The choice of second-line therapy in steroid-resistant immune thrombocytopenia: role of platelet kinetics in a single-centre long-term study.

Splenectomy is a time-honoured well established approach for patients with steroid-resistant immune thrombocytopenia (ITP). However, due to the more recent availability of therapeutic options alternative to splenectomy, such as rituximab and agonists of the thrombopoietin-receptor, the choice of second-line therapy is challenging. Platelet kinetics has been widely used to predict response to splenectomy. We describe the outcome of 70 chronic ITP patients who performed a platelet kinetic study after failure of front-line corticosteroids and subsequently underwent open splenectomy. After a median follow-up from surgery of 20 years, 62 (88.5%) patients responded to splenectomy and 9 patients (13%) relapsed. Achieving a complete response (CR) significantly predicted a higher probability long-term stable response. The pattern of platelet sequestration was predominantly splenic in 52 patients (74%), predominantly hepatic in 12 patients (17%), and diffuse in 6 (9%). Patients with nonsplenic (diffuse and hepatic) sequestration showed significantly lower overall responses compared to patients with splenic captation (P = 0.002). A nonsplenic sequestration significantly correlated with lower CR rate and, among CR patients, predicted an increased risk of relapse. Also, the probability of stable responses in nonsplenic uptake patients was substantially lower than in patients with splenic uptake (85% vs. 50%, P = 0.0083). Platelet life span and platelet turnover did not correlate with response and relapse rate. Overall, splenic sequestration was able to predict not only a better quality, but also a higher durability of the responses. However, it should be enphasized that the response rate and duration of response even in patients with nonsplenic uptake were similar or even superior to those reported in patients treated with rituximab as first option.

Cervical and hysteroscopic injection for identification of sentinel lymph node in endometrial cancer.

OBJECTIVES: The aims of our study were to evaluate the possibility of identifying the sentinel lymph node (SLN) in patients with endometrial cancer (EC) and to directly compare two injection techniques, cervical and hysteroscopic injection. METHODS: Fifty-four patients with endometrial carcinoma, clinical stages I and II, were submitted to complete surgical staging through laparoscopy, as recommended by FIGO in 1988. For the mapping procedure the patients were divided into two groups of injection: the cervical injection group and hysteroscopic injection group. Technetium (Tc) 99m radiocolloid was used as tracer. RESULTS: Intraoperative detection rate of SLN was 70% in cervical group and 65% in the hysteroscopic group (p=n.s.). In the cervical group, all patients had SLN in the pelvis only and the mean SLN removed was 18 (range 2-26). In the hysteroscopic group, all patients had SNLs in the pelvis and two patients had SLN both in the pelvis and above the bifurcation of the aorta. Mean pelvic SLN removed was 20 (range 8-42). CONCLUSIONS: Our data shows that it is possible to identify the SLN in tumours of the endometrium. Both cervical and hysteroscopic techniques are feasible but the hysteroscopic procedure might represent the only method able to highlight the complete lymphatic drainage of the uterus as suggested by the presence of paraaortic positive SLN only in this group.

Effect of a balanced mixture of dietary fibers on gastric emptying, intestinal transit and body weight.

BACKGROUND/AIMS: Dietary fibers are frequently included in diets to decrease body weight, but their scarce palatability and the occurrence of meteorism prevent a long-term intake. The aim of this study was to test a mixture of dietary fibers expressly chosen to decrease their negative properties and strengthen their positive effects. METHODS: In a series of 10 patients with a slight overweight, the effectiveness of a palatable dietary fibers mixture on gastric emptying and intestinal transit was tested with scintigraphic methods. Then, the effects on body weight and digestive sensations and characteristics of defecations, were evaluated for 4 weeks. RESULTS: The intestinal transit was significantly shortened by the fiber intake, while the gastric emptying was delayed, but not significantly. The body mass index significantly and progressively decreased, whereas the sense of satiation significantly increased. No effect on abdominal bloating was referred, whereas a significant increase in number of defecations with stools of normal consistency was observed. The acceptability of the fiber mixture was good. CONCLUSIONS: The present research demonstrated that it is possible to prepare a palatable mixture of dietary fibers that maintains the property of decreasing body weight, favors the sense of satiation and accelerates the intestinal transit, with normalization of the stool consistency without the occurrence of meteorism.

Effects of cardiac resynchronization therapy on diastolic function: evaluation by radionuclide angiography.

