Influence of glycaemic control on platelet bound CD40-CD40L system, P-selectin and soluble CD40 ligand in Type 2 diabetes

AIMS

Type 2 diabetes is a potent cardiovascular risk factor, associated with proinflammatory and prothrombotic processes. The purpose of this study was to investigate whether platelet-bound CD40-CD40L signalling, P-selectin expression and soluble CD40L were increased in patients with diabetes mellitus and can be normalized by improving glycaemic control.

METHODS

Soluble (s) CD40L, platelet surface expression of CD40L, CD40 and P-selectin (CD62P) on platelets were measured by flow cytometry in 71 patients with Type 2 diabetes mellitus and 37 healthy volunteers. In addition, the relationship of HbA1c to CD40-CD40L and P-selectin expression was determined in a longitudinal follow-up.

RESULTS

In patients with Type 2 diabetes, platelet membrane CD40 expression (Type 2 diabetes 3.1+/-0.61 vs. controls 2.5+/-0.85 mean fluorescence intensity; P=0.001), platelet-bound CD40L (1.2+/-0.32 vs. 1.1+/-0.14; P=0.034) as well as surface expression of CD62P (0.66+/-0.19 vs. 0.57+/-0.12; P=0.007) were higher than in control subjects. Plasma sCD40L values (3.2+/-1.70 vs. 1.8+/-0.50 ng/ml; P<0.001) were also significantly increased in Type 2 diabetes. After improving glycaemic control in patients with initial HbA1c>8.5% (n=15), platelet P-selectin and CD40-CD40L expression decreased significantly by 54.0%, 36.22% and 16.26%, respectively 1 year later.

CONCLUSIONS

Type 2 diabetes is associated with up-regulation of the platelet-bound CD40-CD40L system, platelet hyperactivity (enhanced P-selectin expression) and increased sCD40L levels. Improved glycaemic control, however, does help to correct abnormal platelet activation via down-regulation of CD40-CD40L system and P-selectin expression.

A screen of SLC1A1 for OCD-related alleles

SLC1A1, which encodes the neuronal and epithelial glutamate transporter, is a promising candidate gene for obsessive-compulsive disorder (OCD). In this study, we conducted capillary electrophoresis single-strand conformation polymorphism (CE-SSCP) screen for all 12 identified exons, including all coding regions and approximately 50 bp of flanking introns of the human SLC1A1 in 378 OCD-affected individuals. Full sequencing was completed on samples that showed an aberrant SSCP tracing for identification of the underlying sequence variants. Our aim was to determine if there are differences in the frequencies of relatively common alleles, or rare functional alleles, in 378 OCD cases and 281 ethnically matched controls. We identified one nonsynonymous coding SNP (c.490A > G, T164A) and three synonymous coding SNP (c.81G > C, A27A; c.414A > G, T138T; c.1110T > C, T370T) in case samples. We found no statistical differences in genotype and allele frequencies of common cSNPs in SLC1A1 between the OCD cases and controls. The rare variant T164A was found only in one family. Further investigation of this variant is necessary to determine whether and how it is related to OCD. There was no other evidence of significant accumulation of deleterious coding mutations in SLC1A1 in the OCD cases.

Effective organics degradation from pharmaceutical wastewater by an integrated process including membrane bioreactor and ozonation

The enhanced removal of organic compounds from a pharmaceutical wastewater resulting from the production of an anti-viral drug (acyclovir) was obtained by employing a membrane bioreactor (MBR) and an ozonation system. An integrated MBR-ozonation system was set-up by placing the ozonation reactor in the recirculation stream of the MBR effluent. A conventional treatment set-up (ozonation as polishing step after MBR) was also used as a reference. The biological treatment alone reached an average COD removal of 99%, which remained unvaried when the ozonation step was introduced. An acyclovir removal of 99% was also obtained with the MBR step and the ozonation allowed to further remove 99% of the residual concentration in the MBR effluent. For several of the 28 organics identified in the wastewater the efficiency of the MBR treatment improved from 20% to 60% as soon as the ozonation was placed in the recirculation stream. The benefit of the integrated system, with respect to the conventional treatment set-up was evident for the removal of a specific ozonation by-product. The latter was efficiently removed in the integrated system, being its abundance in the final effluent 20-fold lower than what obtained when ozonation was used as a polishing step. In addition, if the conventional treatment configuration is employed, the same performance of the integrated system in terms of by-product removal can only be obtained when the ozonation is operated for longer than 60 min. This demonstrates the effectiveness of the integrated system compared to the conventional polishing configuration.

Fotemustine plus etoposide, cytarabine and melphalan (FEAM) as a new conditioning regimen for lymphoma patients undergoing auto-SCT: a multicenter feasibility study

