependent dilation in IL-6-induced endothelial dysfunction by the activation of H2O2 or a K+ channel in type 2 diabetes.

Tumor necrosis factor-alpha induces endothelial dysfunction in Lepr(db) mice

BACKGROUND

We hypothesized that the inflammatory cytokine tumor necrosis factor-alpha (TNF) produces endothelial dysfunction in type 2 diabetes.

METHODS AND RESULTS

In m Lepr(db) control mice, sodium nitroprusside and acetylcholine induced dose-dependent vasodilation, and dilation to acetylcholine was blocked by the NO synthase inhibitor N(G)-monomethyl-L-arginine. In type 2 diabetic (Lepr(db)) mice, acetylcholine- or flow-induced dilation was blunted compared with m Lepr(db), but sodium nitroprusside produced comparable dilation. In Lepr(db) mice null for TNF (db(TNF-)/db(TNF-)), dilation to acetylcholine or flow was greater than in diabetic Lepr(db) mice and comparable to that in controls. Plasma concentration of TNF was significantly increased in Lepr(db) versus m Lepr(db) mice. Real-time polymerase chain reaction and Western blotting showed that mRNA and protein expression of TNF and nuclear factor-kappaB were higher in Lepr(db) mice than in controls. Administration of anti-TNF or soluble receptor of advanced glycation end products attenuated nuclear factor-kappaB and TNF expression in the Lepr(db) mice. Immunostaining results show that TNF in mouse heart is localized predominantly in vascular smooth muscle cells rather than in endothelial cells and macrophages. Superoxide generation was elevated in vessels from Lepr(db) mice versus controls. Administration of the superoxide scavenger TEMPOL, NAD(P)H oxidase inhibitor (apocynin), or anti-TNF restored endothelium-dependent dilation in Lepr(db) mice. NAD(P)H oxidase activity, protein expression of nitrotyrosine, and hydrogen peroxide production were increased in Lepr(db) mice (compared with controls), but these variables were restored to control levels by anti-TNF.

CONCLUSIONS

Advanced glycation end products/receptor of advanced glycation end products and nuclear factor-kappaB signaling play pivotal roles in TNF expression through an increase in circulating and/or local vascular TNF production in the Lepr(db) mouse with type 2 diabetes. Increases in TNF expression induce activation of NAD(P)H oxidase and production of reactive oxidative species, leading to endothelial dysfunction in type 2 diabetes.

Erythropoietin improves anemia exercise tolerance and renal function and reduces B-type natriuretic peptide and hospitalization in patients with heart failure and anemia

BACKGROUND

Anemia is now recognized as being a common finding in CHF and is associated with increased mortality and morbidity. However, it is uncertain whether the anemia is actually causing the worse prognosis or is merely a marker of more severe cardiac disease. Previous intervention studies with subcutaneous (s.c.) beta-EPO in combination with iron have either been uncontrolled or case-controlled studies. We report a randomized, double-blind, placebo-controlled study of the combination of s.c. EPO and oral iron versus oral iron alone in patients with anemia and resistant CHF.

OBJECTIVES

The present study examines, in patients with advanced congestive heart failure (CHF) and anemia, the effects of beta-erythropoietin (EPO) and oral iron on the anemia and on cardiac and renal functional parameters.

METHODS

Forty consecutive subjects with moderate to severe CHF and anemia (hemoglobin [Hb] <11 g/dL) were studied. They were randomized to receive, in a double-blind fashion, either (a) (group A, the treatment group, 20 patients) s.c. beta-EPO for 3 months twice weekly, in addition to daily oral iron, or (b) (group B, the placebo group, 20 patients) normal saline in s.c. injections and daily oral iron. Two patients in group B were eventually excluded because of a fall of Hb <8 g/dL requiring transfusion, leaving 18 patients in group B. After the 3-months study, the group A patients were maintained on the same treatment for an additional 9 months, whereas in Group B, the placebo and oral iron were stopped.

RESULTS

In group A, after a mean of 3.5 +/- 0.8 months of treatment, there was a significant increase in Hb from 10.4 +/- 0.6 to 12.4 +/- 0.8 g/dL (P < .01); a significant improvement in New York Heart Association functional class from 3.5 +/- 0.6 to 2.8 +/- 0.5 (P < .05); a longer endurance time on exercise testing, from 5.8 +/- 2.2 to 7.8 +/- 2.5 minutes (P < .01); a greater distance walked on exercise testing, from 278 +/- 55 to 356 +/- 88 meters (P < .01); a significant increase in the peak oxygen consumption (VO2) from 12.8 +/- 2.8 to 15.1 +/- 2.8 mL/kg per minute (<.05); and the VO2 at the anaerobic threshold, from 9.2 +/- 2.0 to 13.2 +/- 3.6 mL/kg minute (P < .01). There was also a significant fall in plasma B-type natriuretic peptide levels from 568 +/- 320 to 271 +/- 120 pg/mL (P < .01), a significant reduction in serum creatinine (P < .01), and an increase in estimated creatinine clearance (P < .05). In group B, there were no significant changes in any of the above parameters over the study period. At the end of the 1-year study, the Hb was still higher in group A than group B, and the rate of hospital admissions/patients over the year averaged 0.8 +/- 0.2 in group A and 1.7 +/- 0.8 in group B (P < .01).

