[Clinical Results After Implantation of a New Diffractive, Multifokal Intraocular Lens with a Reduced Near Add Power (+ 2.75 D)]. / Klinische Ergebnisse nach Implantation einer neuen diffraktiven multifokalen Intraokularlinse mit einer reduzierten Nahaddition (+ 2,75 dpt).

PURPOSE: Evaluation of the clinical data 3 months after implantation of a new diffractive multifocal intraocular lens (MIOL) with a reduced near add power of + 2.75 D. METHODS: In a prospective study, patients who underwent cataract surgery or refractive lens exchange with implantation of an MIOL (Tecnis ZKB00, Abbott Medical Optics, Santa Ana, California, USA) were included. Three months postoperative corrected and uncorrected visual acuities at different distances were measured and evaluated. Those patients that underwent bilateral MIOL implantation additionally filled out a questionnaire 3 months postoperatively. RESULTS: Between October 2013 and August 2014, 115 eyes of 62 patients were implanted with the ZKB00 IOL. Mean postoperative refractions were - 0.27 ± 0.44 D for the spherical equivalent, respectively. Mean binocular CDVA was - 0.01 ± 0.3 logMAR with a mean binocular UDVA of 0.06 ± 0.08 logMAR. For near distance in 40 cm, an UNVA of 0.07 ± 0.10 logMAR three months postoperatively was measured. CONCLUSION: The ZKB00 IOL belongs to a group of novel MIOL with an increased intermediate visual performance. Our study shows good visual acuity at all distances, as well as a high rate of satisfaction and subjectively good image quality.

Nutrition and fertility.

The first studies about fertility and nutrition date back to the 70ies and already showed a strict relation among female fertility, weight and body composition. However, the mechanisms of this connection started to be explained only after leptin's discovery. According to some authors' opinion, leptin could interact with reproductive axis at multiple sites with stimulatory effects at the hypothalamus and pituitary and stimulatory or inhibitory actions at the gonads. Leptin could play a role in other physiologic processes such as menstruation and pregnancy, and could initiate the complex process of puberty. It has been showed that conditions in which nutritional status is suboptimal, such as eating disorders, exercise induced amenhorrea, functional hypothalamic amenhorrea and polycystic ovarian syndrome, are associated with abnormal leptin levels. These conditions, are characterized by severe changes in body composition and dietary habits. Since leptin is regulated by body composition and dietary factors, (such as energy intake and macronutrient composition), a strict connection between nutritional intake and fertility regulated by leptin is confirmed. This review focuses on the current knowledge about nutritional factors that influence leptin levels. Since clinical and subclinical nutritional imbalance can determine the development and the maintenance of neuroendocrine and metabolic aberrations, studies on fertility need a deeper attention about dietary habits and nutritional status.

[Role of echocardiography in the different stages of natural history of heart failure]. / Il ruolo dell'ecocardiogramma nelle diverse fasi della storia naturale dello scompenso cardiaco.

The prognostic value of echocardiographic findings in patients with heart failure is well known. In contrast, few studies have addressed the changing significance of echocardiographic findings during the natural history of heart failure. Ejection fraction is useful for stratifying the cardiac risk in the early phase of the disease, but a further risk stratification among patients with ejection fraction < 30%, < 25%, or < 20% has not been observed. On the other hand, the identification of a "restrictive" left ventricular filling pattern allows to select patients with poor prognosis among those with advanced heart failure. In patients with mild to moderate heart failure, the prognostic risk should be assessed by ejection fraction and left ventricular filling pattern integrated with other echocardiographic findings such as pulmonary venous flow pattern, right ventricular function, and transmitral flow pattern changes after exercise. In conclusion, the prognostic significance of echocardiographic findings varies during the natural history of heart failure, and therefore may differ in the way it influences the management and therapeutic approach.

[Neurologic events after heart surgery: the need for a more thorough preoperative assessment]. / Eventi neurologici post-cardiochirurgia: la necessità di una valutazione pre-operatoria più approfondita.

