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Purpose: To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI). Materials and Methods: The Brave Dreams trial ( ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a post hoc assessment, venograms of patients who underwent venous angioplasty were graded as “favorable” (n=38) or “unfavorable” (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared. Results: Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005). Conclusion: Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Post hoc analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.

The enhancement of circulating endothelial progenitor cells (EPCs) obtained by exercise training can be beneficial to patients with cardiac disease. Changes in the levels and differentiation of CD34(pos)/KDR(pos) EPCs, as well as the plasma concentration of vascular endothelial growth factor (VEGF) and stromal cell-derived factor (SDF)-1 EPC-mobilizing cytokines, were evaluated in patients with chronic heart failure after 8 weeks of supervised aerobic training (SAT) and 8 weeks of subsequent discontinued SAT (DSAT).The levels of circulating EPC and EPC differentiation potential of 22 patients who underwent SAT were studied by fluorescence-activated cell sorter analysis and colony forming-unit assay, respectively. The plasma levels of VEGF and SDF-1 were measured by enzyme-linked immunosorbent assay. In response to SAT, the levels of both EPC and VEGF/SDF-1 markedly increased (P.001 vs baseline) but returned to the baseline levels after DSAT. A similar change was observed with the EPC clonogenic potential, but on DSAT the baseline level was incompletely attained.In response to SAT, patients with chronic heart failure show enhanced EPC levels and clonogenic potential that is mirrored by increased plasma VEGF and SDF-1 levels. DSAT can interfere with the maintenance of training-acquired VEGF/SDF-1-related EPC levels and clonogenic potential.

Opinion is divided regarding the influence of iodized oil on MRI signal intensity of hepatic tumours treated with transcatheter arterial chemoembolization (TACE), in which lipiodol deposits. The aim of our study was to ascertain whether or not lipiodol directly influences the MRI signal intensity of hepatocellular carcinoma (HCC) treated by TACE and that of the surrounding liver. Thirteen patients with HCC were studied retrospectively. CT and MRI scans were performed both before and 3 months after TACE. The CT scan was performed to check whether embolized nodules contained lipiodol and how lipiodol was distributed within them. In addition, eight patients were examined prospectively within 7 days after TACE. In these patients a CT scan was performed to see how lipiodol was distributed in the neoplastic nodules and in normal hepatic parenchyma. In the first group of patients the contrast-to-noise (C/N) ratio on T1-weighted (T1W) images and the T2 relaxation time on T2-weighted (T2W) images were calculated for both neoplasm and surrounding liver. In the second group of patients we also measured the signal intensity of non-neoplastic liver that was either permeated or not permeated by lipiodol. The data were analysed with Wilcoxon's test. On T1W images we observed that the retention of lipiodol increased the C/N ratio in all the tumours studied within 1 week after TACE. In the patients studied 3 months after TACE the C/N ratio was not significantly increased. On T2W images lipiodol retention did not change tumour signal intensity. The iodized oil did not change the signal intensity of the liver surrounding the tumour, in comparison with the liver not permeated by lipiodol, on either T1W or T2W images. The results indicate that lipiodol does not modify the signal intensity in non-neoplastic hepatic parenchyma in which it is deposited; after 3 months it does not significantly affect the signal of the tumours that accumulated it. Lipiodol produces a high signal on T1W images over the first few days following TACE in those tumours in which it is deposited.

Routine screening of patients at risk of hepatitis C virus (HCV) infection has become a priority given recent improvements in therapeutic options and the asymptomatic nature of most chronic infections. The aim of this study was to evaluate the performance of the Elecsys® Anti-HCV II assay, a new qualitative antibody immunoassay, compared with currently available assays, and assess its suitability for routine diagnostic testing. The sensitivity of the Elecsys® Anti-HCV II, ARCHITECT® Anti-HCV, AxSYM® HCV 3.0, PRISM® HCV, Vitros® ECi Anti-HCV, Elecsys® Anti-HCV, and ADVIA Centaur® HCV assays was compared using commercially available seroconversion panels and samples from patients known to be HCV positive and infected with HCV genotypes 1-6. Specificity was investigated using samples from blood donors, unselected hospitalized patients, and patients with potential cross-reacting factors or from high-risk groups. The Elecsys® Anti-HCV II assay detected more positive bleeds than the comparator assays, was more sensitive in recognizing early HCV infection, and correctly identified all 765 samples known to be HCV positive, regardless of genotype. The overall specificity of the Elecsys(®) Anti-HCV II assay was 99.84% (n=6,850) using blood donor samples, 99.66% (n=3,922) using samples from unselected hospitalized patients, and 99.66% (n=2,397) using samples from patients with potentially cross-reacting factors or from high-risk groups. The specificity of the Elecsys® Anti-HCV II assay was superior or equal to the comparator assays. In conclusion, the Elecsys® Anti-HCV II assay is a sensitive and specific assay suitable for routine use in the reliable detection of anti-HCV antibodies.

