Recent development in paediatric headache

Headache is one of the most common disorders that occurs during the early, developmental years of life. The present review critically discusses the most recently published reports concerning headache with onset in youngsters, delineating the current status of research in the various fields and outlining areas that require further investigation. Age-related characteristics need to be taken into account with considering the aetiology, diagnosis and treatment of juvenile headache.

"From 0 to 18": what happens to the child and his headache?

Prospective and retrospective studies showed that headaches (migraine and tension-type) with childhood or adolescent onset have age-related characteristics and change over time, with high rate of type changing, remission or improvement. The reasons are unknown. On the other hand, several studies focused on factors that may be precursors of childhood headaches. All these factors may allow a developmental arc to be outlined, defining the natural history of headache from birth to adulthood. Familial (genetic?) influence, hyperreactivity, periodic syndromes and anxiety in childhood are factors that may predict headache onset, against the background of developmental modulation of pain. Biological and psychological factors are probably reciprocally involved, although the link is unclear. The identification of prognostic factors could allow a better framing of headaches and, from an integrated perspective, have important implications as regards clarifying the "nature" of headache.

Vitamin E, lipid profile, and peroxidation in hemodialysis patients

BACKGROUND

Hypertriglyceridemia, lipid peroxidation, and abnormalities of the plasma fatty acid (PUFA) profile may be important risk factors for the atherosclerotic cardiovascular disease in hemodialysis (HD) patients.

METHODS

We investigated how these factors are affected by vitamin E supplementation carried out by oral administration (clinical study 1) and dialysis with vitamin E-modified dialyzers (clinical study 2).

RESULTS

In the HD patients, conditions of relative vitamin E deficiency were observed [lowered vitamin E/triglyceride (TG) ratio] in the presence of high levels of thiobarbituric acid reactants (TBARs) and decreased levels of the polyunsaturated fraction of PUFAs paired with an increased amount of monounsaturated ones (MUFA). In both studies, vitamin E supplementation significantly increased the levels of vitamin E in the plasma without affecting TG levels and provided a partial correction of TBAR levels. Of note was the relative increase in the PUFA fraction, which gave solid proof of an anti(per)oxidant effect of vitamin E supplementation in HD patients. Vitamin E supplementation was also observed to increase plasma levels of reduced glutathione and NOx (NO2 + NO3).

CONCLUSION

The results suggest that vitamin E supplementation may be an effective accessory therapy to combat oxidative stress-lowering lipid peroxidation in HD patients.

Polymeric protein-polyamine conjugates: a new class of uremic toxins affecting erythropoiesis

BACKGROUND

Preliminary evidence on the accumulation of polyamine-protein conjugates (PPCs) was obtained in uremic patients. The presence of these substances in the plasma of hemodialysis (HD) patients was evaluated, and their possible contribution to uremic anemia was investigated by testing the effect of PPC synthesized in vitro on erythroid cell proliferation.

METHODS

Plasma PPC was measured by high-performance liquid chromatography. The in vitro synthesis of PPC from human plasma was carried out by means of the enzyme transglutaminase in the presence of either [3H]-labeled or unlabeled spermidine (SPD). After gel filtration chromatography and detection of the fractions containing [3H]SPD, the latter were tested for their effect on mononuclear bone marrow cell proliferation.

RESULTS

In three out of four patients examined, mainly SPD-protein conjugates (SPD-PC) were observed to accumulate during HD. The levels ranged from 0.17 to 4.93 pmol/mg proteins before dialysis, and these values increased at 30 minutes and at the end of the dialysis up to levels 11.90 pmol/mg. SPD-PC levels in healthy controls were 1.46 +/- 0.82. SPD-PCs synthesized in vitro were recovered in two main fractions showing a molecular weight of> 100 kD (peak 1) and of approximately 30 to 50 kD (peak 3), respectively. The SPD-PC contained in peak 1 showed the greatest inhibitory effect on colony-forming units-erythroid (CFU-E) proliferation without any appreciable effect on burst-forming units-erythroid (BFU-E).

CONCLUSION

We demonstrate that SPD-PC can accumulate in HD patients. These substances, which affect CFU-E proliferation, can be considered as an at yet unrevealed class of uremic toxins contributing to the onset of the uremic anemia.

H2O2-induced block of glycolysis as an active ADP-ribosylation reaction protecting cells from apoptosis

H2O2 treatment on U937 cells leads to the block of glycolytic flux and the inactivation of glyceraldehyde-3-phosphate-dehydrogenase by a posttranslational modification (possibly ADP-ribosylation). Glycolysis spontaneously reactivates after 2 h of recovery from oxidative stress; thereafter cells begin to undergo apoptosis. The specific ADP-ribosylation inhibitor 3-aminobenzamide inhibits the stress-induced inactivation of glyceraldehyde-3-phosphate-dehydrogenase and the block of glycolysis; concomitantly, it anticipates and increases apoptosis. Exogenous block of glycolysis (i.e., by culture in glucose-free medium or with glucose analogs or after NAD depletion), turns the transient block into a stable one: this results in protection from apoptosis, even when downstream cell metabolism is kept active by the addition of pyruvate. All this evidence indicates that the stress-induced block of glycolysis is not the result of a passive oxidative damage, but rather an active cell reaction programmed via ADP-ribosylation for cell self-defense.

