Search

Background and Aims: Intestinal ultrasonography (IUS) is challenging to learn. This prospective study examined how the accuracy of IUS increases with operator experience ("learning curve") and if prior abdominal ultrasound experience facilitates the learning process., Methods: The study included two trainees with limited abdominal ultrasound experience (< 50 exams) and two with extensive experience (> 500 exams). Each trainee performed 99 examinations and reported four IUS findings. An expert sonographer repeated the exam, and concordance (k) between the expert and trainees was assessed in three consecutive testing periods of 33 exams each., Results: A progressive improvement in concordance was observed for all IUS findings from Period 1 to Period 3, overall and for both groups of trainees, although those with experience in abdominal ultrasound had faster learning curves. The minimum number of examinations required to achieve concordance with the expert operator for detecting increased bowel wall thickness was 84 and detecting bowel dilatation was 79. However, a minimum of 97 examinations was necessary to achieve concordance for detecting intra-abdominal complications, considered an advanced IUS competence., Conclusion: Basic competence in IUS can be acquired with relatively few examinations, while advanced competence requires more extensive training, particularly for gastroenterologists without abdominal ultrasound experience., Competing Interests: Conflict of interest CB served as a consultant for Takeda, Ferring, AbbVie, Galapagos, MSD and Janssen. SS received lecture fees from Takeda Pharmaceuticals and Janssen Pharmaceuticals and served as a consultant and advisory board member for AbbVie and Janssen Pharmaceuticals. FF served as consultant for MSD, Amgen, AbbVie, Jannsen, Galapagos and Pfizer. AA received consulting/advisory board fees from AbbVie, Allergan, Amgen, Arena, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Eli Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Mylan, Nestlé, Pfizer, Protagonist Therapeutics, Roche, Samsung Bioepis, Sandoz and Takeda; speaker's fees from AbbVie, Amgen, Arena, Biogen, Bristol Myers Squibb, Eli Lilly, Ferring, Galapagos, Gilead, Janssen, MSD, Novartis, Pfizer, Roche, Samsung Bioepis, Sandoz, Takeda and Tigenix; and research grants from Biogen, MSD, Pfizer and Takeda. DR provided consultancies for Biogen, Celltrion, Galapagos, Janssen and Takeda. GM served as speaker or advisory board member for Alfa Sigma, Arena Pharmaceuticals, Fresenius Kabi, Galapagos, Gilead, Janssen Cilag, Roche and Takeda. GF received consultancy fees from Ferring, MSD, AbbVie, Takeda, Janssen, Amgen, Sandoz, Samsung Bioepis, and Celltrion., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Data regarding the clinical outcome of patients with immune checkpoint inhibitor (ICI)-induced colitis are scant. We aimed to describe the 12-month clinical outcome of patients with ICI-induced colitis., Materials and Methods: This was a retrospective, European, multicentre study. Endoscopy/histology-proven ICI-induced colitis patients were enrolled. The 12-month clinical remission rate, defined as a Common Terminology Criteria for Adverse Events diarrhoea grade of 0-1, and the correlates of 12-month remission were assessed., Results: Ninety-six patients [male:female ratio 1.5:1; median age 65 years, interquartile range (IQR) 55.5-71.5 years] were included. Lung cancer (41, 42.7%) and melanoma (30, 31.2%) were the most common cancers. ICI-related gastrointestinal symptoms occurred at a median time of 4 months (IQR 2-7 months). An inflammatory bowel disease (IBD)-like pattern was present in 74 patients (77.1%) [35 (47.3%) ulcerative colitis (UC)-like, 11 (14.9%) Crohn's disease (CD)-like, 28 (37.8%) IBD-like unclassified], while microscopic colitis was present in 19 patients (19.8%). As a first line, systemic steroids were the most prescribed drugs (65, 67.7%). The 12-month clinical remission rate was 47.7 per 100 person-years [95% confidence interval (CI) 33.5-67.8). ICI was discontinued due to colitis in 66 patients (79.5%). A CD-like pattern was associated with remission failure (hazard ratio 3.84, 95% CI 1.16-12.69). Having histopathological signs of microscopic colitis (P = 0.049) and microscopic versus UC-/CD-like colitis (P = 0.014) were associated with a better outcome. Discontinuing the ICI was not related to the 12-month remission (P = 0.483). Four patients (3.1%) died from ICI-induced colitis., Conclusions: Patients with IBD-like colitis may need an early and more aggressive treatment. Future studies should focus on how to improve long-term clinical outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Mounting evidence indicates that periodontitis-related oral bacteria may contribute to gut microbial dysbiosis. This clinical study aimed to explore the oral-gut microbial signatures associated with periodontitis and to longitudinally evaluate the effect of periodontal treatment on the oral and gut microbial composition. Stool and saliva samples from generalized stage III/IV periodontitis patients ( n = 47) were collected and analyzed by 16S ribosomal RNA gene amplicon sequencing, before and 3 mo after steps I to II of periodontal therapy. Periodontally healthy matched subjects ( n = 47) were used as controls. Principal