Detecting myocardial salvage after primary PTCA: early myocardial contrast echocardiography versus delayed sestamibi perfusion imaging.

The extent of myocardial salvage after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) is variable and cannot be predicted on the basis of either vessel patency or early regional wall motion assessment. The aim of this study was to evaluate the reliability of microvascular integrity, as shown by myocardial contrast echocardiography (MCE), as an indicator of tissue salvage and a predictor of late functional recovery, and to compare MCE with the quantification of tracer activity in sestamibi perfusion imaging. METHODS: Twenty-six patients with AMI who received successful treatment with primary PTCA were examined with MCE during cardiac catheterization immediately before and after vessel recanalization. Myocardial contrast effect was scored as 0 (absent), 0.5 (partial) or 1 (normal). Wall motion was assessed by two-dimensional echocardiography on admission and 1 mo later with a 16-segment model and 4-point score. Resting sestamibi SPECT was collected within 1 wk after AMI. The risk area was defined by MCE as the sum of the segments with no perfusion (score 0) before PTCA. Myocardial viability was defined by MCE as an increase in contrast score in the same segments after PTCA and by sestamibi SPECT as a preserved tracer activity (>60% of peak activity). The functional recovery after 1 mo detected by two-dimensional echocardiography was the reference standard for viability. RESULTS: A total of 50 segments showed perfusion defects before PTCA (risk area). Immediately after PTCA, the MCE score increased in 44 of 50 segments, whereas sestamibi SPECT showed preserved activity in 22 of 50 segments. After 1 mo, the wall motion score decreased in 22 of 50 segments (viable segments) and was unchanged in the remaining 28 segments. Thus, MCE showed a sensitivity of 91% and a specificity of 14% in detecting viable myocardium, whereas sestamibi SPECT showed a lower sensitivity (68%) but a significantly higher specificity (75%; P < 0.00001). The positive predictive values were 45% and 68% for MCE and SPECT (P < 0.005), respectively, and the negative predictive values were 67% and 71%, respectively. On a patient basis, SPECT was more specific (79% versus 21%; P < 0.01) and showed a higher overall predictive accuracy (88% versus 50%; P < 0.01) than MCE. CONCLUSION: The demonstration of microvascular integrity by MCE performed immediately after primary PTCA has a limited diagnostic value in predicting salvaged myocardium. Conversely, tracer activity quantification in resting sestamibi SPECT performed in a later stage is confirmed to be a reliable approach for recognizing myocardial stunning and predicting functional recovery.     

123I-hippuran renal scintigraphy with evaluation of single-kidney clearance for predicting renal scarring after acute urinary tract infection: comparison with (99m)Tc-DMSA scanning.

The value of (123)I-hippuran (OIH) renal sequential scintigraphy (RSS) in predicting the evolution of defects detected by (99m)Tc-dimercaptosuccinic acid (DMSA) scanning during a first episode of acute pyelonephritis (APN) was assessed. METHODS: Fifty-eight children with APN underwent (99m)Tc-DMSA planar scanning and (123)I-OIH RSS during acute infection and at least 5 mo later. Renal lesions found by (99m)Tc-DMSA scanning were classified according to the following (99m)Tc-DMSA grading system: 0 = normal, 1 = 1 lesion, 2 = 2 lesions, and 3 = diffuse damage with renal parenchymal subversion. Renal scarring was diagnosed whenever a renal cortical defect detected at the first (99m)Tc-DMSA examination persisted on the follow-up (99m)Tc-DMSA examination. Single-kidney clearance rate (Cl) was evaluated by a method that was previously validated at our institution and is based on time-activity curves measured on the heart and kidney areas by the region-of-interest technique. RESULTS: (99m)Tc-DMSA scanning showed renal damage in 76 kidneys and had negative findings for the remaining 40 kidneys (2 patients had bilaterally negative findings). (99m)Tc-DMSA scanning determined 40 kidneys to be grade 0, 49 to be grade 1, 21 to be grade 2, and 6 to be grade 3. For (99m)Tc-DMSA grades of 0-3, the corresponding Cl mean values (in mL/min/1.73 m(2) of body surface area [BSA]) were 292 +/- 33, 237 +/- 39, 210 +/- 54, and 140 +/- 53, respectively. The Spearman regression coefficient (R) demonstrated a significant correlation between (99m)Tc-DMSA grade and Cl (R = 0.69, P < 0.0001). Thirty-six of the lesions detected by staging (99m)Tc-DMSA were shown to have recovered on follow-up renal scans, whereas 40 developed scars. A significant difference in Cl was found between the 2 groups (P < 0.0002). The Cl cutoff value was determined by univariate discriminant analysis; a Cl value of 232 mL/min/1.73 m(2) of BSA discriminated best between scarred and nonscarred kidneys, with a specificity, sensitivity, positive predictive value, negative predictive value, and overall accuracy of 95%, 95%, 90%, 97%, and 95%, respectively. CONCLUSION: Cl evaluation, in the course of acute urinary tract infection, is highly valuable in predicting the fibrotic evolution of renal damage detected on acute (99m)Tc-DMSA scanning. Also, our data show close agreement between Cl and the grade determined by staging (99m)Tc-DMSA.     

