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BACKGROUND: MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate gene expression at post-transcriptional level, having a role in many biological processes, such as control of cell proliferation, cell cycle, and cell death. Altered miRNA expression has been reported in many neoplasms, including pituitary adenomas (PAs). PURPOSE: In this study, we aimed to evaluate the expression of 20 miRNAs involved in pathways relevant to pituitary pathophysiology, in PAs and normal pituitary tissue and to correlate their expression profile with clinical and pathological features. METHODS: Pituitary tumor samples were obtained during transphenoidal surgery from patients with non-functioning (NFPA, n = 12) and functioning (n = 11, 5 GH-, 3 ACTH-, 3 PRL-omas) PAs. The expression of selected miRNAs in PAs and in normal pituitary was analyzed by RT-qPCR. miRNAs expression was correlated with demographic, clinical, and neuroradiological data and with histopathological features including pituitary hormones immunostaining, Ki-67 proliferation index, and p53 immunohistochemistry evaluation. RESULTS: All evaluated miRNAs except miR-711 were expressed in both normal and tumor pituitary tissue. Seventeen miRNAs were significantly down-regulated in pituitary tumors compared to normal pituitary. miRNAs were differentially expressed in functioning PAs or in NFPAs, as in the latter group miR-149-3p (p = 0.036), miR-130a-3p (p = 0.014), and miR-370-3p (p = 0.026) were significantly under expressed as compared to functioning tumors. Point-biserial correlation analysis demonstrated a negative correlation between miR-26b-5p and Ki-67 (p = 0.031) and between miR-30a-5p and 'atypical' morphological features (p = 0.038) or cavernous sinus invasion (p = 0.049), while 508-5p was inversely correlated with clinical aggressiveness (p = 0.043). CONCLUSIONS: In this study, we found a significant down-regulation of 17 miRNAs in PAs vs normal pituitary, with differential expression profile related to functional status and tumor aggressiveness.

Hashimoto’s thyroiditis (HT) is often associated with rheumatic disorders (arthritis, etc.), but many HT patients report non-specific rheumatic signs and symptoms in the absence of clinically evident rheumatic diseases. Aim of this study was to evaluate the prevalence of non-specific rheumatic manifestations (RMs) in HT subjects without classified autoimmune comorbidities. 500 HT patients (467 F, 33 M; median age 41 years, range 14–69) and 310 age- and sex-matched controls, consecutively referred to the Endocrine Unit of Messina University Hospital, were evaluated for non-specific RMs. None took l-thyroxine. Exclusion criteria: autoimmune comorbidities, infectious, and/or inflammatory diseases, history of neoplasia, BMI > 30 kg/m2. In our HT cohort, 100 patients (20%) complained of one or more RMs, vs 21 controls (6.8%; P

Advanced glycation end products (AGEs) are increased in conditions of oxidative stress and promote inflammation by interacting with their receptor RAGE on cell membrane. By contrast, the soluble receptor sRAGE exerts protective effects by competing with RAGE for ligand binding. AGEs/sRAGEs interaction is involved in the pathogenesis of several diseases related to oxidative stress. In the present study, we evaluated the AGEs/sRAGEs oxidative balance in Hashimoto’ thyroiditis (HT). We measured the levels of sRAGE, by ELISA, and AGEs, by spectrophotometric method, in the serum of 50 HT patients (5 M, 45 F; mean age 38.5 ± 12 years) and 50 age-, sex- and BMI-matched healthy controls. All subjects were euthyroid at recruitment and none was on LT-4 therapy. Serum sRAGEs were significantly lower (median 424 vs 738 pg/ml; p = 0.001) and AGEs higher (205 vs 114 AU/g prot; p = 0.001) in HT patients compared to controls, and the two parameters were inversely correlated (p = 0.016). Accordingly, the AGEs/sRAGEs ratio was threefold higher in HT patients than controls (0.48 vs 0.15; p = 0.0001). In regression analysis models, serum TPO-Ab were the main predictors for AGEs and sRAGEs levels and AGEs/sRAGEs ratio (p

