Endoscopic treatment of superficial colorectal neoplasms. Retrospective analysis of a single center technique and results.

Endoscopic Submucosal Dissection (ESD) is a technique developed in Japan for "en bloc" resection of larger superficial neoplasms of the gastrointestinal tract as an alternative to the traditional Endoscopic Mucosal Resection (EMR), with removal of the lesion in multiple fragments ("piecemeal"). ESD offers a lower recurrence rate and allows a more accurate histopathological examination. This procedure is however considered technically difficult and therefore requires an adequate learning curve, it is time consuming with more discomfort for the patient, it has a higher complication rate, it is more expensive. To overcome these disadvantages, in the Western countries a hybrid technique called Circumferential Submucosal Incision - Endoscopic Mucosal Resection (CSI-EMR) has been developed and is especially employed for colonic lesions. This article analyzes retrospectively the results obtained in a single centre by a single operator in the treatment of 23 patients (12 men and 11 women, average age 65,6 years), all suffering from superficial, larger than ≥ 20 mm colorectal neoplasms: 9 were treated with ESD for rectal lesions and 14 were treated with CSI-EMR for colonic lesions. Findings show a technical success rate of 66,6% for ESD and 78,5% for CSI-EM, and a 0% recurrence rate during follow-up, 4,3% bleeding and 13% perforation complications. The histology of the removed lesions showed 13 (56,5%) low grade dysplasia adenomas, 8 (34,7%) high grade dysplasia adenomas, one grade 1 sigmoid colon adenocarcinoma infiltrating the submucosal layer without lymphovascular invasion, with free margins (R0), treated conservatively, and one grade 1 cecum adenocarcinoma, infiltrating the submucosal layer, with lymphovascular invasion and involved excision margin, treated surgically with no residual neoplastic disease in the surgical specimen. These data are in line with the most significant ones in literature, except for the higher complication rate, which the authors ascribe to the "learning curve" and the smaller number of treated patients.

Assessment of eating behaviour in young women requesting nutritional counselling and their mothers.

OBJECTIVE: The aim of this study was to explore the influence of maternal eating behaviour on a clinical population of young women compared with a non-clinical one. METHODS: A group of 59 young women (age 16-30 yr) attending a weight-loss Clinic and their mothers (n=59; age 37-64 yr) were enrolled. They were compared with a group of female students (n=59; age 18-36 yr) and their mothers (n=59; age 41-67 yr). Body weight and height were measured and body mass index (BMI) calculated. Eating behaviour was assessed by using the Eating Disorders Inventory (EDI), Eating Inventory (EI) and Eating Attitude Test 26 (EAT-26). RESULTS: The EDI-2 scales significantly different between the groups were drive for thinness, bulimia, body dissatisfaction, inadequacy, enteroceptive awareness and insecurity. The EI scales values were all different between the groups and consistently higher in the clinical populations. The differences between groups were even more striking for the EAT-26 scales; the clinical young women had the highest scores. The daughter-mother correlation for each scale in the clinical and non-clinical groups showed that the EDI-2 scales assessing eating behaviour, drive for thinness, bulimia and body dissatisfaction, were significantly related in the non clinical group but not in the clinical group. On the other side, the clinical group showed correlation for the scales assessing psychopathological traits such as perfectionism, interpersonal disrupt, enteroceptive awareness, impulsivity and insecurity. For EI scales the correlation was significant for disinhibition in the non clinical group. A correspondence was observed for dieting in the non clinical group and for food preoccupation in the clinical group. EDI-2, EI and EAT-26 scales assessing eating behaviour were strongly predictive of BMI in both groups. CONCLUSIONS: Maternal eating behaviour influences the young women; in particular mothers-daughters of the clinical group showed some problems, for which they still had to grow up and stand out. Finally, the control population revealed some eating disorders as well.

Why do normal weight young women look for diet-therapy? Findings from a pilot study in a clinical and non-clinical population.

