Child-Pugh Class and Not Thrombocytopenia Impacts the Risk of Complications of Endoscopic Band Ligation in Patients with Cirrhosis and High Risk Varices.

Background and Aims: Endoscopic band legation (EBL) is an effective method for the prophylaxis of acute variceal bleeding (AVB). This procedure may be associated with several complications, particularly bleeding. Our analysis aimed to evaluate the risk of complications due to EBL in a cohort of patients who underwent EBL for the prophylaxis of variceal bleeding and the eventual presence of risk predictors. Patients and Methods: We retrospectively analysed data from consecutive patients who underwent EBL in a primary prophylaxis regimen. For all patients, simultaneously with EBL, we recorded the Child-Pugh and MELD score, platelet count and US features of portal hypertension. Results: We collected data from 431 patients who performed a total of 1028 EBLs. We recorded 86 events (8.4% of all procedures). Bleeding after EBL occurred 64 times (6.2% of all procedures), with the following distribution: intraprocedural bleeding in 4%; hematocystis formation in 17 cases (1.7%); 6 events (0.6%) of AVB due to post-EBL ulcers. None of these events presented a correlation with platelet count (84,235 ± 54,175 × 103/mL vs. 77,804 ± 75,949 × 103/mL; p = 0.70) or with the condition of severe thrombocitopenia established at PLT < 50,000/mmc (22.7% with PLT ≤ 50,000/mmc vs. 15.9% with PLT ≥ 50,000/mmc; p = 0.39). Our results showed a relationship between cumulative complications of EBL and Child-Pugh score (6.9 ± 1.6 vs. 6.5 ± 1.3; p = 0.043). Conclusions: EBL in cirrhotic patients is a safe procedure. The risk of adverse events depends on the severity of liver disease, without a relationship with platelet count.

RESIST-HCV Criteria to Monitor Progression of Low-Risk Esophageal Varices in Patients With Compensated Cirrhosis After HCV Eradication: The SIMPLE Study: SIMPLE: Scoring Index to Monitor Progression of Low-risk Esophageal varices.

INTRODUCTION: Noninvasive criteria to predict the progression of low-risk esophageal varices (EV) in patients with compensated hepatitis C virus (HCV) cirrhosis after sustained virological response (SVR) by direct-acting antivirals (DAAs) are lacking. Our aim was to assess the diagnostic performance of Rete Sicilia Selezione Terapia-HCV (RESIST-HCV) criteria for EV progression compared with elastography-based criteria (Baveno VI, Expanded Baveno VI, and Baveno VII-HCV criteria). METHODS: All consecutive patients observed at 3 referral centers with compensated HCV cirrhosis with or without F1 EV who achieved sustained virological response by DAAs were classified at last esophagogastroduodenoscopy (EGDS) as RESIST-HCV low risk (i.e., low probability of high-risk varices [HRV]) if platelets were >120 × 10 9 /L and serum albumin >3.6 g/dL or RESIST-HCV high risk (i.e., high probability of HRV) if platelets were <120 × 10 9 /L or serum albumin <3.6 g/dL. The primary outcome was the progression to HRV. The area under the receiver operating characteristic curve and decision curve analysis of noninvasive criteria were calculated. RESULTS: The cohort consisted of 353 patients in Child-Pugh class A (mean age 67.2 years, 53.8% males). During a mean follow-up of 44.2 months, 34 patients (9.6%, 95% CI 6.7%-13.5%) developed HRV. At the last EGDS, 178 patients (50.4%) were RESIST-low risk, and 175 (49.6%) were RESIST-high risk. RESIST-HCV criteria showed the highest area under the receiver operating characteristic curve (0.70, 95% confidence interval 0.65-0.75), correctly sparing the highest number of EGDS (54.3%), with the lowest false-positive rate (45.7%), compared with elastography-based criteria. Decision curve analysis showed that RESIST-HCV had higher clinical utility than elastography-based criteria. DISCUSSION: Biochemical-based RESIST-HCV criteria are useful to easily predict HRV development after HCV eradication by DAAs in patients with compensated cirrhosis and low-risk EV.