Background: There is a growing awareness that nutritional habits may influence risk of several inflammatory and immune-mediated disorders, including autoimmune diseases, through various mechanisms. The aim of the present study was to investigate dietary habits and their relationship with redox homeostasis in the setting of thyroid autoimmunity. Materials and Methods: Two hundred subjects (173 females and 27 males; median age, 37 years) were enrolled. None were under any pharmacological treatment. Exclusion criteria were any infectious/inflammatory/autoimmune comorbidity, kidney failure, diabetes, and cancer. In each subject, serum thyrotropin (TSH), free thyroxine, antithyroid antibodies, and circulating oxidative stress markers were measured. A questionnaire on dietary habits, evaluating the intake frequencies of food groups and adherence to the Mediterranean diet, was submitted to each participant. Results: Among the 200 recruited subjects, 81 (71 females and 10 males) were diagnosed with euthyroid Hashimoto's thyroiditis (HT); the remaining 119 (102 females and 17 males) served as controls. In questionnaires, HT subjects reported higher intake frequencies of animal foods (meat, p = 0.0001; fish, p = 0.0001; dairy products, p = 0.004) compared with controls, who reported higher intake frequencies of plant foods (legumes, p = 0.001; fruits and vegetables, p = 0.030; nuts, p = 0.0005). The number of subjects who preferentially consumed poultry instead of red/processed meat was lower in HT subjects than in controls (p = 0.0141). In logistic regression analysis, meat consumption was associated with increased odds ratio of developing thyroid autoimmunity, while the Mediterranean diet traits were protective. In HT subjects, serum advanced glycation end products (markers of oxidative stress) were significantly higher (p = 0.0001) than in controls, while the activity of glutathione peroxidase and thioredoxin reductase, as well as total plasma antioxidant activity, were lower (p = 0.020, p = 0.023, and p = 0.002, respectively), indicating a condition of oxidative stress. Stepwise regression models demonstrated a significant dependence of oxidative stress parameters on consumption of animal foods, mainly meat. Conclusions: The present study suggests a protective effect of low intake of animal foods toward thyroid autoimmunity and a positive influence of such nutritional patterns on redox balance and potentially on oxidative stress-related disorders.

Objective Hashimoto’s thyroiditis (HT), the most common autoimmune thyroid disease at any age, is often associated with other autoimmune diseases. The present study was aimed to describe the type and frequency of non-thyroidal autoimmune diseases (NTADs) in HT patients and to delineate the clinical pattern of diseases clustering in pediatric/adolescent and adult age. Design Cross-sectional study. Methods 1053 newly diagnosed HT patients (500 adults (467 F, mean age 40.2 ± 13.7 years) and 553 children/adolescents (449 F, mean age 11.1 ± 3.0 years)) were evaluated for common NTADs by means of careful recording of medical history, physical examination and assessment of selected autoantibody profiles. Results The prevalence of associated NTADs was significantly higher in adults than that in pediatric/adolescent HT patients (P P P Conclusions Age at HT presentation may influence autoimmune diseases clustering, favoring the association of specific NTADs in different ages of life. Moreover, the association between HT and NTADs increases with age and occurs most frequently in adults.

The adherence by endocrinologists to guideline regarding levothyroxine (LT4) therapy and the compliance of patients may impact the management of hypothyroidism. The aim of this study was to compare the adherence of Italian endocrinologists to the ATA/AACE and ETA guidelines on the management of newly diagnosed primary hypothyroidism and to validate the Italian version of the Morisky-Green Medical Adherence Scale-8 (MMAS-8) questionnaire as applied to the evaluation of the adherence of patients with hypothyroidism to LT4 treatment.This was an observational, longitudinal, multicenter, cohort study, involving 12 Italian Units of Endocrinology.The study enrolled 1,039 consecutive outpatients (mean age 48 years; 855 women, 184 men). The concordance of Italian endocrinologists with American Association of Clinical Endocrinologists/American Thyroid Association (AACE/ATA) and European Thyroid Association (ETA) recommendations was comparable (77.1% and 71.7%) and increased (86.7 and 88.6%) after the recommendations on LT4 dose were excluded, considering only the remaining recommendations on diagnosis, therapy, and follow-up. The MMAS-8 was filled out by 293 patients. The mean score was 6.71 with 23.9% low (score6), 38.6% medium (6 to8), 37.5% highly (= 8) adherers; the internal validation coefficient was 0.613. Highly adherent patients were not more likely to have good control of hypothyroidism compared with either medium (69% versus 72%, P = .878) or low (69% versus 43%, P = .861) adherers.Clinical management of hypothyroidism in Italy demonstrated an observance of international guidelines by Italian endocrinologists. Validation of the Italian version of the MMAS-8 questionnaire provides clinicians with a reliable and simple tool for assessing the adherence of patients to LT4 treatment.AACE = American Association of Clinical Endocrinologists; ATA = American Thyroid Association; EDIPO = Endotrial SIE: DIagnosis and clinical management of Primitive hypothyrOidism in Italy; eCRF = electronic case report form; ETA = European Thyroid Association; fT3 = free triiodothyronine; fT4 = free thyroxine; LT4 = levothyroxine; MMAS-8 = Morisky-Green Medical Adherence Scale-8; PH = primary hypothyroidism; T3 = triiodothyronine; T4 = thyroxine; TSH = thyroid-stimulating hormone; US = ultrasonography.