component analysis was carried out to identify oral-gut microbial profiles between periodontitis patients at baseline and healthy subjects; periodontitis samples were longitudinally compared before and after treatment. β-Diversity of gut microbial profiles of periodontitis patients before treatment significantly differed from healthy controls ( P < 0.001). Periodontal therapy was associated with a significant change in gut microbiota ( P < 0.001), with post-treatment microbial profiles similar to healthy volunteers. A higher abundance of Bacteroides , Faecalibacterium , Fusobacterium , and Lachnospiraceae was noted in fecal samples of periodontitis patients at baseline compared to healthy controls. In contrast, Lactobacillus was the only genus more abundant in the latter. Additionally, periodontal therapy led to a parallel reduction in the salivary carriage of periodontal pathobionts, as well as gut Bacteroides , Lachnoclostridium , Lachnospiraceae , Oscillospiraceae , and Ruminococcaceae , to levels similar to healthy controls. Collectively, discriminating oral-gut microbial signatures of periodontitis were found. Periodontal treatment both mitigated oral dysbiosis and altered gut microbial composition, signifying potential broader implications for gastrointestinal health and disease., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), with a 6% to 74% prevalence and a negative impact on patient survival and quality of life, although the prevalence is apparently declining due to improved disease treatment. We aimed to investigate the prevalence, pathogenesis, and clinical correlates of anemia in Italian patients with IBD., Methods: A multicenter, prospective, observational study, involving 28 Italian gastroenterology centers, was conducted to investigate the epidemiology and consequences of IBD-associated anemia. Clinical and laboratory data of anemic patients were obtained at study enrolment., Results: Anemia was diagnosed in 737 of 5416 adult IBD outpatients (prevalence 13.6%); females were more commonly affected than males (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.7) and had more severe anemia. In the majority of cases, anemia was due to iron deficiency (62.5% of cases; 95% CI, 58.3%-66.6%), either isolated or in association with inflammation and/or vitamin deficiencies; anemia of inflammation accounted for only 8.3% of cases. More severe anemia was associated with increasing fatigue and worse quality of life. Only 68.9% of anemic patients with iron deficiency (95% CI, 63.4%-73.8%) and 34.6% of those with vitamin deficiencies (95% CI, 26.2%-44.2%) were properly treated with supplementation therapy., Conclusions: In Italy, the prevalence of IBD-associated anemia is lower than previously reported. Anemia of IBD is most commonly due to iron deficiency and contributes to fatigue and poor quality of life, but remains untreated in a large proportion of patients with iron and/or vitamin deficiencies. This study is registered at clinicaltrials.gov as NCT02872376., (© The Author(s) 2022. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation. All rights reserved. 
For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The use of ustekinumab and vedolizumab as second-line therapies in patients with Crohn's disease (CD) in which tumour necrosis factor alpha inhibitors (TNFi) failed is still debated. The aim of this study was to compare, in a large multicenter observational retrospective cohort, the effectiveness of ustekinumab and vedolizumab as second-line therapies, as assessed by clinical and objective outcomes including endoscopy and gastrointestinal imaging., Methods: Clinical response, remission, and steroid-free remission at weeks 26 and 52 were evaluated in a retrospective propensity score-weighted and propensity score-matched cohort of patients in which TNFi failed. Objective response and remission were evaluated by 1 or more techniques among endoscopy, magnetic resonance/computed tomography enteroclysis, and small bowel ultrasound., Results: A total of 470 patients with CD (239 treated with ustekinumab and 231 treated with vedolizumab) were included in the study. At week 26, clinical outcomes were similar between the 2 groups. At week 52, clinical remission (ustekinumab 42.5% vs vedolizumab 55.5%, P = 0.01) and steroid-free remission (ustekinumab 40.6% vs vedolizumab 51.1%, P = 0.038) rates were significantly higher in vedolizumab-treated patients. Three hundred two patients (hundred thirty-five treated with ustekinumab and hundred sixty-seven treated with vedolizumab) had an objective evaluation of disease activity at baseline and week 52. At week 52, objective response and remission rates were similar between the 2 groups. Clinical response at week 26 predicted steroid-free remission at week 52 in both ustekinumab-treated and vedolizumab-treated patients. Safety profiles were similar between the 2 groups., Discussion: In patients with CD in which TNFi failed, both ustekinumab and vedolizumab showed similar clinical effectiveness after 26 weeks of treatment. At 1 year, vedolizumab was associated with a higher rate of clinical remission when compared with ustekinumab. However, no difference was observed between the 2 groups when objective outcomes were investigated at this time point., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