The behavioural factors that drive a normal weight woman to embark on a diet and to look for nutritional support in weight loss clinics are still not completely understood. A pilot cross-sectional study was carried out in 70 young (age range: 18-35 yr), normal weight women attending a weight loss clinic in South of Italy (Naples). They were compared to a population of 94 normal weight students (age range:17-23 yr) who had never attended a weight loss clinic. Subjects with eating disorders have been excluded. Weight and height were measured and body mass index (BMI) was calculated. Eating behaviour was assessed using a validated Italian version of the Eating Disorders Inventory (EDI) questionnaire. The two groups were matched for BMI (22.4 vs 22.1 kg/m2), smoking and physical activity. Students were more educated and less likely to be on a diet at the time of the study. Students had statistically significant lower scores for drive for thinness, body dissatisfaction, inadequacy and interpersonal disrupt. The bulimia scale was the only significant predictor (p<0.05) of BMI in the patients' group; body dissatisfaction (p<0.05) predicted BMI in the control group. This study has shown that weight concern and health awareness are not the only factors that lead a normal weight woman to look for nutritional counselling but there is an underlying substrate of psychological and social distress behind the request, which should be properly assessed before starting any nutritional therapy in the clinical practice.

Application of the SCOFF, Eating Attitude Test 26 (EAT 26) and Eating Inventory (TFEQ) Questionnaires in young women seeking diet-therapy.

BACKGROUND: Eating disorders (EDs) affect an increasing proportion of young women in western countries. Psychometric questionnaires represent valuable tools to investigate various and critical areas directly involved in the pathogenesis of EDS and to support diagnosis and therapeutic decisions. METHODS: 162 young women (16-35 years old) seeking diet therapy were recruited. We classified subjects in normal eating behaviour (NEB) (n = 87), binge eating disorder (BED) (n = 12) and bulimic EDNOS (Eating Disorders not Otherwise Specified) (n = 63). The SCOFF, Eating Attitudes Test (EAT 26) and Three Factor Eating Questionnaire (TFEQ) were administered. Body mass index (BMI) was utilised to assess the nutritional status. An analysis of the reliability and validity (sensitivity and specificity) of the SCOFF, EAT 26 and TFEQ was performed. RESULTS: Body mass index (BMI) of NEB, BED and bulimic EDNOS was 27.7, 35 and 31.1, respectively. BED showed the highest values at the dishinibition, hunger and food preoccupation scales but conversely, they were the least restrained group. The SCOFF was significantly associated with the dishinibition (r = 0.31), hunger (0.31), dieting (r = 0.34) and food preoccupation scales (r = 0.34). The reliability analysis showed that the SCOFF, EAT 26 and TFEQ had a Cronbach alpha of 0.47, 0.85 and 0.75, respectively. The ROC curves identified cut off points of 3, 10 and 25 as the best compromise between specificity and sensitivity for the SCOFF, EAT 26 and TFEQ, respectively. CONCLUSIONS: The SCOFF is a valuable tool for the screening of abnormal eating behaviours but the diagnosis should be always confirmed and supported by the administration of other questionnaires and structured interviews. We have also confirmed the high reliability of the EAT 26 and TFEQ even though the utilisation of these questionnaires has generated some issues about their application in populations characterised by loss of control and overeating episodes.

Integrated medical-psychiatric treatment of the "crisis phase" in severe protein-energy malnutrition secondary to major eating disorders.

C.A., a 23-year old male was admitted in the clinical nutrition medical ward for severe, complicated protein-energy malnutrition (PEM) [body mass index (BMI) 11.08 kg/m2; body weight kg 35.81 due to major eating disorders. C.A.'s personality was narcissistic, with a rigid psychic structure. During hospitalitation (lasted 72 days) two acute episodes (a possibly self-inflicted damage and a persecution feeling) occurred that we consider as part of the "crisis phase", the period in which the patient's restrictive behaviour is no longer able to keep his personality equilibrium stable. The patient was treated by an integrated medical and psychiatric approach, including periods of never forced parenteral nutrition, nutritional and intensive psychoterapeutic interventions. For a short period the patient received also a pharmacological support (aloperidol orally). Treatment was successful and the patient was discharged completely autonomous and followed up on an outpatient basis. After about one year follow-up he is still in good clinical condition and in sufficient psychological equilibrium.

