Dopamine receptors in human platelets

The expression of dopamine receptors by human platelets was investigated by Western blot analysis and immunocytochemical techniques using antibodies raised against dopamine D1-D5 receptor protein. The influence of dopamine D1-like and D2-like receptor agonists on adrenaline-induced platelet aggregation was also investigated. Western blot analysis revealed that platelet membranes bind anti-dopamine D3 or D5 receptor protein antibodies, but not anti-D1, D2 or D4 receptor protein antibodies. Cytospin centrifuged human platelets exposed to anti-dopamine D3 or D5 receptor protein antibodies developed a specific immune staining, whereas no positive staining was noticeable in platelets exposed to other antibodies tested. Both the D1-like receptor agonist 1-phenyl2,3,4,5-tetrahydro-(1H)-3-benzazepine-7,8-diol hydrochloride (SKF 38393) and the D2-like receptor agonist 7-hydroxy-N,N-di-n-propyl-2-aminotetralin (7-OH-DPAT) dose-dependently inhibited adrenaline-induced platelet aggregation. These effects were decreased respectively by the D-like and D2-like receptor antagonists R(+)-2,3,4,5-tetrahydro-3-methyl-5-phenyl-1H-3-benzazepin-7-ol hydrochloride (SCH 23390) and (-)sulpiride. The above findings indicate that human platelets express dopamine D3 and D5 receptors probably involved in the regulation of platelet function.

Interferon-beta dose and efficacy: the OPTIMS study

Interferon beta (IFN-beta) reduces exacerbation rates in patients with relapsing-remitting multiple sclerosis (MS), but some patients do not respond to treatment. Recent studies have shown a clear dose-response effect on the reduction of exacerbation rates, and on burden of disease accumulation and active lesion frequency seen on MRI. During treatment with 8 MIU IFN-beta we noticed a 30% rate of treatment failure. We then treated non-responders with 12 MIU IFN-beta and observed significant improvement in the clinical signs of disease activity. In order to compare the efficacy of two different doses of IFN-beta-1b, a multicenter study for the optimization of interferon for MS (OPTIMS) has been organized. The design of the study is presented here.

Kaposi's sarcoma following allogeneic hematopoietic stem cell transplantation for chronic myelogenous leukemia

Unlike solid organ transplantation, Kaposi's sarcoma (KS) occurs rarely following hematopoietic stem cell transplantation (HSCT). In fact, only 5 cases of KS have been reported after allogeneic or autologous HSCT. The usual treatment combines a substantial decrease in, or elimination of, immunosuppressive therapy along with local measures such as surgical excision, cryotherapy or radiation therapy. A 46-year-old woman with chronic myelogenous leukemia who had received an allogeneic HSCT previously from an HLA-identical sibling, presented on day +814 with human herpes virus-8-associated KS involving her left lower extremity. She had been on continuous immunosuppressive therapy since her transplant because of chronic graft-versus-host disease. The intensity of immunosuppressive therapy was decreased once a diagnosis of KS had been established. However, the nodular lesions continued to progress in size and number. Therefore, a course of irradiation was administered to sites of bulk disease on her legs. Furthermore, thalidomide was initiated along with a topical retinoid, alitretinoin 0.1% gel applied twice daily to the nonirradiated lesions. This approach yielded a partial response in both irradiated and nonirradiated lesions over the course of the following 7 months. Both thalidomide and alitretinoin 0.1% gel appear to be beneficial in HSCT-associated KS and exhibit tolerable side effects.

Anti-GM1 and anti-sulfatide antibodies in polyneuropathies. Threshold titers and accuracy

OBJECTIVES

To determine threshold titers and diagnostic accuracy of anti-GM1 and anti-sulfatide antibodies (Ab) for autoimmune polyneuropathies (PN) in overall and for particular subtypes of them.

MATERIALS AND METHODS

In this study 84 PN patients, 120 epileptics and 93 healthy controls' sera were tested by enzyme-linked immunosorbent assay for autoAbs and results confirmed by thin-layer chromatography. Frequencies of positive patients at increasing cut-off were compared to determine threshold titers. Accuracy was determined by Receiver Operator Characteristic analysis.

RESULTS

A 1:2,000 titer for IgM anti-GM1 and a 1:4,000 titer for IgM anti-sulfatide Ab resulted to be threshold titers for autoimmune PN in overall. IgM anti-GM1 and anti-sulfatide Ab had low discriminating capacity between autoimmune PN and other PN, but good discriminating capacity between motor neuropathy (for anti-GM1 Ab) or PN in IgM-paraproteinemia or chronic painful sensory axonal PN (for anti-sulfatide Ab) and other PN.

CONCLUSION

Our results suggest that testing IgM anti-GM1 or anti-sulfatide Ab is useful only for diagnostic confirmation of specific subtypes of autoimmune PN.

