Physical anhedonia in Parkinson's disease

Anhedonia is the inability to experience physical or social pleasure. Its physical component is hypothesised to be due to dysfunction of a dopaminergic frontotemporal-subcortical circuit and has never been investigated as a possible affective complication of Parkinson's disease (PD). The aim of this study was to formally assess prevalence and correlates of physical anhedonia in PD patients compared with normal controls. Twenty five people with PD and 25 matched controls were administered a psychometric battery exploring mainly executive functions and mood. Hedonic tone was assessed using Chapman's Physical Anhedonia Scale. PD patients also underwent MRI linear measurement of frontal structures. Anhedonia levels were significantly higher in PD patients with respect to controls, although not extremely elevated; prevalence rate was 40% for parkinsonians, while no anhedonics were found among controls. Clinical, neuropsychological, and quantitative neuroradiological features did not show any significant correlation with physical anhedonia. Physical anhedonia appears to be a relatively frequent, although mild, affective disturbance of PD, independent from neurological, frontal, and depressive aspects.

Deep brain stimulation for the treatment of Parkinson's disease: the experience of the Neurosurgical Department in Monza

deep brain stimulation is a widely accepted surgical therapy for the symptomatic treatment of advanced parkinson's disease; high frequency chronic stimulation of the subthalamic nucleus proved its efficacy to control the major motor symptoms. In the neurosurgical department of Monza we treated 72 parkinsonian patients (November 1998-January 2003). One year follow-up results are: decrease of tremor 90%, hypertonous 56%, bradykinesia 70%, voice impairment amelioration 30%, mean total daily L-dopa intake reduced 58%. Freezing and balance did not ameliorate, some voice impairment and psychic derangement have been observed. Major surgical complications were: haemorrage (1 case - transient hemiparesis), infections (2 cases), pulmonary embolisation (1 case). To optimise the surgical results, careful clinical and instrumental selection of the patients are mandatory before surgery.

MRI indirect stereotactic targeting for deep brain stimulation in Parkinson's disease

AIM

Stereotactic localisation of brain targets for functional neurosurgery might be obtained with different neuroimaging sources. Magnetic resonance (MR) might be of particular interest for its high definition of the various brain structures; unfortunately, magnetic field distortion and inaccuracy in imaging reproduction constrain the use of MRI in stereotactic surgery.

METHODS

We present an experimental work devoted to the utilization of MRI in the targeting of the subthalamic nucleus for deep brain stimulation (DBS) in Parkinsonian patients.

RESULTS

Experimental data were obtained after PVC phantom and fixed human brain measurements of the stereotactic coordinates of specific basal ganglia structures. Intrinsic and external sources of error and imaging distortion have been carefully corrected. Afterwards, 36 patients, operated for DBS in the subthalamus for Parkinson's disease (PD), have been investigated. MRI targeting proved to be clinically successful; comparing anatomical and neurophysiological findings, MRI targeting scattered from the neurophysiological targeting in a minority of cases.

CONCLUSION

MRI targeting proved to be reliable for functional stereotactic surgery, pending careful and adequate quality control of the distortion and of the sources of error.

[Skull base fractures with TMJ involvement: literary review and case report]

The authors report their experience in the treatment of middle skull base fractures with TMJ involvement of ten patients affected by fractures of the glenoid cavity and of the petrous part of the temporal bone, with TMJ disfunction and facial nerve palsy. The treatment has been based on functional rest, a liquid diet for 5 days and than a functional physiotherapy aimed at rehabilitation of the TMJ. The efficacy of treatment has been showed after 2 months by restoring the dental occlusion and the TMJ's function in nine out of ten cases. Three out of four patients (75%) at the same control showed a full resolution of the facial nerve palsy. At an eighth month's follow-up all the cases had a complete resolution of the symptoms. Finally no significant studies have been reported in literature to set standardized protocols for the treatment of glenoid cavity fractures. According to the experience of authors the fractures of the medium cranial base involving the glenoid cavity should be treated as the current trends of intracapsular TMJ fractures. The orthopedic-functional treatment turns out particularly efficacious when there isn't a reduction of mandibular vertical heights.

An assessment of factors related to tumor thickness and delay in diagnosis of melanoma in southern Italy

BACKGROUND

Since survival of patients with melanoma is strongly correlated with the Breslow tumor thickness of the primary lesion, factors that influence stage at diagnosis and delay in diagnosis are considered to be crucial. To test the relationship between tumor thickness and some social and clinical variables (including diagnosis/treatment delay) and the relationship between the diagnosis/treatment delay and some clinical variables, we analyzed data on 530 patients with melanoma from our Institute.

METHODS

In the analysis, Breslow tumor thickness was categorized into two categories (< or =1.49, > or =1.5). Three time intervals were examined to evaluate diagnostic delay: patient delay, time from first symptom to seeking medical advice; medical delay, time from first medical consultation to hospital admission; total delay, time from first symptom to resection. The variables evaluated in the analysis were: age at diagnosis, education, occupational status, first symptom, visibility of tumor, anatomic site, and physician who made the initial diagnosis.

RESULTS

A significant risk of having a Breslow tumor thickness > or =1.5 mm was noted in patients who had a low level of education (odds ratio 3.0, 95% confidence interval 1.9-5.0) or who were unemployed (odds ratio 1.7, 95% confidence interval 1.1-2.8). With respect to patient delay, a delay >3 months for anatomic locations visible to patients was associated with significant risk (odds ratio 1.7, 95% confidence interval 1.1-2.6); with respect to medical delay, a delay >3 months was associated with a higher risk in patients examined by a dermatologist (odds ratio 2.0, 95% confidence interval 1.2-3.4).

CONCLUSIONS

Our results clearly indicate that in Southern Italy poorly educated and unemployed subjects are at risk of being diagnosed at a more advanced stage, and admission to an oncological hospital causes a delay (waiting list) in the time interval related to the doctor (medical delay).

[Prospective regional study of an epidemic of respiratory syncytial virus (RSV) bronchiolitis]

This prospective study was designed to identify risk factors associated with admission in pediatric intensive care units (PICU) among infants hospitalized for treatment of RSV induced bronchiolitis. This study was population-based and was conducted in Burgundy, a French region with 1,800,000 inhabitants where passive immunoprophylaxis for RSV bronchiolitis was not set up at the time of the study.

