Two novel mutations of the human Δ7-sterol reductase (DHCR7) gene in children with Smith–Lemli–Opitz syndrome

We analyzed seven unrelated children with the Smith-Lemli-Opitz syndrome (SLOS) for mutations in the delta7-sterol reductase gene by using SSCP and direct sequencing. We identified two novel mutations (V330M and R363C) in the DHCR7 gene. Reported mutations found in this study were T93M (3/14 alleles), E448K (2/14), and W151X, G244R, P329L, and R446Q (each found in one allele). The so-called common IVS8-1 G --> C was found in three alleles, confirming its relative rarity among Italian SLOS families. By using a scoring system, clinical severity did not seem to correlate with 7DHC levels and type of mutation. Expanding the spectrum of mutations in SLOS, our study does not support direct genotype-phenotype correlation.

[Long gamma nail for the treatment of subtrochanteric fracture of the femur]

PURPOSE OF THE STUDY

The standard gamma nail is commonly used for the treatment of trochanteric fractures but cannot be used if the fracture lies at the level of the distal locking. Theoretically, the long gamma nail would overcome this inconvenience and could be used for all cases of subtrochanteric and trochanteric-shaft fractures.

MATERIAL AND METHODS

Clinical and radiological charts were established in 1990 for a multicentric study. The radiology work-up included an AP view of the pelvis and an oblique lateral view of the hip. Two classifications were used: Seinsheimer and Muller as modified by Nazarian. Three stages of fracture reduction were recorded: 1=anatomic reduction, 2=acceptable reduction, 3=poor reduction. From January 1995 to December 1999, 46 patients were treated with the long gamma nail. Twenty-four cases were excluded for various reasons (from which 3 early death). 22 remaining patients were followed for more than six months. Mean age was 68 years (range 42-96); there were six women and 16 men. Ten patients were traffic or work accident victims and 12 had had a home accident.

RESULTS

Mean duration of surgery was 70 minutes. Three patients required revision surgery within a week of the initial osteosynthesis. Mean hemoglobin level before surgery was 12.9 g/dl; 8.9 g/dl during the first postoperative week. Mean hospital stay was 14 days. Weight-bearing with support was possible early after surgery in 16 patients who walked with crutches or a walker. Mean delay to weight-bearing was 11 days. At three months, all patients were using an aid for walking; at six months, four patients used a walker. Bone healing was achieved on the average at the twelfth week. Radiological reduction was anatomic in four, acceptable in three and poor in 15.

DISCUSSION

We advocate the AO classification as it allows a structured analysis of all fractures within a unique system. We compared our results with nine series reported in the literature using other therapeutic methods (screw-plate, nail-plate, Ender nail). The operative time for the long gamma nail (70 min) was comparable with that for other surgical techniques. Treatment with the long gamma nail favors bone healing and limits the risk of infection. Radiological results in our series were poor, but there were no cases with nonunion and the morbidity was low.

Successful pregnancy in a woman with mut- methylmalonic acidaemia

We report on a favourable pregnancy in a woman affected by mut- methylmalonic acidaemia. Under vitamin B12 and carnitine therapy she remained symptom-free throughout pregnancy, labour, delivery and the postpartum period and gave birth to a term, healthy female newborn. At follow-up, the child shows normal somatic and neurocognitive development.

[Neural determination in Xenopus laevis embryos: control of early neural gene expression by calcium]

In amphibian embryos the central nervous system derives from the dorsal region of the ectoderm. Molecular studies led to the formulation of the "neural default model" in which neural development is under the inhibitory control of members of the BMP family. These growth factors also act as epidermis inducers. The neural fate is revealed by factors secreted by the Spemann Organizer such as noggin, chordin, follistatin, Xnr3 and cerberus which act by blocking BMP signalling. We propose a new model for neural cell determination in which a signalling pathway controlled by an increase in intracellular calcium suppresses the epidermis fate and activates the neural fate instead. This increase in calcium is due to an influx through calcium channels of the L-type, expressed in ectodermal cells during gastrulation. The possible involvement of a calcium-dependent phosphatase (calcineurin) to inhibit the epidermis fate and a calcium-calmodulin kinase (CaMkinase II) which activates the neural fate is discussed.

Synergistic cytotoxicity exhibited by combination treatment of selective retinoid ligands with taxol (Paclitaxel)

The focus of this study was to develop retinoic acid receptor (RAR) RAR alpha/beta selective agonists with anticancer efficacy and reduced toxicity associated with RAR gamma activity. In these studies, we report the identification and characterization of high-affinity RAR alpha/beta selective agonists with limited RAR gamma activity. These compounds inhibited human tumor cell line proliferation with similar efficacy to that observed for a pan-RAR agonist. However, for most tumor cell lines, the efficacy of these compounds was restricted to the micromolar range. To determine whether the RAR alpha/beta selective agonists could be additive or synergistic with existing agents, we investigated the effects of combining RAR alpha/beta selective agonists with various cytotoxic agents. Our results showed that the alpha/beta selective retinoids dramatically lowered the effective dose of Taxol needed to induce cytotoxicity of a wide range of tumor cell lines. This synergy was specific to tubulin-modifying agents and could not be observed with a variety of other cytotoxic agents of diverse function. Examination of pathways common to Taxol and retinoid signaling revealed that this synergy was related in part to effects on Bcl-2 expression/phosphorylation as well as the activity of the c-Jun NH(2)-terminal kinase and activator protein-1. In contrast, the tubulin polymerization induced by Taxol was not further affected by cotreatment with a variety of retinoid receptor ligands. These observations indicate that potent RAR alpha/beta selective agonists may be of therapeutic benefit in combination with Taxol therapy.

