Functional involvement of cerebral cortex in adult sleepwalking

The pathophysiology of adult sleepwalking is still poorly understood. However, it is widely accepted that sleepwalking is a disorder of arousal. Arousal circuits widely project to the cortex, including motor cortex. We hypothesized that functional abnormality of these circuits could lead to changes in cortical excitability in sleepwalkers, even during wakefulness. We used transcranial magnetic stimulation (TMS) to examine the excitability of the human motor cortex during wakefulness in a group of adult sleepwalkers. When compared with the healthy control group, short interval intracortical inhibition (SICI), cortical silent period (CSP) duration, and short latency afferent inhibition (SAI) were reduced in adult sleepwalkers during wakefulness. Mean CSP duration was shorter in patients than in controls (80.9 +/- 41 ms vs. 139.4 +/- 37 ms; p = 0.0040). Mean SICI was significantly reduced in patients than in controls (73.5 +/- 38.4% vs. 36.7 +/- 13.1%; p = 0.0061). Mean SAI was also significantly reduced in patients than in controls (65.8 +/- 14.2% vs. 42.8 +/- 16.9%; p = 0.0053). This neurophysiological study suggests that there are alterations in sleepwalkers consistent with an impaired efficiency of inhibitory circuits during wakefulness. This inhibitory impairment could represent the neurophysiological correlate of brain "abnormalities" of sleepwalkers like "immaturity" of some neural circuits, synapses, or receptors.

Dysfunction of arousal systems in sleep-related migraine without aura

Primary headaches are closely related to sleep. Modifications in the patterns of arousal during sleep have been reported in migraine, especially in the nights preceding a headache attack. We aimed at evaluating the pattern of arousal from sleep in a group of patients affected by sleep-related migraine. We enrolled 10 consecutive patients, three males and seven females, aged between 20 and 62 years, who presented frequent attacks of migraine without aura (more than five per month), closely related to sleep (more than one-half of the attacks occurred during sleep, causing an awakening). A control group was studied, matched for age and sex. Patients and controls underwent a full-night polysomnographic study, following adaptation; arousal pattern was studied by the scoring of the high-frequency EEG arousal and by the cyclic alternating pattern (CAP). Migraineurs showed a lower CAP rate in non-rapid eye movement (NREM) sleep and, in particular, a lower number of A1 phases (low-frequency, high-amplitude EEG bursts) compared with the controls. Migraineurs also showed a lower index of high-frequency EEG arousals during rapid eye movement (REM) sleep. The reduction in the CAP rate indicates a lower level of arousal fluctuation in NREM sleep. The reduced arousal index in REM suggests a dysfunction in neural structures involved in both the control of REM sleep and the pathophysiology of migraine, such as the hypothalamus and the brainstem.

A sleep study in cluster headache

Cluster headache (CH) is a primary headache with a close relation to sleep. CH presents a circa-annual rhythmicity; attacks occur preferably during the night, in rapid eye movement (REM) sleep, and they are associated with autonomic and neuroendocrine modifications. The posterior hypothalamus is the key structure for the biological phenomenon of CH. Our aim is to describe a 55-year-old man presenting a typical episodic CH, in whom we performed a prolonged sleep study, consisting of a 9-week actigraphic recording and repeated polysomnography, with evaluation of both sleep macrostructure and microstructure. During the acute bout of the cluster we observed an irregular sleep-wake pattern and abnormalities of REM sleep. After the cluster phase these alterations remitted. We conclude that CH was associated, in this patient, with sleep dysregulation involving the biological clock and the arousal mechanisms, particularly in REM. All these abnormalities are consistent with posterior hypothalamic dysfunction.

Degradation of lansoprazole and omeprazole in the aquatic environment

Lansoprazole and omeprazole degrade in water leading to sulfides, benzimidazolones and a red complex material. Degradation is accelerated in acid medium and by solar simulator irradiation. Benzimidazoles, dianilines and pyridines have also been identified.

Prolonged ECMO support for virus-induced cardiorespiratory failure early after cardiac surgery

Extracorporeal membrane oxygenation (ECMO) after cardiac surgery is a rescue for life-threatening respiratory or circulatory failure. Although ECMO support for short periods (<10 days) represents an effective means of respiratory and cardiac support, treatment for longer periods remains controversial. We describe successful long-term use of ECMO support (48 days) for acquired virus-induced respiratory failure complicated by circulatory collapse following heart surgery.