RESULTS

From December 1st 1999 to April 30th 2000, 484 infants were hospitalized for RSV bronchiolitis in Burgundy: 19.6% were born prematurely (gestational age [GA] below 37 weeks) and at admission, 68.3% had a postnatal age below six months (mean = 5 +/- 5.9 months; median value = 3 months). The duration of hospitalization was 7.3 +/- 12.4 days (median value = 6 days). Among the 484 infants, 31 (6.4%) needed admission in PICU, eight needed mechanical ventilation (1.7%) and one died (0.2%). Univariate analysis identified anamnestic risk factors associated with admission in PICU: prematurity; low birth weight; past history of neonatal respiratory distress syndrome (RDS); mechanical ventilation for RDS treatment; bronchopulmonary dysplasia (BPD) and congenital heart disease. Multivariate analysis identified three independent factors associated with an increased risk for admission in PICU: GA below 32 weeks; RDS and congenital heart disease.

CONCLUSION

This study suggests that population at risk for severe RSV bronchiolitis with PICU admission should include all very preterm infants with RDS whatever the outcome of RDS (with or without BPD). These epidemiological data could be helpful to set up indications for passive immunoprophylaxis of RSV induced bronchiolitis.

Weekly docetaxel in the treatment of elderly patients with advanced breast cancer: a Minnie Pearl Cancer Research Network phase II trial

PURPOSE

To evaluate the efficacy and toxicity of docetaxel administered weekly to elderly or poor-performance status patients with advanced breast cancer.

PATIENTS AND METHODS

Forty-one patients with advanced breast cancer who were either over the age of 65 or considered to be poor candidates for combination chemotherapy received docetaxel 36 mg/m2 weekly for 6 consecutive weeks, followed by 2 weeks without treatment. The median age of patients in this trial was 74 years, and 73% of patients had one or more visceral sites of metastases. Seventy-five percent of patients received weekly docetaxel as first-line treatment for metastatic breast cancer, and the other 25% received it as second-line treatment. Thirty-six patients were assessable for efficacy, and all patients were assessed for toxicity.

RESULTS

A total of 448 doses of weekly docetaxel were administered to 41 patients. Thirteen patients (36%) had objective responses to treatment, and an additional 13 patients (36%) had stable disease or minor response. Median time to progression for responding and stable patients was 7 months (range, 3 to 27 months). Median survival for the entire group was 13 months, with 1- and 2-year actuarial survival rates of 61% and 29%, respectively. Severe neutropenia occurred in only 0.4% of courses, and no other hematologic toxicity was observed. Grade 3/4 fatigue was the most common toxicity, occurring in 20% of patients.

CONCLUSION

Weekly docetaxel therapy is active and well tolerated by elderly and/or poor-performance status patients with advanced breast cancer. This treatment can be administered with minimal myelosuppression. Weekly docetaxel provides an additional option for treatment in this difficult subgroup of patients with metastatic breast cancer. Well-tolerated combination regimens containing weekly docetaxel merit evaluation for this patient population.

Mobilization of calcium from intracellular stores, potentiation of neurotransmitter-induced calcium transients, and capacitative calcium entry by 4-aminopyridine

In this study we analyzed the effect of 4-aminopyridine (4-AP) on free cytosolic calcium concentration ([Ca(2+)](i)) in basal conditions, after stimulation with neurotransmitters, and during capacitative calcium entry. Using fura-2 ratiometric calcium imaging, we found that 4-AP increased [Ca(2+)](i) in type I astrocytes, neurons, and in skeletal muscle cells. The [Ca(2+)](i) elevation induced by 4-AP was concentration-dependent and consisted of two phases: the first was dependent on intracellular calcium mobilization, and the second was dependent on extracellular calcium influx. 4-AP also increased the second messenger inositol trisphosphate in both neurons and astrocytes. In astrocytes, 4-AP treatment potentiated the sustained phase of the [Ca(2+)](i) elevation induced by ATP and bradykinin. In addition, capacitative calcium entry was potentiated severalfold by 4-AP, in astrocytes and muscle cells but not in neurons. These effects of 4-AP were completely and promptly reversible. 4-AP blocked voltage-sensitive K(+) currents in astrocytes. However, voltage-sensitive K(+) channel blockers inhibiting these currents did not affect agonist-induced calcium transients or capacitative calcium entry, indicating that 4-AP effects on [Ca(2+)](i) were not caused by the blockade of voltage-gated K(+) channels. We conclude that 4-AP is able to affect calcium homeostasis at multiple levels, from increasing basal [Ca(2+)](i) to potentiating capacitative calcium entry. The potentiation of capacitative calcium entry in astrocytes or muscle cells may explain some of the therapeutic activities of 4-AP as a neurotransmission enhancer.

Cannabinoid receptor activation and elevated cyclic AMP reduce glutamate neurotoxicity

Cannabinoid receptor activation in vivo reduces ischemic injury, a phenomenon that has not been successfully reproduced in vitro. Because cyclic adenosine monophosphate (cAMP) levels are radically elevated during ischemic reperfusion, but cannabinoid receptor activation reduces cAMP levels, we hypothesized that cannabinoids might prevent in vitro glutamate toxicity if reperfusion was simulated by cAMP supplementation after glutamate removal. Although neuronal cultures were unaffected by the single addition of either cannabinoid or dibutyryl cAMP (dbcAMP), glutamate toxicity was reduced by 20% when cannabinoid was present during glutamate exposure and either dbcAMP or forskolin was added after glutamate removal. Further studies revealed that cannabinoid receptor activation reduces glutamate toxicity by attenuating calcium influx through N- and P/Q-type calcium channels. The effect of glutamate exposure on neuronal cAMP levels was also examined. Glutamate exposure significantly reduced neuronal cAMP levels, although suppression was even greater when cannabinoid was present. Because neurological outcome after ischemia is poor when cAMP levels during reperfusion are low, it is hypothesized that cAMP elevation after glutamate exposure may offset excitotoxic and/or cannabinoid receptor-induced cAMP depletion. Cannabinoids protect against ischemic injury in vivo, but only reduce toxicity in vitro when cAMP levels are elevated, possibly suggesting that cAMP elevation during reperfusion reduces brain injury by off-setting the effect of Gi/o protein-coupled systems on adenylate cyclase.

Usefulness of handgrip to improve ibutilide efficacy in organizing atrial electrical activity during atrial fibrillation

We analyzed the effect of handgrip on atrial electrical activity during atrial fibrillation (AF) by recording right and left atrial activity in 15 patients with persistent AF under baseline conditions and after saline and ibutilide infusions. The handgrip test for 15 seconds, which was always associated with a significant increase in mean atrial cycle length, was recorded in both atria (right atrium: saline vs saline + handgrip 141 +/- 29 vs 171 +/- 24 ms, p <0.001; ibutilide vs ibutilide + handgrip: 197 +/- 43 vs 221 +/- 39 ms, p <0.005). Handgrip favorably modifies atrial electrophysiologic properties during AF.

