Impact of positive end-expiratory pressure on chest wall and lung pressure-volume curve in acute respiratory failure

To investigate whether chest-wall mechanics could affect the total respiratory system pressure-volume (P-V) curve in patients with acute respiratory failure (ARF), and particularly the lower inflection point (LIP) of the curve, we drew the total respiratory system, lung, and chest-wall P-V curves (P-Vrs, P-VL, and P-VW, respectively) for 13 patients with ARF, using the supersyringe method together with the esophageal balloon technique. Measurements were randomly repeated at four different levels of positive end-expiratory pressure (PEEP) (0, 5, 10, 15 cm H2O) and from each P-V curve we derived starting compliance (Cstart), inflation compliance (Cinf), and end compliance (Cend). With PEEP of 0 cm H2O (ZEEP), an LIP on the P-Vrs curve was observed in all patients (7.5 +/- 3.9 cm H2O); in two patients an LIP was detected only on the P-VL curve (8.6 and 8.7 cm H2O, respectively); whereas in seven patients an LIP was observed only on the P-VW curve (3.4 +/- 1.1 cm H2O). In four patients, an LIP was detected on both the P-VL and P-VW curves (8.5 +/- 3.4 and 2.2 +/- 1.0 cm H2O, respectively). The LIP was abolished by PEEP, suggesting that a volume-related mechanism was responsible for the observed LIP on both the P-VL and P-VW curves. At high levels of PEEP, an upper inflection point (UIP) appeared on the P-Vrs and P-VL curves (11.7 +/- 4.9 cm H2O and 8.9 +/- 4.2 cm H2O above PEEP, respectively) suggesting alveolar overdistension. In general, PaO2 increased with PEEP (from 81.7 +/- 35.5 mm Hg on ZEEP to 120 +/- 43.8 mm Hg on PEEP 15 cm H2O, p < 0.002); however, the increase in PaO2 with PEEP was significant only in patients with an LIP on the P-VL curve (from 70.5 +/- 16.2 mm Hg to 117.5 +/- 50.7 mm Hg, p < 0.002), the changes in PaO2 in patients without an LIP on the P-VL curve not being significant (from 91.3 +/- 45.4 mm Hg to 122.2 +/- 41.1 mm Hg). We conclude that in ventilator-dependent patients with ARF: (1) the chest-wall mechanics can contribute to the LIP observed on the P-Vrs curve; (2) the improvement in PaO2 with PEEP is significant only in patients in whom LIP is on the lung P-V curve and not on the chest wall curve; (3) high levels of PEEP may overdistend the lung, as reflected by the appearance of a UIP; (4) measurement of P-Vrs alone may be misleading as a guide for setting the level of PEEP in some mechanically ventilated patients, at least in the supine position, although it helps to prevent excessive alveolar overdistension by indicating the inflection volume above which UIP may appear.

Cell proliferation as a predictor of response to chemotherapy in metastatic breast cancer: a prospective study

Many biologic prognostic markers are available for patients with breast cancer, and considerable interest has been devoted to confirm preliminary evidence of their role as indicators of treatment response. It remains to be assessed whether such markers are predictors of response only to first-line or also to successive therapies. Proliferative activity, defined by the 3H-thymidine labeling index (TLI), was determined on the primary lesion from 76 patients at time of first diagnosis. At relapse, patients underwent chemotherapy as absolute (48 cases) or relative (28 cases) first-line treatment, and their clinical response was analyzed in relation to the TLI of the primary lesion. The objective clinical response was significantly higher for rapidly (47%; CL, 33-61%) than for slowly proliferating tumors (15%; CL, 1-29%). These findings held true also when adjusted for metastatic site, previous treatment, chemotherapy regimen administered, and hormone receptor status. However, the direct relation between cell proliferation and benefit from chemotherapy held true only when such a treatment was used as an absolute first-line approach. Cell proliferation of primary lesions represents a consistent indicator of response to chemotherapy over time. Previously administered regimens, at least hormone therapy, could alter the proliferation-related chemosensitivity profile of individual tumors.

Gene amplification and proliferative kinetics in relation to prognosis of patients with gastric carcinoma

BACKGROUND

The differences in survival of gastric carcinoma patients who have identical clinical or pathologic stages prompted the authors to investigate the prognostic significance of biologic features that are known to affect the clinical aggressiveness of other tumor types.

