Silent ischemia is more prevalent among hypertensive patients with microalbuminuria and salt sensitivity

Some patients with essential hypertension manifest greater than normal urinary albumin excretion (UAE). Salt-sensitive hypertensives also manifest greater UAE compared to salt-resistant individuals. Although the significance of these associations is not well established, several lines of evidence suggest that microalbuminuria and/or salt sensitivity may be associated with greater prevalence of cardiovascular risks and events. In this study, we have evaluated by ergometric exercise 42 subjects with microalbuminuria and 42 matched individuals with normal UAE. All these subjects also underwent a standardized protocol to determine blood pressure sensitivity to a high salt intake. Patients with microalbuminuria displayed greater levels of ambulatory blood pressure and a greater rise in systolic blood pressure during exercise compared to patients with normal UAE (33.1 +/- 1.56 vs 26.4 +/- 1.7 mmHg, P < 0.001). Seven hypertensive patients with microalbuminuria developed ST segment depression during exercise compared to only one subject with normal UAE. Salt-sensitive patients manifested greater UAE than salt-resistant subjects (58 and 14 mg, 24 h, P < 0.001) and greater prevalence of silent ischemia (6 vs 2) than salt-resistant individuals. In conclusion, these studies have shown that hypertensive individuals with microalbuminuria and/or salt sensitivity manifest an increased prevalence of silent ischemia.

Evidence of apoptosis via TUNEL staining in muscle biopsy from patients with mitochondrial encephaloneuromyopathies

Apoptosis is an evolution-conserved form of cell death essential for development and maintenance of tissue homeostasis. Dysregulation of apoptosis has been implicated in several pathological conditions, including neurodegenerative disorders. The crucial role of mitochondria in regulation of the apoptotic pathway prompted us to investigate the pattern of apoptosis in muscle biopsies from 17 patients with mitochondrial encephaloneuromyopathies caused by mtDNA defects. The results were compared with muscle biopsies from controls and from patients with myopathies without mitochondrial impairment. The terminal deoxynucleotidyl transferase-mediated dUTP nick and labelling (TUNEL) reaction was used as marker of apoptosis. Our findings were very heterogeneous, even between patients with the same mtDNA mutations, suggesting that tissue evaluation of apoptotic process is less useful than in vitro techniques, for investigating the role of apoptosis in mitochondrial pathologies.

Do CLL B cells correspond to naive or memory B-lymphocytes? Evidence for an active Ig switch unrelated to phenotype expression and Ig mutational pattern in B-CLL cells

Recent work suggests that chronic lymphocytic leukemia (B-CLL) expressing unmutated immunoglobulin V genes could correspond to the proliferation of naive B cells whereas those expressing mutated genes, may correspond to the proliferation of post-germinal center B cells. Current data from gene profiling expression have failed to demonstrate a clear-cut distinction between these two forms of B-CLL disease. In the present study, we have investigated the complete V(H) nucleotide sequence and the presence of RNA transcripts from different C(H) domains in 25 B-CLL patients. Our results demonstrate that: (1) expression of IgD is not related to the mutational frequency and activation of the isotype switch pathway; (2) isotype switch, leading to simultaneous expression at the transcriptional and protein level of IgM, IgD, IgG and IgA, occurs in a small percentage of patients, and (3) different mechanisms such as VDJ duplication and trans-splicing or RNA splicing of long nuclear transcript, could be involved in isotype switch. Our results highlight the difficulty in assigning a normal counterpart to B-CLL cells and raise the possibility that a different B cell development pathway, independent from classical germinal centers, might exist in B-CLL.

Quantitative real-time reverse transcription polymerase chain reaction: normalization to rRNA or single housekeeping genes is inappropriate for human tissue biopsies

Careful normalization is essential when using quantitative reverse transcription polymerase chain reaction assays to compare mRNA levels between biopsies from different individuals or cells undergoing different treatment. Generally this involves the use of internal controls, such as mRNA specified by a housekeeping gene, ribosomal RNA (rRNA), or accurately quantitated total RNA. The aim of this study was to compare these methods and determine which one can provide the most accurate and biologically relevant quantitative results. Our results show significant variation in the expression levels of 10 commonly used housekeeping genes and 18S rRNA, both between individuals and between biopsies taken from the same patient. Furthermore, in 23 breast cancers samples mRNA and protein levels of a regulated gene, vascular endothelial growth factor (VEGF), correlated only when normalized to total RNA, as did microvessel density. Finally, mRNA levels of VEGF and the most popular housekeeping gene, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), were significantly correlated in the colon. Our results suggest that the use of internal standards comprising single housekeeping genes or rRNA is inappropriate for studies involving tissue biopsies.