CONCLUSIONS

In anemic CHF patients, correction of anemia with EPO and oral iron leads to improvement in New York Heart Association status, measured exercise endurance, oxygen use during exercise, renal function and plasma B-type natriuretic peptide levels and reduces the need for hospitalization.

Rise and fall of B-type natriuretic peptide levels in patients with coronary artery disease and normal left ventricular function after cardiac revascularization

BACKGROUND

Recently, it was shown that B-type natriuretic peptide levels are increased in patients with acute coronary syndromes.

AIMS

To assess the relation between B-type natriuretic peptide and ischemia in patients with stable and unstable angina pectoris with normal left ventricular function in relation to the extent of ischemia and response to revascularization.

METHODS

Fifty-nine consecutive patients were enrolled in the study, patients were divided into two groups: stable angina patients (group I, n=18), and unstable coronary patients (group II, n=41). Baseline characteristics were compared with 15 age-matched and sex-matched participants. B-type natriuretic peptide levels were measured at baseline and 3, 7 and 90 days after coronary revascularization in group I and II.

RESULTS

Patients with unstable angina pectoris had increased B-type natriuretic peptide levels compared with stable angina pectoris patients (B-type natriuretic peptide levels: controls 15.5+/-13 pg/ml, stable angina pectoris group 28.4+/-19 pg/ml, unstable angina pectoris group 104+/-81 pg/ml; P<0.01). A relationship between the number of affected coronary vessels and B-type natriuretic peptide was assessed (one-vessel 29.9+/-21 pg/ml, two-vessel 93.8+/-87 pg/ml, three-vessel 119+/-88 pg/ml; P<0.01). After revascularization, B-type natriuretic peptide levels decreased in groups I and II (25+/-20 vs. 39+/-28 pg/ml) and were similar after 90 days in percutaneous transluminal coronary angiograghy and in coronary artery bypass grafting groups (percutaneous transluminal coronary angiography 26+/-22 pg/ml, coronary artery bypass grafting 36+/-26 pg/ml; NS).

CONCLUSIONS

B-type natriuretic peptide levels increase in unstable angina pectoris patients and are linked to the extent of coronary disease in patients with normal left ventricular systolic function, and returned to baseline level after surgical or catheter revascularization.

AGING AND VESTIBULAR SYSTEM: SPECIFIC TESTS AND ROLE OF MELATONIN IN COGNITIVE INVOLVEMENT

Balance disorders are frequent with aging. They are particularly important because they decrease social autonomy of the aged subjects and they often provoke falls. The cause is always multifactorial. There is evidence that aging affects multiple sensory inputs, as well as the muscoloskeletal system and central nervous system ability to perform sensorimotor integration. For the evaluation of decreased balance skills in elderly, a specific questionnaire has been prepared, in order to identify high risk of falling called falling risk inventory (FRI) questionnaire, and a complex psycho-sensory-motor test has been studied by means of posturography, in order to detect specific vestibular impairment. Regarding ethiopathogenesis of balance disorders in aged subjects, because the decline of behavioral and cognitive performances are due also to decline of biological rhythm control, the role of melatonin (the hormone regulating circadian rhythms, being strictly connected with cerebellar function, and it is well known that cerebellum acts in elderly both at motor and cognitive regulation. The goals of the present paper are: (i) To present a self-administered FRI questionnaire aimed at identifying possible causes of falls and quantifying falling risk in aged. (ii) To validate posturography as a specific test to investigate vestibular involvement in elderly in correlation with FRI. (iii) To present a complex behavioral test (NT) aimed at evaluating both spatial orientation and spatial memory in elderly, factors involved into the genesis of complex dizziness and unsteadiness. (iv) To evaluate the role of melatonin in cognitive involvement in dizzy, old subjects due to the functional correlations between circadian rhythms, cerebellum balance disturbances and cognitive disorders. General conclusions are: FRI correlates with falling risk. Posturography identifies specific vestibular impairments correlated to balance disorders and elderly falls. Spatial orientation is altered in about 40% of dizzy patients but no significant differences are revealed in melatonin rhythm. Spatial memory is highly altered only in subjects with inversion of circadian melatonin rhythm it is possible to hypothesize that the alteration of the normal circadian melatonin rhythm plays some role in the genesis of dizziness in a subpopulation of patients.