A Genetic and Metabolic Staging System for Predicting the Outcome of Nonalcoholic Fatty Liver Disease.

Nonalcoholic fatty liver disease (NAFLD) is an emerging cause of liver-related events (LREs). Here, we have assessed the ability of a composite score based on clinical features, metabolic comorbidities, and genetic variants to predict LREs. A total of 546 consecutive patients with NAFLD were recruited and stratified according to the fibrosis-4 (FIB-4) index. LREs were defined as occurrence of hepatocellular carcinoma or hepatic decompensation. Cox regression multivariate analysis was used to identify baseline variables associated with LREs. The UK Biobank was used as the validation cohort, and severe liver disease (incidence of cirrhosis, decompensated liver disease, hepatocellular carcinoma, and/or liver transplantation) was used as the outcome. LREs were experienced by 58 patients, only one of whom was in the cohort of patients with a FIB-4 score < 1.3. Multivariate Cox regression analysis of 229 patients with a FIB-4 score ≥ 1.3 highlighted clinical variables independently associated with the development of LREs, including older age, low platelet count, low albumin, low high-density lipoprotein cholesterol, certain genetic factors, and interactions between genetic factors and sex or diabetes. The area under the curve (AUC) for the model was 0.87 at 1, 3, and 5 years. Our novel Genetic and Metabolic Staging (GEMS) scoring system was derived from the Cox model linear predictor, ranked from 0 to 10, and categorized into five classes (0-5, 5-6, 6-7, 7-8, and 8-10). The risk of LREs increased from 4% in patients in the best class (GEMS score 0-5) to 91% in the worst (GEMS score 8-10). GEMS score was associated with incident severe liver disease in the study population (hazard ratio, 1.56; 95% confidence interval, 1.48-1.65; P < 0.001) as well as in the UK Biobank cohort where AUCs for prediction of severe liver disease at 1, 3, and 5 years were 0.70, 0.69, and 0.67, respectively. Conclusion: The novel GEMS scoring system has an adequate ability to predict the outcome of patients with NAFLD.

Impact of direct-acting antivirals (DAAs) on cardiovascular diseases in patients with chronic hepatitis C.

INTRODUCTION: In the last years the Hepatitis C virus (HCV) infection was a relevant public health problem due to the large number of affected people worldwide and the impact on hepatic and extrahepatic complications. The availability of direct-acting antivirals (DAAs) and the very high rate of sustained virological response (SVR) after treatment has radically changed the course of HCV chronic infection. EVIDENCE ACQUISITION: We searched PubMed for articles published between January 1, 1995, through December 31, 2020, in English language. EVIDENCE SYNTHESIS: Robust evidence showed a close link between HCV infection and development of cardiovascular disease (CVD), as result of the atherogenic effect of the virus. CONCLUSIONS: This review aimed to explore the evidence linking HCV infection with cardiovascular disease and to evaluate the impact of SVR after DAAs on cardiovascular complications.

PNPLA3 rs738409 C>G Variant Predicts Fibrosis Progression by Noninvasive Tools in Nonalcoholic Fatty Liver Disease.

Liver fibrosis is the main predictor of events in patients with nonalcoholic fatty liver disease (NAFLD),1 and its evolution is characterized by a nonlinear trend2,3 mostly affected by metabolic risk factors, severity of liver inflammation and steatosis, and weight loss.3 The rs738409 C>G common variant in PNPLA3 gene has been associated with severity of fibrosis and risk of liver-related events in NAFLD.4,5 Noninvasive tests as Fibrosis-4 (FIB-4) and liver stiffness measurement (LSM) are useful to rule-out advanced fibrosis and they could be reliable to predict fibrosis progression.2,6 We aimed to evaluate in patients with NAFLD whether PNPLA3 rs738409 C>G variant impacts on fibrosis progression, noninvasively assessed by FIB-4 and LSM.

