[Role of antibiotic therapy in diabetic foot management]

Antibiotic therapy is not the most important component in diabetic foot ulcer management which should be based on weight bearing avoidance and arterial revascularization. However antibiotic therapy is necessary in presence of extensive deep involvement or systemic signs of infection. Initial antimicrobial treatment depends on bacteria supposed origin. For patients not coming from hospital, the initial choice antibiotic is an amoxicillin/clavulanate agent because it offers optimal coverage for most pathogens involved in those diabetic foot lesions (gram positive cocci, gram negative and anaerobic organisms). For patients at high risk to be infected with nosocomially acquired pathogens, the initial antibiotic therapy must cover methicillin-resistant staphylococci, resistant pseudomonas aeruginosa or enterobacteriae. In all cases, when definitive reliable cultures are reported, initial antibiotic regimens should be revised to narrow the coverage to specific pathogens. In presence of osteomyelitis, a temporary combination of two agents which are known to reach high bone concentrations is necessary, and antibiotic therapy should be continued for at least two months. In other cases, antibiotic treatment duration depends on clinical out come.

Disseminated Mycobacterium terrae infection in a patient with advanced human immunodeficiency virus disease

Mycobacterium terrae has been rarely implicated in human disease and never in patients infected with human immunodeficiency virus (HIV). We describe an HIV-infected patient with disseminated infection by M. terrae with pulmonary and cutaneous clinical manifestations. M. terrae was isolated from both sputum and urine, and identified by both conventional tests and high-performance liquid chromatography. Clinical and microbiological characteristics of this case are compared with those reported in the literature.

Different types of response to foreign antigens by leech leukocytes

We used morphological and immunocytochemical approaches to characterize and to show the behavior of cells involved in leech inflammatory responses. Leeches were injected with bacterial lipopolysaccharide, fluoresceinated yeasts, sulfate spheres and ciliates (Protozoa). Shortly after injection, migrating cells appeared in the area of injection. The response of the cells occurred in relation to the injected micro or macro antigens. Each injection first provoked a migration of cells towards the non-self material. Afterwards, different responses (degranulation, phagocytosis, encapsulation, melanization) occurred. The migrating cells involved in these series of processes have a similar behavior and are characterized by CD markers of macrophages, NK cells and granulocytes, which are typical of many invertebrates and vertebrates.

Recent techniques for tracing pathways in the central nervous system of developing and adult mammals

Over the last 20 years, the choice of neural tracers has increased manyfold, and includes newly introduced anterograde tracers that allow quantitation of single-axon morphologies, and retrograde tracers that can be combined with intracellular fills for the study of dendritic arbors of neurons which have a specific projection pattern. The combination of several different tracers now permits the comparison of multiple connections in the same animal, both quantitatively and qualitatively. Moreover, the finding of new virus strains, which infect neural cells without killing them, provides a tool for studying multisynaptic connections that participate in a circuit. In this paper, the labeling characteristics, mechanism of transport and advantages/disadvantages of use are discussed for the following recently introduced neural tracers: carbocyanine dyes, fluorescent latex microspheres, fluorescent dextrans, biocytin, dextran amines, Phaseolus vulgaris leucoagglutinin, cholera toxin and viruses. We also suggest the choice of specific tracers, depending on the experimental animal, age and type of connection to be studied, and discuss quantitative methodologies.

[Combined renal and pancreas transplantation as treatment for chronic renal insufficiency of diabetic origin: a series of 50 consecutive transplantations]

STUDY AIM

The aim of this study was to report the results of 50 transplantations of kidney and pancreas performed in the same surgical centre for chronic renal insufficiency of patients with insulino-dependent diabetes.

PATIENTS AND METHOD

From 1989 to 1999, 50 pancreatic transplantations were consecutively performed, 48 combined with a kidney transplantation and two in patients having a functioning kidney graft. The whole pancreas was transplanted in the right iliac fossa through an extraperitoneal approach with duodeno-vesical bypass of exocrine secretion. The kidney was transplanted in the left iliac fossa through a different extraperitoneal approach. Immunosuppression protocol included Azathioprine replaced by Mycophenolate Mofetil since 1996, associated with corticotherapy and Ciclosporine replaced by FK 506 since 1997. Recipients were 32 women and 18 men (mean age: 37 +/- 5 years) treated by insulinotherapy since 23 +/- 6 years and receiving 35 +/- 10 insulin units per day. Peptide C was 0.33 +/- 0.35 mg/mL and serum creatinin 726 +/- 260 mumol/L.

