The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies

OBJECTIVE

The role of self-monitoring of blood glucose (SMBG) in type 2 diabetes is still a matter of debate. In the framework of a nationwide outcomes research program, we investigated the frequency of SMBG and its association with metabolic control and quality of life (QoL).

RESEARCH DESIGN AND METHODS

The study involved 3,567 patients with type 2 diabetes who were recruited by 101 outpatient diabetes clinics and 103 general practitioners. Patients completed a questionnaire investigating SMBG practice and QoL (diabetes-related stress, diabetes health distress, diabetes-related worries, and Centers for Epidemiologic Studies-Depression scale).

RESULTS

Data on SMBG were available for 2,855 subjects (80% of the entire study population). Overall, 471 patients (17%) stated that they tested their blood glucose levels at home > or =1 time per day, 899 patients (31%) tested their blood glucose levels > or =1 time per week, and 414 patients (14%) tested their blood glucose levels <1 time per week, whereas 1,071 patients (38%) stated that they never practiced SMBG. A higher frequency of SMBG was associated with better metabolic control among subjects who were able to adjust insulin doses, whereas no relationship was found in all other patients, irrespective of the kind of treatment. Multivariate analyses showed that an SMBG frequency > or =1 time per day was significantly related to higher levels of distress, worries, and depressive symptoms in non-insulin-treated patients.

CONCLUSIONS

Our findings suggest that SMBG can have an important role in improving metabolic control if it is an integral part of a wider educational strategy devoted to the promotion of patient autonomy. In patients not treated with insulin, self-monitoring is associated with higher HbA(1c) levels and psychological burden. Our data do not support the extension of SMBG to this group.

[Helical CT as preferred imaging modality in the diagnosis of pulmonary embolism]

PURPOSE

We investigated the role of Helical Computed Tomography (CT) as primary screening imaging modality in the diagnosis of pulmonary embolic disease.

MATERIAL AND METHODS

We retrospectively reviewed the CT examinations, resulted positive for pulmonary embolism, performed in 134 patients (69 men and 65 women, ranging in age 23-83 years) from June 1998 to June 1999. CT was performed with a helical unit (thickness 3 mm, reconstruction interval 2 mm, pitch 1.5) after intravenous contrast agent (120 mL) rapid infusion (4 mL/s, 15s acquisition delay from bolus starting) and using a power injector. The spiral acquisition was performed from the apex of the pulmonary trunk to the diaphragm. Pulmonary embolism was considered as complete when a filling defect was present in a main pulmonary artery, as moderate when a filling defect was observed in an interlobar pulmonary artery and as very small when a filling defect was identified in a segmental pulmonary artery.

RESULTS

Helical CT allowed us to identify the presence of a filling defect in the main pulmonary artery in 60.4% of cases (complete pulmonary embolism), in an interlobar pulmonary artery in 27.6% of cases (moderate pulmonary embolism) and in a segmental pulmonary artery in 11.9% of cases (very small pulmonary embolism). At helical CT study, pulmonary embolus was identified as complete filling defect (92.5% of cases), thromboembolic mass floating freely in the lumen (28.3%) and partial filling defect (19.4%). Pleural effusion and pulmonary infarction were associated in 46.2% and 20.1% respectively.

DISCUSSION AND CONCLUSIONS

Pulmonary embolic disease continues to be a major cause of morbidity and mortality. The clinical diagnosis of pulmonary embolism remains an important challenge: among the different imaging modalities, contrast-enhanced helical CT can be used as primary screening imaging modality in the diagnosis of pulmonary embolism, allowing us to detect the presence of pulmonary embolus in the main, lobar and segmental artery, as demonstrated in our experience.

Effect of femoral stiffness on bone remodeling after uncemented arthroplasty

The current study examined the relationships among femoral stiffness, implant stiffness, and bone remodeling in 40 femurs retrieved at autopsy from 20 patients with unilateral uncemented hip replacements. The purpose of the study was to determine if the magnitude of periprosthetic bone loss after arthroplasty was correlated with, and could be predicted from, stem and femoral stiffness terms. For analysis, the contralateral normal femur was used as a control to represent the unremodeled condition of the in vivo implanted femur. Bone loss attributable to remodeling was quantified by video-densitometric analysis. Stiffness terms were calculated as the product of the elastic modulus and geometric properties digitized from cross-sectional slab radiographs. Femoral stiffness calculations accounted for variations in modulus attributable to patient differences in bone mineral density and geometric properties attributable to differences in the shape of individual femurs. Similarly, calculations of implant stiffness accounted for variations in implant shape. Results showed axial bone stiffness was the variable most strongly correlated with bone loss. Individual stem stiffness terms were not significantly correlated with bone loss. Multiple linear regression analysis, using stem-to-bone stiffness ratios as independent variables, accounted for 46% of the variance in bone loss data. In the regression analysis, the axial stem-to-bone stiffness ratio was the strongest correlate with bone loss. Although these results show the influence of mechanical stiffness factors on bone remodeling, other factors (hormonal status, drugs, disease, activity level) could represent the variance in bone loss data not accounted for in the study.