Over the last years, there have been several reports on the occurrence of acute liver damage (ALD) in patients affected with Graves’ ophthalmopathy (GO) receiving intravenous glucocorticoids (ivGCs). This article is aimed at reviewing the literature on this specific topic and reporting two new cases of ALD occurring in GO patients while on ivGCs. The terms “glucocorticoid therapy” and “Graves’ Ophthalmopathy”/“Graves’ Orbitopathy”/”Thyroid eye disease” were used both separately and in conjunction with the terms “liver disease,” “liver damage,” “hepatotoxicity,” “liver failure,” to search MEDLINE for articles published since the first report of ALD in 2000 and up to 2015. ALD [defined as an increase in alanine aminotransferase (ALT) >300 U/L] during or after completion of ivGCs has been so far reported in 17 fully documented cases. Overall, one-half of those patients were diagnosed as having autoimmune hepatitis (AIH) and in the vast majority of the remaining cases a diagnosis of methylprednisolone(MP)-induced hepatotoxicity was suspected. The clinical course of liver injury varied from asymptomatic hypertransaminasemia in the vast majority of patients to fatal hepatic failure in four patients receiving higher (>8 g) cumulative doses of MP. The overall risk of ALD is relatively low (~1 %), and seems higher using a single dose >0.5 g and a cumulative dose >8.5 g MP. Whenever ivGC treatment is required, serum liver enzymes, viral hepatitis markers, and autoantibodies related to AIH should be obtained prior to ivGC administration. Liver function should be monitored during ivGC and up to 6 months after the end of treatment. Prolonging observation after 6 months is likely unnecessary, since all cases of ALD so far reported always occurred well within this term.

Technetium-99m (Tc-99m)-tetrofosmin is a radio isotope that has been shown to be an accurate alternative to thallium-201 for detecting coronary artery disease. However, its prognostic value is less well determined. To this end, 459 consecutive patients (mean age 58 +/- 10 years) with suspected or known coronary artery disease underwent exercise single-photon emission tomography Tc-99m-tetrofosmin scintigraphy. Follow-up, defined as the time from scanning until a soft event (revascularization procedures), a hard event (myocardial infarction and cardiac death), or patient response, lasted up to 78 months (median 38). An ischemic scintigraphic perfusion score, which takes into account both the extent and severity of reversible perfusion defects, was calculated to estimate the severity of perfusion abnormalities. Patients with normal scans were at low risk of events (yearly hard event rate 0.5% and soft event rate 0.9%). The rate of outcomes increased significantly with abnormal scans (yearly hard event rate 4.9% and soft event rate 10.3%). Statistical analysis using the Kaplan-Meyer survival curves showed a significant difference in event-free survival between patients with normal and abnormal scans. With use of Cox proportional-hazards analysis, after adjusting for prescan information, nuclear data provided incremental prognostic value for hard events (clinical and exercise data vs nuclear data; chi-square = 15.5 vs 33.4, p

Background. Technetium 99m-labeled myocardial agents have been proposed as an alternative to thallium 201. The aim of this study was to assess retrospectively the accuracy of exercise myocardial 99mTc-tetrofosmin scintigraphy with tomographic imaging (SPECT) in a large group population in the evaluation of coronary artery disease. Furthermore we evaluated the relation between the severity of scintigraphic impaired myocardial perfusion and the angiographic coronary artery stenoses in patients without myocardial infarction and with stenosis localized exclusively in the proximal segment of the 3 main coronary arteries. Methods and Results. The study group consisted of 235 consecutive patients, 204 (87%) of whom were men, with a mean age of 57 ± 10 years, and with suspected or known coronary artery disease, who underwent 99mTc-tetrofosmin SPECT and coronary angiography. Furthermore, 61 patients in a low-likelihood group for coronary artery disease were also studied. Significant disease was defined by ≥50% luminal coronary artery stenosis in ≥1 native coronary artery or major branch or in a saphenous vein graft or arterial mammary graft. The overall sensitivity was 95%, specificity was 76%, and predictive accuracy was 95%. The normalcy rate for the low-likelihood group was 93%. Sensitivity was 71% for the left anterior descending artery, 61% for the left circumflex artery, and 73% for the right coronary artery. Specificity was 94% for the left anterior descending artery, 96% for the left circumflex artery, and 91% for the right coronary artery. Predictive accuracy was 79% for the left anterior descending artery, 78% for the left circumflex artery, and 81% for the right coronary artery. In patients without myocardial infarction linear regression analysis between scintigraphy and angiography showed a significant correlation in patients with severe proximal coronary artery stenosis (r = 0.53, P < .002), but not in those with moderate proximal stenosis (r = 0.31, P = NS). Conclusions. This study shows that 99mTc-tetrofosmin SPECT is accurate in the detection of coronary artery disease. The relation of the severity of scintigraphic impaired myocardial perfusion and angiographic coronary artery stenosis, however, may differ significantly in patients with proximal stenosis of different severity.