Pelvic haemophilic pseudotumour: management of a patient with high level of inhibitors

Haemophilic pseudotumour (HP) is a rare but very serious complication of haemophilia. HP affects mainly patients with severe haemophilia and those who have developed antibodies to factor VIII or factor IX. We report on a 45-year-old man with haemophilia A and high titres of inhibitors who developed an extensive HP with progressive destruction of the right ilium over a period of 12 years. The different therapeutic options (conservative management by replacement therapy, surgical approach, radiotherapy, percutaneous evacuation with secondary refilled cavity and transcatheter arterial embolization) are reviewed.

Quantification of the effect of mammographic screening on fatal breast cancers: The Florence Programme 1990-96

Breast cancer cases diagnosed in women aged 50-69 since 1990 to 1996 in the City of Florence were partitioned into those who had been invited to screening prior to diagnosis and those who had not. All cases were followed up for vital status until 31 December 1999. The cumulative number of breast cancer deaths among the cases were divided by screening and invitation status, to give the rates of cancers proving fatal within a period of 8 years of observation (incidence-based mortality). We used the incidence-based mortality rates for two periods (1985-86, 1990-96), pre and during screening. The incidence-based mortality ratio comparing 1990-96 and 1985-86 was 0.50 (95% CI : 0.38-0.66), a significant 50% reduction. For noninvited women, compared to 1985-86, there was a 41% significant mortality reduction (RR=0.59, 95% CI : 0.42-0.82). The comparable reduction in those invited was a significant 55% (RR=0.45, 95% CI : 0.32-0.61). The incidence ratio of rates of cancers stage II or worse was close to one when the noninvited in 1990-96 were compared with 1985-86 (RR=0.97, 95% CI : 0.78-1.21). Excluding prevalent cases, the rate of stage II+ breast cancer cases was 42% lower in Screened women compared with the noninvited (RR=0.58, 95% CI : 0.45-0.74). This study confirmed that new treatments and the first rounds of the screening programme contributed to reducing mortality from breast cancer.

Does family history influence survival in breast cancer cases?

A few studies have suggested a relatively better prognosis for breast cancer (BC) cases reporting a positive family history (FH). We aimed at comparing the survival of patients according to FH in a large hospital-based series of 1,278 BC cases. Information on FH for BC was obtained at diagnosis by interview. All cases reporting a first- or second-degree FH for breast carcinoma were compared with cases without FH. Overall survival was estimated using a product-limit method. Hazard ratios (HRs) and the corresponding 95% confidence intervals (95% CIs), adjusted for confounding factors, were computed using proportional hazard models. Overall, 240 (18.8%) cases reporting, at diagnosis, a positive FH (156 with at least 1 first-degree relative and 84 with at least 1 second-degree relative) were compared with 1,038 patients without FH for BC. No significant differences were found in terms of distribution of age at diagnosis, tumor stage, nodal involvement, receptor status and histology. Cumulative survival rates at 5 years for cases without FH and with first-degree and second-degree FH for BC were 79.8 (95% CI 77.0-83.0), 78.6 (95% CI 70.0-88.0) and 80.2 (95% CI 68.0-92.0), respectively (log-rank test, chi(2) (2) = 0.02, p = 1.0). After adjustment for age, pathologic size and nodal involvement, the HR among cases of invasive cancer with a first-degree FH of BC was 0.91 (95% CI 0.55-1.48); however, the HR for cases with second-degree FH was 1.18 (95% CI 0.62-2.25) compared to cases without FH. Our study, based on a large series of consecutive invasive BC cases, did not find any significant survival differences associated with a positive FH for breast carcinoma, suggesting the existence of a large heterogeneity among BC cases with FH.

