The autonomic nervous system in systemic sclerosis. A review

The autonomic nervous system is an underestimated target of systemic sclerosis alterations. In this review we analyzed the major manifestations of its involvement, reconsidering the main theories of its pathogenesis.

[Peripheral neuropathy rehabilitation. Indications for a diagnostic-rehabilitation approach]

The increased incidence of occupational neurological disorders has led, in recent years, to the development of new specialties in neurorehabilitation for the recovery of deficits of central nervous system (CNS) lesions. This same development has not occurred for damage to the peripheral nervous system (PNS), the treatment of which is still based on empirically applied rehabilitation techniques. This is due to the fact that the peripheral neuropathies comprise a vast groups of disorders caused by a huge variety of etiological agents; in order to identify their exact cause and thus be able to differentiate rehabilitation techniques it is necessary to classify them. The aim of this study is to summarize the main rehabilitation strategies, pharmacological treatments and surgical techniques used most effectively in the management of peripheral neuropathies in order to develop a therapeutic rehabilitation strategy for each of the different forms and lay the bases for the development of specific guidelines.

Pupillocynetic activity of substance P in systemic sclerosis

OBJECTIVE

In systemic sclerosis (SSc), dysfunctions of peripheral nervous system (PNS) have been observed. Substance P (SP) instillation in human eye induces a cholinergic-independent pupil myosis. Pupil basal diameters (PBD) and pupil responsiveness to SP, expressed as area under the curve (AUC), were studied by pupillometry to assess SP-ergic fiber state and function in SSc.

METHODS

Forty SSc patients [24 with limited (lSSc), 16 with diffuse (dSSc) disease] and 40 controls underwent pupillometric evaluation. After evaluation of PBD, SP 10-3 M was instilled in one eye and placebo in the contralateral eye. Antinuclear (ANA), anticentromere (ACA), and anti-Scl-70 autoantibodies were correlated with PBD and AUC.

RESULTS

PBD was significantly lower in SSc patients versus controls (p < 0.001). PBD was minor in lSSc versus both dSSc and controls (p < 0.05), but no difference was found between dSSc and controls. In SSc, SP 10-3 M induced greater myosis compared to controls (p < 0.001). SP 10-3 M-induced myosis was higher in lSSc versus both dSSc and controls (p < 0.05). ACA significantly correlated with decreased values of PBD and AUC (p < 0.001).

CONCLUSION

Our results show that PBD is reduced in patients with SSc and that SP induces a more intense myosis in SSc than controls. Moreover, in lSSc PBD is lower and SP increases the myosis in lSSc compared to dSSc and controls. This suggests a peculiar dysfunction of PNS in patients with the limited subset of SSc.

Can continuous physical training counteract aging effect on myoelectric fatigue? A surface electromyography study application

OBJECTIVES

To compare the myoelectric onset of muscle fatigue in physically active trained young skiers with respect to elderly skiers and to test whether continuous training can counteract the selective loss of type II muscle fibers usually observed with aging.

DESIGN

An observational, cross-sectional study of the myoelectric onset of muscle fatigue in the left tibialis anterior muscles.

SETTING

Surface electromyography recorded with portable devices at a downhill ski rescue lodge in the Italian Alps.

PARTICIPANTS

Fifty-four physically trained, active skiers (43 men, 11 women; age range, 24-85y).

INTERVENTIONS

Questionnaire on physical activity and 2 sustained isometric voluntary contractions at 20% and 2 at 80% of the maximal voluntary contraction level.

MAIN OUTCOME MEASURES

Isometric contractions and mean and median spectral frequencies calculated to monitor the myoelectric manifestations of muscle fatigue.

RESULTS

Fatigue indices did not differ significantly between younger and older subjects and, thus, did not show a correlation between myoelectric manifestations of muscle fatigue and age in physically active subjects.

CONCLUSION

It appears possible that aging skeletal muscles subjected to continuous exercise develop an adaptive response that counteracts the selective loss of type II muscle fibers usually observed in the muscles of elderly sedentary subjects. Our results suggest that physical activity could be considered in the elderly within a broad rehabilitative framework in which appropriate and even tailored physical training could be planned to counteract the physiologic effects of aging on muscle fiber distribution.