Tetrofosmin is a new technetium 99m-labeled myocardial perfusion agent that has demonstrated favorable imaging characteristics in recent clinical trials. However, it is not certain whether 99mTc-tetrofosmin compared with thallium 201 would underestimate myocardial viability in regions with left ventricular dysfunction.To this end 15 patients (mean age 52+/-7 years) with coronary artery disease and left ventricular dysfunction (ejection fraction 35%+/-8%) documented on angiography underwent both quantitative rest-redistribution 201Tl and rest 99mTc-tetrofosmin single photon emission computed tomography imaging. RESULTS; Of 240 total segments on rest-redistribution 201Tl protocol 139 (58%) segments had irreversible 201Tl defects. Of these segments 79 (57%) had only mild to moderate reduction of 201Tl uptake (51% to 85% of normal uptake), whereas the remaining 60 (43%) had severely reduced tracer uptake (or = 50% of normal uptake). On 99mTc-tetrofosmin protocol 180 (75%) segments had abnormal 99mTc-tetrofosmin uptake; of these segments 120 (67%) had mild to moderate reduction of 99mTc-tetrofosmin uptake, whereas 60 (33%) had severely reduced activity. Among hypokinetic regions concordance between 201Tl and 99mTc-tetrofosmin regarding myocardial viability with a cutoff point of 50% of peak activity was obtained in 28 (90%) of 31 segments (K' = 0.80), leaving only 3 of 31 regions discordant (p = NS). Similarly, among akinetic or dyskinetic regions concordance between the two tracers regarding myocardial viability was achieved in 54 (93%) regions (K' = 0.75), leaving only 4 of the 58 regions discordant (p = NS).These data show that when the severity of uptake was considered within abnormal segments, a similar amount of 201Tl viable regions were observed by 99mTc-tetrofosmin. Thus these two agents may provide comparable information about myocardial viability when quantitative analysis of defect severity is performed.

The term Marine-Lenhart syndrome describes the association between Graves’ disease and autonomously functioning thyroid nodules (AFTN), such as toxic adenoma or toxic multinodular goiter. The two diseases may coexist or may be present at different moments in the same patient. In the literature, there are many reports on the development of Graves’ disease after radioiodine treatment for AFTN, but very little information may be found on the occurrence of AFTN after radioiodine therapy for Graves’ disease. We describe here the case of a female patient with Graves’ disease who was successfully treated with radioiodine for Graves’ disease, returning to normal thyroid function. Three years later, biochemical analysis and ultrasound examination identified a thyroid nodule that progressively increased in size. The 99mTc-pertechnetate scintigraphy showed avid uptake in the right lobule, which corresponded to a nodular lesion consistent with AFTN.

Purpose: This multicenter study was carried out to compare the efficacy of intrauterine insemination (IUI) and intraperitoneal insemination (IPI) associated with multiple follicular development as treatment for unexplained infertility. Method: A total of 205 couples completed the trial. Sixty-seven couples underwent treatment with IPI (group A) and 138 couples underwent treatment with IUI (group B). Results: Clinical pregnancy was obtained in 23 couples in group A (pregnancy rate: 34.3%) and in 36 couples in group B (pregnancy rate: 26.1%). No significant difference was observed between group A and group B. As for the evolution of pregnancies and the incidence of twin pregnancies, no significant difference was observed between the two groups. Conclusions: Because IUI and IPI allow us to obtain same results and IPI is more invasive than IUI, the latter technique can be considered the method of choice and IPI should be used when IUI is difficult to perform, as in the presence of a tight cervical canal.

Objective To evaluate the therapeutic effects of a GnRH agonist (GnRH-a), leuprolide acetate (LA) plus a pill containing ethinyl E 2 plus cyproterone acetate (CPA) in a group of women with severe hirsutism who were unresponsive to oral contraceptive (OC) therapy. Design Twenty-four patients suffering from severe hirsutism secondary to polycystic ovary disease (PCOD) were treated for 12 months with 3.75 mg IM LA every 28 days in association with 0.035 mg/d ethinyl E 2 plus 2 mg/d CPA (Diane; Schering, Berlin, Germany) for 21 d/mo. Setting Patients were recruited in the Institute of Obstetrics and Gynecology, St. Bambino Hospital, University of Catania, Catania, Italy. Hormonal assays were performed in the Hormone Laboratories of St. Bambino Hospital, University of Catania, Catania, Italy. Main Outcome Measure Every 3 months the hirsutism score was evaluated. Mean serum concentrations of LH, FSH, E 2 , total and free T, androstenedione (A), sex hormone-binding globulin (SHBG), and DHEAS were determined. Every 6 months a vaginal ultrasound examination was performed. Results In all patients after 6 and 12 months of treatment with LA plus OC, the hirsutism score improved significantly. Serum levels of LH, FSH, E 2 , total and free T, A, and DHEAS decreased significantly, whereas SHBG showed a marked increase. A significant reduction in the ovarian size was observed. Conclusion Gonadotropin-releasing hormone agonist, associated with a pill containing CPA, reduced the hirsutism in severely affected women with PCOD who are unresponsive to OC treatment alone.