METHODS

One hundred twenty-four tumor samples from patients who had received radical or palliative surgery were analyzed for c-myc, c-K-ras, hst, and c-erb B-2 gene amplification by means of the Southern blot technique. Of these tumors, 70 were also examined for cell kinetics by means of the thymidine labeling index (TLI).

RESULTS

The analysis of associations between gene amplification and the anatomicopathologic variables (TNM classification, site of tumor, and histology) showed that amplification represents a late event in the natural history of gastric carcinoma. Gene amplification showed a slight, statistically insignificant, negative impact on overall survival (OS) (P = 0.09). Amplification of c-erb B-2 correlated in a statistically significant way with reduced OS (P = 0.03). Cox multiple regression analysis revealed that neither c-erb B-2 amplification nor TLI had prognostic significance in relation to OS.

CONCLUSIONS

These data indicate that amplification of the examined oncogenes did not reveal a new independent prognostic factor for patients with gastric carcinoma. However, the authors' results did show a strong correlation between gene amplification and tumor progression, which warrants further study involving larger series of patients. At the same time, the TLI results underlined the need to identify the most suitable biologic material for use in the estimation of proliferative indexes in gastric carcinoma.

Gene amplification and proliferative kinetics in relation to prognosis of patients with gastric carcinoma

BACKGROUND

The differences in survival of gastric carcinoma patients who have identical clinical or pathologic stages prompted the authors to investigate the prognostic significance of biologic features that are known to affect the clinical aggressiveness of other tumor types.

METHODS

One hundred twenty-four tumor samples from patients who had received radical or palliative surgery were analyzed for c-myc, c-K-ras, hst, and c-erb B-2 gene amplification by means of the Southern blot technique. Of these tumors, 70 were also examined for cell kinetics by means of the thymidine labeling index (TLI).

RESULTS

The analysis of associations between gene amplification and the anatomicopathologic variables (TNM classification, site of tumor, and histology) showed that amplification represents a late event in the natural history of gastric carcinoma. Gene amplification showed a slight, statistically insignificant, negative impact on overall survival (OS) (P = 0.09). Amplification of c-erb B-2 correlated in a statistically significant way with reduced OS (P = 0.03). Cox multiple regression analysis revealed that neither c-erb B-2 amplification nor TLI had prognostic significance in relation to OS.

CONCLUSIONS

These data indicate that amplification of the examined oncogenes did not reveal a new independent prognostic factor for patients with gastric carcinoma. However, the authors' results did show a strong correlation between gene amplification and tumor progression, which warrants further study involving larger series of patients. At the same time, the TLI results underlined the need to identify the most suitable biologic material for use in the estimation of proliferative indexes in gastric carcinoma.

The prognostic value of predischarge quantitative two-dimensional echocardiographic measurements and the effects of early lisinopril treatment on left ventricular structure and function after acute myocardial infarction in the GISSI-3 Trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico

BACKGROUND

Left ventricular dilatation and a low ejection fraction after acute myocardial infarction are independent indicators of a poor prognosis. ACE inhibitors have been shown to decrease left ventricular dilatation after myocardial infarction. In the GISSI-3 trial, patients were randomly assigned, within 24 h of onset of myocardial infarction symptoms, to 6 weeks of treatment with lisinopril, nitroglycerin, both or neither, in an open, 2 x 2 factorial design. The study showed that early treatment in relatively unselected patients with lisinopril decreases mortality at 6 weeks and severe left ventricular dysfunction. We assessed (1) the prognostic value of pre-discharge 2-D echocardiographic variables, and (2) the effects of lisinopril on the progression of left ventricular dilatation.

METHODS AND RESULTS

2-D echocardiograms were available pre-discharge in 8619 GISSI-3 trial patients discharged alive. In 6405 of these patients, a 2-D echocardiographic study was also available at 6 weeks, and at 6 months. Pre-discharge end-diastolic and end-systolic volumes, and ejection fraction predicted 6-month mortality and non-fatal clinical congestive heart failure (P < 0.01). The increase in left ventricular volumes over time was significantly reduced by 6 weeks' lisinopril treatment in patients with wall motion asynergy pre-discharge of > or = 27%. Patients with wall motion asynergy < 27% showed no dilatation and lisinopril did not affect volumes at 6 months. Patients randomized to lisinopril also had smaller volumes after withdrawal of treatment at 6 weeks. Lisinopril did not affect left ventricular ejection fraction.