This was a multicentre case series supported by the European Crohn's and Colitis Organisation [ECCO] and performed as part of the Collaborative Network of Exceptionally Rare case reports [CONFER] project. The aim was to report on whether cutaneous lesions associated with inflammatory bowel disease [IBD] and refractory to standard medical therapy including anti-tumour necrosis factors [anti-TNFs], would respond to the newer biologic agents ustekinumab [UST] or vedolizumab [VDZ]. This report includes 28 patients with cutaneous lesions from 14 centres, all of whom had failed immunomodulator and anti-TNF therapy. Metastatic Crohn's disease [MCD] was diagnosed in 10 patients: UST led to remission in five cases and partial response in four cases, with a single report of VDZ inducing remission. All cases of MCD treated with UST responded after the first or second dose, and the median time for the five cases that attained remission was 5 months. Pyoderma gangrenosum [PG] was diagnosed in four cases: three of these attained remission with UST [median time to remission 4 months] and one case did not respond to VDZ. There were seven cases of erythema nodosum [EN]: UST led to remission in four cases and partial response in 1 case whilst VDZ had partial response in 2 cases and non-response in two cases. There were seven single cases of other inflammatory lesions. In summary, UST appears to be useful for different cutaneous lesions including MCD, PG, and EN, whereas VDZ does not appear to be useful for lesions that are independent of disease activity., (© The Author(s) 2020. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: There is no agreeing if rescue therapy can avoid short-term colectomy in patients treated for severe steroid-refractory ulcerative colitis., Aims: The aim of our study was to identify predictors of response to infliximab and cyclosporine A., Methods: In this cross-sectional study, 49 patients with severe ulcerative colitis were included. Response to therapy was defined as three or more point reductions in Mayo score after 6 months of treatment and avoidance of colectomy after 1 year. The predictors analysed were gender, age, time from ulcerative colitis diagnosis, months of steroid or/and azathioprine therapy before onset of the severe phase, smoking habits, extension of the disease, laboratory analyses and Mayo score., Results: Patients treated with infliximab showed a statistically significant higher response rate in case of moderate Mayo score (P = 0.04). Ex-smokers had very low chance of response to infliximab (P = 0.03). In the group treated with cyclosporine A, patients with C-reactive protein >3 mg/L had a response rate significantly higher than those with C-reactive protein <3 mg/L (P = 0.03); those with negative C-reactive protein and moderate Mayo score did not responded to therapy, while in the ones with elevated C-reactive protein and/or severe Mayo score, 15 versus 4 responded (P = 0.008)., Conclusions: Our data suggest that cyclosporine A is advisable in ex-smokers. In never smokers or active smokers, infliximab can be prescribed in case of Mayo score ≤10 and/or negative CRP, while cyclosporine A is indicated in case of Mayo score >10 and positive CRP.

