Multiple sclerosis in the Republic of San Marino: a prevalence and incidence study.

Studies on the distribution of multiple sclerosis (MS) carried out in Southern Europe in the last years have shown a significant increase in the frequency of the disease. A previous descriptive survey in the Republic of San Marino, northern Italian peninsula, published in 1984 established that this area is at high risk for MS. We updated the frequency estimates of the disease by adopting a complete enumeration approach. On 31 December 2005, 50 MS patients (36 women and 14 men) yielded a crude prevalence rate of 166.7 per 100, 000 (95% CI 123.7-220), 235.3 (95% CI 165-327.4) for women and 95.2 (95% CI 52-160) for men. The average incidence from 1990 to 2005 was 7.9 (95% CI 5.3-11.1) per 100,000, 11.7 (95% CI 7.6-17.3) for women and 3.9 (95% CI 1.7-7.7) for men. We did not detect any significant temporal trend over the study period. These results confirm that in San Marino the disease occurs more frequently than that suggested in the past and support the data on MS frequency in continental Italy. The marked increase in MS prevalence ratio is partly due to the increasing survival of patients and the accumulation of new incidence cases owing to the reduction in diagnostic latency for better quality of neurological diagnostic procedures. However, an increased incidence of the disease could be considered.

Prevalence and incidence of cluster headache in the Republic of San Marino.

Based on a preceding survey performed in 1985, the authors estimated the prevalence and incidence of cluster headache (CH) in the Republic of San Marino (26,628 inhabitants at 31 December 1999). All cases were diagnosed by direct interview according to International Headache Society criteria. The prevalence rate was 56/100,000 (95% CI 31.3 to 92.4), and the incidence rate was 2.5/100,000/year (95% CI 1.14 to 4.75). Most cases showed rare clusters. This is the first prospective study on the incidence of CH.

The spatial organization of cholinergic mosaics in the adult mouse retina.

We analysed the spatial organization of the cholinergic amacrine cell mosaics in the mouse retina, as part of a general study of the major mouse retinal arrays, aiming at providing intrinsic cellular reference grids to monitor anomalies in retinal growth and/or functional organization in mouse models of retinal degeneration. The spatial organization of the cells was analysed by means of the nearest neighbour distance analysis, as well as by the analysis of Voronoi and Delaunay tesselations. We found non random cell spacing in both cholinergic arrays, although the mosaic in the ganglion cell layer tiles the retina scarcely better than a random distribution. Autocorrelation analysis revealed no detectable pattern in cell positioning, but there was a tendency towards a minimal spacing between array elements. Finally, we found no correlation in the spatial organization of the two arrays.

[The diabetic foot seen by the surgeon. Personal experience]. / Il piede diabetico visto dal chirurgo. Esperienza personale.

BACKGROUND: The aim of this study is to evaluate a major amputation risk criterion in diabetic patients with trophic lesions of the foot. The records of a series of 100 consecutive patients (65 males and 35 females) with diabetic foot ulcer treated in our surgical facilities between January 1992 and December 1997, in collaboration with diabetologists and podiatrists, have been reviewed retrospectively. METHODS: In 26 cases the ulcer involved both limbs and, therefore, the feet observed in this study have been 126. Accurate diagnosis of the underlying cause was the first step and in cases with a poor blood supply (69 limbs; 55%) unresponsive to medical therapy (44 limbs) vascular reconstruction (37 limbs), spinal cord stimulator (SCS) implantation (3 limbs) or major amputation (4 limbs) were performed. According to Wagner grading there were 42 grade 2 ulcers (33%), 38 grade 3 (30%), 43 grade 4 (34%) ad 3 grade 5 (3%). RESULTS: One patient died postoperatively after SCS implantation. All but 4 neuropathic ulcers (53 limbs) healed in a mean time (+/- SD) of 5.2 +/- 3.8 months and all but 10 vascular ulcers (59 limbs) healed in a mean time of 6.3 +/- 4.1 months. Of the latter group in 4 cases the patient died before ulcer healing while in 6 cases (8.7%) a major amputation was performed (in 2 cases after vascular reconstruction procedures). Minor amputations of the forefoot have been performed in 23 instances (33%) of vascular ulcer and in 10 cases (17%) of neuropathic ulcer. CONCLUSIONS: Since ischemia is the main risk factor for amputation, it is suggested that a particular effort should be made in improving the vascular diagnostic, both clinical and strumental, capabilities of our diabetologists and podiatrists in order to detect the vascular insufficiency in earlier stages.