The functional ccpA gene is required for carbon catabolite repression in Lactobacillus plantarum

We report the characterization of the ccpA gene of Lactobacillus plantarum, coding for catabolite control protein A. The gene is linked to the pepQ gene, encoding a proline peptidase, in the order ccpA-pepQ, with the two genes transcribed in tandem from the same strand as distinct transcriptional units. Two ccpA transcription start sites corresponding to two functional promoters were found, expression from the upstream promoter being autogenously regulated through a catabolite-responsive element (cre) sequence overlapping the upstream +1 site. During growth on ribose, the upstream promoter showed maximal expression, while growth on glucose led to transcription from the downstream promoter. In a ccpA mutant strain, the gene was transcribed mainly from the upstream promoter in both repressing and non repressing conditions. Expression of two enzyme activities, beta-glucosidase and beta-galactosidase, was relieved from carbon catabolite repression in the ccpA mutant strain. In vivo footprinting analysis of the catabolite-controlled bglH gene regulatory region in the ccpA mutant strain showed loss of protection of the cre under repressing conditions.

[Small bowell volvulus - combined radiological findings]

PURPOSE

We retrospectively evaluated the radiological findings observed at plain abdominal film, abdominal sonography and abdominal CT performed in 66 patients with surgically proven small bowel volvulus.

MATERIAL AND METHODS

Sixty-six patients (35 women and 31 men, ranging in age 38-77 years) with surgically proven small bowel volvulus were submitted to plain film, sonography and CT of the abdomen. Abdominal plain film was performed in the upright position (postero-anterior view) in 46 cases, and in the supine position in 20 cases. On plain abdominal film we evaluated the following findings: bowel loops dilatation, air-fluid levels and site of obstruction. At abdominal US, performed with 3.5 e 7.5 MHz probes, we retrospectively searched for: bowel loop dilatation, bowel wall thickening, peristalsis alteration, extraluminal fluid. CT was performed with a helical unit (thickness 4 mm, reconstruction interval 4 mm, pitch 1.5), after intravenous contrast agent (120 ml) infusion (3 ml/s, 55 s acquisition delay from bolus starting) and using a power injector. The following CT findings were searched for: whirl sign, beak sign, extraluminal fluid, bowel loop dilatation, bowel wall thickening, bowel wall or mesenteric alterations.

RESULTS

Plain abdominal film showed the following findings: air-fluid levels (92.4% of cases), bowel loops dilatation (71.2%), site of obstruction (42.4%). Abdominal sonography demonstrated bowel loop dilatation (48.5%), extraluminal fluid (48.5%), peristalsis alteration (27.3%), bowel wall thickening (27.3%). The most frequent CT findings were: bowel loop dilatation (95.5%), bowel wall thickening (78.8%), beak sign (69.7%), mesenteric alterations (66.7%), extraluminal fluid (54.5%), whirl sign (13.6%).

CONCLUSIONS

Air-fluid levels and bowel loop dilatation were the most frequent radiological findings in our series. Plain abdominal film allowed us to identify signs of obstruction, whereas signs of bowel wall necrosis were accurately shown by abdominal CT.

The relationship between physicians' self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes. The QuED Study Group--quality of care and outcomes in type 2 diabetes

OBJECTIVE

To investigate the relationship between beliefs of physicians relative to intensive metabolic control in type 2 diabetes and levels of HbA1c obtained in a sample of their patients.

RESEARCH DESIGN AND METHODS

Physicians' beliefs were investigated through a questionnaire sent to a sample of self-selected clinicians participating in a nationwide initiative aimed at assessing the relationship between the quality of care delivered to patients with type 2 diabetes and their outcomes. At the same time, physicians were asked to collect clinical data on a random sample of their patients, stratified by age (<65 vs. > or = 65 years). Mean HbA1c levels in the study population were thus evaluated according to target fasting blood glucose (FBG) used by their physicians.

