Validation of the Italian version of the Stanford Childhood Health Assessment Questionnaire for measuring functional status in children with chronic arthritis

The Stanford Health Assessment Questionnaire developed by Singh et al. to measure functional status in children with chronic arthritis (CHAQ) was translated into Italian (I-CHAQ), with minor modifications to obtain cross-cultural equivalence. This version was evaluated in a series of 96 patients with juvenile rheumatoid arthritis (JRA), both males and females ranging in age from 3 to 19 years (mean age 9.9 years). All three onset subtypes and all four classes of disability were represented in the sample. The questionnaire was filled in by the parents if the children were less than 8 years of age (23 cases), and by the children themselves in all other cases; a health professional was always present to provide assistance. As expected, JRA patients with a systemic or polyarticular disease onset had higher scores than those with a pauciarticular onset, and there were statistically significant differences in disability index values between patients from different Steinbrocker functional classes. The instrument showed good reproducibility in a test-retest over a two-week period, a high correlation between the child and parent scores, excellent internal reliability, and good convergent and discriminant validity.

Outcome of left ventricular aneurysmectomy with patch repair in patients with severely depressed pump function

To determine the efficacy of left ventricular (LV) aneurysm resection and endoventricular patch repair with septal exclusion in patients with severely depressed pump function, we retrospectively selected 62 patients (mean age 59 +/- 7 years) with preoperative LV ejection fraction < or = 20%, from a series of 322 patients with postinfarction LV aneurysm who underwent this type of surgery at our center during a 5-year period. Mean ejection fraction was 17 +/- 3%; all patients were in New York Heart Association (NYHA) class III/IV, and all had hemodynamic and electrophysiologic studies before and after surgery. We analyzed both operative and long-term survival, and hemodynamic, electrophysiologic, and angiographic variables, as well as the symptomatic state after surgery. Follow-up was available in all patients (mean 23 +/- 14 months). Subtotal endocardiectomy and cryotherapy were associated in patients presenting with spontaneous or inducible ventricular arrhythmias (VA). Hospital mortality rate was 19.3%. Ejection fraction improved from 17 +/- 3% to 37 +/- 10% (p < 0.001); ventricular arrhythmias decreased significantly after surgery. Factors influencing early mortality at multivariate analysis were the presence of critical lesions on the circumflex artery and the duration of cardiopulmonary bypass. At 1-year control, a significant reduction in NYHA class was observed and no patient was in NYHA class IV. The improvement in ejection fraction was maintained (39 +/- 11%), as well as the reduction in inducible and spontaneous ventricular arrhythmias. There were 5 late deaths at follow-up, accounting for a late mortality of 10% at 5 years.

Regional myocardial performance of non-ischaemic zones remote from anterior wall left ventricular aneurysm. Effects of aneurysmectomy

The aim of this work was to investigate the effects of resecting a post-infarction left ventricular anterior aneurysm on the kinetics of the non-ischaemic inferior wall, remote from the healed lesion. Thirteen patients, with an anterior post-infarction aneurysm and a normal right coronary artery who underwent aneurysmectomy with endoventricular circular patch plasty reconstruction, had a complete haemodynamic study before and shortly after surgery. The shape of the left ventricle was quantitatively analysed by calculating the regional curvature at 90 points of the angiographic outlines (30 degrees right anterior oblique projection). Segmental wall motion was studied by means of the centreline method and by constructing pressure-length loops from the endocardial movement of 18 chords intersecting the left ventricular inferior contour and by simultaneously tracing the high-fidelity left ventricular pressure. Analysis of pressure-length regional loops showed a complex pattern of abnormal contraction and relaxation in the non-ischaemic inferior regions at baseline; after surgery such abnormalities decreased significantly and tended to revert to normal in many cases. Left ventricular shape in the inferior region was abnormal in 10/13 patients in that there was negative curvature at the interface between the aneurysm and the inferior wall that was corrected to positive after surgery. Regional inferior wall motion and global ejection fraction significantly improved after surgery in these 10 patients. The three patients whose global ejection fraction did not improve showed no inferior negative curvature pre-operatively, nor did they show an increase in inferior wall motion. The results indicate that regional function and shape in inferior, non-ischaemic regions, remote from an anterior aneurysm, are abnormal but potentially correctible if the abnormal mechanical burden imposed on the wall is relieved.

