Morphological and morphometric changes in the cervix uteri of the rat at term pregnancy induced by hyaluronidase.

Intracervix injection of hyaluronidase during pregnancy has been proposed to accelerate cervix ripening. We evaluated the morphological and morphometric changes of the uterine cervix of pregnant rats, caused by the action of this enzyme. Ten female rats were equally divided between an experimental group (G II) and a control group (G I). On the 20th day of pregnancy, under light microscopy, a greater thinning of the superficial muciferous epithelium, with lamina propria rich in blood vessels and in eosinophils was found in G II. The histometric count of G II showed a smaller number of collagen fibers (average 248 vs 552 in the control group) and a greater concentration of eosinophils (average 18.20 vs 9.20 in the control group). The Student's t-test showed a significant difference in collagen fibers (p < 0.0001) and in eosinophils (p < 0.0007). The action of this enzyme caused a predominance of flaccid connective tissue, a lower concentration of collagen fibers and an increased concentration of eosinophils, confirming its utilization in cervix ripening.

Heat related mortality in warm and cold regions of Europe: observational study.

OBJECTIVES: To assess heat related mortalities in relation to climate within Europe. DESIGN: Observational population study. SETTING: North Finland, south Finland, Baden-Württemberg, Netherlands, London, north Italy, and Athens. SUBJECTS: People aged 65-74. MAIN OUTCOME MEASURES: Mortalities at temperatures above, below, and within each region's temperature band of minimum mortality. RESULTS: Mortality was lowest at 14.3-17.3 degrees C in north Finland but at 22.7-25.7 degrees C in Athens. Overall the 3 degrees C minimum mortality temperature bands were significantly higher in regions with higher than lower mean summer temperatures (P=0.027). This was not due to regional differences in wind speeds, humidity, or rain. As a result, regions with hot summers did not have significantly higher annual heat related mortality per million population than cold regions at temperatures above these bands. Mean annual heat related mortalities were 304 (95% confidence interval 126 to 482) in North Finland, 445 (59 to 831) in Athens, and 40 (13 to 68) in London. Cold related mortalities were 2457 (1130 to 3786), 2533 (965 to 4101), and 3129 (2319 to 3939) respectively. CONCLUSIONS: Populations in Europe have adjusted successfully to mean summer temperatures ranging from 13.5 degrees C to 24.1 degrees C, and can be expected to adjust to global warming predicted for the next half century with little sustained increase in heat related mortality. Active measures to accelerate adjustment to hot weather could minimise temporary rises in heat related mortality, and measures to maintain protection against cold in winter could permit substantial reductions in overall mortality as temperatures rise.

Winter mortality in relation to climate.

We report further details of the Eurowinter survey of cold related mortalities and protective measures against cold in seven regions of Europe, and review these with other evidence on the relationship of winter mortality to climate. Data for the oldest subject group studied, aged 65-74, showed that in this vulnerable group, high levels of protection against indoor and outdoor cold at given outdoor temperatures were found mainly in countries with cold winters, and were associated with low levels of excess mortality at a given level of outdoor cold. Regions such as London that had poor protection against cold and/or high baseline mortalities had higher levels of winter excess mortality than expected for the coldness of their winters.

Winter mortality in Emilia-Romagna, Italy.

In this epidemiological study we have studied during 1997 in Emilia-Romagna (population about four million) Italy, mortality from ischaemic heart disease, hypertension, cerebrovascular and respiratory disease in 50-89 year-olds. The data were collected from "Ufficio Risorse Informative" and "servizio Meteorologico" of the Emilia-Romagna region. The results show high indices of deaths in the elderly, the highest being those of the 80-89 year-olds, during the winter with a maximum in January. There were some differences between males and females with regard to cold-related mortality of the different diseases. Comparing mortality rates of persons living in the North (Piacenza) and in the South (Rimini) of Emilia-Romagna, a consistent lower mortality was found in the people of Rimini. These results confirm the close relationship between advanced age, cold and excess mortality in Emilia-Romagna. The results suggest that at least two factors may be involved in explaining excess winter mortality: the sympathetic system changes in the elderly and the effects of cold on some haemostatic factors.

Thrombosis of a mitral valve prosthesis resulting from Staphylococcus epidermidis endocarditis.