RESULTS

Of 456 physicians, 342 (75%) returned the questionnaire. Among the responders, 200 diabetologists and 99 general practitioners (GPs) recruited 3,297 patients; 2,003 of whom were always followed by the same physician and 1,294 of whom were seen by different physicians in the same structure on different occasions. Only 14% of the respondents used target FBG levels < or = 6.1 mmol/l, whereas 38% pursued values >7.8 mmol/l, with no statistically significant difference between diabetologists and GPs. The analysis of the relationship between FBG targets and metabolic control, restricted to those patients always seen by the same physician, showed a strong linear association, with mean HbA1c values of 7.0 +/- 1.6 for patients in the charge of physicians pursuing FBG levels < or = 6.1 mmol/l and 7.8 +/- 1.8 for those followed by physicians who used target values >7.8 mmol/l. After adjusting for patients' and physicians' characteristics, the risk of having HbA1c values > 7.0% was highly correlated with physicians' beliefs. Patients followed by different physicians in the same unit showed a risk of inadequate metabolic control similar to that of patients followed by physicians adopting a nonaggressive policy.

CONCLUSIONS

Doctors adopt extremely heterogeneous target FBG levels in patients with type 2 diabetes, which in turn represent an important independent predictor of metabolic control. To improve patient outcomes, physicians-centered educational activities aimed at increasing the awareness of the potential benefits of a tight metabolic control in patients with type 2 diabetes are urgently needed.

Plasma homocysteine and microvascular complications in type 1 diabetes

BACKGROUND

Homocysteine is involved in a complex and dynamic system of vascular injury and repair and may thus contribute to the development of diabetic microangiopathy. This still debated issue has important scientific and clinical implications, since hyperhomocysteinemia can be corrected nutritionally.

AIMS

1) To evaluate the association between fasting plasma homocysteine, type 1 diabetes and its microvascular complications; 2) to elucidate the basis of this association by investigating the major determinants of plasma homocysteine in relation to diabetic microangiopathy.

METHODS

We studied sixty-six consecutive patients with type 1 diabetes mellitus of > 10 years duration and normal serum creatinine (< 115 mumol/L, 1.3 mg/dL), and free from clinically detectable cardiovascular diseases. Forty-four non-diabetic controls were also studied. Plasma concentrations of homocysteine, folate and vitamin B12 were investigated together with the C677T mutation in the gene coding for methylenetetrahydrofolate reductase (MTHFR), a key enzyme in homocysteine metabolism. Renal and retinal diabetic complications were evaluated as albumin/creatinine ratio on early-morning, urine spot collection and fundus photographs.

FINDINGS

Fasting plasma homocysteine levels were very similar in patients and controls. Patients with microalbuminuria or proliferative retinopathy had significantly higher values than those without: 9.4 +/- 3.1 vs 7.4 +/- 2.8 mumol/L, p < 0.02 and 9.5 +/- 2.6 vs 7.3 +/- 3.0 mumol/L, p < 0.05. This difference was not attributable to confounders, such as age, sex and smoking, nor to dissimilar plasma folate and vitamin B12 concentrations. In contrast, homozygosity for the C677T mutation in the MTHFR gene--the commonest genetic defect linked to moderately increased plasma homocysteine--was significantly more frequent in patients with microalbuminuria and/or proliferative retinopathy (50% vs 13%, p < 0.004), odds ratio 6.7 (95% CI 1.7-27.6).

CONCLUSIONS

Type 1 diabetes as such is not associated with increased plasma homocysteine levels, though patients with microalbuminuria and/or proliferative retinopathy display significantly higher values than those without. This difference is not attributable to obvious confounders, nor to differences in vitamin status, and may be partly mediated by genetic factors. Plasma homocysteine, together with other diabetes-related noxae, may thus be in a position to contribute to the development of nephropathy and the progression of retinopathy.

Phenotypic variability in Bartter syndrome type I

Limited phenotypic variability has been reported in patients with Bartter syndrome type I, with mutations in the Na-K-2Cl cotransporter gene (BSC). The diagnosis of this hereditary renal tubular disorder is usually made in the antenatal-neonatal period, due to the presence of polyhydramnios, premature delivery, hypokalemia, metabolic alkalosis, hypercalciuria, and nephrocalcinosis. Among nine children with hypercalciuria and nephrocalcinosis, we identified new mutations consistent with a loss of function of the mutant allele of the BSC gene in five. Three of the five cases with BSC gene mutations were unusual due to the absence of hypokalemia and metabolic alkalosis in the first years of life. The diagnosis of incomplete distal renal tubular acidosis was considered before molecular evaluation. Three additional patients with hypokalemia and hypercalciuria, but without nephrocalcinosis in the first two and with metabolic acidosis instead of alkalosis in the third, were studied. Two demonstrated the same missense mutation A555T in the BSC gene as one patient of the previous group, suggesting a single common ancestor. The third patient presented with severe hypernatremia and hyperchloremia for about 2 months, and a diagnosis of nephrogenic diabetes insipidus was hypothesized until the diagnosis of Bartter syndrome type I was established by molecular evaluation. We conclude that in some patients with Bartter syndrome type I, hypokalemia and/or metabolic alkalosis may be absent in the first years of life and persistent metabolic acidosis or hypernatremia and hyperchloremia may also be present. Molecular evaluation can definitely establish the diagnosis of atypical cases of this complex hereditary tubular disorder, which, in our experience, may exhibit phenotypic variability.