Regional and cellular expression of the parkin gene in the rat cerebral cortex

A mutation in the parkin gene has been identified as the cause for an autosomal recessively inherited form of early onset Parkinson's disease. We have recently isolated the mRNA coding for the rat homologue of parkin and showed its widespread expression in the central nervous system (CNS) by in situ hybridization. In the present study we investigated the distribution of parkin in the rat cerebral cortex with a polyclonal antibody that reacts with a single approximately 52-kDa protein, corresponding to the predicted molecular mass of parkin. Conventional light microscopic studies revealed intense parkin immunoreactivity (IR) throughout the cortex. Examination of mixed cortical neuro-glial cultures by indirect immunofluorescence technique coupled to traditional epifluorescence and confocal microscopy analysis demonstrated the expression of parkin in the cytoplasm and neurites of neurons, and its absence in glial fibrillary acidic protein (GFAP)-positive astrocytes. The predominant neuronal parkin-IR and -mRNA expression was confirmed by Western blot analysis and reverse transcription-polymerase chain reaction (RT-PCR), respectively, performed on highly enriched neuronal and type I astrocytes cultures. The information gathered in our study about the cellular and subcellular distribution of parkin should facilitate further research on its physiological role in the nervous system.

Prevention of beta-amyloid neurotoxicity by blockade of the ubiquitin-proteasome proteolytic pathway

In many neurodegenerative disorders, such as Alzheimer's disease, inclusions containing ubiquitinated proteins have been found in the brain, suggesting a pathophysiological role for ubiquitin-mediated proteasomal degradation of neuronal proteins. Here we show for the first time that the beta-amyloid fragment 1-40, which in micromolar levels causes the death of cortical neurons, also induces the ubiquitination of several neuronal proteins. Prevention of ubiquitination and inhibition of proteasome activity block the neurotoxic effect of beta-amyloid. These data suggest that beta-amyloid neurotoxicity may cause toxicity through the activation of protein degradation via the ubiquitin-proteasome pathway. These findings suggest possible new pharmacological targets for the prophylaxis and/or treatment of Alzheimer's disease and possibly for other related neurodegenerative disorders.

Neuroprotective antioxidants from marijuana

Cannabidiol and other cannabinoids were examined as neuroprotectants in rat cortical neuron cultures exposed to toxic levels of the neurotransmitter, glutamate. The psychotropic cannabinoid receptor agonist delta 9-tetrahydrocannabinol (THC) and cannabidiol, (a non-psychoactive constituent of marijuana), both reduced NMDA, AMPA and kainate receptor mediated neurotoxicities. Neuroprotection was not affected by cannabinoid receptor antagonist, indicating a (cannabinoid) receptor-independent mechanism of action. Glutamate toxicity can be reduced by antioxidants. Using cyclic voltametry and a fenton reaction based system, it was demonstrated that Cannabidiol, THC and other cannabinoids are potent antioxidants. As evidence that cannabinoids can act as an antioxidants in neuronal cultures, cannabidiol was demonstrated to reduce hydroperoxide toxicity in neurons. In a head to head trial of the abilities of various antioxidants to prevent glutamate toxicity, cannabidiol was superior to both alpha-tocopherol and ascorbate in protective capacity. Recent preliminary studies in a rat model of focal cerebral ischemia suggest that cannabidiol may be at least as effective in vivo as seen in these in vitro studies.

[Diabetic foot. Physiopathology, clinical aspects, and recent therapeutic approaches]

Diabetic foot is a complication of diabetes mellitus occurring in 15% of patients that is of specific surgical interest. Over the past few years, preventive measures and the use of new therapeutic resources has reduced the number of patients undergoing demolitive surgery. The authors present a concise but at the same time sufficiently detailed picture of modern knowledge of the physiopathology, clinical aspects and current therapeutic guidelines for diabetic foot. In particular, they analyse the validity of various forms of complementary treatment to surgery, including techniques to stimulate tissue repair processes, hyperbaric oxygen therapy and laser therapy, and they underline the importance of using a multidisciplinary approach to this pathology. To this end, they review all the articles on the subject reported on Medline from 1992 to June 1998, presenting and commenting on the most significant results.

Randomized trial of sequential administration of G-CSF and GM-CSF vs. G-CSF alone following peripheral blood progenitor cell autograft in solid tumors

A trial was conducted to investigate whether the sequential administration of recombinant human granulocyte colony-stimulating factor (G-CSF) and recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) could accelerate reconstitution of hematopoiesis, compared with G-CSF alone following high-dose chemotherapy (HDCT). A group of 34 consecutive patients with solid tumors undergoing HDCT and autologous peripheral blood progenitor cell (PBPC) transplantation was studied. Conditioning regimen included carboplatin, etoposide, mitoxantrone, and melphalan for breast cancer and cyclophosphamide or ifosfamide, carboplatin, and etoposide for the other tumors. HDCT was delivered from day -3 to day -1. PBPC were infused on day 0, and on the same day growth factors were administered subcutaneously (s.c.) 5 microg/kg each. Seventeen patients were randomized to receive G-CSF from day 0 to day 13 after HDCT (arm A), and 17 patients received G-CSF from day 0 to day 6 and GM-CSF from day 7 to day 13 (arm B). Patients were stratified, and their characteristics were homogeneous in both arms for age, performance status, and number of previous chemotherapy courses and CD34+ infused. The median time to absolute neutrophil count (ANC) >500/microl was 10 days in arm A and 9 days in arm B (p = 0.96). Days to platelet (PLT) count >20,000 were not different in the two treatment arms (p = 0.1), but patients randomized to arm A had a lower platelet count compared with patients in arm B. One month after PBPC transplantation, a statistically significant difference in PLT count was observed (arm A median 150x10(3)/microl (90-310), arm B median 254x10(3)/microl (117-387),p = 0.0013). The days patients had fever >38 degrees C were 39 in arm A and 26 in arm B (p = 0.18). The difference in the length of hospital stay was not statistically significant between the groups (Mann-Whitney sum rank test). After a median follow-up of 30 months, 21 patients were alive and 20 were disease free. These data show that the two growth factors are associated with different patterns of hematopoietic recovery, and larger randomized trials in groups of more homogeneous patients will be needed to define the effects and benefits of combination growth factor therapies.