Performance of the pulmonary autograft in four infants after the Ross procedure

Pulmonary valve autografts have proven to be valid aortic valve substitutes in children. The objective of this study is to evaluate the performance of the pulmonary autograft (PAG) in systemic position and its adjustment to growth in four infants who underwent a Ross operation. Between April 1998 and January 2000, four infants whose aortic valve anatomy and function were judged unsuitable for a valve-sparing operation underwent successful Ross operation. All patients were followed postoperatively with echocardiograms to evaluate the function and the dimensional changes of the PAG within the systemic circulation. The PAG adjustments to growth were compared to the growth of the pulmonary root of healthy patients matched for body surface area, with the purpose to evaluate the effects of the systemic pressure on the pulmonary vascular wall, as a passive dilatation process versus a true and active structural adaptation. Median follow-up was 53 months (range, 48-65). There were no early deaths or reoperations. All patients were asymptomatic and in stable hemodynamic conditions. The PAG annulus grew according to body surface area without dilatation. PAG valve regurgitation was present but mild in three patients. Trans-PAG peak gradients were not significant. The PAG diameter at the level of the sinuses of Valsalva and sinotubular junction increased rapidly and steadily in all patients during follow-up compared to controls. The Ross operation in infants provides acceptable immediate surgical and hemodynamic results. However, significant midterm increases in PAG sinuses and sinotubular junction diameters require close and continued observation.

Optimized sample preparation for isotopic analyses of CO2 in air: systematic study of precision and accuracy dependence on driving variables during CO2 purification process

A systematic analysis of efficiency, reproducibility and accuracy of cryogenic purification of CO(2) from air samples for isotopic analyses is presented. The technical characteristics of the cryogenic line are given in detail. To study the cryogenic process, three different operating parameters are considered: flow rate of the gas entering the line, pressure of the gas in the line, and CO(2)-trap shape. Experimental results demonstrate that efficiency, reproducibility and accuracy strongly depend on the CO(2)trap shape. Moreover, a dependence of reproducibility and accuracy on the flow rate of the gas is found, but not on its pressure. High precision (< or =0.02 per thousand for delta(13)C and < or =0.05 per thousand for delta(18)O) and good accuracy (<0.09 per thousand for delta(13)C and <0.14 per thousand for delta(18)O) is achieved after applying the N(2)O correction.

Influence of cholinergic circuitries in generation of high-frequency somatosensory evoked potentials

OBJECTIVE

High-frequency oscillations (HFOs) evoked by upper limb stimulation reflect highly synchronised spikes generated in the somatosensory human system. Since acetylcholine produces differential modulation in subgroups of neurons, we would determine whether cholinergic drive influences HFOs.

METHODS

We recorded somatosensory evoked potentials (SEPs) from 31 scalp electrodes in 7 healthy volunteers, before and after single administration of rivastigmine, an inhibitor of central acetylcholinesterase. Right median nerve SEPs have been analysed after digital narrow bandpass filtering (500-700 Hz). Raw data were further submitted to Brain Electrical Source analysis (BESA) to evaluate the respective contribution of lemniscal, thalamic and cortical sources. Lastly, we analysed by Fast Fourier transform spectral changes after drug administration in the 10-30 ms latency range.

RESULTS

Rivastigmine administration caused a significant increase of HFOs in the 18-28 ms latency range. Wavelets occurring before the onset latency of the conventional N20 SEP did not show any significant change. A similar increase concerned the strength of cortical dipolar sources in our BESA model. Lastly, we found a significant power increase of the frequency peak at about 600 Hz in P3-F3 traces after drug intake.

CONCLUSIONS

Our findings demonstrate that the cortical component of HFOs is significantly enhanced by cholinergic activation. Pyramidal chattering cells, which are capable to discharge high-frequency bursts, are mainly modulated by cholinergic inputs; by contrast, acetylcholine does not modify the firing rate of fast-spiking GABAergic interneurons. We thus discuss the hypothesis that cortical HFOs are mainly generated by specialised pyramidal cells.