Effect of Sunlight Exposure on Anthocyanin and Non-Anthocyanin Phenolic Levels in Pomegranate Juices by High Resolution Mass Spectrometry Approach.

Quali-quantitative analyses of anthocyanins and non-anthocyanin phenolic compounds performed with the use of liquid chromatography coupled with high resolution mass spectrometry, were evaluated in juice of pomegranate fruits ('Dente di Cavallo'), in relation to different light exposures (North, South, West and East). A total of 16 compounds were identified, including phenolic acids, flavonoids, hydrolysable tannins, and anthocyanins, known for their health-promoting effects. Striking differences were observed about the total phenolic content, which was high in juices from fruits with east- and north-facing position, while it was lower in juices facing south. The greatest contents of total flavonoids and anthocyanins were recorded in fruit juices with southern exposure; however, there are no great differences in the content in phenolic acids. Tannins were mainly synthesized in fruit juices with West exposure. The results showed that the position within the tree had no significant effects on color juice, however, it significantly (p < 0.05) affected data on fruit weight, soluble sugars and juice yield. Remarkable synergies existed among polyphenols and phytochemicals in pomegranate juice, but collecting fruits with different solar exposure could enhance different health benefits, i.e., the juices with higher polyphenols content could have more anticancer effect or those with higher tannins content could have more antimicrobial effect.

Trace element compartmentation in the seagrass Posidonia oceanica and biomonitoring applications.

This study investigated the trace element bioaccumulation capacity of the Mediterranean seagrass Posidonia oceanica, and its suitability as a bioindicator of contamination in water and sediments. Results showed that P. oceanica leaves accumulate higher concentrations of Ni and Zn. Since P. oceanica regenerates its leaves periodically, the higher concentrations in aerial organs may suggest a "removal" strategy according to which P. oceanica accumulates greater concentrations of trace elements in its temporary organs. In turn, P. oceanica seems to adopt an exclusion strategy for toxic non-essential elements (As, Cr, Pb). Results showed also that P. oceanica organs are correlated with As, Cd, Cu, Ni, and Zn concentrations in sediments. No significant relationship was found between P. oceanica and water. This study showed that P. oceanica may adopt different tolerance strategies compared to mainland-rooted macrophytes, and its possible use as a bioindicator of trace elements in sediments should be considered.

Levels of heavy metals in wetland and marine vascular plants and their biomonitoring potential: A comparative assessment.

The present study investigated the levels of As, Cd, Cr, Cu, Hg, Mn, Ni, Pb and Zn in the seagrasses Posidonia oceanica and Cymodocea nodosa, and in the wetland macrophytes Phragmites australis, Arundo donax, Typha domingensis, Apium nodiflorum, and Nasturtium officinale. Results showed that the bioaccumulation capacity from sediments, translocation, total levels in plant tissues, and bioindication of metals in sediments, are generally species-specific. In particular, the patterns of metals in the aquatic plants studied were overall independent of ecology (coasts vs wetlands), biomass, anatomy (rhizomatous vs non rhizomatous plants), and life form (hemicrytophytes vs hydrophytes). However, marine phanerogams and wetland macrophytes shared some characteristics such as high levels of heavy metals in their below-ground organs, similar capacity of element translocation in the rhizosphere, compartmentalization of metals in the different plant organs, and potential as bioindicators of Cu, Mn and Zn levels in the substratum. In particular, the present findings indicate that, despite ecological and morphological similarities, different plant species tend to respond differently to exposure to heavy metals. Furthermore, this seems to result from the species individual ability to accumulate and detoxify the various metals rather than being attributed to differences in their ecological and morpho-anatomical characteristics.

An enigmatic clinical entity: A new case of olfactory schwannoma.