Vascular endothelial growth factor and prognosis in patients with node-negative breast cancer

Vascular endothelial growth factor (VEGF) has emerged as one of the most important angiogenic growth factors from experimental in vitro and in vivo studies. In the present study, we investigated the relationship between VEGF expression and microvessel density (MVD) and defined their prognostic relevance on a series of 242 patients with node-negative breast cancer, using immunohistochemical methods. In parallel, estrogen and progesterone receptors were quantitatively assessed using the dextran-charcoal technique and cell proliferation was evaluated as S-phase cell fraction according to (3)H-thymidine-labeling index (TLI). The percentage of VEGF-expressing cells varied from 0-95% in the different tumors and was unrelated to menopausal status, tumor size or steroid receptor status. Conversely, a significant inverse relation was observed with patient age or tumor cell proliferation, albeit with very poor correlation coefficients. A significant relation was observed between VEGF expression and MVD (r(s) = 0.55, p < 0.001). Clinical outcome analyzed as a function of high and low VEGF expression showed slight differences in terms of both disease-free survival (DFS) and overall survival (OS) that never reached statistical significance. Moreover, the trend was paradoxically in favor of patients with highly VEGF-expressing tumors. Finally, DFS and OS curves, when analyzed as a function of VEGF expression or MVD, were superimposable. In conclusion, our study did not highlight a prognostic relevance of VEGF expression in patients with node-negative breast cancer, as already observed for MVD.

Secondary omental torsion in children: report of two cases and review of the literature

Torsion of the greater omentum (TGO) may be due to a congenital abnormal attachment of its free edge. There are no specific symptoms that allow a preoperative differential diagnosis of this condition from common pathologies such as acute appendicitis. Attachment of the omentum to the large bowel and the absence of concomitant diseases make it possible to distinguish TGO secondary to a congenital attachment anomaly from omental infarction, primary TGO, and TGO secondary to an acquired attachment anomaly (attachment to cysts, tumours, hernias, surgical scars, or perforated bowel segments). Resection of the ischaemic portion of the omentum permits complete resolution of the clinical symptoms. The authors report two cases of TGO in children due to abnormal attachment of the greater omentum to the ascending and transverse colon, respectively.

Assessment of the early impact of the population-based breast cancer screening programme in Florence (Italy) using mortality and surrogate measures

The aim of this study was to evaluate the effects by the end of 1999 of the Florence breast screening programme that started in 1990. Approximately 60000 women (aged 50-69 years) were enrolled from 1990 to 1993. Breast cancer cases diagnosed from 1990 to 1996 were partitioned by the method of detection, classified by their tumour size and nodal status and followed-up for mortality at on the 31 December 1999. Incidence-based mortality in the 50-74-year-old women and advanced carcinomas rates were assessed. Due to low compliance (approximately 60%) and the long enrollment phase, only approximately 35% of the total age-specific population person-years were screened. The number of invasive cases diagnosed was 1122, 17% higher than the 958 expected. After the prevalence screening, a reduction of approximately a quarter in advanced carcinomas was observed in the invited women (Odds Ratio (OR): 0.74; 95% Confidence Interval (CI): 0.55-0.98). In the period 1990-1999, 547 breast cancer deaths were observed: 78 (14%) occurred in women invited and half of these in never responders, 385 (70%) occurred in cases diagnosed before screening started. Disproportionate numbers of deaths occurred in women with advanced tumours. The 19% mortality reduction for the invited women was of borderline statistical significance (observed/expected (O/E) deaths: 0.81; 95% CI: 0.64-1.01); by a one-sided test the result would be unequivocally significant. The mortality reduction attributable to screening in the whole population over the 10-year period was 3.2%. The incidence-based mortality analysis confirmed the current follow-up time is too short for screening to have had a major effect on the breast cancer mortality trends. Screening performance might be improved by a higher level of compliance and shorter interval times, but the estimate of the mortality reduction for the invited and the lower rate of advanced carcinomas confirmed that the effect of the programme is in the expected direction.

Diagnostic imaging of tumors of the hand and wrist

Tumors of the hand and wrist most commonly result from dystrophic lesions and hamartomas. Neoplastic lesions are rare. Imaging modalities are required for their detection and accurate location, careful assessment of the internal structure and borders, evaluation of the relation with surrounding tendons, nerves, and vessels, and are also required for staging. A variety of imaging techniques, including standard radiographs, sonography, CT, and MRI, can be obtained. The aim of this article is to present paradigmatic images of a variety of expansible lesions of the hand and wrist and to describe and compare the diagnostic findings of different imaging techniques.