The dopaminergic system in hypertension

Dopamine exerts cardiovascular and renal actions mediated through interaction with specific dopamine receptors. Dopamine receptors are cell surface receptors coupled to G-proteins and classified into two main super families based on biochemical, pharmacological and molecular characteristics. The dopamine D1-like receptor super family includes D1 and D5 receptors, known also in rodents as D1A and D1B sites. These receptors are linked to stimulation of adenylate cyclase. The dopamine D2-like receptor super family includes D2, D3 and D4 receptors. These receptors are linked to inhibition of adenylate cylase or not related with this enzyme activity. They also interfere with opening of Ca+2 channels and are linked to stimulation of K+ receptors. Dopamine receptor subtypes are expressed in brain as well as in extracerebral structures such as the heart, blood vessels, carotid body, kidney, adrenal gland, parathyroid gland and gastrointestinal tract. In the kidney, which represents the peripheral organ where dopamine receptors were more extensively investigated, dopamine receptors are involved in regulation of hemodynamic, electrolyte and water transport, as well as renin secretion. Hypertension-related dopamine receptor changes were also investigated primarily in the kidney. Defective renal dopamine production and/or dopamine receptor function have been reported in human primary hypertension as well as in genetic models of animal hypertension. There may be a primary defect in D1-like receptors and an altered signalling system in the proximal tubules that lead to reduced dopamine-mediated effects on renal sodium excretion in hypertension. Studies on the influence of hypertension on dopamine D2-like receptors are sparse Disruption of either D1A or D3 receptors at the gene level causes hypertension in mice. Using peripheral blood lymphocytes as possible markers of the status of dopamine receptors in essential hypertension, no changes of dopamine D1-like receptors were noticeable, whereas an increase of dopamine D2-like receptors likely representing an up-regulation mechanism was reported. Available information collectively indicates an involvement of peripheral dopaminergic system in hypertension consisting either in impaired receptor transduction mechanisms and/or in receptor loss. A better knowledge of molecular bases of these changes may contribute to the development of specific therapeutic approaches in the future.

Influence of age on L-type Ca2+ channels in the pulmonary artery and vein of spontaneously hypertensive rats

The influence of age on the density and localization of L-type Ca2+ channels was studied during development of hypertension in the pulmonary artery and vein of spontaneously hypertensive rats (SHR) and age-matched normotensive Wistar-Kyoto (WKY) rats by radioligand binding assay and light microscope autoradiography. SHR were examined at 6 weeks (juvenile, pre-hypertensive stage), 12 weeks (young, developing hypertension) and 24 weeks (mature, established hypertension). The dihydropyridine-type Ca2+ antagonist [3H]nicardipine was used as a radioligand. It was bound specifically to sections of rat pulmonary artery and vein. Dissociation constant (Kd) values were similar in WKY rats and SHR, whereas maximum density of binding sites (Bmax) values increased in SHR in comparison with WKY rats. This increase was noticeable from the pre-hypertensive phase. The pharmacological profile of [3H]nicardipine binding was similar in different age groups of either normotensive and hypertensive rats. Quantitative analysis of autoradiographs from SHR revealed a progressive increase of silver grains in smooth muscle of tunica media and to a lesser extent in the adventitia of pulmonary artery but not of pulmonary vein from pre-hypertensive stage to developing hypertension. No further changes were observed in established hypertension. The above data indicate that the density of L-type Ca2+ channels of pulmonary arteries is increased in SHR. This augmentation after the pre-hypertensive phase suggests the occurrence of dysregulation of Ca2+ handling in the pulmonary vasculature of developing SHR.

Reduced density of dopamine D2-like receptors on peripheral blood lymphocytes in Alzheimer's disease

Clinical and pathological evidence points to an involvement of dopamine in Alzheimer's disease (AD). The present study was designed to assay dopamine D1-like and D2-like receptors on peripheral blood lymphocytes (PBL) in 20 patients with AD and in 25 healthy controls by radioligand binding assay techniques with [3H][R]-(+)-(-)chloro-2,3,4,5 tetrahydro-5-phenyl-1H-3-benzazepin-al-hemimaleate (SCH 23390) and [3H]7-hydroxy-N,N-di-n-propyl-2-aminotetraline (7OH-DPAT) as radioligands. The density of dopamine D1-like receptors and the affinity of [3H]SCH 23390 and [3H]7OH-DPAT binding to PBL were similar in both groups investigated. AD patients revealed a lower density of dopamine D2-like receptors on PBL than controls (P=0. 0016). The pharmacological profile of [3H]SCH 23390 and [3H]7OH-DPAT binding to PBL was consistent with the labeling of dopamine D5 and D3 receptor subtypes, respectively. The reduced density of dopamine D2-like receptors on PBL is consistent with the observation of changes in the expression of D2-like receptors in dopaminergic brain areas in AD. Our findings support the hypothesis of an involvement of dopamine in AD, even in those patients with no evidence of Parkinsonism, behavioral abnormalities or psychosis.