The occurrence of neurologic complications after cardiac surgery varies widely and has increased during the last years for several reasons: older age of patients, higher prevalence aortic valve replacement, and more careful diagnosis of cerebral ischemia. Recent studies showed that embolic mechanism is involved in most patients, and two main clinical outcomes are detectable: type I outcome, consisting of TIA and ischemic stroke, and type II outcome, consisting of cognitive defects and seizures. The overall prevalence of neurologic complications after cardiac surgery is nearly 16% and suggests the need of systematic preoperative evaluation of patients for identifying those with high risk and the individualization of the surgical strategy. The preoperative work-up should include two-dimensional echocardiography, transesophageal echocardiography (for detecting patients with ascending aortic lesion who need alternative surgical strategies, i.e. different site of cross clamping, cannulation, and proximal anastomosis of the venous graft), Doppler ultrasound of carotid arteries (for identifying those candidates to combined surgery), and psychobehavioural evaluation (for selecting patients with cognitive deterioration who could be treat by off-pump surgery). In conclusion, a preoperative stratification of the neurologic risk, and a more careful postoperative monitoring should be mandatory for preventing and adequately treating neurologic complications of cardiac surgery.

[Interactions between physical training and pharmacologic treatment in the prevention of ventricular remodelling in patients with left ventricular dysfunction]. / Interazione tra training fisico e terapia farmacologica nella prevenzione del rimodellamento ventriculare nel paziente con disfunzione ventricolare sinistra.

Exercise training is a recommended treatment for chronic heart failure. So far, randomized clinical trials showed that exercise training can improve peak oxygen consumption and reduce neurohormonal and adrenergic activation, nevertheless, the effect on left ventricular remodeling is still controversial. The present study reviewed the randomized clinical trials that investigated the effects of exercise training on left ventricular remodeling. After a first study that showed a worsening of left ventricular function, the following studies showed a neutral effect, and finally, the ELVD-CHF study showed both a reduction in left ventricular dilation and an improvement of ejection fraction. These different results could be explained by the pharmacological treatment before exercise training: in the first study patients did not assume ACE-inhibitors, in the following studies most patients assumed ACE-inhibitors and, finally, in ELVD-CHF, patients assumed ACE-inhibitors and about one fifth of them were on beta-blockers too. In conclusion, exercise training may improve peak oxygen consumption and reduce neurohormonal and adrenergic activation in patients with chronic heart failure. Further studies are necessary to assess if exercise training, associated with ACE-inhibitors and beta-blockers, can reverse or prevent left ventricular remodeling.

An aortocaval fistula diagnosed with 1.5-T magnetic resonance angiography.

We report a case of aortocaval fistula demonstrated with gadolinium-enhanced magnetic resonance (MR) angiography. Specific radiographic features of this rare complication, such as early and intense enhancement of the inferior vena cava, are underlined with MR imaging. The exact location of the fistula can also be assessed with this noninvasive imaging technique. Moreover, the absence of iodinated contrast media makes it particularly suited for stable patients with renal insufficiency. A complete preoperative assessment of abdominal aortic aneurysm can be performed with MR imaging.

Cardiologic complications of subarachnoid hemorrhage.

Cardiac complications are frequent in patients with subarachnoid hemorrhage (SAH). They include ECG abnormalities, cardiac arrhythmias, myocardial damage, and neurogenic pulmonary edema. The pathophysiology of these abnormalities is related to an imbalance of the autonomic cardiovascular control and to increased circulating and local myocardial tissue catecholamines. Cardiac involvement is more common in patients with severe neurological deficits and it may increase the morbidity associated with SAH because of the occurrence of life-threatening arrhythmias or pulmonary edema. Monitoring of cardiac events in patients with SAH might result in a better understanding of their clinical outcome, as well as providing a basis for specific treatment capable of preventing myocardial necrosis and cardiac arrhythmias.

[Intra-arterial antiblastic treatment of breast carcinoma]. / Terapia antiblastica per via intrarteriosa del carcinoma della mammella.