Kidney transplantation is a therapeutic option of choice for patients with end-stage disease. Laparoscopic living donor nephrectomy (LLDN) is a less invasive alternative to the open procedure to increase the number of renal donors. However, several studies have reported that this technique requires a long learning curve, and that the complication rate varies from 6.4% to 16.5%. Among these, chylous ascites (CA) is a severe and rare complications of LLDN. The treatment option for this condition is primarily conservative. Surgery is considered after failure of conservative treatment and its role, however, remains controversial. We report a case of CA as a complication of laparoscopic donor nephrectomy. A 44 year old woman underwent LLDN of the left kidney. There were no intraoperative or immediate postoperative complications and the patient was discharged home on postoperative day 3. Two weeks after discharge, the patient returned for a routine follow-up visit and presented with abdominal distension, discomfort, and dyspnea. A CT scan of the abdomen with oral and intravenous contrast revealed significant ascites in all four quadrants of abdomen and pelvis. An ultrasound guided paracentesis was performed, and 7 L of chyle was aspirated Conservative management with medium chain triglyceride and spironolactone was immediately initiated; the symptoms improved after paracentesis, and the CA completely resolved after 3 days of therapy. However, to prevent recurrence, the patient consumed a low-fat medium chain triglyceride diet for 6 months. CA needs to be considered as a potential severe and rare complication of LLDN, and conservative management should be proposed to all patients, reserving the surgical treatment to treatment failure.

We report the results of monolateral dual kidney transplantation with grafts with multiple arteries. Among the 42 monolateral DKT performed in a seven-yr period, 12 (28.5%) patients received renal grafts with multiple arteries. In six patients, the accessory arteries were anastomosed end-to-side or side-to-side on the aortic patch. In six patients, with three or more accessory arteries, a vascular reconstruction with an inferior vena cava patch was performed, before implanting the kidney. There were no intraoperative complications in the entire series, and there were no immediate vascular complications. Vascular reconstruction of kidneys with multiple arteries may be performed safely even in monolateral dual kidney transplantation. Inferior vena cava may be an attractive alternative in vascular reconstruction for kidneys with multiple arteries.