Dopamine receptor immunohistochemistry in the rat choroid plexus

1. Earlier studies have demonstrated a high density of dopamine D1-like receptor binding in the choroid plexus by light microscope autoradiography, but the dopaminergic specificity of this binding was questioned. 2. In this study the localization of dopamine receptor subtypes was investigated in the rat choroid plexus by Western blot analysis and immunohistochemistry using antibodies raised against dopamine D1-D5 receptor protein. 3. Western blot analysis revealed reactivity with immune bands of approximately 50 and 51 KDa corresponding to dopamine D1 and D5 receptors, respectively. Dopamine D1-like (D1 and D5) receptor protein immunoreactivity insensitive to superior cervical ganglionectomy was located in smooth muscle of choroid arteries and to a larger extent within choroid plexus epithelium. 4. Western blot analysis revealed reactivity with immune bands of approximately 53 KDa and 40-42 KDa corresponding to dopamine D2 and D4 receptors, respectively, and no dopamine D3 receptor reactivity. Dopamine D2-like receptor protein immunoreactivity displayed a distribution similar to that of tyrosine-hydroxylase (TH)-immunoreactive sympathetic fibres and disappeared after superior cervical ganglionectomy. It consisted in the expression of dopamine D2 and to a lesser extent of D4 receptor protein immunoreactivity perivascularly and associated with choroid epithelium. No D3 receptor protein immunoreactivity was found in rat choroid plexus. 5. The above results indicate that rat choroid plexus expresses dopamine receptor protein, being dopamine D1-like receptors predominant in epithelium and arterial smooth muscle and D2-like receptors in sympathetic nerve fibres supplying choroid plexus epithelium and vasculature. 6. These findings suggests that dopamine receptors with a different anatomical localization may modulate production of cerebrospinal fluid.

In situ hybridization and immunocytochemistry of alpha1-adrenoceptors in human peripheral blood lymphocytes

1 alpha1-Adrenoceptor subtypes were investigated in cytospin centrifuged preparations of human peripheral blood lymphocytes by in situ hybridization and immunocytochemistry. 2 In situ hybridization cytochemistry revealed alpha1A-, alpha1B-, and alpha1D-receptor mRNA in human peripheral blood lymphocytes. Lymphocytes hybridized for alpha1A receptor subtype represented approximately 30% of total lymphocytes, those hybridized for alpha1Beta- and alpha1D-receptor subtypes averaged 42 and 25% of total lymphocytes, respectively. 3 Cytospin centrifuged lymphocytes exposed to anti-alpha1A-, alpha1Beta- or alpha1D-receptor protein antibodies, developed specific immunostaining. Approximately 27% of total lymphocytes were immunoreactive for alpha1A-receptor protein, 40% displayed alpha1B-receptor protein immunoreactivity and 22% alpha1D-receptor protein immunoreactivity. Analysis of percentages as well as of lymphocyte morphology of in situ hybridized and immunolabelled lymphocytes suggests the co-expression of mRNA receptor signal and protein receptor immunostaining in the same lymphocyte. 4 The demonstration of both alpha1-adrenoceptor mRNA and receptor protein subtypes suggests that alpha1-adrenoceptors may have a role in regulating lymphocyte function. 5 The possibility of demonstrating receptor protein immunoreactivity in a small amount of blood, such as that required for preparing cytospin-centrifuged lymphocytes, may stimulate research to evaluate the role of these receptors in lymphocytes and to establish if assessment of lymphocyte alpha1-adrenoceptors may represent a marker of their status in health and disease.

Allergic gastroenteropathy in preterm infants

OBJECTIVES

To determine the clinical presentation, histopathologic features, and outcome of biopsy-proven allergic gastroenteropathy (AGE) in preterm infants. We hypothesized that AGE is a more frequent cause of gastrointestinal disease in this population than previously suspected.

STUDY DESIGN

The retrospective portion of the study, from 1992 to 1997, included preterm infants <37 weeks' gestation who underwent biopsy because of suspected AGE. The prospective portion, from January to December 1998, included 20 infants undergoing endoscopy and biopsy because of suspected AGE.

RESULTS

Twenty-five infants (12 retrospective/13 prospective) with mean gestational age of 29 weeks at birth and mean postnatal age at diagnosis of 78 days were diagnosed with AGE. Three clinical patterns of presentation were noted: group 1, gastroesophageal reflux disease (n = 5); group 2, non-specific feeding intolerance (n = 8); and group 3, lower gastrointestinal bleeding (n = 12). Ten patients had negative biopsy findings (3 retrospective/7 prospective) and had clinical features indistinguishable from those of groups 1 and 2. Patients in group 3 were most likely to have positive biopsy findings (12 of 12). Fifteen patients responded to a casein hydrolysate formula, and 10 patients required an amino acid-based formula. Patients with AGE who had eosinophilic infiltration and villous atrophy took longer to recover than those with eosinophilic infiltration alone (P <.03). Subsequently, most have tolerated formula challenges and are currently tolerating cow's milk.