RESULTS

One patient died on d10 from pulmonary artery thrombosis due to unknown drepanocytosis. The most frequent postoperative complications were leakage of duodeno-vesical anastomosis (n = 9) decreasing in frequency with experience, reoperated with preservation of the pancreatic graft in all cases and venous thrombosis of the pancreatic graft (n = 5) with a definitive loss of function. Secondary deaths occurred at 24, 36, 48, 50, 72 months with functioning grafts in two patients. With a mean 5-year follow-up, 44 patients were alive (88% of the whole series), 34 of them with two functional grafts (68% of the whole series) Sixteen pancreas grafts were lost: three by death of the patients, eight from surgical complications, four by rejection and one by transplantectomy of a functional graft.

CONCLUSION

Combined kidney and pancreas transplantation is now very efficient in the treatment of diabetic renal insufficiency. Total pancreas transplantation through an extraperitoneal approach seems to be the safest method. A very strict selection of both donors and recipients is necessary.

Possible roles of extracellular matrix and cytoskeleton in leech body wall muscles

Round circomyarian fibres of leeches are peculiar helical muscles. The fibres are characterized by a lack of junctions, being separated by a thick extracellular matrix, and by scarce end-plates. Even so, the fibres grouped in units show the same degree of contraction. Biochemical, immunocytochemical and ultrastructural studies were performed in order: (a) to demonstrate the presence in the extracellular matrix of fibronectin, collagen type IV and laminin and in the cytoskeleton of desmin and alpha-actinin; (b) to show the possible link of extracellular matrix with the scaffold of intermediate filaments; (c) to evaluate how the extracellular matrix can play a role in the transduction of a signal during contraction-relaxation-superelongation phases.

Histopathological changes after induced injury in leeches

Cells involved in leech inflammatory responses have been characterized by morphological, histochemical, and immunohistochemical methods. Macrophage-like cells, NK-like cells, and granulocytes migrated shortly after injury by pricking with bacterial lipopolysaccharide. Inflammatory responses increased progressively and provoked cell migration to the body wall and then to wound surfaces. Macrophages, NK cells, and granulocytes display similar features and behavior traits in invertebrates and vertebrates.

[Epidemiology of cardio-vascular complications of diabetes]

Epidemiologic studies indicate that hyperglycaemia is responsible for microangiopathy, but that its role in macroangiopathy is more controversial. The relative risk of coronary heart disease (CHD) is 2- to 3-fold greater for diabetic men and 3- to 5-fold greater for diabetic women. It is greater for lower limb arteriopathy (4- to 6-fold) and amputations (10- to 20-fold). Although relative risk is rather constant for different populations, absolute CHD risk depends on other risk factors and the rate of risk in the non-diabetic population. Yet hyperglycaemia is also a causal factor for CHD risk, as demonstrated in cohort studies of Type 1 diabetic patients without diabetic glomerulopathy or any associated CHD risk factors, and especially in diabetic Pima Indians who are genetically protected against hypercholesterolaemia and hypertension. Finally, according to WESDR and UKPDS data, the 10-year risk of cardiovascular mortality increases by 10% for every 1% increase in HbA1c value. Hyperglycaemia can be linked to atherogenesis through several pathways: gluco-oxidation of the extracellular matrix inducing accelerated atherosclerosis, endothelial dysfunction, with a decreased production or inactivation of NO, a thrombogenic tendency, with increase in PAI1, Willebrandt factor and platelet aggregation, and last (but not least) dyslipidaemia subsequent to lipoprotein glycooxidation and increased production of VLDL. Hyperglycaemia was associated with hyperlipoproteinaemia and high plasma triglyceride levels, low plasma HDL levels and high plasma levels of small and dense LDL in three high risk populations: diabetic women, Asian migrants, and the Finnish population of Kupsio. Moreover, impaired glucose tolerance appears to be a CHD risk marker indicative of insulin resistance apparently responsible for atherosclerosis related to an association of CHD risk factors rather than to hyperinsulinaemia. The precedence of insulin resistance over onset of Type 2 diabetes is consistent with the existence, at diagnosis, of clinical complications of atherosclerosis in 20% of cases, as confirmed in the UKPDS study. Finally, though blood glucose control by sulphonylureas and insulin does not appear to be deleterious, these drugs have not shown their efficacy in reducing macrovascular adverse events in Type 2 diabetes, either because the cumulative incidence of events is inadequate (DCCT) or the efficacy of long-term hypoglycaemic effects is not apparent (UKPDS). Moreover, these studies have shown that exogenous as well as endogenous hyperinsulinaemia can lead to increase in weight, with potentially atherogenic android fat distribution. In conclusion, though the correlation between hyperglycaemia and microangiopathy is linear and well-established worldwide (with every 1% increase or decrease in HbA1c resulting in a 30% increase or decrease in microangiopathic events), the same is not true for macroangiopathy, whose prevalence is variable among populations. Thus, CHD mortality due to diabetes is 5-fold lower in France than in Finland, though the Monica study indicates a disparity within the French community.