Dialysis hypersensitivity: a fading problem?

Allergic-type reactions experienced by patients on chronic hemodialysis are frequently reported in the literature, often related to compounds released during the hemodialysis sessions, in particular ethylene oxide (ETO). In these studies, dialysis patients seem to have higher values of IgE than those observed in a reference population. The aim of our work was to investigate IgE-related parameters of 126 dialysis patients in comparison with two control groups composed of healthy subjects and predialysis patients. IgE values were not significantly different in nonallergic dialysis patients, with a geometric mean (X) of 27.5 kU/l, when compared to healthy controls (X = 38 kU/l) and predialysis subjects (X = 40.7 kU/l). Higher values of IgE (X = 74.1 kU/l) were detected in allergic dialysis patients. However, only 3 patients, all without detectable antibodies against ETO, complained of anaphylactic symptoms during dialysis sessions in a 4-year surveillance period. At variance, 6 symptom-free patients carried IgE antibodies against ETO (range 0.7-15 kU/l), usually with high total IgE. Our results suggest a reduced frequency of hypersensitivity reactions during dialysis sessions. Furthermore, uremia does not alter IgE reactivity in the predialysis period or after long-term maintenance dialysis treatment.

Charge-density-wave transitions in the local-moment magnet Er5Ir4Si10

We report the observation of a new type of charge-density wave (CDW) in the large magnetic-moment rare-earth intermetallic compound, Er5Ir4Si10, which then orders magnetically at low temperatures. Single crystal x-ray diffraction shows the development of a 1D incommensurate CDW at 155 K, which then locks into a purely commensurate state below 55 K. The well-localized Er3+ moments are antiferromagnetically ordered below 2.8 K. We observe very sharp anomalies in the specific heat at 145 and 2.8 K, signifying the bulk nature of these transitions. Our data suggest the coexistence of strongly coupled CDW with local-moment antiferromagnetism in Er5Ir4Si10.

Sleep hygiene and migraine in children and adolescents

Although sleep problems are a common complaint in migraine patients, the role of sleep habits and hygiene as triggering factors of head pain attacks has been poorly analyzed. The aim of this study was to evaluate the effect of modifying bad sleep habits across several headache parameters. Based on our previous study, we selected 70/164 migraineurs (42.7%) with poor sleep hygiene and randomly assigned them to two groups: group A migraineurs, who were instructed to follow directions to improve sleep hygiene; and group B migraineurs who were not given instructions on improving sleep hygiene. Mean duration and frequency of migraine attacks were significantly reduced at follow-up in group A, while group B showed only an insignificant initial reduction. No differences were found in the severity of migraine attacks that seemed related to a higher prevalence of nocturnal symptoms such as bedtime struggles, hypnic jerks, nightmares, and restless sleep. Our study is an alternative approach to the treatment of migraine, i.e. treatment through a simple modification of sleep behavior without recurring to pharmacological treatment.

Overexpression of erythrocyte glutathione S-transferase in uremia and dialysis

BACKGROUND

Overexpression of glutathione S-transferase (GST; EC 2.5. 1.18) has been documented in the erythrocytes of patients with chronic renal failure, and this event may well be of relevance from a clinical standpoint. In fact, it could serve as a marker of uremic toxicity overall, which can contribute to impair the function and survival of the erythrocytes. However, the biochemical details of this phenomenon are poorly understood.

METHODS

In this study, we characterized the expression of GST in erythrocytes of 118 uremic patients under different clinical conditions. The mechanisms responsible for the regulation of protein expression and enzyme activity were investigated in light of different dialysis approaches, oxidative stress, uremic toxins, erythrocyte age, and erythropoietin (EPO) supplementation.

RESULTS

Mean GST activity in uremic patients was highly overexpressed with respect to controls, and this phenomenon was exclusively attributable to an increased expression of GST. Overexpression of GST did not appear to be dependent on oxidative stress and was not influenced by vitamin E supplementation. In the same manner, both erythrocyte age and EPO supplementation apparently did not interfere with the GST concentrations, which were the same in controls and patients. Preliminary experiments suggested that high-molecular weight or protein-bound toxins could play some role in the overexpression of GST.

CONCLUSIONS

GST expression may be a useful marker for the individual accumulation of uremic toxins as well as of the efficiency of new dialysis strategies in removing them.

Biological effects of oxidant stress in haemodialysis: the possible roles of vitamin E