CONCLUSIONS

2-D echocardiography independently contributes to pre-discharge risk stratification in terms of 6-month mortality and clinical heart failure after myocardial infarction, and early, short-term treatment with lisinopril in unselected myocardial infarction patients attenuates left ventricular dilatation; an effect evident in patients with larger infarcts. These results probably only partly explain the effect of lisinopril on total mortality concentrated in the first week after infarction.

High- and low-risk groups: early and late prognostic stratification

Prognostic data obtained from studies carried out since the advent of thrombolysis confirm the notion that short-term survival after acute myocardial infarction is primarily influenced by age and clinical indicators of infarct size or global left ventricular dysfunction. In survivors of the in-hospital phase of infarction, markers of left ventricular failure or dysfunction are still the most powerful risk predictors, whereas qualitative variables related to residual ischaemia do not predict outcome. The relatively low overall risk profile of survivors of the in-hospital phase of infarction in the GISSI-2 study appears to reflect favourable changes in the sizes of risk strata that result from a general improvement in management strategies.

Detection of cytomegalovirus-matrix protein (pp65) in leukocytes of HIV-infected patients with painful peripheral neuropathy

Painful peripheral neuropathy (PPN) in HIV-infected patients has been increasingly associated with cytomegalovirus (CMV) infection at other sites. In the last few years, the detection of CMV lower matrix phosphoprotein (pp65) antigen in leukocytes has become a major tool in the diagnosis of CMV systemic infection in immunocompromised patients. In this study, CMV antigen detection was assessed in 13 HIV-infected patients with PPN and, as controls, in 82 HIV seropositive patients without any evidence of peripheral nerve syndromes (10 with CMV retinitis and 72 without CMV end-organ disease). CMV antigenemia was found in 10 (76.9%) patients with PPN, in 5 (6.9%) without CMV disease, and in all 10 patients (100%) with CMV retinitis. Of the 10 PPN patients with CMV antigenemia, only 3 presented with CMV retinitis, while the remaining 7 had no clinical evidence of overt CMV infection at other sites. CMV pp65-positive cells were also found in three of the four cerebrospinal fluid (CSF) samples collected from PPN patients. Ganciclovir was effective in improving neurological symptoms in two of the four treated patients. The findings suggest that active CMV infection may be associated with PPN in HIV infection even in the absence of CMV disease at other sites. The detection of CMV-matrix pp65 antigen in the blood and CSF leukocytes could represent a simple and rapid tool of selecting PPN patients for antiviral therapy.

Predictors of nonfatal reinfarction in survivors of myocardial infarction after thrombolysis. Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) Data Base

OBJECTIVES

This study was designed to reassess the prediction of recurrent nonfatal myocardial infarction in patients recovering from acute myocardial infarction after thrombolysis.

BACKGROUND

Recurrent nonfatal myocardial infarction is a strong and independent predictor of subsequent mortality. Current knowledge of risk factors for nonfatal reinfarction is still largely based on data gathered before the advent of thrombolysis. Thus, this prospective study was planned to identify harbinger of nonfatal reinfarction in the postinfarction patients of the multicenter Grouppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial.

METHODS

Predictors of nonfatal reinfarction at 6 months were analyzed by multivariate technique (Cox model) in 8,907 GISSI-2 survivors of myocardial infarction with clinical follow-up, relying on a set of prespecified variables reflecting residual ischemia, left ventricular failure or dysfunction, complex ventricular arrhythmias, comorbidity as well as demographic and historical factors.

RESULTS

The postdischarge to 6-month incidence rate of nonfatal reinfarction was 2.5%. Independent predictors of nonfatal reinfarction were cardiac ineligibility for exercise test (relative risk 2.97, 95% confidence interval [CI] 1.98 to 4.45), previous myocardial infarction (relative risk 1.70, 95% CI 1.22 to 2.36) and angina at follow-up (relative risk 1.50, 95% CI 1.10 to 2.04). On further multivariate analysis, performed in 6,580 patients with both echocardiographic and electrocardiographic monitoring data available, a history of angina emerged as an additional risk predictor (relative risk 1.58, 95% CI 1.10 to 2.25).