CONCLUSIONS

AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management.

Neurotrophins and neurotrophin receptors in human pulmonary arteries

The localization of neurotrophins (NTs) and NT receptors was analyzed in sections of human extra- and intrapulmonary arteries by Western blot analysis and immunohistochemistry. In extrapulmonary branches of human pulmonary artery, NT and NT receptor immunoreactivity was located in the tunica intima, within endothelium, in the tunica media, within smooth muscle and in the tunica adventitia. In different sized intrapulmonary arteries, NT and NT receptor immunoreactivity was observed primarily in the tunica adventitia. A faint NT and NT receptor immunoreactivity was observed in the tunica media of large-sized branches of intrapulmonary arteries, but not within medium- or small-sized intrapulmonary vessels or in tunica intima of different sized intrapulmonary arteries. These findings suggest that NTs may have a role in the control of vascular responses in the pulmonary system acting as local paracrine or autocrine mediators. The possible relevance of the NT system in human pulmonary vasculature identified in this study is discussed.

Gene amplification as means for determining therapeutic strategies in human cancers

Pharmacogenomic analysis aspires to identify individuals with specific genetic characteristics in order to predict a positive response or reduce a negative response to a therapeutic modality. While the search continues for the many single nucleotide polymorphisms which will be used in such genetic analyses, other genetic alterations in specific cell types have proven useful in determining the potential for response to therapy. One such genetic alteration is amplification of entire gene sequences which results in overexpression of a gene product or protein. Amplification of the HER2 (neu, erbB-2) oncogene is found in up to 35% of human breast cancers and is associated with a poor prognosis. In addition, this genetic alteration may predict response to various therapeutic modalities. Assays are available to detect the HER2 protein receptor or copies of the HER2 gene sequence to determine eligibility for Herceptin treatment or adriamycin treatment in node positive patients, respectively. This model represents a somatic event used in the functional determination of a therapeutic strategy.

Does high-dose interferon beta-1b improve clinical response in more severely disabled multiple sclerosis patients?

Prospective clinical open label follow-up of 52 multiple sclerosis patients treated with interferon beta-1b. After 18 months of treatment at standard 8 million international units (MIU) dose, subcutaneously on alternate days, IFNB dose was increased to 12 MIU in ten clinically non-responder patients. Eighteen months after, mean exacerbation rate, number and severity of exacerbations and number of patients with exacerbations or requiring corticosteroid treatment significantly improved, becoming similar to those of IFNB responders, always treated with 8 MIU. Baseline EDSS score of non-responders was higher than that of responders. Frequency and severity of adverse events were trending higher and dropout frequency higher in 12 MIU IFNB-treated patients.

Response to long-term hGH therapy in two children with Schwachman-Diamond syndrome associated with GH deficiency

Schwachman-Diamond syndrome is a rare congenital disorder characterized by pancreatic insufficiency, metaphyseal anomalies, recurrent infections, hematologic abnormalities, and growth retardation. Slow growth in these patients has been attributed to nutritional deficits, recurrent infections, and skeletal anomalies. Two cases of Schwachman-Diamond syndrome associated with growth hormone deficiency have been previously reported. We report here on 2 additional cases with this unusual association. Therefore, growth failure in Schwachman-Diamond syndrome should not be assumed to be due to chronic illness or recurrent infections; other etiologies for growth failure should be sought. However, the presence of metaphyseal disorders probably interferes with the long-term efficacy of growth hormone substitutive therapy.

Expanded polytetrafluoroethylene in external valvuloplasty for superficial or deep vein incompetence

The authors evaluated the long-term safety of expanded polytetrafluoroethylene (ePTFE) implants used in external valvuloplasty for treatment of incompetence of the long saphenous and common and superficial femoral veins. During a 15-year period patients with superficial and/or deep venous disease and hypertension due to pure superficial or deep vein incompetence underwent an external valvuloplasty with ePTFE sutures, or an ePTFE cardiovascular patch placed as a sleeve around the incompetent vein segment, or an ePTFE tubular graft placed around the venous segment. Postoperative follow-up evaluations consisted of clinical examinations, high-resolution ultrasonography, and color duplex scanning, and a complete blood count performed at 1, 3 and 6 months, and repeated for at least 4 years, every 2 years after the procedure. A total of 101 patients (38 men and 63 women; mean [+/- sd] age, 44+/-12 years) underwent external valvuloplasty between January 1983 and December 1998; 82 of them completed the 4-year follow-up. Forty of the 82 patients had been operated on for superficial vein incompetence, 42 for deep vein incompetence. Overall, the mean follow-up time was 7.8+/-3.6 years (range, 4 to 13). There were no infections, thromboses,foreign-body reactions to the ePTFE implants, or other prosthesis-related complications requiring explantation. One granuloma (noninfected) developed in association with a tubular ePTFE implant around a long saphenous vein, but it did not necessitate implant removal. Seven patients required (at least after 4 years) a second procedure for recurrent or new venous incompetence. Therefore, in this observational study, ePTFE implants used to treat or correct venous incompetence were well tolerated on a long-term basis.