Congenital true pancreatic cyst in pediatric age: case report

Congenital pancreatic cysts are rare lesions in pediatric age. We present a case of congenital true pancreatic cyst in otherwise asymptomatic boy aged 4 years. Clinical history, laboratory, imaging, immunohistological findings and surgical treatment are also described.

Ultrasound of the elbow

Ultrasonography (US) is an efficient alternative to magnetic resonance (MR) imaging for evaluation of soft tissues of the elbow. US is able to diagnose several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint. In cubital tunnel syndrome, US identifies ulnar nerve abnormalities and extrinsic lesions that may cause nerve entrapment. Occult fractures, osteophytes and intra-articular loose bodies can also be imaged. In para-articular swelling, US is able to assess the presence of capsular and synovial processes and to differentiate them from soft tissue tumors. Key advantages of this technique include cost-effectiveness, availability and ability to perform a dynamic examination.

Post-operative GnRH analogue treatment after conservative surgery for symptomatic endometriosis stage III-IV: a randomized controlled trial

BACKGROUND

In order to decrease endometriosis recurrence after surgical therapy, it has been proposed to use a post-surgical oestrogen-lowering medical treatment. Results from previous trials on this topic are contradictory.

METHODS

A total of 89 women were randomized, by computer-generated list, after laparoscopic conservative surgery for symptomatic endometriosis stage III-IV to receive monthly i.m. injections of gonadotrophin-releasing hormone (GnRH) analogue, leuprolide acetate depot (3.75 mg) for 3 months (n = 44) or to an expectant management (n = 45). All patients were followed up every 6 months for evaluation of pain symptoms, fertility and objective disease recurrence.

RESULTS

During the follow-up, which ranged from 6-36 months, five (33%) of the 15 women who wanted children and who were allocated the GnRH analogue and six (40%) of the 15 given no treatment became pregnant (not significant). Moderate/severe pelvic pain recurred during the follow-up in 10 (23%) of the women allocated the GnRH analogue and 11 (24%) of those allocated no treatment; the cumulative pain recurrence rates at 18 months were 23 and 29% respectively (not significant). Four women (9%) treated with GnRH analogue and four women (9%) who received no treatment had objective disease recurrence as demonstrated by gynaecological examination and/or pelvic ultrasonography.

CONCLUSIONS

This study does not support the routine post-operative use of a 3 month course of GnRH analogue in women with symptomatic endometriosis stage III-IV.

Genetic leukoencephalopathies with unknown metabolic pathogenesis

The authors describe the principal forms of genetic leucodystrophies with unknown metabolic pathogenesis, indicating their main clinical signs and the new findings concerning the molecular genetic that are useful for the laboratory confirmation of the clinical suspicion.

Ultrasound of the elbow

This article describes the use of ultrasound (US) in the evaluation of the elbow. US is able to visualize several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint as well as to delineate the nature of soft-tissue swelling, such as a space-occupying lesion or synovial enlargement. Occult fractures, osteophytes and intra-articular loose bodies can be depicted with this technique as well. At the cubital tunnel, US allows accurate imaging of the ulnar nerve and to document changes that occur in compressive syndromes. Over other imaging modalities, US offers several key advantages, including cost effectiveness, availability and ability to perform a dynamic examination of tendon movement and joint motion. With continued experience, it is likely that the use of US will increase further with regards to evaluation of soft-tissue abnormalities of the elbow.

Ultrasound of the hand

A recent development of high resolution transducers has increased the possibility to evaluate the most superficial body structures. The assessment of the normal anatomy and of the pathological changes of the hand and the wrist has become popular among musculoskeletal sonologists and nowadays ultrasound is considered one of the first line imaging techniques in the assessment of this district. Ultrasound must always be performed after a standard radiograph since the association of the two techniques can diagnose a wide variety of disorders. Some lesions however cannot be detected and require more invasive and expensive modalities (CT, MRI, CT and MRI arthrography). The goal of this article is to present the ultrasound appearance of inflammatory and traumatic diseases of the hand and wrist as well as the findings in entrapment neuropathies and soft tissue tumors.