BEAM is a widely used conditioning regimen for relapsed/refractory lymphoma patients undergoing auto-SCT. We conducted a multicenter study with an alternative regimen (fotemustine plus etoposide, cytarabine and melphalan (FEAM)) in which BCNU was substituted by the chloroethylnitrosourea fotemustine (FTM). Eighty-four patients with relapsed/refractory Hodgkin's (n=20) and non-Hodgkin's lymphoma (n=64) were conditioned with a FEAM regimen (FTM 150 mg/m(2) on days -7, -6, etoposide 200 mg/m(2) and cytarabine 400 mg/m(2) on days -5, -4, -3, -2 and melphalan 140 mg/m(2) on day -1). Patients were evaluated for toxicity and engraftment parameters. Median times to neutrophil (>500 x 10(9)/l) and plt (>20 000 x 10(9)/l) engraftment were 11 and 13 days, respectively. Grade 3 mucositis occurred in 19 patients (23%), while G3 nausea/vomiting and G3 diarrhea were observed in 13 (15%) and 6 (7%) patients, respectively. No severe hepatic, renal or pulmonary toxicity was detected. Seven patients (7%) experienced G4 mucositis, while no other G4 toxicities or unexpected adverse events of any grade were recorded. Transplant-related mortality was 2.4%. We conclude that a FEAM regimen is feasible and safe. Although toxicity and engraftment times compared favorably with BEAM, longer follow-up is needed to evaluate fully its efficacy and long-term safety.

A family-based association study of the glutamate transporter gene SLC1A1 in obsessive-compulsive disorder in 378 families

SLC1A encodes the neuronal and epithelial glutamate transporter and was previously tested as a candidate for obsessive-compulsive disorder (OCD) by several research groups. Recently, three independent research groups reported significant association findings between OCD and several genetic variants in SLC1A1. This study reports the results from a family-based association study, which examined the association between 13 single nucleotide polymorphisms (SNPs) within or in proximity to the SLC1A1 gene. Although we did not replicate association findings for those significant SNPs reported by previous studies, our study indicated a strong association signal with the SNP RS301443 (P-value = 0.000067; Bonferroni corrected P-value = 0.0167) under a dominant model, with an estimated odds ratio of 3.5 (confidence interval: 2.66-4.50). Further, we conducted single SNP analysis after stratifying the full data set by the gender status of affected in each family. The P-value for RS301443 in families with the male affected was 0.00027, and the P-value in families with female affected was 0.076. The fact that we identified a signal which was not previously reported by the other research groups may be due to differences in study designs and sample ascertainment. However, it is also possible that this significant SNP may be part of a regulator for SLC1A1, given that it is roughly 7.5 kb away from the boundary of the SLC1A1 gene. However, this potential finding needs to be validated biologically. Further functional studies in this region are planned by this research group.

Obsessive-compulsive disorder: subclassification based on co-morbidity

BACKGROUND

Obsessive-compulsive disorder (OCD) is probably an etiologically heterogeneous condition. Many patients manifest other psychiatric syndromes. This study investigated the relationship between OCD and co-morbid conditions to identify subtypes.

METHOD

Seven hundred and six individuals with OCD were assessed in the OCD Collaborative Genetics Study (OCGS). Multi-level latent class analysis was conducted based on the presence of eight co-morbid psychiatric conditions [generalized anxiety disorder (GAD), major depression, panic disorder (PD), separation anxiety disorder (SAD), tics, mania, somatization disorders (Som) and grooming disorders (GrD)]. The relationship of the derived classes to specific clinical characteristics was investigated.

RESULTS

Two and three classes of OCD syndromes emerge from the analyses. The two-class solution describes lesser and greater co-morbidity classes and the more descriptive three-class solution is characterized by: (1) an OCD simplex class, in which major depressive disorder (MDD) is the most frequent additional disorder; (2) an OCD co-morbid tic-related class, in which tics are prominent and affective syndromes are considerably rarer; and (3) an OCD co-morbid affective-related class in which PD and affective syndromes are highly represented. The OCD co-morbid tic-related class is predominantly male and characterized by high conscientiousness. The OCD co-morbid affective-related class is predominantly female, has a young age at onset, obsessive-compulsive personality disorder (OCPD) features, high scores on the 'taboo' factor of OCD symptoms, and low conscientiousness.

CONCLUSIONS

OCD can be classified into three classes based on co-morbidity. Membership within a class is differentially associated with other clinical characteristics. These classes, if replicated, should have important implications for research and clinical endeavors.

Superficial venous thrombosis: role of inherited deficiency of natural anticoagulants in extension to deep veins

AIM

Superficial venous thrombosis (SVT) has been considered for a long time a limited clinical condition of low importance, but this approach has changed in recent years, when several studies demonstrated that extension to deep veins occurs in 7.3 to 44% of patients, with high prevalence of pulmonary embolism. The aim of this study was to evaluate the prevalence of inherited deficiency of natural coagulation inhibitors in patients suffering from SVT in both normal and varicose veins, and to understand their role in extension to deep veins.

METHODS

The study included 83 patients with SVT, without clinically obvious risk factors. Ultrasound examination was performed, and deficiencies of Protein C, Protein S and Antithrombin (AT) were investigated.

RESULTS

In the patients where SVT occurred in normal veins, coagulation inhibitor deficiencies were 6.45% in the absence of extension and 62.5% in patients with extension to deep veins. In the patients with varicose vein SVT, the presence of these factors was less evident, but their prevalence was considerably higher in those with extension to deep veins (36.3%) than in non-extension (6.06%).

CONCLUSIONS

Present data confirm the role of inherited thrombophilic states related to inhibitor deficiency, considering them as risk factors for SVT in normal veins. Furthermore, an association has been found between their presence and the progression of SVT to deep veins.

Clinical Trial: High-dose furosemide plus small-volume hypertonic saline solutions vs. repeated paracentesis as treatment of refractory ascites

BACKGROUND

In patients with cirrhosis, ascites is defined as refractory when it cannot be mobilized or recurs early in standard diuretic therapy.