PURPOSE: To report our personal experience with the locoregional treatment of breast cancer. MATERIAL AND METHODS: Eighteen patients aged 33-67 years (mean: 54 years) were treated with 31 sessions of intra-arterial antiblastic infusion, 5 of them for neoadjuvant purposes (Group 1), 5 for palliation in unresectable tumors (Group 2) and 8 for cutaneous recurrences after mastectomy (Group 3). RESULTS: 2/5 CR and 3/5 PR were obtained in Group 1; 2/5 lesions were made resectable and 3/5 RP obtained in stage III or unresectable lesions (Group 2). Finally, 3/8 CR, 3/8 PR, 1/8 SD and 1/8 PD were observed in Group 3. An objective response according to WHO criteria was demonstrated in 15/18 cases (88%). We had no post-treatment hematologic complications, but one patient presented focal subcutaneous sclerosis and one cutaneous necrosis. CONCLUSIONS: The morphological efficacy of intraarterial antiblastic infusion in our series was similar to that of other series. No definitive conclusions can be drawn yet about clinical results and long-term survival. This poorly invasive and low risk procedure, which should be combined with other treatments, permits to reduce the extent of surgery and to treat skin recurrences.

[Complicated atherosclerosis of the ascending aorta as a cause of recurrent cerebral embolisms in young adulthood]. / Aterosclerosi complicata dell'aorta ascendente come causa di embolie cerebrali recidivanti in età giovanile.

The authors report the case of a young woman (47 yrs old) who underwent cardiac evaluation for recurrent unexplained cerebral transient ischemic attacks. In the search for a source of embolization, a transesophageal echocardiography was performed and this revealed an atherosclerotic complex plaque of the ascending aorta as the sole potential source of cerebral embolism, while the remaining aortic wall was normal. The atheroma showed a calcific portion inserted on the aortic wall and a mobile hypoechogenic portion protruding into the aortic lumen. Furthermore, we found increased levels of cholesterol, fibrinogen and plasmatic homocysteine after methionine loading. Atherosclerotic lesions of the aortic arch are a rare cause of embolism in young patients with stroke, but they can lead to important complications such as thrombosis and embolism, similar to atherosclerotic lesions in elderly patients. The mechanisms that predispose for atherosclerosis of the aorta in young patients are still unknown. It was recently reported that not only hypercholesterolemia but also elevated levels of fibrinogen and homocysteine are independent risk factors for cerebrovascular disease. It is possible that these factors may be important predictors of atherosclerosis of the thoracic aorta in young patients, but more clinical data are still necessary. This case report confirms the importance of performing a TEE study and examining the cholesterol, fibrinogen and homocysteine plasmatic concentrations in all of young patients with unexplained stroke or transient ischemic attacks.

Type and extent of myocardial injury related to brain damage and its significance in heart transplantation: a morphometric study.

BACKGROUND: Focal myocardial necrosis reported in patients who died of brain lesions and in donor hearts soon after insertion has been attributed to catecholamine-related injury induced before operation, or in the perioperative period. Interpretation of the morphofunctional type of myocardial injury observed and its quantification may help understand both its pathophysiology and clinical relevance. METHODS: In 27 patients without heart disease who died of intracranial brain hemorrhage after berry aneurysm rupture, terminal clinical signs were correlated with the presence of absence of myocardial injury. All hearts were systematically examined, and the total histologic area was measured in square millimeters, with both the number of foci and myocardial cells showing necrosis, normalized to 100 mm2. Forty-five cases of fatal head trauma (26 "instantaneous" and 19 "rapid" deaths) in normal subjects and 38 cases of acquired immunodeficiency syndrome with (14 cases) or without (24 cases) severe brain damage were used as control subjects. RESULTS: Contraction band necrosis was the only form of myocardial necrosis found in 89% of patients with acute brain hemorrhage. Its extent was 26 +/- 34 foci and 67 +/- 104 necrotic myocardial cells x 100 mm2. In patients with acquired immunodeficiency syndrome, its frequency was 58% in those without and 78.5% with severe brain lesions, with foci and myocardial cell values of 1 +/- 1.5 and 10 +/- 22 and 7 +/- 16 and 17 +/- 32, respectively. In head trauma cases with instantaneous death, the frequency was 4% (one case only with foci 0.5 and myocardial cells 35), whereas with a rapid death it was 40% (foci 12 +/- 18 and myocardial cells 21 +/- 33). CONCLUSIONS: The observed myocardial injury was present in all groups examined, being maximal in patients with intracranial brain hemorrhage with longer survival and minimal in patients with head trauma who died instantaneously. In this setting, this lesion is typical of catecholamine myotoxicity and may express a sympathetic overstimulation either in the agonal period and independent of therapy or be caused by brain injury, especially intracranial brain hemorrhage. However, the extent of myocardial injury observed was minimal and should not jeopardize cardiac function if hearts from such subjects are transplanted.

