Contrast echocardiography for pulmonary arteriovenous malformations screening: does any bubble matter?

AIMS: To evaluate diagnostic accuracy of contrast echocardiography (CE) as compared with CT, for the screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia (HHT); to evaluate the clinical significance of semi-quantitative analysis of a shunt on CE. METHODS AND RESULTS: A blinded prospective study was conducted in 190 consecutive subjects at risk of HHT who underwent screening for PAVMs, including clinical evaluation, pulse oximetry, standard and CE, and chest multirow CT without contrast medium. A semi-quantitative analysis of the shunt size was performed according to the contrast echo opacification of the left-sided chambers: Grade 0, no bubbles; 1, occasional filling with <20 bubbles; 2, moderate filling; 3, complete opacification. The first 100 patients were compared with 100 controls. A total of 119 (63%) patients had positive CE (32.2% Grade 1, 13.1% Grade 2, 11% Grade 3, 6.3% with patent foramen ovale). The overall diagnostic performance of CE was sensitivity 1.00, specificity 0.49, positive predictive value (PPV) 0.32, negative predictive value (NPV) 1.00. The PPV for the different grades was 0.00 for Grade 1, 0.56 for Grade 2, 1.00 for Grade 3; the NPV of Grade 0 was 1.00. A significant correlation was found between the CE grading and the number of PAVM, and complications (P < 0.0001). CONCLUSION: CE is an extremely sensitive procedure for the detection of PAVMs with substantial clinical impact.

Doppler ultrasonographic grading of hepatic vascular malformations in hereditary hemorrhagic telangiectasia -- results of extensive screening.

AIMS: In previous studies, the prevalence of hepatic vascular malformations (VMs) in a large Italian family with hereditary hemorrhagic telangiectasia (HHT) was examined by Doppler ultrasonography (US) as screening technique, and the relevant Doppler US findings were described and classified. Thereafter, Doppler US has been routinely used to screen HHT families for liver involvement. Hepatic VMs were evaluated and classified on the basis of Doppler US findings. METHODS: Three hundred and forty-six subjects belonging to 64 pedigrees were checked for the presence of signs of HHT. All of them underwent abdominal Doppler US screening for hepatic VMs. Vascular abnormalities were classified as minimal if the hepatic artery was dilated in extrahepatic tract only and measured > 6 mm; as moderate if the hepatic artery was dilated in both intra and extrahepatic tract; and as severe if complex changes of the arterial hepatic branches were associated with hepatic and/or portal vein dilatation. Furthermore, Doppler parameters, both qualitative (flow direction, turbulence) and quantitative (peak flow velocity and resistivity index in hepatic artery, mean velocity in portal vein, diastolic peak flow velocity in hepatic veins), were entered into our VM classification. RESULTS: HHT was found in 222 subjects, with hepatic VMs detected by Doppler US in 92 (41.4 %) (24 males, 68 females, mean age 52.2). Hepatic VMs were minimal in 11 subjects, moderate in 70, and severe in 11. CONCLUSIONS: On the basis of our proposed grading, hepatic VMs can be easily classified in subjects with HHT by Doppler US. Depending on the degree of hepatic vascular derangement, appropriate programs for follow up and/or therapy can be designed.

Airbag and hearing loss: our experience.

The international literature reports sporadic cases of sudden sensorineural hearing loss associated with Airbag inflation in subjects involved in car accidents, who had never suffered from hearing loss and had no history of pathologies that could otherwise explain the hearing loss. The authors have studied the actual incidence of this possibility, analysing 25 subjects submitted to an airbag inflation. Only subjects who had never suffered from previous otological pathology were considered for the study. The examination was carried out 3 to 10 days after the accident. Otoscopical examination, tympanometry and audiometry were normal in all the examined subjects. The Author's opinion is that traumatic hearing loss following airbag inflation is a rare or exceptional incident that probably occurs in subjects with a particular susceptibility and sensitivity.

[Tuberculous otitis]. / Otite tubercolare.

Recent works show an increase of the incidence of extrapulmonary tuberculosis with a peculiar localization to the middle ear, until now considered a rare clinical manifestation. At the Ear, Noise, Throat Clinic of the University of Ferrara a total of 5 cases of tuberculous otitis media were observed during the last 25 years. Aim of the present study is to describe their clinical manifestations, their symptomatic aspects and the way to reach a careful diagnosis and more rapid therapeutic choice.

[Hypopharyngeal fibrolipoma: description of a case and review of the literature]. / Fibrolipoma de hipofaringe: descripción de un caso y revisión de la literatura.

A rare case of hypopharyngeal fibrolipoma is reported. The main symptom which brought the patient to an ENT examination was a severe inspiratory dyspnea. Symptomatology, diagnosis, treatment and follow-up of this benign tumour are described and the literature review is discussed.

[New therapeutic prospects in acute acoustic trauma]. / Nuove prospettive terapeutiche del trauma acustico acuto.

A total of 50 young soldiers hospitalized for high frequency hearing loss and tinnitus following exposure to gun impulse noise was studied in order to ascertain the effects of two kinds of medical treatment. A first group (18 subjects) was treated for 10 consecutive days with cerebral gangliosides. In a second group (17 subjects) gangliosides were associated with subcutaneous infiltration of bupivacaine chlorhydrate (0.5%). A third group (15 subjects) was taken as control. An improvement in hearing threshold (= greater than 20 dB at 4-8 kHz) and a consistent relief of tinnitus was respectively found in 52% and 66% of the treated subjects, while hearing status and tinnitus persisted unchanged among the control group subjects. The amount of hearing improvement over the control group proved to be statistically significant, although no significant difference was demonstrated between the two kinds of medical treatment. Since therapy was initiated 5 to 21 days after acoustic trauma, these results indicate that a pharmacological treatment may be effective even in cases where diagnosis is forwarded relatively late in respect to the trauma.

The vestibular cortical projection during spinal decompensation.

The removal of spinal afferents in rabbits submitted to unilateral lesion of the labyrinth and fully compensated greatly modified the field potentials as well as the single unit responses recorded from the cortical vestibular area during stimulation of the intact eighth nerve. In particular, an increase of contralateral and a decrease of ipsilateral potentials were observed. These asymmetrical responses indicate that the influence of the spinal cord in compensating the effects of unilateral lesion of the labyrinth is directed to balance not only the electrical activity of the brain-stem structures, but also that of the cerebral cortex. It appears, therefore, that spinal signals intervene not only in the compensation of vestibulospinal and vestibulo-oculomotor functions but also of cortical functions, such as that related to vestibular sensation.