Oxidative stress has been proposed to play a role in many disease states, including cardiovascular and infectious diseases, cancer, diabetes and neurodegenerative pathologies. The fact that these diseases have an increased incidence in uremia, and particularly in dialysis patients, suggests an increased exposure to oxidative stress in this condition. In haemodialysis (HD), the absence of a complete correction of the uremic toxicity together with the untoward effects of the dialysis, malnutrition and the progressive worsening of the clinical condition, can lead to a high susceptibility to oxidative stress by an abnormal production of oxidants - including reactive oxygen species (ROS) and uremic toxins with prooxidant function - and defective antioxidant protection. One of the most investigated biological effects of the oxidative stress in the HD patients is lipid peroxidation in plasma and blood cell membranes. Moreover, we have recently described how abnormal apoptosis in peripheral blood leukocytes is associated with cell oxidative stress (intracellular thiol depletion). Vitamin E, in both in vitro and in vivo conditions, has been proposed to partially correct these effects. In this review we evaluated some features of two new dialysis strategies using an antioxidant approach to the protection against the oxidant stress in HD. Their rationale is based on the emerging role of vitamin E in counteracting some biological effects associated with oxidant stress namely lipid peroxidation and apoptosis. These techniques use: 1) the recirculation of the dialysate through a suspension of vitamin E-enriched liposomes combined with the supplementation by the dialysate with ascorbic acid, this method has been called hemolipodialysis; 2) the coating of the dialysis membrane with vitamin E (vitamin E- modified dialysis membranes). These unconventional approaches to the antioxidant therapy in HD open a widely unexplored and promising field in the evolution of the biomaterials and dialysis quality.

Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study

Migraine with juvenile onset changes over time. The existence of prognostic factors is a point of focus. A strict relationship between migraine or tension-type headache (TTH) and psychiatric factors has been suggested, but the exact role and the influence on evolution of headache is unknown.

OBJECTIVE

To analyze the evolution of migraine and TTH and psychiatric comorbidity (P-Co) from 1988 to 1996.

MATERIAL AND METHOD

100 subjects (40M, 60F; mean age 17.9 years; SD 2.7 years; range 12-26 years) were examined at our Center. The International Headache Society (IHS) criteria were employed. Psychometric tests and clinical interviews aided psychiatric diagnosis (DSM-III-R). SCID (Structured Clinical Interview for DSM-III-R) was employed in 1996. Chi square and logistic regression are used for statistical analysis.

FINDINGS

Migraine and TTH change their clinical characteristics, with a high tendency to remission (mostly in males). The presence of P-Co in 1988 is related to a worsening or unchanging situation in 1996. Headache-free subjects did not present any psychiatric disorders in 1996. Anxiety disorders in 1988 are related to enduring of headache. Migraine shows comorbidity with anxiety disorders and depression.

CONCLUSION

P-Co is a notable problem in clinical practice. Diagnostic, prognostic, and treatment implications require a systematic assessment of P-Co.

Evolution of headache in childhood and adolescence: an 8-year follow-up

OBJECTIVE

Headache is a notable problem in clinical practice and a frequent symptom in childhood and adolescence. The main aim of the present study is to analyze the evolution of migraine and tension headache (TH) using an 8-year follow-up.

METHOD

100 subjects (F60, M40; mean age 17.9; SD 2.6; range 12-26), randomly selected among all patients first seen in 1988 at the Headache Center, were directly contacted. We employed IHS criteria both in 1988 (the data were taken by the clinical charts) and 1996. We took into account changes in headache types and improvement, unchanging, worsening or remission of headache. This analysis was made with regard to gender differences and age at onset of headache, too. The chi-squared test is employed.

FINDINGS

High tendency to remit (34%) or improve (45%) was recorded. A worsening situation was seen in 6% and an unchanging situation in 15%. In 1988, we had 57% migraine without aura (MwoA), 7% migraine with aura, 28% episodic tension-type headache (ETTH), and 8% chronic TH (CTTH). In 1996, we saw 30% MwoA, 2% MwA, 31% ETTH, and 3% CTH. Migraine shows a lower tendency to remit than TH (28.1% vs 44.4%). MwoA persists in the same form in 43.8% and becomes ETH in 26.3%. ETTH persists in the same form in 26.3% and changes in MwoA in 10.7%. Of headache-free subjects, we recorded a high tendency to remit (34%) and improve (95%); 13 were females (21.7%) and 21 were males (52.5%). The course of headache is not related to age at onset.

CONCLUSION

Headache with juvenile onset changes its characteristics over time, with a high tendency to remit (mostly in males) or improve. The implications for pathophysiology and the role of hormonal factors are called into question.

S-nitrosylation of glyceraldehyde-3-phosphate dehydrogenase decreases the enzyme affinity to the erythrocyte membrane

The effects of nitric oxide (NO) or related molecules on the binding of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) to the red blood cell (RBC) membrane were investigated. It was demonstrated that submillimolar concentrations of the NO donor sodium nitroprusside (SNP) not only strongly inactivated GAPDH by S-nitrosylation of the enzyme thiols but also decreased the binding affinity of GAPDH for the RBC membrane. In fact, the incubation with SNP for 60 min at 30 degrees C and at a concentration > 50 microM induced the dissociation of the native GAPDH from the white unsealed membranes (standard ghosts) in a concentration-dependent manner with a partial recovery of the enzyme activity and thiols when SNP concentrations higher of 1 mM were used. Binding experiments under saturating conditions indicate a Ka value for the nitrosylated GAPDH of 3.5 +/- 0.8 x 10(6) M-1, which was more than 50% less than the Ka value of 7.6 +/- 0.6 x 10(6) M-1 observed for the native enzyme. These data were also confirmed in reassociation experiments under nonsaturating conditions. Dithiothreitol (DTT), which at concentrations of less than 1 mM catalyzed the S-nitrosylation of GAPDH and the consequent modification of the binding properties described above, the concentrations higher than 5 mM restored both the enzyme activity and the binding properties. Furthermore, the enzyme-membrane association induced before the incubation step afforded at least partial protection from the loss of titrable thiols and from the inactivation induced either spontaneously or by SNP. Taken together, these data not only confirm the key role of the active site cysteine residues in the catalytic function of GAPDH but also suggest that they may be involved in the NO-dependent regulation of GAPDH binding to the RBC membrane.