Extracorporeal dialysis in neonatal hyperammonemia: modalities and prognostic indicators

We investigated the prognostic indicators in ten hyperammonemic neonates: four treated by continuous arteriovenous hemodialysis (CAVHD), four with continuous venovenous hemodialysis (CVVHD), and two with hemodialysis (HD). Plasma ammonium levels decreased significantly within the first 24 h irrespective of dialysis modality (from 1419 to 114 micromol/l, median values; P<0.0001). CVVHD achieved the highest ammonium clearance. HD provided highest ammonium extraction but clearance was hampered by severe hemodynamic instability. Five patients had a good outcome (normal at follow-up of 9-59 months), five had poor outcome (four died and one has severe neurological damage). Total coma duration was shorter in patients who had a good outcome (47+/-11 vs 78+/-13 h; P=0.02). Remarkably, only coma duration before dialysis determined this difference (22.2+/-10.1 vs 48.8+/-11.2 h; P=0.02). In cases with good outcome, coma duration was <33 h, whereas the others exceeded this limit. The prognosis was not related to dialysis modality, rapidity in reducing ammonium levels or to the underlying metabolic defect. In conclusion, results showed CVVHD to be the optimal modality for extracorporeal ammonium detoxification. However, the most relevant indicator for prognosis was coma duration before the start of dialysis. Therefore, major efforts should be made to refer patients quickly to highly specialized centers.

Clinical and molecular findings in hyperornithinemia-hyperammonemia-homocitrullinuria syndrome

The authors report the clinical and molecular findings in eight patients with hyperornithinemia, hyperammonemia, and homocitrullinuria (HHH) syndrome. The most consistent neurologic finding was spastic paraparesis, seen in five of the eight patients. However, all showed signs of pyramidal tract involvement. A broad spectrum of pathogenetic mutations (including missense, nonsense, splice site, insertion, and deletions) were identified in the ORNT1 gene.

Clinical and electroencephalographic effects of topiramate in patients with epilepsy and healthy volunteers

Although topiramate, one of the newer drugs used in treating epilepsy, is effective in reducing seizure frequency and has a wide spectrum of action, it often induces intolerable adverse effects, predominantly related to the central nervous system. Information that would help document adverse reactions early, thus allowing topiramate doses to be adjusted during the drug titration and maintenance phases, could be obtained from electroencephalogram (EEG) studies. We studied the clinical effects and EEG changes induced by topiramate in patients with refractory partial epilepsy receiving the drug as add-on therapy. To exclude effects related to the other drugs and to epilepsy itself, we compared data from patients and healthy volunteers. After receiving topiramate, 22.6% of patients became seizure free and 29% had their seizures reduced by 50% or more. Topiramate nevertheless induced noteworthy adverse reactions, the main problems being sedative and cognitive changes. Also, in healthy volunteers, a single 100-mg dose of topiramate induced mild adverse reactions, mainly affecting concentration and attention, with difficulties in speech and writing. In patients with epilepsy, the EEG changes induced by topiramate consisted of increased delta and theta activities and decreased activity in the rapid bands. This recognizable topiramate-induced EEG pattern was again evident in the healthy volunteers, in whom we also detected a significant reduction in the alpha frequency rhythm. Our results confirm that topiramate needs to be introduced gradually while patients undergo close neuropsychologic and neurophysiologic monitoring to detect adverse sedative and cognitive reactions early. The EEG correlate of these events seems to be increased activity in the slower frequency bands.

Prevalence and prognostic value of quantified electroencephalogram (EEG) alterations in cirrhotic patients

BACKGROUND/AIMS

The electroencephalogram (EEG) is frequently altered in cirrhotic patients. We, therefore, performed a study to ascertain the features and the prognosis of cirrhotic patients without current overt hepatic encephalopathy (OHE) who have EEG alterations.

METHODS

A series of 296 consecutive cirrhotic patients who had undergone quantified-EEG was studied. The median follow-up was 442 days, 128 patients had bouts of OHE and 78 patients died from liver-related causes. Another group of 124 cirrhotic patients with a median follow-up of 223 days was examined to validate the prognostic model.

RESULTS

EEG alterations were detected in 38% of the patients. The prevalence of EEG alterations was associated with the severity of cirrhosis (class B: odds ratio (OR) = 2.3, 95% confidence interval (CI) = 1.2-4.7; class C: OR = 3.5, 95% CI = 1.6-7.7), but not with the aetiology (alcoholic vs. non-alcoholic: OR = 0.9; 95% CI = 0.5-1.5). The EEG predicted the occurrence of OHE (chi2 = 26; P < 0.001) and mortality (chi2 = 34; P < 0.001), also adjusting for Child-Pugh class by a multivariate analysis. In the patients with a Child-Pugh score of > or = 8, the EEG discriminated between those patients with a higher 1-year risk of OHE (hazard ratio (HR) = 3.3, 95% CI = 1.8-6.1) and death (HR = 3.1, 95% CI = 1.7-5.6).