Myocardial function and transmural blood flow during coronary venous retroperfusion in pigs.

BACKGROUND: The degree of recovery of regional myocardial contraction during coronary venous retroperfusion has not been well established, particularly in the absence of coronary collateral channels. Therefore, the maximal functional benefit attainable with coronary venous retroperfusion was assessed in pigs by means of using selective pump retroperfusion of the left anterior descending vein, with venting of the left anterior descending artery to zero pressure. METHODS AND RESULTS: In eight anesthetized open-chest pigs during selective left anterior descending venous retroperfusion over a range of retroperfusion flows, regional myocardial function (percent systolic wall thickening by sonomicrometry) increased progressively to an average of 62% of control values at a retroperfusion flow rate 200% of control arterial flow. Progressive thickening of the end-diastolic dimension of the anterior wall was observed with increasing retroperfusion flow (from 8.7 +/- 0.9 to 10.7 +/- 2.3 mm, p less than 0.001). Perfusion pressures within the left anterior descending vein increased linearly with increased retroperfusion flow rates (up to 132 +/- 57 mm Hg with retroperfusion flow 200% of control). A gradual increase of retrograde left anterior descending arterial outflow was observed with increasing retroperfusion flows; however, the absolute amount (maximum, 8.3 +/- 4.1 ml/min) was much too low to explain the extent of functional recovery. Transmural myocardial capillary blood flows in the anterior wall with retroperfusion flows of 100% and 200% of control arterial flow were 0.22 and 0.42 ml/min/g with corresponding subendocardial blood flows of 0.14 and 0.29 ml/min/g; ratios of endocardium to epicardium were 0.51 and 0.61, respectively. Thus, capillary blood flows during selective retroperfusion were relatively low despite considerable restoration of regional systolic wall thickening, and a significant difference was noted in the slopes of the relations between regional systolic wall thickening and myocardial blood flow during retroperfusion and anterograde arterial perfusion (p less than 0.05). With retrograde injection of silicone elastomer at different retroperfusion pressures (50, 75, and 100 mm Hg) in three pigs, capillaries were well visualized, and profuse intramyocardial venous anastomotic connections were seen at the highest retroperfusion pressure (100 mm Hg), whereas there was filling of small venules but little capillary filling at the lowest retroperfusion pressure (50 mm Hg). CONCLUSIONS: Considerable recovery of regional myocardial function with low regional capillary blood flows were observed during acute venous retroperfusion with high retroperfusion flows with arterial blood. These findings together with low levels of retrograde arterial outflow and visualization of retrograde capillary filling with a rich venous network provide evidence for possible oxygen delivery via the intramyocardial venous plexus.

[Malignant ventricular arrhythmias: nonpharmacological therapies]. / Aritmie ventricolari maligne: terapie non farmacologiche.

In these last few years the indications for non pharmacological options in the therapy of malignant ventricular arrhythmias have been extended. Some of these approaches (antiarrhythmic surgery, cardiac transplant, automatic implantable cardioverter defibrillator) have an exact clinical collocation, some others are still experimental. Our personal experience and the recent literature have been analysed to explain the state of the art of these therapies. We undoubtedly think that these options are a valid alternative to drugs in non responder patients. The choice needs an accurate evaluation. The clinical picture, not only arrhythmic, and the specific aim of each procedure should be carefully considered.