Propranolol in hypoglycaemia unawareness

The effect of propranolol on the occurrence of hypoglycaemic symptoms was assessed in insulin-dependent diabetic patients with hypoglycaemia unawareness. A double-blind, randomised parallel group study (2:1 fashion) was conducted over 4-week period. The propranolol group (n = 9) received 20 mg (week 1 and 2) and 30 mg (week 3 and 4) twice daily, and the other group (n = 5) a matched placebo for 4 weeks. Patients included had experienced at least two severe hypoglycaemic episodes (coma or seizures) during the previous year, which were characterised by a lack of adrenergic symptoms and required the assistance of another person. The mean number of hypoglycaemias during the study period was similar in both groups (placebo: 13 +/- 2 propranolol: 11 +/- 1), whereas the number of totally asymptomatic hypoglycaemias (< 0.6 g/l) was lower on propranolol than on placebo (3 +/- 1 vs 8 +/- 3, NS) and the number of symptomatic hypoglycaemias was higher (7.2 +/- 2 vs 4.6 +/- 1, NS). Subjective evaluation of treatment by the investigators showed 0/5 successes in the placebo group and 5/9 in the propranolol group (chi2 = 4.32, p = 0.038). The main advantage of propranolol over placebo was an increased incidence of sweating. The ratio [number of hypoglycaemias with sweating/total number of hypoglycaemias] being higher with propranolol (0.28 +/- 0.08 vs 0.06 +/- 0.02, p = 0.06). This pilot study suggests that beta-blockers may be useful in restoring adrenergic symptoms during hypoglycaemia in insulin-dependent diabetic patients without warning symptoms of hypoglycaemia. This beneficial effect seems to be predominantly related to an increase in hypoglycaemia-induced sweating. A larger study is needed to confirm or invalidate these preliminary results.

[Diagnostic criteria for type 2 diabetes]

A new definition of diabetes is just about to be adopted by WHO. The main change concerns the glycemic threshold for diagnosis of diabetes. Its value will decrease from 7.7 mmol/L to 7 mmol/L. This drop is neither the consequence of a methodological change (diabetes remains defined by glycemic values at risk of retinopathy) nor a revision of the gold standard (glycemic value > or = 11 mmol/L at 2 h. post glucose load remains the most accurate criterion for diagnosis). The only purpose of the new definition is to better correlate fasting glycemia with the 2 h. post load value during OGTT. So, the new definition of diabetes with a glycemic value > or = 7 mmol/L will allow to do diagnosis without OGTT. The WHO experts hope that this simplification will improve the earliness of diagnosis and treatment. WHO will propose to categorize 3 groups according to glycemic values: normal values < 6.05 mmol/L, diabetic values > 7 mmol/L, and impaired fasting glucose encompassing values above normal but below the diagnosis cut-off for diabetes (plasma glucose > or = 6.05 mmol/L to < 7.0 mmol/L). This impaired fasting glucose should be considered as a risk factor for diabetes and cardiovascular disease.