Effects of peptide T derivatives on the proliferation of cultured human keratinocytes

[D-Ala1]peptideT-amide, the linear hexapeptide H-Thr-Hse-Asn-Tyr-Thr-Asp-OH (LPT) and its cyclic analog, cyclo(-Thr-Hse-Asn-Tyr-Thr-Asp-) (CPT), were tested for their effects on the proliferation of cultured normal human keratinocytes (KTs) in comparison with vasoactive intestinal peptide (VIP). [D-Ala1]PT-NH2, LPT and VIP (all 0.1 mumol/l) increased the cell number in KT cultures, whereas CPT was ineffective. The VIP antagonist [N-Ac-Tyr1,D-Phe2]GRF (1-29)-NH2 significantly inhibited the VIP effects on KTs. On the other hand this antagonist did not affect the peptide T (PT) compounds-induced stimulation of KTs, providing indirect evidence that the mitogenic effects of VIP and PT peptides are probably mediated via different receptors.

Nerve growth factor receptor and neurochemical markers in human oral mucosa: an immunohistochemical study

BACKGROUND

The innervation of the oral mucosa has so far been studied mainly by histochemical and ultrastructural techniques. Only few studies have investigated the presence of neural proteins and neurotransmitters in human gingival mucosa.

OBJECTIVE

The purpose of the present study was to evaluate the presence and distribution of neural structural and transmitter proteins in different areas of normal human oral mucosa.

METHOD

Indirect immunofluorescence was employed on specimens taken from different mucosal regions (gingiva, lips, gums, palate). Both structural (low-affinity nerve growth factor receptor, NGFr; protein gene product 9.5, PGP 9.5) and neuropeptide markers (substance P; calcitonin gene-related peptide; vasoactive intestinal peptide, neuropeptide Y) were used.

RESULTS

NGFr and PGP 9.5 intensely labelled both nerve fibres and selected epithelial cells, while neuropeptide immunoreactivity was scarcely expressed and exclusively localized in nerve fibres.

CONCLUSIONS

Similarly in the distribution pattern and neurochemistry between oral and cutaneous innervation is apparent. Expression of NGFr could be relevant to the trophism of both the oral innervation and epithelium.

Replacement of the ascending aorta and aortic arch with bovine pericardial grafts. A preliminary report

Bovine pericardial (BP) grafts have been clinical use at Biocor Hospital since 1989 for replacement or repair of the ascending aorta (AsAo) and initial segment of the aortic arch (AoAr). The main advantages of BP grafts that have justified their clinical application are much easier surgical technique, perfect hemostasis and low cost. From Feb/89 to Feb/94, 88 BP grafts were implanted in the AsAo or the AoAr. There were 33 valved conduits, 47 non-valved conduits and 8 patches. The main indication for the procedure was acute dissection of the aorta, accounting for 50% of the cases. The total hospital mortality was 20.4%. Follow-up was obtained in all but two patients. Patients who survived 2 or more years postoperatively (n = 31) underwent either an echocardiographic or an angiographic study in order to access the behavior of the graft, which was perfect in all of them. The current follow-up is short and complications such as calcification may still develop. However the present study has clearly shown the superior handling and better hemostasis of BP grafts compared to the classical Dacron prosthesis.

Lung function and diffusing capacity for carbon monoxide in patients with juvenile chronic arthritis: effect of disease activity and low dose methotrexate therapy

OBJECTIVE

We measured lung function, in terms of lung volumes, forced expiratory flow-volume curves and diffusing capacity of carbon monoxide (DLCO), in a group of 61 patients with juvenile chronic arthritis (42 female; age range 5 to 33 years) to ascertain whether disease activity and treatment with low dose methotrexate (MTX) influenced these parameters. The whole population was divided into subgroups based on onset type (systemic, n = 27; pauciarticular, n = 12; polyarticular, n = 22), disease activity (active, n = 42; inactive, n = 19), and MTX treatment (treated, n = 27; not treated, n = 34).

