Drinking water quality: an in vitro approach for the assessment of cytotoxic and genotoxic load in water sampled along distribution system

An in vitro approach was performed to assess the quality of drinking water collected at two treatment/distribution networks located near the source (Plant #1) and the mouth of River Po (Plant #2). The water was sampled at different points of each distribution network, before (raw water) and after the chlorine dioxide disinfection, and in two points of the pipeline system to evaluate the influence of the distribution system on the amount and quality of the disinfection by-product. Cytotoxicity and genotoxicity of water extracts were evaluated in human peripheral lymphocytes and Hep-G2 cells by the use of the micronucleus (MN) test and Comet assay. Raw water samples of both plants induced cytotoxic effects, but not the increases of MN frequency in Hep-G2 cells and in human lymphocytes. Increases of DNA damage in human leukocytes was detected by Comet assay for raw water of Plant #2 at concentration > or = 0.25 Leq/mL. The disinfection process generally has reduced the toxicity of water samples, even if potential direct DNA-damaging compounds have been detectable in drinking water samples. The proposal approach, if currently used together with chemical analysis, can contribute to improve the monitoring drinking water.

Iron, zinc and aluminium ferritin content of hemodialysis hyperferritinemic patients: comparison with other hyperferritinemic clinical conditions and normoferritinemic blood donors

The present study describes the specific content of ferritin iron, zinc and aluminium in four different groups: 1) hemodialysis hyperferritinemic patients; 2) septic patients; 3) iron overloaded patients with hematologic diseases; and 4) blood donors. In all four groups high levels of aluminium and zinc were found in addition to those of iron. However, the sum of the ferritin ions of the control group is significantly higher than that of the other three groups. Furthermore, while ferritin of hemodialysis patients has the same molecular ratio of metal ions as control group (high Al content vs. Fe and Zn), a lower Al/Fe ratio is found both in septic and hematological patients. The results of the present paper might help to explain the high percentage of hyperferritinemia found in hemodialysis patients also in presence of low transferrin saturation and in absence of inflammatory markers. Moreover, the high content of ions other than iron in the ferritin core leads us to believe that ferritin is not only an iron storage protein but rather a regulator of redox active ions.

Recurrent infections in patients with nickel allergic hypersensitivity

Nickel (Ni) is the most common contact allergen among the general population in the industrialized world. Ni has been shown to exhibit immunomodulatory, if not immunotoxic, effects in several experiments conducted on humans and on rodents. This study tests the incidence of different infectious diseases in 100 patients with Ni hypersensitivity and compares it to data from 100 healthy volunteers. One hundred subjects with Ni hypersensitivity were enrolled. A group of 100 matched healthy volunteers with negative European standard patch test were enrolled as healthy controls. In patients with Ni hypersensitivity a higher incidence of recurrent herpes labialis (RHL), urinary tract infections (RUTI), genital candidiasis, and upper respiratory tract infections (RURTI) was detected. Fifteen patients with nickel allergic hypersensitivity (NAH) followed a Ni-poor diet. After a one-year diet a net reduction of incidence of RHL was found. Indeed, the number of episodes of RHL per year decreased from 6 +/- 2.75 to 2.4 +/- 1.2. Conversely, among the matched control group with NAH following a normal daily dietary nickel intake the RHL number did not show any statistically significant changes (6.1 +/- 1.7 vs 6 +/- 1.5 ). In conclusion, our study demonstrates a higher incidence of recurrent infections among patients with NAH. A low-Ni diet reduces the number of RHL episodes per year.

Effect of gliclazide immobilization into layered double hydroxide on drug release

This paper deals with a new hydrotalcite-like compound used as a matrix to improve dissolution rate of the poorly water-soluble drug gliclazide and to administer at the same time micro- and oligo-elements useful to improve insulin performance. Gliclazide is a second-generation sulfonylurea compound used in the treatment of type II diabetes mellitus. As a consequence of the poor water solubility, its absorption is limited. Thus, a new hydrotalcite-like compound containing Zinc and Chromium, micronutrients directly involved in the physiology of insulin and in the carbohydrate, lipid and protein metabolism, was synthesized. The gliclazide-hydrotalcite-like clay nanohybrid was prepared via ion-exchange in its nitrate form and was characterized by inductively coupled plasma-optical emission spectrometry and thermogravimetric analysis. The drug loading resulted in 42.9% (w/w). As a consequence of the intercalation, the interlayer distance of the host increased from 0.89 nm (interlayer distance of nitrate form) to 1.5 nm. The intercalation product was submitted to solubility measurements and in vitro dissolution test. A remarkable improvement of the apparent solubility and dissolution rate in comparison to the crystalline drug was observed in acid fluids (pH 1.2 and 3). The presence of chromium and zinc cations was also found in the medium. These results showed that the hybrid nanostructure could represent a promising system to improve drug dissolution rate and to release cations involved in the performance of insulin.

