Noninvasive diagnosis of cirrhosis: A review of different imaging modalities

Progressive hepatic fibrosis can lead to cirrhosis, so its early detection is fundamental. Staging fibrosis is also critical for prognosis and management. The gold standard for these aims is liver biopsy, but it has several drawbacks, as it is invasive, expensive, has poor acceptance, is prone to inter observer variability and sampling errors, has poor repeatability, and has a risk of complications and mortality. Therefore, non-invasive imaging tests have been developed. This review mainly focuses on the role of transient elastography, acoustic radiation force impulse imaging, and magnetic resonance-based methods for the noninvasive diagnosis of cirrhosis.     

Electrical synchronization achieved by multipoint pacing combined with dynamic atrioventricular delay

Cardioneuroablation (CNA) is an endocardial ablation technique aiming to prevent the autonomic imbalance occurring in vasovagal syncope (VVS). A 46-year-old female was referred to our center for pacemaker implantation due to recurrent syncopal episodes despite conventional treatments. A 22-s asystole was detected on head-up tilt testing. After a discussion with the patient and her family, we decided to perform CNA. Positive response was confirmed, and procedural endpoints were defined using pre-procedural atropine response test. Ganglionated plexus (GP) sites were detected and ablated by using fractionated electrogram (FE)-based strategy. During baseline electrophysiological study, AA and PR intervals were calculated as 810 ms and 164 ms, respectively. Based on our ablation order, radiofrequency ablation (RFA) was started from the left inferior and left superior GPs, respectively. A significant vagal response with sinus pauses and atrioventricular (AV) block was detected during RFA. Ablation of the right superior GP caused a significant increase of sinus rate with continuing AV block. After completion of ablation on the right superior and inferior GPs, PR interval was still 164 ms although AA interval decreased to 640 ms. After RFA on the posteromedial left GP which provides mainly vagal innervation of AV node, PR interval and cycle length of sinus node were detected as 134 ms and 540 ms, respectively. Selective parasympathetic innervation principles of the sinus node and AV node were previously demonstrated. We described a case of successful parasympathetic denervation of the sinus node and AV nodes using CNA.

     

Feasibility and efficacy of electrical cardioversion after cardiac resynchronization implantation in patients with permanent atrial fibrillation

Purpose

Patients with permanent atrial fibrillation (AF) who undergo cardiac resynchronization therapy (CRT) may spontaneously recover sinus rhythm during follow-up. We tested the feasibility and efficacy of electrical cardioversion attempted after 3?months of CRT in patients with permanent AF and measured the long-term maintenance of sinus rhythm.

Methods

Twenty-eight consecutive patients with permanent AF in whom CRT defibrillators had been implanted were scheduled for internal electrical cardioversion after 3 months (group A) and were compared with a control group of 27 patients (group B).

Results

In group A, 22 patients (79?%) were eligible for cardioversion; sinus rhythm was restored in 18 (82?%) of these, with no procedural complications. After 12?months, 16 patients (58?%) in group A were in sinus rhythm, compared with one group B patient who spontaneously recovered sinus rhythm (4?%, p?<?0.001). On 12-month evaluation, ejection fraction had improved in both groups, but a reduction in left ventricular end-systolic volume was recorded only in group A patients (p?=?0.018 versus baseline).

Conclusions

In patients with permanent AF, the rhythm control strategy consisting of internal cardioversion, performed by means of the implanted cardioverter?Cdefibrillator after 3?months of CRT, was associated with a high rate of sinus rhythm resumption on long-term follow-up and with a better echocardiographic response to CRT than that seen in patients treated according to a rate control strategy.     

Poor glycaemic control in type 2 diabetes patients reduces endothelial progenitor cell number by influencing SIRT1 signalling via platelet-activating factor receptor activation

Aims/hypothesis

Downregulation of levels of endothelial progenitor cells (EPCs) during in-vitro short-term exposure to high glucose concentrations relates to reduced activity of silent information regulator 1 (SIRT1) and increased synthesis of platelet-activating factor (PAF). We investigated the possible relationship between PAF and SIRT1 pathways in EPCs during altered glucose homeostasis.

Methods

SIRT1 and PAF receptor (PAF-R) levels were determined by western blot, RT-PCR and confocal laser-scanning microscopy. In-vivo experiments were performed on 48 type 2 diabetic patients (25 with poor glycaemic control and 23 with good glycaemic control) and 20 control individuals. In-vitro experiments with the PAF-R antagonist CV3988 were performed on EPCs isolated from leucocyte-rich buffy coat of healthy human donors.

Results

Decreased SIRT1 protein levels were observed in EPCs from type 2 diabetic patients compared with control individuals (p?<?0.01). Notably, the SIRT1 level was consistently lower in patients with poor glycaemic control than in those with good glycaemic control (p?<?0.01). Diabetic patients also showed an upregulation of PAF-Rs; this response occurred to a greater extent in individuals with poor glycaemic control than in those with good glycaemic control. In-vitro experiments confirmed that EPCs respond to PAF stimulation with decreased SIRT1 protein and SIRT1 mRNA levels. Moreover, reduction of SIRT1 levels and activity were abolished by CV3988.

Conclusions/interpretation

These findings unveil a link between PAF and SIRT1 pathways in EPCs that contributes to the deleterious effect of hyperglycaemia on the functional properties of EPCs, crucial in diabetes and peripheral vascular complications.     