A 70-year-old man with a Duromedics mitral valve prosthesis had two episodes of infective endocarditis caused by enterococcus (1994 and 1996). Colonoscopy revealed five polyps. Surgical resection was performed and 2 days later the patient had dyspnea and fever. Because of a suspected valve thrombosis, intravenous heparin was given which resulted in hematic effusion in the Douglas' cul-de-sac. Intravenous heparin was withdrawn but the patient continued to have a worsening dyspnea, hyperthermia and hypotension. The patient was transferred to our Institution in cardiogenic shock. Acute thrombosis of the valve was diagnosed by echocardiography, and the patient died before transesophageal Doppler echocardiography was performed. Post mortem examination revealed mitral valve infective thrombosis. In patients with valvular prostheses, endocarditis is an added thromboembolic risk.

[Effects of reperfusion and coronary reocclusion on the variability of heart rate in patients with acute myocardial infarction]. / Influenza della riperfusione e della riocclusione coronarica sulla variabilità della frequenza cardiaca in pazienti con infarto miocardico acuto.

The aim of this study was to analyze the very early (first 24 hours) effect of successful or failed thrombolytic therapy on the autonomic nervous system. Thirty consecutive patients with a first acute myocardial infarction were enrolled in the study, and admitted to the Coronary Care Unit within 6 hours of the onset of symptoms and treated with systemic thrombolytic therapy. All patients underwent 24-hour Holter monitoring in order to analyze ST segment variation. The autonomic nervous system was evaluated by frequency-domain heart rate variability: low frequency/high frequency ratio (LF/HF) was measured at the beginning of Holter monitoring (T1), 15 min after reperfusion or 1 hour from the start of thrombolytic therapy (T2) and after 24 hours (T3). Reperfusion status was assessed by a > or = 50% reduction in ST segment elevation within 90 min of thrombolytic therapy, and early CK-MB peak. Early coronary reocclusion was detected by early reduction in ST segment elevation followed by stable ST segment re-elevation. Twenty patients (66%) showed successful thrombolytic therapy (Group 1), 5 patients (17%) had no evidence of successful thrombolytic therapy (Group 2) and 5 patients (17%) showed an early reocclusion (Group 3). LF/HF ratio values at T1 were similar in the three groups (5.66 +/- 1.7 vs 5.65 +/- 1.2 vs 5.51 +/- 0.9, NS). At T2, LF/HF ratio was significantly higher in Group 1 and 3 than Group 2 patients (9.21 +/- 1.7 and 11.1 +/- 1.2 vs 5.58 +/- 1.4, respectively, p < 0.001). In Group 1 LF/HF ratio was significantly lower at T3 when compared with T1 and T2 (1.9 +/- 1 vs 5.66 +/- 1.7 and 9.21 +/- 1.7, respectively, p < 0.001). Conversely, in Group 3 LF/HF ratio at T3 was similar to values measured at T1 (5.59 +/- 1.7 vs 5.51 +/- 0.9, respectively, NS) and significantly higher than those detected in Group 1. In Group 2, LF/HF ratio resulted substantially unchanged at T3 (5.49 +/- 1.7, NS). In conclusion, 1) successful thrombolytic therapy induces early beneficial effects on the autonomic nervous system function, as shown by increased heart rate variability values, when compared with failed thrombolytic therapy; 2) however, during the early period following coronary reperfusion, a transient but dramatic increase in sympathetic activity is observed. This could trigger coronary flow instability, thus facilitating reocclusion, by activating different pathogenetic mechanisms (increased vascular tone, platelet activation, thrombogenic factor prevalence); 3) early coronary vessel reocclusion precludes favorable effects of reperfusion on sympatho-vagal balance observed after the first 24 hours.

Left ventricular metastasis from uterine leiomyosarcoma.

Cardiac metastases are uncommon but seem to be increasing in incidence, possibly in relation to prolonged survival of cancer patients. Leiomyosarcoma metastatic to the heart is extremely rare. We report the case of a 57-year-old woman previously treated for uterine leiomyosarcoma who presented with dyspnea, electrocardiographic changes mimicking myocardial infarction, and normal enzymes. A left intraventricular mass, suspected as cardiac metastasis, was revealed by echocardiography. The patient died 1 week later. At autopsy the mass proved to be histologically a metastasis of the uterine tumor.