[Insulin-dependent diabetes and psychiatric pathology: general clinical and epidemiologic review]

Insulin dependent diabetes mellitus is one of the most common metabolic diseases and affects 150,000 persons in France. To achieve good metabolic control requires a strict daily management of the treatment by the patients themselves. Lack of active involvement can have direct consequences which underlines the importance of a good adherence to the treatment. About 50% of the patients do not obtain adequate metabolic control. The major problem of insulin treatment consists in the repeated occurrence of severe hypoglycemias which may be accompanied by an alteration of the perception of hypoglycaemic signs. On the other hand, when the risk of severe hypoglycaemia is removed, glycosylated haemoglobin levels rise. Permanent hyperglycaemia leads to numerous somatical complications. An extremely dramatic combination of these two types of metabolic unbalance is represented by the brittle diabetes characterised by very frequent and extreme oscillations between hypo and hyperglycaemia. This raises the question of the influence of psychopathological factors on metabolic control and the possibility of improving metabolic control by acting on these factors. Epidemiological studies in diabetic patients have established higher prevalence rates of psychiatric disorders, in particular mood and anxiety disorders. The current prevalence rate of depression was found to be homogeneous in the literature about 11% and life time prevalence rates of major depressive disorders vary between 24% and 29%. The symptom profile of depression in diabetic patients is similar to that in depressed non diabetic psychiatric patients and it has been shown that highly sensitive psychiatric diagnosis of depression can be made among diabetic patients. There is no specific personality pattern in diabetic patients. There seems to be a relationship between metabolic control as defined by glycosylated haemoglobin and psychiatric disorders. Indeed, high levels of glycosylated haemoglobin are found in patients with psychiatric disorders. There seems to be some evidence of an association between blood glucose levels and actual emotional states. Nothing is known about the specificity of the link between psychiatric disorders and insulin-dependent diabetes mellitus. No study has evaluated if the relationship between psychiatric disorders and insulin-dependent diabetes mellitus is due to the disease itself or to the chronic feature of diabetes.

Phobic symptoms, particularly the fear of blood and injury, are associated with poor glycemic control in type I diabetic adults

OBJECTIVE

To investigate the presence of psychiatric disorders and symptoms in type I diabetic patients and to identify those that may influence metabolic control as assessed by GHb levels.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study. One hundred and two consecutive patients with type I diabetes who were regular outpatient visitors of a diabetology department were evaluated. The psychiatric assessments included self-rating questionnaires (General Health Questionnaire and Fear Questionnaire) and observer-rating questionnaires (Montgomery-Asberg Depression Rating Scale [MADRS] and Mini International Interview). Diabetic characteristics were assessed by a structured interview. The observer was blind to the diabetic characteristics of the patients.

RESULTS

Type I diabetic patients with GHb levels > or = 8% had higher psychological distress, scored significantly higher for symptoms of agoraphobia and for fear of blood and injury, had substantially higher levels of anxiety-depression, and performed significantly fewer blood glucose measurements per day. They did not differ in MADRS score from patients with GHb levels < 8%. Multivariate analysis showed that GHb was positively associated with the total score of phobic symptoms and the level of anxiety-depression and inversely associated with the number of daily blood glucose measurements. These factors explained 41% of the variance of GHb. The inverse relationship between GHb and the number of blood glucose measurements per day was mainly influenced by the fear of blood and injury. Patients with high scores for the fear of blood and injury performed fewer blood glucose measurements and had poorer glycemic control; conversely, subjects without fear of blood and injury performed more daily blood glucose measurements and had better glycemic control.

CONCLUSIONS

Phobic symptoms are frequent in patients with type I diabetes. The intensity of phobic symptoms and anxiety-depression negatively influences metabolic control. Increased fear of blood and injury may lead some patients to perform few home blood glucose measurements and may result in poorer glycemic control. This suggests that, by decreasing the fear of blood, injury, and injection, metabolic control may be improved.

Treatment of osteomyelitis in the diabetic foot. Contribution of conservative surgery

OBJECTIVE

To compare the duration of healing of foot ulcers with osteomyelitis in diabetic patients treated by medical treatment versus medical treatment associated with conservative orthopedic surgery.

RESEARCH DESIGN AND METHODS

We entered into the study 67 diabetic patients who had a foot ulcer with osteomyelitis without ischemia requiring a peripheral arterial reconstruction. Thirty-two diabetic patients were included in a first historic group from 1986 to 1993, treated by antibiotic therapy, offloading, and wound care. Thirty-two patients were included from September 1993 to March 1995, treated by the same medical treatment and conservative orthopedic surgery.