RESULTS

We found that maximal-mid expiratory flow (MMEF) was significantly reduced in patients with active disease (p < 0.025). The mean DLCO value, expressed as a percentage of the predicted value, and DLCO corrected for the hemoglobin value were lower than expected (67% and 80%, respectively). Multiple regression analysis showed that the forced vital capacity (FVC), forced expiratory flow in one second (FEV1) and DLCO were all correlated to the clinical subtype of the disease (p < 0.05, p < 0.02, p < 0.02, respectively), and MMEF was related to disease activity (p < 0.025). There was no evidence of any effect of MTX treatment on the pulmonary parameters.

CONCLUSION

This study confirms that JCA is characterized by an impairment of lung function, mainly involving the small airways, and by interstitial damage. These changes are related to the clinical subtypes of the disease and to disease activity.

Alterations in left ventricular shape in patients with angina and single-vessel coronary disease

BACKGROUND

Left ventricular shape alterations, apparently independent of acute ischaemia or previous myocardial infarction, have been described in patients with stable angina. Our previous observations had been made in a group of patients with multivessel coronary disease; it was therefore not possible to establish a clear-cut anatomical relationship between the location of ischaemia and the changes in left ventricular contour. The aim of this work was to extend the previous observations by analysing left ventricular shape in patients with angina and single-vessel coronary disease, in whom the potentially ischaemic region can be easily localized.

METHODS

Fifty-eight patients with stable or unstable angina were retrospectively selected if they had single-vessel disease, normal regional and global function and no previous myocardial infarction: 37 had a critical stenosis (more than 75% diameter reduction) of the left anterior descending artery and 21 had a critical stenosis of the right coronary artery. Patients with left ventricular hypertrophy or any other obvious cause of myocardial dysfunction were excluded. All patients underwent haemodynamic study. Left ventricular global shape was evaluated by calculating eccentricity and circular indices; regional curvature was measured at 90 points along the angiographic contours (right anterior oblique projection) by applying a windowed Fourier analysis. Results were compared with those obtained in 16 normal subjects.

RESULTS

Patients had significant diastolic alterations in left ventricular shape, which assumed a more rounded aspect than normal. Regional curvature was significantly altered at several points pertaining to the anterior, apical and inferior segments. The pattern of changes in regional curvature was about the same in the left anterior descending and right coronary artery groups, with the involvement of regions supplied by angiographically normal arteries, although the extent of alteration was greater in patients with stable, chronic angina (more than 6 months) and in patients with stenosis of the left anterior descending artery.

CONCLUSIONS

Patients with angina, no previous myocardial infarction and normal systolic function had left ventricular shape abnormalities either in the potentially ischaemic or in the remote zones. The mechanism leading to these changes is still speculative.

Left ventricular shape changes induced by aneurysmectomy with endoventricular circular patch plasty reconstruction

Aneurysmectomy with left ventricular (LV) patch plasty reconstruction for anterior post-infarction LV aneurysm is usually followed by favourable haemodynamic results. The aim of this work was to describe the changes in LV shape induced by the intervention and to correlate them to the pre-operative data and to the surgical results. Twenty-two patients submitted to aneurysmectomy with this technique underwent a haemodynamic study before and 10-15 days after the intervention. Segmental wall motion was studied by the centreline method. LV shape was analysed by calculating the regional curvature of angiographic outlines (RAO 30 degrees projection). Results showed an improvement in LV pump function in 17 patients, which appeared mainly due to increased systolic shortening of the inferior wall. The intervention-induced modifications of LV geometry were characterized by: (1) marked reduction in end-diastolic volume, (2) shift of the angiographic apex counterclockwise, towards the aortic corner, (3) disappearance of the rim with negative curvature corresponding to the infero-apical border of the aneurysm, where the inferior wall resumed a normal outward convexity. No significant difference was found between the pre-operative haemodynamic data of patients who improved after surgery and those who did not. The presence of a rim of negative curvature at the infero-apical border of the aneurysm was the only pre-operative sign with a predictive value for the surgical outcome.