Many studies showed insulin resistance amelioration in HCV-patients achieving Sustained Virologic Response (SVR) but results on glycemic control in diabetic patients are unclear. This study aimed to assess fasting glucose (FG) and glycated hemoglobin (HbA1c) values before and after therapy with direct-acting antivirals (DAAs) in HCV-patients with type 2 diabetes mellitus (T2DM). Of the 122 consecutively recruited patients with chronic hepatitis C and T2DM, 110 patients were treated with DAAs and 12 remained untreated. Clinical, biochemical, virological, and metabolic features were collected both at baseline and at 12 weeks after the end of therapy (EOT) or after a comparable period of time in untreated patients. A total of 101 patients obtained a SVR (Group 1), while nine were relapsers. Group 2 (21 patients) was composed by the nine relapsers and the 12 untreated patients. A significant reduction of mean FG (134.3 ± 41.32 mg/dL vs 152.4 ± 56.40 mg/dL, P = 0.002) and HbA1c values (46.51 ± 16.15 mmoL/moL vs 52.15 ± 15.43 mmoL/moL, P <  0.001) was found in Group 1 but not in Group 2 (140.6 ± 47.87 mg/dL vs. 145.31 ± 30.18 mg/dL, P = 0.707, and 55.31 ± 20.58 mmoL/moL vs. 53.38 ± 9.49 mmoL/moL, P = 0.780). In Group 1, 20.7% of patients could reduce or suspend their antidiabetic therapy compared to none in Group 2 (P = 0.03), despite the significant weight increase observed in Group 1. SVR induced a significant amelioration of glycemic control in diabetic HCV-patients, despite a significant weight increase; larger prospective studies are needed to verify whether these results are maintained over the long-term., (© 2017 Wiley Periodicals, Inc.)

Aim: With the idea that a small diameter stapler should cause less sphincter trauma, we began to use the 25mm circular stapler to perform ileo-pouch-anal anastomosis (IPAA) and we report our experience., Material of Study: A retrospective study using a bowel function questionnaire and a quality of life questionnaire has been conducted on a group of patients who underwent IPAA using a 25mm stapler, Results: We performed IPAA using a 25mm circular stapler in 37 patients. Postoperative mortality was nil and morbidity was 27%. One anastomotic stenosis occurred. Long term follow-up information was available on 28 patients. Mean follow-up was 70 months (range 8-177). Mean number of bowel movements was 4.5 (range 2-10, median 4.5) during the day and 0.9 (range 0-10, median 0) at night. Out of 28 patients, 19 (68%) were fully continent and 32% had occasional soiling, no one reported incontinence. All patients except one were able to withold their stool for more than 15 minutes. Daytime pad use was: never 86%, occasionally 3%, frequently 11%; nightime pas use was never 86%, occasionally 7% and frequently 7%. Bowel regulating drugs use was never 82%, occasionally 14%, regularly 4%. Evacuation difficulties were: never 75%, occasionally 21%, frequently 4%., Discussion: Our results compare favourably with the literature, which reports median bowel frequency 6-7.6/24h, 9.4- 33% urgency, 17-44% daytime soiling and 32-61% nighttime soiling., Conclusions: Our results must be considered preliminary but we found the 25-mm stapler safe and adequate to perform IPAA., Key Words: IPAA, Ulcerative Colitis, Stapler, Function.

Gastric cancer (GC) remains a frequent and important cause of cancer mortality worldwide. Many factors affect the prognosis of GC, but invasion and metastasis are the leading causes of death. Due to the various stage-oriented therapies available, after the diagnosis of GC it is important to determine the staging preoperatively in order to choose the appropriate management. GC staging is the workhorse of endoscopic ultrasound (EUS). EUS can distinguish the different wall layers of the gastrointestinal tract as well as assess regional lymph nodes. Furthermore, samples of suspicious lesions or lymph nodes can be obtained by means of EUS-guided fine-needle aspiration (EUS-FNA). In this narrative review, we highlight the current status of the usefulness of EUS for GC staging, with focus on early GC that still remains a diagnostic and therapeutic challenge. In particular, the possibility to ameliorate the accuracy of EUS, in this context, by using instruments with increased ultrasound frequency is emphasized.