Is the erythrocyte membrane fatty acid composition a valid index of skeletal muscle membrane fatty acid composition?

Recent studies suggest that insulin sensitivity is related to the fatty acid composition of phospholipids in skeletal muscle (SM) membranes. Since it is difficult to obtain muscle biopsies, it may be useful to have information on the fatty acid composition using more accessible cells such as erythrocytes. This would be possible only if the composition of erythrocyte and muscle membranes are very similar. Since no comparative data are available, we evaluated the phospholipid fatty acid composition of erythrocyte and SM membranes in 16 individuals, 10 nondiabetics (male to female ratio, 4:6; age, 50 +/- 11 years; body mass index, 27 +/- 5 kg/m2; mean +/- SD) and 6 type 2 diabetic patients (male to female ratio, 2:4; age, 64 +/- 5 years; body mass index, 27 +/- 4 kg/m2). All patients underwent abdominal surgery, during which a biopsy of the abdominal rectus muscle (50 to 100 mg) was obtained. Erythrocyte and SM phospholipid fatty acids were extracted and then methylated; the methyl fatty acids were separated and quantified by gas chromatography. Compared with erythrocyte membranes, muscle membranes showed a significantly higher proportion of omega-6 polyunsaturated fatty acid ([PUFA] 43.0% +/- 3.1% v29.7% +/- 1.6%, P < .001) and lower saturated fatty acid ([SFA] 41.1% +/- 1.5% v 43.4% +/- 1.2%, P < .001), monounsaturated fatty acid ([MUFA] 11.5% +/- 1.7% v 20.0% +/- 1.9%, P < .001), and omega-3 PUFA (3.8% +/- 0.6% v 7.4% +/- 1.0%, P < .001). The greatest increase involved linoleic acid (26.9% +/- 2.8% v 10.3% +/- 1.6%, P < .001), whereas lignoceric acid (0.8% +/- 0.2% v 5.0% +/- 0.6%, P < .001) and oleic acid (10.4% +/- 1.6% v 13.5% +/- 1.3%, P < .001) were significantly lower. These results show that erythrocyte and muscle membrane phospholipid fatty acids are significantly different. Therefore, data on SM membranes cannot be extrapolated on the basis of measures of erythrocyte phospholipid fatty acid composition.

Cardiac abnormalities in type 1 diabetes

BACKGROUND

Left ventricular (LV) structural and hemodynamic consequences of type 1 diabetes mellitus are not fully understood.

METHODS

To evaluate LV geometry, systolic and diastolic function in type 1 diabetes, Doppler echocardiograms were performed in 40 normotensive, type 1 diabetic patients without coronary heart disease or valvular lesions (22 men, 18 women, mean age 43 +/- 6 years, body mass index 24.7 +/- 2.8 kg/m2) and in 40 age and sex-matched non-diabetic normotensive controls (22 men, 18 women, mean age 43 +/- 5 years, body mass index 23.2 +/- 2.8 kg/m2), in a case-control design.

RESULTS

Patients had higher systolic blood pressure than controls (p < 0.03) and comparable diastolic blood pressure and heart rate. LV dimension and mass were higher in patients than in controls (both p < 0.0001) whereas relative wall thickness did not differ. For comparable levels of end-systolic stress, patients exhibited a higher ejection fraction than controls (p < 0.01) and normal midwall shortening. Cardiac output was also higher (p < 0.001), whereas total peripheral resistance was lower in patients than in controls (p < 0.0001). Isovolumic relaxation time and E deceleration were prolonged in patients and peak A velocity was greater than in controls (all p < 0.01), whereas the difference in duration between A and pulmonary vein peak reverse flow at atrial contraction was comparable. In subgroup analyses, all reported features were independent of a) presence of target organ damage; b) duration of disease; c) levels of glycosylated hemoglobin.

CONCLUSIONS

In normotensive patients with type 1 diabetes: 1) there was a moderate increase in LV mass; 2) LV chamber function was supernormal and wall mechanics was normal; 3) LV active relaxation was impaired but chamber stiffness was normal.

[Spiral computed tomography in the assessment of vascular lesions of the pelvis due to blunt trauma]

PURPOSE

We investigated the role of Helical Computed Tomography (CT) in the evaluation of low or high flow vascular injuries in patients with blunt pelvic trauma.