[Thrombolytic therapy in the treatment of thromboembolism of the right cardiac cavity during pulmonary embolism: our experience with rt-PA and review of the literature]. / La terapia trombolitica nel trattamento dei tromboemboli nelle cavità cardiache destre in corso di embolia polmonare: nostra esperienza con l'rt-PA e revisione della letteratura.

In 4 consecutive patients admitted for multiple pulmonary embolism 2-dimensional echocardiography showed large right atrial migrant thromboemboli in transit, floating and prolapsing into the right ventricle in diastole. This pattern was always associated with the echocardiographic signs of pulmonary hypertension. All the patients were treated with intravenous infusion of 100 mg of rt-PA in 3 hours. rt-PA determined the dissolution and disappearance of the right atrial thromboemboli (it took 4 hours in 2 patients and 5 hours in the remaining 2), and the concomitant disappearance of the echocardiographic signs of pulmonary hypertension. During and after the rt-PA therapy there was no evidence of further pulmonary embolism. The fibrinolytic treatment for right atrial thromboemboli during multiple pulmonary embolism is a promising alternative to right atrial thrombectomy: our results indicate that rt-PA acts rapidly and is effective and safe; if these results will be confirmed in a larger group of patients, rt-PA could become the first-choice therapy of right atrial thromboembolus.

[ST segment depression in precordial leads in patients with inferior acute myocardial infarction: the role of right ventricular involvement]. / Sottoslivellamento anteriore del tratto ST in pazienti con infarto miocardico inferiore acuto: influenza del coinvolgimento ventricolare destro.

The aim of the present study was to evaluate the influence of right ventricular involvement on the magnitude of precordial ST segment depression during inferior acute myocardial infarction. For this reason 61 patients (55 M, 6 F; mean age 53 years--range 38-73 years) admitted in our CCU for inferior acute myocardial infarction were studied by coronary angiography within 3-5 days from the onset of symptoms. The angiography showed either occlusion or critical coronary stenosis ranging as follows: on right coronary artery proximal (Group 1) to the first branch for right ventricle in 22 patients, on right coronary artery distal to the first branch for right ventricle in 25 patients (Group 2) and on circumflex artery (Group 3) in 14 patients. No difference in LAD disease were noted between the 3 groups. Using myocardial scintigraphy (Tc-99m- pyrophosphate) we confirmed the presence or the absence of right ventricular involvement in the 3 groups. In the 3 groups the magnitude of ST segment depression in V2, selected as representative left-sided precordial lead, ranged as follows: Group 1: -0.25 +/- 1.34 mm; Group 2: -1.64 +/- 1.80 mm; Group 3: -2.00 +/- 1.97 mm. In patients with right ventricular involvement (Group 1) there was a statistically significant reduction of precordial ST segment depression either in comparison to Group 2 (p less than 0.01) or to Group 3 (p less than 0.005) but none between Group 3 and 2. (ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of the intravenous administration of captopril in patients with chronic congestive heart failure]. / Effetti emodinamici della somministrazione endovenosa di captopril in pazienti affetti da scompenso cardiaco congestizio cronico.

The aim of the present study was to evaluate the hemodynamic response to the intravenous administration of the angiotensin converting enzyme-inhibitor captopril. Plasmatic renin activity was also monitored. The study population included 10 patients with chronic congestive heart failure: 3 were in the second NYHA functional class, 5 in the third, and 2 in the fourth. The patients received a first dose of 5 mg of captopril followed, after 10 min, by a second bolus-dose of 15 mg. Hemodynamic and hormonal measurements were repeated in the following 4 hours. The greatest hemodynamic effect, considered as the time of maximal mean arterial pressure and systemic vascular resistances decrease, and cardiac index increase, was noted 20 min after the first bolus dose administration. Mean arterial pressure (MAP) decreased by 13% (p less than 0.01), mean pulmonary artery pressure (MPAP) by 14% (p less than 0.05), right atrial pressure (RAP) by 30% (NS), wedge pressure (WPP) by 23% (p less than 0.01), systemic vascular resistances (SVR) by 21% (p less than 0.05), pulmonary vascular resistances by 22% (NS); cardiac index (CI) increased by 12% (p less than 0.05), stroke volume index by 10% (NS). Heart rate didn't change. The plasmatic renin activity (PRA) increased by 339% (p less than 0.01) reaching the maximal level in concomitance with the greatest hemodynamic effect. Hemodynamic changes were already noted 5 min after the first dose and lasted up to 75 min later.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of acute myocardial infarction by indium-111 antimyosin antibodies and correlation with the traditional techniques for the evaluation of extent and localization.