CONCLUSIONS

In conclusion, quantified-EEG had a prognostic value for the occurrence of bouts of OHE and mortality in cirrhotic patients.

Testosterone replacement therapy for hypogonadal men with major depressive disorder: a randomized, placebo-controlled clinical trial

BACKGROUND

Symptoms of male hypogonadism include low libido, fatigue, and dysphoria and are alleviated with testosterone replacement. The prevalence of major depressive disorder (MDD) in hypogonadal men is not known, nor is the antidepressant efficacy of testosterone replacement in depressed, hypogonadal men.

METHOD

A 6-week double-blind, placebo-controlled clinical trial was conducted in 32 men with DSM-IV MDD and a low testosterone level, defined as total serum testosterone < or = 350 ng/dL. Patients were randomly assigned to receive weekly 1-mL intramuscular injections of either testosterone enanthate, 200 mg, or sesame seed oil (placebo). The primary outcome measure was the 24-item Hamilton Rating Scale for Depression (HAM-D).

RESULTS

Thirty patients were randomly assigned to an intervention; 13 received testosterone, and 17 received placebo. Mean +/- SD age was 52+/-10 years, mean testosterone level was 266.1+/-50.6 ng/dL, and mean baseline HAM-D score was 21+/-8. All patients who received testosterone achieved normalization of their testosterone levels. The HAM-D scores decreased in both testosterone and placebo groups, and there were no significant between-group differences: reduction in group mean HAM-D score from baseline to endpoint was 10.1 in patients who received testosterone and 10.5 in those who received placebo. Response rate, defined as a 50% or greater reduction in HAM-D score, was 38.5% (5/13) for patients who received testosterone and 41.2% (7/17) for patients who received placebo. Patients receiving testosterone had a marginal but statistically significant improvement in sexual function (p = .02).

CONCLUSION

In this clinical trial with depressed, hypogonadal men, antidepressant effects of testosterone replacement could not be differentiated from those of placebo.

Genotypic correlates of phenotypic resistance to efavirenz in virus isolates from patients failing nonnucleoside reverse transcriptase inhibitor therapy

Efavirenz (also known as DMP 266 or SUSTIVA) is a potent nonnucleoside inhibitor of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) activity and of HIV-1 replication in vitro and in vivo. Most patients on efavirenz-containing regimens have sustained antiviral responses; however, rebounds in plasma viral load have been observed in some patients in association with the emergence of mutant strains of HIV-1. Virus isolates from the peripheral blood mononuclear cells (PBMCs) of patients with such treatment failures, as well as recombinant viruses incorporating viral sequences derived from patient plasma, show reduced in vitro susceptibility to efavirenz in association with mutations in the RT gene encoding K103N, Y188L, or G190S/E substitutions. Patterns of RT gene mutations and in vitro susceptibility were similar in plasma virus and in viruses isolated from PBMCs. Variant strains of HIV-1 constructed by site-directed mutagenesis confirmed the role of K103N, G190S, and Y188L substitutions in reduced susceptibility to efavirenz. Further, certain secondary mutations (V106I, V108I, Y181C, Y188H, P225H, and F227L) conferred little resistance to efavirenz as single mutations but enhanced the level of resistance of viruses carrying these mutations in combination with K103N or Y188L. Viruses with K103N or Y188L mutations, regardless of the initial selecting nonnucleoside RT inhibitor (NNRTI), exhibited cross-resistance to all of the presently available NNRTIs (efavirenz, nevirapine, and delavirdine). Some virus isolates from nevirapine or delavirdine treatment failures that lacked K103N or Y188L mutations remained susceptible to efavirenz in vitro, although the clinical significance of this finding is presently unclear.

Human herpesvirus 7 is latent in gastric mucosa

Chronic gastritis is associated frequently with persistent infection by Helicobacter pylori. However, not all patients with chronic gastritis have evidence of H. pylori infection, suggesting that other factors might contribute to the development of gastritis. The present study was undertaken to evaluate a possible etiologic role of human herpesvirus 7 (HHV-7). HHV-7 DNA was detected in about 80% of gastric biopsies, both in healthy mucosa from individuals without evidence of inflammation and in biopsies from patients with histologically confirmed chronic gastric inflammation. HHV-7 was present also in H. pylori negative samples, was associated specifically with gastric tissue and not with residual blood within the mucosa, and was present with high viral loads. HHV-7 DNA persisted in several patients also after remission of gastric inflammation and the viral presence did not correlate with specific symptoms. Analysis by RT-PCR showed that HHV-7 is transcriptionally inactive in chronic gastritis lesions. These observations show that gastric tissue represents a site of HHV-7 latent infection and a potential reservoir for viral reactivation.