A combinated approach to investigate the biochemistry and hydrography of a shallow bay in the south Adriatic Sea: the Gulf of Manfredonia (Italy)

The main goal of this study is to understand the hydrological and biochemical set up and processes of a marine coastal area located in the western side of the south Adriatic sea (the gulf of Manfredonia) by the use of both satellite images and in situ investigations A water sampling in the gulf of Manfredonia was performed at 18 fixed stations in June 2003; physico-chemical and biological parameters (temperature, salinity, dissolved oxygen and fluorescence) were measured along the water column and water samples were collected to analyse dissolved nutrients (ammonia, nitrite, nitrate, phosphate and silicate), total nutrients (nitrogen and phosphorus), chlorophyll a and total suspended solids. Surface spatial distributions of field collected data were examined to characterize biochemical and hydrographic conditions of the Gulf of Manfredonia and these results were related with the remote sensing analysis data. Remote sensed data (obtained by Landsat 7 TM and Modis Terra) were processed to obtain maps of chlorophyll a, temperature and optical characteristics of the gulf; these maps were compared to in situ data. From physico-chemical measurements no stratification was observed in the water column except for the south-eastern area. High concentrations of silicate and ammonia were observed in the northern zone of the gulf, while nitrate, phosphate, chlorophyll a and total suspended solids distributions showed higher values in the central coastal zone. These results were confirmed by remote sensing analysis; Modis elaboration showed a distribution with higher concentrations of chlorophyll a near the coast and Landsat images highlighted the extension of the surrounding agricultural areas crossed by the two main rivers which discharge into the gulf. The integration between field data with the remote sensing analysis showed to be a valid support in coastal zone management.

Plasma adrenomedullin and endothelin-1 levels are reduced and Raynaud's phenomenon improved by daily tadalafil administration in male patients with systemic sclerosis

The aim of our study is to evaluate in Systemic Sclerosis (SSc) male patients the tadalafil effects on Raynaud's phenomenon and on AM and ET-1 plasma levels. In an open-label study 20 consecutive male patients with SSc were enrolled and received 10 mg of tadalafil daily for 12 weeks. The primary endpoint was the subjective reduction of frequency and duration of Raynaud's attacks measured with a 10-point Raynaud's Condition Score; the secondary aim was to modify Adrenomedullin (AM) and Endothelin-1 (ET-1) plasma levels. After the treatment Raynaud's phenomenon was improved by once-daily tadalafil (decrease of mean number of Raynaud's attacks and of Raynaud's Condition Score) and plasma AM and ET-1 levels decreased. The results of our study lead us to postulate the beneficial effect of adding long term inhibition of Phosphodiesterase type 5 to Systemic Sclerosis' therapy.

Evaluation of postnatal growth in very low birth weight infants: a neonatologist's dilemma

Very low birth weight (VLBW) infants' survival has greatly increased in the last few decades thanks to the improvement in obstetrical and neonatal care. The correct evaluation of postnatal growth of these babies is nowadays of primary concern, although the definitions of their optimal nutrition and postnatal growth pattern are still controversial. It is known that VLBW infants have a specific postnatal growth pattern markedly different from that of higher birthweight full-term infants. Prospective longitudinal studies are needed to trace VLBW infants growth charts for weight, length and head circumference. These charts will be a useful tool to monitor postnatal growth of VLBW infants both during hospitalisation and after discharge, up to 2 or 3 years of age. A useful tool in VLBW infants growth evaluation could also be absolute velocity charts that, allowing a better and earlier identification of growth anomalies, could permit the observation of phenomena not yet visible on distance charts. Very low birth weight (VLBW) infants' survival has greatly increased in the last few decades thanks to the improvement in obstetrical and neonatal care. These neonates represent about 1-1.5% of all live born infants in developed countries (1) and they constitute the large majority of the population in neonatal intensive care units (NICUs). For this reason, the correct evaluation of their postnatal growth is of primary concern nowadays although the definitions of optimal nutrition and postnatal growth pattern are still controversial.