This clinical study evaluated the accuracy of planar myocardial scintigraphy with antimyosin monoclonal antibodies radiolabeled with indium-111 (AMA-Fab) in the detection and localization of acute myocardial infarction (AMI). Fifty-seven patients admitted for suspected AMI were studied; 17 patients underwent thrombolytic therapy with intravenous streptokinase and 11 had clinical signs of reperfusion; 9 had had a previous myocardial infarction. Fifty of 57 patients were discharged from the coronary care unit with a confirmed diagnosis of AMI. The AMA-Fab study results were positive for AMI in 49 patients (98%) and negative in 1 (2%). Among the 7 patients without AMI, 5 had unstable angina, 1 had Prinzmetal's variant angina and 1 had acute pancreatitis. AMA-Fab results were negative in 6 of 7 patients (85%) and positive in 1 (15%). Therefore, the sensitivity and specificity of AMA-Fab scintigraphy were 0.98 and 0.85, respectively. To assess accuracy in defining the extent and location of AMI, AMA-Fab results were compared with those of the electrocardiogram, echocardiogram, technetium-99m pyrophosphate myocardial scintigraphy and coronary angiography and left ventriculography. AMA-Fab scintigraphy showed a good concordance with the traditional techniques in the topographic definition of the infarcted regions. No uptake of AMA-Fab was seen in the regions of previous old infarcts. Ten healthy volunteers also underwent AMA-Fab scintigraphy. No evidence of myocardial tracer uptake was noted in them. No adverse reactions or side effects were noted after injection of AMA-Fab in any patient. It is concluded that planar myocardial scintigraphy with AMA-Fab is a reliable method for AMI detection and location.

[Thromboembolus migrating into the right heart in pulmonary embolism. Echocardiographic and clinico-therapeutic aspects in 7 cases and review of the literature]. / Tromboembolo migrante nelle cavità cardiache destre in corso di embolia polmonare. Aspetti ecocardiografici e clinico-terapeutici su 7 casi e revisione della letteratura.

We report the clinical, echocardiographic and therapeutic aspects and the evolution of 7 cases of right cardiac migrant thromboembolus in pulmonary embolism (5 M and 2 F, aged 43 to 91). Our data are also compared with all the cases reported in the literature (77 patients). During a sample year (1987) we systematically performed two-dimensional echocardiograms (2D Echo) as early as possible in all the patients admitted to our Coronary Care Unit for suspected pulmonary embolism; among 42 patients the diagnosis of pulmonary embolism was confirmed in 30 out of 42 patients. A relatively high incidence of thromboembolus was found (5/30, 17% in 1987); this finding seems to be relative to the early execution of the 2D Echo study (thromboembolus was found in 4/5 patients when 2D Echo was performed within 20 hours and in only 1/23 when 2D Echo was performed later). The 2D Echo was always evocative of freely floating migrant thromboembolus (6 in right atrium, 1 in right ventricle) and no differential diagnosis with thrombi in situ or other masses was necessary. The therapy for 6 patients hospitalized for pulmonary embolism and surviving the first hours (1 patient died immediately) was: surgical in 1 case, medical in the other 5. Medical therapy consisted only of heparin-calcium in one patient and heparin-calcium + dipyridamole in another because of contra-indications for more aggressive therapy. One patient underwent anticoagulant therapy with i.v. heparin. The remaining two underwent fibrinolytic therapy with urokinase and, afterwards, anticoagulant therapy: in 1 case the therapy was started after the embolization of the mass in the pulmonary artery had occurred; in the other one we observed the progressive reduction of thromboembolus until its disappearance within 5 days without any signs of further embolization. All patients survived and were discharged within 25 days, despite the occurrence of lung embolization in 4 of them. The review of 77 cases reported in the literature shows good outcomes for embolectomy when compared with medical therapy, but almost half of the patients underwent surgical therapy directly. Medical therapy experience, particularly with thrombolytic agents (10 cases in all), is still too scarce to exclude its role, as indeed our experience seems to indicate.