[Medical and surgical therapy of familial hypophosphatemic vitamin D resistant rickets with ambulation disorders]. / Trattamento medico e chirurgico del rachitismo ipofosfatemico familiare vitamino-D resistente con disturbi della deambulazione.

Three children with familial hypophosphatemic rickets showed, in the untreated state, active rickets of the metaphyseal areas of long bones. All were treated with combined phosphate /1-2 g daily by mouth in 4-5 divided doses) and vitamin D2 therapy for 2-5 years. The radiological appearance of the metaphyses became practically normal in two, whereas little change took place in the endosteal bone surface. Bone biopsies demonstrated osteomalacia. Therefore, two subjects were given phospate (1-2 g daily) and 1-alpha-hydroxyvitamin D (0.25-0.50 microgram daily) for 2 years; then phosphate (1 g daily) and 1.25 dihydroxyvitamin D (0.25-0.50 microgram daily) combined therapy for 5 years; the third patient had phosphate (1 g daily) and 1.25 dihydroxyvitamin D (0.25 microgram daily) combined therapy for 2 years. After therapy with low doses of 1.25 dihydroxyvitamin D, X-rays showed a nearly normal bone aspect, without nephrocalcinosis in all patients. All subjects were submitted to osteothomies with positive results.

Prophylaxis of thromboembolic events in congestive heart failure.

In patients with heart failure the incidence of thromboembolism is 0.9-5.5%/year (mean 1.9%/year), but no randomized studies are available to support the indication for anticoagulant therapy in those patients. Atrial fibrillation and previous thromboembolic events seem to be the major risk factors, whereas the effect of ventricular dysfunction has not been independently evaluated; nonetheless several studies suggest that thromboembolism is more likely among those patients with lower ejection fraction and lower peak exercise oxygen consumption. Anticoagulant therapy seems to be indicated also in patients with left ventricular aneurysm with mobile and protruding thrombi. Several studies of patients with dilated cardiomyopathy show that the incidence of thromboembolism ranges from 1.6 to 4.5%/year in patients not treated with anticoagulants, while it is virtually absent in anticoagulated patients. The clinical opportunity of long-term anticoagulant treatment in heart failure patients should be weighted not only on the clinical markers of thromboembolic risk, but also on the relative risk/benefit ratio of the single patient.

[Uni- or biventricular circulatory assist devices. Selection criteria and patients' follow-up, choice of device]. / Assistances uni- ou biventriculaires. Critères de sélection et de surveillance des patients, choix du dispositif.

Therapy of patients presenting with cardiogenic shock refractory to medical treatment can be undertaken with uni or biventricular circulatory assist devices. Pre implantation evaluation of patients is aimed at defining the etiology as well as the extent of uni versus biventricular heart failure, the possibility of recovery of myocardial function improvement of vital organ function and the possibility of cardiac transplantation. Circulatory assist devices must provide efficient support of the failing ventricles, allow recovery of myocardial function or cardiac transplantation under optimal circumstances. The choice of uni-biventricular support of total artificial heart is discussed as well as criteria useful in defining a therapeutic strategy.

