Metastatic tumors to the stomach： Clinical and endoscopic features

INTRODUCTION The stomach is an unusual site for metastasis. There have been several published reports on metastatic lesions in the stomach. However, information on gastric duodenal metastases is generally limited to single case reports. The present study …     

Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: a systematic review

Intravesical instillation of Bacillus Calmette-Guerin (BCG) is used with efficacy and safety in the treatment of patients with intermediate and high-risk superficial bladder carcinoma. Arthralgia and/or arthritis is one of the rare severe complications following intravesical BCG immunotherapy. We searched MEDLINE in order to analyze the frequency of this clinical complication, its pathogenesis and outcome. The electronic search was conducted using the following key words: “BCG immunotherapy” and “Arthritis, arthralgias and BCG immunotherapy”. At the end of a process of abstract analysis, 48 papers were included in the systematic review. All the selected papers, except one that was a clinical review, described at least one case of arthritis after BCG therapy. The BCG immunotherapy resulted to be safe and efficacious in the treatment of bladder cancer; the development of reactive arthritis is rare and can evolve in a chronic process. The review of the literature highlighted that reactive arthritis following BCG intravesical instillation is a complication usually well controlled with the discontinuation of the immunotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Only a small portion of patients with a particular genetic background will develop a chronic process.     

Mapping and ablation: A worldwide perspective

Currently, many ablative techniques have reported excellent long-term results in restoring and maintaining sinus rhythm among patients with paroxysmal and persistent AF. Catheter ablation of AF should not be performed too late over time when recurrent paroxysmal AF progresses to the persistent or to the permanent form. Among patients with permanent AF, the stepwise approach requires very extensive lesions in both the left and right atrium to obtain the same success rate as reported by CPVA as performed in Milan many years ago. Long-term prospective multicenter randomized studies comparing the impact of medical therapy with catheter ablation strategy on “hard” outcomes such as morbidity and mortality are required to better define the patient population that may mostly benefit from ablation at the lowest risk and acceptable cost.     

Active acromegaly enhances spontaneous parathyroid hormone pulsatility

In healthy subjects, parathyroid hormone (PTH) is secreted in a dual fashion, with low-amplitude and high-frequency pulses superimposed on tonic secretion. These 2 components of PTH secretion seem to have different effects on target organs. The aim of our study was to evaluate whether growth hormone excess in acromegaly may modify the spontaneous pulsatility of PTH. Five male patients with newly diagnosed active acromegaly and 8 healthy subjects were evaluated by 3-minute blood sampling for 6 hours. Plasma PTH concentrations were evaluated by multiparameter deconvolution analysis. Plasma PTH release profiles were also subjected to an approximate entropy (ApEn) estimate, which provides an ensemble measure of the serial regularity or orderliness of the release process. In acromegalic patients, baseline serum PTH values were not significantly different from those measured in the healthy subjects, as well as tonic PTH secretion rate, number of bursts, fractional pulsatile PTH secretion, and ApEn ratio. Conversely, PTH pulse half-duration was significantly longer in acromegalic patients vs healthy subjects (11.8+/-0.95 vs 6.9+/-1.6 minutes; P=.05), whereas PTH pulse mass showed a tendency (P=.06) to be significantly greater in acromegalic patients. These preliminary data suggest that growth hormone excess may affect PTH secretory dynamics in patients with acromegaly. Potentially negative bone effects of the modifications of PTH secretory pattern in acromegaly should be investigated.     

Sources of error and interpretation of plaque morphology by optical coherence tomography

This study was performed to assess the strengths and weaknesses of optical coherence tomography (OCT) intravascular imaging in identifying plaque morphology. Seventy-nine postmortem human coronary arterial sections classified as fibrous-cap atheromas, calcific plaques, fibrous plaques, and complicated lesions were studied. OCT was able to identify 45% of fibrous-cap atheromas (kappa=0.27, p<0.01), 68% of fibrocalcific plaques (kappa=0.40, p<0.001), 83% of fibrous plaques (kappa=0.37, p<0.001), and 100% of complicated lesions (all thrombi; kappa=1, p<0.001). Misinterpretation was caused mainly by the low OCT signal penetration, which could not detect lipid pools or calcium behind thick fibrous caps, and by an inability to distinguish calcium deposits from lipid pools or the opposite. Lesions with thick (>150 microm) caps were histologically identified as 25 thick fibrous-cap atheromas, 8 fibrocalcific plaques, and 5 fibrous plaques; all these lesions were relatively "stable." In contrast, lesions with fibrous caps<150 microm were either vulnerable or stable lesions (11 thin-fibrous-cap atheromas and 11 fibrocalcific plaques). In conclusion, although OCT images may give an indication of the overall composition of large homogenous signal-poor regions, such as lipids or calcified areas, they could be unreliable in differentiating areas with heterogenous compositions. OCT may easily recognize relatively stable lesions.     