Can the reversible regional wall motion abnormalities on stress gated Tc-99m sestamibi SPECT predict a future cardiac event?

BACKGROUND: Myocardial stunning has recently been demonstrated by use of stress gated technetium 99m sestamibi single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy. However, its prognostic value is less well determined. The aim of this study was to investigate the prognostic value of reversible regional wall motion abnormalities (RWMAs). METHODS AND RESULTS: We studied 303 consecutive subjects with known or suspected coronary artery disease who underwent 2-day stress-rest gated Tc-99m sestamibi SPECT and were followed up for 19 +/- 16 months. Clinical and test-derived variables were evaluated to predict cardiac death, nonfatal myocardial infarction (MI), unstable angina, and early or late coronary revascularization. Reversible RWMAs were identified in 102 patients. On Cox analysis, the presence, site, degree, and extent of reversible RWMAs did not identify an adverse outcome, except in patients without prior MI. After adjustment for prescan data, the strongest predictors of hard events and all cardiac events were poststress RWMAs and the amount of ischemia. The addition of poststress RWMAs to the combined model of prescan and perfusion data yielded incremental prognostic value. CONCLUSION: Poststress RWMAs and ischemia by perfusion were the most powerful predictive parameters of cardiac events. However, myocardial stunning should always be considered, particularly in patients without prior MI and in the referral of patients for early revascularization.     

Consumption of fresh fruit rich in vitamin C and wheezing symptoms in children. SIDRIA Collaborative Group, Italy (Italian Studies on Respiratory Disorders in Children and the Environment)

BACKGROUND: A beneficial effect of fresh fruit consumption on lung function has been observed in several studies. The epidemiological evidence of the effect on respiratory symptoms and asthma is limited. The consumption of fruit rich in vitamin C was examined in relation to wheezing and other respiratory symptoms in cross sectional and follow up studies of Italian children. METHODS: Standardised respiratory questionnaires were filled in by parents of 18 737 children aged 6-7 years living in eight areas of Northern and Central Italy. The winter intake of citrus fruit and kiwi fruit by the children was categorised as less than once per week, 1-2 per week, 3-4 per week, and 5-7 per week. A subset of 4104 children from two areas was reinvestigated after one year using a second parental questionnaire to record the occurrence of wheezing symptoms over the intervening period. RESULTS: In the cross sectional analysis, after controlling for several confounders (sex, study area, paternal education, household density, maternal smoking, paternal smoking, dampness or mould in the child's bedroom, parental asthma), intake of citrus fruit or kiwi fruit was a highly significant protective factor for wheeze in the last 12 months (odds ratio (OR) = 0.66, 95% confidence intervals (CI) 0.55 to 0.78, for those eating fruit 5-7 times per week compared with less than once per week), shortness of breath with wheeze (OR = 0.68, 95% CI 0.56 to 0.84), severe wheeze (OR = 0.59, 95% CI 0.40 to 0.85), nocturnal cough (OR = 0.73, 95% CI 0.65 to 0.83), chronic cough (OR = 0.75, 95% CI 0.65 to 0.88), and non-coryzal rhinitis (OR = 0.72, 95% CI 0.63 to 0.83). In the follow up study fruit intake recorded at baseline was a strong and independent predictor of all symptoms investigated except non-coryzal rhinitis. In most cases the protective effect was evident even among children whose intake of fruit was only 1-2 times per week and no clear dose-response relationship was found. The effect was stronger (although not significantly so (p = 0.13)) in subjects with a history of asthma; those eating fresh fruit at least once a week experienced a lower one year occurrence of wheeze (29. 3%) than those eating fruit less than once per week (47.1%) (OR = 0. 46, 95% CI 0.27 to 0.81). CONCLUSIONS: Although the effect of other dietary components cannot be excluded, it is concluded that the consumption of fruit rich in vitamin C, even at a low level of intake, may reduce wheezing symptoms in childhood, especially among already susceptible individuals.     