Cervical cord dysfunction during neck flexion in Hirayama's disease

Neck flexion may play a role in the pathogenesis of Hirayama disease. Upper limb somatosensory evoked potentials were recorded in five patients with Hirayama disease, six patients with ALS, and 14 healthy subjects. Neck flexion caused a significant amplitude decrease of the N13 cervical response only in patients with Hirayama disease. Direct cord compression or microvascular changes can in theory account for this position-related dysfunction.

Surgical treatment of complete A-V canal defects in children before 3 months of age

OBJECTIVES

Surgical repair of complete A-V canal defects (CAVCD) is a well established procedure which is currently performed in infancy. The aim of this study is to evaluate surgical results of correction in early infancy in comparison to older age.

METHODS

From January 1985 to March 2001, 119 consecutive patients (age range 27 days to 83 months, mean 6.7 months) underwent repair of CAVCD in our Institution. Forms with unbalanced ventricles in association with Fallot's tetralogy or heterotaxia were excluded from this series. Fifty-eight patients (49%) underwent correction before 3 months of age (Group A), and 61 patients (51%) after 3 months (Group B). Surgical repair was accomplished with a double patch technique in 100 patients (84%). Associated surgical lesions were treated simultaneously in 48 patients (40%).

RESULTS

There were 11 operative deaths (<30 days) (two in Group A (3.4%) and nine in Group B (15%)) (P = 0.05). The remaining patients were discharged home in good haemodynamic condition. Reoperation for postoperative left A-V incompetence occurred in five patients in Group A and in eight patients in Group B. There were eight late deaths (three in Group A and five in Group B), of which four were non-cardiac related. At a mean follow-up time of 80 months (range 2-184 months) 100 patients are asymptomatic and well, and free from oral medication. Echocardiographic examination showed absent or mild residual left A-V valve incompetence in 91 patients (49 in Group A and 42 in Group B) and moderate left A-V valve incompetence in nine patients (four in Group A and five in Group B). Kaplan-Meier survival estimates at 10 years were 90% for Group A and 75% for Group B. Kaplan-Meier freedom from reoperation at 10 years was 89% for Group A and 84% for Group B.

CONCLUSIONS

Our data demonstrate that repair of CAVCD under 3 months of age is the ideal approach to this malformation with a lower mortality rate at operation compared to older patients. Logistic analysis showed that an operative age >3 months is, compared to an age < or =3 months, an incremental risk factor for hospital mortality with an odds ratio of 4.8 (95% confidence limit 1-23.5) (P = 0.05). In the long term, freedom from reoperation for left A-V valve incompetence is higher when compared to children repaired at an older age.

Surgical treatment of complex cardiac anomalies: the 'one and one half ventricle repair'

OBJECTIVE

One and one half ventricle repair is a surgical option for congenital cardiac anomalies characterised by right ventricle (RV) hypoplasia and/or dysplasia.

METHODS

From March 1994 to March 2001, eight patients (mean age 9.1 years, range 7 months to 35 years) with hypoplastic and/or dysplastic RV underwent correction of their intracardiac anomaly in association with a BCPS (one and one half ventricle repair). Preoperative diagnoses included: Ebstein's anomaly of tricuspid valve (TV) in two, inlet ventricular septal defect (VSD) in association with straddling/overriding TV in two patients, pulmonary atresia-intact ventricular septum in one, tertralogy of Fallot in association with complete atrioventricular canal defect in one, truncus arteriosus in one and heterotaxy syndrome with VSD and anomalous systemic venous return in one. Four patients underwent previous surgery which included: main pulmonary artery (MPA) banding in two patients, pulmonary valvotomy, central shunt and right ventricular outflow tract reconstruction in one, pulmonary artery separation from truncus arteriosus and modified Blalock-Taussig shunt in one, and MPA closure in one. Two patients underwent a bidirectional cavo-pulmonary shunt before the one and a one half ventricle repair. Associated cardiac lesions were treated simultaneously.

RESULTS

There were no hospital deaths. All the patients were discharged home in good clinical conditions. There were no late deaths or reoperations. At mean follow-up of 29.8 months (range 8 months to 7.3 years) all the patients are alive and in good general conditions. MPA percutaneous balloon dilation was performed in two patients at 33 and 4 months, respectively, both after MPA reconstruction (which was previously ligated) and dilation of the left pulmonary artery branch in one patient, repeated twice at 10 and 14 months from repair, for a hypoplastic left pulmonary artery after truncus arteriosus repair.