Bioreactivity and biocompatibility of a vitamin E-modified multi-layer hemodialysis filter

BACKGROUND

The present study was designed to test the biocompatibility of a new vitamin E-modified multi-layer membrane (CL-E filter), as well as its ability to protect against oxygen free radicals during hemodialysis (HD).

METHODS

We investigated, both in vitro and in vivo, the bioreactivity of the filter with respect to the blood antioxidants and its ability to prevent lipoperoxidation. The effects on the leukocyte respiratory burst were also studied. Cuprammonium rayon was used as a comparison material (CL-S filter).

RESULTS

The in vitro results demonstrated that, under controlled conditions, CL-E is able to preserve blood antioxidants, and particularly vitamin E, from the spontaneous consumption observed in the incubation with CL-S filters and in control incubations. In accordance with this observation, the rate of the oxidative demolition of lipids either in plasma and red blood cells (RBC) or from rat brain homogenate decreased after the exposure to CL-E filters in comparison with the CL-S filter. Moreover, in the absence of any significant cytotoxic effects due to both the types of material studied, the production of oxygen free radicals and nitric oxide (NO) by leukocytes was higher after their in vitro exposure to CL-S, but was quite similar to that of the control leukocytes after exposure to CL-E. In vivo, a one-month treatment with the CL-E filter increased plasma vitamin E by 84.3% with respect to treatment with CL-S; this gain slightly decreased to 68.9% when CL-E treatment was prolonged to three months. In the RBC, vitamin E was found to have increased by 76.7% and 113.4% at one and three months, respectively. Plasma glutathione (GSH) levels determined at three months were significantly increased from 0.10 +/- 0.02 to 0.33 +/- 0.12 mumol/ml, while the erythrocyte GSH was only slightly increased. The leukocyte function estimated as responsiveness to soluble chemical stimuli in CL-S-treated patients was significantly improved both qualitatively and quantitatively after CL-E treatment. The presence of an increased number of mononuclear cells undergoing programmed cell death (apoptosis) in CL-S-treated patients (18.8 +/- 1.7% vs. a control value of 6.5 +/- 2.3%) as well as the apoptogenic effect of their plasma in vitro on U937 cells was significantly corrected after CL-E treatment (mean decrease in apoptotic mononuclear cells at 24 hours of culture, 25.5% and 27.1% at 1 and 3 months, respectively). The anti-apoptogenic effect of CL-E treatment showed a close dependence on the increase in vitamin E in the blood cell compartment.

CONCLUSIONS

This study suggests that this vitamin E-modified membrane can be considered a highly biocompatible material, the antioxidant properties of which can exert a site-specific and timely scavenging function against oxygen free radicals in synergy with a hypostimulatory action on the PMN respiratory burst.

Oxidative damage during hemodialysis using a vitamin-E-modified dialysis membrane: a preliminary characterization

A comparison of the oxyradical exposure during hemodialysis (HD) carried out with vitamin-E-modified cellulose (CL-E) or conventional membranes, studying red blood cell (RBC) and plasma lipoperoxidation and RBC glutathione metabolism, was done. In this preliminary characterization of a new and original approach to the prevention of free radical damage in HD, the results obtained indicate that lipoperoxidation in plasma and RBC is decreased and therefore oxidative damage can be significantly decreased using CL-E dialysis membranes instead of conventional membranes.

Bicarbonate versus lactate buffer in peritoneal dialysis solutions: the beneficial effect on RBC metabolism

OBJECTIVE

Using the erythrocyte as a model for other kinds of cells not directly exposed to peritoneal dialysis (PD) solutions, we investigated the tolerance of the cell metabolism to lactate and bicarbonate buffers.

DESIGN

We studied, in vivo (in two groups of 5 PD patients each) and in vitro, the Embden-Meyerhof pathway (EMP) because it represents a potential target for the unphysiological effects of lactate or bicarbonate buffers. The EMP is the main glucose-utilizing route in the red blood cell (RBC), producing energy and reducing power.

METHODS

The enzymatic activities of the key steps in the glycolytic pathway and the energy charge (EC), determined by the levels of phosphorylated adenine nucleotides, were investigated spectrophotometrically and by high performance liquid chromatography (HPLC) in two groups of patients undergoing lactate (L-group) and bicarbonate (B-group) PD, respectively. The in vitro effects of both bicarbonate and lactate buffers on some EMP enzyme activities and energy production were determined. Cellular pH (pHi) was also investigated.