The brassica MIP-MOD gene encodes a functional water channel that is expressed in the stigma epidermis

In crucifers, the ability of the stigma to differentially modulate hydration of pollen grains, depending on whether the pollen is recognized to be compatible or incompatible, represents a crucial stage in pollination. Our recent analysis of the mod mutation of Brassica, which results in a breakdown of the self-incompatibility response, led to the isolation of a gene linked to the MOD locus which is expressed at low levels in mod mutants. The gene is predicted to encode a plasma membrane-localized aquaporin-like protein and has been designated MIP-MOD. We utilized reporter gene analysis to demonstrate that the MIP-MOD promoter is active in Brassica papillar cells as well as in some vegetative tissues. The encoded protein is also likely to be plasma membrane-localized based on the observation that all plasma membrane-intrinsic aquaporin-like proteins in Brassica leaves are enriched in plasma membrane fractions. The MIP-MOD protein results in a low but measurable enhancement in osmotic water permeability of Xenopus oocytes and hence represents a functional aquaporin. The results are consistent with the notion that MIP-MOD is involved in the regulation of water transport across the stigma epidermal cell membrane.

[Rehabilitation of the first dorsal interosseous muscle by transfer of the extensor pollicis brevis tendon]

Weakness of the pinch grip between index finger and thumb, in ulnar nerve palsy, leads to severe loss of hand function. The first dorsal interosseous plays a major rôle as it abducts and flexes the index finger at its base and stabilizes the MP joint of this finger. Replacement of this muscle is therefore important. The authors report the results of eight clinical cases of replacement of the first dorsal interosseous by extensor pollicis brevis. They obtained good improvement of hand function, in terms of objective and subjective results, in all cases.

Abrogation of nerve growth factor-induced terminal differentiation by ret oncogene involves perturbation of nuclear translocation of ERK

Oncogenic variants of the receptor tyrosine kinase, Ret, cause formation of tumors of neuroendocrine derivation in the multiple endocrine neoplasia type 2 and, thus, likely interfere with antiproliferative and/or differentiative extracellular signals. Here we took advantage of two rat pheochromocytoma-derived cell lines (PC12/MEN2A and PC12/MEN2B) to investigate whether Ret-induced nerve growth factor (NGF) unresponsiveness might involve impairment of ERK signaling. In fact, these cells, stably transfected with distinct forms of the active ret oncogene, fail to block proliferation, even upon NGF stimulation. In these cells we show the presence of both chronic ERKs activity and high expression levels of MKP-3, an ERK-specific phosphatase. Despite the presence of MKP-3, ERK activity can be further stimulated by NGF, but it fails to translocate into the nucleus and consequently to induce immediate-early gene transcription. Because of the presence of MKP-3, our results suggest the existence of a negative regulatory feedback acting on ERKs as a mechanism responsible for the abrogation of NGF-induced terminal differentiation. Indeed, MKP-3 seems to be implicated in the persistence of ERKs in cell cytoplasm. This interpretation is further supported by the observation that in ret-transfected cells, forced expression of an active form of MEK-1 may overcome this block; it restores transcription from the c-fos promoter, induces translocation of ERKs into the nucleus, and inhibits cell proliferation.

Signaling through Ras is essential for ret oncogene-induced cell differentiation in PC12 cells

Specific germline mutations of the receptor tyrosine kinase, Ret, predispose to multiple endocrine neoplasia types 2A and 2B and familial medullary thyroid carcinoma. The mechanisms by which different Ret isoforms (Ret-2A and Ret-2B) cause distinct neoplastic diseases remain largely unknown. On the other hand, forced expression of these mutated versions of Ret induces the rat pheochromocytoma cell line, PC12, to differentiate. Here we used an inducible vector encoding a dominant-negative Ras (Ras p21(N17)) to investigate the contributions of the Ras pathway to the phenotype induced in PC12 cells by the expression of either Ret-2A or Ret-2B mutants. We show that the Ret-induced molecular and morphological changes are both mediated by Ras-dependent pathways. However, even though inhibition of Ras activity was sufficient to revert Ret-induced differentiation, the kinetics of morphological reversion of the Ret-2B- was more rapid than the Ret-2A-transfected cells. Further, we show that in Ret-transfected cells the suc1-associated neurotrophic factor-induced tyrosine phosphorylation target, SNT, is chronically phosphorylated in tyrosine residues, and associates with the Sos substrate. These results indicate the activation of the Ras cascade as an essential pathway triggered by the chronic active Ret mutants in PC12 cells. Moreover, our data indicate SNT as a substrate for both Ret mutants, which might mediate the activation of this cascade.