Effect of lengthening of peptide backbone by insertion of chiral beta-homo amino acid residues: conformational behavior of linear peptides containing alternating L-leucine and beta-homo L-leucine residues

The synthesis and the solution behavior of the linear peptides containing a beta-homo (beta-H) leucine residue-Boc-Leu-beta-HLeu-Leu-OMe, Boc-beta-HLeu-Leu-beta-HLeu-Leu-OMe, and Boc-Leu-beta-HLeu-Leu-beta-HLeu-Leu-OMe-as well as the solid structure of the tripeptide, are reported. The conformational behavior of the peptides was investigated in solution by two-dimensional nmr. Our data support the existence in solution with different families of conformers in rapid interchange. The crystals of the tripeptide are orthorhombic, space group P2(1)2(1)2, with a = 15.829(1) A, b = 29.659(1) A, c = 6.563(1) A, and Z = 4. The structure has been solved by direct methods and refined to final R1 and wR2 indexes of 0.0530 and 0.1436 for 2420 reflections with I > 2sigma(I). In the solid state, the tripeptide does not present intramolecular H bonds, and the peptide backbone of the two leucine residues adopts a quasi-extended conformation. For the beta-HLeu residue, the backbone conformation is specified by the torsion angles straight phi(2) = -120.9(4) degrees, mu(2) = 56.7(4) degrees, psi(3) = -133.2(4) degrees. The side chains of the three residues assume the same conformation (g(-), g(-), trans), and all peptide bonds, except the urethane group at the N-terminus, are in the trans conformation. Preliminary conformational energy calculations carried out on the Ac-NH-beta-HAla-NHMe underline that the conformations with mu angle equal to 180 degrees and 60 degrees assume lower energy with respect to the others. In addition, we found a larger conformational freedom for the psi angle with respect to the straight phi angle.

Natural history of cirrhotic patients with small esophageal varices: a prospective study

OBJECTIVE

Contrasting data are available on the natural history and bleeding risk of small esophageal varices. The aim of this prospective study was to evaluate a large series of consecutive cirrhotics with a first endoscopic diagnosis of small varices.

METHODS

Between 1987 and 1992, 258 patients with small varices and no previous bleeding were enrolled. Patients were clinically examined every 6 months and were followed until a first episode of bleeding and/or death, or until June 1998. None received any treatment to prevent bleeding. Endoscopies were planned at 18-month intervals.

RESULTS

The cumulative risk of bleeding was low (3% at 2 yr and 8% at 4 yr) and remained low in patients in whom varices remained small at 2nd endoscopy, whereas it increased significantly when varices enlarged. The increase of varices appeared to be rather linear in time: at the 2nd endoscopy varices remained small in 79% of patients and increased in 21%; at the 3rd endoscopy varices remained small in 55%, whereas at the 4th 33% of patients still had small varices. Clinical and biochemical data at the 1st and 2nd endoscopy were included in a multiple logistic regression analysis. Only the increase in Child-Pugh score appeared to be a significant predictor of enlarged varices; the risk of aggravation increased by 37.5% for every unit of impairment of the score.

CONCLUSIONS

The present study shows that patients with small varices have a low bleeding risk. An increase in Child-Pugh score during follow-up suggests enlargement of varices, thus an increase in bleeding risk. In these patients closer endoscopic surveillance is recommended.

cAMP-induced cytoskeleton rearrangement increases calcium transients through the enhancement of capacitative calcium entry

In this report we investigated the correlation between cell morphology and regulation of cytosolic calcium homeostasis. Type I astrocytes were differentiated to stellate process-bearing cells by a 100-min exposure to cAMP. Differentiation of cortical astrocytes increased the magnitude and duration of calcium transients elicited by phospholipase C-activating agents as measured by single cell Fura-2-based imaging. Calcium imaging showed differences in the spatial pattern of the response. In both differentiated and the control cells, the response originated in the periphery and gradually extended into the center of the cell. However, the elevation of cytosolic calcium concentration ([Ca(2+)](i)) was particularly evident within the processes and adjacent to the inner cell membrane of the differentiated astrocytes. In addition, differentiation significantly prolonged the duration of the [Ca(2+)](i) elevation. Potentiation of the calcium transients was mimicked by forskolin-induced differentiation and abolished by a specific protein kinase-A blocker. Conversely, the enhancement of the calcium transients was not mimicked by brief exposure to cAMP not causing morphological differentiation, and in PC12 cells that did not undergo morphological changes after 100 min of cAMP treatment. Impairing cAMP-induced cytoskeleton re-organization, by means of cytochalasin D and nocodazole, prevented the potentiation of the calcium transients in cAMP-treated astrocytes. Phospholipase C activity and sensitivity to inositol (1,4,5)-trisphosphate were not involved in the enhancement of the calcium responses. Also, potentiation of the calcium transients was dependent on extracellular calcium. Calcium storage and thapsigargin-depletable intracellular calcium reservoirs were analogously not increased in differentiated astrocytes. Rearrangement of the cell shape also caused a condensation of the endoplasmic reticulum and altered the spatial relationship between the endoplasmic reticulum and the cell membrane. In conclusion, morphological rearrangements of type I astrocytes increase the magnitude and the duration of agonist-induced calcium transients via enhancement of capacitative calcium entry and is associated with a spatial reorganization of the relationship between cell membrane and the endoplasmic reticulum structures.

Thrombin mutants with altered enzymatic activity have an impaired mitogenic effect on mouse fibroblasts and are inefficient modulators of stellation of rat cortical astrocytes

We produced recombinant human thrombin mutants to investigate the correlation between the thrombin enzyme and mitogenic activity. Single amino acid substitutions were introduced in the catalytic triad (H43N, D99N, S205A, S205T), in the oxy-anion binding site (G203A) and in the anion binding exosite-1 region (R73E). Proteins were produced as prethrombin-2 mutants secreted in the culture medium of DXB11-derived cell lines. All mutants were activated by ecarin to the corresponding thrombin mutants; the enzymatic activity was assayed on a chromogenic substrate and on the procoagulant substrate fibrinogen. Mutations S205A and G203A completely abolished the enzyme activity. Mutations H43N, D99N and S205T dramatically impaired the enzyme activity toward both substrates. The R73E mutation dissociated the amidolytic activity and the clotting activity of the protein. The ability of thrombin mutants to induce proliferation was investigated in NIH3T3 mouse fibroblasts and rat cortical astrocytes. The ability of the thrombin mutants to revert astrocyte stellation was also studied. The mitogenic activity and the effect on the astrocyte stellation of the thrombin mutants correlated with their enzymatic activity. Furthermore the receptor occupancy by the inactive S205A mutant prevented the thrombin effects providing strong evidence that a proteolytically activated receptor is involved in cellular responses to thrombin.