CONCLUSIONS

Surgical treatment of congenital cardiac anomalies in the presence of a hypoplastic and or a dysplastic RV by means of one and one half ventricle repair has the advantage of reducing the surgical risk for biventricular repair, and compared to the Fontan circulation, it maintains a low right atrium pressure, a pulsatile pulmonary blood flow and improves the systemic oxygen saturation. Short and medium-term results are promising. Longer follow-up is needed, to prove the efficacy of such a repair, in the long term.

Surgical treatment of complex cardiac anomalies: the 'one and one half ventricle repair'

OBJECTIVE

One and one half ventricle repair is a surgical option for congenital cardiac anomalies characterised by right ventricle (RV) hypoplasia and/or dysplasia.

METHODS

From March 1994 to March 2001, eight patients (mean age 9.1 years, range 7 months to 35 years) with hypoplastic and/or dysplastic RV underwent correction of their intracardiac anomaly in association with a BCPS (one and one half ventricle repair). Preoperative diagnoses included: Ebstein's anomaly of tricuspid valve (TV) in two, inlet ventricular septal defect (VSD) in association with straddling/overriding TV in two patients, pulmonary atresia-intact ventricular septum in one, tertralogy of Fallot in association with complete atrioventricular canal defect in one, truncus arteriosus in one and heterotaxy syndrome with VSD and anomalous systemic venous return in one. Four patients underwent previous surgery which included: main pulmonary artery (MPA) banding in two patients, pulmonary valvotomy, central shunt and right ventricular outflow tract reconstruction in one, pulmonary artery separation from truncus arteriosus and modified Blalock-Taussig shunt in one, and MPA closure in one. Two patients underwent a bidirectional cavo-pulmonary shunt before the one and a one half ventricle repair. Associated cardiac lesions were treated simultaneously.

RESULTS

There were no hospital deaths. All the patients were discharged home in good clinical conditions. There were no late deaths or reoperations. At mean follow-up of 29.8 months (range 8 months to 7.3 years) all the patients are alive and in good general conditions. MPA percutaneous balloon dilation was performed in two patients at 33 and 4 months, respectively, both after MPA reconstruction (which was previously ligated) and dilation of the left pulmonary artery branch in one patient, repeated twice at 10 and 14 months from repair, for a hypoplastic left pulmonary artery after truncus arteriosus repair.

CONCLUSIONS

Surgical treatment of congenital cardiac anomalies in the presence of a hypoplastic and or a dysplastic RV by means of one and one half ventricle repair has the advantage of reducing the surgical risk for biventricular repair, and compared to the Fontan circulation, it maintains a low right atrium pressure, a pulsatile pulmonary blood flow and improves the systemic oxygen saturation. Short and medium-term results are promising. Longer follow-up is needed, to prove the efficacy of such a repair, in the long term.

Permeation of oxygen, water vapor, and limonene through printed and unprinted biaxially oriented polypropylene films

Oriented polypropylene (OPP) and coated OPP (acrylic/OPP/PVDC) films were printed with two commercially available inks to investigate the influence of inks on water vapor and oxygen transmission rates. The permeation of an aroma compound (d-limonene) through coated OPP film printed with these inks was also evaluated at 35 degrees C and 100% relative humidity. The water vapor transmission rate increased significantly through OPP film printed with nitrocellulose-based ink. The oxygen transmission rate was significantly lower through both OPP and coated OPP films printed with the nitrocellulose ink. The effect of inks on limonene permeation was minor compared to the marked increase in permeation measured when the PVDC side of the coated film was exposed to the aroma, compared to the acrylic side. Scanning electron micrographs of coated film cross sections revealed changes in film structure upon exposure to limonene vapors, which were most pronounced when the PVDC side was exposed to limonene.