Human gastrocnemius medialis pennation angle as a function of age: from newborn to the elderly

The aim of the present study was to quantify changes in human skeletal muscle pennation angle (F theta) values during growth and adult life. The human gastrocnemius medialis muscle of 162 subjects (96 males and 66 females) in the age range 0-70 years was scanned with ultrasonography. The subjects were laying prone, at rest, with the ankle maintained at 90 degrees with all muscles relaxed. F theta increased monotonically starting from birth (0 years) and reached a stable value after the adolescent growth spurt. There was a significant (p < 0.05) linear relationship between F theta and muscle thickness (TK). F theta = 0.84 (+/- 0.09) * TK + 3.15 (+/- 1.13). Human gastrocnemius medialis F theta and TK data found in the literature seem to fit the F theta-TK plot in a coherent manner, independent of the physiological or anatomical characteristics of the subject. The present findings indicate that F theta is not a constant parameter but evolves, as is the case for bone length and height, as a function of age.

Age dependence of human gastrocnemius Mg2+: fitting 31P-NMR spectra using quantum mechanics-based prior knowledge

The age dependence of human gastrocnemius Mg2+ concentration is demonstrated. To quantitate Mg2+ concentration, an original and accurate fitting algorithm using quantum mechanics-based prior knowledge is detailed. In a group of 28 volunteers (14 females) in the age range 5-80 years, pH, PCr/ATP and Pi/ATP values in the gastrocnemius were 7.02 +/- 0.02 pH, 4.16 +/- 0.33 and 0.13 +/- 0.02, respectively and independent of age and sex. By contrast, intracellular Mg2+ concentration (mM) decreased linearly (p < 0.05) with age (Mg2+ = 0.7803 +/- 0.0247-0.0027 +/- 0.0005 * age). No difference was found between sexes. From these results, it follows that care must be taken when comparing muscle Mg2+ data from subjects of different age. The hypothesis can be put forward that during aging insufficient intake and/or increased depletion of Mg2+ (e.g., intestinal hypoabsorption or urinary leakage) may affect the musculoskeletal system.

[Somatostatin receptors in non-endocrine tumours]

The study of the antiproliferative action of somatostatin (ss) is important not only to understand the regulation of neuroendocrine tumours that express receptors (sst), but also non-endocrine tumours which express these receptors. We previously demonstrated the presence of sst2 in a wide panel of cell lines from human neuroblastoma. Although hypotheses have been put forward that treatment with ss or its analogs may be beneficial in oncological patients, this does not appear to be the case in neuroblastoma; patients with high sst2 levels (who are therefore sensitive to ss treatment) have per se a relatively positive outcome. Therefore, adjuvant treatment with ss is not necessary. Viceversa, patients with a poor prognosis are essentially characterized by a low expression of sst2 (and therefore are insensitive to a therapy with ss). In these patients adjuvant treatment with ss might be indicated, but would have little chance of success. Although the majority of neuroendocrine tumours expresses sst2, pancreas and prostate cancer express sst1 but not sst2, and are therefore insensitive to octreotide treatment which binds preferentially to sst2. Tumours like colorectal carcinoma and breast cancer also express sst2 in their more favourable forms. However, the concentration of sst2 in colorectal cancer is similar, if not lower than that in the surrounding normal tissue. Therefore, the probability of successful adjuvant therapy with ss is relatively low. In breast cancer, it is possible that sensitivity to estrogens may have a positive influence on the expression of sst2. This might justify clinical trials with ss in breast cancer.

[Reconstruction of the vas deferens: an experimental study on the rat]

BACKGROUND

A microsurgical technique for reconstruction of the vas deferens on an absorbable transanastomotic stent in the rat is described.

METHODS

A microsurgical end-to-end anastomosis of the vas deferens was performed in a group of 10 rats (group A) by suturing with Nylon 10-0 interrupted stitches. In another 10 rats (group B) the same microsurgical anastomosis was performed after insertion of a 0.5 cm long intraluminal chromic catgut 4.0 stent.

RESULTS

Sixty days postoperatively all 20 animals were submitted to roentgenography of the vas deferens. The vas deferens proved radiographically undetectable in 8/10 rats in the unstented group A (80%), whereas the entire course of the vas could be traced in 9/10 rats in group B (90%).

CONCLUSIONS

The encouraging results obtained with this alternative technique, even on structures of limited diameter, suggests that it may be possible to use this procedure in children.