Involvement of Corticotrophin-Releasing Factor and Orexin-A in Chronic Migraine and Medication-Overuse Headache: Findings From Cerebrospinal Fluid

The study set out to investigate the role of corticotrophin-releasing factor (CRF) and orexin-A in chronic migraine (CM) and medication-overuse headache (MOH). Twenty-seven patients affected by CM and 30 with MOH were enrolled. Control CSF specimens were obtained from 20 age-matched subjects who underwent lumbar puncture for diagnostic purposes, and in all of them CSF and blood tests excluded central nervous system or systemic diseases. Orexin-A and CRF were determined by radioimmunoassay methods. Significantly higher levels of orexin-A and CRF were found in the CSF of MOH and to a lesser extent in patients with CM compared with control subjects (orexin-A: P < 0.001 and P < 0.02; CRF: P < 0.002 and P < 0.0003). A significant positive correlation was also found between CSF orexin-A values and those of CRF ( R = 0.71; P < 0.0008), monthly drug intake group ( R = 0.39; P < 0.03) and scores of a self-completion 10-item instrument to measure dependence upon a variety of substances, the Leeds Dependence Questionnaire (LDQ) in the MOH group ( R = 0.68; P < 0.0003). The significantly higher orexin-A levels found in CM and MOH can be interpreted as a compensatory response to chronic head pain or, alternatively, as an expression of hypothalamic response to stress due to chronic pain. A potential role for orexin-A in driving drug seeking in MOH patients through activation of stress pathways in the brain can also be hypothesized.

CSF phosporylated TAU protein levels correlate with cerebral glucose metabolism assessed with PET in Alzheimer's disease

One major goal of drug development would be the establishment of biomarkers as objective indicators of normal biological and pathogenetic processes, or pharmacological response to a therapeutic intervention. A potential approach is to investigate proteins in CSF linked to key neuropathological features of Alzheimer's disease (AD). Recently CSF phosphorylated-Tau (p-Tau) levels have been reported to reflect neurofibrillary changes within the brain of patients with AD, however the use of serial CSF investigations in order to monitor the disease progression is not applicable. PET with FDG reveals characteristic patterns in AD patients, however so far no correlation between in vivo metabolic information and pathological features has been reported. In the present study, we tested whether CSF Tau levels correlate with metabolic rate for glucose consumption in a cohort of 28 AD patients. We found a statistically significative correlation between both CSF total and p-TAU protein and relative metabolic indexes obtained from 18FDG-PET scans in parietal, temporal and occipital lobes bilaterally. These results indicate the existence of a correlation between impairment of cerebral metabolism, estimated throughout FDG-PET, and CSF Tau protein levels.

Preliminary Results of Anaconda™ Aortic Endografts: A Single Center Study

OBJECTIVE

To evaluate the peri-operative results of Anaconda endograft in the first 49 cases treated in a single centre.

METHODS

The study was carried out prospectively on cases of infrarenal abdominal aortic aneurysm (AAA) treated with Anaconda endograft. The characteristics of the proximal aortic neck and of the iliac access vessels were considered. The following operative results were assessed: the main body oversizing, the need to correct the positioning of the main body, the use of iliac extensions, the use of ballooning, the covering of patent hypogastric arteries, the presence of endoleaks and the need for conversion. Peri-operative (30 days) mortality and morbidity were also considered.

RESULTS

Of the 49 cases treated, 44 were males with a mean age of 73 years (range: 55-89 yrs; SD+/-7 yrs). The mean diameter of the AAA was 56 mm (range 45-91 mm; SD+/-11); 4 cases had common iliac aneurysms with a diameter >3 cm. The mean neck diameter and length were 23 mm (range 19-28 mm; SD+/-3) and 25 mm (range 15-50 mm; SD+/-10) respectively. An aortic neck angle between 40 degrees and 70 degrees was present in 10 cases (20%) (mean 58 degrees; SD+/-15 degrees), and 20 cases (41%) had iliac tortuosity with an angle greater than 60 degrees (mean 85 degrees; SD+/-25 degrees). There were no cases of conversion or intra-operative death. One (2%) peri-operative death occurred, for reasons not related to the endograft. There were two cases of iliac limb thrombosis. CT at one month showed 12 cases (25%) of type II endoleak. There were no cases of type I or type III endoleaks.

CONCLUSIONS

The preliminary data of this series demonstrates that the Anaconda endograft has good peri-operative results in the treatment of infrarenal AAAs with a neck length not less than 15 mm.

Improvement of dissolution rate of piroxicam by inclusion into MCM-41 mesoporous silicate

The aim of the present paper was the use of mesoporous silicate MCM-41 to increase the dissolution rate of piroxicam, a non-steroidal anti-inflammatory drug-class II of the Biopharmaceutic Classification System. The inclusion/adsorption compound of piroxicam in MCM-41 was obtained with a drug loading of about 14%. X-ray powder diffraction and differential scanning calorimetry (DSC) revealed the presence of piroxicam not arranged in crystalline form and FT-IR spectroscopy showed the presence of light interactions (hydrogen bonds) between the silicate silanols and the drug. The decrease of Brunauer, Emmett and Teller (B.E.T.) specific surface area and pore volume between free MCM-41 and the inclusion/adsorption compound was a prove of the presence of piroxicam inside the mesopores. The inclusion compound was submitted to in vitro dissolution tests and a remarkable dissolution rate improvement was observed in comparison to the crystalline drug in all tested conditions. The dissolution profile at pH 1.2 was comparable to that of the marketed product Brexin, a formulation with rapid analgesic effect onset. The improvement of dissolution rate is due to both the lack of drug in the crystalline form and to the extremely large surface area of the siliceous support. Physical stability tests of the free drug and the inclusion/adsorption complex were conducted as well over one month storage at 40 degrees C at different relative humidity.