MATERIAL AND METHODS

From May 1998 to December 1999, forty-nine patients (32 men and 17 women, ranging in age 14-59 years) with acute symptoms from blunt pelvic trauma were submitted to Computed Tomography (CT). A conventional radiography of the pelvis had been performed in all cases. CT was performed with a helical unit (thickness 8 mm, reconstruction interval 8 mm, pitch 1.5) after intravenous contrast agent (150-180 mL) rapid infusion (4-5 mL/s, 60 s acquisition delay from bolus starting) and using a power injector. A second spiral acquisition was performed in all cases from the iliac roofs to the inferior border of the pubic symphysis. Vascular hemorrhage was considered as low flow when the hematoma appeared as a focal homogeneous density area and as high flow when associated with contrast agent extravasation. Moreover, traumatic assessment included evaluation of the hematoma, of the leakage site and of the involved vessel.

RESULTS

Radiologic examination of the pelvis revealed fractures in 35/49 patients (71.4%). Helical CT allowed us to identify low flow hemorrhage in 37 patients, affected with hematomas from fracture of the iliac wing or of the sacrum (14 cases), tear of the pelvic (3 cases) or extrapelvic (4 cases) muscular structures, or injury of the venous plexus (20 cases). In four patients two vascular injuries were detected. High flow hemorrhage was seen in 12 patients, who had Helical CT findings of contrast agent extravasation along the common iliac vein (3 cases), external iliac artery (3 cases), internal iliac artery (4 cases), internal pudendal artery (1 case), obturator artery (1 case), inferior epigastric artery (2 cases), superior gluteal artery (2 cases), inferior gluteal artery (1 case), cremasteric artery (1 case). In 6 patients with high flow hemorrhage, two vascular injuries were shown. In all these patients, an extraperitoneal hematoma was associated with the contrast agent extravasation.

DISCUSSION AND CONCLUSIONS

Fractures of the pelvic ring generally result from severe trauma. Management of these injuries must include not only treatment of the skeletal trauma but also of the associated shock and complications. Major blood loss usually occurs as a result of bleeding from the branches of the internal iliac artery. With respect to pelvic plain radiography, CT provides superior detailing of fractures, position of fracture fragments and extent of diastasis of the sacroiliac joints and pubic symphysis. Moreover CT provides diagnostic information regarding the presence or absence of pelvic bleeding and can identify the site of bleeding. In our experience, Helical CT allows us to distinguish high flow hemorrhage, where vascular injuries must be treated first, from low flow hemorrhage which can be managed differently.

A physical and functional analysis of the newly-identified bglGPT operon of Lactobacillus plantarum

A newly-identified bglGPT operon of Lactobacillus plantarum was isolated and expressed in Escherichia coli. The sequence analysis of the cloned DNA fragment showed three open reading frames encoding (i) a 237-amino acid protein (BglG), (ii) a 577-amino acid protein (BglP) and (iii) a 486-amino acid protein (BglT). BglG, BglP and BglT were shown to be homologous to the BglG family of transcriptional antiterminators, to permeases of the phosphoenolpyruvate-dependent phosphotransferase system and to beta-glucosidases, respectively. Complementation of E. coli mutant strains showed that BglP and BglT are a permease and a beta-glucosidase active on the beta-glucosides, 5-bromo-4-chloro-3-indolyl-beta-D-glucopyranoside and p-nitrophenyl-beta-D-glucoside, respectively. BglG was also shown to promote expression of a bglG-lacZ gene fusion in an E. coli bglG(-) background. A ribonucleic antiterminator sequence, the antiterminator-responsive cis-element and a 'catabolite responsive element', were found downstream of the transcriptional start point. Transcription of the operon was repressed 10-fold in L. plantarum cells grown on glucose as compared to ribose.

AP-2 transcription factors in the regulation of ERBB2 gene transcription by oestrogen

Transcription of the ERBB2 oncogene is repressed by oestrogen in human breast cancer cells. We show that a 218 bp fragment of the human ERBB2 gene promoter is responsive to oestrogen in transient transfection in ZR75.1 and SKBR.3 cells when the oestrogen receptor is expressed. Deletion analysis of this fragment shows that a sequence located at the 5' end, which is known to mediate ERBB2 overexpression in breast cancer, is also responsible for the oestrogen response. This sequence binds AP-2 transcription factors and appears functionally identical to an element of the oestrogen-dependent enhancer described in the first intron of human ERBB2. We observed that oestrogen treatment down-regulates expression of AP-2 proteins but does not affect the DNA binding activity of AP-2. Constitutive expression of AP-2beta or AP-2gamma, but not AP-2alpha, abrogates the estrogenic repression. Our results demonstrate that AP-2 transcription factors are implicated in the oestrogenic regulation of ERBB2 gene expression and suggest a complex interplay involving the different AP-2 isoforms and other unidentified factors.