Functional and molecular diversity of PACAP/VIP receptors in cortical neurons and type I astrocytes

In the present study we determined the mRNA-expression of pituitary adenylate cyclase activating polypeptide (PACAP)/vasoactive intestinal peptide (VIP) receptors in primary cultures of rat cortical neurons and type I astrocytes, and investigated the effects of PACAP38 on adenylyl cyclase, inositol phospholipid hydrolysis and intracellular calcium homeostasis. PACAP38 elicited a concentration-dependent (1 nM-100 nM) increase in inositol phosphate levels and [Ca2+]i in neurons but not in type I astrocytes. The PACAP-induced increase of intracellular calcium concentration, [Ca2+]i, was characterized by a spike, compatible with inositol trisphosphate (IP3) -induced calcium mobilization from intracellular stores, and a plateau phase, sustained by activation of capacitative calcium entry triggered by depletion of IP3-sensitive calcium stores. In the absence of extracellular calcium, only the spike phase was present while the plateau phase was clearly reduced. In addition, thapsigargin pretreatment abolished the PACAP38-induced [Ca2+]i rise. Treatment with 1 microM VIP did not affect [Ca2+]i in either neurons or type I astrocytes, clearly indicating the coupling of PAC1-HOP subtype to phospholipase-C in neurons. In addition, as previously reported, PACAP38 stimulated cAMP formation in both neurons and type I astrocytes. Using the reverse transcription polymerase chain reaction, we found mRNA-expression of PAC1 (PACAP - HOP variant) and VPAC2 in neurons, PAC1 (PACAP - R variant), VPAC1 and VPAC2 in astrocytes. These data indicate both a functional and molecular diversity of PACAP and VIP receptors in these cell types and support the view that the PAC1-HOP variant may be responsible for phospholipase-C activation and [Ca2+]i elevation in cortical neurons.

Total and functional hepatic blood flow decrease in parallel with ageing

OBJECTIVES

To study changes in hepatic blood flow with age.

DESIGN

Functional hepatic flow (FHF) and total hepatic flow (THF) were determined by non-invasive methods in 40 normal subjects in four age groups (<45, 45-60, 61-75 and >75 years). All subjects had normal routine liver function tests and no history of liver disease.

RESULTS

THF was measured by pulsed echo-Doppler, as the sum of portal and hepatic artery blood flow; FHF was measured by the hepatic clearance of D-sorbitol. THF significantly decreased with age, particularly in subjects over 75 (from 1445+/-220 ml/min to 1020+/-148; P<0.001), and a similar reduction was observed in FHF (from 1514+/-250 ml/min to 1015+/-163; P<0.001). THF and FHF were strictly correlated in the whole population (r = 0.871; P<0.001) and both correlated with age (r = -0.510 and r = -0.596; P<0.005).

CONCLUSION

With ageing there is a reduction of hepatic blood flow without any additional intrahepatic shunting.

Effectiveness of leukocyte interferon-alpha treatment in patients with chronic hepatitis C not responsive to recombinant interferon

Twenty-four patients with chronic active HCV infection, nonresponders to a previous treatment cycle with recombinant interferon-alpha (r-IFNA), underwent retreatment with leukocyte (LE-) IFN-alpha. This was administered at the dose of 3 MU three times a week, for either six months (group A) or 12 months (group B). All patients were followed-up for a further 12 months. ALT levels significantly (P < 0.05) decreased in group A, with complete response in three cases and a partial response in a further three at the end of treatment. During follow-up all patients again showed increases in ALT values. In group B also ALT significantly (P < 0.05) decreased, with two complete and five partial responses. During follow-up, apart from two patients with partial responses who relapsed, all maintained their initial response. At the end of treatment HCV RNA was no longer detectable in complete responders of both groups, while it was found reduced in those partial responders who maintained their response during follow-up. Partially responding subjects treated for six months evidenced higher levels than those treated for 12 months. IFN-alpha retreatment could therefore be effective in previously nonresponding patients, with a change in the type of interferon administered and the use of higher dosages and/or longer treatment periods.

Bacterial lipopolysaccharide increases interleukin-6 and prostaglandin release in rat cortical type I astrocytes by different mechanisms: role of anti-inflammatory agents

LPS stimulated IL-6 release in a concentration-dependent manner from rat cortical type I astrocytes. This stimulatory action was completely abolished by Dexamethasone (DEX), but was not affected by indomethacin (IND), a 5-cyclooxigenase inhibitor. LPS-induced IL-6 release was partially inhibited by BW 4AC, a 5-lipoxygenase inhibitor. LPS concentration-dependently increased the release of PGE2 from type I astrocytes, an effect completely inhibited by IND. To rule out the possibility that DEX was inhibiting LPS-induced IL-6 release by blocking IL-6 gene expression, we tested the effect of DEX on interleukin 1beta(IL-1)-induced IL-6 release. DEX slightly inhibited IL-1-induced IL-6 release, while IL-1 releasing action on IL-6 was significantly reduced by IND. The involvement of nitric oxide (NO) generation on LPS-induced IL-6 release was also studied. We found that L-NO-arginine, an inhibitor of nitric oxide synthase, concentration-dependently reduced LPS-induced IL-6 release in astrocytes. In conclusion, we provide evidence that LPS action on IL-6 and PGE2 release can be ascribed to the activation of different transduction mechanisms, which can be pharmacologically dissected with the aid of anti-inflammatory drugs.

Cannabidiol and (-)Delta9-tetrahydrocannabinol are neuroprotective antioxidants

The neuroprotective actions of cannabidiol and other cannabinoids were examined in rat cortical neuron cultures exposed to toxic levels of the excitatory neurotransmitter glutamate. Glutamate toxicity was reduced by both cannabidiol, a nonpsychoactive constituent of marijuana, and the psychotropic cannabinoid (-)Delta9-tetrahydrocannabinol (THC). Cannabinoids protected equally well against neurotoxicity mediated by N-methyl-D-aspartate receptors, 2-amino-3-(4-butyl-3-hydroxyisoxazol-5-yl)propionic acid receptors, or kainate receptors. N-methyl-D-aspartate receptor-induced toxicity has been shown to be calcium dependent; this study demonstrates that 2-amino-3-(4-butyl-3-hydroxyisoxazol-5-yl)propionic acid/kainate receptor-type neurotoxicity is also calcium-dependent, partly mediated by voltage sensitive calcium channels. The neuroprotection observed with cannabidiol and THC was unaffected by cannabinoid receptor antagonist, indicating it to be cannabinoid receptor independent. Previous studies have shown that glutamate toxicity may be prevented by antioxidants. Cannabidiol, THC and several synthetic cannabinoids all were demonstrated to be antioxidants by cyclic voltametry. Cannabidiol and THC also were shown to prevent hydroperoxide-induced oxidative damage as well as or better than other antioxidants in a chemical (Fenton reaction) system and neuronal cultures. Cannabidiol was more protective against glutamate neurotoxicity than either ascorbate or alpha-tocopherol, indicating it to be a potent antioxidant. These data also suggest that the naturally occurring, nonpsychotropic cannabinoid, cannabidiol, may be a potentially useful therapeutic agent for the treatment of oxidative neurological disorders such as cerebral ischemia.

[Cultured human urothelium. Possible application in reconstructive surgery of the urinary tract]

The authors focus on and analyse a number of problems linked to urinary tract reconstruction, with special reference to urethral surgery in patients suffering from hypospadias. After having examined a number of approaches used over this period, the authors underline the possible new applications and future lines of research offered by cell culture techniques in the fields of urology and plastic surgery.