Aim: Functional dyspepsia, though benign, leads to deterioration of the quality of life and high costs for healthcare systems. The optimal therapy for functional dyspepsia is still to be defined because of its multifactorial pathogenesis. In an open multicentric study of patients with functional dyspepsia, we prospectively evaluated the benefit of treatment with a food supplement composed of sodium alginate, carbonate calcium, pineapple, papaya, ginger, α-galactosidase and fennel (Perdiges, Bioten Snc, Turin, Italy)., Methods: Ninety-one consecutive patients were included, suffering from functional dyspepsia, who had been previously submitted to therapy to eradicate the infection from Helicobacter pylori (H. pylori) and were waiting to perform the Urea Breath Test (UBT). The primary goal was to establish the percentage of patients who continued to abstain from proton pump inhibitors (PPI) as they waited to carry out the UBT, differentiating between patients who were treated (N.=55) with Perdiges and those who were not (N.=36). Our secondary goal was to document the differences within the 2 groups in terms of symptoms perceived between the start and end of the observation period. The wellness reported, during or in absence of treatment with Perdiges, was evaluated by the use of the VAS scale (Visual Analogical Scale) completed before the start of the treatment and after 30 days., Results: All the patients treated with Perdiges (55/55, 100%) and 31/36 (86.1%) patients who were not (P=0.008) continued to abstain from PPI in the period awaiting the UBT. The VAS scale of those who took Perdiges improved on average by 1.78 points versus a worsening of 0.08 points of those who did not take it (P<0.0001). Furthermore, while among those who took Perdiges there was a statistically significant improvement (P<0.0001) in the VAS scale, between the baseline and the end of treatment, a worsening of 0.08 points (P=0.78) was noticed among the patients who did not take it., Conclusion: Perdiges is significantly effective in the period following treatment to eradicate the infection from H. pylori in patients with functional dyspepsia. This allows to reduce the need to use antisecretive drugs. Further randomised studies, with wide ranging case histories, must assess its long-term efficacy.

Aim: The decrease in bone density may occur as a result of inflammatory bowel disease (IBD). Studies conducted on this issue generally focused on treated IBD patients. It is thus difficult to discriminate the role of disease from the effect of therapy on bone density reduction. We evaluated the prevalence of osteopenia/osteoporosis and abnormalities in indices of bone metabolism in patients with newly diagnosed IBD., Methods: Evaluation of dual-energy X-ray absorptiometry (DXA) at the lumbar spine and intact parathormone (PTH), 25-hydroxy vitamin D and urinary cross-links, on 37 (26 females, median age 35.6±14.5 years) consecutive patients., Results: Sixteen of 37 patients (43%) had normal DXA, 17 (46%) were osteopenic and 4 (11%) osteoporotics. Most male patients >30 years (63%) old as well as young women (62%) had osteopenia/osteoporosis. Mean value of intact-PTH was significantly higher in women >50 years (55.0±18.1 pg/mL) compared with those aged 16-20 years (30.0±14.6 pg/mL) (P=0.042). Furthermore, there was a significant difference between mean value of 25-hydroxy vitamin D in women >50 years old (16.2±4.7 ng/mL) compared to those aged 21-30 years (26.6±7.9 ng/mL) (P=0.041). Intact-PTH was significantly higher in osteoporotic patients (55.7±12.7 pg/mL) compared to normal subjects (28.3±13.0 pg/mL) (P=0.0014)., Conclusion: High prevalence of osteopenia/osteoporosis was observed in this population. On the basis of these data, we propose to perform DXA in male patients aged >30 years and in all women with new diagnosis of IBD.

Celiac disease (CD) is a chronic, immune-mediated disorder, characterized by small intestinal malabsorption of nutrients after the ingestion of gluten by genetically susceptible individuals. The discovery of the wide variations in the nature and intensity of clinical presentation of CD has transformed its status, long considered a rare disease, to that of a common health problem. As patients with CD get older, they tend to present with complaints not directly referable to the gastrointestinal tract. Neurologic symptoms, caused by lesions of the central or peripheral nervous system occasionally occur in patients with CD and are poorly understood. This review focalizes on the present knowledge of the potential relationship between CD and epilepsy. The prevalence of CD among patients with epilepsy is not homogeneously distributed, probably because epilepsy encompasses a heterogeneous group of disorders. In fact, the clinical spectrum of epilepsy related to CD ranges from benign syndromes to intractable epilepsy. The precise mechanism of the potential association between CD and epilepsy is also still under discussion.

Interruption of the aortic arch in association with aortic atresia is a rare condition. We report the second case in literature in which survival was provided by an aortopulmonary fistulous communication.