[Silent myocardial infarction in a patient treated with radiation therapy and polychemotherapy for Hodgkin's lymphoma]. / Infarto miocardico silente in paziente trattata con terapia radiante e polichemioterapia per linfoma di Hodgkin.

A 48-year-old woman with no cardiovascular risk factors was admitted to the hospital because of acute dyspnea. At 27-year-old, she developed Hodgkin's disease, that was successfully treated with splenectomy, combined chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone-MOPP regimen) and radiotherapy (4500 rads). At 43-year-old the lymphoma relapsed and she had further chemotherapy with doxorubicin, bleomycin, vinblastina and dacarbazine. After this treatment, she had an episode of pulmonary edema, attributed to doxorubicin acute cardiotoxicity. She responded to digitalis and diuretics and was discharged with an electrocardiogram (ECG) showing left bundle branch block and a normal echocardiogram. The patient enjoyed good health for several years and 4 months before the present admission the ECG and echocardiogram were unchanged. On this admission there were signs of left ventricular failure with acute pulmonary edema, and a new soft apical murmur (3-4 Levine). The patient required endotracheal intubation and high doses of diuretics, digitalis and vasodilators. The cardiac enzymes were negative, the serial ECGs confirmed left bundle branch block, while the echocardiogram showed moderate to severe mitral regurgitation, akinesia of the interventricular septum and inferior wall with dilation of the left ventricle. A previous silent myocardial infarction was suspected. After recovery, she underwent cardiac catheterization confirming akinesia of the interventricular septum and inferior wall with moderate mitral regurgitation, while coronary angiography showed a critical ostial stenosis of the right coronary artery. In view of a dipyridamole-thallium scan negative for myocardial viability, reperfusion was not attempted. With changes in radiotherapeutic techniques, the incidence of radiation-induced heart disease (pericarditis, myocarditis, conduction abnormalities and, rarely, occlusive coronary artery disease) is declining. Nevertheless, after irradiation of the chest and mediastinum a longterm cardiological follow-up is useful in selecting patients at higher risk of radiation-induced coronary artery disease, who will eventually require coronary angiography and reperfusion intervention.

[Italian clinical cardiology research at the international level. Statistical data from the period 1983-1993]. / Osservazioni sulla ricerca clinica cardiologica italiana di livello internazionale. Dati statistici per il periodo 1983-1993.

Recent studies show that, among advanced countries, the rank of cardiological research finds Italy last for number of scientific publications and for gross expenditure on research and development. To assess more thoroughly the characteristics of Italian clinical cardiological research we examined, over the period 1983-1993, all original articles published by five important international cardiology journals (Circulation, American Heart Journal, American Journal of Cardiology, Journal of the American College of Cardiology and European Heart Journal). During the mentioned period the Italian contribution (743 articles over a total of 16375, mean prevalence of 4.5%) has increased from 3% in 1983-1985 to 5.8% in 1991-1993 (p < 0.0001). Taking into account that research often results from the joint-work of different centers, the 743 articles derived from 1056 contributions from just over 120 centers. Of these contributions 57% were from universities, 23% from hospitals, 19% from research institutes, and 1% from private foundations. The cooperation with foreign countries has steadily increased, particularly with the USA (45%) and with the European nations (42%). Within the first three names, the contribution of female Authors has increased from 7% in 1983-1985 to 16% in 1991-1993 (p = 0.0001). The mean prevalence of female Authors as last name was 4% and did not change with time. As to geographic distribution, 57% of the scientific publications comes from the North, 28% from the Centre, and 15% from the South. After adjusting these data for population size, the percentages were respectively 40, 46, and 14%. An index of productivity (the ratio between the number of scientific contributions from universities and research institutes and their funding) was highest in the North. The Italian scientific contribution to international cardiological research is not satisfactory, although it is significantly increasing; yet, this trend might worsen due to the shortage of funding. The collected data outline that in the three main national geographic areas, the distribution of funds and scientific productivity are markedly unbalanced.

[Cardiac arrhythmia associated with malignant neuroleptic syndrome: description of 2 clinical cases]. / Aritmie cardiache associate a sindrome maligna da neurolettici: descrizione di due casi clinici.