Alzheimer's-specific effects of soluble beta-amyloid on protein kinase C-alpha and -gamma degradation in human fibroblasts

Alzheimer's disease (AD) is a multifactorial disease in which beta-amyloid peptide (betaAP) plays a critical role. We report here that the soluble fraction 1-40 of betaAP differentially degrades protein kinase C-alpha and -gamma (PKCalpha and PKCgamma) isoenzymes in normal (age-matched controls, AC) and AD fibroblasts most likely through proteolytic cascades. Treatment with nanomolar concentrations of betaAP(1-40) induced a 75% decrease in PKCalpha, but not PKCgamma, immunoreactivity in AC fibroblasts. In the AD fibroblasts, a 70% reduction of the PKCgamma, but not PKCalpha, immunoreactivity was observed after betaAP treatment. Preincubation of AC or AD fibroblasts with 50 microM lactacystine, a selective proteasome inhibitor, prevented beta-AP(1-40)-mediated degradation of PKCalpha in the AC cells, and PKCgamma in the AD fibroblasts. The effects of betaAP(1-40) on PKCalpha in AC fibroblasts were prevented by inhibition of protein synthesis and reversed by PKC activation. A 3-hr treatment with 100 nM phorbol 12-myristate 13-acetate restored the PKCalpha signal in treated AC cells but it did not reverse the effects of betaAP(1-40) on PKCgamma in the AD fibroblasts. Pretreatment with the protein synthesis inhibitor, cycloheximide (CHX, 100 microM), inhibited the effects of betaAP(1-40) on PKCalpha and blocked the rescue effect of phorbol 12-myristate 13-acetate in AC fibroblasts but did not modify PKCgamma immunoreactivity in AD cells. These results suggest that betaAP(1-40) differentially affects PKC regulation in AC and AD cells via proteolytic degradation and that PKC activation exerts a protective role via de novo protein synthesis in normal but not AD cells.

[Mechanical physiopathology of remodeling peri-implant bone. The role of cytokine]

For a number of years titanium osteointegrated implants have represented a major step forward in dentistry, plastic and maxillofacial surgery, providing a lively stimulus to research both in their application and in the experimental field. The study of osteointegration has led to a more detailed knowledge of bone remodelling regulation mechanisms and the biological mediators involved. In this review the authors examine the role played by cytokines in the homeostasis of bone tissue, paying special reference to the phase of osteoclast activation and its possible effects on peri-implant bone resorption. The authors focus in particular on the effects of interleukin-6 (IL-6) as an important osteotropic factor and a hypothetical target on which to act in order to modulate its effects for therapeutical purposes.

Mechanisms of bone resorption: analysis of proinflammatory cytokines in peritoneal macrophages from titanium implant--an experimental design

Cytokines, and interleukin-6 in particular, are inflammatory peptide mediators that are extensively studied as regulators of bone tissue homeostasis. They seem to be involved in osteoclast activation and bone resorption and probably play a role in osseointegrated implant rejection. In this study we investigate the ability of titanium implants to cause an imbalance in the homeostatic equilibrium of cytokines using the peritoneal cavity of DB-A2 mice as a model. The inflammatory response was evaluated as a messenger ribonucleic acid expression determined by the semiquantitative reverse transcriptase--polymerase chain reaction technique in peritoneal macrophages from titanium-implanted mice. Interleukin-6 release was detected by a specific quantitative enzyme-linked immunosorbent assay. Our results have shown that titanium implants do not significantly stimulate the proinflammatory cytokine system compared to the control group. The enzyme-linked immunosorbent assay test confirms, after a peak in secretion at day 1 compared with basal levels, a clear decrease in interleukin-6 at basal levels on following control at 6 and 9 days after implantation. The study of the interaction between implanted biomaterials and inflammatory mediators seems to be very promising. Perhaps a better understanding of the mechanisms of bone resorption could lead to finding a new clinical solution for patients with osseointegrated implant rejection.

Titanium bone-integrated implants in extraoral facial prosthetic rehabilitation: surgical planning and long-term follow-up

The authors report on their clinical experience in the reconstruction of complex facial deformities using titanium osseo-integrated implants for the retention of soft silicone prostheses. They also evaluate the importance of this surgical technique as a viable alternative to traditional reconstructive procedures using autologous grafts, both in patients with severe osteomuscular defects and corrective surgery of unsuccessful reconstruction operations. The patients who underwent implantation operations were studied by CT 3D and 99m Tc SPECT (Single Photon Emission Computerized Tomography) procedures to evaluate osseo-integration at 3 weeks, 3, 6, 12, 24 months. The study demonstrates that the radiation emission peaks three weeks after surgery with the maximum bone remodeling activity, and after the functional loading of the implants, 3 months after surgery. High uptake past the eight month after surgery has never been detected and must be considered abnormal. SPECT offers the possibility of obtaining a three dimensional reconstruction of the photon emission of selected structures. The use of these nuclear medicine methods in addition to traditional-type radiological procedures introduce new possibilities, although still in the clinical experimentation phase, for the long-term follow-up of the inserted implants in craniofacial rehabilitation.

[The use of Holmstrom's flap in breast reconstruction]

The authors consider 12 cases of breast-reconstruction after mastectomy, made with the Holmstrom's flap, to verify the validity and the real utility of this way of reconstruction. It has been made a follow-up of 4 years, to verify, in course of time, the characteristics of the reconstructed breasts. All the patients have been operated in a general surgery department. The Holmstrom's flap has been prevalently used in patients, during immediate reconstruction. The breast reconstruction, made with this fascio-cutaneous transposition flap, requires the use of prosthesis. The operating time has a very short duration. The breast reconstruction, made with this method, requires a very short staying in hospital. The nipple-areola complex reconstruction has been made in a second time, few months later. The patients have been examined periodically, to verify, immediately, the result of the flap and, later, the quality of the new breast's shape and the occurrence of capsular contracture. The results achieved with this reconstructive method are a good shape and ptosis as to confer great naturalness to the new breast. The authors conclude that, even if they use the TRAM-flap as first choice in breast-reconstruction, the Holmstrom's flap is a reconstructive technique of great utility in immediate breast reconstruction, that is able to give very good aesthetic results.