Objectives To confirm whether sirolimus-eluting stents (SES) safely reduce the incidence of restenosis in patients with ST-segment elevation acute myocardial infarction compared with bare-metal stents (BMS). Background In the setting of primary angioplasty, stent restenosis occurs in up to 27% of patients. The introduction of drug-eluting stents has drastically reduced the incidence of restenosis in clinically stable patients. Methods We conducted a randomized trial of 320 patients with acute ST-segment elevation myocardial infarction assigned to receive SES or BMS. The primary end point was binary restenosis at 1-year angiographic follow-up. Results At 1 year, the incidence of binary restenosis was lower in the SES group than in the BMS group (9.3% vs. 21.3%, respectively; p = 0.032), as were the rates of target lesion revascularization (4.3% vs. 11.2%; p = 0.02), target vessel revascularization (5% vs. 13.1; p = 0.015), major adverse cardiac events (6.8% vs. 16.8%; p = 0.005), and target vessel failure (8.7% vs. 18.7%; p = 0.007). The incidence of angiographically documented stent thrombosis was 1.2% (n = 2) in the SES group and 0.6% (n = 1) in the BMS group. Conclusions In patients with acute myocardial infarction, SES are superior to BMS, reducing the incidence of binary restenosis by 56%, target lesion revascularization by 61%, target vessel revascularization by 62%, adverse cardiac events by 59%, and target vessel failure by 53% at 1 year. (Sirolimus Eluting Stenting in Acute Myocardial Infarction; http://www.clinicaltrials.gov/ct/show/NCT00288210; NCT00288210)

The study aim was to assess the value of exercise stress testing in identifying asymptomatic patients with moderate or severe valvular aortic stenosis (AS). These patients generally develop symptoms during follow up, and require valvular replacement surgery (VRS) at one to three years after single symptom-limited exercise stress testing. Limited data are available on predictors of outcome in asymptomatic patients with valvular AS. A single symptom-limited exercise stress test might offer more precise risk stratification of patients referred for cardiological evaluation.The safety and diagnostic accuracy of exercise testing to predict symptom development and need for surgery was assessed prospectively in 30 asymptomatic patients (mean age 62+/-14 years) with valvular AS. Twenty patients had moderate AS (mean Doppler gradient 30-49 mmHg), and 10 severe AS (gradientor =50 mmHg). Patients underwent a symptom-limited maximal exercise test with upright bicycle ergometry. There were no complications during and after exercise testing. All patients were followed up for at least 36 months.Ergometry was abnormal in 18 patients (60%); two patients had a fall in systolic blood pressure, one patient had a fall in systolic blood pressure with angina and ECG signs of myocardial ischemia, one had angina and ECG signs of myocardial ischemia, three patients had ECG signs of myocardial ischemia without symptoms, and 11 had dyspnea at low workload. During the following 12 months all patients with a normal exercise test remained asymptomatic (negative predictive value 100%). Ten of the 18 patients with abnormal exercise test experienced symptoms and required VRS, but eight did not (positive predictive value 55%). After 36 months, only two of 12 patients with a normal exercise test developed symptoms and required VRS (negative predictive value 83%); among subjects with abnormal exercise test, four of 18 required VRS. At three years after exercise testing, 10 patients with a normal exercise stress test and four with an abnormal test did not require VRS as they remained asymptomatic (positive predictive value 78%). There was no statistically significant difference in valvular aortic area, maximal and mean gradient between patients with normal and abnormal exercise tests.Exercise stress testing may be performed safely in asymptomatic patients with moderate or severe valvular AS. Tests which meet criteria for normal patients allow physicians confidently to postpone VRS and to suggest a simple, cost-effective method of follow up in such cases. An abnormal test may reveal symptoms or identify a population for closer follow up.

Aortopulmonary window is a rare cardiac malformation presenting either in the isolated form, or in association with other cardiac anomalies. The isolated form usually presents an increased pulmonary blood flow as the main clinical feature, but if associated with other cardiac anomalies the clinical findings change according to the additional defect. Only 19 cases of aortopulmonary window associated with tetralogy of Fallot have been reported. Five of them have associated pulmonary atresia. We report two neonatal cases of aortopulmonary window and tetralogy of Fallot, one of them presenting an associated pulmonary atresia.

A 64-year-old woman developed acute Reiter's syndrome 4 weeks after the start of intravesical Bacillus Calmette-Guerin immunotherapy for a recurrent superficial bladder carcinoma. The absence of any other cause suggests that the bacillus played an etiopathogenic role in this HLA-B27-positive patient.