[Role of depression in the functional recovery and cost of stay in patients with acute cerebrovascular lesions]

BACKGROUND AND PURPOSE

The constant increase in health costs in recent years has led to the introduction of instruments such as DRG--diagnosis-related groups--with the declared aim of best rationalizing in-hospital costs. As part of this rationalisation it has become necessary to identify the causes of prolonged admissions in health-care structures. As far as concerns the rehabilitation of cerebrovascular diseases, attention has been centred on the presence of post-stroke depression. Our study was aimed at analysing the effect of depression on the time spent in hospital and whether the depression also affected on the patient's potential for functional recovery.

METHODS

Patients with acute cerebrovascular lesions admitted to our center for rehabilitation were enrolled in this study. Depressive syndromes and functional deficits were evaluated at admission and discharge.

RESULTS AND CONCLUSIONS

The most depressed patients were those who spent a longer time in hospital, but they were also those who had a greater functional deficit. The depression did not affect the efficacy and efficiency of the rehabilitation treatment. The time spent in hospital did, however, correlate with the clinical condition of the patient at admission and the age of the lesion.

The use of pupillometry in joint and connective tissue diseases

The central and peripheral nervous systems are variably affected in the rheumatic diseases. Automated standardized infrared pupillometry allows the safe, noninvasive assessment of the pupillary innervation. Pupillometry has already been used in studying the autonomic nervous system (ANS) in various rheumatic diseases. In systemic lupus erythematosus, the irideal parasympathetic branch of ANS was more affected then the sympathetic branch. In Sjögren's syndrome, signs of pupillary parasympathetic denervation have been reported. In rheumatoid arthritis, pupil parasympathetic dysfunction has been shown to correlate with ocular dryness. In systemic sclerosis (SSc), both sympathetic and parasympathetic irideal impairment have been demonstrated. Beside providing autonomic innervation, sensory nerves fibers are able to control iris diameter. Exogenous ocular instillation of substance P (SP), a sensory neuropeptide, can determine an omathropine-resistant, non-cholinergic myosis, acting on specific receptors present on the iris sphincter muscle. We first studied pupillary SP-ergic responsiveness in SSc, evaluating substance P (SP)-stimulated pupillary diameters by pupillometry. A higher basal and SP-stimulated myosis was found in lSSc versus both dSSc and controls, whereas no differences existed between dSSc and controls. From the literature, the pupillary parasympathetic nervous system seems to be more affected than the sympathetic branch of ANS in the rheumatic diseases characterized by an inflammatory status. However, we found in SSc both sympathetic and parasympathetic pupil control to be equally impaired. From our experience, we conclude that pupillary nervous control is differently affected in the two subsets of SSc, and that the SP-ergic system seems to be impaired only in lSSc.

Nerve growth factor and neuropeptides circulating levels in systemic sclerosis (scleroderma)

OBJECTIVE

To determine the circulating levels of nerve growth factor (NGF), neuropeptide Y (NPY), and vasoactive intestinal peptide (VIP) in systemic sclerosis (SSc), and to correlate these levels with clinical and laboratory features.

METHODS

Forty four patients with SSc were evaluated for circulating NGF (immunoenzymatic assay), NPY and VIP (radioimmunoassay), anticentromere and antitopoisomerase I autoantibodies, lung disease (pulmonary function tests with carbon monoxide transfer factor (TLCO), ventilation scintiscan with 99mTc DTPA radioaerosol, high resolution computed tomography (HRCT), pulmonary pressure (echo colour Doppler)), heart disease (standard and 24 ECG, echocardiography), cutaneous involvement (skin score), joint involvement (evidence of tender or swollen joints, or both), peripheral nervous system (PNS) involvement (electromyography), rheumatoid factor, angiotensin converting enzyme (fluorimetric method), von Willebrand factor (ELISA), and erythrocyte sedimentation rate (ESR) (Westergren).

RESULTS

Circulating NGF levels in SSc were significantly increased compared with controls (p<0.00001) and significantly higher in the diffuse than in the limited subset of patients (p<0.01). Patients with articular disease had significantly higher levels of NGF. A significant indirect correlation between NGF levels and TLCO was detected (p<0.01), but no correlation was found between NGF and HRCT, DTPA, skin score, PNS involvement and angiotensin converting enzyme and von Willebrand factor levels, antitopoisomerase or anticentromere antibodies, and ESR. NGF levels increased progressively as the disease worsened. Similarly, VIP circulating levels were significantly increased in patients with SSc (p<0.001), whereas the increase of NPY levels did not reach statistical significance. However, both neuropeptides, following the same trend as NGF, increased as the disease worsened (skin score and lung disease).