AIM

To compare the safety and efficacy of intravenous high-dose furosemide + hypertonic saline solutions (HSS) with repeated paracentesis in patients with cirrhosis and refractory ascites.

PATIENTS AND METHODS

Eighty-four subjects (59/25 M/F) with cirrhosis, mostly of viral aetiology, admitted for refractory ascites, were randomly assigned to receive furosemide (250-1000 mg/bid i.v.) plus HSS (150 mL H(2)O with NaCl 1.4-4.6% or 239-187 mEq/L) (60 patients, Group A) or to repeated paracentesis and a standard diuretic schedule (24 patients, Group B).

RESULTS

During hospitalization, Group A patients had more diuresis (1605 +/- 131 mL vs. 532 +/- 124 mL than Group B patients; P < 0.001) and a greater loss of weight at discharge (-8.8 +/- 4.8 kg vs. -4.5 +/- 3.8 kg, P < 0.00). Control of ascites, pleural effusions and/or leg oedema was deemed significantly better in Group A.

CONCLUSIONS

This randomized pilot study suggests that HHS plus high-dose furosemide is a safe and effective alternative to repeated paracentesis when treating hospitalized patients with cirrhosis and refractory ascites. Larger studies will be needed to evaluate long-term outcomes such as readmission and mortality.

Sapap3 and pathological grooming in humans: Results from the OCD collaborative genetics study

SAP90/PSD95-associated protein (SAPAP) family proteins are post-synaptic density (PSD) components that interact with other proteins to form a key scaffolding complex at excitatory (glutamatergic) synapses. A recent study found that mice with a deletion of the Sapap3 gene groomed themselves excessively, exhibited increased anxiety-like behaviors, and had cortico-striatal synaptic defects, all of which were preventable with lentiviral-mediated expression of Sapap3 in the striatum; the behavioral abnormalities were also reversible with fluoxetine. In the current study, we sought to determine whether variation within the human Sapap3 gene was associated with grooming disorders (GDs: pathologic nail biting, pathologic skin picking, and/or trichotillomania) and/or obsessive-compulsive disorder (OCD) in 383 families thoroughly phenotyped for OCD genetic studies. We conducted family-based association analyses using the FBAT and GenAssoc statistical packages. Thirty-two percent of the 1,618 participants met criteria for a GD, and 65% met criteria for OCD. Four of six SNPs were nominally associated (P < 0.05) with at least one GD (genotypic relative risks: 1.6-3.3), and all three haplotypes were nominally associated with at least one GD (permuted P < 0.05). None of the SNPs or haplotypes were significantly associated with OCD itself. We conclude that Sapap3 is a promising functional candidate gene for human GDs, though further work is necessary to confirm this preliminary evidence of association.

Rituximab plus gemcitabine, ifosfamide, oxaliplatin (R-GIFOX) as salvage therapy for recurrent Hodgkin lymphoma

8579

Background: Gemcitabine (G), ifosfamide (Ifo), oxaliplatin (Ox) and rituximab (R) have been accounted of cross-synergy in preclinical and early clinical studies in Hodgkin lymphoma (HL). We assessed activity, toxicity and stem cells (SCs) mobilizing capacity of a bi-weekly salvage combination with these agents in HL recurring after conventional or high dose therapy (HDT). Methods: Patients were scheduled to receive 3 R-GIFOX courses followed by SCs mobilization and HDT if elegible for autologous transplantation (ASCT) or 3 more courses if not. R-GIFOX consisted of R 375 mg/m2 D1, G 1000 mg/m2 D2, Ox 130 mg/m2 D3 and Ifo 5 g/m2 D3, as a 24-h single infusion, G-CSF 5 mcg/kg/d DD 7–11 (10 mcg/kg/d, 3rd course until SCs mobilization). Results: Twenty-one patients (median age 33 yrs, r 22–64) with relapsed (n = 16) [post-ASCT (n=6), <12 mo.s (n=7), > 12 mo.s (n=3)] or primary progressive (n = 5) HL, were prospectively accrued. Ten patients (48%) had received ≥ 2 previous CHT lines and 15 (78%) had GHLSG recurring HL prognostic score ≥ 2. Eighty-three total courses were delivered (median 3, r 3–6). CTCAE v3.0 G4 thrombocytopenia occurred in 18% of courses, G4 infection in 11%. Ifosfamide was withdrawn at the 4th course in 2 patients, both aged 64 yrs, due to tachyarrhythmia and encephalopathy. Actual dose intensity of the first 3 courses was 82%, 86%, 92 % for G, Ifo and Ox, respectively. The overall response according to FDG-PET/IWC criteria after 3 courses was 86%, with 2 partial and 16 complete responses (CRs) (76%; CR=10, CRu=6). Four CRs were achieved among the 6 patients with post-ASCT relapses. Eight of 14 eligible patients had effective CD34+ cells harvest [median 4,35 × 106/kg (r 2,91–11.45)] and proceeded to subsequent ASCT. Five ’bad mobilizers’ had previously undergone radiation therapy (n=3) and radioimmunotherapy (n=2). At 42 mo.s. Failure Free Survival was 57%. At a median f.u. of 12 mo.s for CRs, Disease Free Survival was 79% in patients eligible for ASCT and 41% in those unfit treated with additional R-GIFOX. Conclusions: R-GIFOX retains an attractive therapeutic potential in recurring HL, enabling pre-ABMT cytoreduction and mobilization, and also a safe delivery of a full salvage program to patients unfit for HDT.