Proposal of a flexible structural-organizing model for the Intensive Care Units

BACKGROUND

The aim of this study was to verify the capability of the Italian Group for the Evaluation of Intervention in Intensive Care Medicine (Gruppo Italiano Valutazione Interventi in Terapia Intensiva, GiViTI) Intensive Care Units (ICUs) in providing high level care (HLC) and to develop a flexible organiziational model, allowing for different levels of care in each ICU.

METHODS

Once the number of active beds, personnel and technology of each ICU were determined, we computed whether the available bed number and all available resources could provide HLC according to international standards. For ICUs lacking staff or equipment for safe HLC in all declared beds, we calculated the best combination between HLC and observation/monitoring beds with less need for nurses and technology (low level of care, LLC) in order to optimise the utilization of each bed. We also investigated the work organisation of physicians and nurses in these units.

RESULTS

There are 2 070 available beds in the 293 GiViTI ICUs. To provide HLC according to international criteria, the beds would decrease to 80.9%, because 144 ICUs do not have nurses or equipment to provide HLC in each bed. In order to maximize the suitable use of available resources, these ICUs would have to reduce the HLC bed number using the regained nurse workload for LLC. Because of this, the total number of HLC beds would further decrease to 65.9% of all declared beds. During Sundays and holidays, the bed/doctor and the bed/nurse ratios increase in most ICUs.

CONCLUSION

To maximize the staff and equipment resources available, the bed numbers of a general ICU providing HLC must vary, even daily, according to the level of care provided. This level is not always high for all patients present. Applying this organizing model to each ICU, we could have enough flexibility to face the different demands for assistance if the ICU is built as a large open space to achieve the best clinical model and use of resources.

Common carotid agenesis and internal carotid stenting

Agenesis of common carotid artery is rare and no report of stenting procedures (carotid artery stenting) for associated stenosis of the internal carotid have been published. We report a case of internal carotid stenosis associated with this anomaly. A 73-year-old male with left internal carotid artery originating from the arch, with significant stenosis, was referred to us. Wallstent was deployed with success. Carotid artery stenting should be reserved to uncomplicated arch anatomy and plaques with low fragmentation risk.

Antitumor activity of the combination of synthetic retinoid ST1926 and cisplatin in ovarian carcinoma models

BACKGROUND

The novel adamantyl retinoid ST1926 is a potent inducer of apoptosis in ovarian carcinoma cells. Since the pro-apoptotic effect is associated with activation of p53, in this study we have investigated the efficacy of combination of ST1926 with cisplatin, a DNA-damaging agent that is known to induce p53-dependent apoptosis.

MATERIALS AND METHODS

The efficacy of ST1926 and its combination with cisplatin was evaluated in human ovarian carcinoma models, including resistant tumors.

RESULTS

Oral treatment with ST1926 alone caused a marginal tumor growth inhibition (<50%), but the combination with cisplatin resulted in an improved efficacy, most evident in terms of tumor growth delay without a substantial increase of toxicity. The combination therapy achieved the best effects against the HOC18 ovarian carcinoma tumor, resulting in an appreciable number of animals without evidence of disease at the end of the experiment. In contrast to the marginal effect of ST1926 alone against the subcutaneous-growing tumors, loco-regional (intraperitoneal) treatment achieved a marked increase of survival of animals with ascitic IGROV-1 tumor.

CONCLUSIONS

The present results document the efficacy of the combination of cisplatin with ST1926 and provide a rational basis for the design of novel, well-tolerated platinum-based treatment approaches in human ovarian carcinoma.

Lack of association between mtDNA haplogroups and Alzheimer’s disease in Tuscany

Mitochondrial DNA (mtDNA) haplogroup-specific polymorphisms were previously related to several neurodegenerative diseases, including Alzheimer's disease (AD). However, the precise role of mtDNA haplogroups in the neurodegenerative cascade leading to AD is still unclear. In this work we have genotyped predefined European mtDNA haplogroups in 209 patients with AD and 191 matched controls. In order to minimise the risk of "genetic contamination", which could lead to false associations between gene markers and disease, we were careful to enrol in the study only patients and controls of clear Tuscan origin (with at least three generations of Tuscanborn relatives). The frequency of the haplogroups did not differ between the two groups, and no correlation with gender, ApoE genotype, age of onset or disease status was observed. Further studies will be required to define the contribution of mtDNA haplogroups, if any, to the pathogenesis of AD. A correct population selection, in order to minimise the risk of genetic contamination, is essential in these studies.