Body composition, eating behavior, food-body concerns and eating disorders in adolescent girls.

AIMS: Dieting is a behavioral phenomenon which is becoming more frequent among adolescents and the search for weight loss, through dieting, may result in an unbalanced nutrition both quantitatively and qualitatively. Our study intended to look at the eating habits and behavior on a cohort of adolescent girls to verify the presence of unbalanced diets and the prevalence of eating disorders with particular attention to the partial syndromes (EDNOS). METHODS: A cross-sectional double-stage study was carried out on a group of schoolgirls in the suburbs of Naples. We assessed anthropometrical measures, body composition (skinfolds and bioimpedance analysis), dietary intake by means of 3-day food records and we administered the Eating Disorder Inventory 2 and Psychosocial Factor Risk Questionnaire. A multidisciplinary and double-stage approach had been used to get a better diagnosis of eating disorders in our sample. RESULTS: 156 adolescent girls, 14-18 years old, took part in our study. Height, weight, and BMI were 160.38 cm, 58 kg and 22.6, respectively. Analysis of food intake showed that all the values reported, with the exception of lipids and sodium, were below the recommendations by LARN. We observed a prevalence of 1.28% of bulimia nervosa, 1.28% of binge eating, and 10.25% of eating disorders not otherwise specified. EDI 2 and PRFQ confirmed how important drive for thinness and body dissatisfaction dimensions are when we deal with adolescent girls and with the phenomenon of dieting. The study confirmed the validity of the PRFQ questionnaire to evaluate mass media influence on body perception and eating behavior of adolescents. CONCLUSION: Multidisciplinary and well-designed studies are needed to systematically and accurately study eating habits and behavior of adolescents to tackle more efficiently the increasing spread of eating disorders and obesity.

Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach.

OBJECTIVES: Factors predicting clinical outcome in the short-term treatment of anorexia nervosa. DESIGN: Longitudinal follow-up study. SETTING: Department of Clinical and Experimental Medicine, "Federico II" University of Naples. PARTICIPANTS: Fifty-eight young anorectic women consecutively attending the outpatient Unit between January 1997 and December 2000. MAIN OUTCOME MEASURES: Body weight changes over six months' follow-up. RESULTS: Body weight changes in the short term was exclusively predicted by the prevalent underlying psychiatric disorder, being increased in the patients with prevalently depressive traits, decreased in those with psychotic features and unchanged in those with a prevalently narcissistic personality. CONCLUSIONS: The prevalent psychiatric disorder seems to predict clinical outcome in the short term. Body weight gain per se cannot always be the main target of medical intervention, at least in the early phase of the treatment of malnutrition secondary to major eating disorders.

Interdisciplinary treatment of a female outpatient population. Organizational model and preliminary results.

OBJECTIVE: To compare the efficacy of diet alone vs interdisciplinary therapy. METHOD: 256 women were divided into an interdisciplinary therapy group composed of 102 subjects and a control group composed of 154 subjects treated by means of diet alone. RESULTS: 21.56% of the interdisciplinary group did not come for the 2 check-ups compared with 49.35% of the diet group (p < 0.001). A weight loss of 5.88 kg and 4.18 kg for the interdisciplinary and the diet group was recorded 8 weeks after the start of the programme (second check-up). DISCUSSION: Interdisciplinary therapy is necessary to personalize treatment and satisfy the patient's desire and need for appropriate and effective management.

Healing of acute myocarditis with left ventricular assist device: morphological recovery and evolution to the aspecific features of dilated cardiomyopathy.