Olfactory schwannomas, also described as subfrontal or olfactory groove schwannomas, are very rare tumors, whose pathogenesis is still largely debated. We report a case of olfactory schwannoma in a 39-year-old woman who presented with anosmia and headache. The clinical examination did not show lesions in the nose-frontal region and there was no history of neurofibromatosis. Head MRI and CT scan revealed a lobulated extra-axial mass localized in the right anterior cranial fossa that elevated the ipsilateral frontal pole. Bilateral frontal craniotomy demonstrated a tumor strictly attached to the right portion of the cribriform plate that surrounded the right olfactory tract, not clearly identifiable. The immunohistochemical analysis suggested the diagnosis of typical schwannoma. The patient was discharged without any neurological deficit and a four-month postoperative MRI scan of the brain showed no residual or recurrent tumor.

H, C, and O Stable Isotope Ratios of Passito Wine.

In this study we investigated the effect of the grape withering process occurring during the production of Italian passito wines on the variability of the (D/H)I, (D/H)II, δ(13)C, and δ(18)O of wine ethanol and the δ(18)O of wine water. The production of PDO Erbaluce di Caluso Passito in five different cellars in Piedmont (Italy) was considered in two successive years. Moreover, samples of 17 different traditional Italian passito wines taken at different stages of maturation were taken into account. We found that the δ(18)O of must and wine water and the δ(18)O of ethanol decrease in the case of passito wines produced in northern and central Italy using postharvest drying of the grapes in dedicated ventilated or unventilated fruit drying rooms (fruttaio), during autumn-winter. For passito wines produced in southern Italy, where the main technique involves withering on the plant (en plein air), δ(18)O tends to increase. The (DH)I of wine ethanol did not change during withering, whereas the (DH)II and δ(13)C values changed slightly, but without any clear trend. Particular attention must be therefore paid in the evaluation of the δ(18)O data of passito wines for fraud detection.

Pneumatic dilation and botulinum toxin: when and why?

Pneumatic dilation and botulinum toxin:when and why? The endoscopic treatment options of achalasia include botulinum toxin (BT) injection and pneumatic dilation (PD) of the lower esophageal sphincter (LES). BT can reduce the LES pressure by blocking the release of acetylcoline from presynaptic cholinergic nerve terminals in the myenteric plexus. Although the procedure is safe and good initial response is reported, there is a wide variability in the duration of the response and the effect tends to decrease over time. BT is usually recommended for elderly patients or patients with comorbid illnesses, who are poor candidates for more invasive procedures. PD aims at tearing the muscle fibers of the LES and is considered the most effective nonsurgical treatment for achalasia. Technical details of the procedure vary in different institutions and in many clinical settings the choice between PD or minimally invasive surgical myotomy depends upon local expertise in the procedures. Further endoscopic treatment options such as submucosal esophageal myotomy or self-expanding metallic stents are being studied.

Down-regulation of HOXA4, HOXA7, HOXA10, HOXA11 and MEIS1 during monocyte-macrophage differentiation in THP-1 cells.

The translocation t(9;11)(p22;q23) generates the MLL-AF9 oncogene and is commonly associated with monocytic acute myeloid leukemia (AML-M5; FAB-classification). For the oncogenicity of MLL-AF9, the (over)expression of several other genes, including selected HOXA cluster genes as well as MEIS1 (a HOX cofactor), is required. We previously showed that the down-regulation of MLL-AF9 expression is not obligatory for monocyte-macrophage maturation in AML-M5 cells carrying t(9;11)(p22;q23). In this study, we analyzed the expression patterns of HOXA4, 5, 6, 7, 9, 10 and 11 (defined as 'HOXA-code' genes) and MEIS1 by semiquantitative RT-PCR during the monocyte-macrophage differentiation induced by phorbol 12-myristate 13-acetate (PMA) in THP-1 cells carrying t(9;11)(p22;q23) and expressing MLL-AF9. The analyses were performed in THP-1 cells expressing MLL-AF9 even after PMA treatment. The results showed that all the analyzed genes were expressed in untreated THP-1 cells. After the induction of differentiation, we observed a down-regulation of HOXA4, 7, 10, 11 and MEIS1, an up-regulation of HOXA6, and no significant variation in the expression of HOXA5 and 9. These data indicate that the expression of most HOXA-code genes, as well as MEIS1, could be implicated in the differentiation blockage observed in MLL-AF9-related leukemias.

Somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide in chemotherapy-pretreated patients with advanced lung adenocarcinoma and low performance status.

BACKGROUND: We previously reported on an improvement in survival and quality of life in chemotherapy-naïve patients with advanced non-small-cell lung cancer and low performance status (PS) treated with a combination of biotherapeutical agents and cyclophosphamide. In this study, we assessed the survival, clinical status, and toxicity of this multidrug regimen in chemotherapy-pretreated patients with advanced lung adenocarcinoma and low PS. METHODS: Patients with stage IIIB or IV lung adenocarcinoma, who had progressed after prior standard chemotherapy, and with an Eastern Cooperative Oncology Group PS > or = 2, received a daily combination of somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide. RESULTS: Twenty-three (23) patients were enrolled. The median age was 59 years (range, 42-75). The PS was 2 and 3 in 73.9% and 26.1% of patients, respectively. The median overall survival (intent-to-treat analysis) was 95 days (range, 19-214). The side-effects were mild, mostly consisting of diarrhea, nausea and vomiting, and drowsiness of Grade 1-2. There was an improvement in both respiratory and general symptoms, which was more evident in patients surviving more than 95 days. CONCLUSIONS: The combined regimen of somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide is well tolerated and can improve disease-related symptoms in heavily pretreated patients with late-stage lung adenocarcinoma and poor PS.

Normal percentage of CD56bright natural killer cells in young patients with a history of repeated unexplained implantation failure after in vitro fertilization cycles.

Changes in endometrial leukocyte subpopulations and most of all in the percentage of uterine natural-killer cells (uNK), during the menstrual cycles, may have a pivotal role in the implantation process. An increase of activated NK cells (CD56dim CD16+ CD69+) in the peripheral blood of patients with a reduced rate of embryo implantation in IVF treatment has been reported elsewhere, but we found, by using flow cytometry, normal endometrial lymphocyte subpopulations in young patients with a history of repeated unexplained implantation failure who were undergoing IVF cycles for idiopathic infertility.

Somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide in advanced non-small-cell lung cancer patients with low performance status.

BACKGROUND: The prognosis of low performance status (PS) patients with advanced non-small-cell-lung cancer (NSCLC) is dismal. In these patients, we have determined the survival, clinical benefits, and toxicity of a multidrug regimen, based on cyclophosphamide and biotherapeutical agents. METHODS: Patients with a diagnosis of stage IIIB or stage IV NSCLC, no previous surgery or chemoradiotherapy, and an Eastern Cooperative Oncology Group (ECOG) PS equal to or greater than 2 received a daily combination of somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide. RESULTS: Twenty-eight (28) patients were enrolled. The median age was 64 years (range, 35-74). The PS was 2 and 3 in 78.6% and 21.4% of patients, respectively. The median overall survival (intent-to-treat analysis) was 12.9 months (range, 1.5-33.5 months), The overall survival rates at 1 and 2 years were 51.2% and 21.1%, respectively. The side-effects were very mild, mostly consisting of diarrhoea, nausea/vomiting, and drowsiness of grade 1-2. Most patients experienced an improvement of both respiratory (cough and dyspnoea) and general (pain, fatigue, and insomnia) symptoms. CONCLUSIONS: Low PS patients with advanced NSCLC may benefit from a combination of somatostatin, retinoids, melatonin, vitamin D, bromocriptine, and cyclophosphamide, in terms of survival and quality of life, with very low side-effects.

Down-regulation of MLL-AF9, MLL and MYC expression is not obligatory for monocyte-macrophage maturation in AML-M5 cell lines carrying t(9;11)(p22;q23).