Clonal expansions of V delta 1+ and V delta 2+ cells increase with age and limit the repertoire of human gamma delta T cells

We have investigated the complexity of the human gamma delta T cell repertoire by means of a VJ heteroduplex analysis method. cDNA obtained from peripheral blood mononuclear cells was amplified with V delta 1-C delta or V delta 2-C delta primers. The product was denatured and renatured to allow random reannealing of the strands and the heteroduplexes carrying mismatched junctional sequences were separated from the homoduplexes on polyacrylamide gels. Whenever one or more T cell clones were expanded to over 10% of the polyclonal background, discrete bands of homo- and heteroduplex appeared. This method was applied to the analysis of the peripheral gamma delta compartment from healthy donors and rheumatoid arthritis patients of different ages. While samples from young individuals showed a polyclonal pattern, a clear tendency towards oligoclonality appeared with increasing age, both in normal individuals and rheumatoid arthritis patients. We also show that the VJ junctional sequence derived from the heteroduplex fragments can be successfully used to isolate and characterize the corresponding T cell clones in vitro, even after a period of 1 year. In conclusion, our findings indicate that the complexity of the gamma delta T cell repertoire decreases with age as a consequence of the expansion of a few T cell clones.

Expression and function of nerve growth factor and nerve growth factor receptor on cultured keratinocytes

Keratinocytes, a key cellular component both for homeostasis and pathophysiologic processes of the skin, secrete a number of cytokines and are stimulated by several growth factors. Nerve growth factor (NGF) is synthesized in the skin and basal keratinocytes express the low-affinity nerve growth factor receptor (NGF-R). We present evidence that normal human keratinocytes in culture express the low- and the high-affinity NGF-R both at the mRNA level, as determined by reverse-transcription polymerase chain reaction and at the protein level, as shown by cytofluorimetric analysis. NGF significantly stimulates the proliferation of normal human keratinocytes in culture in a dose-dependent manner. This effect can be prevented by the addition of both an anti-NGF neutralizing antibody and a high-affinity NGF-R (trk) specific inhibitor, the natural alkaloid K252a. By contrast, keratinocyte proliferation is not inhibited by an anti-low-affinity NGF-R monoclonal antibody, thus suggesting that NGF effect on human keratinocytes is mediated by the high-affinity NGF-R. Moreover, NGF mRNA is expressed in normal human keratinocytes and NGF is secreted by keratinocytes in increasing amounts during growth, as detected by enzyme-linked immunosorbent assay. These results suggest that NGF could act as a cytokine in human skin and take part in disorders of keratinocyte proliferation.

Dipyridamole angina: a specific symptom of severe multivessel disease

BACKGROUND

Several studies have indicated that ischemia induced by dipyridamole is frequently associated with angina or ischemic ST-segment depression and that it occurs mainly in patients with three-vessel disease, those with collateral vessels, or those with both.

METHODS

In order to analyze the diagnostic relationships among them, we studied 227 consecutive patients who underwent coronary angiography and dipyridamole-thallium scintigraphy.

RESULTS

A perfusion defect was found in 134 patients. Of these, 88 patients (66%) showed no significant ECG modifications or angina; 46 (34%) had a transient ST-segment depression, which was associated with typical angina ('dipyridamole angina') in 12. These 12 patients had three-vessel disease with intercoronary collateral circulation. Among the 134 patients with coronary critical stenoses and a positive thallium-dipyridamole test, collateral vessels were detected in 91 (68%).

CONCLUSION

Dipyridamole angina, occurring during a positive dipyridamole-thallium test, is usually a manifestation of severe coronary stenoses with collateral circulation. However, as a diagnostic symptom it is characterized by high specificity but low sensitivity.

Surgical repair of transposition of great arteries and total anomalous pulmonary venous return to the coronary sinus (TGA with TAPVR)

The association of transposition of the great arteries (TGA) and total anomalous pulmonary venous return (TAPVR) is very rare; we report one case of this malformation with an intracardiac type of TAPVR draining into the coronary sinus. The surgical repair was performed directing the coronary sinus blood flow to the tricuspid valve. The proximity of the anatomical structures allowed an intra-atrial patch repair similar to a modified Mustard procedure. In the postoperative period the child developed low cardiac output for 2 days, requiring inotropic support and mechanical ventilation. Her recovery was otherwise uneventful. The postoperative echocardiogram showed an intact repair with perfect flow through the patch from the pulmonary veins to the right ventricle. Almost 2 years after surgery, the patient underwent cardiac catheterization that showed integrity of the surgical repair with normal pressures in all heart chambers. To our knowledge this is the first report in the medical literature of surgical treatment of this association.