Neoadjuvant chemotherapy (CT) and postoperative chemoradiation (PCRT) in locally advanced, resectable, gastric cancer (LAGC). Preliminary results of a pilot study

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Background: Curative surgery is achieved in fewer than 50% of patients (pts) in LAGC. PCRT has shown significant improvement in disease control and survival but a limited impact on metastatic disease. To improve this results, a combined modality approach, including IORT, was planned. Methods: Pts with resectable LAGC (stage T3–4 and/or N+) were eligible. EGDS, EUS, abdomen CT were used for staging. 3 cycles of ECF (Epirubicin 50mg/mq, q 3wks; Cisplatin 60mg/mq, q 3wks and 21-day c.i. 5-FU 200mg/mq/day) were planned before radical surgery. IORT (10–15 Gy) included the high risk area defined at surgery. Postop RT included gastric area, anastomosis, duodenal stump and draining lymph node stations. RT (41.4–45 Gy in 23–25 fractions) and concurrent c.i. 5-FU (200 mg/mq/day) were administered. An oral caloric intake >= 1500 Kcal was provided. Results: From June 2001 to December 2006, 22 pts (13 M and 9 F), median age 64 yrs (41–74), with uT3N1 (21pts) and uT2N1 (1pt), entered the study. Tumor location was proximal in 10, lower in 8 and middle in 4 pts, respectively. All pts underwent the planned neoadjuvant ECF with a median of 3 cycles (range 3–5). Toxicity was moderate (<= grade 3) without toxic deaths: nausea and vomiting in 3%, mucositis in 3%, hematological in 7%. Twenty/22 pts underwent surgery (in progress in 2 pts) and 15 (75%) had R0 resection. Tumor downstaging was reported in 9/20 (45%) pts (8 pT2, 1pT1). IORT with 12.5 Gy (10–15 Gy) was given to 12 pts and 12 pts had PCRT. Eight pts were excluded from PCRT for postop complications (2 pts), disease progression (3 pts) or pN3 (3 pts). All 12 pts completed RT with a median dose of 41.4 Gy (41.4–56Gy), but 3 (25%) required RT interruption and 5 pts (40%) also definitive 5-FU interruption (overall PCRT compliance of 60%). Major toxicity from PCRT consisted of G3 asthenia and anorexia, requiring parenteral nutrition. Conclusions: Neoadjuvant CT confirmed feasible in LAGC and resulted in a substantial downstaging with a favourable R0 resection rate. Combined modality approach with IORT and PCRT appears attractive, but limited compliance to PCRT was observed. A definitive evaluation and data on disease control and survival will be reported.

No significant financial relationships to disclose.

TROP2 is a major determinant of growth and metastatic spreading of human cancer

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Background: The TROP2 gene encodes a transmembrane calcium signal transducer, involved in the regulation of cell- cell adhesion. Methods: To identify the role of Trop-2 in transformed cells, we studied its expression pattern and function by DNA array and SAGE analysis, Northern and Western blotting, flow cytometry, confocal microscopy and IHC in experimental systems and in man. Overexpression or down-regulation of Trop-2 and directed mutagenesis were used to identify its role in tumor growth and metastasis in vivo. Results: DNA microarray, EST, SAGE, RT-PCR and Northern blot analysis of human tumors revealed expression of the TROP2 gene in most cancers. IHC analysis of human tumors (1755 cases) revealed a corresponding overexpression of Trop-2 protein. Trop-2 potently stimulated the growth of tumor cells, whereas TROP2 siRNA inhibited it. Deletion of the cytoplasmic region of Trop-2 abolished the growth stimulatory capacity, as did mutagenesis of the S303 PKC phosphorylation site. Proteomic analysis showed that multiple PKC isoforms partecipate to the Trop-2 signaling network. In vivo imaging showed dynamic colocalization of PKCs and Trop-2 in vivo in membrane ruffles and podosomes. DN PKCs and siRNA abolished Trop-2-induced growth. Strikingly, comparative global gene expression analysis revealed that TROP2 was the only gene up-regulated across different metastatic models, tumor types and animal species. IHC analysis revealed a dramatic up-regulation in metastases from colon, stomach, breast and ovary tumors in man. To assess if Trop-2 may play a causal role in metastatic spreading, TROP2-transfected KM12SM colon cancer cells were orthotopically injected in nude mice. TROP2-overexpressing transfectants demonstrated increased metastatic potential to the liver. Deletion of the HIKE domain of Trop-2 severely diminished, whereas that of the whole cytoplasmic region vastly increased metastatic diffusion, indicating the existence of both metastatic enhancers and silencers in the Trop-2 cytoplasmic tail. Conclusions: Our findings demonstrate that Trop-2 is a novel, widespread, stimulator of human cancer growth and a unique marker and causal factor of metastatic cancer, and candidate Trop-2 as a target of novel diagnostic and therapeutic procedures.