[Neurolysis of the median nerve at the wrist with 2-portal endoscopic technique. Analysis of 102 consecutive cases]

Based on a retrospective clinical series, the authors evaluated the results of endoscopic nerve release according to Chow's technique, particularly in terms of the complications. The population consisted of 96 patients, corresponding to 102 hands, operated between January 1993 and January 1996. Paraesthesiae had completely resolved at 3 months in 87.2% of cases, while 29.7% of patients complained of discomfort in the hypothenar region. At last review, with a mean follow-up of 13.5 months, paraesthesiae had completely resolved in the same proportion of patients. 93.3% of patients with discomfort in the hypothenar region reported complete cure and 94 patients (92.2%) declared to be satisfied. Eighteen patients were operated on both sides. None of them preferred the conventional technique either in the short-term or in the long-term. One case of section of the superficial palmar arch, one case of severe reflex sympathetic dystrophy, one neurological complication (1%) in the form of dysaesthesia in the middle finger, persisting at last follow-up, one incomplete opening of the extensor retinaculum subsequently repaired via an open approach. Chow's technique presents certain advantages in terms of postoperative comfort, but the safety of this technique must be ensured by prevention of neurovascular complications, based on respect of 3 golden rules: thorough training in the technique, preferably in the anatomy laboratory, open conversion at the slightest doubt concerning visibility of the extensor retinaculum and compliance with the absolute contraindications of the technique.

Tyrosine hydroxylase deficiency with severe clinical course: clinical and biochemical investigations and optimization of therapy

Tyrosine hydroxylase deficiency was diagnosed after determination of cerebrospinal fluid neurotransmitters and DNA analysis in a child with severe axial hypotonia and hypokinesia associated with dystonic and ballistic movements. L-dopa therapy was unsuccessful, whereas a combination with selegiline, a selective monoamine oxidase-beta inhibitor, with low-dose L-dopa markedly improved the severe clinical picture.

Novel 7-DHCR mutation in a child with Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive disorder characterized by minor facial anomalies, mental retardation, and multiple congenital abnormalities. Biochemically, the disorder is caused by deficient activity of 7-dehydrocholesterol reductase, which catalyzes the reduction of the Delta7 double bond of 7-dehydrocholesterol to produce cholesterol. Recently, mutations in the gene encoding 7-dehydrocholesterol reductase (7DHCR) were found to cause SLOS. We report the first molecular characterization of an Italian SLOS patient. Interestingly, his paternal 7DHCR allele, of Arab origin, harbored a novel P329L mutation which in combination with a maternal splice-site (IVS8-1 G>C) mutation resulted in a relatively milder phenotype.

Computer-assisted EEG monitoring during carotid endarterectomy

The purpose of this study was to develop a reliable method of EEG analysis during carotid endarterectomy. EEGs of 104 patients under general anesthesia were processed by three different methods: a) "on-line" visual analysis during surgery, b) "off-line" visual analysis in laboratory, and c) computer analysis. To identify pathological EEGs, variability and asymmetry indexes of the 0.5-3.5 Hz and 8-15 Hz bands, absolute power and variability indexes of spectral edge frequency (SEF), and main dominant frequency were evaluated. On-line visual analysis showed clamp-related modifications in 29 EEGs (27.9%). Off-line visual analysis detected 24 pathological EEGs (23.1%): 18 with major changes and 6 with moderate changes. Computer analysis showed 21 EEGs (20.19%) with at least one altered index and 7 (6.7%) with altered variability for both SEF and 8-15 Hz power. The statistical analysis was significant for SEF variability and for 8-15 Hz power variability and asymmetry (P < 0.0001, analysis of variance test). While SEF and 8-15 Hz power variability did not appear influenced by anesthesia and single electrode artifacts, 8-15 Hz power asymmetry index was confounded by the presence of contralateral internal carotid occlusion. The data show that the use of these spectral indexes adds objective information to visual analysis, supporting and making easier intraoperative strategies. Their routine clinical use does not involve additional costs remaining technical requirements unchanged compared to traditional recording.

Direct detection of Clostridium perfringens enterotoxin in patients' stools during an outbreak of food poisoning

An outbreak of diarrhoea in a hotel affected 25 time keepers attending the 1997 Mediterranean Games. Epidemiological investigation implicated a 'pasta al ragù' consumed at the hotel's restaurant and Clostridium perfringens food poisoning was identified by direct detection of C. perfringens enterotoxin in patients' stools. This report confirms that a careful evaluation of epidemiological features, together with the availability of direct and rapid laboratory methods, may lead to a prompt identification of C. perfringens food poisoning.

Synthesis of a series of sulfinic acid analogs of GABA and evaluation of their GABAB receptor affinities

A series of gamma-aminobutyric acid (GABA) 1 analogs was prepared in which the carboxylic acid group of GABA was replaced with a sulfinic acid group and their affinity for the GABAB receptor investigated.

Tachykinins in the lungs

Tachykinins are neuropeptides which regulate various biological responses, some of which are potentially important in the pathogenesis of pulmonary diseases such as asthma. Tachykinins produce their biological effects by stimulating specific tachykinin receptors (NK(1), NK(2) and NK(3)). Tachykinins have a variety of effects in the lungs. They are among the most potent bronchoconstrictor agents known and have potent effects on airway blood vessel caliber, causing vasodilation by an endothelium-dependent mechanism. Exogenously administered tachykinins (substance P, neurokinin A and neurokinin B) induce mucus secretion in most species, including humans. In addition to having effects on airway secretion, tachykinins also modulate the mucociliary clearance mechanisms of the airway. Tachykinin receptors are found on pulmonary/bronchial C fibers, and both excitatory and inhibitory effects of tachykinins on neural discharge and neurotransmitter release from these nerves have been described. Tachykinins are also involved in several reflex responses, particularly the cough reflex. Tachykinins have been implicated in the inflammatory response in the lungs and they also participate in the regulation of the immune system. A considerable body of evidence implicates tachykinins as important mediators of the neurogenic inflammatory response in a variety of pulmonary diseases. It is thus expected that tachykinin receptor antagonists will prove useful in the therapy of diseases such as asthma, allergic rhinitis and chronic bronchitis.