Left ventricular remodeling in chronic aortic regurgitation

Left ventricular (LV) shape in chronic volume overload due to aortic regurgitation is commonly described as rounder than in normal subjects. This statement derives from observations of qualitative nature or based on the measure of eccentricity index. We analyzed LV shape and function in 16 normal subjects (N) and in 24 patients with chronic pure aortic regurgitation (AR), without coronary artery disease or associated mitral regurgitation. LV cavity geometry was quantitatively evaluated from end-diastolic and end-systolic outlines obtained in 30 degrees RAO angiographic projection, by calculating: 1. the eccentricity and circularity indexes, 2. the regional curvature at 90 equidistant points using a windowed Fourier series approximation of contours, in which the number of harmonics and filter-window were locally chosen in order to minimize the reconstruction errors and to maximize the smoothness of the curve, 3. by measuring the length of the anterior and posterior hemi-perimeter of LV outlines and 4. by performing a Fourier analysis of LV contours. Neither eccentricity nor circularity indexes were adequate to differentiate shape abnormalities, whereas Fourier geometric analysis indicated abnormalities of shape in AR. Regional curvature showed that diastolic outline of AR had a greater curvature of the anterobasal, anterolateral and inferoapical regions and a lower curvature of the anteroapical one. Systolic outline showed a greater curvature of the inferoapical region and a lower curvature of the anteroapical one.(ABSTRACT TRUNCATED AT 250 WORDS)

Autoradiographic detection of substance P receptors in normal and psoriatic skin

Substance P has been detected in human skin and has been implicated in the pathogenesis of certain inflammatory cutaneous disorders. However, little is known about the number and distribution of substance P binding sites in the skin. Receptor autoradiography was employed to detect and quantitate substance P receptors in normal as well as psoriatic skin. Substance P binding sites were distributed in the epidermis and dermis both in normal and psoriatic skin. In the dermis, the highest densities of SP binding sites were found in the areas corresponding to the dermal papillae and the adnexal structures. Quantitative analysis revealed that saturable binding was obtained both in the epidermis and in the labeled dermal areas. Rosenthal plot values were consistent with a single population of binding sites. No difference in the binding measurements was observed between normal and psoriatic skin. The presence of substance P receptors in the epidermis and in the dermal papillae raises interesting issues on the possible targets of this peptide in human skin both under physiologic and pathologic conditions.

Effects of positive inotropic stimulation (post-extrasystolic potentiation) on non-uniformity of left ventricular contraction in patients with coronary artery disease

In patients with chronic coronary artery disease, post-extrasystolic potentiation (PESP) slightly worsens relaxation, increasing the constant tau of ventricular pressure decay. However, it does not negatively influence left ventricular (LV) diastolic filling. To our knowledge, no data are available on the effects of PESP on segmental relaxation in chronic coronary artery disease. The effects of PESP on the LV pressure-volume (P/V) relationship and on segmental pressure-length loops (P/L) were studied in eight patients with coronary artery disease submitted to LV angiography. P/V loops were constructed by means of frame-to-frame analysis of ventriculograms and simultaneous high-fidelity LV pressure tracings; P/L loops were calculated by the endocardial movement of 45 chords intersecting the LV outline (centreline method). PESP was produced by programmed stimulation during ventriculography. P/V and P/L loops were studied in basal conditions and after PESP.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative evaluation of left ventricular shape in anterior aneurysm