No significant financial relationships to disclose.

Do non-steroidal anti-inflammatory drugs influence the steroid hormone milieu in male athletes?

Prostaglandins modulate the hypothalamus-pituitary-adrenal and -gonadal axis pathways. We explored the effects of a single course of treatment with acetylsalicylic acid (ASA), an inhibitor of prostaglandin synthesis, on the steroid milieu in athletes. Morning plasma cortisol (F), dehydroepiandrosterone sulphate, free-testosterone, testosterone (T) and their ratios were evaluated before and after the administration of either ASA or placebo in twelve male athletes, when affected by minor musculoskeletal trauma and, as control, after a five/six week wash-out in healthy conditions respectively. One tablet of ASA (800 mg), or placebo, was administered two times daily for 10 days during treatment. All the volunteers suspended exercise training during treatment. The results revealed that compared to placebo, plasma F was significantly lower after ASA treatment (p = 0.023). Furthermore, the comparison of hormone's absolute and percentage of variations (Delta and Delta%) between ASA and placebo treatment showed significant differences respectively for DeltaF (p = 0.045), for DeltaT (p = 0.047), for DeltaT/F (p = 0.042), for DeltaF% (p = 0.04) and for DeltaT% (p = 0.049). Our data suggest that in comparison to placebo, a short-term ASA treatment is able to influence the plasma steroid milieu in athletes. Due to the observed variability of the individual hormonal patterns, further research is required to substantiate these findings.

Molecular analysis of the pre-BCR complex in a large cohort of patients affected by autosomal-recessive agammaglobulinemia

Autosomal-recessive agammaglobulinemia is a rare and heterogeneous disorder, characterized by early-onset infections, profound hypogammaglobulinemia of all immunoglobulin isotypes and absence of circulating B lymphocytes. To investigate the molecular basis of the disease, 23 patients with early-onset disease and no mutations in Bruton tyrosine kinase, the gene responsible for X-linked agammaglobulinemia, were selected and analyzed by direct sequencing of candidate genes. Two novel mutations in the mu heavy chain (muHC) gene (IGHM) were identified in three patients belonging to two unrelated families. A fourth patient carries a previously described G>A nucleotide substitution at the -1 position of an alternative splice site in IGHM; here, we demonstrate that this mutation is indeed responsible for aberrant splicing. Comparison of bone marrow cytofluorimetric profiles in two patients carrying different mutations in the IGHM gene suggests a genotype-phenotype correlation with the stage at which B-cell development is blocked. Several new single nucleotide polymorphisms (SNPs) both in the muHC and in the lambda5-like/VpreB-coding genes were identified. Two unrelated patients carry compound heterozygous variations in the VpreB1 gene that may be involved in disease ethiology.

Jugular vein-mammary artery fistula after catheterism for hemodialysis: case report

The demographic characteristics of hemodialysis (HD) patients increase the need for the tunneled cuffed permanent catheter (TCC) as a definitive vascular access (VA) for HD. The internal jugular vein is increasingly being used as a route for TCC or temporary catheter placement and can be associated with serious complications. Among them other authors have described arteriovenous fistula (AVF) creation between the common carotid artery and the right jugular vein. We describe a case of an AVF between the right internal jugular vein and the right internal mammary artery. The fistula was detected during the TCC placement in a patient who underwent several jugular and subclavian catheterisms for HD in her clinical history.

Aortic Arch Anomalies are Associated with Increased Risk of Neurological Events in Carotid Stent Procedures

OBJECTIVE

To establish the risk of carotid artery stent (CAS) complications in patients with aortic arch anomalies.

METHODS

In a prospective series of patients submitted to CAS, all cases with arch anomalies were compared with cases with normal arch anatomy (type I, II and III) in order to assess the impact of anatomic characteristics on technical and clinical outcome. Outcome was evaluated in term of neurological complications and technical success.

RESULTS

Of 214 consecutive patients undergoing CAS, 189 (88.3%) had normal arch anatomy and 25 (11.7%) arch anomalies. The arch abnormalities included common origin of brachiocephalic trunk and left common carotid artery in 22 cases (10.2%), separate origin of right subclavian and common carotid in 2 cases (0.9%) and left common carotid agenesis with separate arch origin of internal and external carotid in 1 case (0.5%). The two groups were not different in term of epidemiology and preoperative clinical and morphological characteristics. Technical failure occurred overall in 26 cases (12%) and neurological complication in 14 cases (6.5%). All symptoms were temporary. Technical failure was higher in the arch anomaly group; however the difference did not reach statistical significance (89.6% vs 76.4%, P=0.1). Neurological complications occurred more frequently in the arch anomaly group (20% vs 5.3%, P=0.039). Type of arch was the only variable independently associated with neurological complications (OR=2.01, p=0.026).