CONCLUSIONS

The 6-month incidence of nonfatal reinfarction is rather low in survivors of myocardial infarction after thrombolysis. Cardiac ineligibility for exercise testing and a history of coronary artery disease are risk predictors. Recurrent nonfatal infarction is not predictable by qualitative variables reflecting residual ischemia, except by postdischarge angina. Prediction of nonfatal reinfarction appears less accurate than prediction of mortality, as almost 50% of reinfarctions occur in patients without any of the identified risk factors.

Natural history of gallstones in non-insulin-dependent diabetes mellitus. A prospective 5-year follow-up

This prospective study was undertaken to assess the natural history of gallstones in patients with non-insulin-dependent diabetes. Four hundred forty outpatients with diabetes mellitus were studied; 81 of these had gallstones diagnosed by ultrasound. On the basis of the information they gave, they were divided into two groups: A, asymptomatic; and B, symptomatic (previous episode(s) of biliary pain) at recruitment. Five years after diagnosis, the patients were recalled and questioned about their symptoms. Three of 81 could not be traced and eight had died from diseases not related to gallstones. Seventy were finally evaluated, 47 belonging to group A, 23 to group B. The cumulative percentage of initially asymptomatic patients who presented with biliary pain or complications during the follow-up was 14.9% (4.2% for complications). Of group A patients, 17% underwent cholecystectomy (one prophylactic, six elective and two emergency). One patient (2.1%) died after operation of obstructive jaundice. Of group B patients, 47.8% had biliary symptoms or complications (8.7% cholecystitis); 21.7% were operated (17.4% elective, 4.3% emergency cholecystectomy). Since few patients with asymptomatic gallstones and non-insulin-dependent diabetes mellitus develop pain or complications over time, prophylactic cholecystectomy is probably not advisable.

Differential survival of patients with AIDS according to the 1987 and 1993 CDC case definitions

OBJECTIVE

To evaluate the impact of the 1993 Centers for Disease Control and Prevention (CDC) revised classification system for human immunodeficiency virus and expanded surveillance case definition for acquired immunodeficiency syndrome (AIDS) on the number of cases and on survival of patients with AIDS.

DESIGN

Retrospective analysis of data from a prospective cohort study of patients treated with zidovudine.

PATIENTS

A total of 3515 patients enrolled in the Italian National Registry of Zidovudine-Treated Patients between July 1987 and December 1991 were analyzed.

MAIN OUTCOME MEASURES

Numbers and survival probability estimates (using the Kaplan-Meier method) for patients satisfying the 1993 CDC case definition compared with patients fulfilling the 1987 CDC classification. Multiple regression analysis was also used to analyze the combined effect of independent variables on survival.

RESULTS

According to the new classification system, the number of AIDS cases in the study population would increase by 188%. While the median survival of patients meeting the 1987 definition was 24 months, at the end of 57 months 53% of patients meeting the 1993 definition were still alive. Among the patients meeting the laboratory criteria for AIDS diagnosis using the new definition (CD4+ lymphocyte count < 0.20 x 10(9)/L [200/microL]), the presence of an AIDS-defining illness was a strong independent predictor of death.

CONCLUSIONS

The application of the new definition results in a considerable increase in the number of cases. Survival for patients classified according to the 1993 definition is much longer than for those classified with the 1987 definition. Clinical status plays a major role in predicting survival outcome among patients whose CD4+ lymphocyte counts meet the new case definition.

Determinants of 6-month mortality in survivors of myocardial infarction after thrombolysis. Results of the GISSI-2 data base. The Ad hoc Working Group of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-2 Data Base

BACKGROUND

Current knowledge of risk assessment in survivors of myocardial infarction is largely based on data gathered before the advent of thrombolysis. It must be determined whether and to what extent available information and proposed criteria of prognostication are applicable in the thrombolytic era.