SPECT in the long-term evaluation of osteointegration in intraoral and extraoral implantology

Scintigraphic methods used in intraoral and extraoral implantology allow the evaluation of bone metabolism in the peri-implant zones, providing anatomic images and functional dynamics information on the osteointegration process. Twenty-five patients who underwent implantation operations for the application of intra- and extraoral prostheses were studied using technetium 99 m single photon emission computed tomographic (SPECT) procedures to evaluate osteointegration dynamics at 3 weeks, and 3, 6, 12, and 24 months. The study demonstrates that radiation emission peaks 3 weeks after surgery with the maximal bone remodeling activity and 6 months after surgery after the functional loading of the implants only in intraoral fixtures. High uptake past the eighth month after surgery has never been detected and must be considered abnormal. SPECT offers the possibility of obtaining a three-dimensional reconstruction of the photon emission of selected structures. The use of these nuclear medicine methods in addition to traditional-type radiological procedures introduces new possibilities, although still in the clinical experimentation phase, for early diagnosis and inserted implant prognosis.

High prevalence of hepatitis C virus infection in patients with B-cell lymphoproliferative disorders in Italy

Starting from the observation that a number of consecutive patients with non-Hodgkin's lymphoma (NHL) resulted positive for hepatitis C virus (HCV) antibodies on routine testing, we set up a survey for HCV contact prevalence in all patients with lymphoproliferative disorders (LPD) followed in our institution. We searched for HCV antibodies by a third-generation ELISA technique, followed by a confirmation test (RIBA III); serum viral RNA and HCV genotype were investigated by a RT-PCR technique. We screened a total of 315 patients suffering from B-NHL (91), multiple myeloma (56), MGUS (48), chronic lymphocytic leukemia (57), Waldentrom's macroglobulinemia (13), Hodgkin's disease (HD)(43), and T-NHL (9). While only 1 of 52 patients with a non-B-LPD (HD or T-NHL) had signs of HCV contact (i.e., 1.9%, which is in the range of the normal population in the South of Italy), 59 of 263 patients with a B-LPD (22.4%) had HCV antibodies or RNA, or both, with no major differences among the various types of disorders, except for WM, in which the rate was higher (61.5%). The same prevalence was found for patients tested at diagnosis or during the follow-up, and in transfused or never-transfused patients. Only a few patients were aware of having a liver disease; one-half of HCV-positive patients never had transaminase increase. A review of data from Central and Northern Italy is included, showing similar findings; a report from Japan has confirmed such an association, while limited surveys in England have not revealed any correlation. These findings may have important biological and clinical implications.

Immediate TRAM flap breast reconstruction in an obese patient with relapsing benign phyllodes tumor: report of a case

The authors present a case of relapsing benign phyllodes cystosarcoma of the breast in an obese female treated with a simple mastectomy and an immediate reconstruction using a bipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. After a brief review of treatment options for phyllodes tumors, they discuss the advantages of TRAM flap breast reconstruction, suggesting that it may also be applied in obese patients.

Comparison of treatment with two different doses of leukocyte interferon alpha in patients with chronic hepatitis C

BACKGROUND/AIMS

This study was carried in order to investigate whether human leukocyte interferon-alpha administered for 12 months at two different dosages, improves long-term responses in chronic hepatitis C and to see whether pre-treatment gamma-glutamyl transpeptidase values help to predict the clinical response to Interferon.

METHODOLOGY

Forty-five patients were treated for 12 months with natural Interferon-alpha: 3 MU (group A: 31 cases); 6 MU (group B: 14 cases). Biochemical and virological responses were monitored during treatment and follow-up.

RESULTS

Alanine aminotransferase was normalized in 58.1% (Group A) and 54.5% (Group B) of patients by the end of the treatment. Due to side effects 3 patients had to discontinue treatment. During follow-up, remission was maintained in 30.8% and 45.4% of patients respectively (p = 0.046). After 12 months of therapy, respectively 46.7% and 45.4% of patients with complete biochemical response, cleared virus from serum, as did, among long-term responders, 3/8 and 3/4 evaluated patients. Independently of dosage, a complete response was found more often in patients with normal pre-treatment gamma-glutamyl transpeptidase than in those with pre-treatment abnormal values.

CONCLUSIONS

High dosage of IFN alpha was associated with a significantly greater rate of sustained biochemical response and with a better chance of viremia becoming negative. Pre-treatment gamma-glutamyl transpeptidase was able to predict the outcome of the treatment.

Somatostatin inhibits interleukin 6 release from rat cortical type I astrocytes via the inhibition of adenylyl cyclase

Interleukin 6 is a pleiotropic cytokine produced in the central nervous system (CNS) that has been involved in both direct neurotrophic activities and in the regulation of the production of acute phase proteins both at peripheral and central levels. In rat cortical type I astrocytes, interleukin 6 release is under the control of cAMP-protein kinase A and calcium-phospholipids-protein kinase C systems. Somatostatin is a neuropeptide, acting as a neurotransmitter, highly concentrated within the CNS, where it has been involved in the modulation of learning and memory processes. The aim of this study was to characterize the effects of somatostatin on the release of interleukin 6 from rat cortical type I astrocytes and the intracellular mechanisms involved in this activity. Our results show that somatostatin, in a concentration-dependent manner, inhibited basal and forskolin-stimulated interleukin 6 release from rat cortical type I astrocytes in culture. The EC50 of the inhibitory action was calculated to be approximately 10 nM. Furthermore, this effect of somatostatin was completely abolished by pretreating cortical astrocytes with pertussis toxin that, uncoupling, by ADP-rybosylating, the inhibitory GTP-binding protein from the receptors, prevents the activation of the intracellular effectors such as the adenylyl cyclase enzyme. To identify the intracellular mechanism mediating the effects of somatostatin on the interleukin 6 release, we evaluated the peptide modulation of basal and stimulated intracellular accumulation of cAMP. In our experimental conditions somatostatin significantly inhibited both basal and forskolin-stimulated cAMP accumulation. Conversely, somatostatin did not affect the increase of interleukin 6 release induced by dibutyryl-cAMP, a nonhydrolizable cAMP analog that, bypassing the effects of somatostatin on adenylyl cyclase activity, directly activated protein kinase A. These observations support the hypothesis that somatostatin inhibitory activity on interleukin 6 release is mediated by its effects on cAMP production. Somatostatin analog SMS 201-995 did not affect interleukin 6 production either in basal or stimulated conditions. Since, SMS 201-995 was reported to bind with high affinity only to somatostatin receptors type 2, 3 and 5, the lack of effect of this compound on interleukin 6 release suggests that the inhibitory action of somatostatin could be mediated by the activation of either type 1 or type 4 somatostatin receptors. In conclusion, our data demonstrate that the release of interleukin 6 from rat cortical type I astrocytes is inhibited by somatostatin through the activation of a somatostatin receptor coupled to the inhibition of adenylyl cyclase via a G-protein sensitive to pertussis toxin.