RESULTS

The healing rate was 57% in the group treated by the medical treatment alone versus 78% in the surgical group (P < 0.008). The duration of healing was 462 +/- 98 days versus 181 +/- 30 days (P < 0.008).

CONCLUSIONS

Conservative surgery contributes to an increase in the healing rate of foot ulcers with osteomyelitis compared with a medical treatment alone.

Erdheim-Chester disease. Clinical and radiologic characteristics of 59 cases

We made a retrospective evaluation of clinical and radiologic features, treatment, and outcome of Erdheim-Chester disease, a rare non-Langerhans cell histiocytosis. We had 7 patients coming from 3 French teaching hospitals and reviewed 52 cases from the literature. These cases were considered to have Erdheim-Chester disease when they had either typical bone radiographs (symmetrical long bones osteosclerosis) and/or histologic criteria disclosing histiocytic infiltration without features for Langerhans cell histiocytosis (no S-100 protein, no intracytoplasmic Birbeck granules). Ages at diagnosis ranged from 7 to 84 years (mean +/- SD = 53 +/- 14 yr) with a male/female ratio of 33/26. Bone pain was the most frequent clinical sign (28/59), mostly located in the lower limbs. Exophthalmos and diabetes insipidus were found in respectively 16/59 and 17/59 patients. General symptoms (fever, weight loss) and "xanthomas" (mainly located on the eyelids) were present in 11/59 patients. Retroperitoneal involvement was found in 17/59 patients. Skeletal X-ray showed typical osteosclerosis of the diaphysis of the long bones in 45/59 patients. Bone radiographs showed osteolytic lesions of the flat bones (skull, ribs) in 8 patients. Histologic diagnosis was performed after a bone biopsy (28 patients), a retroorbital biopsy (9 patients), and/or a biopsy of the retroperitoneal infiltration or the kidney (11 patients). Six of our 7 patients but only 5 of 52 patients from the literature had the complete histologic criteria, disclosing no Birbeck granules or S-100 immunostaining. In other cases, histologic results usually described a xanthogranulomatous infiltration by foamy histiocytes nested in fibrosis. Treatment was corticotherapy (20/59), chemotherapy (8/59), radiotherapy (6/59), surgery (3/59) and immunotherapy (1 patient). Twenty-two patients died after a mean follow-up of 32 +/- 30 mo (range, 3-120 mo). In conclusion, Erdheim-Chester disease may be confused with Langerhans cell histiocytosis as it sometimes shares the same clinical (exophthalmos, diabetes insipidus) or radiologic (osteolytic lesions) findings. However, it also appears to have distinctive features. Patients are older and have a worse prognosis than those with Langerhans cell histiocytosis, and the diagnosis relies on the association of specific radiologic and histologic findings.

Association between intra-abdominal fat and hypertension in android obese diabetics

We have examined the relationship between visceral fat measured by MRI on a transverse cut through L3, insulin sensitivity assessed by the somatostatin-insulin-glucose test, and arterial blood pressure in 18 obese (11 women and 7 men), non insulin-dependent diabetic patients with android body fat distribution. Extent of visceral fat and insulin sensitivity were not different between women and men. Insulin sensitivity correlated significantly with visceral fat (r = -0.54, p < 0.05) but not with body mass index, L3 subcutaneous fat, or with waist to hip circumference ratio. Moreover, insulin sensitivity was lower in hypertensive compared to normotensive diabetic patients (Steady State Plasma Glucose = 18.8 +/- 3 mmol/l vs 15.1 +/- 3.3 mmol/l p < 0.05) and L3 visceral fat was greater (238 +/- 70 cm2 vs 106 +/- 36 cm2 p < 0.01), although there were no differences in body mass index, L3 subcutaneous fat, waist to hip circumference ratio or age. In conclusion, visceral fat quantity correlates with insulin sensitivity and blood pressure in android obese diabetics with similar morphotype (comparable body mass index and waist to hip circumference ratio).

Are free fatty acids related to plasma plasminogen activator inhibitor 1 in android obesity?