The MLL-AF9 oncogene originates from the translocation t(9;11)(p22;q23), which is mainly associated with monocytic acute myeloid leukaemia (AML-M5; FAB-classification). In AML-M5 THP-1 cells carrying t(9;11) (p22;q23) and expressing MLL-AF9, we previously showed that MLL-AF9 expression is down-regulated during monocyte-macrophage maturation. We have subsequently observed that in a 'rapid-growing' variant of the THP-1 cell line (THP-1-R) MLL-AF9 down-regulation does not occur. MLL fusion proteins (including MLL-AF9) deregulate MYC transactivation activity, and both presence and absence of MYC down-regulation have been reported during monocyte-macrophage maturation in THP-1 cells. In the present study, we analyze the expression patterns of MLL-AF9, MLL wild-type and MYC after induction of monocyte-macrophage terminal differentiation in the AML-M5 cell lines, THP-1, THP-1-R, Mono-Mac-6 (MM6) and MOLM-13, all of which carry t(9;11)(p22;q23) and express MLL-AF9. RT-PCR analysis indicated that down-regulation of MLL-AF9, MLL or MYC is not necessary to abolish malignant phenotypes by induction of terminal monocyte-macrophage differentiation in leukaemic cells carrying t(9;11)(p22;q23).

Occurrence of mucous aggregates and their impact on Posidonia oceanica beds.

Mucous macro-aggregates of both pelagic and benthic origin are recurrently observed in the meadows formed by the seagrass Posidonia oceanica around the island of Ischia (Gulf of Naples, Italy). In the past two decades, major events occurred in 1991, 1993 and 2000, when a thick layer of mucilage covered vast areas of the meadows. To investigate the environmental triggers for mucilage formation and the effects of macro-aggregates on the functional and structural status of P. oceanica, a number of abiotic and biotic parameters were monitored over three years within the frame of a research project on Adriatic and Tyrrhenian mucilages (MAT). Basic environmental parameters (salinity, temperature, irradiance, dissolved oxygen concentration) in the water column and inorganic nutrient concentrations above and within P. oceanica meadows were measured. As descriptors of the status of the seagrass, shoot density and the nitrogen content of the leaves were monitored. Moreover, a reconstructive technique (lepidochronology) was employed to track back annual plant production. During the three-year study, mucous aggregates produced by benthic algae were observed in spring-summer and a major event of macro-aggregates of pelagic origin affecting P. oceanica canopy was observed in autumn 2000. Each of these episodes was observed for a few weeks to one month. We hypothesize nutrient limitation to explain the short duration of the benthic algal blooms that were responsible of macroaggregate formation; a highly dynamic circulation resulted in the dispersion of the pelagic aggregates deposited on the meadows. None of the descriptors of the structure of the meadow and of plant performance showed any obvious alterations in relation to the occurrence of mucilage coverage. Presumably, the short duration of the mucilage episodes recorded were not enough to induce such alterations, at least at the temporal and spatial scales considered.

Evaluation of left ventricular function in long-term survivors of childhood Hodgkin disease.

BACKGROUND: Data on the presence of myocardial abnormalities in long-term Hodgkin disease survivors are contradictory. The purpose of this study was to determine if myocardial performance index (MPI) was capable of discovering cardiac abnormalities. PROCEDURE: Echocardiographic evaluation was performed in 31 survivors of Hodgkin disease (mean age 17.0 years), who received doxorubicin as part of chemotherapeutic treatment (median dose 164.8 +/- 42.5 mg/m(2)). Control group comprised 22 healthy subjects (mean age 16.7 years). RESULTS: Peak A velocity was increased (P = 0.004) and peak E/A velocity ratio was lower (P = 0.002) in patients compared to controls. Mean isovolumetric contraction time was longer in patients than in controls (P = 0.0001). Ejection time was significantly shorter in patients than in the controls (P = 0.001). Consequently, the MPI was significantly greater in the patients than in the controls (P = 0.0001). Abnormal MPI was found in 25/31 patients (83%). CONCLUSIONS: The Doppler-derived index of combined systolic and diastolic myocardial performance demonstrates the presence of subtle cardiac abnormalities in the majority of Hodgkin disease survivors.