[A case of cutaneous myiasis caused by Dermatobia hominis]

Due to increasing international travelling of European population, tropical parasitic diseases may be imported more frequently in temperate countries. We describe a subject who travelled in Brasil and returned to Italy with a subcutaneous nodule containing a phase-II Dermatobia hominis larva; such larva is reported with photographic documentation.

Short-term low-dose pantoprazole-based triple therapy for cure of Helicobacter pylori infection in duodenal ulcer patients

BACKGROUND

The eradication of Helicobacter pylori infection has been achieved using various therapy regimens, but the efficacy of the proton-pump inhibitor pantoprazole as part of these regimens has not yet been widely tested.

AIM

To evaluate the efficacy and tolerability of a 1-week low-dose pantoprazole-based triple therapy in patients with H. pylori-positive duodenal ulcer.

METHODS

In an open single-centre prospective study, 71 patients with endoscopically proven active duodenal ulcer and H. pylori infection received pantoprazole 40 mg o.m. for 4 weeks, and during the first week a combination antimicrobial treatment comprising tinidazole 500 mg b.d. plus clarithromycin 250 mg b.d. H. pylori eradication was defined as concordant negative histology and rapid urease test performed at endoscopy 4-6 weeks after the end of treatment, confirmed 4 weeks later by 13C-urea breath test.

RESULTS

Sixty-six patients (93%) completed the trial and five patients were lost to follow-up. H. pylori infection was cured in 61 out of the 66 patients who completed the trial (per-protocol analysis: 92.4%, 95% CI: 83.2-97.5%; intention-to-treat analysis: 85.9%, 95% CI: 75.7-93.0%). At final endoscopy, 65 out of 66 patients had healed ulcer (98.5%). Mild adverse events occurred in six patients (9.1%).

CONCLUSIONS

One-week low-dose pantoprazole-based triple therapy is a simple, effective and well-tolerated regimen for ulcer healing and H. pylori eradication in patients with duodenal ulcer.

Visual attention in cirrhotic patients: a study on covert visual attention orienting

Attentional dysfunction, which influences overall cognitive productivity, is not well characterized in cirrhotic patients. The aim of this study was to clarify the features of covert visual attention orienting in cirrhotics without overt hepatic encephalopathy. One hundred consecutive cirrhotic patients and 40 controls were enrolled. Visual covert attention orienting was assessed by the Posner test, which evaluates the effect of a cue on visual reaction times. Patients were characterized by the number connection test (NCT) and electroencephalographic (EEG) spectral analysis. The severity of liver disease was graded using standard laboratory parameters and the Child-Pugh's classification. Fifty-five psychometric and EEG evaluations were performed in the follow-up of 17 patients to assess the relationship between the variations of psychometric and neurophysiological findings. NCT and quantified-EEG parameters (altered in 19% and 40% of cirrhotic patients, respectively) were linked to each other and to the severity of liver disease. The Posner test showed a delay of visual reaction times in class B-C cirrhotic patients. Reaction times were correlated with ammonia and EEG parameters. The effect of the cue was higher in cirrhotic patients than in controls, particularly in the invalid position. This study suggests that cirrhotic patients have a reduced activity rate and reduced capacity to disengage attention previously focused on a cue. Such alterations are linked to NCT and EEG findings.

Study on the Sternberg paradigm in cirrhotic patients without overt hepatic encephalopathy

Memory dysfunction is reported in cirrhotics. The aim of this paper was to increase insight into memory function of cirrhotic patients without overt hepatic encephalopathy. Eighty-six consecutive cirrhotics without overt hepatic encephalopathy (aged 54+/-10 yr., mean+/-s.d.) and 28 controls (52+/-10 yr.) with comparable education level were enrolled. Seventeen patients were class A, 55 class B, 14 class C according to Child-Pugh classification; 29 had alcoholic cirrhosis. The presence of subclinical signs of central nervous system dysfunction were assessed by Number Connection Test (NCT) and quantified EEG analysis. Memory scanning was evaluated by reaction times (RTs) in the Sternberg paradigm. MANOVA analysis showed that RTs were higher (F1,99=11, p<0.01) and time outs (TOs) more frequent (F1,110=10, p<0.01) in cirrhotics than in controls, whereas button press errors (BPEs) did not differ significantly (F1,110=2, p=n.s.). In cirrhotics, an interaction Child-Pugh class x memory set size was found (F2,146=4, p<0.05), showing exceedingly delayed RTs with greater memory set size in class C patients. Patients with altered NCT had significantly prolonged RTs (F1,71=4, p<0.05) and more TOs (F1,82=11, p<0.01) than patients with normal NCT. Cirrhotics with altered EEG had significantly prolonged RTs (F2,70=6, p<0.01). RTs were found to be correlated to alpha relative power (r=-0.4, p<0.01) and theta relative power (r=0.4, p<0.01). In conclusion, cirrhotics without over encephalopathy, but with NCT or EEG alterations, perform a computerized digit recognition task more slowly and with higher TOs than cirrhotic patients with normal NCT or EEG. In severe liver insufficiency (class C cirrhotics) also an impairment of memory scanning was detected. Sternberg test performance correlates with NCT and quantitative EEG parameters.