The electrocardiograms and the vectocardiograms of 26 childrens, up to 3 years of age, affected by A-V canal, were been analyzed. The pattern of QRS loop in the 3 planes, the voltage of right maximum spatial vector (RMSV) and left maximum spatial vector (LMSV), their projection onto the horizontal (azimuth) and frontal plane (elevation) were related to right ventricular systolic pressure. The qualitative and quantitative evaluation of VCG Showed a better correlation with the haemodynamic data than the electrocardiogram. In all but 3 cases, the high frequency of superior orientation and counterclockwise rotation of QRS loop in the frontal plane was found; moreover the good correlation of right ventricular systolic pressure to the rotation of QRS loop on the horizontal plane was also confirmed. In fact, the latter was counterclockwise in the cases with a low pressure, whereas it became clockwise in those with higher pressure. Moreover a good direct correlation of the right ventricular pressure with forward orientation of LMSV on the horizontal plane was found. In differential diagnoses with other congenital heart diseases with superior orientation and anticlockwise rotation on the frontal plane, useful results were obtained by using the calculation of elevation time (the interval between point 0 and intersection of the QRS loop with the axis) which is significantly lower in the A-V canal. Terminal forces directed posteriorly and to the right and with a delay no longer than 0,03 inches do not warrant the diagnosis of left anterior hemiblock with a right bundle branch block associated. On the contrary, on the basis of anatomical and electrophysiologic studies we believe that in this disease there is an asinchrony in the activation i.e. the postero-inferior region, then the left lateral wall and finally the tree high part of right ventricle wall are sequentially activated.

36 patients, less than two years old, affected by Fallot's tetralogy were studied by vectorcardiography. The configuration of the QRS loop in the three orthogonal planes, the voltage of the 0.10 sec spatial vector, RMSV and LMSV vectors, and their azimuth and elevation were evaluated. Such data have been correlated to arterial oxygen saturation. Qualitative analysis showed a clockwise or figure eight QRS loop on the H and F planes in the great majority of cases; and only in a counterclockwise loop on the H plane was the suspicion of an arterial oxygen saturation greater than 85% especially in cases older than two months. The terminal forces of the QRS loop on the H plane were always directed under the O point, Whereas in the valvular pulmonary stenosis, terminal forces are generally superior to the O point. Quantitative analysis demonstrated the constant increase of the RMSV and the direct relationship of the LMSV to arterial oxygen saturation, and so it was the principal parameter for evaluation of the left ventricular volume and the size of pulmonary flow and the degree of pulmonary stenosis. The relationship between the azimuth of 0.01 sec spatial vector to O2 saturation was highly significant, showing a progressive anterior development of the former, as the latter increased.

A group of 37 patients, less than 2 years old, with a ventricular septal defect of variable degree, and a left to right shunt, were studied by vectorcardiography. The duration, the direction and the aspect of the QRS loop on the three orthogonal planes, the voltage of the 0.01; 0.02; 0.04 vectors, the right and the left maximum spatial vectors and their projection on the H and F planes were analyzed and correlated to the right ventricular systolic pressure and Qp/Qs. A clockwise or an eight-type loop on the frontal plane, regardless of RVSP, was observed; on the H plane the loop is, usually, counterclockwise when the pressure is low or medium, and can be of the eight-type but never clockwise when the pressure is systemic. Very interestingly, the quantitative analysis showed a consistent increase of the LMSV. A progressive relationship between the spatial vectors and the right ventricular pressure was noted. The diagnosis of combined ventricular hypertrophy depend upon the following findings: the majority of cases showed a large, counterclockwise and anterior QRS loop on the H with the maximum vector to the left and anteriorly; in all cases the 0.01; 0.02; 0.04 vectors were enlarged, thus warranting the diagnosis of combined ventricular hypertrophy in the first few months of life. 4 cases with low RVSP presented increased initial forces to the right and anteriorly directed, while the major portion of the loop was in the left posterior quadrant on the H plane, with a counterclockwise direction. In our view, the differential diagnosis between this type of aspect and that of diastolic overload of the left ventricle can rest only on the increased voltage of the 0,02 vector which means both systolic and diastolic overload of the right ventricle when accompanied by an increased 0.01 vector which indicates volume overload of left ventricle. Likewise only a quantitative analysis can help in differentiating a combined ventricular hypertrophy from a normal tracing in children under 6 months who show an eight-type loop on the H plane with initial and medium vectors directed anteriorly to the left and counterclockwise, and terminal vectors to the right, posteriorly and clockwise, or in those cases with an anterior clockwise loop on the H plane. Moreover, in the first month of life, the VCG of large VSD with increased pulmonary flux and pressure, can be differentiated from the normal by the QRS loop on the H plane which is clockwise, with initial vectors directed to the left and anteriorly with increased LMSV.