RESULTS

The B-group showed an EC value near the control levels, while in the L-group a significantly lower EC value was observed (t-test: p < 0.05 vs both B-group and controls). The key enzymes in the EMP, and in particular hexokinase, were higher in the L-versus B-group (p < 0.03 for the comparison of the Hk mean values). As demonstrated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis, the bound form of glyceraldehyde-3-phosphate dehydrogenase (G-3-PD), an inactive form of this EMP enzyme, was significantly higher in the L-group with respect to the B-group (p < 0.004). In the in vitro experiments, high lactate concentrations acutely inhibited the key enzymatic steps of glycolysis, producing a significant decrease in glucose consumption and adenosine triphosphate production. These effects were not observed when bicarbonate was used in the incubations. Both in vivo and in vitro lactate, but not bicarbonate, induce a significant drop in pHi (p < 0.05). Decreased levels of pHi like those observed in the lactate-incubated RBC were demonstrated to be able to inhibit G-3-PD activity (25 +/- 2%) here used as an indicator of the actual decrease in pH.

CONCLUSION

This study provides evidence for a damaging action of lactate with respect to bicarbonate buffer on the RBC metabolism. This condition was demonstrated observing a cell energy depletion, which coincides in vitro with an acute EMP impairment; the lactate accumulation together with the consequent lowering of pHi seem to be responsible for this effect, which was not observed when bicarbonate was used instead of lactate.

Morphological alterations and increased resistance to hemolysis in t-butyl hydroperoxide incubated RBC from elderly subjects

The response of human red blood cells (RBC) to oxidative stress has been studied with the aim to evaluate any difference in the behavior of cells from young and old subjects. Thus, RBC from 5 young (27 +/- 2 years) and 5 old (80 +/- 5 years) individuals have been treated with the organic peroxide t-butyl hydroperoxide (TBHP). The two groups behaved differently: after 4 hrs of incubation in 0.5 mM TBHP, RBC from young donors showed a higher level of hemolysis; instead, RBC from old individuals showed abnormal morphologies, being absent in unstressed RBC, with constriction and budding, which could be identified as poikilocytosis. The same abnormal forms are found in patients with spectrin mutation, leading us to hypothesize that TBHP causes damage to the cytoskeletal spectrin. This suggests that poikilocytosis might be an early stage of red blood cell hemolysis because their presence is associated to a lower level of hemolysis.

Uraemic pruritus is not related to plasma histamine concentrations

Pruritus is a common symptom in uraemic patients and its aetiology is poorly understood, although several factors have been implicated, including high histamine plasma levels. The aim of the study was to evaluate plasma levels of histamine in patients on maintenance haemodialysis in relation to the presence of itching (35 pruritic patients = group A; 50 non-pruritic patients = group B). Furthermore, we compared the values obtained with those of a healthy control group (64 subjects). We observed increased plasma histamine levels in uraemic patients compared with healthy controls. However, no relationship was found between plasma histamine values and itching because groups A and B showed overlapping values and there was no correlation between the intensity of pruritus and plasma histamine concentrations in group A patients. In conclusion, we suggest that there is no evidence for plasma histamine playing a significant part in uraemic pruritus.

[The treatment with intramuscular interferon of female genital condylomatosis: beta-IFN vs alfa-2a-IFN]

The authors have investigated the efficacy of i.m. therapy with interferon (IFN) in the treatment of female genital condylomatosis: 94 consecutive patients underwent a randomized therapy with two different IFNs: beta-IFN and alpha-2A-IFN (3,000.000 UI i.m. on alternate days for 4 weeks). A total and/or partial response was observed in 76.5% of cases (72/94). Observed response was unrelated with used IFN, independently of type and seat of treated lesion. There was only an important difference between the two treatments in the incidence of side-effects and drop-out (31% and 6.3% with alpha-2A-IFN and 14.8% and 2.1% with beta-IFN). Systemic therapy with IFN is a good alternative to destructive techniques in the treatment of HPV-associated pathology of female lower genital tract.

Redox state, antioxidative activity and lipid peroxidation in erythrocytes and plasma of chronic ambulatory peritoneal dialysis patients

Red blood cells and plasma reduced and oxidized glutathione levels, glutathione peroxidase (GSH-Px) activity, thiobarbituric acid reactants (TBAR) of both chronic ambulatory peritoneal dialysis (CAPD) patients and a matched control group were investigated in this study. Oxidized and reduced pyridinic nucleotides in red blood cells (RBC), in which NADPH is a direct expression of hexose monophosphate shunt function, were also studied. The results obtained indicate that RBC and plasma are exposed to oxidative stress in CAPD. This condition is characterized by a decreased GSH/GSSG ratio, particularly evident in RBC as a consequence of the GSSG accumulation. Lipid peroxidation is increased, as indicated by raised TBAR levels, and reduced pyridinic nucleotides are decreased. Increased GSH-Px levels and unmodified or slightly increased GSH content were observed in the RBC but not in plasma, which showed decreased GSH and unmodified peroxidase activity. Peroxidase correlated positively with TBAR levels in the RBC lysates. In a subgroup of patients treated with erythropoietin (vs. untreated patients and controls) no differences were observed in the glutathione-related parameters studied. These data suggest that a mechanism for adaptation to oxidative conditions may be present in CAPD and its effects on RBC integrity are discussed in comparison with the hemodialysis conditions previously studied.