Malignant neuroleptic syndrome (alteration of consciousness, muscle rigidity and hyperthermia) is a potentially lethal condition, due also to its life-threatening complications. In particular, hypokinetic and hyperkinetic arrhythmias can be rare and severe early manifestations of this illness, and they deserve a careful approach because of their drug-refractoriness. Arrhythmias associated with the malignant neuroleptic syndrome depend on various mechanisms: neurotransmitter receptor blockades typical of neuroleptic drugs, clustered lipid droplets among the cardiac myofibrils and possible electrolytic disorder due to diaphoresis. The two cases described here presented hypokinetic and hyperkinetic (supraventricular and ventricular) arrhythmias. The arrhythmias, which failed to respond to antiarrhythmic drugs, were temporarily suppressed by DC shock, over-drive pacing and correction of electrolytic imbalance. In case 1, prolonged bromocriptine treatment was required. Complete wash-out of the causative agents resulted in lasting regression of arrhythmias. In conclusion, a correct treatment and a favourable outcome of this syndrome can be achieved only through early diagnosis.

[Aortic dissection similar to giant cell arteritis: diagnostic difficulties and efficacy of steroid therapy]. / Dissezione aortica da verosimile arterite giganto-cellulare: perplessità diagnostiche, efficacia della terapia steroidea.

The authors report a case of an acute aortic dissection in a sixty year old patient who two months previously had an ischemic cerebral vascular accident. On the basis of a remittent fever and of raised acute phase proteins the authors suspected a giant cell arteritis as possible pathogenic cause of the clinical presentation. Ruled out infective and neoplastic disorders, after an unhelpful temporal artery biopsy, steroid treatment was introduced at the recommended dosage. Three months after, while reducing steroid therapy, the acute phase proteins raised again to come back to normal values only after restoring full steroid dosage. This pattern of response to steroid treatment may further support the diagnosis of giant cell arteritis even after an unhelpful temporal artery biopsy.

[Exudative pericarditis with pleural plaques caused by exposure to asbestos, resolved with steroidal treatment]. / Pericardite essudativa associata a placche pleuriche da esposizione all'asbesto, risolta da trattamento steroideo.

We report a case of a 73-year old railwayman with an asymptomatic large pericardial effusion diagnosed by a routine echocardiogram. By clinical and laboratory tests we excluded an immune, infectious, tuberculous and neoplastic origin of the pericardial effusion. A computed tomography scan of the thorax showed left pleural plaques. Pleural and pericardial biopsies showed fibrohyaline plaques and diffuse aspecific, chronic inflammation consistent with asbestos exposure. By using steroid treatment there was no further evidence of pericardial inflammation or pericardial effusion at 8 month follow-up. Steroid drugs are therefore suggested as a first choice treatment in patients with pleuropericardial effusion as well as chronic asbestos exposure.

[Cardiac tamponade and rheumatoid arthritis: medical approach or pericardiectomy?]. / Tamponamento cardiaco e artrite reumatoide: approccio medico o pericardiectomia?

The authors report the case of a sixty-seven-year-old man with seronegative rheumatoid arthritis since 1967. After the treatment was discontinued, a symptomatic pericardial effusion developed during an exacerbation of rheumatoid arthritis. Histological findings suggested a rheumatoid origin. Consecutive pericardiocentesis and a concomitant adequate treatment resolved cardiac tamponade, at least during short-term follow-up. However, a long term observation will be necessary to exclude recurrent effusion or evolutive constrictive pericarditis.

[Late thrombolysis in acute myocardial infarct: short and long term effects on left ventricular function]. / La trombolisi tardiva nell'infarto acuto del miocardio: effetti a breve e lungo termine sulla funzione ventricolare sinistra.