Prospective multicenter study on urologic complications after radical surgery with or without radiotherapy in the treatment of stage IB-IIA cervical cancer

A national collaborative group has conducted a multicenter prospective study on the use of a specific glossary for the complications associated with the treatment of cervical cancer, which were analytically described in 1989. This report analyzes the urologic complications with particular reference to radical surgery in stage IB-IIA cancer cases. In the prospective multicenter clinical study 2024 patients with frankly invasive cervical cancer were enrolled (IB = 1041; IIA = 308; IIB = 384; IIIA-B = 237; IV = 54). This report considers 1349 patients with stage IB-IIA disease. Treatment modalities in this group of patients were: type III radical surgery in 21.9%; type III radical surgery followed by radiotherapy in 20.8%; type III radical surgery preceded by radiotherapy in 7.3%; type II radical surgery in 3.1%; type II radical surgery followed by radiotherapy in 8.4%; type II radical surgery preceded by radiotherapy in 18.8%; surgery plus chemotherapy plus radiotherapy in 3.5%; radiotherapy alone in 16%. In this case series 873 complications were registered, and among these 341 (39.1%) were described in the urinary tract. Among 277 bladder complications 47.3% were grade 1; 47.3% grade 2, and 5.4% grade 3. Among 64 ureter complications 59.4% were grade 1; 17.2% grade 2, and 23.4% grade 3. Distribution of severe urinary complications was different according to site (bladder or ureter) and treatment modalities (radical surgery alone: bladder 1.3%, ureter 1.3%; radical surgery followed by radiotherapy: 1.4% bladder, 2.8% ureter; radical surgery preceded by radiotherapy: 3% bladder, 0% ureter). Different distributions of severe urinary complication were also observed in respect to stage (IB vs IIA); treatment: elective vs nonelective. In 673 patients treated with radical surgery plus or minus radiotherapy 123 relapses were registered (18.2%). Incidence of relapse was not different in patients suffering from mild/severe complications vs patients without complications. Disease-free survival, death from tumor, and death from other causes were not different in the group with complications in comparison to the group without complications.

[Diagnostic sensitivity of computerized tomography in closed trauma of the diaphragm. Retrospective study of 35 consecutive cases]

PURPOSE

To evaluate the effectiveness and role of CT in blunt diaphragmatic injuries by reviewing our 8-year experience.

MATERIAL AND METHODS

We reviewed the preoperative CT findings of 35 patients with surgically confirmed diaphragmatic rupture. Surgical repair was performed in the acute setting (within 12 hours of trauma) in 22 cases, and late (8 months-5 years) in 13 cases. Twenty-eight patients (80%) were examined with conventional CT and 7 (20%) with Helical CT. Scans were initiated at the thoracic inlet to the pubic symphysis, with 8-mm slice thickness, after i.v. contrast agent administration. Four-mm slices were acquired in the region of interest; sagittal and coronal reformations were obtained for Helical CT images.

RESULTS

In the acute group, 20 patients had left hemidiaphragmatic and 2 right hemidiaphragmatic rupture; thoracic herniation of the abdominal organs was seen in all cases. Of the 13 patients examined long after trauma, the left hemidiaphragm was ruptured in 12 cases (with visceral herniation in 4), and the right hemidiaphragm in 1, with no herniation. The diaphragmatic rent was found in the dome (15 cases, 43%), musculotendinous junction (11 cases, 31%), muscular portion (8 cases, 23%), and at the muscular attachments on the ribs (1 case, 3%). CT diagnosed diaphragmatic rupture in all the acute cases (22/35 patients, 63%) and in 4 patients with visceral herniation (11%) examined long after trauma. CT findings were questionable in the 9 cases (25%) not presenting visceral herniation. As for the site of diaphragmatic injury, CT never depicted the diaphragmatic rent in the dome and at the musculotendinous junction (74%), not even with thin slices and the multiplanar Helical technique. CT detected indirects signs of injury at the muscular portion (23%), showing the injury site directly in the case with diaphragmatic avulsion (3%).

CONCLUSION

CT is a reliable tool in the diagnosis of suspected diaphragmatic injury in the acute trauma setting. Long after trauma, CT performs poorly because it depicts the diaphragmatic rent only in some peripheral traumas. Helical CT has greater diagnostic potentials, but the injury site and type do affect its capabilities.

[Prognostic factors in the treatment of advanced cervical cancer. A retrospective study]

BACKGROUND

The value of prognostic factors in patients with advanced cervix carcinoma treated by radiotherapy was assessed in a retrospective study.