Dilated cardiomyopathy may result from an acute myocarditis. Little is reported in vivo documenting the progression from the acute inflammatory disease to the healing phase. We describe the consecutive light and electron microscopy studies performed on five myocardial sample series in a 47-year-old female patient who was referred to our hospital with acute myocarditis. She was sustained with left ventricular assist device (LVAD) for 63 days, and then she died of cerebral hemorrhage. The first three consecutive endomyocardial biopsies (days 2, 4, 36 from onset) documented the acute and early healing phase of the inflammatory disease. In the last two biopsies (days 50 and 64 from onset) active inflammation and myocyte necrosis were absent. The histopathological features were those commonly observed in most patients diagnosed with dilated cardiomyopathy, namely myocyte hypertrophy, nuclear size and shape irregularities, and interstitial fibrosis. Overall, the myocyte morphology significantly improved and LVAD support likely contributed to the structural recovery. The major conclusions to be drawn from this case are: 1) the aspecific pathologic findings of dilated cardiomyopathy patients may result from an acute myocardial inflammation; 2) immediate endomyocardial biopsy in patients with clinically diagnosed myocarditis minimizes the risk of missing the diagnosis of inflammatory disease; to this aim a precise definition of "early onset" is especially needed; 3) LVAD support may contribute to the morphological recovery of severely damaged myocytes.

Enteroviral infection causing fatal myocarditis and subclinical myopathy.

UNLABELLED: Enteroviral RNA detection in myocarditis and dilated cardiomyopathy is rare. Enteroviral particles and RNA have recently been identified in patient's skeletal muscle, suggesting that skeletal more than heart muscle hosts the virus in chronic infection. Enteroviral RNA and virus-like particles were found in the myocardium and in the skeletal muscle of two patients with fatal myocarditis: a 39 year old man who died five days after the onset of febrile flu; and a 49 year old woman, assisted for 50 days with a left ventricular assist device, who then died from cerebral haemorrhage. Automated sequencing, alignment, and sequence comparison confirmed the enteroviral origin of polymerase chain reaction products and excluded contamination. These findings agree with prior observations of enteroviral localisation in the skeletal muscle of patients with dilated cardiomyopathy, and further support the hypothesis that skeletal rather than heart muscle may host the virus and serve as a reservoir in cardiomyopathies related to chronic infection. KEYWORDS: enterovirus; myocarditis; viral particles; skeletal muscle

The Eating Disorder Inventory in evaluation of impaired eating behaviour in subjects requesting nutritional consultation.

The present study evaluated impaired eating behaviour in women seeking participation in a diet-based programme of weight reduction or achievement of ideal body weight. Forty-seven obese, 42 overweight and 14 normal-weight subjects, attending an Italian university outpatient clinic completed the Eating Disorder Inventory (EDI). Forty-eight mothers of primary school children (25 normal-weight and 23 overweight) were used as controls. The EDI consists of 8 subscales, 3 evaluating psychopathology related to eating disorders (drive for thinness, bulimia, body dissatisfaction) and 5 evaluating general psychopathology (intereoceptive awareness, ineffectiveness, maturity fears, perfectionism, interpersonal distrust). Significantly altered scores in the first three subscales were observed both in normal-weight and overweight outpatients compared to the controls. The overweight outpatients scored higher than the obese patients in terms of drive for thinness and bulimia and higher than the normal-weight women for terms of bulimia, body dissatisfaction and drive for thinness. The overweight controls scored significantly higher than the normal-weight controls in the first three subscales in the remaining subscales, mean values were also higher in the overweight group, though significance was only reached in the interpersonal distrust and interoceptive awareness subscales. Impaired eating behaviour is frequent in subjects seeking participation in weight reduction or ideal body weight achievement programmes.

Mitochondrial DNA mutations and mitochondrial abnormalities in dilated cardiomyopathy.