High prevalence of hepatitis C virus infection in patients with B-cell lymphoproliferative disorders in Italy

Starting from the observation that a number of consecutive patients with non-Hodgkin's lymphoma (NHL) resulted positive for hepatitis C virus (HCV) antibodies on routine testing, we set up a survey for HCV contact prevalence in all patients with lymphoproliferative disorders (LPD) followed in our institution. We searched for HCV antibodies by a third-generation ELISA technique, followed by a confirmation test (RIBA III); serum viral RNA and HCV genotype were investigated by a RT-PCR technique. We screened a total of 315 patients suffering from B-NHL (91), multiple myeloma (56), MGUS (48), chronic lymphocytic leukemia (57), Waldentrom's macroglobulinemia (13), Hodgkin's disease (HD)(43), and T-NHL (9). While only 1 of 52 patients with a non-B-LPD (HD or T-NHL) had signs of HCV contact (i.e., 1.9%, which is in the range of the normal population in the South of Italy), 59 of 263 patients with a B-LPD (22.4%) had HCV antibodies or RNA, or both, with no major differences among the various types of disorders, except for WM, in which the rate was higher (61.5%). The same prevalence was found for patients tested at diagnosis or during the follow-up, and in transfused or never-transfused patients. Only a few patients were aware of having a liver disease; one-half of HCV-positive patients never had transaminase increase. A review of data from Central and Northern Italy is included, showing similar findings; a report from Japan has confirmed such an association, while limited surveys in England have not revealed any correlation. These findings may have important biological and clinical implications.

[Plastic surgery of the abdominal wall in laparocele in a patient with previous kidney transplant]

The authors report the case of a patient undergoing kidney transplant from a non-related but compatible living donor who subsequently developed a voluminous incisional hernia affecting almost the entire small intestine in the right iliac fossa, the site of earlier surgery. After having analysed the problems involved when a transplant patient requires further surgery owing to the chronic administration of drugs, the authors describe the case. The patient was treated using the insertion of a prolene graft and remodelling the abdominal wall in correspondence with the lower quadrants using abdominoplasty without repositioning the umbilicus.

Increased intensification and total dose of cyclophosphamide in a doxorubicin-cyclophosphamide regimen for the treatment of primary breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-22

PURPOSE

The National Surgical Adjuvant Breast and Bowel Project (NSABP) initiated a randomized trial (B-22) to determine if intensifying but maintaining the total dose of cyclophosphamide (Cytoxan, Bristol-Myers Squibb Oncology, Princeton, NJ) in a doxorubicin (Adriamycin, Pharmacia, Kalamazoo, MI)-cyclophosphamide combination (AC), or if intensifying and increasing the total dose of cyclophosphamide improves the outcome of women with primary breast cancer and positive axillary nodes.

PATIENTS AND METHODS

Patients (N = 2,305) were randomized to receive either four courses of standard AC therapy (group 1); intensified therapy, in which the same total dose of cyclophosphamide was administered in two courses (group 2); or intensified and increased therapy, in which the total dose of cyclophosphamide was doubled (group 3). The dose and intensity of doxorubicin were similar in all groups. Disease-free survival (DFS) and overall survival were determined using life-table estimates.

RESULTS

There was no significant difference in DFS (P = .30) or overall survival (P = .95) among the groups through 5 years. At 5 years, the DFS of women in group 1 was similar to that of women in group 2 (62% v 60%, respectively; P = .43) and to that of women in group 3 (62% v 64%, respectively; P = .59). The 5-year survival of women in group 1 was similar to that of women in group 2 (78% v 77%, respectively; P = .86) and to that of women in group 3 (78% v 77%, respectively; P = .82). Grade 4 toxicity increased in groups 2 and 3. Failure to note a difference in outcome among the groups was unrelated to either differences in amount and intensity of cyclophosphamide or to dose delays and intervals between courses of therapy.

CONCLUSION

Intensifying or intensifying and increasing the total dose of cyclophosphamide failed to significantly improve either DFS or overall survival in any group. It was concluded that, outside of a clinical trial, dose-intensification of cyclophosphamide in an AC combination represents inappropriate therapy for women with primary breast cancer.

[Plastic surgery by the Limberg-Dufourmentel method in the treatment of a pilonidal sinus. The anatomicosurgical considerations and an emblematic case]

Limberg-Dufourmentel's cutaneous flap may be used to fill in the loss of residual substance after the radical excision of sinus pilonidalis in the sacrococcygeal region. According to the authors, this technique enables some aspects of the locoregional anatomic conformation typically linked to the onset of this pathology to be modified, as well as permitting more accurate radical surgery. By way of example, the authors report the case of a 20-year-old subject with sinus pilonidalis who was successfully treated using this surgical technique.

Human leucocyte interferon-alpha in chronic hepatitis C resistant to recombinant or lymphoblastoid interferon-alpha: a randomized controlled trial

Patients with biopsy-proven chronic hepatitis C, who failed to respond to a previous course of either recombinant (rIFN-alpha) or lymphoblastoid (Ly IFN-alpha) interferon-alpha, were randomized to receive either leucocyte (Le) IFN-alpha (patients) or a second course of the same IFN-alpha (controls), to compare the efficacy and safety of these treatment schedules. All patients received the same dose of IFN-alpha as was used during their previous treatment (3 million units (MU) or 6 MU three times weekly) for 6 months. Patients with a normal alanine aminotransferase (ALT) value at month 6 were treated for a further 6 months. All patients were followed-up for 12 months after treatment. A total of 69 patients were enrolled, 44 in the Le IFN-alpha group and 25 in the control group. At the end of the treatment period, 13 of the 44 patients (29.5%) in the Le IFN-alpha group had a biochemical response (normal ALT) and six of 44 (13.6%) patients had undetectable serum hepatitis C virus (HCV) RNA. At the end of the follow-up period, 10 patients (22.7%) had normal ALT values and serum HCV RNA was undetectable in three (6.8%). None of the patients in the control group showed normal ALT values at any time. Genotype 1b tended to be more frequent among non-responders (61 vs 45%): basal gamma-glutamyl transpeptidase (gamma-GT) values were lower in responders than in non-responders (33.3 +/- 11.70 Ul-1 vs 58.4 +/- 33.04; P = 0.01). Le IFN-alpha was well tolerated by all patients. These results support the use of Le IFN-alpha in patients with chronic hepatitis C who are non-responders to a previous treatment with recombinant or lymphoblastoid IFN-alpha.

[Surgical treatment of rhinophyma using dermo-epidermal graft. A case report]

Rhinophyma is a nosographical form that has always attracted attention, even among non-experts, owing to the marked aesthetic damage it often causes. Several types of surgery have been proposed for its treatment in an attempt to elaborate a technique that is easy to apply and guarantees satisfactory results in clinical and aesthetic terms. After a short review of the general aspects of the pathology, the authors illustrate the case of a patient with rhinophyma treated with a full thickness dermo-epidermic graft, and emphasise that this surgical solution, provided that the indications are correct, is still a valid alternative.