PGE(1) treatment of severe intermittent claudication (short-term versus long-term, associated with exercise)--efficacy and costs in a 20-week, randomized trial

The efficacy, safety, and cost of prostaglandin E1 (PGE1) in the treatment of severe intermittent claudication was studied comparing a long-term treatment protocol (LTP) with a short-term treatment protocol (STP) in a randomized 20-week study. The study included 980 patients (883 completed the study) with an average total walking distance of 85.5 +/-10 m (range 22-119). Phase 1 was a 2-week run-in phase (no treatment) for both protocols. In LTP, phase 2 was the main treatment phase. In the LTP, treatment was performed with 2-hour infusions (60 microg PGE1, 5 days each week for 4 weeks. In phase 3 (4-week interval period) PGE1 was administered twice a week (same dosage). In phase 4 (monitoring lasting 3 months, from week 9 to 20) no drugs were used. In STP phase 2 treatment was performed in 2 days by a 2-hour infusion (first day: morning 20 microg, afternoon 40 microg; second day morning and afternoon 60 microg). The reduced dosage was used only at the first cycle (week 0) to evaluate tolerability or side effects. Full dosage (60 microg bid) was used for all other cycles. The same cycle was repeated at the beginning of weeks 4, 8, and 12. The observation period was between weeks 12 and 20. A treadmill test was performed at inclusion, at the beginning of each phase, and at the end of 20th week. A similar progressive physical training plan (based on walking) and a reduction in risk factors levels plan was used in both groups. Intention-to-treat analysis indicated an increase in walking distance, which improved at 4 weeks and at 20 weeks in the STP more than in the LTP group. At 4 weeks the variation (increase) in pain-free walking (PFWD) was 167.8% (of the initial value) in the LTP group and 185% in the STP group (p<0.05). At 4 weeks the variation (increase) in total walking distance (TWD) was 227.6% of the initial value in the LTP group and 289% in the STP group (p<0.05). At 20 weeks the increase in PFWD was 496% of the initial value in the LTP group vs 643% in the STP group (147% difference; p<0.02). The increase in TWD was 368% in the LTP group and 529% in the STP group (161% difference; p<0.02). In both groups there was a significant increase in PFWD and TWD at 4 and 20 weeks, but results obtained with STP are better considering both walking distances. No serious drug-related side effects were observed. Local, mild adverse reactions were seen in 6.3% of the treated subjects in the LTP and 3% in the STP. Average cost of LTP was 6,664 Euro; for STP the average costs was approximately 1,820 E. The cost to achieve an improvement in walking distance of 1 m was 45.8 E with the LTP and 8.5 E with the STP (18% of the LTP cost; p<0.02). For an average 100% increase in walking distance the LTP cost was 1,989 E vs. 421 E with STP (p<0.02). Between-group analysis favors STP considering walking distance and costs. Results indicate good efficacy and tolerability of PGE, treatment. With STP less time is spent in infusion and more in the exercise program. STP reduces costs, speeds rehabilitation, and may be easily used in a larger number of nonspecialized units.

Helmet accommodation analysis using 3D laser scanning

A method used to determine the probable population accommodation of a helmet sizing system is described. The method involves the use of 3D laser scanning, as a means of measuring helmet standoff distance (distance between the inside of the helmet and the skull), and the selection of a representative sample of test subjects. The laser scanner and the software developed to calculate standoff distance proved to be an excellent tool for the assessment of helmet fit. The main advantages include ease of use and visualization of problem areas. This 3D-analysis method gives designers objective evidence of the need for design changes as well as an idea of what these changes should be. A comparison was made between standoff distance results obtained from the scanner and those obtained using a physical measurement method (a probe). Although discrepancies were found between the two, sources of errors intrinsic to both methods make it difficult to determine which of the two methods yielded the truest standoff distance. Analysis of the comparison data shows laser scanning to be slightly more conservative than the probe method for standoff distance purposes, i.e. erring on the side of safety.