P lacement of intracoronary stents during percutaneous transluminal coronary angioplasty (PTCA) decreases the morbidity of acute closure,1 the shortterm requirement for repeat revascularization by achieving a large lumen.2,3 However, stent implantation does not prevent neointimal hyperplasia, and instent restenosis still remains between 20% and 30%.4 Because of favorable initial results, stents are implanted in multivessel PTCA and as a partial revascularization in some patients, especially in elderly and high-risk patients, therefore leaving a potential source of ischemia irrespective of stent restenosis.5 Thus, in an era of cost savings, the ability to localize ischemia noninvasively and detect stent restenosis accurately is crucial in the selection of patients who require further angiographic evaluation. The effectiveness of perfusion scintigraphy in the follow-up of symptomatic and asymptomatic patients with PTCA has been defined by several studies.6–9 However, there are few prospective data regarding the usefulness of exercise perfusion imaging in patients with coronary stent implantation.10 Therefore, the aim of this study was to assess, prospectively, the accuracy of exercise technetium99m (Tc-99m)-tetrofosmin single-photon emission tomography (SPECT) for detecting restenosis after coronary stent implantation. • • • The study group consisted of 97 patients, 74 (76%) men (mean age 58 6 12 years) who, after successful stenting procedures in native coronary arteries, prospectively underwent Tc-99m-tetrofosmin tomographic myocardial scintigraphy and coronary angiography. The average interval between the stent implantation and the scintigraphic myocardial scintigraphy study was 128.4 6 41.0 days (range 88 to 191), whereas that from the scintigraphic study to coronary angiography was 57 6 25 days (range 30 to 64). Because coronary stent implantation in 10 patients was performed in 2 vascular territories, 107 stented vascular territories were included in the evaluation. Patients were excluded with stents in bypass grafts, intervening myocardial infarction, or for revascularization procedures between stent placement and scintigraphic imaging. Prior myocardial infarction ($1 month) corresponding to the stented artery was present in 51 cases. There were 31 patients (60%) with a Q-wave myocardial infarction, and 20 (40%) with a non–Q-wave myocardial infarction. Myocardial viability and residual ischemia assessed by dobutamine echocardiography was documented in most cases (89%) of infarcted territories. At angiography performed before stenting there were 38 patients (39%) with 1-vessel disease, 49 (51%) with 2-vessel disease, and 10 (10%) with 3-vessel disease. Two patients (2%) had previous coronary artery bypass graft surgery. One hundred thirty-five stents (mean length 19 6 7 mm) were implanted in 107 coronary arteries as previously described.11 The distribution of the stented arteries were: 59 (55%) left anterior descending, 20 (19%) left circumflex, and 28 (26%) right coronary artery. Stents were implanted electively in 49% of patients, for suboptimal PTCA in 30% and in bailout due to dissection or vessel closure in 21%. The mean stenosis before stenting was 85 6 12% and after stenting 8 6 7%. Stenting was performed as complete revascularization in 51 patients (53%) and as partial revascularization in the remaining 46 patients (47%). Treadmill testing was performed with the modified Bruce protocol after appropriate pharmacologic washout and according to general standards. Patients underwent 2-day SPECT scintigraphy using Tc-99mtetrofosmin. Representative sections composed of 3 short-axis sections (apical, midventricular, and basal), and of the midventricular vertical long axis combined to assess apical segments, were selected for analysis as described by Garcia et al.12 A 4-point scoring system for segmental uptake of Tc-99m-tetrofosmin was used in which 0 5 normal, 1 5 mildly reduced, 2 5 moderately reduced, and 3 5 severely decreased uptake. Patterns of perfusion defects were separately determined in each segment for rest and stress studies as previously described.13 Defect extension and severity were separately analyzed by 2 observers blinded to each other’s readings. Of the total 832 segments scored, agreement was reached in 790 (95%), whereas in the remaining segments a split decision was resolved by consensus. Myocardial segments were assigned to individual coronary arteries as previously described.13 The observers had knowledge of the vessel of stent implantation but were unaware of the results of the control coronary angiography or the results of exercise testing and clinical findings. Coronary artery stenosis was assessed specifically by 2 experienced cardiologists by means of manual calipers without knowledge of exercise scintigraphic study results. Significant disease From the Institute of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy. Dr. Galassi’s address is: Via Antonello da Messina 75, Acicastello 95021, Catania, Italy. E-mail: argal @ ctonline.it. Manuscript received August 6, 1999; revised manuscript received and accepted December 14, 1999.

Renal vascular anomalies are frequent and are not usually problematic, especially when they have been identified and localised with preoperative imaging; computed tomography angiography is a fast and minimally invasive procedure that may afford accurate visualisation of arterial and venous anatomy. We report on our experience with the utilisation of multi-detector row angiography in the preoperative evaluation of living kidney donors. Nineteen living kidney donors underwent multidetector row scan angiography with 3D post-processing. The subjects were 12 male and 7 female donors with a mean age of 60 years. Renal vascular anomalies were identified in 52.6% of donors. A total of 10 supernumerary arteries were identified. Surgical correlation was available for 19 kidneys (17 left and 2 right). The donated kidneys were selected on the basis of CT scan and renal function. CT scan identified all 29 arteries including 10 double right or left arteries (100% specificity and sensitivity). Dual multi-phase multi-detector row CT angiography is a minimally invasive and highly accurate method for preoperative evaluation of renal donors. It affords comprehensive depiction of the arterial and venous anatomy of the kidney, which is particularly critical for planning and performing the donor nephrectomy, especially via a laparoscopic approach.

Stroke is the third cause of death in western countries and its complications lead to significant socio-economic problems related to the prolonged hospitalization and rehabilitation of patients with neurological lesions. Severe atherosclerotic lesions of the carotid artery are the main cause of stroke and transient ischemic attacks. Their incidence may reach 5-7% per year in patients with carotid artery stenosis70% with or without symptoms. Time-honored carotid endarterectomy is still regarded as the gold standard therapy for primary and secondary prevention of stroke. However, surgery is not free of complications and the rate of perioperative stroke ranges from 5.1 to 14.3%. A group of patients at a particularly high risk of stroke during surgical endarterectomy is represented by patients with significant carotid stenosis in the presence of an occluded contralateral artery. Indeed, carotid cross-clamping during operative surgery in the absence of an adequate collateral flow may result in a critical flow reduction during the operation and therefore increases the risk of periprocedural strokes. In the North American Symptomatic Carotid Endarterectomy (NASCET) trial, the overall risk of stroke was 5.1%, whereas it increased up to 14.3% in patients with an occluded contralateral carotid artery. Recently, carotid stenting has been increasingly used as an endovascular technique for carotid revascularization, especially after the introduction of neuroprotection devices which improved the safety of the procedure. Therefore, it may be an attractive alternative to carotid endarterectomy, especially when the surgical risk is too high. We describe the immediate and late outcomes of 3 patients treated with carotid artery stenting in the presence of contralateral carotid occlusion.