Heart rate, PR, and QT intervals in normal children: a 24-hour Holter monitoring study

A dynamic electrocardiographic Holter monitoring study was performed in 32 healthy children (20 males and 12 females, age range 6-11 years old), without heart disease, according to clinical and noninvasive instrumental examination. We evaluated atrioventricular conduction time (PR), heart rate (HR), and QT interval patterns defining the range of normality of these electrocardiographic parameters. The PR interval ranged from 154 +/- 10 ms (mean +/- SD) for HR less than or equal to 60 to 102 +/- 12 ms for HR greater than or equal to 120 (range 85-180). The absolute mean HR was 87 +/- 10 beats/min (range 72-104), the minimum observed HR being 61 +/- 10 (range 51-79), the maximum 160 +/- 20 beats/min (range 129-186). Daytime mean HR gave a mean value of 93 +/- 10 (range 71-148), while during night hours it was 74 +/- 11 (range 54-98). The minimum QT interval averaged 261 +/- 10 ms for HR greater than 120 and the maximum 389 +/- 9 ms for HR less than or equal to 60; the corresponding mean value of QTc (i.e., QT corrected for HR) ranged from 388 +/- 8 for HR less than or equal to 60 beats/min to 403 +/- 14 ms for HR greater than 120 beats/min. The results of the present study provide data of normal children which can be readily compared against those of subjects in whom cardiac abnormalities are suspect or patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Paraganglioma of the cauda equina region. Clinicopathologic study of 31 cases with special reference to immunocytology and ultrastructure

Thirty-one paragangliomas of the cauda equina region were studied (18 men and 13 women, ages 30-71 years [mean, 51 years]). Symptoms (1 day to 15 years in duration; mean, 48 months) included low back pain (87%), sensory/motor deficits (35%), urinary/fecal incontinence (13%), and paraplegia (6%). All patients studied had some myelographic block. Cerebrospinal fluid protein level ranged from 56 to 7000 mg/dl (mean, 1109 mg/dl). Most tumors were limited to the filum terminale, although one also involved the conus medullaris and two clearly arose from a caudal nerve root. All but one were entirely intradural. The tumor was totally excised in 26 cases; these patients remain disease-free. Of three patients whose tumors were excised subtotally, two received radiotherapy; the one non-radiated patient died of tumor-related complications. No autopsy was performed. One partially encapsulated tumor that had been subjected to biopsy and irradiation presented 1 year later with osseous invasion and retroperitoneal extension; 20 years after subtotal excision, this patient is alive but paraplegic. Morphologically, all tumors resembled paraganglioma at other sites. Cytologic atypia and mitotic activity generally were absent to mild. Fourteen (45%) cases showed ganglionic differentiation. All tumors tested were immunoreactive for neuron-specific enolase and neurofilament protein, and most showed somatostatin or serotonin reactivity. S-100 protein immunoreactivity was noted in sustentacular cells and, to a lesser extent, within chief cells and neurons. The authors conclude that paragangliomas are largely benign and encapsulated and respond to simple resection. When surgically feasible, gross total removal should be the goal of surgery. When subtotal resection is necessary or when local invasion leaves a question as to completeness of tumor removal, irradiation seems mandatory although far from guaranteeing prevention of recurrence. Biopsy alone is undesirable.     

Radiofrequency ablation of locally advanced pancreatic adenocarcinoma: An overview

Radiofrequency ablation(RFA)of pancreatic neoplasms is restricted to locally advanced,non-resectable but nonmetastatic tumors.RFA of pancreatic tumors is nowadays an ultrasound-guided procedure performed during laparotomy in open surgery.Intraoperative ultrasound covers the mandatory role of staging,evaluation of feasibility,guidance and monitoring of the procedure.Different types of needle can be used.The first aim in the evaluation of RFA as a treatment for locally advanced pancreatic ductal adenocarcinom...     

Clinical trial: the effects of a probiotic mixture on non‐steroidal anti‐inflammatory drug enteropathy – a randomized,double‐blind,cross‐over,placebo‐controlled study

Aliment Pharmacol Ther 2010; 32: 209–214

Summary

Background Non‐steroidal anti‐inflammatory drugs (NSAIDs) can cause serious gastrointestinal side effects. Faecal calprotectin assay represents a simple and practical method for diagnosis of NSAID enteropathy. Intestinal micro‐organisms are necessary for the development of NSAID‐induced small bowel lesions and hence it has been suggested that probiotics could protect against NSAID enteropathy. Aim To evaluate the effect of a probiotic mixture in comparison with placebo on faecal calprotectin concentrations (FCCs) in healthy volunteers receiving indomethacin. Methods In a double‐blind, cross‐over trial, 20 healthy volunteers ingested a daily dose of probiotic mixture (VSL#3) or placebo for 21 days. From day 16 to day 19, all subjects were also administered 50 mg/day of indomethacin. FCCs were measured the day before starting probiotic/placebo ingestion (T0), and every day from day 15 to day 21. Results During dosing with probiotic, median FCCs were significantly increased only at day 17 with respect to T0 values, whereas during dosing with placebo, they were significantly increased at every day from day 17 to day 21 with respect to T0 values. Conclusions Treatment with VSL#3 before and during indomethacin therapy significantly reduces FCCs in healthy subjects with respect to placebo, suggesting that this approach could be useful in decreasing indomethacin‐induced intestinal inflammation.