The fatal wound of Hector, according to a drawing by Peter Paul Rubens designed for tapestry weaving

According to the Iliad(Chapter XXII, Verses 322-329), Hector, while fighting his last duel, was almost entirely protected by bronze armor, with only a small area "where the clavicle marks the boundary between neck and thorax" exposed. It was precisely into this area, "the shorter way to death," that Achilles thrust his lance. This fatal wound, although covering Hector with blood, allowed the victim to pronounce a few words. In designing the Story of Achilles, his fourth and last series of drawings especially designed for tapestry weaving, Rubens depicted Achilles stabbing Hector near the midline of his neck. There is evidence that Rubens was always well acquainted with the literary sources of his pictures. It is also likely that he became familiar with contemporary editions of the Iliad that were enhanced with commentaries. Realizing that the wound depicted in his original drawing should have prevented Hector from speaking, Rubens altered the scene, then showing the lance piercing the cervical vascular bundle. The careful scrutiny for literary accuracy that was typical of Rubens' artistic behavior did not prevent an additional minor imprecision in the final tapestry. Nevertheless, his outstanding expressive power enabled him to give form to a gigantic baroque representation of the death of Hector in masterly fashion.

Repair of congenital mitral valve dysplasia in infants and children: is it always possible?

OBJECTIVES

Surgical management of congenital malformation of the mitral valve (MV) in the pediatric age group remains a therapeutic challenge for the wide spectrum of the morphological abnormalities and the high incidence of associated cardiac anomalies. We reviewed our experience so as to assess whether MV conservative surgery is always advisable and its results are superior to MV replacement.

METHODS

Thirty-four consecutive children (20 male and 14 female) with a mean age of 5.9 years (range 45 days-18 years) treated surgically for congenital MV disease between January 1987 and June 1999. Four patients (11.7%) were under 12 months of age, while 21 patients (62%) were younger than 5 years. Twenty-two patients presented with MV incompetence (or prevalent incompetence), while 12 presented with stenosis (or prevalent stenosis). Associated cardiac lesions were present in 22 patients (62.8%).

RESULTS

Mitral valve reconstruction was possible in all. There were no operative deaths. Three patients required reoperation for MV restenosis (a re-repair in one and MV replacement with mechanical prosthesis in two) 4 months, 27 months and 5.6 years after repair with no operative deaths. There was only one late death for prosthetic valve thrombosis. Follow-up data reveal that the 33 surviving patients are asymptomatic and well 4 months-12 years (mean 72 months) after surgery. At 12 years, actuarial survival and freedom from reoperation are 96.8 and 85.9%, respectively. Echocardiography performed in all of them shows no or mild incompetence or stenosis in 26 (78%), while residual moderate MV incompetence persists in six.

CONCLUSIONS

Our experience indicates that MV reconstructive procedures in infants and children with congenital MV dysplasia may be effective and reliable with low mortality and low incidence of reoperation rate. Mitral valve repair should always be attempted, especially in infants, despite the frequent severity of MV dysplasia, to avoid the drawbacks of the currently available prostheses.

Selective membrane recruitment of EEA1 suggests a role in directional transport of clathrin-coated vesicles to early endosomes

The molecular mechanisms ensuring directionality of endocytic membrane trafficking between transport vesicles and target organelles still remain poorly characterized. We have been investigating the function of the small GTPase Rab5 in early endocytic transport. In vitro studies have demonstrated a role of Rab5 in two membrane fusion events: the heterotypic fusion between plasma membrane-derived clathrin-coated vesicles (CCVs) and early endosomes and in the homotypic fusion between early endosomes. Several Rab5 effectors are required in homotypic endosome fusion, including EEA1, which mediates endosome membrane docking, as well as Rabaptin-5 x Rabex-5 complex and phosphatidylinositol 3-kinase hVPS34. In this study we have examined the localization and function of Rab5 and its effectors in heterotypic fusion in vitro. We report that the presence of active Rab5 is necessary on both CCVs and early endosomes for a heterotypic fusion event to occur. This process requires EEA1 in addition to the Rabaptin-5 complex. However, whereas Rab5 and Rabaptin-5 are symmetrically distributed between CCVs and early endosomes, EEA1 is recruited selectively onto the membrane of early endosomes. Our results suggest that EEA1 is a tethering molecule that provides directionality to vesicular transport from the plasma membrane to the early endosomes.

Surgical closure of apical ventricular septal defects through a right ventricular apical infundibulotomy

BACKGROUND

We present a new understanding of the anatomic position of apical ventricular septal defects and its surgical relevance. These defects occur between the left ventricular apex and the infundibular apex, rather than between the left and right ventricular apices. Often a sizable apical recess, the infundibular apex lies anteriorly and inferiorly to the moderator band and is the most leftward part of the right ventricle.