No significant financial relationships to disclose.

Improvement in borderline personality disorder in relationship to age

OBJECTIVE

It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age.

METHOD

A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years.

RESULTS

Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1.

CONCLUSION

Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

Gender differences in genetic linkage and association on 11p15 in obsessive-compulsive disorder families

Several clinical and genetic studies have reported gender differences in obsessive-compulsive disorder (OCD). Previously, we conducted a linkage genome scan using multipoint allele-sharing methods to test for linkage in 219 families participating in the OCD Collaborative Genetics Study. When these families were stratified by proband's gender, suggestive linkage to chromosome 11p15 at marker D11S2362 (KAC(all) = 2.92, P = 0.00012) was detected in families with male probands, but not in the ones with female probands. We have since conducted fine mapping with a denser microsatellite marker panel in the region of 11p15, and detected a significant linkage signal at D11S4146 (KAC(all) = 5.08, P < 0.00001) in the families of male probands. Subsequently, 632 SNPs were genotyped spanning a 4.0 Mb region of the 1 LOD unit interval surrounding the linkage peak in the original families and an additional 165 families. Six SNPs were associated with OCD (P < 0.001): two SNPs were identified when all the families were included, and four SNPs only in male proband families. No SNP showed significant association with the OCD phenotype only in the families with a female proband. The results suggest a possible gender effect in the etiology of OCD.

Third Generation Cognitive-behavioral Therapy and Minfulness

Objective:

To introduce mindfulness pointing out its potentialities when applied in the psychopatology scope.

Method:

The authors had proceeded to a research on this third generation cognitive therapy through the bibliographical retraction, from scientific articles and publications. Trying and describing what he is one practical regular one of Mindfulness.

Results:

The practice of Mindfulness Practical of Mindfulness divulged in multiple publications, disclosing to be about a new generation of the Cognitive Therapy. It describes its possible clinical applicability in some psycopathologic features, with bigger emphasis in the disturbances of the anxiety. It is proceeded a summary revision from some conceptual boardings and more recent scientific studies.

Conclusion:

Psicotherapeutic thechniques based in the practice of Mindfulness can be applied in clinical context complementing the cognitive theory based in the restructuring of the thought with the essential component of acceptance. However it would be very important to appear more randomized control trials that allow to prove its therapeutical effectiveness.

Acceptance and Mindfulness-based Psychotherapies

Aims:

Exploration of the essential features of Mindfulness-based therapies, considered the third wave of cognitive therapy.

Methods:

Databases were searched for literature on the principles through which mindfulness-based therapies may operate, the possible mechanisms of action underlying these interventions, their clinical applications and evidence of their therapeutic and adverse effects. Mindfulness-based cognitive therapy (MBCT), which has been developed for depression relapse prevention, is highlighted.

Results:

These techniques have been used for various applications such as chronic pain control, stress reduction and prevention of depression relapse. Some of their important features are cultivation of conscious awareness and attention on a moment-to-moment basis, with openness, curiosity and a non-judgemental attitude and their aim is to change cognitive processes, rather than cognitive content. There have been some well-designed empirical evaluation studies published addressing the effectiveness of these interventions but current evidence of their mechanisms is limited.

Conclusions:

There is evidence that mindfulness-based approaches add an important dimension to available psychotherapies in the management of the psychological aspects of a range of mental and physical health problems.

Recurrent Venous Thromboembolism Complicated by Heparin-Induced Thrombocytopenia as a First Manifestation of an Occult Cancer: A Case Report

Heparin-Induced Trombocytopenia (HIT) is a serious and potentially fatal complication of patients on heparins. Its management is difficult and it can be more complicated in patients with cancer because of the hemorrhagic risk carried out by direct inhibitor of thrombin, the currently approved drug for HIT. At present, it is not clear whether cancer patients also have an increased risk of HIT. We describe the case of a patient with occult cancer at the moment of the index venous thrombosis, who developed Deep Vein Thrombosis (DVT) and concomitant HIT with thrombotic complications (recurrent contralateral venous thrombosis). The management of HIT was efficaciously based on the combined use of alternative antithrombotic regimens (Dermatan-Sulphate and Defibrotide), without an increased risk of bleeding. This case highlights the potential relationship between DVT, as first episode of an occult cancer, and the risk of developing HIT. The use of alternative antithrombotic therapy seems to be efficacious even in this high-risk cancer patient.

Do bulbar-onset amyotrophic lateral sclerosis patients have an earlier respiratory involvement than spinal-onset amyotrophic lateral sclerosis patients?

AIM

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease involving limbs and bulbar muscles. The major cause of death in these patients is respiratory insufficiency. However, bulbar-onset ALS patients have a shorter survival than those with spinal-onset. It is not established if this difference is related to an earlier respiratory dysfunction in bulbar-onset patients. The aim of the present study was to determine if bulbar-onset patients have an earlier respiratory impairment as compared with the spinal-onset ones.