METHODS

From January 1977 through December 1990, 261 patients (average age 60 years) were treated at the Radiotherapy Department of the University of Turin. Distribution by stage was: 142 T2b (54%), 8 T3a (3%), 98 T3b (38%) and 13 T4 (5%). 83% of the patients underwent radiotherapy alone; the total dose was 45-88 Gy in 91 patients (42%) with poor clinical conditions, 60-75 Gy in 121 (56%) and 75-80 Gy in 5 cases. 17% of the patients was treated by surgery combined with radiotherapy. The median follow-up was 50 months (minimum 2, maximum 177 months).

RESULTS

The 5-year NED survival and local control were 42% (52% for T2b, 33% for T3 and 15% for T4). The severe (G3-G4) complication rate was very low (1.9%).

CONCLUSION

In our series, the prognostic factors which significantly influenced survival in the uni-variate analysis were: advanced T stage, contemporary infiltration of parametrium and vagina, nodal status, non squamous neoplasm, younger age and the absence of brachytherapy in the radiotherapy alone protocol.

Complete amino acid sequence determination of the major allergen of peach (Prunus persica) Pru p 1

The major protein allergen of peach (Prunus persica), Pru p 1, has recently been identified as a lipid transfer protein (LTP). The complete primary structure of Pru p 1, obtained by direct amino acid sequence and liquid chromatography-mass spectrometry (LC-MS) analyses with the purified protein, is described here. The protein consists of 91 amino acids with a calculated molecular mass of 9178 Da. The amino acid sequence contains eight strictly conserved cysteines, as do all known LTPs, but secondary structure predictions failed to classify the peach 9 kDa protein as an 'all-alpha type', due to the high frequency of amino acids (nine prolines) disrupting alpha helices. Although the sequence similarity with maize LTP is only 63%, out of the 25 amino acids forming the inner surface of the tunnel-like hydrophobic cavity in maize ns-LTP 16 are identical and 7 similar in the peach homolog, supporting the hypothesis of a similar function.

Retrovirus-mediated IL-4 gene therapy in spontaneous adenocarcinomas from MMTV-neu transgenic mice

Gene therapy approaches to the treatment of experimental cancer are usually based on established neoplastic cell lines which are manipulated in vitro and subsequently transplanted in host animals. However, the relevance of these artificial models to the biology and therapy of human tumors is uncertain. We have previously validated an experimental model based on MMTV-neu transgenic mice in which breast tumors arise spontaneously in 100% of animals and have many features in common with their human counterpart, including the involvement of the neu oncogene and the ability to metastatize. In this article we report the effect of intratumoral, retrovirus-mediated, IL-4 expression on the growth of breast tumors arising in these mice. The size of IL-4 inoculated tumors on the right side was significantly smaller than that of controlateral untreated tumors, suggesting a local effect of IL-4. In addition, the non-injected tumors on the left side of treated animals were significantly smaller than those arising in control transgenic mice, suggesting that IL-4 can also inhibit tumor growth systemically. These findings suggest that IL-4 gene transfer can significantly reduce the growth rate of spontaneously arising breast tumors and that immune-based gene therapy could efficiently complement other approaches based on different mechanisms, such as suicide gene transfer or antisense technology.

The effectiveness, safety and epidemiology of the use of acarbose in the treatment of patients with type II diabetes mellitus. A model of medicine-based evidence

OBJECTIVE

To assess the efficacy, safety and extent of perceived indications of acarbose, a new antidiabetic agent, under routine clinical practice conditions in an unselected Northern Italian population of type II diabetic patients.

METHODS

The study population was assigned to three different groups according to the physician's clinical judgement: group A (acarbose considered as an elective treatment); group B (acarbose considered to be of uncertain benefit): group C (acarbose deemed not to be appropriate). Group B patients were randomized either to continue their standard treatment or to add acarbose to it. Patients with type II diabetes mellitus were recruited from 17 diabetes outpatient clinics from one Italian region (Lombardy). A total of 1027 patients were recruited (group A: 283; group C: 494; group B: 250, of whom 124 were randomly assigned to standard treatment + acarbose and 126 to standard treatment alone). Acarbose was administered for 1 year at a median dose of 100 mg 3 times daily. Drug efficacy was evaluated in terms of mean HbAlc, pre- and post-prandial glycaemic values. Additional endpoints were the proportion of patients with HbA1c levels below 8% at the end of the study period and the proportion of subjects who needed a modification in the standard treatment. The safety and tolerability profiles of the drug were also investigated. Data on HbA1c, fasting and post-prandial blood glucose levels were analysed over time using repeated-measures analysis [Generalized Estimating Equation (GEE) models].