The purpose of the study was to analyze left ventricular (LV) shape in post-infarction anterior aneurysm by utilizing quantitative analysis of wall curvature. Forty-one patients (39 men, 2 women; mean age 56 years) subjected to surgical intervention for LV aneurysm complicating an anterior myocardial infarct were retrospectively evaluated. In all patients the presence of resectable aneurysmal tissue had been confirmed by direct surgical examination. Patients with inferior myocardial infarction and patients who had undergone percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery were excluded. Pre-intervention ventriculograms (RAO projection) were analyzed. LV wall excluded. Pre-intervention ventriculograms (RAO projection) were analyzed. LV wall motion was studied by applying the centerline method. Regional curvature of end-diastolic and end-systolic outlines was calculated at 90 equidistant points from aortic corner (point 1) to mitral plane (point 90). Patients with LV anterior aneurysm show a typical pattern of alterations in wall curvature, which is characterized by a shifting of the angiographic apex (the point with the greatest curvature) towards the mitral plane, and by a sharp shift of curvature values at the antero-basal and infero-apical regions, marking the borders of the sac. These hinge points closely correspond to the external limits of wall motion abnormalities. Significant correlations were found between degree of regional curvature alterations and severity of global LV dysfunction, as indicated by decrease of ejection fraction and increase of end-systolic volume. In conclusion, quantitative evaluation of LV shape by means of wall curvature analysis allows recognition of the characteristic morphologic changes of the aneurysm, i.e., wall expansion and deformation.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropeptides and skin inflammation

Neuropeptides (NP) are protein compounds contained both in the central and peripheral nervous system. They can be antidromically released from sensory nerves and are implicated in the so-called neurogenic inflammation. They also exert a number of functions within the immune system and are thought to act as trophic as well as mitogenic substances. Several NP have been detected in human skin by immunohistochemical and radioimmunological techniques, and recent reports have demonstrated that NP could be involved in the mechanisms of certain dermatoses. The involvement of NP in either physiological or pathophysiological skin conditions is discussed. Moreover, a few questions, which still need to be addressed, are raised, and future directions this field of research should take are outlined.

Expression of growth-associated protein 43 and nerve growth factor receptor in human skin: a comparative immunohistochemical investigation

The growth-associated protein 43 (GAP43) is a neuronal membrane protein involved in axonal growth and regeneration as well as in the modulation of synaptic plasticity. It is present in sensory and sympathetic neurons, where it is consistently associated with the expression of nerve growth factor receptor (NGFr). We investigated, by means of immunohistochemistry, the presence and distribution of the GAP43-immunoreactivity (IR) and of the NGFr-IR in the adult normal human skin from various body regions. In adjacent sections, a comparison with the distribution of the neuronal markers protein gene product 9.5 (PGP 9.5), substance P (SP), and calcitonin gene-related peptide (CGRP) was performed. Our results indicate that in adult human skin 1) a GAP43-IR is morphologically present in epidermal and dermal nerve fibers; 2) a NGFr-IR is associated with neuronal as well as non-neuronal elements of cutaneous nerves; 3) the basal epidermal cell layer expresses a NGFr-IR, which is unevenly distributed according to the different body areas; and 4) there is suggestive evidence for a simultaneous expression of GAP43-, NGFr-, PGP 9.5-, SP-, and CGRP-IR in at least part of the cutaneous nerve fibers. The presence of GAP43-immunoreactive nerve fibers might be a marker of a continuous synaptic remodeling in adult skin, whereas the distribution of the NGFr-IR could be relevant for our understanding of the maintenance of the neuronal-target relationship(s).

[Analysis of regional kinetics of the left ventricle by integration of morphologic data]

Regional left ventricular (LV) curvature analysis is a useful tool to assess the pathomorphological changes in LV shape which occur in different heart diseases. As LV shape changes follow regular trajectories, we used the curvature extrema and the normalized curvature variations as the features for identifying the movement of the borders during the cardiac cycle (curvature-motion method: CM). The regional curvature was calculated using a windowed Fourier series approximation of contours, in which the number of harmonics and filter-window were locally chosen in order to minimize the reconstruction errors and to maximize the smoothness of the curve. Analysis programs were tested on a series of ventricle-shaped contours, software generated. Left ventricular diastolic and systolic outlines obtained from RAO 30 degrees LV angiography in 24 patients with aortic insufficiency and in 16 subjects without heart disease were analyzed. Left ventricular curvature and regional wall motion were calculated in each subject. In respect to normal subjects, LV shape in aortic regurgitation definitely appears asymmetric because of the elongation of the anterior hemiperimeter and the prevailing expansion of the apical and anterolateral regions. These alterations in cavity geometry correlate to the decrease in pump function. According to these results wall motion analysis using the CM showed a greater extension of LV asynergy, while usual methods as the centerline or the radial one indicate a greater damage of the apical regions. Thus, the CM method seems to be a promising tool for wall motion analysis.