Plasminogen activator inhibitor 1 (PAI-1) levels are elevated in obese insulin-resistant subjects. However the mechanism underlying increased PAI-1 levels is unknown. To determine the impact of diabetes on PAI-1 levels and its possible relationship to insulin resistance, hyperinsulinemic euglycemic clamp studies were performed in nine lean control subjects, nine non-diabetic obese subjects and eight obese patients with NIDDM. Fasting plasma PAI-1 levels were 4.0 to 4.7 fold higher in the two obese groups than in the control group. During the 40 mU/m2 x min insulin infusion, suppression of FFA concentration was correlated with fasting plasma PAI-1 levels in both obese non-diabetic and obese NIDDM subjects. It is concluded that (1) obesity rather than diabetes itself plays a major role for the increased PAI-1 levels in NIDDM; (2) resistance to the antilipolytic effect of insulin, resulting in increased FFA concentrations, may participate in producing elevated PAI-1 levels in android obese subjects.

[Nocturnal hypoglycemia in insulin-dependent diabetics]

OBJECTIVES

Repeated hypoglycaemia has been reported to impair recognition of subsequent hypoglycaemia with a high risk of severe hypoglycaemia. This intensified insulin therapy may be dangerous in insulin-dependent diabetes mellitus (IDDM) patients with unawareness of hypoglycaemia.

METHODS

We assessed the incidence of nocturnal hypoglycaemia and the benefit of an additional bedtime snack in IDDM patients treated by 2 or 3 daily injections. Capillary blood glucose was measured by finger strip at 10 p.m. and plasma venous glycaemia was determined at 0, 2, 4 and 8 a.m.

RESULTS

The study was composed of two phases. In the first phase, patients (n = 93) did not receive any snack at bedtime. Blood glucose fell to 2.75 mmol/l or less in 33%. Among the 40 patients with a 10 p.m. glycaemia of 9 mmol/l or less, 57.5% experienced nocturnal hypoglycaemia vs 15% of the 53 others. The second phase concerned 106 IDD patients. An additional bedtime snack was given when 10 p.m. blood glucose was 9 mmol/l or less. The incidence of hypoglycaemia fell to 32% (14 of 44 IDDM) i.e. a significant benefit of 44% (p < 0.01). However patients who received this additional bedtime snack had a slightly higher 8 a.m. glycaemia than those with 10 p.m. glycaemia at 9 mmol/l or less during the first phase (9.61 +/- 5.67 mmol/l vs 7.75 +/- 4.30 mmol/l) but this result is not significant.

CONCLUSION

Prevention of nocturnal hypoglycaemia may be achieved in IDDM patients by bedtime glucose determination and an additional snack when glycaemia is 9 mmol/l or less.

Suspected postprandial hypoglycemia is associated with beta-adrenergic hypersensitivity and emotional distress

Suspected postprandial (reactive or idiopathic) hypoglycemia is characterized by predominantly adrenergic symptoms appearing after meals rich in carbohydrates and by their rare association with low blood glucose level (< 2.77 mmol/L). We studied heart rate, blood pressure, plasma insulin, C-peptide, and catecholamine responses during a 5-h oral glucose tolerance test in eight patients with suspected postprandial hypoglycemia and eight age-, sex-, and body mass index-matched healthy controls. We also evaluated beta-adrenergic sensitivity by using the isoproterenol sensitivity test. Psychological profile was assessed by the Symptom Checklist (SCL-90R) self-report symptom inventory. Patients with suspected postprandial hypoglycemia had higher beta-adrenergic sensitivity (defined as the dose of isoproterenol required to increase the resting heart rate by 25 beats/min) than controls (mean +/- SEM, 0.8 +/- 0.13 vs. 1.86 +/- 0.25 microgram isoproterenol; P = 0.002). After administration of glucose (75 g) blood glucose, plasma C-peptide, plasma epinephrine, and plasma norepinephrine responses were identical in the two groups, but plasma insulin was higher in the patients (group effect, P = 0.02; group by time interaction, P = 0.0001). Both heart rate and systolic blood pressure were significantly higher (but remained in the normal range) after glucose administration in patients with suspected postprandial hypoglycemia than in controls (group by time interactions, P = 0.004 and 0.0007, respectively). After glucose intake, seven patients had symptoms (palpitations, headache, tremor, generalized sweating, hunger, dizziness, sweating of the palms, flush, nausea, and fatigue), whereas in the control group, one subject reported flush and another palpitations, tremor, and hunger. Analysis of the SCL-90R questionnaire revealed that patients had emotional distress and significantly higher anxiety, somatization, depression, and obsessive-compulsive scores than controls. We may conclude that patients with suspected postprandial hypoglycemia have normal glucose tolerance, increased beta-adrenergic sensitivity, and emotional distress.

