[Advanced stage vasculopathies of the lower extremities. Medical and management aspects in amputees]

AIM

The paper reports the experience of an operating unit for the rehabilitation of amputees. The unit includes doctors and physiatrists working at the 6th Division of Internal Medicine and the Centre for Motor Rehabilitation at the "Ospedali Riuniti" in Trieste.

METHODS

Subjects were selected on the basis of their psychophysical characteristics and coexistent pathologies. All subjects took part in a hospitalised rehabilitation programme lasting for 60-90 days. This period was followed by outpatient controls that continued for one year after discharge. Clinical conditions, self-sufficiency and quality of life were monitored and studied using special questionnaires.

RESULTS

Of a total of 45 amputees, 27 were not regarded as suitable and 9 died while in hospital. Eighteen were selected for prosthesis; 14 completed the programme and 11 were followed-up for one year as planned. One patient did not attend the follow-up, 1 patient had a stroke and 1 patient died from myocardial infarction.

CONCLUSIONS

Eleven of the 45 amputees included in the study were successfully treated with prothesis. The medical, nursing and economic commitment appears to have been considerable. The expectations of all subjects were high and remained high during rehabilitation in hospital, but deteriorated rapidly at home with the onset of depressive type symptoms. This may have been due to disappointment following their high expectations and the fact that post-discharge assistance was not always appropriate. The high cost-benefit ratio underlines the importance of the careful selection of candidates for rehabilitation.

Insulin prophylaxis down-regulates islet antigen expression and islet autoimmunity in the low-dose Stz mouse model of diabetes

The aims of this study were to evaluate in an autoimmune diabetes animal model [low-dose streptozotocin (LD-STZ) mouse] (a) the efficacy of a prophylactic insulin treatment as a diabetes prevention tool, and (b) its possible mechanisms through both the insulitis evaluation and islets antigen expression. Diabetes was induced in male C57Bl6/J mice with STZ (50 mg/kg b/w for five consecutive days); insulin (1 U/day) was injected subcutaneously for ten consecutive days before the induction of diabetes and for a further ten days. Seventy-one male C57Bl6/J mice were grouped as follows: Group 1 (n = 25) made diabetic with i.p. STZ, Group 2 (n = 21) made diabetic with i.p. STZ and injected subcutaneously with insulin, Group 3 (n = 15) injected with insulin, while Group 4 (n = 10) comprised normal animals as controls. The animals of each group were killed at two intervals: half of them at day 12 and the remainder at day 24 from the beginning of the STZ treatment. A significant reduction of glycemia levels and insulitis severity was observed between mice of Group 1 vs. Group 2 at day 12 and day 24. Down-regulation of islet antigen expression (insulin, A2B5, GM2-1, ICA Ag) was achieved even without a complete metabolic suppression of beta-cell activity. In conclusion, prophylactic insulin treatment is effective to reduce glycemia levels and insulitis severity and down-regulates islet antigen expression in the LD-STZ model.

Atherosclerosis and inflammation. Patterns of cytokine regulation in patients with peripheral arterial disease