Coronary artery disease does not occur in all the patients with acute myocardial infarction. Coronary artery diseases occurs in 97% of cases; in the other 3% of cases, myocardial infarction is caused by coronary spasm (40%, intracoronary thrombosis (60%) due to platelet hyperreactivity, peripartum thrombophilia or use of oral contraceptives. Myocardial infarction in young women is an infrequent event. Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction that typically occurs during the peripartum period. A few cases of myocardial infarction in premenopausal women with no risk factors for coronary artery disease and normal coronary arteries have been reported. We describe 2 consecutive cases of acute myocardial infarction occurred in young, premenopausal women, without risk factors for cardiovascular diseases.

The use of abciximab (c7E3 Fab; ReoPro , Eli LillyCompany, Indianapolis, Indiana) during percutaneous coronary intervention (PCI) decreases the incidence of early (30-day) and late (6-month to 1 year) adverse cardiac ischemic events. In a high-risk population, abciximab also reduced the need for target lesion revascularization. PCI of lesions with complex morphology, particularly long lesions, is associated with more complicated outcomes. The use of multiple and/or long intracoronary stents to cover long coronary lesions may lower the incidence of acute or subacute occlusion, but is still limited by a high late restenosis rate. We characterized patients undergoing elective implantation of long or multiple overlapping coronary stents and determined the impact of abciximab administration on clinical and angiographic outcomes.In a prospective, single-center randomized trial, a total of 107 patients undergoing elective implantation of long or multiple overlapping coronary stents were randomly assigned to receive either standard-dose heparin (n = 53) or abciximab plus low-dose heparin (n = 54). The use of abciximab was not associated with an increased incidence of bleeding or vascular complications compared to standard heparin regimen (3.7% versus 3.8%, respectively; p = NS). A 68% reduction in composite in-hospital cardiac events (i.e., death, myocardial infarction, urgent revascularization) was observed in the abciximab group (3.7% versus 11.5%, p = 0.1). At 6-month follow-up, a 48% reduction of target lesion revascularization (11% versus 21%; p = 0.1) and a decrease in binary angiographic restenosis were observed for abciximab-treated patients (17% versus 34%; p0.05).The peri-procedural use of abciximab during implantation of long or multiple overlapping coronary stents is safe and effective, as it does not increase bleeding or vascular complications compared to standard heparin anticoagulation and reduces the incidence of in-hospital adverse cardiac events; moreover, abciximab improves 6-month clinical and angiographic outcomes in such a complex setting.

The separation of patients with suspected or known coronary artery disease into low- and high-risk subgroups by means of noninvasive testing is highly relevant in the selection of patients who require further diagnostic or therapeutic investigation. We evaluated whether exercise electrocardiographic variables during exercise testing might be a means of predicting the severity of myocardial ischemia as assessed with myocardial scintigraphy.We retrospectively reviewed 816 consecutive patients (mean age, 57+/-10 years) who underwent exercise technetium-99m tetrofosmin single photon emission computed tomography (SPECT) for the assessment of suspected or known coronary artery disease. Eight independent significant predictors of the extent and severity of reversible perfusion defects (ischemic perfusion score), which when integrated in a diagnostic algorithm satisfactorily discriminated patients with no reversible perfusion defects (sensitivity, 75%; specificity, 80%) and patients with severe impaired myocardial perfusion (or =11 ischemic perfusion score; sensitivity, 77%; specificity, 82%), were identified by means of stepwise discriminant analysis. However, patients with mildly to moderately impaired myocardial perfusion (or =21 but11 ischemic perfusion score) were poorly discriminated (sensitivity, 50%; specificity, 78%). The set of variables that were significant (P.0001) for prediction included sex, myocardial infarction, exercise angina, the maximal amount of ST segment depression, rate-pressure product threshold criteria, slope of ST segment depression, ST/heart rate index, and peak exercise heart rate.The results of the use of clinical and electrocardiographic exercise variables satisfactorily agrees with the results from scintigraphy only for patients with no reversible perfusion defects and with severely impaired myocardial perfusion. However, it fails as an approach with universal applicability.