Nomograms used to define the short-term treatment with PGE(1) in patients with intermittent claudication and critical ischemia. The ORACL.E (Occlusion Revascularization in the Atherosclerotic Critical Limb) Study Group. The European Study

Infusional, cyclic PGE1 treatment is effective in patients with intermittent claudication and critical limb ischemia (CLI). One of the problems related to chronic PGE1 treatment in vascular diseases due to atherosclerosis is to evaluate the variations of clinical conditions due to treatment in order to establish the number of cycles per year or per period (in severe vascular disease reevaluation of patients should be more frequent) needed to achieve clinical improvement. In a preliminary pilot study a group of 150 patients (mean age 67+/-12 years) with intermittent claudication (walking range from 0 to 500 m) and a group of 100 patients with CLI (45% with rest pain, and 55% gangrene; mean age 68 +/-11 years) the number of PGE1 cycles according to the short-term protocol (STP) needed to produce significant clinical improvement was preliminarily evaluated. Considering these preliminary observations, the investigators established a research plan useful to produce nomograms indicating the number of cycles of PGE1-STP per year needed to improve the clinical condition (both in intermittent claudication and CLI). A significant clinical improvement was arbitrarily defined as the increase of at least 35% in walking distance (on treadmill) and/or the disappearance of signs and symptoms of critical ischemia in 6 months of treatment in at least 75% of the treated patients. With consideration of the results obtained with the preliminary nomograms a larger validation of the nomograms is now advisable. A cost-effectiveness analysis is also useful to define the efficacy of treatment on the basis of its costs. The publication of this report in two angiological journals (Angeiologie and Angiology) will open the research on nomograms to all centers willing to collaborate to the study. The data are being collected in the ORACL.E database and will be analyzed within 12 months after the publication of this report.

Superficial vein valve repair with a new external valve support (EVS). The IMES (International Multicenter EVS Study)

The aim of this international multicenter trial was to evaluate the effects of a new surgical device (Gore External Valve Support-EVS) and technique for external valvuloplasty of the long saphenous vein (LSV). Patients with superficial venous disease and venous hypertension due to pure superficial venous incompetence were randomized into two treatment groups, the first treated with "conventional treatment" (ligation or stripping) and the second with external valvuloplasty with the EVS. Patients with uncomplicated varicose veins within the age range of 35-65 years were included. Incompetence with presence of functional cusps at the saphenofemoral junction (SFJ), with vein dilatation were the main inclusion criteria. The EVS comprised of a GORE-TEX patch material (including a nitinol frame) that is placed around the vein, producing a reduction in the caliber of the vein. Also the vein section becomes elliptical. These combined actions are aimed to reduce incompetence, allowing a better closure of the cusps. The EVS was placed at the SFJ after limited dissection of the vein and ligation of collaterals. The procedure was randomized as an alternative to simple ligation or stripping (according with the procedure commonly used in the center). The associated ligation of distal incompetent veins was allowed. The main outcome measures of the study were evaluated by color-duplex (morphologic findings and evaluation of reflux) and with ambulatory venous pressure (AVP) or air-plethysmography (APG). Main endpoints of the first year of the study and main subject of this report (mainly concerning safety within the first year of follow-up) were considered presence/absence of reflux; patency of the veins; mobility/function of vein cusps; occurrence of thrombosis; tolerability of the device; and increased complexity and operating time needed for the EVS. At 1 year 30 patients had been randomized (14 EVS implanted, 16 controls). Reflux was absent in all EVS patients, all treated veins were patent, and all cusps were mobile. No thrombosis had been observed and the tolerability of the device was very good. The increased complexity required by placing the EVS was limited (5-12 minutes more). In conclusion results of the first year show efficacy and tolerability of the EVS. In selected patients (superficial LSV incompetence, reflux-dilatation, functional SFJ cusps, incompetence mainly due to enlargement of the vein), the EVS could be an effective alternative to "destructive" ligation and/or stripping of the vein. Prolonged follow-up will indicate the clinical potentials of the EVS.

A Prospective Multicenter Clinical Trial Comparing One- and Two-Stage Titanium Screw-Shaped Fixtures with One-Stage Plasma-Sprayed Solid-Screw Fixtures

BACKGROUND

Brånemark fixtures were originally placed in two stages, whereas titanium plasma-sprayed (TPS) solid-screws are placed in one stage. Long-term survival rates for both types of implants are excellent. Excellent survival rates have also been reported for machined screw-shaped (MS) titanium implants placed in one stage. A small number of studies have compared different implant systems and methods of implant placement.

PURPOSE

The purpose of this study is to report clinical outcomes from a prospective longitudinal, multicenter study comparing Brånemark MS fixtures (Nobel Biocare, Yorba Linda, California, USA) placed in either one or two stages with a one-stage TPS system (ITI Straumann, Waldenburg, Switzerland).