Inflammatory phenomena at sites of atherosclerotic plaques are increasingly thought to be major determinants of the progression and clinical outcome of atherosclerotic disease. Therefore, attention is being paid to systemic markers/mediators which may reflect the inflammatory activity in the plaques. This study evaluates the pattern of the main proinflammatory cytokines tumor necrosis factor-alpha (TNFalpha), interleukin-1beta (IL-1beta), and interleukin-6 (IL-6), their soluble receptors/antagonist, and a variety of inflammatory markers, in patients with peripheral arterial disease (PAD). Eight patients with PAD suffering from claudicatio intermittens (CI), eight with critical limb ischemia (CLI) and eight controls (C) were studied. Blood samples were collected at baseline in all groups and. for C and CI, immediately after and 4 h after a 30-min treadmill test. Baseline: no differences in cytokine plasma levels were detected among the three groups. In contrast, soluble receptors of TNF (type I and II) and of IL-6, and IL-1beta receptor antagonist (IL-1ra) were increased in CI and CLI patients, as compared to C. Of note, IL-Ira correlated with the occurrence and stage of the disease in a highly significant proportion of the patients, reaching a predictive value for the disease of P < 0.0001. The opposite trend was observed for the soluble receptor of IL-1beta. Notably, in the patients no alterations could be found in white blood cell counts, expression of CD11c adherence molecule by circulating monocytes or, in vitro. O2- release from zymosan-activated neutrophils. Moreover, plasma levels of platelet activating factor (PAF), of neutrophil elastase and of the acute phase reactants C-reactive protein (CRP) and alpha1-acid glycoprotein were not found to be significantly altered. In contrast, the acute-phase proteins alpha1-antitrypsin (alpha1AT) and haptoglobin (HG) were found to be increased. Effect of treadmill: IL-1beta and TNFalpha remained at baseline levels following exercise, and IL-6 dropped to undetectable levels. Among cytokine antagonists, again the most relevant changes concerned the IL-1ra, which was significantly increased immediately after the treadmill test, both in CI and C, and returned to baseline levels after 4 h. In contrast, soluble TNFalpha, IL-1beta and IL-6 receptors, PAF, and the other markers of leukocyte activation were not found to be altered. Soluble TNFalpha and IL-6 receptors were shown to inhibit the biological effects of their ligands. Similarly, IL-1ra and the acute phase proteins alpha1AT and HG have been reported to exert anti-inflammatory functions. The increased plasma levels of these agents, together with low levels of inflammatory cytokines and other pro-inflammatory mediators such as PAF and alpha1-acid glycoprotein, appear to draw an undescribed picture, so far, of upregulation of a composite systemic anti-inflammatory mechanism in atherosclerotic patients. IL-1ra appears to be a reliable marker of the state of activation of this mechanism. These results may provide a basis for developing new insights into the pathogenesis of the atherosclerotic disease.

Venous thromboembolism and renal cell carcinoma

There is a vast amount of literature documenting the relationship between cancer and venous thromboembolism. Nevertheless, many aspects of this association remain obscure and the best approach to be taken towards a patient with apparently idiopathic venous thromboembolism has yet to be defined. We present a case of a patient with venous thromboembolism in whom abdominal ultrasonography, prescribed as a cautionary measure to rule out the presence of a tumour, revealed liver metastases, while the subsequent CAT scan showed hepatic angiomatosis and two small bilateral renal carcinomas. Although there are as yet no indications in the literature on screening patients with idiopathic venous thromboembolism for occult tumours, our case shows how the clinical decision to perform abdominal ultrasonography saved the patient's life.

Detection of subtle phenotypes: the case of the cell adhesion molecule csA in Dictyostelium

Dictyostelium amoebae aggregate into a multicellular organism by cAMP-driven chemotaxis and cell-cell adhesion. Cell adhesion is mediated by an EDTA-sensitive and an EDTA-resistant adhesion system. The latter is developmentally regulated and triggered by homophilic interactions of the membrane glycoprotein csA; on disruption of the encoding gene, EDTA-resistant contacts fail to form. Nevertheless, csA-null cells under usual laboratory conditions aggregate normally and complete development. By using experimental conditions that reproduce more closely the habitat of Dictyostelium amoebae, evidence is provided that csA is required for development and that its expression confers a selective advantage to populations of wild-type cells over csA-null mutants. The latter display reduced cell-cell adhesion, increased adhesiveness to the substratum, and slower motility, which lead to their sorting out from aggregating wild-type cells. It is proposed that the experimental conditions commonly used in the laboratory are not stringent enough to assess the developmental role of csA and other proteins. The assay described can be used to detect subtle phenotypes, to reexamine the developmental role of apparently nonessential genes, and to test the validity of recent models on emergence and maintenance of apparent genetic redundancy.

[Computerized digital thermometry in Raynaud's disease. Personal experience]

BACKGROUND

Computerized digital thermometry has been used for instrumental diagnosis of Raynaud's disease, that is characterized by diminution of the cutaneous temperature of the fingers and the late delayed recovery. Thermometry permits to measure basal temperature of the ten fingers, during cooling to 10 degrees C ("cold test") and the response, measuring temperature minute by minute up to 25 degrees.

METHODS

In order to assess vasospastic ischemic disease a total of 66 subjects have been examined: 19 were asymptomatic for acrolocalised pathologies (control subjects) and 47 were symptomatic.

RESULTS

No close correlation was observed between clinic and instrumental data. In fact 31.5% of the asymptomatic subjects had a "non-normal" reaction to the test; on the other hand, in the group of female over-50-years-old with symptoms suggesting Raynaud's disease, 38.5% of cases revealed "normal" instrumental patterns. Therefore no discriminating parameters were identified which might have allowed the instrumental identification of subjects suffering from Raynaud's disease compared to healthy individuals.