[Beta-interferon treatment of HPV infections of the lower genital tract in women]

In the period 9-1989/12-1991, 47 fertile women affected by genital HPV infection have been treated with i.m. systemic beta-interferon (3 x 10 x 6 UI every other day for 4 weeks). We have noticed 1 case of drop-out (2, 1%). At the short-medium follow-up (> or = 6 months), the therapy has proved to be probably and/or certainly efficacious in 74.4% of cases (35/47). In patients with condylomas in the cervical region, the less respondent part, we have noticed a reaction in 64.3% of cases; in those who have an extra-cervical or diffused HPV infection, in 89.4%. In the patients with complete follow-up, treated with supplementary DTC if necessary, the recovery ratio reached 92.5%. The i.m. systemic therapy with beta-IFN is efficacious in the treatment of genital HPV infections: it is well tolerated and offers the possibility of obtaining a useful "therapeutic integration" with the traditional destructive physical techniques of therapy.

[Usefulness of ultrasonographic techniques in catheterization of the internal jugular vein in patients with chronic heart failure]

BACKGROUND

The right internal jugular vein as a route for right heart catheterization and continuous infusion of drugs is increasingly used in patients with heart failure. Although this approach has several advantages, a small but definite number of unsuccessful vein punctures and/or of complications have been reported. This prospective study was designed to evaluate the usefulness of ultrasound techniques for cannulating internal jugular vein in a series of 310 consecutive patients with chronic heart failure.

METHODS

In all patients a duplex scanning of internal jugular veins was performed before the cannulation. A subgroup of 62 patients was selected for having a "difficult" cannulation according to the following criteria: previous failure of cannulating the vein (3 unsuccessful needle advances); neck abnormalities; severe emphysema and respiratory insufficiency. In these patients a Doppler-guidance system, which consisted of a miniature ultrasound Doppler transducer inserted in a standard 19 gauge needle, was used. The needle was advanced under the skin following the maximal audio signal of the venous flow. The following variables were considered: success rate, number of needle advances to cannulate the vein, time elapsed from local anesthesia and the insertion of the catheter, minor and major complications.

RESULTS

Duplex scanning showed that in 14 patients (4.5%) the right internal jugular vein was occluded or severely narrowed. In all patients the left internal jugular vein, which showed a compensatory dilatation, was successfully cannulated. In 294 of the remaining 296 patients the position of the vein was anterior to the carotid artery at a depth of 4-27 mm below the skin. With respect of the triangle formed by the two heads of the sternocleidomastoid muscle, the vein was central in 35%, medial in 15% and lateral in 60% of cases. Based on duplex scanning ultrasound data, 285 patients underwent internal jugular vein cannulation, which was achieved at the first attempt in 74% and within 3 attempts in 87% of cases. Minor and major complications occurred in 4 (1.4%) and in 1 (0.3%) respectively. By the Doppler guidance system, the cannulation was successfully achieved in 79% of patients at the first attempt and in 98% of patients (61/62) within 3 attempts. In one patient an uneventful puncture of the carotid artery occurred. The time to perform the cannulation was not significantly different using the two approaches (conventional approach: 4.4 +/- 3 minutes; Doppler guidance system: 4.2 +/- 2). Overall the internal jugular vein was successfully cannulated in 307/310 patients (99%).

CONCLUSIONS

Ultrasound techniques provide useful information which facilitates the cannulation of the internal jugular vein in patients with heart failure. The Doppler guidance method allows a rapid and safe cannulation of the vein even in cases that are difficult using the conventional approach.

[Etiology, diagnosis and course of infectious diarrhea in the Liestal canton hospital (5-year retrospective study)]

Between 1987 and 1991 219 patients (1.3% of all hospitalized patients) with acute infectious diarrhea were investigated retrospectively. 52% of the patients were hospitalized and 48% were outpatients. In 55% the inducing diarrhea microorganism could be identified. The most frequently detected pathogens were endemic Salmonella sp. and Campylobacter jejuni (65%). Imported diarrheas (Shigella sp. and parasites) were rare, as only 15% of the patients had a history of travel. All Clostridium difficile infections were associated with antibiotic treatment. The stool examinations for bacteria were positive in 92/160 patients (57%). Stool examinations for occult blood or fecal leukocytes were highly useful in detecting the infectious agent. In 70% of the patients with positive occult blood test or 81% of the patients with fecal leukocytes, an infectious agent in the stool was found. All patients recovered with few complications. 31% of the patients were treated by antibiotics because of septic disease or pathogenic parasites.

Active compression-decompression resuscitation: effect on resuscitation success after in-hospital cardiac arrest

OBJECTIVES

The purpose of this study was to test the hypothesis that active compression-decompression would improve resuscitation success in human subjects after cardiac arrest.

BACKGROUND

Active compression-decompression cardiopulmonary resuscitation is a new method that improves cardiopulmonary hemodynamic function in animal models and humans after cardiac arrest.

METHODS

We conducted a prospective randomized clinical trial in patients with in-hospital cardiac arrest. Patients were assigned to receive standard manual or active compression-decompression cardiopulmonary resuscitation. The primary study end points were spontaneous return of circulation, 24-h survival and survival to hospital discharge.