METHODS

A protocol was designed to compare implant survival rates, changes in crestal bone for titanium MS fixtures placed in one and two stages, and plasma-sprayed solid-screw fixtures placed in one surgical stage. Twenty-nine patients ranging in age from 24 to 82 years received MS fixtures in one stage. The average age for males was 58 years (n = 11), whereas the ages for females (n = 18) ranged from 15 to 84 years (average 58 years). Twenty-nine patients received machined titanium fixtures placed in two stages. There were 20 females ranging in age from 23 to 74 years (average 54 years) and 9 females ranging from 24 to 74 years (average 46 years). Twenty-five patients received TPS fixtures. There were 15 males, ranging in age from 57 to 79 (average 70), and 10 females, ranging in age from 40 to 83 years (average 62 years). Bone quality and quantity were determined from radiographs and during site preparation. Patient age, sex, location of implant placement according to jaw, length of fixtures, and number of lost fixtures were entered onto computer code sheets and continuously entered into a locked computer system. For one- and two-stage MS fixtures, nonstandardized periapical radiographs were taken at abutment connection and follow-up. Solid screws were x-rayed at prostheses connection and follow-up. The average time between implant restoration and radiographic follow-up was 15 months. The x-rays were scanned into a computer, and a program designed to measure radiographs was used to determine changes in crestal bone. Measurements for one- and two-stage MS fixtures were made from the top of the implant shoulder to the first bone to implant contact mesial and distally. Plasma-sprayed screws were measured from the bottom of the implant to the coronal most bone to implant contacts mesial and distally. Mesial-distal radiographic measurements were averaged and changes were compared using the t-test for related samples.

RESULTS

This report presents data from the 2- to 3-year follow-up examinations. Twenty-nine patients received 80 one-stage MS fixtures. Between 0 and 1 year, two fixtures were lost, resulting in a 97.5% cumulative survival rate (CSR). The CSR remained unchanged through the 2- to 3-year follow-up. Twenty-eight patients received 78 two-stage MS fixtures. One implant was lost prior to loading and two were lost between 0- and 1-year follow-up, yielding a 96.2% CSR at the end of 1 year. The CSR remained unchanged through the 2- to 3-year follow-up. Twenty-three patients received 78 solid-screw plasma-sprayed screws. One implant was lost prior to loading and one between the 0- to 1-year follow-up, accounting for a 97.4% CSR at the 2- to 3-year follow-up. Changes in bone crest measurements for one-stage titanium threaded fixtures were insignificant (-0.11 mm, p = .08, maxillary; 0.07 mm, p = .42, mandibular). For two-stage MS fixtures, crestal bone loss was insignificant in maxillae (-0.16 mm, p = .92) and significant in mandibles (-0.43 mm, p = .000). There was significant bone loss for TPS implants in maxillae and mandibles (maxillae, 1.31 mm, p = .04; mandibles, 0.98 mm, p = .000).

CONCLUSIONS

Cumulative survival rates for MS fixtures placed in one and two stages as well as one-stage TPS screws up to the 2- to 3-year follow-up examination were similar, indicating excellent clinical results. Radiographic measurements for changes in crestal bone loss were clinically insignificant for fixtures placed in one stage. For two-stage fixtures, maxillary changes were insignificant, whereas mandibular bone loss was statistically significant but clinically insignificant. Changes in crestal bone loss for TPS implants were statistically significant.

Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10-year follow-up trial--final results

The study was planned to evaluate efficacy and costs of endovascular sclerotherapy (ES) in comparison with surgery and surgery associated with sclerotherapy in a prospective (10-year follow-up), good-clinical-practice study. Patients with varicose veins and pure, superficial venous incompetence were included. Of the patients randomized into the three groups 39 (group A) were treated with ES, 40 (B) with surgery + sclerotherapy, and 42 with surgery only (C). Surgery consisted of ligation of the SFJ (saphenofemoral junction) and of incompetent veins detected with color duplex. Of the preselected 150 patients, 121 subjects entered the study; 96 completed the 10-year follow-up (mean age 52.6 +/- 6 years; 51 men, 45 women). Dropouts were due to nonmedical problems. At 10 years no incompetence was observed in subjects treated with SPJ ligation (B and C). In the ES group 18.8% of the SFJs were patent and incompetent and in 43.8% of limbs the distal (below-knee) venous system was still incompetent [16.1% in the surgery + sclerotherapy group (p < 0.05) and 36% in the group treated with surgery only (p < 0.05 vs B and 0.05 vs A)]. Color duplex of the long saphenous vein indicated atrophy or obstruction of a segment (average 6.7 cm) after SFJ ligation (4.2 cm after ES). The cost of ES was 68% of surgery while the cost of surgery and sclerotherapy was 122% of surgery only. Endovascular sclerotherapy is an effective, cheaper treatment option, but surgery after 10 years is superior.