RESULTS

The analysis of Group B showed that, after treatment for 1 year, the mean reduction in HbA1c levels in the acarbose group with respect to the control group was 0.30% (95% confidence limits -0.60 +0.02; P = 0.07), while the mean reduction in post-prandial glycaemia was 17 mg-dl(-1) (95% c.l. -33.5 -0.8; P = 0.04). No difference resulted for fasting blood glucose levels. When looking at the baseline HbA1c levels, it emerged that the mean benefit associated with the use of acarbose was 0.14% (95% c.l. -0.6 +0.28; P = 0.5) in patients with HbAlc levels below 8%, 0.28% (95% c.l. -0.6 +0.05; P = 0.09) in those with values between 8% and 9.9% and 0.65% (95% c.l. -1.36 +0.06; P = 0.07) in those with values > or =10%. Only patients treated with diet+/-oral anti-diabetic agents (OAA) benefited from acarbose treatment (mean benefit = 0.37%, 95% c.l. -0.65 -0.08), while no effect was shown for insulin-treated subjects. The proportion of patients with HbA1c below 8% increased from 31% to 44% in the acarbose group and from 40% to 45% in the control group (absolute difference between baseline and end-of-study values = 8.0% in favour of acarbose-treated patients; P = 0.058). Patients treated with acarbose were significantly more likely to undergo a dose reduction in concomitant diabetic treatments compared with the control group; they were also less likely to require an increase in the dose of standard treatment and to start insulin during the study period. One third of the patients could not assume the drug for the whole study period, mainly due to gastrointestinal side-effects.

CONCLUSIONS

The design adopted in this study allowed an integrated evaluation of the overall effectiveness of acarbose in clinical practice. The benefits of the drug in an unselected population of non-insulin-dependent diabetes mellitus (NIDDM) patients are significant but of marginal clinical relevance. Only a better definition of the subgroups of patients who are more likely to benefit from long-term treatment, particularly through possible postponement of secondary OAA failure, will allow a reliable definition of the cost-effectiveness of this complementary component of anti-diabetic strategy.

Expression of the bglH gene of Lactobacillus plantarum is controlled by carbon catabolite repression

A newly identified bglH gene coding for a phospho-beta-glucosidase of Lactobacillus plantarum was isolated and expressed in Escherichia coli. The sequence analysis of the cloned DNA fragment showed an open reading frame encoding a 480-amino-acid protein with a calculated molecular mass of 53 kDa. The bglH gene was shown to be expressed on a monocistronic transcriptional unit. Its transcription was repressed 10-fold in L. plantarum cells grown on glucose compared to the beta-glucoside salicin as a sole carbon source. A catabolite-responsive element (CRE) spanning from -3 to +11 with respect to the transcriptional start point was found, and its functionality was assessed by mutational analysis. In vitro and in vivo DNA binding experiments suggested the occurrence of a DNA-protein complex at the CRE site, which would mediate glucose repression of bglH expression.

[Prognostic factors in the treatment of carcinoma of the cervix uteri in IB-IIA stage. Retrospective study]

January, 1977, to December, 1990, 311 patients with stage IB-IIA cervix carcinoma were treated at the Radiotherapy Department of the University of Turin. The distribution by stage was: 232 T1b (74.6%) and 79 T2a (25.4%). One hundred and eighty-nine patients (77% T1b-23% T2a) underwent preoperative radiotherapy, 63 patients (58% T1b-42% T2a) radiotherapy alone and 59 (85% T1b-15% T2a) postoperative radiotherapy. The first group of patients was treated according to three treatment protocols, based on different surgical procedures. During the median follow-up period of 86 months (82.6% of the patients underwent a minimum 3-year follow-up), 55 locoregional relapses (17%) and 21 extrapelvic metastases (7%) were observed. The 5-year NED survival rate and local control was 80%. The prognostic factors which significantly influenced survival in the univariate analysis, were: disease stage (p < .01), age (p < .05), the period between first symptom and therapy (p = .01), treatment protocols (radiotherapy combined with surgery versus radiation therapy alone: p < .05), residual disease after brachytherapy (p < .01), nodal status (p < .00001). In the radiotherapy alone group, the total dose influence on survival was not statistically significant (p = .12). In our series, histology and surgical procedures did not seem to influence prognosis. In the multivariate analysis, treatment protocol, age and residual disease after brachytherapy did not influence the prognosis, whereas the total dose of radiotherapy, pain (as first symptom) and Wertheim-Meigs surgery approach are prognostic factors. Severe late-effects were 17: 13 in the radiotherapy plus surgery protocol and 4 in the radiotherapy alone protocol. The incidence of major complications seems to correlate with surgical impact.