METHODS AND RESULTS

We reassessed risk prediction in the 10,219 survivors of myocardial infarction with follow-up data available (ie, 98% of the total) who had been enrolled in the GISSI-2 trial, relying on a set of prespecified variables. The 3.5% 6-month all-cause mortality rate of these patients compared with the higher value of 4.6% found in the corresponding GISSI-1 cohort, originally allocated to streptokinase therapy, indicates a 24% reduction in postdischarge 6-month mortality. On multivariate analysis (Cox model), the following variables were predictors of 6-month all-cause mortality: ineligibility for exercise test for both cardiac (relative risk [RR], 3.30; 95% confidence interval [CI], 2.36-4.62) and noncardiac reasons (RR, 3.28; 95% CI, 2.23-4.72), early left ventricular failure (RR, 2.41; 95% CI, 1.87-3.09), echocardiographic evidence of recovery phase left ventricular dysfunction (RR, 2.30; 95% CI, 1.78-2.98), advanced (more than 70 years) age (RR, 1.81; 95% CI, 1.43-2.30), electrical instability (ie, frequent and/or complex ventricular arrhythmias) (RR, 1.70; 95% CI, 1.32-2.19), late left ventricular failure (RR, 1.54; 95% CI, 1.17-2.03), previous myocardial infarction (RR, 1.47; 95% CI, 1.14-1.89), and a history of treated hypertension (RR, 1.32; 95% CI, 1.05-1.65). Early post-myocardial infarction angina, a positive exercise test, female sex, history of angina, history of insulin-dependent diabetes, and anterior site of myocardial infarction were not risk predictors. On further multivariate analysis, performed on 8315 patients with the echocardiographic indicator of left ventricular dysfunction available, only previous myocardial infarction was not retained as an independent risk predictor.

CONCLUSIONS

A decline in 6-month mortality of myocardial infarction survivors, seen within 6 hours of symptom onset, has been observed in recent years. Ineligibility for exercise test, early left ventricular failure, and recovery-phase left ventricular dysfunction are the most powerful (RR, > 2) predictors of 6-month mortality among patients recovering from myocardial infarction after thrombolysis. Qualitative variables reflecting residual myocardial ischemia do not appear to be risk predictors. The lack of an independent adverse influence of early post-myocardial infarction angina on 6-month survival represents a major difference between this study and those of the prethrombolytic era.

Cell kinetics and prognosis in gastric cancer

METHODS

The potential proliferative activity of primary gastric cancer was determined using the in vitro tritiated thymidine labeling index (LI) technique.

RESULTS

The proliferative rate had a wide range (0.1-28.4%) with a median value of 9.3%. The cell kinetics of the primary tumor were not related to clinicopathologic features, such as the patient's age and sex or the tumor's histologic type and stage. The contribution of cell kinetics to prognosis was investigated in a series of 28 patients (median follow-up, 34 months). The 3-year survival rate was 50% for patients with slowly proliferating tumors compared with only 13% for those with rapidly proliferating tumors. Moreover, in patients with high-LI tumors, the risk of death was more than sixfold greater than for those with low-LI tumors.

CONCLUSIONS

These data suggest that cell kinetic studies might be an important discriminant to predict prognosis in gastric cancer.

Chronic dialysis in patients with systemic amyloidosis: the experience in northern Italy

The clinical outcome of 61 patients with renal amyloidosis treated with chronic dialysis was reviewed. Eighteen patients, 4 with primary or AL amyloidosis and 14 with reactive or AA amyloidosis, died within one month from starting treatment. The other 43 patients were treated with dialysis for 3 to 199 months and are the object of this study. Sixteen patients had AL amyloidosis and 27 had AA amyloidosis. Thirty-five patients were treated with hemodialysis (HD) for a mean period of 40 +/- 47 months and 8 were treated with continuous ambulatory peritoneal dialysis (CAPD) for 20 +/- 15 months. Patient survival rate at 1 and 5 years was 68% and 30% respectively. There was no difference in survival rate between patients treated with HD and those treated with CAPD, while patients younger than 45 had a better 5-year survival rate. Twenty four (60%) patients achieved a satisfactory rehabilitation with dialysis. At the last follow-up, 15 patients (14 on HD, 1 on CAPD) were alive 61 +/- 58 months after starting dialysis. Twenty-eight patients died after 30 +/- 20 months. The main causes of death were: cardiovascular accident (11), stroke (3), sepsis (5) and cachexia (5). The most important extra-renal complications of amyloidosis were related to cardiovascular involvement (heart failures, arrhythmias, hypotension) and gastrointestinal involvement (malabsorption). Intra-dialytic hypotension in patients on HD and peritonitis in patients on CAPD were the main problems related to dialytic procedure. his study confirms that life expectancy and the quality of life of dialysis patients with systemic amyloidosis are poorer than those of general dialysis population.(ABSTRACT TRUNCATED AT 250 WORDS)