While Fontan operation is considered a palliative procedure for the treatment of complex congenital heart disease, its morbidity and mortality are certainly not negligible, especially in high-risk patients. In our opinion, a bidirectional cavo-pulmonary anastomosis with an additional source of blood flow to the lungs (Blalock-Taussig shunt, pulmonary artery banding, native pulmonary stenosis) represents a valuable surgical option in this subset of patients. From November 1992 to September 1994, sixteen patients with complex congenital heart disease underwent bidirectional cavo-pulmonary anastomosis, leaving an additional source of blood flow in place (modified Blalock-Taussig shunt in 9 cases, pulmonary artery banding in 6 cases, native pulmonary stenosis in 1 case). Eight of these patients (50%) were reinvestigated after a mean follow-up of 15.7 months (range 1-26 m). It has been possible to differentiate two types of pulmonary blood flow, according to the nature of the additional flow source; in the case of cavo-pulmonary anastomosis and pulmonary artery banding or pulmonary stenosis, pulmonary blood flow was pulsatile and evenly distributed to both lungs, while in the case of bidirectional cavo-pulmonary anastomosis and Blalock-Taussig shunt, pulmonary flow was non pulsatile and asymmetric (angiographic criteria). There were no hospital deaths. Late mortality was 12.5% (2 pts) due to worsening of atrioventricular valve regurgitation. In one of these two patients, prolonged pleural and pericardial effusion occurred. In conclusion, bidirectional cavo-pulmonary anastomosis with an additional flow source is a good alternative to classic or fenestrated Fontan operation in the treatment of complex congenital heart disease. The best results are obtained with an additional flow source represented by pulmonary artery banding or pulmonary stenosis, due to pulsatility and uniform distribution of blood flow in the pulmonary district. Morbility and mortality compare favorably with the rates observed in classic or fenestrated Fontan operation.

In children, acute myocardial infarction is a rare complication of infective endocarditis. Since it is usually fatal, few data on the patients who have survived are available. We report the case of a child with acute myocardial infarction and residual impairment of the coronary reserve, complicating a mitral endocarditis.

Fetal cardiac anatomy was studied by ultrasound in 96 pregnancies between 16 and 24 weeks' gestation. Sequential approach was used to identify all venous, atrioventricular and ventriculoarterial connections as well as intracardiac anatomy. A standard CSE was performed after birth in all patients to confirm the normal heart anatomy. Aortic arch, pulmonary veins and pulmonary artery branches resulted sometimes uncertainly identified but a nearly complete morphological heart study was performed in almost all cases.

The cerebral arteriovenous fistula is a rare cause of neonatal cardiac failure. We have recently observed three cases of severe cardiac failure associated with an arterio-venous malformation of the vein of Galen. At echocardiography and angiography the right cardiac chambers were seen to be more enlarged than the left ones. This may have resulted to some extent from an insufficient right-to-left shunt during foetal life due to a relatively small foramen ovale confronting an increased systemic venous return. Two of the neonates were operated upon and one survived. Based on our experience and on a review of the literature we feel that the diagnostic clues are: 1) severe cardiac enlargement; 2) a vascular bruit on the head; 3) hyperpulsatile neck vessels, sometimes with small peripheral pulses.

Two hundred and one pregnancies considered at high risk for congenital heart disease (CHD) underwent fetal cross-sectional echocardiographic (CSE) examination. In 190 cases a structurally normal heart was correctly predicted; seven cases of CHD were identified, but in two of them the specific diagnosis was inaccurate. One false positive diagnosis of a small ventricular septal defect was made. There were three false negative diagnoses: two of ventricular septal defects and one of aortic coarctation. We conclude that severe heart malformations can be reliably identified or excluded by CSE in utero, but important anatomical details may be missed. Therefore, prognosis should be based only on the structures identified to multiple-scan planes.

In 1983, a US National Collaborative Study (NCS) proposed criteria for the diagnosis of hemodynamically significant patent ductus arteriosus (PDA) in premature infants with respiratory distress syndrome (RDS), but the widespread use of pulsed Doppler cross-sectional echocardiography (PD-CSE) in neonatal intensive care units has made direct assessment of the ductus possible thus providing more timely therapy. We have compared the results in 30 premature infants with severe RDS, assessed according to the guidelines of the US NCS, with those in 51 infants whose PDA was diagnosed by PD-CSE. Together with a significant reduction in the age at treatment (7.8 +/- 3.9 vs 2.4 +/- 1.1 days), there was a reduced dependence on artificial ventilation (14.8 +/- 11.0 vs 7.8 +/- 2.7 days), a reduction in the number requiring surgical ligation of PDA (9 vs 2), a decreased incidence of bronchopulmonary-dysplasia (BPD) (40% vs 16%), and a reduction of unfavorable outcome of treatment (death or BPD) (76% vs 49%).