METHODS

Four patients (2 boys and 2 girls) with a mean age of 109 days (range, 48 to 217 days) underwent patch closure through an apical infundibulotomy, which allowed complete visualization of the muscular apical ventricular septal defect.

RESULTS

There were no early or late deaths at operation. No significant residual shunt at ventricular level was detected by postoperative two-dimensional and Doppler echocardiography. Intraoperative comparison of right atrial and pulmonary arterial blood samples showed a difference of less than 5%. At a mean follow-up of 18 months, all the patients are asymptomatic and growing well.

CONCLUSIONS

The successful outcome of these 4 patients indicates that surgical closure of apical ventricular septal defects can be achieved safely and completely in early infancy through a limited right ventricular apical infundibulotomy. Long-term follow-up of these and similar patients is needed to provide further evaluation of this approach.

Straddling tricuspid valve as a sign of ventriculoatrial malalignment: A morphometric study of 19 postmortem cases

BACKGROUND

Straddling tricuspid valve, despite extensive investigation, remains an incompletely understood form of complex congenital heart disease.

METHODS

A morphometric study of 19 postmortem cases of straddling tricuspid valve was performed, and the results were compared with 32 normal control heart specimens.

RESULTS

In straddling tricuspid valve, marked malalignment of the ventricles was always found relative to the atria. The angle between the ventricular septum and the atrial septum in the short-axis projection averaged 61 degrees +/- 24 degrees, the normal ventriculoatrial septal angle averaging 5 degrees +/- 2 degrees (P <. 001). The right ventricular sinus (inflow tract) was significantly smaller than the left (P <.01). A ventricular septal defect was present in 79%: atrioventricular canal type in 42%, atrioventricular canal type confluent with a conoventricular defect in 26%, and a conoventricular defect in 11%. When the straddling tricuspid valve adhered to the crest of the muscular ventricular septum (n = 4 cases, 21%), the 2 salient findings were (1) an intact ventricular septum and (2) double-outlet right atrium. The nonstraddling part of the tricuspid valve opened into the small right ventricle. The straddling part of the tricuspid valve opened into the larger left ventricle. The mitral valve also opened into the left ventricle. Hence hearts with double-outlet right atrium had 3 atrioventricular valves. Congenital mitral stenosis was present in 26% of this series.

CONCLUSION

Straddling tricuspid valve was always characterized by marked ventriculoatrial malalignment, indicated by an abnormally large ventriculoatrial septal angle, best seen in the short-axis projection.

Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study

PURPOSE

This study was performed according to a prospective, randomized, double-blind, multicenter design. The aim was to test the efficacy of local application of nifedipine gel" in healing acute anal fissure by relaxing the internal anal sphincter.

METHODS

Two hundred eighty-three patients who gave informed consent were recruited; they received a clinical examination. A questionnaire to evaluate the symptoms and the pain was administered, and a proctoscopy and anorectal manometry were performed. Patients treated with nifedipine (n = 141) used topical 0.2 percent nifedipine gel every 12 hours for three weeks. The control group, consisting of 142 patients, received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy. Manometry was performed before and on Days 14 and 21. Anal pressures were measured by recording resting and squeeze pressures.

RESULTS

Results obtained were as follows: total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients (P < 0.01), as opposed to 50 percent of the controls (P < 0.01), and previously elevated maximum resting anal pressures decreased from a mean value +/- standard deviation of 72.5 +/- 10.07 mmHg to 50.5 +/- 10.03 mmHg in the nifedipine group. This represents a mean reduction of 30 percent (P < 0.01). We also observed a significant decrease in squeeze pressures in nifedipine-treated patients (from a mean +/- standard deviation of 130.5 +/- 19.25 mmHg to 108.5 +/- 18.55 mmHg, a mean reduction of 16.8 percent; P < 0.01). No changes in anal pressures were observed in the control group. We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine.

CONCLUSIONS

Our study clearly demonstrates that the therapeutic use of nifedipine, which at present is used only in cardiovascular pathologies, should be extended with local use to the conservative treatment of anal fissures.