Brain metabolism after recurrent insulin induced hypoglycaemic episodes: a PET study

Neuropsychological testing was carried out and the rate of oxygen metabolism in the brain was measured by PET in 15 highly selected patients with type 1 diabetes. The aim was to investigate the impact on the brain of hypoglycaemic comas resulting from insulin treatment. No significant difference was found between nine patients with a history of more than 10 hypoglycaemic comas and six others who denied any history of such events. These data suggest that intensified insulin treatment, although increasing the frequency of hypoglycaemic coma, may not always be harmful for the brain. This may be explained by the limited duration of hypoglycaemic coma induced by conventional insulin treatment.

Penile fracture: an unusual presentation with lacerations of bilateral corpora cavernosa and partial disruption of the urethra

Fracture of the penis is a relatively uncommon form of urologic trauma. We report an unusual case of rupture of both corpora cavernosa associated with partial disruption of the urethra. The patient underwent surgical repair using a Foley catheter as a urethral stent. The patient experienced excellent results with preservation of all functions.

Efficacy of recombinant alpha-interferon 2a and 13-cis-retinoic acid in the treatment of squamous cell carcinoma

BACKGROUND

Recent in vitro and in vivo studies hypothesize a synergistic effect of 13-cis-Retinoic Acid (13cRA) and recombinant alpha-IFN 2a (alpha-IFN) in the treatment of squamous cell carcinoma (SqCC).

PATIENTS AND METHODS

35 patients with SqCC in several sites were treated with 13cRA (0.6-1 mg/kg/day) combined with alpha-IFN (6 x 10(6) I.U./day), continuously for 3 months.

RESULTS

We observed an objective response in 41% of cases (13/32 evaluable patients) with 5 complete and 8 partial responses. Toxicity was mild and always rapidly reversible, with no haematological side effects.

CONCLUSIONS

These preliminary data confirm the feasibility and effectiveness of the combination of 13cRA and alpha-IFN in the therapy of SqCC, also in pre-treated patients, with acceptable toxicity and good compliance.

[The mammographic images of the irradiated breast after conservative therapy for carcinoma]

The mammographic patterns of the patients treated with conservative surgery (quadrantectomy) plus radiotherapy for early breast carcinoma were evaluated to assess treatment-induced changes over time and to improve the differential diagnosis between postirradiation effects and possible tumor recurrences. The mammographic examinations of 79 patients who had undergone quadrantectomy and radiotherapy for breast carcinoma (stage T1-T2) were examined. Skin thickening, edema, fibrosis, distortion and calcifications were considered and classified by comparing the radiographic patterns of the treated breast with those of the contralateral and untreated one. Pattern changes over time were also evaluated and quantified by comparing serial follow-up examinations of the same breast. The percentage of patients with irradiation-induced skin thickening steadily reduced from 100% at 6 months to just above 50% at 4 years. The number of patients showing diffuse irradiation-induced edema decreased from 56% at 6 months to 15% at 1 year and to 0% at 2 years, while the number of cases with localized edema decreased more slowly. The incidence of localized postirradiation breast fibrosis increased to 74% at 4 years, while diffuse fibrosis stabilized around 14%. The patients with no postoperative breast distortion accounted for nearly 33% of the examined cases, while those with minimal distortion approximated 58% and those with gross distortion 9%. In conclusion, the overall results confirmed the value of mammography in the follow-up of the patients treated with QUART.

Effect of intermittent mechanical force on bone tissue in vitro: preliminary results

The structure of metatarsal bones from 18-day-old rats subjected to intermittent mechanical force in organ culture are reported. The application of mechanical force enhances the osteoid thickness and osteoblast number in the periosteum and increases the number of viable osteocytes. These results indicate that (1) the mature bone tissue survives in organ cultures; (2) the mechanical forces better preserve the structure of the osteocytes and stimulate the osteoblasts, and (3) stimulate the osteogenesis.