Patency of the ductus arteriosus (PDA) is a common finding in small premature infants. Recently pulsed-Doppler-cross sectional echocardiography (PD-CSE) has been successfully used in these patients. We report a case of a premature infant with an unusual PD-CSE pattern.

Vascular thrombosis is a harmful and rather frequent event in sick premature infants. Only recently has intracardiac thrombosis been described in preterm babies and virtually all the surviving cases are those treated surgically. We report the cases of two premature infants with intra-atrial thrombosis detected by cross-sectional echocardiography and successfully treated with heparin and urokinase for 12 and 16 days, respectively. Our patients required larger doses of urokinase over a longer period of time than are required at older ages to obtain thrombolysis. Our data suggest that fibrinolytic therapy may be an alternative to surgery in premature babies with right atrial thrombosis and that cross-sectional echocardiography is very useful in the titration of the therapy in order to achieve consistent dissolution of the thrombus.

The usual non invasive diagnostic methods may not be able to estimate a mild residual gradient in infants treated for Coarctation of the Aorta (CA) so we tried to determine whether Pulsed Doppler (PD) may be useful in these cases. We studied 16 children (Group A) treated for CA, clinically considered as good operative results (arm to leg gradient less than or equal to 10 mmHg) and admitted for cardiac catheterization to study associated cardiac defects. Ten children with congenital heart disease different from CA were studied as a control (Group B). Percutaneous left cardiac catheterization was performed in all children with pull-back recording of the aortic pressure across aortoplasty before angiography. PD study was performed with an ATL Mark 600 and a 3 MHz transducer positioned in the suprasternal notch. The sample volume was moved into the descending aorta in order to obtain peak flow velocity (PFV) and estimate systolic gradient (DEG). Cardiac catheterization gradients (CCG) ranged from 0 to 20 mmHg (3.9 +/- 6.3 mmHg) in Group A while no gradient was recorded at the Isthmus in Group B. In Group A the frequency shift changed just below the aortoplasty; PFV and DEG ranged respectively from 1 to 2.3 m/s (1.6 +/- 0.3 m/s) and from 4 to 22 mmHg (10 +/- 4.8 mmHg). In Group B the descending aorta PFV ranged from 0.8 +/- 1.3 m/s (1 +/- 0.2 m/s). PFV in Group A was higher than in Group B (p less than 0.001). CCG were plotted against DEG; the linear regression gave a satisfactory coefficient of correlation (R = 0.93 and p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

The echocardiographic appearances in a case of persistent truncus arteriosus with aortic arch interruption and truncal valve dysplasia was noted in a 24 week fetus. Elective termination of pregnancy was carried out and all the echocardiographic findings were confirmed by pathological examination suggesting the possibility of accurate prenatal diagnosis of such lesions.

Congenital Heart Malformations (CHM) can be present together with Extracardiac Malformations (ECM) in a single individual, however the frequency and the patterns of associations are not well defined because the casistics of the literature are little comparable. The diagnosis of CHM has been demonstrated with cardiac catheterization in any case. Between January 1st, 1976 and December 31st, 1983 cardiac catheterization has been performed in 1012 children and 971 of them were affected by Congenital there was at least one ECM as well (group B); 311 ECM were present in group B. VSD (p less than 0.05) and Atrioventricular Septal Defects (AV.SD) (p less than 0.01) resulted associated with ECM while T.F. (p less than 0.05) and isolated TGA (p less than 0.01) showed the tendency to occur in isolation. VDS resulted associated with gastrointestinal anomalies (p less than 0.05), AV.SD with T21 (p less than 0.001), aortic valve (p less than 0.05) and supra-valve (p less than 0.001) stenosis with Nervous System abnormalities. Pulmonary stenosis showed little tendency to occur together with T21 (p less than 0.05).