Eighty-one patients suffering from pulmonary stenosis with intact interventricular septum were divided into two groups according to their age: Group I (greater than 2 years), Group II (less than 2 years). In Group I, patients with RVSP up to 50 mmHg have been included in subgroup A; patients with RVSP from 50 to 90 mmHg in subgroup B, patients with RVSP greater than 90 mmHg in subgroup C. In Group II forms with RVSP less than or equal to 60 mmHg have been considered moderate and forms with RVSP greater than 60 mmHg severe. The rotation and duration of the QRS loop on the various planes, presence of a terminal slowing, the ratios 0,01"/LMSV and 0,02"/LMSV, the LMSV and the RMSV in order to assess the most significant vcgraphic parameters to predict severity of the stenosis have been analysed. A fair correlation has been found between RMSV and RVSP (r = 0,55 in Group I; r = 0,54 in Group II). The AA. conclude that a counterclockwiseloop on the H plane and the presence of a terminal slowing are the most reliable parameters for recognizing the light forms, while the clockwise loop on the H plane and a markedly increased voltage of RMSV indicate more severe stenosis.

Cell-mediated response in 60 patients affected by acuminated condylomas has been studied; this was investigated with aspecific in vivo tests (intradermal-reaction with tuberculin, trichophytin, candidine) and by in vitro tests (blood test with cell count, lymphocyte typing, serum proteins, serum immunoglobulin) and was compared with a control group. The results obtained confirm the hypothesis that condylomas acuminata usually occurs in patients with well-preserved cell-mediated immunity.

Our study was aimed at describing the diagnostic imaging patterns of carcinoid liver metastases. Six patients with liver metastases secondary to carcinoid tumor were examined. The metastases were histologically proved in each patient. All patients were examined with ultrasonography (US), Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Digital Subtraction Angiography (DSA). All patients were treated with transcatheter embolization of liver metastases. Diagnostic imaging methods showed ten to many dozen metastases in each patient. Tumor size ranged 0.5 to 14 cm. US showed hypoechoic, hyperechoic and isoechoic carcinoid liver metastases with a hypoechoic halo. Large lesions had anechoic central areas due to colliquative necrosis. Hypoechoic patterns were the most frequent ones. Precontrast CT showed hypodense metastases; very small lesions were isodense relative to surrounding liver. CT during contrast agent injection showed that the metastases were hyperdense in the arterial phase; contrast enhancement was poorer in the portal phase. Large lesions showed a hypodense central area due to necrosis which remained hypodense in the late phase. The metastases were hypointense on T1-weighted and hyperintense on T2-weighted MR images. Gradient echo dynamic imaging with Gd-DTPA showed high-signal metastases in the arterial phase and lower signal intensity in the portal phase. DSA, an essential exam before embolization, showed tortuous and elongated intra- and extrahepatic arteries and tumor neovascularization with no malignant abnormalities. In the capillary phase, tumor uptake and inhomogeneous hypervascular patterns were shown. Portal veins were only displaced and compressed, but never infiltrated by the metastases. All the techniques we used contributed to assess liver involvement by carcinoid metastases. DSA must be used only before treatment; both CT and MRI showed the hypervascular patterns of the metastases, but no technique could predict their nature.

Introduction. Italy and Europe were declared polio-free in June 2002, but increasing migration, even from undeveloped countries where polio still exists, may lead to a come-back of circulating poliovirus (PV) and infection in previously polio-free areas. It is consequently advisable to continue to monitor the immunity of the population in polio-free areas. The aim of this study was to assess the current prevalence of neutralizing antibodies in recently-immunized children and in elderly people who were never vaccinated. Methods. Sera from 511 healthy subjects resident in the Veneto Region were examined to assay their antibody titer for PV 1, 2 and 3, using the microneutralization test. Data were analyzed by chi-squared test, Student?s t-test and linear regression analysis, using EPI-Info 2000 supplied by the Centers for Disease Control and Prevention (Atlanta, GA, USA). Results. Neutralizing antibodies in group A (231 subjects aged 1-17 years) showed significantly higher geometric mean titers (GMTs) than in group B (280 subjects aged 65-100 years) for all three PV serotypes (P : 0.001). Nobody simultaneously lacked neutralizing antibodies for all three serotypes. There were no difference between the two groups in terms of male/female GMTs for the three PV. Antibodies decreased with time since vaccination, but the difference was only significant for PV 3. GMTs were lower in the elderly, with no significant difference among the three PV. Discussion. The population examined showed a good level of protection against the three PV strains: both groups A (vaccinated) and B (naturally immunized) revealed a valid immunity to poliovirus. Conclusion. Immunization programs and immunity status population screening are still advisable until polio has been worldwide eradicated., Journal of Preventive Medicine and Hygiene, Vol 47, No 1 (2006)