Mitochondrial (mt)DNA defects, both deletions and tRNA point mutations, have been associated with cardiomyopathies. The aim of the study was to determine the prevalence of pathological mtDNA mutations and to assess associated defects of mitochondrial enzyme activity in dilated cardiomyopathy (DCM) patients with ultrastructural abnormalities of cardiac mitochondria. In a large cohort of 601 DCM patients we performed conventional light and electron microscopy on endomyocardial biopsy samples. Cases with giant organelles, angulated, tubular, and concentric cristae, and crystalloid or osmiophilic inclusion bodies were selected for mtDNA analysis. Mutation screening techniques, automated DNA sequencing, restriction enzyme digestion, and densitometric assays were performed to identify mtDNA mutations, assess heteroplasmy, and quantify the amount of mutant in myocardial and blood DNA. Of 601 patients (16 to 63 years; mean, 43.5 +/- 12.7 years), 85 had ultrastructural evidence of giant organelles, with abnormal cristae and inclusion bodies; 19 of 85 (22.35%) had heteroplasmic mtDNA mutations (9 tRNA, 5 rRNA, and 4 missense, one in two patients) that were not found in 111 normal controls and in 32 DCM patients without the above ultrastructural mitochondrial abnormalities. In all cases, the amount of mutant was higher in heart than in blood. In hearts of patients that later underwent transplantation, cytochrome c oxidase (Cox) activity was significantly lower in cases with mutations than in those without or controls (P = 0.0008). NADH dehydrogenase activity was only slightly reduced in cases with mutations (P = 0.0388), whereas succinic dehydrogenase activity did not significantly differ between DCM patients with mtDNA mutations and those without or controls. The present study represents the first attempt to detect a morphological, easily identifiable marker to guide mtDNA mutation screening. Pathological mtDNA mutations are associated with ultrastructurally abnormal mitochondria, and reduced Cox activity in a small subgroup of non-otherwise-defined, idiopathic DCMs, in which mtDNA defects may constitute the basis for, or contribute to, the development of congestive heart failure.

Effect of L-carnitine on myocardial metabolism: results of a balanced, placebo-controlled, double-blind study in patients undergoing open heart surgery.

The effects of L-carnitine on cardiac performance after open heart surgery were evaluated in a balanced, placebo-controlled, double-blind study in 38 patients. Preoperative haemodynamic status was good in all of them. Seventeen subjects underwent mitral valve replacement and 19 patients coronary artery bypass grafting. Five grams L-carnitine were given intravenously over 2 h, twice daily for 5 consecutive days; moreover, 10 g L-carnitine in 1500 ml cardioplegia were administered through the aortic root after aortic cross-clamping. Surgery was always planned on treatment day 3. The post-ischaemic functional recovery of the heart was assessed by clinical parameters, as well as by biochemical and ultrastructure evaluations on biopsy specimens. No differences were found between the control and the treatment group with respect to all clinical parameters of cardiac performance after cardiopulmonary bypass. At anaesthesia induction, serum carnitine was significantly increased in treated patients, but carnitine concentrations in the right atrial biopsy obtained just before aortic declamping were similar in the two groups. In patients with mitral valve replacement, L-carnitine therapy was associated with significantly higher concentrations of pyruvate, ATP and creatine phosphate in papillary muscle. Glycogen levels were also higher in the treated group, but the difference was not statistically significant. Myocardial ultrastructure on septal biopsies, obtained within 5 min from weaning from extracorporeal circulation, showed better preservation scores for all considered parameters (nucleus, sarcoplasmic reticulum, mitochondria and cellular oedema) in the treated subjects, although the difference reached statistical significance only for nuclei. When biochemical and ultrastructural data are considered, these findings suggest that L-carnitine improves myocardial metabolism. However, it cannot be concluded that L-carnitine provides an advantageous support therapy for well-compensated patients requiring cardiac surgery. In contrast, the positive effects of L-carnitine on cardiac recovery after bypass might become clinically relevant in the surgical setting for haemodynamically compromised patients, in which further investigations are required.

Restrictive cardiomyopathy, atrioventricular block and mild to subclinical myopathy in patients with desmin-immunoreactive material deposits.