METHODS

From the population of ALS patients followed in our centre, we studied 82 patients (45 spinal-onset and 37 bulbar-onset, group 1 and 2 respectively), all evaluated between 6-18 months after disease onset. We investigated forced vital capacity, maximal inspiratory (PI max) and expiratory (PE max) pressures, mouth occlusion pressure at 100 ms after inspiration, arterial blood gases, percutaneous nocturnal oxymetry, phrenic nerve conduction, needle electromyography (EMG) of the right diaphragm and right internal intercostals muscles and functional ALS scale (ALS-FRS).

RESULTS

No statistical difference was found for gender and disease duration between both groups, but bulbar-onset patients were older. PI max and PE max were statistically lower (P<0.001 and P<0.006, respectively) in group 2. However, no correlation was found between bulbar ALS-FRS subscore and PI max or PE max.

CONCLUSIONS

Our results support that PI max and PE max are sensitive measurements of respiratory dysfunction in bulbar patients. Probably, this finding cannot be solely explained by the oro-facial weakness of bulbar-patients. We speculate that respiratory accessory muscles weakness can contribute for this observation.

An analysis of peroxisome proliferator-activated receptor gamma (PPAR-gamma 2) Pro12Ala polymorphism distribution and prevalence of type 2 diabetes mellitus (T2DM) in world populations in relation to dietary habits

BACKGROUND AND AIM

The human peroxisome proliferator-activated receptor gamma (PPAR-gamma) is involved in lipid storage, glucose homeostasis and adipocyte differentiation. The Ala allele of the Pro12Ala polymorphism has been associated with a protective effect against T2DM. Ala allele frequencies are known for many populations, but data are absent for other interesting human groups.

METHODS AND RESULTS

We examined samples from Ethiopia, Benin, Ecuador and Italy. In addition, we performed an analysis of the Pro12Ala polymorphism distribution in world populations, also in relation to T2DM prevalence and the diet lipid content. In the European populations, the Ala allele frequencies are distributed according to a latitudinal trend, with the highest in the northern and central European populations and the lowest in the Mediterranean populations. Considering the world populations, a significant inverse relationship between Ala frequency and T2DM prevalence was observed mainly in populations where energy from lipids exceeded 30% of the total energy intake.

CONCLUSION

Northern Europe's cold climate has been hypothesised to have played a role in contributing to the present pattern. Moreover our analysis appears to confirm, at a population level, the protective effect of Ala allele against T2DM, already observed in case-control studies, but only in populations with a diet rich in lipids.

Ischemic stroke in patients with diabetic foot

AIM

The diabetic foot syndrome is the most frequent cause of hospitalization of diabetic patients and one of the economically most demanding complications of diabetes. People with diabetes have been shown to have higher mortality than people without diabetes, but the cerebrovascular risk profile of these patients is not fully evaluated. The aim of our study was to evaluate the possible role of diabetic foot as a cerebrovascular risk marker in type 2 diabetic patients.

METHODS

We enrolled 102 type 2 diabetes patients with diabetic foot and 123 diabetic patients without diabetic foot.

RESULTS

Statistically significant differences were found in the distribution of the main cardiovascular risk factors with exception of hypertension. We observed a higher prevalence of previous cerebrovascular events (transient ischemic attack, ischemic stroke) and of incidence of new onset cerebrovascular events at a 5-year follow-up. Regarding clinical subtype of ischemic stroke classified according to Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification on a retrospective and prospective basis, we observed a higher prevalence of both the lacunar and large artery atherosclerosis subtype with a slight higher prevalence of lacunar subtype in patients with diabetic foot.

CONCLUSION

Our results show a worse cerebrovascular risk profile in diabetic patients with diabetic foot than in diabetic subjects without foot ulceration with a higher prevalence of cardiovascular risk factors and of anamnestic cerebrovascular events and incidence of new cerebrovascular events at a 5-year follow-up.

Phase II study of a fixed dose-rate infusion of gemcitabine associated with erlotinib in advanced pancreatic carcinoma

15013

Background: The efficacy of gemcitabine in pancreatic cancer can be improved by its combination with erlotinib. Likewise, a fixed dose-rate infusion of gemcitabine seems to be superior to the conventional 30-minute infusion. Our objective was to evaluate the efficacy and toxicity of a fixed dose-rate infusion of gemcitabine associated with erlotinib in patients with advanced adenocarcinoma of the pancreas. Methods: From May 2005 to October 2006, 21 chemotherapy-naïve patients were included, median age 62 years (range 47 - 78), male/female 12/9. Five patients (24%) had locally advanced disease and 16 (76%) distant metastases. The Karnofsky score was 80–100 in 11 (52%), and 60–70 in 10 (48%). Treatment consisted of gemcitabine 1200 mg/m2 given as a 120-minute infusion on days 1, 8, 15, plus erlotinib 100 mg p.o daily. Cycles were repeated every 4 weeks. Results: A total of 80 cycles of chemotherapy were delivered with a median of 3.8 per patient (range 1- 8). There were five partial responses (24%, 95% CI: 8.4 - 47.6%), whereas seven patients had stable disease (33%) and 9 had a progression (43%). The median time to progression was 4 months. After a median follow-up of 6 months (1–14 months), the median overall survival has not been achieved. Toxicity was low. Grade 3- 4 WHO toxicities per patient were as follows: neutropenia in 5 (24%), thrombocytopenia in 1 (5%) and anaemia in 3 (14%). Grade 1–2 rash appeared in 8 (38%) and grade 3 in 3 (14%). Four patients (19%) had diarrhoea grade 1–2. Conclusions: These preliminary results suggest that a fixed dose-rate infusion of gemcitabine associated with erlotinib is active and well tolerated in patients with advanced pancreatic carcinoma.