Background: Coronary stent implantation is associated with improved angiographic short‐term and mid‐term clinical outcome. However, restenosis rate still remains between 20 and 30%. Hypothesis: The purpose of the study, performed as a prospective angiographic follow‐up to detect restenosis, was to evaluate the immediate and the 6‐month angiographic results of repeat balloon angioplasty for in‐stent restenosis. Methods: From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6‐month control angiography. Of the 96 lesions that showed in‐stent restenosis (>50% diameter stenosis) (29%), 72 underwent balloon angioplasty. Results: The primary success rate was 100%. Follow‐up angiogram at a mean of 6.9 ± 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in‐stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 ± 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in‐stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). Conclusions: Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic‐restenosis rate during repeat 6‐month follow‐ups. The subgroup of patients with diffuse, severe, and/or body location in‐stent restenosis proved to be at higher risk of recurrent restenosis.

The aim of the study is to assess the safety of trapidil in the setting of coronary stenting and to evaluate its efficacy in reducing angiographic in-stent restenosis. One hundred eighteen patients undergoing Palmaz-Schatz stent implantation were randomly assigned to receive antiplatelet therapy using either aspirin (325 mg/d) or trapidil (400 mg/d), in combination with ticlopidine (500 mg) for the first month. At entry, both groups were comparable with regard to clinical, angiographic, and procedural characteristics. At 6-month angiographic follow-up, >50% restenosis occurred in 15 of 52 lesions (28.8%) of the aspirin group and in 14 of 47 lesions (29.8%) of the trapidil group (P=not significant, NS). At 6-month clinical follow-up, there was no difference in the two groups in the rate of adverse events (2.0% vs. 2.1%, P=NS), medication side effects (4.0% vs. 4.2%, P=NS), and peripheral vascular complications (4.0% vs. 4.2%, P=NS). In conclusion, treatment with trapidil seems to be associated with a similar incidence of stent restenosis and adverse cardiac events as compared to aspirin and could be a valuable alternative to aspirin in the setting of coronary stenting.

The case of a 51-year-old woman with exertional angina pectoris and isolated anomalous origin of the left anterior descending coronary artery from the right coronary artery is reported. This anomalous artery was not narrowed, coursed in front of the pulmonary artery and did not present either anatomical derangement at the take off or intramyocardial course. The mechanism of ischaemia could not be identified.

Arteriographic findings of neovascularity and fistula formation between coronary arteries and left atrium have occasionally been described in association with left atrial thrombosis in patients with mitral valve disease. The validity of these coronary arteriographic findings in diagnosis of atrial thrombi has been evaluated in 112 patients with mitral valve disease. Comparison was made with surgery. The study furnished these diagnostic values: sensitivity 70%, specificity 85%, positive predictive value 72%. Even if this angiographic finding is complementary in diagnosis of atrial thrombosis, its identification during coronary arteriography in patients with mitral valve disease is useful. Its detection could improve diagnostic prediction of thrombosis, especially in patients without previous embolic events or where echocardiography failed to reveal thrombi.

Background In southern Europe, the risk of cancer in patients with end-stage kidney disease receiving dialysis has not been well quantified. The aim of this study was to assess the overall pattern of risk for de novo malignancies (DNMs) among dialysis patients in the Friuli Venezia Giulia region, north-eastern Italy. Methods A population-based cohort study among 3407 dialysis patients was conducted through a record linkage between local healthcare databases and the cancer registry (1998–2013). Person-years (PYs) were calculated from 30 days after the date of first dialysis to the date of DNM diagnosis, kidney transplant, death, last follow-up or December 31, 2013, whichever came first. The risk of DNM, as compared to the general population, was estimated using standardized incidence ratios (SIRs) and 95% confidence intervals (CIs). Results During 10,798 PYs, 357 DNMs were diagnosed in 330 dialysis patients. A higher than expected risk of 1.3-fold was found for all DNMs combined (95% CI: 1.15–1.43). The risk was particularly high in younger dialysis patients (SIR = 1.88, 95% CI: 1.42–2.45 for age 40–59 years), and it decreased with age. Moreover, significantly increased DNM risks emerged during the first 3 years since dialysis initiation, especially within the first year (SIR = 8.52, 95% CI: 6.89–10.41). Elevated excess risks were observed for kidney (SIR = 3.18; 95% CI: 2.06–4.69), skin non-melanoma (SIR = 1.81, 95% CI: 1.46–2.22), oral cavity (SIR = 2.42, 95% CI: 1.36–4.00), and Kaposi’s sarcoma (SIR = 10.29, 95% CI: 1.25–37.16). Conclusions The elevated risk for DNM herein documented suggest the need to implement a targeted approach to cancer prevention and control in dialysis patients.