RESULTS

Fifty-three consecutive patients after cardiac arrest undergoing 64 resuscitation attempts were studied (30 women, 23 men; mean [+/- SD] age 71 +/- 13 years, range 38 to 96). Spontaneous return of circulation was observed in 24 (47%) of 53 patients and was increased in patients receiving active compression-decompression compared with those receiving standard manual cardiopulmonary resuscitation (15 [60%] of 25 vs. 9 [32%] of 28, respectively, p = 0.042); 24-h survival was increased (12 [48%] of 25 vs. 6 [21%] of 28, respectively, p = 0.041); and there was a trend toward improved survival to hospital discharge (6 [24%] of 25 vs. 3 [11%] of 28, respectively, p = 0.198) when active compression-decompression was compared with standard manual cardiopulmonary resuscitation.

CONCLUSIONS

Active compression-decompression cardiopulmonary resuscitation improves return of spontaneous circulation and 24-h survival after in-hospital cardiac arrest. Active compression-decompression cardiopulmonary resuscitation appears to be a beneficial adjunct to standard manual cardiopulmonary resuscitation.

Effect of orthotopic cardiac transplantation on peripheral vascular function in congestive heart failure: influence of cyclosporine therapy

The objective of this study was to examine peripheral vascular function before and after cardiac transplantation and to assess the effect of immunosuppressive therapy on peripheral vascular reactivity. Peripheral vascular function abnormalities present in congestive heart failure may be reversed with cardiac transplantation, but immunosuppressive therapy may alter these changes in the peripheral vasculature. Venous occlusion plethysmography was used to study peripheral vascular function in nine patients with severe congestive heart failure who underwent cardiac transplantation. Forearm blood flow and forearm vascular resistance were measured in patients with congestive heart failure in response to cold stimulation, maximal hyperemia, and hand grip exercise (1) before transplantation; (2) 24 to 36 hours posttransplantation before the commencement of cyclosporine; (3) 6 to 8 days posttransplantation in the presence of therapeutic cyclosporine levels; and (4) 6 weeks posttransplantation. Venous capacitance was also measured. After cardiac transplantation, mean arterial pressure increased and remained elevated. Forearm blood flow initially increased after transplantation but subsequently decreased with cyclosporine. Cold-induced reflex sympathetic activation decreased immediately after transplantation but was significantly enhanced with cyclosporine. The maximal vasodilatory response following ischemic cuff occlusion and with 5 minutes of isometric hand grip exercise increased significantly after transplantation and remained improved at 6 weeks. Thus after cardiac transplantation, peripheral vasodilator function improves and is not altered by cyclosporine. However, with cyclosporine therapy resting forearm vascular resistance increases and reflex sympathetic vasoconstriction is enhanced, suggesting that cyclosporine may potentiate adrenergic-mediated peripheral vasoconstriction and thus may contribute to posttransplant hypertension.

Erythrocyte Na+,K(+)-ATPase properties and adenylate energy charge in normotensives and in essential hypertensives

The activity and some kinetic properties of RBC Na+,K(+)-ATPase (EC 3.6.1.37) were investigated in essential hypertensives (EH; 40 subjects) and normotensives (NT; 20 subjects). A decrease in ouabain-sensitive 86Rb uptake as well as ouabain-sensitive ATPase activity was found in EH. [Na+]i and [K+]i of EH did not show any statistical difference from NT. Na+,K(+)-ATPase showed a reduced Mg2+ activation and the apparent Km value for Mg2+ was 2-fold increased in the EH group. The influence of temperature on the Na+,K(+)-ATPase showed a reduced modulation and a minor activity peak at 37 degrees C in the patients, consequently the calculated activation energy of the enzyme was increased at temperatures lower than 40 degrees C. Increased RBC adenylate energy charge (EC) was observed in EH when compared with NT. A negative correlation between EC and total Na+,K(+)-ATPase activity was found when all subjects were compared and also in both groups, showing a possible pump involvement in the regulation of the RBC metabolic flux in EH. These data provide evidence about some modifications in active Na+,K+ transport and in EC in RBC which allows a further characterization of membrane cation fluxes in EH.

Pursuing usableness and effectiveness in the development of a shared patient centered information system

Our experience supplying a shared patient centred information system is here described, pointing out some of the critical aspects underlying usableness and effectiveness. Between and within unit integration, together with providing each professional role with added value and the special attention to adjust input and information retrieval to the actual needs (often identified only by an assiduous frequentation), has proved to be the essential point. A study case is presented.

Erythrocyte redox state in uremic anemia: effects of hemodialysis and relevance of glutathione metabolism

Reduced and oxidized glutathione and pyridine coenzymes, glutathione-related enzymes and Cu,Zn-superoxide dismutase (Cu,Zn-SOD) were investigated in the RBC of patients with chronic renal failure (CRF) and in age- and sex-matched controls. The effects of hemodialysis (HD) were also studied. A defective RBC redox state was shown in the CRF group based on a decreased GSH/GSSG ratio and NADPH levels. Increased activities of glutathione transferase (GSH-S-T) and Cu,Zn-SOD were observed before HD. Dialysis apparently restores the levels of antioxidant enzymes and at the same time strongly affects the redox state. Thus we can speculate that HD can generate severe redox impairment inducing damage in RBC and plasma antioxidant enzymes. Increased erythrocyte GSSG and GSM-S-T levels coupled with a reduced hexose monophosphate shunt (HMPS) function may be useful indexes of oxidative stress in uremic anemia.