No significant financial relationships to disclose.

Tratamiento de la artrosis postraumática de la interfalángica proximal mediante artroplastia de carbono pirolítico

Objetivos: Valorar los resultados obtenidos mediante la artroplastia de carbono pirolítico en pacientes con artrosis postraumática de las interfalángicas proximales.

Material y Método: Se analizan un total de 25 pacientes (24 hombres, 1 mujer) con artrosis postraumática de la articulación interfalángica proximal (IFP), que fueron valorados clínica y radiográficamente, después de haber sido intervenidos mediante una artroplastia de carbono pirolítico. Todos los casos fueron operados por vía dorsal, siguiendo siempre el mismo protocolo rehabilitador postquirúrgico. El seguimiento medio de estos pacientes fue de 42 meses, con un mínimo de 12 meses y un máximo de 72 meses.

Resultados: Comparando la escala analógica de dolor y el rango de movilidad en el pre y postoperatorio, se obtuvieron en 24 casos, unos buenos resultados. El único caso que fue considerado como malo, presentó una subluxación dorsal del componente distal del implante, que requirió de una reducción quirúrgica. En cuanto a los hallazgos radiográficos, en el 10 % de los casos se objetivaron finas bandas radiolúcidas peri-implante, si bien no se correlacionó este hallazgo con un deterioro clínico.

Conclusiones: La artroplastia de sustitución de la articulación IFP mediante un implante de carbono pirolítico, constituye una alternativa muy válida en los casos de artrosis postraumática. Sin embargo, es preciso contar son series más largas y con más tiempo de evolución para validar este tipo de tratamiento.

Pesticide fate in tropical wetlands of Brazil: an aquatic microcosm study under semi-field conditions

A contamination of off-site aquatic environments with pesticides has been observed in the tropics, yet only sparse information exists about pesticide fate in such ecosystems. The objective of our semi-field study was to elucidate the fate of alachlor, atrazine, chlorpyrifos, endosulfan, metolachlor, profenofos, simazine, and trifluralin in the aqueous environment of the Pantanal wetland (MT, Brazil). To this aim, water and water/sediment microcosms of two sizes (0.78 and 202 l) were installed in the outskirts of this freshwater lagoon environment and pesticide dissipation was monitored for up to 50 d after application. The physical-chemical water conditions that developed in the microcosms were reproducible among field replicates for both system sizes. Pesticide dissipation was substantially enhanced for most pesticides in small microcosms relative to the large ones (reduced DT(50) by a factor of up to 5.3). The presence of sediment in microcosms led to increased persistence of chlorpyrifos, endosulfan, and trifluralin in the test systems, while for polar pesticides (alachlor, atrazine, metolachlor, profenofos, and simazine) a lesser persistence was observed. Atrazine, simazine, metolachlor, and alachlor were identified as the most persistent pesticides in large water microcosms (DT(50) > or = 47 d); in large water/sediment systems endosulfan beta, atrazine, metolachlor, and simazine showed the slowest dissipation (DT(50) > or = 44 d). A medium-term accumulation in the sediment of tropical ecosystems can be expected for chlorpyrifos and endosulfan isomers (11-35% of applied amount still extractable at 50 d after application). We conclude that the persistence of the studied pesticides in aquatic ecosystems of the tropics is not substantially lower than during summer in temperate regions.

A case control study between diabetic and non-diabetic subjects with ischemic stroke

AIM

The clinical and prognostic profile of diabetic stroke patients is still an unclarified topic. The aim of the present study is to compare clinical features and risk factor profile in diabetics and in non-diabetics affected by acute ischemic stroke.

METHODS

We have included 98 diabetics and 102 matched non-diabetic subjects affected by acute ischemic stroke and matched by age (+/-3 years) and gender. We determined the Scandinavian Stroke Scale (SSS) on admission and the Rankin disability scale on discharge and after a 6 months follow-up. Ischemic stroke has been classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. We anamnestically evaluated the presence of hypertension, hypercholesterolemia, any records of transient ischemic attack, and stroke. Using conditional logistic regression analysis, we calculated adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Diabetes was associated with lacunar ischemic stroke subtype (OR 3.89, 95% CI 2.23-6.8), with a record of hypertension (OR 2.53, 95% CI 1.48-4.32), and with a better SSS score at admission (OR 0.58, 95% CI 0.36-0.96). The association of diabetes with lacunar stroke remained significant also after adjustment for hypertension (adjusted OR 3.37, 95% CI 1.9-5.99) or for large artery atherosclerotic and cardioembolic stroke subtypes (adjusted OR 2.69, 95% CI 1.08-6.69).

CONCLUSIONS

Our study shows some significant differences in acute ischemic stroke among diabetics in comparison with non-diabetics (higher frequency of hypertension, higher prevalence of lacunar stroke subtype, lower neurological deficit at admission in diabetics).