CONCLUSION

Aortic arch anomalies are not infrequent and are associated with increased risk of neurological complications. The indication for CAS should be carefully evaluated in these cases.

Managing intensive supports. The attitudes of the health care workers of five Italian Hospitals to institution of CPR and admission to the ICU

AIM

The aim of the paper was to examine the attitudes of the health care workers (HCW) of five Italian Hospitals towards intensive supports, in the hypothesis that a large involvement could help to solve the problems of a more adequate management of vital supports.

METHODS

DESIGN

Hospital HCWs' attitudes towards cardiopulmonary resuscitation (CPR) and ICU admission were investigated using a self-administered questionnaire.

SETTING

five Italian Hospitals.

PARTICIPANTS

all the doctors (MD) and nurses (RN), except those working in obstetrics and in paediatrics.

INTERVENTION

a questionnaire was offered to all eligible participants (4903 HCW) and 2466 analysable files (50.3%) were obtained.

RESULTS

In spite of a great variation in responses among health care givers, the majority of answers is almost in line with current professional and bioethical documents, at both international and national level. This, also when the proposed solution is not clearly recognised by the Italian laws. The statistically significant differences depend on profession (RN/MD), on working area and experiential working characteristics. A strict minority of workers would trust their colleagues in case of hypothetical personal critical illness.

CONCLUSIONS

Our data confirm both the importance of communication among HCW, in order to reach the best decision for every patient, and the great need of continuous educational programs which could compensate for lack of experience and help to create/maintain a strong bioethical and patient-oriented attitude.

Diffusion Tensor Imaging of the Spinal Cord at 1.5 and 3.0 Tesla

PURPOSE

The feasibility of highly resolved diffusion tensor imaging (DTI) of the human cervical spinal cord was tested on a clinical MR unit operating at 3.0 Tesla. DTI parametrical maps and signal-to-noise ratios (SNRs) were compared to results recorded at 1.5 Tesla.

MATERIALS AND METHODS

Eight healthy volunteers and one patient participated in the study. A transverse oriented single-shot ECG-triggered echo-planar imaging (EPI) sequence with double spin-echo diffusion preparation was applied for highly resolved DTI of the spinal cord. The signal yield, fractional anisotropy (FA), and mean diffusivity (MD) were compared for both field strengths. The clinical applicability of the protocol was also tested in one patient with amyotrophic lateral sclerosis (ALS) at 3.0 T.

RESULTS

A mean increase in SNR of 95.7 +/- 4.6 % was found at 3.0 Tesla compared to 1.5 Tesla. Improved quality of the DTI parametrical maps was observed at higher field strength (p < 0.02). Comparable FA and MD (reported in units of 10 (-3) mm (2)/s) values were computed in the dorsal white matter at both field strengths (1.5 T: FA = 0.75 +/- 0.08, MD = 0.84 +/- 0.12, 3.0 T: FA = 0.74 +/- 0.04, MD = 0.93 +/- 0.14). The DTI images exhibited diagnostic image quality in the patient. At the site of the diseased corticospinal tract, a decrease of 46.0 +/- 3.8 % in FA (0.40 +/- 0.03) and an increase of 50.3 +/- 5.6 % in MD (1.40 +/- 0.05) were found in the ALS patient.

CONCLUSION

The 3.0 Tesla field strength provides higher image quality in DTI of the spinal cord compared to 1.5 T. The proposed DTI protocol seems adequate for the assessment of spinal cord diseases.

Carotid Stent Failure: Results of Surgical Rescue

AIM

Little data is available on surgical "rescue" of failed carotid stents (CAS). We have analyzed a series of CAS failures treated by conventional open surgery.

REPORT

Five patients underwent surgery after CAS failure, either electively (4) or as an emergency (1). Elective surgical "rescue" was for stent restenosis (2 cases) or stent misplacement (2 cases). Emergency surgery was performed for entrapment of the protection system in the stent. Surgical rescue was accomplished by perimedial endarterectomy and "en bloc" plaque and stent extraction in 3 cases, and by vein bypass in 2 cases, with no neurological complications.

CONCLUSION

Surgical rescue of failed CAS is effective.

Endovascular and Hybrid Treatment of Recurrent Thoracoabdominal Aneurysms in an HIV-positive Patient

INTRODUCTION

We report a case of staged endovascular and hybrid treatment of recurrent thoracoabdominal aneurysms (TAAA) in a 55-year-old HIV-positive man.

REPORT

A patient, who had previously been surgically treated for a type III TAAA, presented with recurrent aneurysms. The patient was treated by a combination of endovascular and open surgery. Neither visceral nor spinal ischemia were observed.