A person to person hepatitis A outbreak

A person to person outbreak of hepatitis A is described: 90 cases of hepatitis A occurred in a small town in Calabria, southern Italy; all cases were under 18 years of age with the highest age-specific incidence rate in the 6-10 year age group. Transmission was identified by tracing close contacts with other incubating or active cases; only eight out of 90 cases were not identified as having a very probable or possible contact with an infecting case. Transmission was high between family members leading to a secondary family attack rate of 51% in children under 16. An enteric disease educational campaign was carried out together with IgG and no cases of hepatitis A were reported in the two years following the investigation.     

The effects of ambient temperature on life span, lipid peroxidation, superoxide dismutase, and phospholipase A2 activity in Drosophila melanogaster

Aging changes were examined in Drosophila melanogaster. Lifespan was determined in two strains of male and female Drosophila raised at 19 degrees, 24 degrees, and 29 degrees C. The results show an inverse relationship between lifespan and temperature. In addition, lipid peroxidation rates and superoxide dismutase activity were measured in homogenates and phospholipase A2 activity was determined in crude membrane samples prepared from this species. Temperature was found to be directly correlated with the rate of lipid peroxidation in each group. The longest-lived group, wild-type females, exhibited the lowest rate of lipid peroxidation at each temperature; whereas the shortest-lived group, vestigial wing males, displayed the highest rates of lipid peroxidation. Older (40-53 day) vestigial wing males also exhibited significantly higher superoxide dismutase activity than younger vestigial wing males (0-5 day) and higher phospholipase A2 activity than wild-type females of the same age. These results indicate that there is an association between lipid peroxidation rates and lifespan in Drosophila, and that aging changes may include an increase in superoxide dismutase and phospholipase A2 activity. These findings agree with the hypothesis that free radicals are involved in the aging process in Drosophila.     

A murine model of asbestosis.

Balb/c mice were exposed to aerosolized chrysotile fibers and evaluated as a host for the study of asbestos-induced pulmonary disease. Histologically, an initial macrophage reaction was found to progress to "asbestos body" formation and diffuse focal interstitial fibrosis within 1 year of a chronic exposure period. This reaction was most intense in areas adjacent to respiratory bronchioles and alveolar ducts. Two morphologically distinct tumors at the pulmonary visceral surface were also discovered among a high percentage of asbestos-exposed mice. Bronchoalveolar lavage demonstrated an eventual alteration of the retrievable cell populations among the dusted animals. Evaluation of systemic B-lymphocyte activity suggested a stimulation of this cell subset following chrysotile inhalation. These results demonstrate that subsequent to chronic asbestos exposure, the mouse develops pulmonary and immunologic changes very similar to those noted in human asbestosis.     

Long-term oxygen therapy in chronic respiratory failure: a Multicenter Italian Study on Oxygen Therapy Adherence (MISOTA)

BACKGROUND: The adherence to the prescribed oxygen therapy is difficult to obtain for patients on long-term oxygen therapy (LTOT). There is little information on the modalities of oxygen utilisation for patients on LTOT who are using liquid oxygen in real life. STUDY OBJECTIVE: Evaluation of the behaviour and the knowledge regarding LTOT in a large group of patients mainly using liquid oxygen. DESIGN AND SETTING: Questionnaire administered to consecutive outpatients on domiciliary LTOT for at least 6 months referring to one of 20 clinics throughout Italy. Blinded to this result, the physician who cared for the patient completed another questionnaire. RESULTS: We evaluated 1504 patients (mean age 71.6 years; males 64%; 74% suffering from COPD). Most respondents (93%) used liquid oxygen with mobile device. Fifteen per cent of patients had a prescribed length of oxygen therapy less than 15 h/day; 21% reported to practice oxygen for less than 15 h/day. Patients reported using oxygen for less hours than had been prescribed during the day at rest (P=0.02, k=0.80) during exercise (P=0.002, k=0.72) and at night (P=0.0036, k=0.77). There was no difference between the flow prescribed by the physician and that known and practised by the patient at rest or during sleep; during exercise the flow reported by patients was lower than that prescribed by the physician. Patients used in the night but not at rest or during exercise, a lower level of oxygen flow than what they knew had been prescribed. Fifty-five per cent of patients received indications to modify the oxygen flow in the various situations of life. Liquid oxygen was almost always useful to decrease breathlessness. Most (84%) patients possessed a mobile device, but only 40% declared they used it daily, 'shame' being indicated as the principal barrier. On the physicians' side, we found that the criteria used in prescribing did not always correspond to evidence-based recommendations. CONCLUSION: The widespread use of liquid oxygen did not automatically assure optimal adherence to the prescribed treatment as regards times and modality of oxygen use. A better education of patients, relatives, and the general public, as well as increased self-assessment on the part of health caregivers would improve the practice of LTOT in Italy.