[Stabilimetry and cranio-cervico-mandibular disorders]

BACKGROUND

Cranio-cervico-mandibular disorders can cause disturbances in posture. Stabilimetry measures spatio-temporal variations in the center of body pressure and evaluates the mechanisms of maintenance of balance. The study used a stabilimetric platform to evaluate posture changes in patients with cranio-cervico-mandibular disorders before and after treatment for malocclusion.

METHODS

Between February 1998 and December 2000, 60 patients with cranio-cervico-mandibular disorders were recruited from the Dentistry Clinic of the University of Sassari. Each patient underwent two stabilimetric examinations (closed mouth with cotton wads inserted between the dental arches). The tests were conducted on a stabilimetric platform. Measurement of body posture load and sway were analyzed with a specific software program that correlated the vestibular, somatosensory and visual systems, and determined the role of each in postural control.

RESULTS

The stabilimetric analysis showed that the adoption of the plaque allowed rebalance of the postural system, without affecting the visual system. After treatment, 64% of patients experienced remission of pain symptoms with orthotic therapy.

CONCLUSIONS

The relationship between malocclusion and posture should be seen from a holistic standpoint in other to gain a global therapeutic outcome.

Low ureteral obstruction caused by umbilical ligament in a 37 year old man: a case report

Arterial vascular anomalies rarely cause extrinsic ureteral obstruction and only 11 cases have been reported so far. This paper deals with an unusual extrinsic obstruction of the left ureter caused by a residue of the umbilical artery in a 37 years old man. The patient had left flank pain due to serious hydronephrosis on the same side. At operation a fibrous cord, a residue of the left umbilical artery, partially obstructed the distal left ureter. Partial left terminal ureterectomy with ureteroneocystostomy was performed. In the differential diagnosis of low extrinsic ureteral obstructions also the uncommon vascular anomalies of the umbilical artery should be taken into consideration.

Antacids and cimetidine treatment for gastro-oesophageal reflux and peptic oesophagitis

Thirty three children aged 2 to 42 months (mean 9 months) with gastro-oesophageal reflux and peptic oesophagitis took part in a treatment trial comparing cimetidine (20 mg/kg/day) with an intensive regimen of antacids (Maalox, 700 mmol (mEq)/1 X 73 m2/day). All children were evaluated clinically and by radiology, acid reflux test, and endoscopy. After 12 weeks of treatment all were again evaluated clinically, by pH measurement, and endoscopy. Twenty nine children, 15 on antacid and 14 on cimetidine, completed the trial. Eight patients on antacid and seven on cimetidine were cured; five on antacid and six on cimetidine improved; and two patients on antacid and one on cimetidine underwent surgery. Both groups of children showed a statistically significant reduction in the score of clinical, pH, and endoscopic variables after treatment. Lower oesophageal sphincter pressure before treatment did not correlate significantly with the final total score. Antacids in large quantities are as effective as cimetidine in medical treatment of gastro-oesophageal reflux and peptic oesophagitis.

Fluoroangiographic and echographic study on a juxtapapillary hamartoma of the retinal pigment epithelium

A patient with a juxtapapillary hamartoma is described, in consideration not only for the scarcity of such cases described in the literature, but also for the clinical and echographic characteristics that were observed for the involvement of the right eye, and because the patient was female. Echography and especially standardized A-scan echography, showing a lesion at high reflectivity without acoustic shadowing, allowed us to exclude the presence of a malignant melanoma and retinoblastoma, and directing us to the diagnosis of a malformation of angiomatous type.

Study of a form of pulverulent cataract in a large kindred

A large kindred (64 members in four generations), affected by a form of apparently congenital pulverulent cataract, was studied for linkage of its gene locus with that of the Fy blood group. No indication of linkage was found. The involvement of the cortex distinguishes this form from the zonular pulverulent cataract (total nuclear) of Nettleship and Ogilvie, the locus of which is probably linked with Fy. A correlation between morphological and genetic heterogeneity, based on the linkage with Fy, cannot be established because of the scarcity of published data.

Retraction syndrome with posterior lenticonus

A case of a 4-year-old child with retraction syndrome and an associated posterior lenticonus is presented. The lack of specific morphological chromosome abnormalities and of any disturbance of amino acid metabolism, in our case, suggests that the retraction syndrome, in nonhereditary types, is the result of dysgenesis during the middle of the third trimester of pregnancy.