CONCLUSION

The hybrid treatment of recurrent TAAA could offer lower mortality and morbidity. Patients with HIV/AIDS treated for aortic aneurysms require close follow-up.

Anal canal duplication: a retrospective analysis of 12 cases from two European pediatric surgical departments

Anal canal duplication (ACD) represents an extremely rare intestinal congenital anomaly of unknown origin. Usually evidenced within 2 years of age, nearly 45% of reported cases present associated malformations such as presacral mass, anorectal malformation (ARM) and genitourinary anomalies. The confirmative diagnosis is histopathological, with evidence of an anal mucosal lining (squamous +/- transitional epithelium), surrounded from a smooth muscle coat and anal glands. We review a conjoined experience from two European pediatric surgical departments. From 1970 to 2005, 12 patients were observed, seven in Pescara, Italy (1997-2005), five in Barcelona, Spain (1970-2004) - mean age at diagnosis 17.8 months, range 0-60; M:F = 1:11. Clinical presentation, diagnostic-surgical approach, and complications were reviewed. According to clinical presentation, patients could be divided in three age groups: asymptomatic (mean age 4.8 months, six patients - one with an associated complex genitourinary malformation, one with a presacral mature teratoma, one with ACD evidenced hysthologically on a retroanal mass removed during the correction of an ARM), mildly symptomatic - constipation, mucous discharge (mean age 29.2 months, four patients - one with associated presacral ependymoma and intestinal neuronal dysplasia type B, one with presacral mass) and complicated - perineal abscess, recurrent fistula (mean age 34 months, two patients). In 11 cases a perianal orifice was evident (ten posteriorly located). The pelvic-MRI was the preferred diagnostic tool in Pescara (5/7, with presacral mass in two patients), fistulography in Barcelona (5/5), where one presacral mass was discovered intraoperatively. Eleven patients underwent surgical removal of the ACD (five perineal approach, five posterior sagittal approach, and one PSARP). Histopathological findings confirmed the diagnosis in operated cases (11). The parents of the male patient denied the consent to surgical treatment. The only major post-operative complication was a sphincteric insufficiency (one case), surgically treated. When facing a perianal orifice, attention should be paid to ACD, particularly in female patients with coexistent genitourinary or intestinal malformations. Pelvic US and MRI are the gold standard to evidence the not rarely associated presacral mass. Surgical early removal (mucosectomy or perineal/posterior sagittal approach, depending on length of ACD and associated presacral mass) is warranted, also in asymptomatic patients, because of the risk of inflammatory complications and cancer (the latter reported in literature in adults).

NF-kappaB activity and iNOS expression in monocytes from internal jugular blood of migraine without aura patients during attacks

This study investigated nuclear factor-kappa B (NF-kappaB) activity by electrophoresis mobility gel shift assay and IkappaBalpha expression by Western blot analysis in monocytes obtained from serial samples of internal jugular venous blood taken from seven migraine patients without aura during attacks. Inducible nitric oxide synthase (iNOS) expression was also assessed by reverse transcription-polymerase chain reaction. An increase in NF-kappaB activity peaked 2 h after attack onset. This was accompanied by a transient reduction in IkappaBalpha expression. Up-regulation of iNOS was evident at 4 h, maintained at 6 h and reduced at the end of the attack. These findings substantiate the hypothesis of transitory delayed inflammation, as suggested by the animal model, and suggest the possibility of using therapeutic approaches to target NF-kappaB transcription in the treatment of migraine.

Antimicrobial properties of alpha-MSH and related synthetic melanocortins

The natural antimicrobial peptides are ancient host defense effector molecules, present in organisms across the evolutionary spectrum. Several properties of α-melanocyte stimulating hormone (α-MSH) suggested that it could be a natural antimicrobial peptide. α-MSH is a primordial peptide that appeared during the Paleozoic era, long before adaptive immunity developed and, like natural antimicrobial molecules, is produced by barrier epithelia, immunocytes, and within the central nervous system. α-MSH was discovered to have antimicrobial activity against two representative pathogens, Staphylococcus aureus and Candida albicans. The candidacidal influences of α-MSH appeared to be mediated by increases in cell cyclic adenosine monophosphate (cAMP). The cAMP-inducing capacity of α-MSH likely interferes with the yeast's own regulatory mechanisms of this essential signaling pathway. It is remarkable that this mechanism of action in yeast mimics the influences of α-MSH in mammalian cells in which the peptide binds to G-protein-linked melanocortin receptors, activates adenylyl cyclase, and increases cAMP. When considering that most of the natural antimicrobial peptides enhance the local inflammatory reaction, the anti-inflammatory and antipyretic effects of α-MSH confer unique properties to this molecule relative to other natural antimicrobial molecules. Synthetic derivatives, chemically stable and resistant to enzymatic degradation, could form the basis for novel therapies that combine anti-inflammatory and antimicrobial properties.