OBJECTIVES: We present clinical data and heart and skeletal muscle biopsy findings from a series of patients with ultrastructural accumulations of granulofilamentous material identified as desmin. BACKGROUND: Desmin cardiomyopathy is a poorly understood disease characterized by abnormal desmin deposits in cardiac and skeletal muscle. METHODS: Clinical evaluation, endomyocardial and skeletal muscle biopsy, light and electron microscopy and immunohistochemistry were used to establish the presence of desmin cardiomyopathy. RESULTS: Six hundred thirty-one patients with primary cardiomyopathy underwent endomyocardial biopsy (EMB). Ultrastructural accumulations of granulofilamentous material were found in 5 of 12 biopsy samples from patients with idiopathic restrictive cardiomyopathy and demonstrated specific immunoreactivity with anti-desmin antibodies by immunoelectron microscopy. Immunohistochemical findings on light microscopy were nonspecific because of a diffuse intracellular distribution of desmin. All five patients had atrioventricular (AV) block and mild or subclinical myopathy. Granulofilamentous material was present in skeletal muscle biopsy samples in all five patients, and unlike the heart biopsy samples, light microscopic immunohistochemical analysis demonstrated characteristic subsarcolemmal desmin deposits. Two patients were first-degree relatives (mother and son); another son with first-degree AV block but without myopathy or cardiomyopathy demonstrated similar light and ultrastructural findings in skeletal muscle. Electrophoretic studies demonstrated two isoforms of desmin--one of normal and another of lower molecular weight--in cardiac and skeletal muscle of the familial cases. CONCLUSIONS: Desmin cardiomyopathy must be considered in the differential diagnosis of restrictive cardiomyopathy, especially in patients with AV block and myopathy. Diagnosis depends on ultrastructural examination of EMB samples or light microscopic immunohistochemical studies of skeletal muscle biopsy samples. Familial desminopathy may manifest as subclinical disease and may be associated with abnormal isoforms of desmin.

Gastric spiral bacteria in wild rats from Italy.

Forty-three wild rats (Rattus norvegicus) trapped in Milan (Italy) were examined for gastric spiral bacteria and to evaluate associated histological lesions. Spiral bacteria were histologically detected in the stomach of 10 rats (23%). The morphological features of these microorganisms, observed using both light and electron microscopy, correspond to those of Helicobacter heilmannii. Mild gastritis characterized by focal lymphoplasmacytic infiltration of the lamina propria was observed in six rats with gastric spiral bacteria. Our findings suggest a causal role of these bacteria in inducing a gastric inflammatory response.

Coexistence of mitochondrial DNA and beta myosin heavy chain mutations in hypertrophic cardiomyopathy with late congestive heart failure.

OBJECTIVE: To investigate the possible coexistence of mitochondrial DNA (mtDNA) mutations in patients with beta myosin heavy chain (beta MHC) linked hypertrophic cardiomyopathy (HCM) who develop congestive heart failure. DESIGN: Molecular analysis of beta MHC and mtDNA gene defects in patients with HCM. SETTING: Cardiovascular molecular diagnostic and heart transplantation reference centre in north Italy. PATIENTS: Four patients with HCM who underwent heart transplantation for end stage heart failure, and after pedigree analysis of 60 relatives, eight additional affected patients and 27 unaffected relatives. A total of 111 unrelated healthy adult volunteers served as controls. Disease controls included an additional 27 patients with HCM and 102 with dilated cardiomyopathy. INTERVENTION: Molecular analysis of DNA from myocardial and skeletal muscle tissue and from peripheral blood specimens. MAIN OUTCOME MEASURES: Screening for mutations in beta MHC (exons 3-23) and mtDNA tRNA (n = 22) genes with denaturing gradient gel electrophoresis or single strand conformational polymorphism followed by automated DNA sequencing. RESULTS: One proband (kindred A) (plus seven affected relatives) had arginine 249 glutamine (Arg249Gln) beta MHC and heteroplasmic mtDNA tRNAIle A4300G mutations. Another unrelated patient (kindred B) with sporadic HCM had identical mutations. The remaining two patients (kindred C), a mother and son, had a novel beta MHC mutation (lysine 450 glutamic acid) (Lys450Glu) and a heteroplasmic missense (T9957C, phenylalanine (Phe)-->leucine (Leu)) mtDNA mutation in subunit III of the cytochrome C oxidase gene. The amount of mutant mtDNA was higher in the myocardium than in skeletal muscle or peripheral blood and in affected patients than in asymptomatic relatives. Mutations were absent in the controls. Pathological and biochemical characteristics of patients with mutations Arg249Gln plus A4300G (kindreds A and B) were identical, but different from those of the two patients with Lys450Glu plus T9957C(Phe-->Leu) mutations (kindred C). Cytochrome C oxidase activity and histoenzymatic staining were severely decreased in the two patients in kindreds A and B, but were unaffected in the two in kindred C. CONCLUSIONS: beta MHC gene and mtDNA mutations may coexist in patients with HCM and end stage congestive heart failure. Although beta MHC gene mutations seem to be the true determinants of HCM, both mtDNA mutations in these patients have known prerequisites for pathogenicity. Coexistence of other genetic abnormalities in beta MHC linked HCM, such as mtDNA mutations, may contribute to variable phenotypic expression and explain the heterogeneous behaviour of HCM.