Multidetector-row CT evaluation of nontraumatic acute thoracic aortic syndromes

Acute thoracic aortic syndromes encompass a spectrum of emergencies presenting with acute chest pain and marked by a high risk of aortic rupture and sudden death. These include nontraumatic disease entities of the thoracic aorta, namely, dissection, intramural haematoma, penetrating atherosclerotic ulcer and aneurysm rupture. In clinical practice, the most frequent imaging procedure used in the diagnostic assessment of these diseases is computed tomography (CT), which, thanks to recent technological developments [multidetector-row computed tomography (MDCT)], affords important diagnostic possibilities and very interesting future perspectives. This paper on the use of MDCT in the evaluation of acute thoracic nontraumatic aortic syndromes illustrates the examination technique and the key imaging findings related to each disease. Moreover, the role of MDCT for planning specific treatment is also highlighted.

Development, reliability and validity of a self-administered questionnaire on subjective opinion about delusions and voices

OBJECTIVE

This study focuses on the psychometric characteristics of a self-report instrument, the Delusion and Voices Self-Assessment (DV-SA) questionnaire, to assess delusions and auditory hallucinations from the clients' perspective.

METHODS

The DV-SA was administered to 70 schizophrenic patients in treatment in an outpatient mental health clinic in Naples, Italy. It was administered twice to determine the test-retest reliability. A clinician who was blind to the patients' DV-SA ratings also rated the Brief Psychiatric Rating Scale (BPRS). Sensitivity to change was assessed in 30 patients who completed a 24-week course of cognitive-behavioural therapy sessions.

RESULTS

The DV-SA showed good internal consistency and structure, and an acceptable average of item-total correlation. The test-retest reliability was very satisfactory. The comparison between DV-SA and BPRS showed a good association for illness severity.

CONCLUSIONS

The DV-SA may be a reliable, valid and sensitive instrument for assessing subjective experiences on delusions and auditory hallucinations. The brevity and limited need for assistance make it an efficient instrument to assess patients' evolution during therapy.

Successful salvage therapy of intravenous cyclophosphamide for refractory polymyositis in an elderly patient: case report

Dermatomyositis and polymyositis may affect children and adults and are now widely recognized as major causes of disability which, thanks to the introduction of immunosuppressive drugs, is often treatable, at least to some extent. Few data exist regarding polymyositis in elderly patients. We describe a case of refractory life-threatening polymyositis in an elderly patient, successfully treated with intravenous cyclophosphamide.

Risk factors profile and clinical outcome of ischemic stroke patients admitted in a Department of Internal Medicine and classified by TOAST classification

AIM

A classification of ischemic stroke subtypes tailored for individual patients is hard to achieve. In 1993, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) group developed a new system to classify the subtypes of ischemic stroke. In our study we applied the TOAST classification to a group of consecutive patients affected by ischemic stroke, to evaluate outcome and factors associated to each stroke subtype.

METHODS

To evaluate the prognosis and the associated factors of ischemic stroke subtypes, we classified according to the TOAST classification a cohort of 159 consecutive patients affected by an acute ischemic stroke. We evaluated neurological deficit at admission by Scandinavian Stroke Scale and scored disability at discharge and 6 months after discharge using the Rankin disability scale. We determined 30 days survival and anamnestically evaluated major vascular risk factors.

RESULTS

Patients with cardioembolic stroke and stroke of undetermined etiology had a greater neurological deficit on admission and the worst prognosis either in terms of disability or mortality. Lacunar stroke had the least neurological deficit at admission and the best prognosis. Hypercholesterolemia and smoking were more frequent among patients with large artery atherosclerotic stroke. Hypertension, a history of transient ischemic attack and diabetes were more frequent among patients with lacunar stroke. A weak association with hypertension and smoking was observed for cardioembolic stroke.

CONCLUSIONS

The TOAST classification is useful in the clinical setting because it identifies ischemic stroke subtypes with different prognosis and with a different profile of associated factors.

Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q

Obsessive-compulsive disorder (OCD) is the tenth most disabling medical condition worldwide. Twin and family studies implicate a genetic etiology for this disorder, although specific genes have yet to be identified. Here, we present the first large-scale model-free linkage analysis of both extended and nuclear families using both 'broad' (definite and probable diagnoses) and 'narrow' (definite only) definitions of OCD. We conducted a genome-scan analysis of 219 families collected as part of the OCD Collaborative Genetics Study. Suggestive linkage signals were revealed by multipoint analysis on chromosomes 3q27-28 (P=0.0003), 6q (P=0.003), 7p (P=0.001), 1q (P=0.003), and 15q (P=0.006). Using the 'broad' OCD definition, we observed the strongest evidence for linkage on chromosome 3q27-28. The maximum overall Kong and Cox LODall score (2.67) occurred at D3S1262 and D3S2398, and simulation based P-values for these two signals were 0.0003 and 0.0004, respectively, although for both signals, the simulation-based genome-wide significance levels were 0.055. Covariate-linkage analyses implicated a possible role of gene(s) on chromosome 1 in increasing the risk for an earlier onset form of OCD. We are currently pursuing fine mapping in the five regions giving suggestive signals, with a particular focus on 3q27-28. Given probable etiologic heterogeneity in OCD, mapping gene(s) involved in the disorder may be enhanced by replication studies, large-scale family-based linkage studies, and the application of novel statistical methods.

