Beneficial effects of C1 esterase inhibitor in ST-elevation myocardial infarction in patients who underwent surgical reperfusion: a randomised double-blind study.

BACKGROUND: The inflammatory cascade has been hypothesized to be an important mechanism of post-ischaemic myocardial reperfusion injury and several studies demonstrated that C1 esterase inhibitor (C1-INH) is effective in post-ischaemia myocardial protection. Therefore, we aimed to investigate prospectively in a randomised double-blind study the cardioprotective effects of C1-INH in ST segment elevation myocardial infarction (STEMI) in patients who underwent emergent reperfusion with coronary artery bypass grafting (CABG). METHODS: In this study, we enrolled 80 patients affected with STEMI who underwent emergent CABG. Patients were assigned in two groups (C1-INH group: receive 1000 UI of C1-INH; and placebo group: receive a saline solution). The effects of C1-INH on complement inhibition, myocardial cell injury extension and clinical outcome were studied. Haemodynamic data and myocardial function were monitored. C1-INH, C3a, C4a complement activation fragments and cardiac troponin I (cTnI) serum levels were measured before, during and after surgery. RESULTS: Patient characteristics were not different between the two groups. The overall in-hospital mortality rate was 6.2%. No statistical significant difference was observed between the two groups with regard to early mortality (p=0.36). Statistical significant difference between the two groups was showed for cardiopulmonary bypass support (p=0.04), administration of high dose of inotropes drugs (p=0.001), time of intubation (p=0.03), intensive care unit (ICU) stay (p=0.04) and in-hospital stay (p=0.03). A significant improvement in mean arterial pressure (p=0.03), cardiac index (p=0.02) and stroke volume (p=0.03) was showed in C1-INH group versus placebo group. The serum cTnI levels were significantly low in the C1-INH group versus placebo group after reperfusion, during the observation period. Plasma levels of C3a and C4a complement fragments were reduced significantly in C1-INH group. No drugs-related adverse effects were observed. CONCLUSIONS: The inhibition of the classic complement pathway by C1-INH appears to be an effective mean of preserving ischaemic myocardium from reperfusion injury as demonstrated by low serum cTnI levels in C1-INH group. Therefore, the use of C1-INH during CABG as a rescue therapy in STEMI patients is probably an effective treatment to inhibit complement activity and to improve cardiac function and haemodynamic performance without impacting early mortality. Large randomised study should be performed to support our results.     

Video-EEG Study of Psychogenic Nonepileptic Seizures: Differential Characteristics in Patients with and without Epilepsy

Summary:  Purpose: Psychogenic nonepileptic seizures (PNES) are episodes that may resemble epileptic seizures (ES) but are not associated with abnormal electrical discharges in the brain. Video-EEG recording of a typical episode is considered the best diagnostic tool available. PNES are, however, also documented in patients with epilepsy (PNES/ES). The purpose of this study was to assess this comorbid population, focusing on the differences between patients with PNES/ES and patients with PNES alone.
Methods: We reviewed 110 PNES episodes, occurring spontaneously or induced by means of suggestion techniques, recorded in our video-EEG laboratory over a period of eight years. We identified two subgroups of patients, consisting of 85 PNES cases and 25 PNES/ES cases, and assessed any differences in their characteristics by reviewing a number of variables (age, sex, clinical features, antiepileptic therapy, age of onset, time to diagnosis, pathological history, and length of follow-up).
Results: The comparison between the two subgroups revealed that PNES/ES patients displayed some statistically significant differences when compared with PNES alone patients, i.e., younger age, a higher percentage of spontaneously activated events, a shorter disease duration, a longer time to PNES diagnosis, and a lower percentage lost at follow-up.
Conclusions: This study confirms that PNES is a common, though probably underestimated, occurrence in epilepsy services. Our results shed light on some different characteristics between PNES and PNES/ES patients.     

RT-PCR-RFLP for genetic diversity analysis of Tunisian Grapevine fanleaf virus isolates in their natural host plants

Genetic diversity was characterized in 20 isolates of Grapevine fanleaf virus (GFLV) recovered from naturally infected grapevine plants (Vitis vinifera) in the North of Tunisia. Viral RNAs were isolated by oligoprobe capture, and a 605 bp fragment containing a part of the viral coat protein gene was amplified by RT-PCR. Sequence variation among isolates was characterized by restriction fragment length polymorphism (RFLP) analysis and confirmed by sequencing. The GFLV infections are found as a complex mixture of closely related genomes. In further studies, RFLP analyses of virus isolates using AluI showed that GFLV populations in Tunisian vineyards consist of two restrictotypes corresponding to distinct sub-populations Sp1 and Sp2. The relative field distribution of these sub-populations showed that Sp2 was more abundant. Individual genomes were recovered by cloning the RT-PCR products. The sequences were found to vary from each other by as much as 11%. Cloning from mixed infections showed that Sp2 are also predominant.     