Consequences of coronary occlusion on changes in regional interstitial myocardial neuropeptide Y and norepinephrine concentrations.

An attempt to determine the consequences of prolonged ischemia on simultaneous regional changes in norepinephrine (NE) and neuropeptide Y (NPY) interstitial myocardial concentrations in a pig model in vivo was made. The aim of the authors was to investigate further the mechanism of the major NE release previously observed in perfused hearts preserved using a Langendorff technique. Regional myocardial ischemia was induced by ligation of the left anterior descending coronary artery (LAD) in ten anesthetized pigs. NE and NPY release was studied using interstitial microdialysis, a technique initially used to monitor neurotransmitter kinetics in brain dialysate samples. Four dialysis probes were implanted into the left ventricular wall of the beating heart. Two were implanted into the ischemic region (LAD) (for NE and NPY determinations, respectively) and the remaining two into the non-ischemic left circumflex coronary artery region (LCX). Dialysate NE and NPY concentrations, as indices of interstitial myocardial NE and NPY concentrations, were measured by HPLC and RLA, respectively. A slight but significant increase in NPY levels was observed in both territories (LAD: from 190 +/- 27 to 349 +/- 62 pmol/l, LCX: 146 +/- 30 to 257 +/- 52 pmol/l) suggesting moderate stimulation of cardiac sympathetic nerve activity following LAD occlusion. On the contrary, a marked but progressive increase in NE release was observed in the ischemic region (from 8.8 +/- 1.0 to 251.4 +/- 44.8 nmol/l), when NE levels in the non-ischemic region remained stable (from 10.3 +/- 2.1 to 11.0 +/- 1.9 nmol/l). These results demonstrate the utility of regional in-vivo myocardial NE and NPY monitoring using microdialysis. The strong and sustained NE accumulation occurring in the ischemic region is consistent with the hypothesis of a local non-exocytotic metabolic NE release in case of prolonged myocardial ischemia, when exocytotic release remain only minimal as attested by the slight increase in NPY observed.

Complicaciones cardiológicas en la hemorragia subaracnoidea / Cardiologic complications of subarachnoid hemorrhage

Las complicaciones cardíacas en los pacientes con hemorragia subaracnoidea son frecuentes. Incluyen anormalidades electrocardiográficas, arritmias, daño miocárdico y edema pulmonar neurogénico. La fisiopatología de estas anormalidades se relaciona con un disbalance del control autonómico cardiovascular y con un aumento en las catecolaminas circulantes y tisulares miocárdicas. El compromiso cardíaco es más común en pacientes con déficits neurológicos severos y puede incrementar la morbilidad asociada con las hemorragias subaracnoideas por la aparición de arritmias mortales o edema pulmonar. El monitoreo de los eventos cardíacos en pacientes con hemorragias subaracnoideas puede permitir una mejor comprensión de su evolución clínica y proveer las bases para un tratamiento específico que permita prevenir la necrosis miocárdica y las arritmias cardíacas

Complicaciones cardiológicas en la hemorragia subaracnoidea / Cardiologic complications of subarachnoid hemorrhage

Las complicaciones cardíacas en los pacientes con hemorragia subaracnoidea son frecuentes. Incluyen anormalidades electrocardiográficas, arritmias, daño miocárdico y edema pulmonar neurogénico. La fisiopatología de estas anormalidades se relaciona con un disbalance del control autonómico cardiovascular y con un aumento en las catecolaminas circulantes y tisulares miocárdicas. El compromiso cardíaco es más común en pacientes con déficits neurológicos severos y puede incrementar la morbilidad asociada con las hemorragias subaracnoideas por la aparición de arritmias mortales o edema pulmonar. El monitoreo de los eventos cardíacos en pacientes con hemorragias subaracnoideas puede permitir una mejor comprensión de su evolución clínica y proveer las bases para un tratamiento específico que permita prevenir la necrosis miocárdica y las arritmias cardíacas (AU)