[Percutaneous angioplasty of arterio-venous fistulae with Zijlstra catheters]

Brescia-Cimino arteriovenous fistulas are the most common vascular accesses in hemodialysis patients. Arterial blood pressure inside the vein and repeated punctures cause progressive sclerosis of the vessel wall and stenosis or occlusion are the final outcome. Percutaneous dilatation is an effective method to preserve arteriovenous fistulas function. From January 1991 through December 1992, eleven dilatations were performed in 10 patients (7 women and 3 men, mean age: 55 years) using a Zijlstra dedicated catheter provided with multiple infusion holes, which allows long dilatation times and therefore progressive wall distention. A high-pressure balloon yields better results in case of stiff and diffuse stenosis. The immediate results of the maneuver were good in all patients. One acute thrombosis of the fistula was observed a few hours after the procedure, and a second dilatation was performed in a patient 8 months after the first one. Mean arteriovenous fistula patency time was 6 months. Finally, a critical review of the international literature on the subject is made and the value of dilatation in the treatment of fistula stenosis is reported; the necessity to use new dedicated catheters in also stressed.

[Extracorporeal hemodialysis: various++ metabolic and erythrocyte-membrane features of uremic subjects]

Extracorporeal dialysis in uremic subjects produces erythrocyte alterations on energetic and redox metabolism. On this basis, we have tried to verify a fundamental parameter for the integrity of the red blood cell namely the glutathione content both in the oxidized and reduced form. Comparisons were made between two groups of subjects (similar in age, sex and number). One group consisted of uremic subjects undergoing dialysis and the other in healthy controls. As well as a slight increase in reduced glutathione (GSH), an accumulation of oxidized glutathione (GSSG) was found which, in postdialysis patients, reached values up to 3 times higher than in controls. This means a lowering in the ratio GSH/GSSG. There was also a decrease in total Mg(++)-ATPase activity, significantly found in erythrocyte ghosts of postdialysis patients. The hypothesis of a reduced efflux of GSSG as well as an increase in its formation speed (activation of glutathione peroxidase) is taken into consideration.

[Evaluation of an immunoenzymatic method for determining TSH and establishment of reference values]

In the present work we reported the results of the valuation of IMx Ultrasensitive hTSH assay which is a Microparticle Enzyme ImmunoAssay (MEIA) for quantitative determination of human stimulating hormone (hTSH) in the human serum or plasma. We have determined the method's precision, within run and between run, sensitivity and recovery. This method has been compared with another one (Immuno RadioMetric Assay). Also reference values have been calculated in the "normal" male and female population and shortly commented.

[Uptake of 86Rb by human erythrocytes: modification of the method and applications]

In this study we applied a method generally used for the study of Na+,K(+)-ATPase, as well as other systems of potassium transport, which makes use of a rubidium isotope (86Rb) as analogue of the potassium and is known as uptake of the 86Rb. This method proved to be particularly sensitive and versatile for kinetic studies of this pump system, allowing to assess possible alterations. Its application in the study of sodium and potassium transport in erythrocytes of uremic subjects in extracorporeal dialysis made it possible to reveal certain alterations due both to pump-dependent and pump-independent uptake. In fact, the results show the hypothesis of restoration of Na+,K(+)-pump activity for elimination during dialysis of one or more inhibitor present in the uremic plasma. Furthermore, a reduction in aspecific flows was noted which could be the result of more generalized damage of the membrane.

Recombinant human erythropoietin reduces free erythrocyte protoporphyrin levels in patients on chronic dialysis

We studied the significance of free erythrocyte protoporphyrin (FEP) in relation to iron status, aluminum levels and anemia in uremic patients on chronic dialysis. All but 1 patient showed high FEP values closely related to the degree of anemia. Increased FEP levels are due to a defective heme synthesis, not related to iron deficiency or aluminum overload. Treatment of anemia with recombinant human erythropoietin reduced FEP values. We therefore hypothesize that recombinant human erythropoietin ameliorates an enzymatic defect in heme synthesis.

The molecular basis for the generation of the human soluble interleukin 2 receptor

Using an enzyme-linked immunosorbent assay (ELISA) employing two monoclonal antibodies recognizing distinct epitopes on the interleukin 2 receptor (IL2R) alpha chain (Tac molecule), we previously demonstrated that activated lymphocytes release a soluble interleukin 2 receptor molecule (sIL2R) in vitro and in vivo. The sIL2R is biochemically and structurally related to Tac, but its precise origin and functional role remain to be defined. We report here that a single IL2R cDNA is sufficient to direct the synthesis of both cell-associated and soluble released IL2R molecules. Northern analysis of IL2R cDNA transfected L-cell lines revealed the presence of mRNA species unaccounted for by known transcription termination or internal splice sites. Nevertheless, S1 nuclease digestion studies failed to detect alternately spliced mRNA transcripts that specifically lack transmembrane or cytoplasmic domains and which may encode a secreted IL2R molecule. Therefore sIL2R does not appear to be the product of a unique post-transcriptional splicing event. In the absence of any post-translational modifications, sIL2R is most likely generated by enzymatic cleavage and release of cell surface Tac. This proteolytic release of Tac may be but one example of a common cellular mechanism for regulating the membrane expression of cell surface molecules.