Paraneoplastic rheumatic syndromes: report of eight cases and review of literature

Malignant neoplasms are associated with a wide variety of paraneoplastic rheumatological syndromes. The paraneoplastic nature should be based on specific criteria. We report a series of eight cases of paraneoplastic rheumatic syndromes revealing an underlying neoplasia. Our series consists of six men and two women, with a mean age of 46.1 (20-69?years). The first case is a hypertrophic osteoarthropathy of Pierre Marie that occurred in a 20-year-old man 1?month after treatment for his nasopharyngeal carcinoma; the paraclinical examinations showed lung and bone metastasis. The second case is that of a bilateral shoulder-hand syndrome revealing an invasive squamous cell carcinoma of the cervix in a 63-year-old woman. The third case involved a 69-year-old patient who had surgery 2?years ago for prostate adenocarcinoma and presented with polymyalgia rheumatica revealing bone metastasis. We also report two cases of leukemia in adults revealed by polyarthritis. The sixth observation is that of a paraneoplastic scleroderma that occurred concomitantly with prostate cancer. The seventh case of an acute arthritis showed a B lymphoma. The eighth case is that of a 52-year-old patient who presented with inflammatory arthralgias, and digital clubbing revealing a squamous cell carcinoma of the skin. Paraneoplastic rheumatism remains a rare event, but knowledge of it is essential for early diagnosis of underlying cancer.     

Comparison of the BASDAI and the miniBASDAI in assessing disease activity in patients with ankylosing spondylitis

The BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is the most widely used instrument for the assessment of disease activity in ankylosing spondylitis (AS). Objective. The aims to investigate whether the alternative BASDAI, here termed as the miniBASDAI [(Question (Q) 1 fatigue + Q2 spinal pain) + mean of (Q5 strength morning stiffness + Q6 duration morning stiffness)] / 3], measures disease activity more accurately in the subgroup of AS patients without peripheral manifestations. One hundred and ten patients were included in this cross-sectional study according to the modified New York criteria for AS. Clinical and biological parameters were evaluated. The disease activity was evaluated by the BASDAI. We calculated the miniBASDAI by omitting both the peripheral joints and the enthesitis questions: questions 3 and 4. Patients were dichotomized into a “P+” group if peripheral manifestations were present (at least arthritis or enthesitis) and a “P−” group, the subgroup without peripheral involvement (with either arthritis or enthesitis). Correlation of the BASDAI and miniBASDAI with other disease parameters were examined with the Spearman's rank correlation analysis. One hundred and ten patients were recruited. The percentage of patients with pure axial disease manifestation without peripheral involvement “P − group” was 42.7%. We found a similarly good correlation of the miniBASDAI with patient global, physician on disease activity, BASFI, ESR and CRP if compared to the correlation of the original BASDAI with these disease parameters, also in the group without peripheral involvement. Our study suggests that the BASDAI remains valid in assessing disease activity in AS patients with and without peripheral manifestations.     

Left ventricular thrombosis after blunt chest trauma

A 22-year-old man was admitted to our observation with left ventricular thrombus arising after blunt chest trauma occurring during a ski accident one year before. None was obtained from a review of instrumental and laboratory data at trauma time. Transesophageal echocardiography showed an intraventricular thrombus and severe hypokinesia at the apex. Standard cardiac surgery procedure was performed and postoperative period was uneventful. Echocardiography controls at 6/12 months showed a normal apex kinesia. This case shows the importance of hospitalization, hemodynamics monitorization and late serial echocardiographic controls for timely diagnosis and management of myocardial contusion and consecutive ventricular thrombus formation to prevent life-threatening complications.     

The descending branch of lateral femoral circumflex artery in arterial CABG: early and midterm results

BACKGROUND: Different arterial conduits have been used for coronary artery bypass grafting (CABG), avoiding remote cardiac events associated with graft failure and improving the quality and expectancy of life in patients with coronary artery disease. The goal of this study was to evaluate the early and midterm results of total arterial CABG with the descending branch of the lateral femoral circumflex artery (DLFCA). METHODS: Between February 1997 and December 2001, 147 patients underwent arterial CABG using the DLFCA at our department. The patients were followed to determine perioperative cardiac events. Angiographic follow-up controls were performed at the end of surgery in 81 patients (55.1%), within 1 year in 82 patients (55.7%), and within 3 years in 48 patients (32.6%). The actuarial survival and event-free rates, the occurrence of late cardiac events and death, the cumulative rate of the DLFCA graft patency, and the incidence of spasm were investigated. RESULTS: The DLFCA was used in all patients (113 men and 34 women, with a mean age of 56 +/- 12.6 years). The proximal anastomoses of the DLFCA was performed with the left internal mammary artery (LIMA) in 95% and with the right internal mammary artery (RIMA) in 5% of patients. The distal anastomoses of the DLFCA was performed with the left anterior descending (LAD) coronary artery in 3.5%, with the diagonal artery in 17%, with the intermedius ramus in 7.5%, with the posterior interventricular artery in 2%, and with the branch of circumflex artery in 70% of patients. The in-hospital mortality and morbidity rates were 0% and 7.4%, respectively. Complications related to DLFCA harvesting was transient dysesthesia of the thigh, observed in 6 patients (4%). No postoperative myocardial infarction attributable to DLFCA bypass was observed. During the late follow-up period of 22.09 +/- 16.8 months, cardiac events were observed in 14 patients (9.5%), including recurrence of angina in 6, arrhythmia requiring hospitalization in 4, congestive heart failure in 2, percutaneous transluminal angioplasty in 1, and sudden death in 1 patient. Actuarial 1- and 3-year survival rates after surgery were 100% and 99.3%, respectively. Actuarial 1- and 3-year event-free rates were 97.3% and 90.5%, respectively. Actuarial 1- and 3-year patency rates were 97.5% and 93.7%, respectively. CONCLUSIONS: No adverse effects were exhibited after CABG using the DLFCA graft in this early and midterm follow-up period. The excellent patency rate of DLFCA and the low incidence of spasm stimulate us to continue and extend the use of the DLFCA in CABG.