Enteroviral RNA and virus-like particles in the skeletal muscle of patients with idiopathic dilated cardiomyopathy.

The role of chronic viral infection in the etiopathogenesis of idiopathic dilated cardiomyopathy (IDC) has generated considerable research. Enteroviruses were the favorite candidates as etiologic agents of IDC. However, enteroviruses were rarely demonstrated in affected hearts. We investigated whether enteroviral infection persists in the heart and in extracardiac sites, particularly in skeletal muscle, in patients with IDC. Blood and myocardial and skeletal muscle samples were collected at cardiac transplantation from 31 IDC patients, 24 non-IDC heart disease patients, and 3 heart donors. Samples underwent ultrastructural studies and ribonucleic acid (RNA) extraction. RNA was reverse-transcribed, and 2 nested fragments (bps 179 and 126) were amplified in the highly conserved 5' noncoding region of enteroviral genomic RNA. Enteroviral RNA was found in the skeletal muscle of 12 cases, whereas only 4 hearts (2 of which with positive skeletal muscle) were positive. Of the 24 controls, 2 were positive (1 muscle and heart, 1 muscle only). Automated sequencing confirmed the enteroviral nature of the amplified products. Ultrastructural study showed enterovirus-like particles in 4 of the enterovirus-positive muscles, and myopathic changes in all enterovirus-positive cases. Skeletal muscle hosts chronic enteroviral infection in more than one third of patients with sporadic IDC. Two hypotheses may explain this link. Myocardial damage may derive directly from recurrent subclinical heart infections caused by enteroviruses harbored in skeletal muscle. Alternatively, enterovirus-related myopathy may trigger an autoimmune response to antigens shared by muscle and myocardium. Further studies are needed to assess the importance of these, non-mutually exclusive mechanisms in IDC pathogenesis.

Ten-year experience with endomyocardial biopsy in myocarditis presenting with congestive heart failure: frequency, pathologic characteristics, treatment and follow-up.