Effective pre-emptive therapy with Ganciclovir and specific immunoglobulins for CMV infection in a bone marrow transplanted patient

BACKGROUND

A 29-year-old man, who underwent allogeneic bone marrow transplantation (BMT) for acute non lymphoid leukemia (ANLL), presented with blood pancytopenia and mild hypoxemia on day +39, without signs of acute graft versus host disease (GVHD).

METHODS AND RESULTS

Cytomegalovirus (CMV) antigens were detected on WBCs and cells from bronchoalveolar lavage by immunofluorescence (IF) with specific murine monoclonal antibodies. Prompt treatment with Ganciclovir and high titer CMV immunoglobulins was followed by disappearance of the laboratory findings of CMV infection. Therapy was well tolerated and no side effects were recorded except for hematological depression that did not reverse after withdrawal of the therapy. The patient is relatively well on day + 210.

CONCLUSIONS

Detection of CMV antigenemia appears to be a valuable tool for deciding whether to start CMV therapy with potentially toxic antiviral drugs in BMT patients in early engraftment, with or without overt signs of CMV infection.

In vitro potentiation by lonidamine of the cytotoxic effect of adriamycin on primary and established breast cancer cell lines

Lonidamine is a new potential chemotherapeutic agent, relatively non-toxic, that can positively modulate the efficacy of several antineoplastic drugs. We evaluated the response of two established human breast cancer cell lines (MCF-7 and BRC-230) and of 20 primary breast cancer cell lines to lonidamine, either alone or in combination with adriamycin, the drug most widely used in the management of breast cancer. Different schedules were tested by varying either concentration of the drugs (LND: 10-150 micrograms/ml; ADM: 0.10-0.15 micrograms/ml), or time of exposure (1-96 hours), or sequence of administration (ADM-->LND; LND-->ADM; ADM+LND). Our results indicate slight sensitivity of the cell lines to lonidamine when used alone, whereas an increase of efficacy was noted when lonidamine was added for at least 24 hours after a 4 hour exposure to adriamycin. Such efficacy was significantly greater than that expected from an additive effect between the two drugs. We conclude that lonidamine, when given according to an appropriate schedule, enhances, in vitro, the efficacy of adriamycin. A correct employment of lonidamine in the management of breast cancer might therefore potentiate the therapeutic effect of adriamycin.

[Effect of the resection margin and the extrarectal spread on the recurrence following 2 types of surgical procedures in rectal cancer]

A prospective unrandomized clinical study was conducted to determine the incidence of local recurrences after radical surgery and to ascertain whether the anterior resection could be an effective approach in cases of the tumours of the rectum, also in presence of the unsatisfied distal clearance and the extraparietal spread. For this purpose the length of the rectum below the tumor, mesorectum included, was cut in little cubes of 1 square cm and 10 microslices/cm at random were histologically examined to locate the intramural diffusion and extraparietal spread. Sixty-one patients undergoing curative surgery for rectal cancer entered the trial. Thirty-seven of them have been operated on by anterior resections (AR) and twenty-four by abdominal-perineal amputation. Thirteen local recurrences (21.3%) have been recorded during a five-year follow-up: 9 after AR and 4 after Miles operation. Nine relapses were among the cases with distal clearance less than 3 cm an eight of these have undergone anterior resections. No recurrence was seen in cases with distal clearance greater than 5 cm. Spread was found in 11 (18%) patients. Five recurrences were recorded all belonging to the group with anterior resection. No statistical difference exists between conservative surgical procedure and abdominal-perineal operation. We have been able to demonstrate only the direct relationship between relapse and Dukes C stage after curative rectal surgery.