Gemcitabine, ifosfamide, oxaliplatin and rituximab (R-GIFOX), a new effective cytoreductive/mobilizing salvage regimen for relapsed and refractory aggressive non-Hodgkin’s lymphoma: Results of a pilot study

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Background: We evaluated a new short-course (biweekly), dose intensive, cytoreductive/mobilizing salvage regimen (R-GIFOX) combining the cross-synergistic agents Gemcitabine (G), Ifosfamide (Ifo), Oxaliplatin (Ox) and Rituximab (R), in patients with recurrent CD20+ NHL. Methods: Patients were scheduled to receive three courses of R-GIFOX followed by mobilization and ASCT or three more courses if ineligible for ASCT. Therapy was delivered on a compassionate basis after written informed consent. R-GIFOX consisted of R (375 mg/m2, d 1), G (1000 mg/m2, d 2), Ox (130 mg/m2, d 3), Ifo (5 g/m2, d 3), as a 24-hour single infusion in patients aged ≤ 65 yrs, or fractionated over 3 days (dd 3–5) in those older, G-CSF (5 mcg/kg/d, dd 6–11; 10 mcg/kg/d at the 3rd course). Responses were evaluated after three courses by the integrated FDG-PET/IWC criteria. Results: Twenty patients (median age 62 yrs, r 37–79) with relapsed (n = 15) or refractory (n = 5) aggressive [diffuse large cell (n = 8), mantle cell (MCL) (n = 5), follicular G3 (n = 7)], advanced (stage IV = 75%), poor risk (IPI 3–5 = 60%; previous therapies: median = 2, r 1-4) NHL, were accrued. Eighty-five total courses were given (median 4, r 1–6). Actual dose intensities of the first 3 courses were: G = 82%, Ifo = 83% and Ox = 86.5%. CTCAE v 3.0 toxicity (85 courses) was: G3/G4 thrombocytopenia = 23%; G3/G4 neutropenia = 21%; G3 febrile neutropenia = 5% and G3/G4 infections = 8%. The ORR after three courses was 80%, with 11 complete responses (55%; CR = 8; CRu = 3) and 5 partial; CRu converted to CR at BM biopsy after 6 courses. The ORR was 77 % (6 CR, 4 PR) for patients aged ≤ 65 yrs and 86% (5 CR, 1 PR) for those older. Also, the ORR was 40% (1 CR, 1 PR) for refractory patients and 93% (10 CR, 4 PR) for those relapsed. TTF was 79.4% at a median f.u. of 8 months (r, 2-16). CD34+ cells were harvested in 6 out of 8 eligible patients. Among patients with MCL 3 CRs and 1 PR were obtained, including 2 molecular remissions. Conclusions: R-GIFOX had limited toxicity and good activity in recurrent aggressive NHL. It may offer a less toxic alternative to Cisplatin/ARA-C-based regimens, also for patients aged or unfit for ASCT, and in “difficult” histotypes such as MCL.

No significant financial relationships to disclose.

Tracheobronchial aspiration of foreign bodies: current indications for emergency plain chest radiography

PURPOSE

The purpose of this study was to determine the role of plain chest radiography in the evaluation of patients with suspected foreign-body aspiration.

MATERIALS AND METHODS

During a 5-year period, 31 patients (18 men and 13 women; age range 6 months to 85 years) were referred to our observation for clinical suspicion of foreign-body aspiration. Clinically, the patients presented with cough in 27/31 cases (87.1%), decreased breath sounds in 22/31 (71%), choking in 18/31 (58.1%), fever in 7/31 (22.6%) and cyanosis in 5/31 (16.1%). Suspected foreign-body aspiration had occurred 2-72 h before hospitalisation. Within 2 h of hospitalisation, all patients underwent plain chest radiography performed in the upright position (two projections) in 10/31 (32.3%) patients and in the supine decubitus position in the remaining 21 (67.7%) patients. Plain chest radiography was subsequently integrated with multislice computed tomography (MSCT) of the chest in 3/31 (9.7%) patients and with bronchoscopy in 27/31 (87.1%) patients.

RESULTS

Plain chest radiography showed the presence of a foreign body in the tracheobronchial tree in 7/31 (22.6%) patients, who subsequently underwent successful bronchoscopy in all cases. Foreign bodies included tooth fragment (three cases), nail (two cases), metallic spiral of a ball-point pen (one case) and an earring (one case). In the remaining 24/31 patients, plain chest radiography was positive in 14 cases, showing atelectasis (seven cases), pneumonia (six cases), pulmonary hyperinflation (one case) and pneumomediastinum (one case). Such findings had been caused by an aspirated foreign body, which was subsequently removed by means of bronchoscopy in all 14 patients. Moreover, three of the remaining ten patients with negative plain chest radiograph were submitted to MSCT of the chest, which required in 1 case tracheobronchial aspiration of a foreign body that was subsequently removed by means of bronchoscopy. Overall, plain chest radiography showed the presence of foreign-body aspiration and/or pleuroparenchymal lesions in 21/31 patients (67.7%); bronchoscopy was positive in 23/27 patients (85.2%), localising the foreign body in the right main bronchus in 16/27 patients (59.3%), left main bronchus in 7/27 patients (25.9%), intermediate bronchus in 2/27 patients (7.4%) and right lower lobe bronchus in 2/27 patients (7.4%). No late complications were observed within 6 months of hospital discharge.

CONCLUSIONS

Plain chest radiography remains the initial imaging modality for patients with clinically suspected tracheobronchial aspiration of a foreign body. Nevertheless, in the case of negative chest radiography and a clinical suspicion of foreign-body aspiration, MSCT-possibly integrated with virtual bronchoscopy-should be considered in order to avoid unnecessary bronchoscopy.