CONCLUSIONS

In conclusion, computerised digital thermometry is a technique with a good level of sensitivity, while the specificity is scarce.

[Vascular manifestations in systemic sclerosis (scleroderma)]

Progressive systemic sclerosis (PSS), a disease still of unknown origin, is a generalized autoimmune disorder characterized by immunological abnormalities, microvascular dysfunction, and tissue fibrosis. The mechanism leading to selective microvascular injury in PSS is not completely known, however it is now clear that neuropeptides, vascular endothelium, and disturbances in the regulation of fibroblast function are the three major contributors to the increased fibrosis of skin and internal organs. Thus, endothelial cell and fibroblast dysfunction may be linked through the paracrine activity of soluble endothelial cell products: the cytokine cascade (IL-1, TGF-beta-1, PDGF, TNF, etc.). In systemic sclerosis, the exaggerated generalized vasospastic tendency is clinically represented by Raynaud's phenomenon as shown by an early digital arterial closure after cold stimulation, and by an inadequate vasodilatory response to heat. In this review we summarize recently established data that center around the role of adhesion molecules, immune reactions, and aberrant fibroblast biology and metabolism in effecting vascular and connective tissue alterations in this disease. Only a better knowledge of the pathophysiological process involved in scleroderma might lead to the development of new therapeutic approaches.

[Pulmonary embolism of paraneoplastic origin]

Thromboembolic disease (TE) is an important cause of in-hospital morbidity and mortality. The relationship between cancer and abnormalities of blood coagulation has been recognized for well over a century. Deep venous thrombosis (DVT) of the lower extremities is the most common cause of thromboembolic disease, but pulmonary embolism, upper extremity vein thrombosis, disseminated intravascular coagulation, and other, more unusual, clinical events, may occur. Unexplained TE may serve as a marker for the presence of a hidden tumor. The frequency of pulmonary embolism (PE) among patients with a malignant neoplasm at necropsy is highly increased in the elderly patients. Among subjects with a malignant neoplasm, patients with pancreatic and gastric cancer (mucin-secreting adenocarcinomas), cancer of the large bowel and women with ovarian cancer had the highest frequency of PE. Old age, female sex, gastrointestinal and ovarian cancers must be considered as a significant risk factor for PE. The potentially responsible mechanisms for the thrombotic events, clinical manifestations, diagnostic implications and aspects of treatment of TE in malignant disease are discussed.

[Morphological and functional aspects of the cardiovascular system related to aging: does "aging heart" exist?]

Elderly people are the most rapid growing segment of society, and heart disease is the most common cause of death in this population. The aging process is associated with anatomic and physiologic alterations in the cardiovascular system; consequently, the manifestations of disease in the geriatric population differ from those involving younger patients. To formulate diagnosis of "aging heart" in older patient may be difficult, because of atypical symptoms or of the acceptance of symptoms as manifestations of old age. Aging is, moreover, often associated with a decline in physical activity, which may result in cardiovascular "deconditioning". The treatment strategy is the same as in younger patients, but the higher incidence of adverse effects and complications demands special awareness. In this article we discuss about age-related structural and functional changes that occur in the cardiovascular system, including changes in the heart muscle, valves, conduction system and major arteries.

[Cardiovascular disease and omega-3 fatty acids]

Fish oil is rich in the long chain omega-3 (omega-3) polyinsaturated fatty acids (PUFA), Pioneering studies of Dyerberg and Bang primarily originate interests in this way. The low incidence of acute myocardial infarction they verified within the Greenland Eskimos suggested that a high dietary omega-3 PUFA intake due to marine food might protect against coronary heart disease. They showed that the Eskimos had a beneficial lipid pattern and that their balance between pro-aggregatory thromboxanes and anti-aggregatory prostacyclins was shifted towards an anti-thrombotic state. The two major omega-3 fatty acids are decosapentaenoic acid (EPA C 20:5, omega 3), with five double bonds, and docosahexaenoic acid (DHA C 22:6, omega 3), with six double bonds. These fatty acids' significant effects include reduction of plasma triglycerides and lipoprotein levels as well as of platelets thrombogenicity in the microcirculation, which is due to effects on the mediators production derived from arachidonic acid (prostaglandins and leucotrienes), meddling in inflammatory and immune cell function, retarded atherosclerosis development. Experimental studies of atherogenesis and arterial thrombogenesis support the hypothesis that dietary omega-3 PUFA intake may play a leading role in primary or secondary prevention of coronary heart disease.

[Horton's giant cell arteritis]

Giant cell arteritis (GCA) is a spontaneous vasculitic syndrome specifically involving the walls of medium and large arteries. While involvement of other arterial beds is occasionally identified, this syndrome is most frequently recognized when symptomatic involvement of the temporal arteries occurs. Vascular lesions are characterized by patchy granulomatous infiltrates composed of T cells, macrophages, histiocytes, and giant cells. A better prognosis depends on early recognition of the clinical symptoms and prompt treatment. Diagnosis was based on the 5 clinical criteria previously used by the American College of Rheumatology (1990): 1) age 50 years or older; 2) new localized headache; 3) temporal artery tenderness or decrease in temporal artery pulse; 4) erythrocyte sedimentation over 50 mm/ hour; 5) abnormal result on artery biopsy. Giant cell arteritis was considered a rare disease under age 50; however, it is now known to be an important and significant cause of morbidity and mortality in elderly people. Therefore early recognition and treatment with corticosteroid are very important. There is no general agreement concerning the initial dosage, 40-65 mg/day are commonly recommended. After a few months the majority of patients can be treated with a low maintenance dosage of prednisolone (5 to 7.5 mg/day). The mean duration of treatment is about 5 years. The literature is reviewed and the clinical implications of this disease are discussed.

[The concept of quality of life in cardiac failure]

Chronic congestive heart failure is a common yet devastating syndrome and is a leading cause of morbidity and mortality in the industrialised countries. The incidence and prevalence of chronic congestive heart failure is increasing, placing a growing burden on the health care system. Despite many advances in treatment for heart disease, chronic heart failure is a terminal condition with a death rate as high as that for many malignant tumours. Patients suffering from chronic congestive heart failure report a poor quality of life because of physical symptoms, functional disability, emotional and economic burdens, frequent hospitalisations, and poor prognosis. In the context of heart failure, mortality risk (prognosis quoad vitam) can be measured using a variety of physiological variables; left ventricular (LV) dysfunction plays a primary role in the pathogenesis of congestive heart failure and correlates with prognosis, but a strong quantitative relation between exercise performance and indexes of LV function has not been demonstrated. This finding underscores the importance of psychosocial interventions in improving the quality of life and care outcomes for patients with heart failure. For this reason, questionnaires of quality of life, assessed by direct patient self-reports, have recently been imposed in cardiology, they have been used specially for evaluating most treatment of cardiac failure. The refinement of a definition of quality of life improved methods to study quality of life will contribute to a better understanding of this complex concept in heart failure patients.

[Vascular "remodeling"]

Vascular remodeling means a specific organization of the vascular wall around a diminished lumen as to the before existing conditions, with consequent vascular geometry modification. This organization comes from the response of all vascular components (endothelium, muscular cells, connective component, etc.) to physical and chemical stimuli. Particular behaviour of the vascular wall has lately been pointed out, both in long known pathologies (arteriosclerosis, arterial hypertension, diabetes mellitus, arteriosclerotic aneurysms) and in situations involving both physiopathology (ischaemia-reperfusion, angiogenesis) as therapy (angioplasty).

[Hyperhomocysteinemia: a new independent vascular risk factor?]

The positive correlation existing between hyperhomocysteinemia and atherosclerosis has firmly been established through data derived from numerous epidemiologic and experimental observations as well as from intervention trials. Although most of the clinical data have been obtained in relation to coronary heart disease, hyperhomocysteinemia is also observed in patients with cerebral and peripheral arterial occlusive disease or peripheral venous thrombosis. The prevalence of the heterozygous state is today estimated about 1 to 2 percent of the population. Mild and moderate hyperhomocysteinemia have recently been proposed as an additional and independent risk factor for vascular disease. In this review we therefore describe recent findings about the pathogenesis of hyperhomocysteinemia and their implications for optimal drug therapy.

[Circadian patterns of ischemic events]

These is evidence of circadian variations in the occurrence of ischemic events such as: silent myocardial ischemia, stable angina, instable angina, acute myocardial infarction, sustained ventricular tachycardia, cerebral infarction, transient ischemic attack (TIA) and sudden cardiac death. In the general population many cardiovascular disorders occur with the greatest frequency between 6 and 12 a.m. (i.e. after awakening). Blood pressure, too, follows a distinct circadian pattern. Factors affecting circadian variations in cardiovascular disorders include physiological determinants, such as heart rate, catecholamine release, and platelet aggregation-which themselves cyclically vary-, and exogenous factors such as mental stress, anxiety, and physical activity. In chronotherapy, circadian variations in disease states and in the pharmacodynamic properties of drugs are exploited to improve prevention and treatment. Characterization of diseases states with this approach allows more accurate determination of the times when patients are at highest risk and therefore in greatest need of preventive measures; it also provides a mechanism for designing optimal drug regimens. In this review we therefore describe recent findings about the effects of biorhythms on cardiovascular disorders and their implications for optimal drug therapy.

[Arterial hypertension in an ambulatory population of elderly subjects. Epidemiologic and clinical study in Isonzo]

The authors examine the clinical connotations of arterial hypertension in a geographical population of 1002 patients attending the Cardiological Outpatient Clinic of Unit no.2 in the Isonzo area (Monfalcone) using the most appropriate statistical methods, such as SPSS (Statistical Package for the Social Sciences) implemented on PC IBM AT 286, for multiple linear regression using a stepwise method. 1) Arterial hypertension was the result of a phenomenon which was striking owing to its mean value of 184.7 +/- 20.915 mmHg with equal mode and median of 180 mmHg. In the subgroup of 720 elderly patients this mean value differed slightly, 186.9 +/- 20.648 mmHg, with the same mode and median, whereas in the group of 282 adults the mean was 170.0 +/- 20.540 mmHg with a mode and median of 160 and 175 mmHg respectively. In the overall population 154 cases (15.4%) were affected by slight arterial hypertension with a mean of 158.9 mmHg, and 848 cases (84.8%) presented moderate-severe arterial hypertension with mean values of 189.4 mmHg. In elderly patients the mean rose to 190.4 mmHg whereas it was 186.3 mmHg in adults. 2) Mean age was 65.3 +/- 11.093 years: 70.7 +/- 7.396 years in older patients and 51.7 +/- 6.106 years in adults. Surface ECG showed signs of left ventricular hypertrophy in 292 elderly patients (40.5%) and 85 adults (30.0%), signs of ischemic cardiopathy due to T wave alteration in 246 elderly patients (34.1%) and 101 adults (35.7%), and due to ST tract in 340 (47.2%) and 102 (36.2%) respectively, with equal involvement of the free surface of the left ventricle. The radiographic enlargement of the cardiac shadow in elderly patients was observed in slight form in 153 cases (21.3%) and in moderate and marked form in 222 cases (30.8%), and in adults in 36 (12.8%) and 43 (15.2%) cases respectively. 3) Body weight was normal on average and equivalent to 77.3 +/- 13.578 kg, but of this series 713 cases were overweight and 237 were obese; 504 of elderly patients (70%) were pathological with 346 (48.1%) overweight and 158 (21.9%) obese, and of 209 pathological adults (74.1%), 130 (46.1%) and 79 (28.0%) were respectively overweight and obese. BMI oscillated from 1.70 to 5.60 with a mean of 2.80 +/- 0.409: from 1.70 to 4.21 in elderly patients with a mean of 2.70 +/- 0.379 and in adults from 2.00 to 5.60 with a mean of 2.90 +/- 0.460. 4) Mean cholesterolemia was 237 +/- 48.029 mg% and levels were normal in 203 cases and high in 799 subjects. Elderly patients showed the same mean level with a total of 580 pathological cases (80.5%) divided into 305 (42.3%) cases of slight hypercholesterolemia with a mean of 227.2 mg% and 275 (38.2%) severe cases with levels of 283.7 mg%. Adults presented a mean serum level of 236 +/- 47.588 mg%: 63 (22.3%) cases of normocholesterolemia, 117 (41.5%) cases of slight cholesterolemia with mean serum level of 224.8 mg%, and 102 (36.2%) severe cases with a mean level of 286.2 mg%, resulting in a total of 219 pathological cases (77.7%).

[Liver cirrhosis and cardiovascular system]

The patient with hepatocellular disease shows marked vasodilatation, accompanied by hyperdynamic circulation and opening of arteriovenous shunts. The effect of these circulatory changes and especially the profound vasodilation has only recently been investigated in detail. In patients with hepatocellular failure the extremities are flushed, the pulses bounding, the cardiac output increased and the blood pressure low. The circulation resembles what found with systemic arteriovenous fistulae. The peripheral vasodilatation and splanchnic venous pooling reduce the effective blood volume so activating baroreceptors. The secondary events which follow the vasodilation include stimulation of the sympathetic nervous system. This serves to counteract the tendency to arterial hypotension and probably contributes to renal hypoperfusion and to the hepatorenal syndrome development. The nature of the concerned vasodilators remains speculative, but is likely to be multiple. Whatever its nature, the substance might be formed by the sick hepatocyte, fail to be inactivated by it or bypass it through intra- or extra-hepatic portal systemic shunts. In cirrhosis the cardiac index and reduced systemic vascular resistance correlate with the Child's grade of liver failure. This article provides an overview of the general vasodilatory state and its effects on various organs. The mechanisms and the different vasoactive substances that might be responsible are also discussed.

[Neurocardiogenic (or vasovagal) syncope]

Syncope is a common clinical problem in a general population that is responsible for a significant number of emergency department visits (3%) and hospitalizations (1%) each year. The clinical spectrum of etiologies of syncope includes disorders classified as cardiovascular, noncardiovascular and unexplained. A majority of syncopal events are believed to be caused by vasovagally mediated episodes by hypotension and bradycardia. Although vasovagal syncope is essentially equivalent to simple fainting, the physiologic events that lends to this phenomena are complex. Although not completely understood, the most commonly held theory explaining vasovagal syncope involves a series of reflexive interactions between cardiac mechanoreceptors and the autonomic nervous system. Until the advent of head upright tilt table testing, diagnosis of vasovagal syncope has been an assumption, made when all other causes have been eliminated. Frequently an accurate history, a physical examination and a standard ECG are enough to formulate a correct diagnosis. Head-up tilt test must be considered in patients with an unknown diagnosis, before starting invasive investigation. Tilt table testing, either alone or with a graded-dose infusion of isoproterenol, allows reproduction of the syncopal event in susceptible individuals and monitoring of the patients physiologic responses during the episode. Direct observation and documentation of symptoms permit accurate diagnosis and yield information vital to treatment and symptom control. This article reviews our current understanding of the mechanisms involved in the development of neurally mediated syncope.

[Non-vascular claudication or "painful leg syndrome"]

All angiologists commonly find that a considerable proportion of the persons referred to an angiology clinic are in fact suffering from other pathologies. Many of these patients often complain of polyhedric, vague symptoms, sometimes pyrotic and sometimes disguised as cramps, frequently accompanied by paresthesia or hypasthenia of the lower limbs which is generally justified, above all in elderly patients, as being caused by "circulation disorders". The authors felt the need to perform this study with the aim of both evaluating the prevalence of so-called non-vascular claudication or pseudo-claudication, defined here as "painful leg syndrome", and to identify simple and low-cost clinical and instrumental parameters, which may be useful not only to the general practitioner but also to the angiologist. A large number of patients with "false claudication" (43%) was diagnosed in this series and the most frequent cause was neurological pathology (68%). Anamnesis and an objective examination should, if correctly performed, be sufficient for a rapid diagnosis of non-vascular pathology and should therefore be useful in limiting the number of requests for Doppler tests, thus reducing waiting times and management costs.

[The medical angiology outpatient clinic today. The authors' personal experience and operational proposals]

Over the past two decades the demographic characteristics of our population have changed resulting in a major increase in older age groups and a consequent real increase in the prevalence of vascular diseases' of an atherosclerotic type. This had led to an almost exponential increase in the number of requests for instrumental tests, such as Doppler. The aim of this study, the outcome of a review of the patients attending our outpatient clinic over the past twelve months, was to evaluate the current role of a clinic specialising in medical angiology compared to the changing requests for assistance and to elaborate operating proposals for clinics at various levels, aiming to attain the efficacy and efficiency of outpatient activity in accordance with the objective limitations of health spending and current legislation.

Quality of life in a group of patients with intermittent claudication

In view of the increasing importance of chronic diseases in recent years, not only quantity but also quality of life has been taken into consideration. The aim of this study was to verify the quality of life in patients with peripheral obstructive arteriopathies of second degree according to the Leriche-Fontaine classification. Therefore, the authors administrated three different questionnaires to patients selected among those who came to the Angiology Ambulatory Care of the Medical Clinic of the University of Trieste. The questionnaires used were the following: McMaster Health Index Questionnaire (MHIQ), "Squibb" Quality of Life, General Health Index Questionnaire (GHIQ). The analysis of the results of the questionnaires shows the severe limitation of physical capacities of this kind of patients (overall mean functional limitation of 69% of the maximum value of 1, corresponding to an ideal state of well-being, with negative peaks of 50%). A negative tendency regarding social life and relationship is represented by different scores (from 52% to 66% of ideal maximum) from different items and questionnaires. Also the items concerning somatic disorders, sleeplessness, and states of anxiety gave results near the percentage of 70% and for this reason were indicative of a state of unwell-being. The data obtained from the items regarding the presence of a state of depression gave a result less predictable: a score of 87% with peaks over 90% could be indicative of a positive tendency. This last result, consistent with others of analogous studies in the literature, seems to indicate that peripheral arterial disease, even if physically restricting, does not have a strong impact on the psychological and emotional equilibrium of the patients.

[The evaluation of rehabilitative therapy in peripheral arteriopathy. Our experience]

Motor rehabilitation alone is considered and effective treatment for patients affected by claudicatio intermittens although underlying diseases may often influence but not exclude its efficacy. According to the literature no agreement exists about rehabilitative methods. The authors, in order to contribute to a standardization of rehabilitative methods, report their experience characterized by good results. Moreover, the authors stress the importance of the treatment in desisting from habits like cigarette smoking.

Cell adhesion in the life cycle of Dictyostelium

Three forms of cell adhesion determine the life cycle of Dictyostelium: i) adhesion of bacteria to the surface of the growing amoebae, as the prerequisite for phagocytosis; ii) cell-substrate adhesion, necessary for both locomotion of the amoebae and migration of the slug; iii) cell-cell adhesion, essential for transition from the unicellular to the multicellular stage. Intercellular adhesion has received the most attention, and fruitful approaches have been developed over the past 25 years to identify, purify and characterize cell adhesion molecules. The csA glycoprotein, in particular, which mediates adhesion during the aggregation stage, is one of the best defined cell adhesion molecules. The molecular components involved in phagocytosis and cell-substratum adhesion are less well understood, but the basis has been laid for a systematic investigation of both topics in the near future.

[The vascular changes in arterial hypertension]

Although the causes of high blood pressure vary, it is becoming clear that sustained hypertension is associated with changes in cardiovascular structure: left ventricular hypertrophy, decrease in big-medium arteries compliance and increased wall thickness of small arteries. To some extent, these alterations are natural physiological responses and are protective. However, the risk of circulatory death is closely related to left ventricular hypertrophy, and therefore, it is suggested increasingly that effective antihypertensive treatment requires normalization not only of blood pressure but also of vascular structure. The purpose of this brief review is to identify the type of functional and structural changes that are found in arteries of hypertensive individuals.

[Hasharon hemoglobinopathy in a family]

The authors describe an 18 year old athlete, a carrier of Hasharon haemoglobinopathy, pathology which had been checked in some ascendants too. Such a haemoglobinopathy, which has at first been verified in Ashkenazy Hebrew people and is nowadays rather common in North East Italy, shows clinical and laboratory features which are slightly or not at all mentioned in the literature. The leading reference point in the disease's development is the connection between splenomegaly and repetitive low erythrocytosis with serum iron deficiency and increase of the reticulocyte number. The same laboratory data had been observed in his father and in his paternal grandmother; both of them proved to te heterozygous carriers of Hasharon haemoglobinopathy. In all cases we caught the diagnostic validation by the means of isoelectrophoresis involving haemoglobin lysate in polyacrylamide gel. The authors think that the Hasharon shape they verified may be a variant of the classic phenotype: the splenomegaly and erythrocytosis may signify a brisk and primitive erythropoiesis with increasing reticulocytes, which might compensate for the anomalous synthesis of the alpha chains. Serum iron deficiency may signify an increase of the iron consumption. Moreover, the authors do not exclude the possibility of further associational abnormalities.