Although the efficacy of intravenous thrombolysis in the treatment of acute myocardial infarction has been widely proved, some uncertainty concerning the "temporal window" of administration still persists. The aim of the present investigation was to study whether the late administration of a thrombolytic agent (6 or more hours after the onset of symptoms of acute myocardial infarction) offers any short or long-term advantages with regards to left ventricular function and clinical outcome. We studied 100 consecutive patients at their first episode of myocardial infarction, admitted to Coronary Unit within 24 hours of the onset of symptoms. Of these patients, 62 were administered rt-PA (44 patients within the 6th hour, and 18 between the 6th and 24th hour after the onset of symptoms) and the 38 remaining patients, who did not receive the thrombolytic agent (due to concerns with respect to possible complications), constituted the control group (18 admitted within 6 hours and 20 between 6 and 24 hours). All patients underwent serial electrocardiograms, and echocardiograms upon admission and at discharge to assess the ejection fraction, the asynergy score and the percentage of ischemic area. Furthermore, the survivors were invited for a follow-up examination one year after their acute initial episode. Seven cases of heart failure occurred, before discharge, among the control patients admitted 6 to 24 hours after onset of symptoms, compared with no cases in the subgroup of patients treated with rt-PA during the same time period (p = 0.0068).(ABSTRACT TRUNCATED AT 250 WORDS)

[Sudeck's atrophy. 3 clinical cases]. / L'atrofia di Sudeck. Su tre casi clinici.

Three patients fulfilling criteria for Sudeck's atrophy (reflex sympathetic dystrophy syndrome--RSDS) are described and etiological, pathogenetic and clinical features of the disease are reviewed. RSDS is associated with a wide variety of precipitating factors, each of whom, often in concomitance with metabolic diseases and psychiatric disturbances, may cause the same clinical syndrome, which continues in a "vicious circle" of feed-back mechanisms, correlated with sympathetic hyperactivity. The symptoms may begin gradually and the disorder progresses in stages lasting from weeks to months. The management has not yet been established. Generally, the earlier the syndrome is recognized, the better the results of treatment will be. Analgesics, salmon calcitonin and physiokinesitherapy are recommended. Psychological support is advisable. In more severe patients sympathetic blockade and surgical sympathectomy may be necessary. The effects of hyperbaric oxygen treatment must still be assessed.

[Long-term therapy with gold salts in rheumatoid arthritis. Review of the literature and personal contribution]. / La terapia a lungo termine con sali d'oro nell'artrite reumatoide. Revisione della letteratura e contributo personale.

The present study concerns the controversial subject of rheumatoid arthritis (RA) therapy and particularly use of orally administered gold salts (auric triethylphosphine-Auranofin). It contains the results of a study conducted on 10 patients affected with RA who were treated with auric triethylphosphine associated with conventional therapy for a period varying from 4 to 8 years. The efficacy of this therapy in these patients was comparable to that observed in a survey of other studies. The authors conclude that there are advantages offered to RA patients utilizing chrysotherapy and particularly Auranofin can be administered for an extended period without the development of collateral effects in other organs or systems.

[Effects of long-term iloprost therapy on Raynaud's phenomenon in progressive systemic sclerosis]. / Effetti della terapia a lungo termine con iloprost sul fenomeno di Raynaud nella sclerosi sistemica progressiva.

One of the most appealing current pathogenetic concepts is that progressive systemic sclerosis (PSS) is a reaction to repeated episodes of endothelial cell injury. Injury of small arteries and capillary endothelium initiates reactions which involve increased permeability of the vessels, platelet adherence, myointimal cell proliferation, luminal narrowing and heightened sensitivity of the vessel wall. Clinical evidence of the vessel damage is Raynaud's phenomenon, involving both skin and viscera. The Authors evaluated the effects of iloprost on Raynaud's phenomenon in patients with PSS. This drug provides prolonged vasodilation, reduces platelet aggregation and promotes endothelial lining function repair. This last pattern is of primary importance because it may stop the vicious circle: endothelial injury-platelet hyperaggregation-microangiospasm. Five females were recruited, aged 41-66 years, suffering from well-documented (ARA criteria) PSS, associated with typical Raynaud's phenomenon. The trial provided for intravenous infusion of iloprost at a rate of 1-2 ng/kg/min. First treatment consisted of six-hour infusions on six successive days. After this first treatment, weekly infusions during the winter months were carried on. Drug effectiveness was considered through subjective and objective parameters. All patients showed prominent reduction of number, duration and severity of attacks of Raynaud's phenomenon, improvement of prehensile strength, healing of finger ulcerations and improvement or normalization of digital photoplethysmography. So far, the treatment has been prolonged for years in our patients and still goes on. The side effects of iloprost (headache, flushing, nausea) have been very poor. Therefore, iloprost proved to be a valid drug in the management of Raynaud's phenomenon in patients with PSS, but the inconvenience of intravenous administration may limit its routine use.