While the beneficial effects of cardiac resynchronization therapy (CRT) on left ventricular (LV) systolic function have been demonstrated, no information is available regarding its effects on LV diastolic function during exercise. Using radionuclide angiography, we prospectively evaluated the effects of CRT on diastolic function at rest and during exercise in 15 patients consecutively referred for CRT. All patients underwent equilibrium Tc(99) radionuclide angiography with bicycle exercise performed (1) at baseline; (2) immediately after CRT implantation, in spontaneous rhythm and during CRT; and (3) after 3 months of biventricular stimulation. Diastolic function was assessed by measurements of peak filling rate (PFR). At baseline, activation of biventricular stimulation influenced PFR neither at rest (1.06 +/- 0.34 vs 1.07 +/- 0.50 mL/s during spontaneous rhythm, P = 0.9) nor during exercise (1.45 +/- 0.62 vs 1.33 +/- 0.48 mL/s, P = 0.3). At 3 months, improvements were observed in New York Heart Association functional class and systolic function. By contrast, no improvement in diastolic function was observed either at rest (PFR = 1.11 +/- 0.45 vs 1.07 +/- 0.50 mL/s in spontaneous rhythm at baseline, P = 0.6) or during exercise (1.23 +/- 0.50 vs 1.33 +/- 0.48 mL/s, P = 0.2). These observations indicate that the intermediate benefits conferred by CRT on LV systolic function at rest and during exercise were not accompanied by similar improvements in diastolic function.

Cardiac resynchronization therapy: effects on left and right ventricular ejection fraction during exercise.

In patients with heart failure and wide QRS complex, cardiac resynchronization therapy (CRT) is associated with improvement of symptoms and cardiac function. This study examined the effects of a 3-month period of CRT on left ventricular (LV) and right ventricular (RV) ejection fraction (EF) and on LV volumes, both at rest and during exercise. A CRT system was implanted in 15 patients with severe heart failure and wide QRS. Before implant and 3 months later, all patients underwent assessment of cardiac performance with equilibrium Tc(99) radionuclide angiography with imaging in the best septal left anterior oblique view. Exercise was performed on a bicycle ergometer. At 3 months, a significant improvement in New York Heart Association functional class was observed, and radionuclide angiography showed a significant decrease in LV volumes and a significant increase in LVEF at rest, as well as a significant increase in LVEF during exercise. The remodeling processes associated with CRT did not appear to include RV function, since RVEF did not improve, and changes in RVEF did not correlate with changes in LVEF, neither at rest nor during exercise.

Non-invasive detection of coronary artery stenosis: a comparison among power-Doppler contrast echo, 99Tc-Sestamibi SPECT and echo wall-motion analysis.

BACKGROUND: Power-Doppler imaging is a recently developed method for myocardial contrast echocardiography (MCE). It can selectively evaluate the signal coming from an ultrasound contrast agent, allowing myocardial perfusion studies. OBJECTIVE: To compare the ability of power-Doppler MCE with stress-echo wall-motion and nuclear scan imaging (SPECT) to assess myocardial ischaemia during pharmacological stress, using coronary angiography as reference. METHODS: In 25 patients the three non-invasive imaging modalities were acquired during a single dipyridamole stress test (so as to avoid stress variations). Power-Doppler MCE was acquired using continuous intravenous infusion of Levovist. Echo wall-motion was acquired too. At peak stress 99Tc-Sestamibi was injected; stress SPECT images were acquired 30 min after injection. RESULTS: Power-Doppler MCE and SPECT showed 84% concordance (21 of 25 patients; kappa=0.67) for detection of ischaemia. Concordance based on coronary artery territories for normal perfusion versus fixed defects versus reversible defects was 92% (69 of 75; kappa=0.81), with 100% for left anterior descending, 92% for right coronary artery and 84% for circumflex. Power-Doppler MCE had lower sensitivity than SPECT (89 versus 100%) but higher specificity (100 versus 88%) for identification of stenotic (> or = 70%) coronary arteries as assessed by angiography. Echo wall-motion analysis showed the lowest sensitivity (68%) with 100% specificity. Accuracy was 94% for both power-Doppler MCE and SPECT, and 83% for wall-motion analysis. CONCLUSION: Power-Doppler MCE is a sensitive and specific method for identification of myocardial perfusion during pharmacological stress. Accuracy of power-Doppler MCE for stenotic coronary arteries appears to be slightly higher than stress-echo wall-motion and similar to SPECT.

Exercise renal scintigraphy shows renal ischemia in a transplanted kidney.

Exercise renography is essentially a research method to investigate hypertension and has very limited clinical application. Captopril renography has long been used to study renal artery stenosis causing hypertension with good results. The authors describe a patient with a transplanted kidney supplied by reversal of flow via the external iliac artery. A "steal phenomenon" of the kidney related to ambulation was considered likely. Ischemia of the transplanted kidney was revealed by exercise renography, which showed parenchymal trapping of radiotracer as a result of exercise.