Electroanatomic remodeling of the left atrium in patients undergoing repeat pulmonary vein ablation: mechanistic insights and implications for ablation

Introduction: There is limited information describing late changes in the electroanatomic characteristics of the left atrium (LA) associated with recurrence after an anatomical circumferential pulmonary vein ablation (CPVA) for atrial fibrillation (AF).
Methods and Results: Forty-seven patients (57 ± 8 years) undergoing a repeat ablation after CPVA were included. Using an electroanatomic mapping system, we measured the bipolar voltage by averaging points in the pulmonary vein (PV)-LA junction and four other LA sites. Conduction velocity and AF cycle length (AFCL) were also measured and the results are compared with the first procedure. After an initial decrease observed at the end of the first procedure, voltage and conduction velocity returned to intermediate values in all LA sites, with lower voltage at the LIPV antrum (P = 0.004), and lower conduction velocity across the LIPV and RSPV (P < 0.001). Conduction gaps were more prevalent at the septal aspect of the right PV encircling lines (85%), between the left atrial appendage (LAA) and the LSPV (70%) and lines at the posterior wall (71%). There was a nonsignificant increase in AFCL, with a more widespread distribution of organized electrograms (32.4% vs 46.6%).
Conclusion: Recurrence after CPVA is associated with a reverse process of voltage and conduction velocity increase across ablated areas, especially the PV-LA junction, and is related to the presence of conduction gaps, which are distributed mostly at the septal aspect of the lines encircling the right PVs and at the LAA-LSPV area. Organization of atrial electrograms seen during AF ablation is maintained at a repeat procedure.     

Blood pressure regulation by CCR genes

New genetic evidence strongly supports a role for the immune system in the pathogenesis of essential hypertension (EH) through chemokines and their receptors (CCR) involvement. The aim of the present study was to evaluate the possible relation between CCR2 and CCR5 alleles and blood pressure (BP) levels in hypertensive subjects. In all, 118 essential hypertensive outpatients (male 90, female 28; stage I and II; age 27-54 years; not previously treated with antihypertensive drugs) were selected for the study. All of the subjects underwent office BP measurement. Subsequently, 24-h ambulatory BP monitoring (ABPM) was performed with a Spacelabs 90207 monitor during a regular working day. CCR264I and CCR5Delta32 polymorphisms were determined by polymerase chain reaction (PCR), following the standard molecular biology protocols. Allelic frequencies were the following: CCR5Delta32= 0.097, CCR264I=0.101. Logistic regression analysis showed an association between the CCR5Delta32 allele and the following: 24-h systolic BP (SBP >140 mmHg; p = 0.027), values over the 50th percentile of 24-h SBP (p = 0.032), and the values over the 50th percentile of nighttime SBP (p = 0.039). Office BP showed an association with the Delta32 allele in a range over the 75th percentile of SBP (p = 0.087) and the 75th percentile of DBP (p = 0.085). No significant association was observed for CCR264I and BP levels or between physiological nocturnal BP decline and genotype. The observed results not only support the role of the immune system in the development and maintenance of hypertension, but they also indicate an influence of CCR5Delta32 polymorphism on the establishment of BP levels.     

A prospective randomized controlled trial on the safety and efficacy of alternating deferoxamine and deferiprone in the treatment of iron overload in patients with thalassemia

We compared the safety and efficacy of alternating deferoxamine and deferiprone with that of deferoxamine monotherapy. Sixty transfusion-dependent thalassemia patients regularly treated with deferoxamine were randomized to continue deferoxamine alone or to receive an alternating therapy for one year. Both arms resulted in equivalent decreases of serum ferritin and liver iron concentration. There was no significant difference in the proportion of patients with adverse events in the two therapy groups although the nature of the adverse events differed according to the chelation regimen.     

Sex differences in the association of apolipoprotein E and angiotensin-converting enzyme gene polymorphisms with healthy aging and longevity: a population-based study from Southern Italy

We investigated the association of sex and age with the occurrence of apolipoprotein E (apoE) and angiotensin-converting enzyme (ACE) genotypes in healthy aging and longevity in 1344 healthy individuals and 64 centenarians. As compared to participants younger than 60 years, a significant higher frequency of the apoE/epsilon2 was observed in men aged 60-90 years (p <.001) and in centenarians (p <.001). Logistic regression analysis confirmed this outcome in both participants aged 60-90 years (odds ratio [OR] = 1.897; 95% confidence interval [CI], 1.227-2.931) and centenarians (OR = 3.263; 95% CI, 1.860-5.722). A further significant association of ACE/D allele and age was observed in centenarians (OR = 2.135; 95% CI, 1.253-3.636). Heterosis was also observed at the ACE locus. No relationship between apoE and ACE polymorphism was found. These findings suggest a role of sex in the association of apoE and ACE gene polymorphisms with healthy aging and longevity.