Multiple hemopoietic defects and lymphoid hyperplasia in mice lacking the transcriptional activation domain of the c-Rel protein

The c-rel protooncogene encodes a member of the Rel/nuclear factor (NF)-kappaB family of transcriptional factors. To assess the role of the transcriptional activation domain of c-Rel in vivo, we generated mice expressing a truncated c-Rel (Deltac-Rel) that lacks the COOH-terminal region, but retains a functional Rel homology domain. Mice with an homozygous mutation in the c-rel region encoding the COOH terminus of c-Rel (c-relDeltaCT/DeltaCT) display marked defects in proliferative and immune functions. c-relDeltaCT/DeltaCT animals present histopathological alterations of hemopoietic tissues, such as an enlarged spleen due to lymphoid hyperplasia, extramedullary hematopoiesis, and bone marrow hypoplasia. In older c-relDeltaCT/DeltaCT mice, lymphoid hyperplasia was also detected in lymph nodes, liver, lung, and stomach. These animals present a more severe phenotype than mice lacking the entire c-Rel protein. Thus, in c-relDeltaCT/DeltaCT mice, the lack of c-Rel activity is less efficiently compensated by other NF-kappaB proteins.

Intravenous immune globulin in lysinuric protein intolerance

In addition to systemic manifestations with skeletal, pulmonary, renal, and haematological signs, lysinuric protein intolerance (LPI), a membrane transport defect of cationic amino acids, is often complicated by severe life-threatening immunological manifestations. A 10-year-old boy with LPI who exhibited a severe systemic immunohaematological disease is described here. This patient showed cutaneous lesions similar to the subacute form of systemic lupus erythematosus, severe anaemia and dysproteinaemia, and a marked reduction of circulating T lymphocytes, mainly the CD4+ cells. In vitro bone marrow cell culture studies showed that addition of patient's serum induced macrophage proliferation and inhibited erythroid progenitor cell growth. Treatment with high-dose intravenous immune globulin resolved most of the clinical and laboratory abnormalities.

Ligand stimulation of a Ret chimeric receptor carrying the activating mutation responsible for the multiple endocrine neoplasia type 2B

Inherited activating mutations of Ret, a receptor tyrosine kinase, predispose to multiple endocrine neoplasia (MEN) types 2A and 2B and familial medullary thyroid carcinoma. To investigate the effects induced by acute stimulation of Ret, we transfected both PC12 and NIH 3T3 cells with a molecular construct in which the ligand-binding domain of the epidermal growth factor receptor was fused to the catalytic domain of Ret. Acute stimulation of the chimeric receptor induced PC12 cells to express a neuronal-like phenotype. Moreover, we introduced the dominant mutation, responsible for the multiple endocrine neoplasia type 2B, in the catalytic domain of the Ret chimera. Expression of the mutant chimera, in the absence of ligand stimulation, induces the PC12 cells to acquire a flat morphology with short neuritic processes and transforms the NIH 3T3 cells. Stimulation of the mutant chimera with epidermal growth factor causes a drastic overgrowth of long neuritic processes, with the induction of the suc1-associated protein tyrosine phosphorylation in PC12 cells and higher transforming efficiency in NIH 3T3 cells. These data indicate that the gain-of-function MEN2B mutation does not abrogate ligand responsiveness of Ret and suggest that the presence of Ret ligand could play a role in the pathogenesis of the MEN2B syndrome.

Iron overload in thalassemia: comparative analysis of magnetic resonance imaging, serum ferritin and iron content of the liver

BACKGROUND

Iron overload in patients with thalassemia is a common feature which requires continuous chelation therapy and monitoring. Serum ferritin determination is widely accepted as a simple method for following iron load in patients with primary hemochromatosis; however, several reports on thalassemic patients emphasize that ferritinemia is not accurate and that other methods such as direct measurement of iron in the liver (HIC) and magnetic resonance imaging (MRI) are more precise.

MATERIALS AND METHODS

In order to contribute to the general understanding of iron load in thalassemia we used liver MRI to study 33 thalassemic patients, most of whom were also evaluated for iron content by liver biopsy. The data were then compared with serum ferritin levels.

RESULTS

Ferritin levels ranged between 276 and 8031 ng/mL, and liver iron content ranged from 1.6 to 31.0 mg/g dry weight; grade III or IV liver siderosis was recorded in 23/33 patients, just as 23/33 patients were found to have severe or very severe siderosis at MRI. Significant correlations with ferritin levels were recorded between grade IV and grades III, II and I (p < 0.01, p = 0.02, and p = 0.03, respectively). Ferritinemia also showed significant linearity with liver iron content (r = 0.603, p = 0.001). No significant differences of levels were recorded, however, between patients found to have severe and those with mild iron load at MRI (p = 0.073).

CONCLUSIONS

Our study shows that serum ferritin levels exhibit a tendency to be significantly correlated with the true status of hemochromatosis in thalassemic patients; however, the discrepancies recorded in several patients and the scarce or total lack of correlation with MRI suggest exploring other approaches to this problem in order to make proper decisions about therapy.

The pharmacology of SCH 50911: a novel, orally-active GABA-beta receptor antagonist

Experiments were conducted to characterize the pharmacology of SCH 50911 ((+)-5,5-dimethyl-2-morpholineacetic acid hydrochloride), a structurally novel GABA-B receptor antagonist. Although more potent GABA-B antagonists have been reported, in this study SCH 50911 was compared with CGP 35348, a moderately potent and selective GABA-B antagonist with acceptable in vivo activity. SCH 50911 was more potent to inhibit the binding of GABA to the GABA-B receptor in rat brain (IC50 = 1.1 microM) than CGP 35348 (IC50 = 62 microM). SCH 50911 had no binding affinity for GABA-A, histamine H1, histamine H3, dopamine D1, dopamine D2, serotonin 5-HT2, or muscarinic m1, m2, or m4 receptors. However, SCH 50911 (IC50 = 2.2 microM) was active in a nonspecific muscarinic receptor binding assay, but was devoid of muscarinic agonist or antagonist activity in the isolated guinea pig ileum. SCH 50911 blocked inhibitory responses to baclofen of the guinea pig trachea in a competitive manner (pA2 = 5.8 +/- 0.004). CGP 35348 was 19-fold less potent in this assay (pA2 = 4.6 +/- 0.15). In vivo, SCH 50911 (ED50 = 2.9 mg kg-1, s.c.) and CGP 35348 (ED50 = 5.8 mg kg-1, s.c.) blocked the antitussive effects of baclofen in the guinea pig. In the cat, both SCH 50911 (10 mg kg-1, i.v.) and CGP 35348 (10 mg kg-1, i.v.) shifted the antitussive dose response relationship for baclofen to the right.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of the presence of a third person on the physician-older patient medical interview

OBJECTIVE

To compare communication in triadic (three-person) and dyadic (two-person) older patient medical interviews and to determine the influence of the presence of a third person on the physician-older patient relationship.

DESIGN

Matched sample of dyadic and triadic audiotaped outpatient medical visits. Audiotapes were coded with the Multi-dimensional Interaction Analysis (MDIA) system.

SETTING

Hospital-based medical primary care group practice in a major urban teaching institution.

PARTICIPANTS

Patients 60 years and older who were making their first visit to study physicians. In a sample of 96 audiotaped initial medical visits, 15 encounters involved three persons. These 15 cases were matched with 15 dyadic interviews for gender and race of the patient and for gender and race of the physician.

MAIN OUTCOME MEASURES

Content, interactional processes, and specific language and communication behaviors of older patients, physicians, and third persons in the medical encounter, as measured by the MDIA system.

RESULTS

The specific content and the quality of interactional processes of physicians were not affected by the presence of a third person. However, older patients raised fewer topics in all content areas (medical, personal habits, psychosocial, and physician-patient relationship) in triads than in dyads. Overall, patients were less responsive (ie, the quality of their questioning, informing, and supportiveness was poorer) on patient-raised topics in triads than in dyads. Patients were rated as less assertive and expressive, and there was less joint decision-making and shared laughter in triads than in dyads. Patients were frequently excluded from conversations in visits in which a third person was present.

CONCLUSIONS

The presence of a third person in the medical encounter changes the interactional dynamics of older patient medical interviews and may influence the development of a trusting and effective physician-older patient relationship.

[The growth of the low-birth-weight neonate: assessment at 3 years]

Follow-up studies of low-birth-weight (LBW) neonates have shown a high incidence of growth failure in the first years of life. We evaluated the growth attainment (weight, length and head circumference) in 182 LBW neonates discharged from our Intensive Care Unit between 1982-84 and included in a 3 years follow-up program. The aim of the study is to analyze the correlation between gestational age (GA) and subsequent growth failure. Neonates included in the study were divided in 4 groups (G) according to GA: I G < or = 30 weeks GA; II G = 31-33 weeks GA; III G = 34-36 weeks GA; IV G > or = 37 weeks of gestational age. Growth was evaluated at 40 weeks GA on the basis of Lubchenco and Battaglia centiles, and thereafter at 12, 24 and 36 months according to Scalamandrè greeds. Subnormal weight (< 10 degrees centile) was still evident at 3 years of age in 16.7% of the most premature babies (group I), in 6.2% of babies born between 31 and 33 weeks GA (group II), in 7.1% of babies in group III and in 16.6% of LBW babies born at term of gestation (group IV). Length measurements were satisfactory in PT babies as none of them showed a length < 10 degrees centile by 24 months of age. On the contrary, in the term LBW neonates group 15.6% of babies still showed subnormal length at 3 years of age. Head circumference remained < 10 degrees centile in 16.6% in the I group, in 6.2% in the II group, 21% in the III group and 30% in the IV group.(ABSTRACT TRUNCATED AT 250 WORDS)