Genotypic resistance to zidovudine as a predictor of failure of subsequent therapy with human immunodeficiency virus type-1 nucleoside reverse-transcriptase inhibitors

To define factors predictive of failure to respond to nucleoside reverse-transcriptase inhibitors in human immunodeficiency virus type-1 (HIV-1)-infected subjects pretreated with zidovudine (ZDV), three groups of subjects shifted to double therapy with ZDV plus didanosine (ddI, n = 13), zalcitabine (ddC, n = 14), or lamivudine (3TC, n = 12) were retrospectively evaluated, with respect to addition of the second NRTI, at week 0 and week 24. Factors considered included duration of ZDV pretreatment, CD4+ cell counts, plasma HIV-1 RNA load, peripheral blood mononuclear cell HIV-1 DNA load, and HIV-1 DNA genotypic resistance to nucleoside reverse-transcriptase inhibitors. The three groups were well matched for baseline characteristics and did not differ significantly in virological and immunological response to the different combination treatments. Drug-specific resistance mutations were selected in more than half the cases by 3TC, but not by ddI and ddC. Low-level and substantial genotypic resistance to ZDV was detected 13 (33.3%) and in 19 (48.7%) patients at baseline, respectively, and evolved through week 24 in several patients. When subjects were divided into responders and nonresponders to the second nucleoside reverse-transcriptase inhibitor on the basis of a decrease of more than 0.5 log10 (n = 15) or less than 0.5 log10 (n = 21) in HIV-1 RNA, respectively, baseline genotypic ZDV resistance was the only independent predictor of failure in a logistic regression model (P = 0.003 or P = 0.024, depending on whether low-level resistance was considered or not, respectively). Thus, selection of ZDV resistance mutations may impair subsequent use of different nucleoside reverse-transcriptase inhibitor compounds.

Naturally-occurring anti-Jka in infant twins

Anti-Jka was detected by solid-phase red cell adherence (SPRCA) antibody detection and identification tests in the plasma of a 9-month-old female infant during a routine presurgical evaluation. The patient and her nonidentical twin sister, who also had anti-Jka in her plasma, were products of an uncomplicated in vitro fertilization, full-term pregnancy, and vaginal delivery. Neither twin had been transfused, recently infected, or treated with medication. Their mother had no prior pregnancies or transfusions. Red blood cells (RBCs) from the patient and her sister typed as Jk(a-b+) by direct hemagglutination, and this phenotype was confirmed by negative adsorption and elution studies. Both infants' plasma samples were strongly reactive with 20 examples of Jk(a+) RBCs and nonreactive with 20 examples of Jk(a-) RBCs by SPRCA assays. Anti-Jka was not detected in either twins' plasma by indirect antiglobulin tests by tube method in low-ionic- strength saline solution or polyethylene glycol, or with ficin- or papain-treated RBCs. Monocyte monolayer assays using Jk(a+) RBCs sensitized by either twins' serum were nonreactive (0%). RBCs from both parents typed as Jk(a+b+). Both parents' antibody detection test results by SPRCA assay were negative. The absence of a history of exposure to allogeneic RBCs or possible passive transfer of maternal or other alloantibody classifies these antibodies as naturally-occurring anti-Jka.

[Type of surgical articles. Comparative study of 3 Italian and 3 foreign periodicals]

BACKGROUND

Medical progress in the world is divulged to peers and colleagues through books and scientific journals. It is thus linked not only to the quality of articles, but also to their type.

MATERIAL AND METHODS

The type of articles published in three Italian periodicals (Annali Italiani di Chirurgia; Chirurgia; Minerva chirurgica) and three foreign periodicals published in English (Annals of Surgery; British Journal of Surgery; Surgery, Gynecology & Obstetrics) was compared. The articles were classified according to their potential contribution to medical progress, being divided into two main groups: research papers and simple case series or case reports. Other types of articles (reviews, description of surgical techniques, editorials etc.) were excluded from the study.

RESULTS

Both the total number and the percentage of research papers were markedly superior in the three foreign journals with respect to the three Italian periodicals. All the differences were highly significant.

CONCLUSIONS

The number of research papers published in Italian periodicals should be increased. Greater attention should be paid to quality, at the expense of quantity, since serious research inevitably takes longer to perform.