CONCLUSIONS

The increase of NGF and VIP in patients with SSc, the former in the diffuse subset of the disease, and in patients with prominent articular disease, may suggest a link between neurotransmitters and the disease pathogenesis. Neuropeptide circulating levels seem to increase only in patients with the most severe disease.

Circadian rhythm of arginine vasopressin in hepatorenal syndrome

The etiology of hepatorenal syndrome is still incompletely understood, but the nonosmotic release of arginine vasopressin (AVP) seems to have an important role. Since AVP presents a well-defined daily periodicity in its production and secretion, the aim of the study was to investigate the circadian rhythm in its circulating plasma concentrations in patients with hepatorenal syndrome, compared with healthy controls. Venous blood samples were drawn during a 24 hour period at 2 hourly intervals from a peripheral vein in 10 healthy subjects and in 10 patients with hepatorenal syndrome for the determination of the circulating plasma levels of AVP by radioimmunoassay. Statistical analysis was carried out by the 'cosinor' method. The controls presented a significant (p < 0.002) circadian rhythm in the AVP circulating levels, whereas no rhythm (p > 0.05) was found in patients. The circadian rhythms were significantly (p < 0.005) different between the two groups, patients having higher mean daily concentration and lower circadian variation of AVP. These results confirm the existence of a well-defined circadian rhythm of AVP in healthy subjects, whereas the hepatorenal syndrome patients present a complete loss of the circadian rhythm. It could be hypothesized that primitive damage in circadian time-keeping regulates the circadian rhythm of vasopressinergic neurons, or has a secondary effect on the peripheral vasodilatation in the course of advanced liver disease. This great upset in the temporal and functional organization, together with that of the renin-angiotensin-aldosterone system, could play an important role in promoting and/or in the maintenance of the hydroelectrolyte imbalance that characterizes the hepatorenal syndrome.

Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement

Erectile dysfunction (ED) is common in men with obstructive sleep apnea (OSAS) but no completely convincing hypotheses about the underlying pathogenic mechanisms have been published in the literature. The aims of the present study were to assess the presence of ED in a group of OSAS patients without daytime respiratory failure and to determine whether this dysfunction was related to peripheral nerve involvement. Evaluation of the bulbocavernosus reflex (BCR) and the somato-sensory evoked potentials of pudendal nerve (PSEPs), the most widely established method of documenting pudendal neuropathies as being the cause of impotence, was performed in 25 patients. Data on BCR were compared with those of 25 healthy males volunteers matched for age. BCR was altered in 17 patients: in 6 it was elicited while in 11 it had a prolonged latency and reduced amplitude. Patients with altered BCR presented an higher AHI, an higher percentage of sleep time spent with SaO2 <90% (TST90) and a lower daytime PaO2. Six patient had clinically silent neurophysiological signs of mild polyneuropathy. The degree of OSAS and gas exchange alteration was more severe in patients with polyneuropathy than in those with isolated BCR alteration. ED is a common finding in OSAS patients and this alteration seems to be related to a nerve dysfunction. The development of nerve dysfunction is associated with a more severe degree of OSAS and nocturnal hypoxia.

Circadian rhythm of serum erythropoietin in myelodysplastic syndromes

Myelodysplastic syndromes (MSD) are a group of clonal disorders of the hemopoietic stem cell, often evolving in acute leukemia. They are characterized by anemia, and it has been attributed either to a deficiency in erythropoietin (EPO) secretion or to a resistance to EPO itself. Since in healthy subjects the serum circulating EPO levels fluctuate during the day, the aim of the study was to investigate the diurnal rhythm of EPO in MDS. Two groups of subjects were admitted to the study: (A) 20 adult clinically healthy subjects, and (B) 20 patients with MDS without renal failure. After standard life conditions in hospital lasting one week, venous blood samples were drawn during the span of a whole day and every four hours, starting from midnight, for the measurement of serum EPO levels by RIA. Statistical analysis was carried out by means of the "cosinor" method. The results show that the controls present a significant (p < 0.05) circadian rhythms in serum EPO levels with acrophase in the late afternoon; on the contrary, no significant (p > 0.05) rhythm was detected in patients with MDS. Patients with MDS presented significantly higher (p < 0.05) MESOR and lower (p < 0.001) amplitude of EPO circadian rhythm in respect to the controls; moreover, a significant (p < 0.005) difference was found between the two groups in overall EPO rhythm. These data confirm the existence of a physiological circadian rhythm in serum EPO concentrations with maximum in the afternoon. