Brain MRI white matter lesions in migraine patients: is there a relationship with antiphospholipid antibodies and coagulation parameters?

Brain magnetic resonance imaging (MRI) studies in migraine patients have demonstrated lesions consisting of focal regions of increased signal intensity within the white matter. Antiphospholipid antibodies are known to have a role in many diseases including migraine. The aim of the present study was to ascertain the relationship between MRI-visualized cerebral focal hyperintense lesions and serum antiphospholipid antibody levels, as well as blood coagulation parameters in migraine patients. One hundred and two (77 females, 25 males, mean age 33.8 +/- 11.1) consecutive migraine patients and a control group of 94 (70 females, 24 males, mean age 33.2 +/- 10.8) healthy subjects were enrolled. All individuals underwent brain MRI. Complete blood examinations, autoantibodies, antiphospholipids antibodies including anticardiolipin and lupus anticoagulant (aCL, LAC), antithrombin III, Protein C and S serum levels were ascertained in the subjects who presented white matter lesions on MRI. Twenty-seven (26.4%) migraine patients and six (6.3%) healthy subjects in the control group showed focal regions of increased intensity signal within cerebral white matter (odds ratio 5.3, 95% CI: 1.98-16.36). In migraine patients with white matter lesions, antiphospholipid antibodies were not detected and serum levels of antithrombin III, and proteins C and S were normal. White matter lesions in migraine patients are fairly common. This finding is not associated with antiphospholipid antibodies or abnormal coagulation parameters. The significance of such lesions at present remains unclear.

Four chamber view plus three-vessel and trachea view for a complete evaluation of the fetal heart during the second trimester

OBJECTIVE

To test the efficacy of a recently introduced ultrasonic scanning plane (three vessel and trachea view -3VTV- plus color flow mapping -3VTVC) on a low-risk population for detection of congenital heart disease (CHD).

PATIENTS AND SETTING

Antenatal clinic dealing with local low-risk population. All antenatal patients having a second trimester scan in a 1 year period. All patients had a 3VT plus 3VTC views added to routine four chamber view. Postnatal examinations were performed according to standard hospital protocol.

RESULTS

2847 patients were examined. The plane was achievable in all 23 fetuses with CHD detected, three false negative (aortic coarctation) and two false positive. Sensitivity of the examination was 88.5%, as high as more sophisticated and difficult targeted cardiac scanning. The extra time necessary to perform the test was minimal.

CONCLUSION

3VTV and 3VTCV were satisfactory used as imaging planes in a busy antenatal clinic in a low-risk population. They could be easily added to the four chamber view as routine screening for CHD and increase the detection rate to 90%.

Voluminous mycetoma in a newborn with down syndrome: Role of echocardiography

We report a case of a baby with Down Syndrome and history of a corrective surgery for a duodenum stenosis, which was subjected to a parenteral nutrition with central venous catheter. A two-dimensional color Doppler echocardiographic examination revealed a voluminous oval-shaped mobile inhomogeneous mass adhering to the tricuspid valve. The intraoperative pathology showed that it was a large fungal vegetation. The probable source of Candida Albicans was an infected intravenous catheter. We wish to remark the role of echocardiography in the diagnosis and choice of timing of surgery.

Cetuximab (C225) in recurrent and/or metastatic salivary gland carcinomas (RMSGCs): A monoinstitutional phase II study

5547

Background: EGFR is expressed in 70% of salivary gland carcinomas (SGC). Investigations of anti EGFR treatment seems rational. Aim: To assess activity of C225 in patients with RMSGCs in terms of clinical benefit (CB), defined as occurrence of objective response (CR or PR) or stable disease (SD) for at least 6 months. To correlate treatment outcome with skin toxicity degree and EGFR analysis. Methods: One prior chemotherapy regimen was allowed, except for pts with adenoid cystic carcinoma (ACC) and acinic cell carcinoma for whom 2 lines were allowed. Prior exposure to targeted treatment was not allowed. C225 (Erbitux) was administered iv weekly at 400 mg/mq followed by 250 mg/mq until disease progression, major toxicity or voluntary discontinuation. MRI or CT and PET scan were performed every 6 weeks q4, and q12 thereafter. RECIST response criteria and CTC 3.0. were adopted. Results: From April to December 2005, 30 RMSGCs pts (20 F/10 M; median age 50 yrs), 50% with major SGC, were enrolled. Histotypes were: 23 ACC; 2 mucoepidermoid; 3 myoephitelial; 1 cystadenocarcinoma and 1 acinic cell carcinoma. Thirteen pts (43%) received prior chemotherapy. Localregional (LR) and metastatic (M) disease was present in 13 cases, M in 12, and LR in 5. A median number of 11 drug administration (range 2–31) was given. G2 skin toxicity was recorded in 24 cases. G2 fatigue in 2. At a median FU of 6 months (range 0–8), 2 pts died of PD. Of 22 pts evaluable for response with ≥ 3 months of potential FU, there were 11 SD, 9 PD, while 2 pts refused to continue after 1 months. Currently, 7 of these pts are progression-free at ≥ than 6 months, qualifying for CB definition according to study protocol. Preliminary EGFR analysis showed a high or intermediate expression score in 5 (3 ACC, 1 acinic cell, 1 cistoadenocarcinoma) out of 7 cases, no gene amplification nor chromosome 7 polisomy were found in 3 of 3 analysed ACC. PET results are under evaluation. Conclusions: Hints of activity of C225 in RMSGCs were observed. The early analysis for the CB rate in 23 pts is planned for April 2006, when all of them will have a potential follow-up of ≥ 6 months, and results thereof will be reported.

[Table: see text]

Cardiac and vascular effects of diltiazem, dobutamine and amrinone, drugs used after myocardial revascularization

Hemodynamic care during postoperative management of myocardial revascularization should include vasorelaxing drugs to insure adequate graft and coronary flow, and stimulation of stroke volume to maintain vascular perfusion pressure. We tested the cardiac (inotropic and lusitropic) and vascular (relaxant) effects of diltiazem (0.1 nM to 0.1 mM), dobutamine (10 microM to 10 mM) and amrinone (10 microM to 1 mM) on isolated rat atria and thoracic aorta, and also on isolated human saphenous vein (HSV) and human mammary artery (HMA). Dobutamine produced a maximal positive inotropic effect (+dF/dt max = 29 +/- 7%) at its ED50 for aortic relaxation (88 +/- 7 microM). Conversely, at their ED50 for aortic relaxation diltiazem depressed myocardial contractility and amrinone did not exhibit myocardial effects. In HSV and HMA contracted with 80 mM potassium, diltiazem and dobutamine (but not amrinone) had a vasorelaxant activity similar to that in rat aorta. Norepinephrine-contracted human vessels were significantly more sensitive than potassium-contracted vessels to the relaxant effect of amrinone (ED50 HMA = 15 +/- 5 microM, ED50 HSV = 72 +/- 31 microM, P < 0.05). We conclude that at concentrations still devoid of myocardial effects dobutamine and amrinone are effective dilators in graft segment vessels and rat aorta contracted by membrane depolarization. If the difference between aortic and myocardial tissue still holds in human tissues, at the appropriate concentrations these drugs should be expected to improve cardiac performance while still contributing to the maintenance of graft patency.

Critical thermodynamics of the two-dimensional +/-J Ising spin glass

We compute the exact partition function of 2d Ising spin glasses with binary couplings. In these systems, the ground state is highly degenerate and is separated from the first excited state by a gap of size 4J. Nevertheless, we find that the low temperature specific heat density scales as exp(-2J/T), corresponding to an "effective" gap of size 2J; in addition, an associated crossover length scale grows as exp(J/T). We justify these scalings via the degeneracy of the low lying excitations and by the way low energy domain walls proliferate in this model.

[Respiratory diseases in infants hospitalized during the 1st 2 years of life for viral lower respiratory tract infections: a one-year follow-up]

BACKGROUND

Epidemiologic data suggest strong links between hospitalisation with bronchiolitis in infancy and subsequent higher risk of developing lower respiratory tract infections (LRTI) and/or hyperreactive airway diseases. The aim of this study was to evaluate in an Italian population the natural history of respiratory diseases in children hospitalised for LRTI when they were <2 years.

METHODS

An observational, perspective, longitudinal study was performed through telephone interviews. Nine pediatric tertiary care centres participated to the study evaluating a population of 187 children, hospitalised in the previous year (November 1999-April 2000) for bronchiolitis or pneumonia when they were <2 years of age and participated to a previous study on the prevalence of infant LRTI in Italy (RADAR).

RESULTS

Twenty-three (12.3%) children had a gestational age <36 weeks. In the 12 months following the first hospitalisation, an elevated frequency of respiratory symptoms was found. Indeed, 152 (81.3%) children suffered from not-requiring-hospital-admission respiratory infections and 21 (11.2%) were hospitalized again for LRTI: 11.6% had bronchiolitis, 23.5% bronchitis and 35.2% pneumonia. In addition, 1.2% had gs;3 infectious episodes and 21.4% gs;6: 68 (36.4%) showed wheezy bronchitis and 17 (9.1%) were reported to have asthma; 132 children (71%) took antibiotics during the last year, 19.4% >3 times; 111 (59.4%) bronchodilators and 49 (26.2%) oral corticosteroids. One year after the first hospitalisation, 19 subjects (10.2%) were found to be positive to at least one class of allergens by prick test or RAST.

CONCLUSIONS

Thus, the demonstration of a high morbidity rate for LRTI, wheezing and asthma in this study group during the first year follow-up after hospital admission further support the need for prophylactic interventions to reduce the morbidity and severity of sequelae of LRTI, in particularly in premature children and/or with additional risk factors.

Neonatal hyperbilirubinemia and Gilbert's syndrome

The role of Gilbert's syndrome (GS) in neonatal hyperbilirubinemia, characterized by bilirubin levels higher than 223 microMol/L during the first seven days of life, has been investigated, evaluating the frequency of GS genotype (A(TA)7TAA polymorphism in the promoter of the gene encoding UGT1). The frequency of GS was significantly higher in the hyperbilirubinemic group, even though neither the peak of bilirubin, nor the day on which the highest value was found, differed according to genotype. The normalization of bilirubin levels was slower in neonates with GS. These results confirm the idea that GS is one of the factors contributing to neonatal hyperbilirubinemia, but that other factors play a role in determining neonatal jaundice. The slower decrease of bilirubin levels in A(TA)7TAA homozygous neonates confirms that GS is an important factor in determining a prolonged neonatal jaundice.

Electro-oculographic abnormality in eyes with uveal melanoma

PURPOSE

To seek out correlations between preoperative electro-oculogram (EOG) recordings with different types of uveal melanomas, after surgery.

METHODS

We analysed the EOG recordings of 120 patients with uveal melanomas, histologically verified, 100 in the choroid and 20 in the iris and ciliary body. The EOG data were correlated with the site, size and histological type of the tumor.

RESULTS

In 100 eyes with choroidal melanoma the Arden Index (AI) was less than in fellow eyes (mean 126.6, SD +/- 23.8 and 202.9, SD +/- 47.0; p=0.01). The EOG values were not different with respect to the histological type, site and size of tumor. In cases with iris and ciliary body melanomas the AI were not significantly different from the fellow eyes (mean 180.6, SD +/- 23.6 and 203.2, SD +/- 38.7; p=0.07).

CONCLUSIONS

Since the EOG is abnormal in eyes with choroidal melanoma, it can be considered a powerful auxiliary for diagnosing these tumors.

[Telemedicine in neonatal emergencies]

Telemedicine is the transmission of medical notices and images among remote sites, that uses adequate audio-video systems.

OBJECTIVE

To increase the quality and the amount of medical informations, avoiding unnecessary carriages. Among main fields of interest in Telemedicine, monitoring of cardiovascular parameters and medical emergency represent situations that need to be promptly and appropriately approached. In such a similar conditions, a preliminary transmission to III level Health Institutions of informations as Electrocardiograms or even Echocardiograms may play an essential role in the diagnosis, prognosis and treatment of emergent cardiovascular disease.

METHODS

Since March 1998, an Audio-Video PC-based system that uses integrated services digital network (ISDN) at a bandwith of 384 Kbps, was installed at Pediatric Cardiac Surgery Department of Giovanni XXIII Hospital, Bari, Italy. On July 1999, thanks to Research Funds of the Health Ministry of Italy, similar audio-video systems that use ISDN were installed in the main pediatric institutions of provinces of Puglia and linked in a wide area network.

RESULTS

We report the experience of Telemedicine of a Department of Pediatric Cardiology and Cardiac Surgery, and we try to analyze its impact on improvement of quality of care, once employed in provincial field.

Outcome of liver disease in a large cohort of histologically proven chronic hepatitis C: influence of HCV genotype

OBJECTIVE

To assess the influence of hepatitis C virus (HCV) genotypes on the clinical outcome of liver disease, we analysed 2,307 patients.

RESULTS

The most frequently represented genotypes were 1b (40%) and 2 (28.1%). Patients with these genotypes had a median age higher than patients with other genotypes (P< 0.01). The overall survival of subjects with genotype 1b was poorer than the survival of patients with other genotypes (P< 0.01). Liver cirrhosis was found in 280 patients (12.1%), and type 1b was the most represented isolate among them (P< 0.01). Sixty-two patients (22%) developed hepatocellular carcinoma (HCC) during a follow-up of 1481.8 cumulative years (estimated crude incidence rate, 4.1 cases per 100 person-years for all cirrhotics; 5.9 cases for genotype 1a; 4.5 cases for genotype 1b; and 2.8 cases for genotypes non-1). Considering the whole population of 2,307 patients, only genotype 1b was associated significantly with both cirrhosis and the development of HCC. One hundred and nineteen cirrhotic patients underwent treatment with interferon in uncontrolled studies. Interferon therapy was associated with both better survival (P< 0.01) and a lower cumulative hazard for HCC (P< 0.01).

CONCLUSIONS

Genotype 1b was associated with a poorer prognosis, probably because it leads to cirrhosis and consequently to HCC development. However, our data did not confirm genotype 1b as an independent risk factor for HCC in liver cirrhosis, which plays a major role in carcinogenesis. Interferon should be considered as a useful strategy in cirrhosis for improvement of survival and reduction of HCC risk.

[Vasodilators in isolated human radial arteries]

This paper was designed to evaluate the effectivity of several vasodilators, applied topically, to attenuate the hyperreactivity of radial arteries (RA) implanted as aorto-coronary bypass. Remnant segments of the RA were obtained from 20 operations, and each of the segments was divided into 4 rings. The rings were incubated for 30 minutes in control conditions (n = 20) or in presence of 30 microM of Diltiazem (DILT, n = 6), 30 microM of mibefradil (MIBE, n = 4) or a mixture of 30 microM of verapamil + 30 microM of nitroglycerin (VP-NTG, n = 6). A subsequent exposure to KCl 80 mM (in absence of vasodilators) evoked a sustained contraction in control rings, which was attenuated by 35 +/- 9% by DILT, 48 +/- 13% by VP-NTG and by 69 +/- 20% by MIBE (p < 0.05). Preincubation with vasodilators also attenuated the rate and intensity of rhythmic contractions of the RA. In rings that were cold-stored during 24 hs and then restimulated with KCl 80 mM the depressing effect was still evident: DILT 53 +/- 6%, VP-NTG 46 +/- 14% and MIBE 61 +/- 9% (p < 0.05). The effect of MIBE was more intense and persistent than that of DILT or VP-NTG, even at concentrations eliciting a similar initial depression of contraction. It is concluded that the exposure to vasodilators during a period equivalent to the duration of the surgical preparation of the RA produces an attenuation of the arterial reactivity that might provide an additional protection against RA spasm during the immediate postoperative period.

The international classification of the epilepsies and epileptic syndromes. An algorithm for its use in clinical practice

An algorithm has been structured as a guided reading of the international league against epilepsy (ILAE) syndromic classification to be used in clinical practice by less experienced physicians in newly diagnosed patients. The algorithm followed the original structure of the classification, which identifies major syndromic groups, subgroups, and specific syndromes. Validation required two raters, a resident and a board-certified neurologist, to apply the algorithm with different techniques (direct or recorded interview, medical record consultation) to 19 children and 18 adults with epilepsy with information available at the time of diagnosis. The two raters' diagnoses were compared with those of the caring physicians, and cases where disagreement arose were discussed in conference to achieve consensus. The kappa statistic was used as a measure of inter-rater agreement. Caring physicians and both raters agreed in 51% of cases. Substantial agreement (kappa = 0.75) was obtained between the resident and the neurologist on major diagnostic groups and subgroups, mostly in adults. Agreement with the caring physician was slightly more satisfactory for the resident (kappa=0.67) than for the neurologist (kappa = 0.60). Agreement was better with direct or indirect interview than with record consultation, and improved further after discussion. Agreement was obtained after discussion in 32% of cases, in some of which the caring physician agreed on the resident's diagnosis. Agreement was less satisfactory for specific syndromes. On this basis, an algorithm of the ILAE classification is a fairly reliable instrument only for making a broad syndromic classification of epilepsy at the time of diagnosis. The limits of the algorithm tend mostly to reflect the intrinsic limitations of the classification itself.

Unilateral retinitis pigmentosa: clinical and electrophysiological report of four cases

Unilateral retinitis pigmentosa (URP) is a rare tapetoretinal dystrophy affecting only one eye. The François and Verriest criteria are necessary to make a correct diagnosis of URP: exclude all infective etiologies, check that the clinical signs of retinitis are present in the affected eye and ensure the total absence of any signs or symptoms of retinitis pigmentosa in the fellow eye. The standard electroretinogram and standard electro-oculogram are very useful for the correct diagnosis. Other pigmentary retinopathies simulating retinitis pigmentosa have to be excluded, such as previous retinal inflammatory diseases like syphilis, rubeola, other viral diseases and onchocerciasis. In this paper, 4 cases of URP are reported.

The antineoplastic agent paclitaxel (Taxol) increases contractile activity in human saphenous veins and human mammary arteries

Effects of the antineoplastic agent paclitaxel (Taxol) were studied on contractions of isolated human saphenous vein (HSV) and mammary artery (HMA). Peak force developed by vascular segments with cumulative concentrations of physiologic agonists was enhanced by paclitaxel, producing a shift to the left of dose-response curves. Paclitaxel 1 microM decreased ED50 (in microM) for norepinephrine from 1.01 +/- 0.24 to 0.20 +/- 0.06 (n = 16, p < 0.05) in HSV and from 1.30 +/- 0.30 to 0.51 +/- 0.21 (n = 15, p < 0.05) in HMA and for 5-hydroxytriptamine from 0.64 +/- 0.19 to 0.21 +/- 0.07 (n = 20, p < 0.05) in HSV. Paclitaxel 1 microM also significantly increased the peak force of contractions elicited by endothelin-1 0.01 microM in HSV. In contrast, it did not affect contractions evoked by KCl 80 mM. These results show that paclitaxel produces a hyperreactivity in human vessels challenged by physiologic agonists, which suggests that administration of paclitaxel to patients could augment peripheral resistance and increase blood pressure.

Endoplasmic reticulum contribution to the relaxant effect of cGMP- and cAMP-elevating agents in feline aorta

The contribution of endoplasmic reticulum (ER) and phosphorylation of phospholamban (PLB) to the relaxant effect of cGMP- and cAMP-elevating agents was studied in feline aorta. Sodium nitroprusside (NP, 100 microM) completely relaxed contracture induced by 10 microM norepinephrine. This NP-induced relaxation was partially prevented by tetraethylammonium, suggesting that a fraction of NP-induced relaxation was mediated by activation of K(+) channels. In the absence and presence of tetraethylammonium, the relaxant effect of NP was associated with a significant increase in Ser(16) phosphorylation of PLB immunodetected by phosphorylation site-specific antibodies. The relaxant effect of NP on aortic strips precontracted with 80 mM KCl was significantly reduced by 1 microM thapsigargin. This decrease, which represents the ER contribution to the relaxant effect of NP, reached 23 +/- 9% at 100 microM NP and was closely associated with a dose-dependent increase in Ser(16) phosphorylation (128 +/- 49% over control at 100 microM NP). Effects of NP were associated with a significant increase in activity of protein kinase G and were mimicked by 8-bromo-cGMP. Forskolin produced a dose-dependent relaxant effect on KCl-induced contracture, which reached 64 +/- 8% at 50 microM and was associated with an increase in phosphorylation of Ser(16) residue of PLB (88 +/- 18% over control). Thapsigargin reduced this relaxant effect by 38 +/- 9%. 8-Bromo-cAMP mimicked effects of forskolin. The ER-mediated relaxant effect and the increase in Ser(16) phosphorylation produced by forskolin were partially blocked by the protein kinase A inhibitor H-89 (5 microM). The results indicate that ER partially contributes to the relaxant effect of NP and forskolin in feline aorta. This effect may be mediated by the associated increase in Ser(16) phosphorylation of PLB.

Oscillatory potentials of the electroretinogram in hypertensive patients with different antihypertensive treatment

Oscillatory potentials of the electroretinogram are useful to confirm the diagnosis of essential hypertension. Thirty-five hypertensive patients underwent primary antihypertensive therapy with four different treatments. Oscillatory potentials were recorded before the treatment and after 12 months. The oscillatory response increased in a statistically significant manner in the angiotensin-converting enzyme inhibitor group. This is probably caused by the vasodilatation mechanism, which increases the retinal blood flow.

HCV genotypes in Northern Italy: a survey of 1368 histologically proven chronic hepatitis C patients

BACKGROUND/AIMS

Hepatitis C virus (HCV) easily undergoes genomic changes, thus accounting for the presence of different genotypes, with different geographic distributions and different outcomes of chronic hepatitis. Type 1b is frequently found in advanced diseases; however, since this genotype is the most prevalent in older patients, the association with advanced age and severity of the disease is confounding. The aim of this study was to assess changes in the prevalence of HCV genotypes by surveying a large population of chronic hepatitis C patients in Northern Italy, and to assess if the high prevalence of genotype 1b in older patients with advanced diseases simply reflects the duration of HCV infection, rather than intrinsic biological properties of HCV.

METHODS

We studied 1368 HCV-RNA positive patients, with histologically proven chronic hepatitis. Drug addiction, blood transfusions and sporadically acquired infections represented the risk factors.

RESULTS

Genotype 1b, the most prevalent isolate, and genotype 2a were associated with older age, cirrhosis, sporadically-acquired infections and blood transfusion, while types 1a, 3a, and 4 were associated with younger age, chronic persistent hepatitis and drug addiction. Patients with a history of transfusions were divided into four groups depending on the period of transfusion. The prevalence of genotype 1b decreased with time. Type 3a appeared only after 1979.

CONCLUSION

The severity of chronic hepatitis C could be related more to the duration of the infection rather than to the intrinsic pathogenicity of HCV genotypes.

Effect of myopic excimer laser photorefractive keratectomy on the electrophysiologic function of the retina and optic nerve

PURPOSE

To assess by electrophysiologic testing the effect of photorefractive keratectomy (PRK) on the retina and optic nerve.

SETTING

Eye Clinic, S. Salvatore Hospital, L'Aquila University, Italy.

METHODS

Standard pattern electroretinograms (P-ERGs) and standard pattern visual evoked potentials (P-VEPs) were done in 25 eyes of 25 patients who had myopic PRK for an attempted correction between 5.00 and 15.00 diopters (D) (mean 8.00 D). Testing was done preoperatively and 3, 6, 12, and 18 months postoperatively. The contralateral eyes served as controls. During the follow-up, 3 patients (12%) developed steroid-induced elevated intraocular pressure (IOP) that resolved after corticosteroid therapy was discontinued.

RESULTS

No statistically significant differences were seen between treated and control eyes nor between treated eyes preoperatively and postoperatively.

CONCLUSION

Myopic excimer laser PRK did not seem to affect the posterior segment. The transient steroid-induced IOP rise did not seem to cause functional impairment.

[Effect of insulin on contractile response and calcium binding in rat aorta]

Insulin affects physiological mechanisms involved in blood pressure regulation, and at the cellular level modifies endothelial and vascular smooth muscle functions underlying the changes in peripheral resistance. We describe the effects of preincubation with insulin (40 microU/ml for 1-2 hs) on the contractile reactivity of intact rat aortic rings and on 45Ca2+ uptake of EGTA-hyperpermeabilized rat aortic segments. Preincubation with insulin did not affect either contractions induced by 1 microM of NA, or their relaxation induced by 10 mM of caffeine. The contractile response to 1 microM of Ang-II (which in rat aorta is endothelium-independent) was stimulated by insulin preincubation resulting in increases of both maximal developed force and velocity of its spontaneous relaxation. The difference in 45Ca2+ uptake between insulin-treated and insulin-untreated aortic segments was greater at 5 minutes than it was at 30 minutes.

CONCLUSIONS

Insulin preincubation affects directly the mechanical response of Ang-II stimulated aortic smooth muscle; we suggest that the modification of SR function is one of the mechanisms involved in insulin regulation of cytosolic Ca2+.

Homonymous Bilateral Hemianopsia: Electrophysiological Study of a Case

Described is a case of bilateral homonymous hemianopsia with macular sparing, resulting from head trauma. The case presented lesions of the occipital visual areas which involved entirely the left hemisphere and only partially the right hemisphere. VEP were obtainable only from electrodes placed on the right hemisphere with both right eye and left eye stimulation. VEP mapping showed that each eye projects macular fibres towards functional areas of the right occipital hemisphere.

Electrophysiological examination confirmed objectively and for the first time in man the theory of “double cortical macular representation”.

Clinical implications of this finding are discussed.

[Insulin, vascular reactivity and hypertension]

Several epidemiological studies have shown that there is a relationship between hyperinsulinemia, insulin resistance and arterial hypertension. Insulin produces sympathetic nervous system stimulation, enhances renal sodium retention and it directly modifies vascular mechanisms involved in both contraction and relaxation of the vascular smooth muscle. These actions of insulin could lead either to elevation or reduction of blood pressure. The absence of vasodilation due to insulin resistance and/or the enhancement of the hypertensive effects due to hyperinsulinemia could be the link between insulin and hypertension.

Pulmonary pathology in surfactant-treated preterm infants with respiratory distress syndrome: an autopsy study

The present study examines the histological features of the lungs of neonates who died of respiratory distress syndrome or related complications after surfactant therapy. Our aim was to determine whether these lungs showed any unusual histological findings. Complete autopsies were performed 6-12 h after death in 10 surfactant-treated preterm infants and in 30 infants who died before surfactant therapy was available. Representative paraffin sections of all pulmonary lobes, stained with haematoxylin and eosin, were examined microscopically. A few selected slides were also stained with periodic acid-Schiff, Vierhoff-van Gieson, and Mallory trichrome. Hyaline membrane disease and bronchopulmonary dysplasia were present in each group, although there was an increased incidence of intra-alveolar haemorrhage in surfactant-treated babies (in 8 of 10 surfactant-treated as compared with 7 of 30 untreated babies). Amongst those treated with surfactant, we observed the persistence of acute alveolar damage with unresolved hyaline membrane disease in 5 infants who died at the ages of 5, 6, 10, 12, and 13 days, respectively, and histological evidence of pneumocyte type 2 hyperplasia and dysplasia in 2 infants who died at 22 and 41 days of age, respectively. These observations reveal that surfactant-treated infants who fail to respond to therapy have continuing alveolar injury and an increased incidence of intra-alveolar haemorrhage. Since oxygen radicals can induce pneumocyte damage and necrosis and since free radicals provoke alveolar haemorrhage in animal models, we propose that the lesions we observed may stem from a lack, in some preterm babies, of specific mechanisms that detoxify oxygen radicals.

Colchicine in the treatment of mixed cryoglobulinemia

OBJECTIVE

The best treatment for cryoglobulinemic syndrome (CS) is still an unsolved problem. Recently colchicine has been successfully used to treat vasculitides and other immune-mediated diseases. Therefore, we undertook to treat 17 CS patients with colchicine (1 mg/day for 6-48 months), 8 of them with essential mixed cryoglobulinemia (EMC) and 9 with CS secondary to liver disease.

METHODS

In all patients the clinical and laboratory features were evaluated at the beginning of the study and during the first 6-12 months; 10 cases were followed for a longer period (18-48 months).

RESULTS

During the first period symptoms improved as follows: purpura in 15 of 17 patients, weakness in 9 of 14 and leg ulcers in 3 of 5. Hepatic and renal function tests, hypocomplementemia, rheumatoid factor (RF) titres and the cryocrit also improved. Prolonged follow-up showed a relapse in the different variables, although they remained at better levels than at the beginning. Only the cryocrit showed a further reduction.

CONCLUSION

Though this was a preliminary open study it shows that colchicine is an efficient treatment in CS and suggests that a controlled clinical study should be performed to assess its real value.

The natural history of cryoglobulinemia: symptoms at onset and during follow-up. A report by the Italian Group for the Study of Cryoglobulinemias (GISC)

OBJECTIVE

The cryoglobulinemic syndrome (CS) may be associated with other diseases; when it is not, it is termed essential. Recently the natural history of this disease has been re-evaluated on the basis of its close association with HCV markers. In this context, the GISC has studied a large series of patients from several Italian centres.

METHODS

In a multicentric retrospective study of 913 cases, we evaluated the clinical and laboratory signs at onset in patients with essential mixed cryoglobulinemias (EMC) (654 cases) or secondary cryoglobulinemias (SC) (259 cases) and sought to define possible diagnostic criteria typical of the different CS. We also carried out a retrospective 5-year cohort study on 192 patients selected randomly from the 913 cases described above. In particular, we examined the correlation between the presence/absence of concomitant diseases and the presence of HCV markers on the clinical evolution and survival of the patients.

RESULTS

Purpura, rheumatoid factors (RF), significant C4 consumption, and Brouet's classification type II were more frequent in EMC. Purpura, Meltzer's triad, and Raynaud's phenomenon improved, while renal involvement tended to worsen over time. During the follow-up we did not note a significant change in clinical staging in the patients with Brouet's type II cryoglobulins, in the patients with HCV-related markers, or in the overall series. The most frequent causes of death in 34 patients were liver, cardiovascular, renal, and lymphoproliferative diseases. Lymphomas were diagnosed in 11 patients during follow-up, with particular frequency in the HCV-marker positive patients.

CONCLUSION

Specific clinical and laboratory features typical of the different CS subgroups could not be identified on the basis of these data. Our follow-up data seem, however, to confirm a role for HCV in the mixed cryoglobulinemias.

Hepatitis C antibody and cryoglobulins in patients with cirrhosis and hepatocellular carcinoma

OBJECTIVE

To assess: (1) the role of hepatitis C virus (HCV), hepatitis B virus (HBV) and alcoholism as risk factors for hepatocarcinoma (HCC) in patients with liver cirrhosis, and (2) the presence of cryoglobulins in HCV + patients with and without HCC.

PATIENTS

82 cirrhotic patients, 41 with and 41 without HCC, who were admitted consecutively to our General Medicine Division from January 1992 to June 1994, were studied.

RESULTS

The prevalence of HBV markers, anti-HCV and alcoholism in patients with liver cirrhosis and HCC was 39%, 63.4% and 24%, and in cirrhotics without HCC it was 31.7%, 51.2% and 63.4%, respectively. Cryoglobulins were present in 87.5% of the patients with HCC (78.5% anti-HCV +) and in 57.8% of the patients without HCC (81.8% anti-HCV +). The cryoglobulins, as characterized in 11 cases, were type III in nine cases and type II in two.

CONCLUSIONS

Patients with cirrhosis, especially when associated with HCV and HBV infection, are at high risk for HCC and therefore require careful follow-up. Moreover, a strong association between HCV and the cryoglobulins in cirrhotics with and without HCC was evident, thus supporting the possible role of this virus in stimulating lymphocytes to produce cryoglobulins.

Anti-GOR antibodies, HCV, liver disease and cryoglobulinemia

OBJECTIVE

We investigated the presence of anti-GOR antibodies in patients with essential mixed cryoglobulinemia, since both autoimmune pathogenetic processes and a high prevalence of HCV infection are present in this syndrome.

METHODS

We compared these cases to patients with HCV-related chronic active hepatitis or alcoholism, and to ex-blood donors. A total of 60 patients with biopsy-proven chronic liver disease were studied.

RESULTS

HCV related markers, cryoglobulins, anti-GOR antibodies and ANA were detected in all of the groups.

CONCLUSION

Our data would appear to indicate that anti-GOR are related to the presence of HCV chronic hepatitis and not to cryoglobulinemia or chronic liver damage.

Hepatitis C virus RNA in the bone marrow of patients with mixed cryoglobulinemia and in subjects with noncryoglobulinemic chronic hepatitis type C

Hepatitis C virus (HCV) infection is associated with most mixed cryoglobulinemia (MC) syndromes. In this study, HCV RNA was detected in the peripheral blood mononuclear cells of 11 (73.3%) of 15 patients with MC and in 5 (71.4%) of 7 noncryoglobulinemic patients with chronic hepatitis type C. All patients with cryoglobulinemia and 3 (42.8%) of the 7 without cryoglobulinemia (P < .05) had HCV RNA in bone marrow cells. Subjects in both groups with HCV-positive bone marrow also had HCV RNA in serum. The majority of patients with MC syndromes were infected with HCV subtypes 1b and 2a. Two patients with MC had different genotypes in serum and cells. Further studies are needed to determine which bone marrow cell population is preferentially infected by HCV and to determine if this phenomenon is involved in inducing the production of cryoglobulins.

Oscillatory potentials in subjects with treated hypertension

Oscillatory potentials of the ERG proved to be a sensitive indicator even in mild disturbances of retinal circulation, such as the first stage of hypertensive retinopathy (WHO classification). Oscillatory indexes (OIs) and blood pressure levels of 24 hypertensive patients in stage 1 of the WHO classification, who underwent an antihypertensive therapy for the first time, were considered. The patients were retested after a mean period 8 months. a strict inverse correlation was found between OIs and blood pressure levels.

Early and late results of 100 consecutive total gastrectomies for cancer

The authors present a case study of 100 patients who underwent total gastrectomy out of a total of 376 patients submitted to surgery for gastric cancer between 1970 and 1992. The majority of the neoplasms were located in the middle third of the stomach with histological characteristics of an epithelial type in 92% of the cases, 8 of which were classified Stage IA, 6 Stage IB, 14 Stage II, 24 Stage IIIA, 25 Stage IIIB, and 15 at Stage IV. An R2 total gastrectomy, which included the distal 2-3 centimeters of the esophagus and the proximal 2-3 centimeters of the duodenum, combined with omentectomy and level 1 and 2 lymphadenectomy, was always performed. Thirty-four of the operations were extended and splenectomy was performed in 27 of these. Digestive continuity was obtained in 37 cases with an esophago-jejunostomy on a Roux-en-Y loop. Recanalization of the duodenum was accomplished in accordance with the Moricca technique in 32 cases and the Mouchet-Camey technique in 22 cases. Of the remaining 9, 5 underwent reconstructive surgery as described by Sweet-Allen, 2 as described by Nakayama, and the remaining 2 direct esophago-duodenostomy. The majority of the cases received total parenteral nutrition on the second postoperative day and this was maintained for the following eight days. Post-operative mortality, reported during the initial 30 days was 7%, overall morbidity 17%. A detailed protocol of clinical and diagnostic tests was established for follow-up studies conducted on a 4-month basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between baseline blood pressure and blood pressure decrease after calcium channel blockers in conscious rats

OBJECTIVE

To determine whether vasodilators produce a fall in mean blood pressure (MBP) that is directly proportional to baseline MBP.

DESIGN

The effects on blood pressure of three calcium channel blockers, nitrendipine, nisoldipine and verapamil, were compared with sodium nitroprusside, a drug acting through a different mechanism. The drugs were infused in conscious, unrestrained rats and their effect on MBP was measured.

SETTING

Primary experimental.

ANIMALS

Animals were divided into three groups according to their baseline MBP: high (greater than 119 mmHg), moderate (91 to 119 mmHg) and normal (less than 91 mmHg).

INTERVENTIONS

Five successive infusion rates for each drug were tested in each animal. MBP readings were taken at the end of each infusion period (usually 10 mins).

MAIN RESULTS

At the maximal dose infused, nitrendipine (0.57 mg/kg.min) lowered MBP 13 +/- 6 mmHg in the low MBP rats, 51 +/- 4 mmHg in the rats with moderate MBP and 83 +/- 8 mmHg in the rats with high MBP (P < 0.05 within groups). Similar results (ie, the greater the baseline MBP, the greater the fall in MBP) were obtained with nisoldipine and verapamil. In the same groups, sodium nitroprusside (0.096 mg/kg.min) produced a fall of 52 +/- 3 mmHg, 56 +/- 5 mmHg and 54 +/- 13 mmHg, respectively (not significant).

CONCLUSIONS

Nitrendipine, nisoldipine and verapamil behave as antihypertensives since their effect increased as a function of the initial MBP, while sodium nitroprusside showed no effect related to baseline MBP.

Gastric cancer cell DNA content correlates with early and late results after gastrectomy

The DNA content of 59 adenocarcinomas of the stomach in patients who had undergone subtotal or total gastrectomy more than 5 years before was measured. The DNA measurements were done by flow cytometry performed on Propidium Iodide--stained cells disaggregated from paraffin-embedded tissues. Fifty-nine evaluable good quality histograms of DNA ploidy patterns were obtained. The Proliferative Index (PI) was determined in 35 cases. The remaining 24 cases didn't show a reliable reading histograms. Of the 59 tumors, 33 (56%) were diploid and 26 (44%) were aneuploid; 19 showed a high PI (> or = 3.8%) and 16 a lower one. A statistically significant difference was found between the two groups (diploid/aneuploid and low/high PI) compared to the prognostic values known as T, N and Stage. 65% of the T3-T4 cancers, 54% of the N1-N2 lesions and 58% of the stage III and IV were found to be aneuploid. 73.7% of the 19 tumors presenting high PI, showed an aneuploid pattern. A high PI was found in 71.4% of the T3-T4 tumors. 77.4% of patients of the diploid group (any stage) survived at 5 years against 36% of those presenting aneuploid patterns. Patients with PI > or = 3.8% showed a 42.1% 5-year survival rate. A 94.4% 5-year survival rate of diploid and early stage cancers was documented against a 33.5% of aneuploid and advanced stage cancers.

Modern therapeutic approaches to postmastectomy brachial lymphedema

Over the past 10 years we have treated 36 patients affected by upper limb lymphedema, associated with mastectomy and axillary dissection, by either macrosurgical exeresis or microsurgical techniques. All cases had been unresponsive to prior drug or physical therapy (pressure and thermal therapy). Preoperative upper limb status was thoroughly examined by evaluating volume measurements, dynamic lymphoscintigraphy, venous Doppler fluximetry, ultrasonography, and nuclear magnetic resonance. Selected tests were repeated during follow-up to obtain more statistically significant results. Twenty-five of the 36 patients in our series presented a grade II lymphedema and underwent Degni-Cordeiro's microsurgical indirect lymphatico-venous shunt (L.V.S.) surgery. Fifteen of the 25 also received fasciotomies performed along the posterior aspect of the forearm. Three of the 36 patients presented grade II lymphedema and upper limb venous hypertension. These were treated with multiple fasciotomies alone. The remaining eight patients presented grade III lymphedemas. Seven underwent Kondoleon's partial superficial lymphangectomy, and one was treated with Servelle's total superficial lymphangectomy. Of the 36 patients who underwent surgery, only 27 were checked at 6 months; 22 were seen at 18 months. The remaining patients were followed up for too short of a period of time to be considered. Results were arranged into three groups. Classification criteria were: reduction of upper limb dimensions and the presence of the pre-existing symptoms (episodes of lymphangitis, pain, functional deficits. Results were considered good (class 3), fair (class 2), or poor (class 1). A positive clinical picture (class 2-3) was seen in 74% (20/27) at 6 months and in 59% (13/22) at 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between positive CA 72-4 serum levels and lymph node involvement in patients with gastric carcinoma

CA 72-4 serum marker has been shown to be one of the most specific and sensitive markers for monitoring gastric cancer. In the present study we evaluated the correlation between CA 72-4, CA 19-9 and CEA serum levels, and tumor size and lymph node involvement in gastric carcinoma patients. One-hundred sixty-one patients with primary or recurrent gastric carcinoma were studied. Elevated CA 72-4, CA 19-9, and CEA serum levels were found in 42.2%, 32.3% and 24.2%, respectively. As previously shown, the combination of CA 72-4 and CA 19-9 increased positive samples to 56.5%, while the addition of CEA did not further improve this percentage. Unlike what has been previously published, none of the markers showed a significant correlation with serosal involvement. In fact, elevated serum levels were observed for the three markers in a very low percentage of cases either in T1-T2N0 or T3-T4N0 patients. In contrast, CA 72-4 showed a highly significant correlation with lymph node involvement: T1-T4N0 patients had positive CA 72-4 levels in 5 out of 37 (13.5%), while T1-T4N1 in 12 out of 32 (37.5%), and T1-T4N2 in 20 out of 40 (50%) (p < 0.003). CA 19-9 and CEA serum levels were not significantly correlated. Since the presence of lymph node metastases is considered a negative prognostic factor, these results suggest that the measurement of CA 72-4 serum levels may be an important parameter in the diagnosis and clinical follow-up of patients with gastric carcinoma.

Contrast sensitivity in multifocal intraocular lenses

Contrast sensitivity was measured in two groups of 20 patients each implanted with refractive and diffractive multifocal intraocular lenses and in two control groups of 20 patients each--the first group implanted with a monofocal IOL and the second phakic subjects. All cases had a postoperative follow-up of at least one year and a corrected visual acuity of 20/20- or better. We used two psychophysical tests, Pelli Robson test chart and Vistech 6500 test chart, and an objective test, visual evoked potentials (VEPs). There were no statistically significant differences in contrast sensitivity in the psychophysical tests between the two groups implanted with multifocal IOLs. The situation was different, however, when they were compared with the control group with monofocal IOLs and the group with phakic eyes: the Pelli-Robson test results were not significantly different, but the Vistech 6500 test showed a significant reduction in contrast sensitivity in both groups. The pattern VEPs objective test confirmed these results: no differences were noted between the two different multifocal IOLs, while there was a drop in contrast sensitivity when their results were compared with those of the control groups; the intermediate frequencies were particularly affected by this phenomenon. The contrast sensitivity in patients with multifocal IOLs is reduced despite high visual acuity and this can affect the quality of vision.

High-dose immunoglobulin therapy as an immunomodulatory treatment of rheumatoid arthritis

OBJECTIVE

To investigate the efficacy of high-dose intravenous immunoglobulin (IVIg) in the treatment of refractory rheumatoid arthritis (RA).

METHODS

Ten patients with active, severe RA that was unresponsive to first- and second-line agents were administered IVIg monthly, for 6 months.

RESULTS

Following IVIg treatment, there was significant improvement in both subjective and objective parameters of disease activity in all 9 patients who completed the protocol. This improvement was noted to occur as early as after the second infusion of IVIg. After discontinuation of the treatment, all patients had a relapse of the disease within a few weeks.

CONCLUSION

Since the reduction in clinical activity paralleled a decrease in the CD4+CDw29+:CD4+CD45RA+ cell ratio, some of the therapeutic benefits associated with IVIg may be due to a direct influence on the CD4+CD45RA+ subset. Although the possibility of carrying out further controlled studies on a larger scale is limited by the high cost of the treatment, IVIg appears to be an effective therapy for refractory RA.

Dietary calcium on vascular reactivity in normotensive and spontaneously hypertensive rats

Vascular reactivity and systolic blood pressure (SBP) were studied in tail artery rings isolated from stroke-prone spontaneously hypertensive rats (SHRSP) and normotensive, Wistar-Kyoto rats (WKY). After a control week on a diet with 1% of calcium, the animals were randomly assigned to three groups, which were fed with 1% (control), 0.4% (low) or 2.5% (high) dietary calcium. Both vascular reactivity and SBP were studied in the same animal during 9 weeks after changing diets. In the SHRSP rats on high Ca diet, maximal contractile responses to norepinephrine and serotonin (10(-10) to 10(-4) M) and to KCl (5 to 105 mM) were markedly decreased at the end of the study with respect to the control diet. These vascular changes were accompanied by a decrease of SBP in the same animals. Low calcium diet prevented the age-related increase of SBP in SHRSP rats and produced vascular changes of a lesser magnitude. WKY rats showed no significant modifications of SBP or vascular reactivity. Since plasmatic Ca2+ levels were not altered, the changes detected could not be attributed to a direct depressant effect of high calcium on the vascular smooth muscle cell (i.e. a "stabilizing action" of calcium). It is speculated that high dietary calcium could modulate the synthesis of calcium binding proteins of the plasma membrane, decreasing vascular reactivity and the elevated vascular resistance which is usually present in hypertension.

Symptoms of respiratory allergies are worse in subjects with coexisting food sensitization

Food sensitization was evaluated in 78 subjects with respiratory allergies, both by skin tests with commercial and fresh allergens, and by specific IgE determination. On the basis of the presence or absence of the latter the population was divided into two groups. The group with food-specific IgE showed more severe features of respiratory allergy, including a greater number of positive skin tests and specific IgE determinations, more class 3 and 4 reactions, and more symptoms. The hypothesis that early food sensitization can predispose to severe inhalant allergy is discussed.