The present study summarizes our ten-year (1985-1995) experience with endomyocardial biopsy (EMB) in patients with idiopathic congestive heart failure (CHF), with specific reference to frequency of myocarditis, treatment policy, relative benefits, and follow-up. Of the 601 patients who constituted our series, 38 were clinically suspected of having myocarditis on the bases of a very recent onset of congestive heart failure and/or of arrhythmias and/or of conduction disturbances, and of a close-to-recent history of flu-like febrile illness. Corresponding EMBs showed myocarditis in 16 of the 38 cases (42.1%). A further 10 EMBs, from patients with a recent onset of congestive heart failure without prior infection episodes, showed myocarditis. Therefore, biopsy-proven myocarditis occurred in 26 of the 601 patients (4.3%). Of the 26 cases, 21 were lymphocytic, 1 was necrotizing granulomatous, 1 was eosinophilic and occurred in a patient who later developed overt zoonosis, 1 had some giant cells within endocardial inflammatory infiltrates, and 2 were borderline forms. In active myocarditis, inflammatory cells mostly constituted of T-lymphocytes (CD45RO+) with sparse macrophages (CD68+) and a few B cells (CD20+). B-lymphocytes and macrophages, along with activated T-lymphocytes, all expressed MHC class II HLA DR molecules, which were also expressed "de novo" by activated endothelial calls of capillaries and of small intramural vessels. HLA DR revealed itself as a very useful marker for the detection of activated inflammatory and endothelial cells. We also noted an increase in the number of perivascular and interstitial mast cells. Ultrastructural study was helpful for the characterization of myocyte damage and of interactions between inflammatory cells and myocytes. In 4 cases (1 of whom was later revealed as HIV positive, and subsequently died of AIDS), we found microreticulotubular structures in endothelial cells of small vessel and capillaries; in 7 cases, there were myocyte changes similar to those described in polymyositis; in 1 case, we observed subplasmalemmal buddings, but no viral particles; in 6 cases, there was extensive myocyte damage with myofibrillar lysis and focal adipous metaplasia; the remaining 6 cases showed myocyte damage of differing extent and severity; in the borderline forms, such damage coexisted with interstitial fibrosis. One of the 21 lymphocytic myocardites was not treated because during hospital screening the patient proved to be HIV positive; of the remaining 20 active myocardites, 11 were treated with a 6-month tapered steroid and azathioprine protocol (one was treated for 24 months), while 9 were not treated. The corresponding follow-up was: 6 deaths (congestive heart failure), 2 cardiac transplants and 3 survivals (1 with pace-maker) in the treated group, and 3 deaths (2 of congestive heart failure and 1 of sudden death), 1 cardiac transplant and 5 survivals (1 on the waiting list for transplantation) in the non-treated group. One of the 2 patients with borderline myocarditis died of congestive heart failure, and 1 is alive. Of the 22 patients with clinical diagnosis of myocarditis and negative biopsy, 7 died of congestive heart failure (2 on the waiting list for transplantation), 4 underwent cardiac transplantation, and 11 are alive (1 is awaiting transplantation). Of the 20 patients currently alive, 1 was originally in NYHA class III, 15 were in class II and 4 were in class I. Of the 20 overall patients who died, 12 were originally in NYHA class IV, 6 in class III, 2 in class II; of the 8 patients who underwent transplantation, 6 were originally in NYHA class IV and 2 in class III. Our overall experience shows that the frequency of myocarditis diagnosed according to Dallas criteria is high in patients with clinical diagnosis of myocarditis, while it is extremely low in dilated cardiomyopathy patients. This finding suggests that, although non-specific, recent onset of symptoms and prior febrile infe

Pure pancreatic juice from patients with chronic pancreatitis has an impaired antibacterial activity.

CONCLUSION: These data show that pure pancreatic juice of AICP patients has a markedly defective antibacterial activity. This finding might be of potential clinical interest in the understanding of the pathophysiology of the disease. BACKGROUND: The aim of the present study was to test the antibacterial activity of pure pancreatic juice in patients with chronic pancreatitis. METHODS: The study group consisted of ten patients with ethanol-induced chronic pancreatitis (AICP) and seven control patients free of pancreatic disease. All subjects had recently undergone a secretin-pancreozymin pancreatic function test. After an overnight fast, through a side-viewing endoscope, selective pancreatic duct cannulation was performed. After secretin stimulation, pure pancreatic juice was obtained. Three fractions of different molecular weights were separated. Samples were incubated with 1-mL suspension of 10(5) Escherichia coli ATCC 25,922, and log10 of colony-forming units were counted. Experiments were repeated by grading pancreatic juice concentration, pH of the medium, and inoculum size. RESULTS: No significant change of pH of pure pancreatic juice appeared between AICP and controls. Starting from 6-h observation, pure pancreatic juice of AICP patients showed a significant bacterial colonization vs controls (p < 0.01). A direct correlation appeared between bacterial colonization and either pH and dilution of pancreatic juice (p < 0.001). Antibacterial activity was independent of inoculum size, enzymatic activation or inhibition, and heat treatment. The fraction with 1000-10,000 molecular weight was the one endowed with antibacterial activity.