[Coronary angiographic study of patients with non-Q myocardial infarct: correlations with the initial electrocardiographic aspect and prognosis]. / Studio coronarografico nei pazienti con infarto miocardico non-Q: correlazioni con l'aspetto elettrocardiografico iniziale e la prognosi.

The purpose of our study was to evaluate, during the early phase, the coronary anatomy of the patients who suffered from an acute non-Q myocardial infarction (non-Q MI) and to correlate it with the ECG findings and with clinical evolution. We studied 76 patients (pts.), mean age 56 +/- 9 years, who had their a first non-Q MI (reinfarctions non included). They all underwent angiographic examination within an average period of 18 days (range 5-30 days). In the whole group of patients it is worthwhile noting: A) the elevated occurrence of left main lesions (11% of pts.) and multivessel disease (60%); B) the great percentage (41%) of patients with open infarct-related vessel but with very critical residual stenosis (above 90% of total lumen); C) the presence of collateral vessels in almost all the pts. (91%) with totally occluded infarct-related artery. During the 12 month follow-up, in all groups was a high occurrence (above 70%) of coronary events (postinfarction angina, reinfarction, aortocoronary by pass or PTCA). Furthermore, it is possible to identify a subgroup of patients presenting ST-segment depression with very unfavourable coronary anatomy (80% had multivessel disease, 30% of which had a left main critical stenosis) and high prognostic risk (90% occurrence of coronary events). In the subgroup with ST-segment elevation there was an elevated percentage (65%) of open infarct-related vessel, but with an important residual stenosis. Considering the advantages of revascularization interventions in these high risk patients with extensive residual jeopardized myocardium, we conclude that it is important that all patients with non-Q MI undergo early coronary angiography.

[Incidence and clinical significance of involvement of the right ventricle in acute inferior myocardial infarction]. / Frequenza e significato clinico del coinvolgimento del ventricolo destro in corso di infarto miocardico acuto inferiore.

UNLABELLED: The purpose of our study was to evaluate, with noninvasive procedures, the incidence and the clinical picture of right ventricular involvement in patients with acute transmural inferior myocardial infarction. Our study group was constituted of 107 consecutive patients admitted to our Coronary Care Unit within 10 hours from the onset of symptoms; in every patient a standard 12-leads ECG and the precordial leads V3R and V4R were obtained at admission in CCU and then every 12 hours. 80 patients underwent B-mode echocardiographic evaluation within 36 hours and in 93 patients a myocardial scintigraphy was performed, between the 48th and 72nd hour from the onset of chest pain, 1-2 hours after injection of Tc-99m-pyrophosphate. RESULTS: 45 patients (42.1%) had ECG positive for right ventricular infarction, 49 patients (51.6%) had positive Tc-99m-pyrophosphate scintigraphy and 24 patients (30%) positive echocardiography. By using the positivity of ECG and another method at least, patients were separated into 2 groups: group A (associated inferior and right infarction) was constituted of 45 patients, and group B (isolated inferior infarction) was constituted of 62 patients. In group A we noted a higher incidence of hypotension (systolic blood pressure less than 100 mmHg) and oliguria (less than 30 ml/h)- p less than 0.01-, of 2nd and 3rd A-V blocks-p less than 0.001- and primary ventricular fibrillation -p less than 0.01. The incidence of parossistic atrial fibrillation, severe bradycardia or SA blocks and of mortality was not statistically different between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)