Anthracycline-induced cardiotoxicity in children with cancer: strategies for prevention and management.

The fact that anthracyclines are cardiotoxic seriously narrows their therapeutic index in cancer therapy. The cardiotoxic risk increases with the cumulative dose and may lead to congestive heart failure (CHF) and dilated cardiomyopathy in adults and in children. The prevention of anthracycline-induced cardiotoxicity is particularly important in children who can be expected to survive for decades after being cured of their malignancy. Attempts to reduce anthracycline cardiotoxicity have been directed towards: (i) decreasing myocardial concentrations of anthracyclines and their metabolites by dose limitation and schedule modification; (ii) developing less cardio-toxic analogs; and (iii) concurrently administering cardioprotective agents to attenuate the effects of anthracyclines on the heart. As regards schedule modification, avoidance of anthracycline peak levels may reduce the pathologic and clinical cardiotoxicity, although this has not always been observed. The analogs of doxorubicin, such as idarubicin and epirubicin, have similar cardiotoxicity to that of doxorubicin when given in amounts of equivalent myelotoxicity. Liposomal anthracyclines are a new class of agents that may permit more specific organ targeting, thereby producing less systemic and cardiac toxicity, but more studies are required to assess the advantages, if any, of these preparations over classical anthracyclines. The cardioprotective agent, dexrazoxane, an iron chelator, is highly effective and provides short-term cardioprotection to most patients receiving even the most intensive doxorubicin-containing regimens. Its long-term benefits remain to be determined. In addition, data remain insufficient to make specific recommendations regarding current use of dexrazoxane in children. It is thought that subtle abnormalities, related to anthracycline treatment in childhood, can develop into more permanent myocardial disease resulting in cardiomyopathy, which may progress to CHF. As regards the therapy of patients with anthracycline cardiotoxicity, two different situations have, therefore, to be considered: (i) if the patient presents with cardiac abnormalities, such as a reduction in fractional shortening at echocardiogram, without cardiac symptoms; and (ii) if the patient has CHF. In the presence of CHF, recovery with digitalis-diuretic therapy alone seldom occurs, and in patients who have refractory hemodynamic decompensation, heart transplantation is indicated. In patients with CHF, therapy with ACE inhibitors induces improvement in left ventricular structure and function, but this improvement is transient. Randomized clinical trials are, therefore, necessary to determine the effects of ACE inhibitors in mild-to-moderate left ventricular dysfunction. The beneficial effects of beta-adrenoceptor antagonists (beta-blockers) on cardiac function in heart failure due to anthracyclines seem comparable with those observed in other forms of heart failure with systolic dysfunction. Many drugs are available to treat children with CHF due to anthracycline treatment, but they are only palliative.

[Heart failure in a subject treated with anthracyclines in childhood: myocardial dysfunction is not always the only reason of it]. / Scompenso cardiaco biventricolare in soggetto trattato nell'infanzia con antracicline: non sempre la disfunzione miocardica ne è la causa.

Anthracyclines, found to be efficacious in the treatment of a broad spectrum of pediatric malignancies, are cardiotoxic and may lead to heart failure even a long time after successful treatment of cancer. It is thought that subtle abnormalities can progress to the more permanent myocardial disease, resulting in cardiomyopathy which may progress to congestive heart failure. There are some precipitating factors leading to the sudden onset of cardiac symptoms such as increase in afterload or preload. We describe a young patient with congestive heart failure treated with doxorubicin (cumulative mean dose 420 mg/m2) in infancy because of pelvic sarcoma in whom the appearance of symptoms was related to pulmonary embolism. Four years before hospital admission, the patient presented echocardiographic abnormalities such as left ventricular fractional shortening and thickness reduction and he was treated with ACE-inhibitors. The myocardial ischemia, which is present in pulmonary embolism, probably worsened the left ventricular systolic function and caused congestive heart failure.