A Multimethodological Approach for the Sustainable Management of Perifluvial Wetlands of the Po River (Italy)

/ Marginal aquatic systems (wetlands) of the Po River (Italy) have become the target of a renewed interest because of their value for recreation, natural reserves, and deposits of sand. To preserve these sites, wise management must be the objective of local administrations. In this paper a strategy for the sustainable use of 11 wetlands is presented. It uses simple economic analysis and multiple criteria techniques and provides suggestions to promote sustainability in terms of conservation of natural resources, economic self-sufficiency, and minimization of potential conflicts about the use of the wetlands. In the understanding that sustainability is framed in a long-term perspective, stability analysis is also considered and performed by means of loop analysis, a qualitative technique. Conditions for stability are then discussed about management opportunities.

p185HER2 overexpression in human breast cancer using molecular and immunohistochemical methods

With the successful clinical trials of the engineered antibody Herceptin (in advanced-stage breast cancer) and adriamycin-based chemotherapy regimens (in the adjuvant setting), the need to detect p185HER2 overexpression or associated amplification of the coding gene HER2 in breast cancer patients is escalating. Twenty to 30% of breast carcinomas have overexpression of p185HER2. This condition correlates with poor patient prognosis and predicts response to chemotherapy in lymph node-positive patients. In this study we compare quantitation of p185HER2 in breast cancer at the gene and protein levels using differential polymerase chain reaction (PCR) and immunohistochemistry, respectively. To assign HER2 gene copy numbers, a calibration curve was constructed using normal breast epithelia and breast carcinoma cell lines having known dosages of amplified HER2. We found corresponding molecular and immunohistochemical results in 85% of the 13 paraffin-embedded breast carcinoma cases examined. Two cases were found to have minimum gene amplification but marked p185HER2 overexpression, suggesting an alternative mechanism to overexpression such as transcriptional activation. Although the differential PCR assay exhibits saturation approaching 20 HER2 gene copies, this may not be clinically significant because the immunohistochemical assay also appears to saturate in this gene copy number range.

[Hemorrhoidectomy in muco-hemorrhoidal prolapse using mechanical stapler]

BACKGROUND

The treatment of hemorrhoids has changed throughout the latter years. In selected cases hemorrhoidectomy with circular stapler, in personal opinion, is the best surgical technique. The goal of the present study is to evaluate the therapeutic results of hemorrhoidectomy by means of the above technique in 150 consecutive cases.

METHODS

From March 1997 to November 1999, 150 patients were surgically treated, 84 women and 66 men with a median age of 57 years. 130 patients had III degree, thus with a reducible prolapse, 10 IV degree and 10 patients with II degree hemorrhoids resistant to ambulatory banding and/or sclerotherapy. Every patient was operated with the circular stapler in Day Surgery regimen, and the patients were discharged after 24 hours.

RESULTS

Eight immediate hemorrhages were seen, four of which were surgically treated; 10 patients had urinary retention which required an urinary catheter. Healing was complete in the 15-20th day. The follow-up after one month was performed on 140 patients, at 3 months and at one year, on 100 patients. No suture stenosis and no recurrences of the hemorrhoid prolapse were observed. Follow-up after 6, 12 and 24 months on 100 patients was also considered in order to evaluate the results after surgery and late complications or sequelae. Fifteen patients were reevaluated after one and two months with anorectal manometry which did not demonstrate important alterations of the continence.

CONCLUSIONS

The advantages of this technique is to carry out a radical surgical procedure in a single event, by means of a rapid and mini-invasive technique, with an earlier physical recovery, with the absence of medication in the postoperative period, and an early social and working reestablishment.

[Treatment of complex anal and rectovaginal fistulas using the endorectal mucosal flap technique]

BACKGROUND

Aim of the study is to evaluate the advantages of the surgical technique for the treatment of complex anal and rectovaginal fistulas by means of an endorectal mucosal flap and the removal of the fistular tract. The surgical removal of a fistular tract can lead to incontinence troubles, mostly for high complex transsphincteric fistulas. The endorectal mucosal flap technique involves the meticulous care of the sphincterial structures and of the mucosa of the anal canal, and is, in personal opinion, the best technique for the treatment of such fistulas.

METHODS

The procedure used involves: meticulous study of the anatomic characteristics of the fistula; excision of the secondary opening up to the sphincters level with an elliptic excision of the skin by avoiding keyhole deformities; excision of the primary opening from inside the anal canal, with the interruption of the muscular fibers and their reconstruction; the preparation of an endorectal mucosal flap that is transposed to cover the primary opening of the fistula. 21 patients were treated with this technique, 17 were complex anal fistulas, two were associated to Crohn's disease, and of two rectovaginal fistulas, one was found in a patient with Crohn's disease.

RESULTS

Recurrences were found in five patients (24%), after a median follow-up of 20 months. The delay of fistular healing, over a month, was found in 50% of the cases. No patient had continence troubles.

CONCLUSIONS

The mucosal flap technique is a simple procedure, adequate in preserving the sphincteric function and in preventing deformities of the anal canal. However, it has not demonstrated clear benefits in terms of recurrences compared to other techniques, but it is highly considered for the treatment of complex anal fistulas, in terms of continence and for the earlier and better healing of the wounds and for the better tolerance of the patient.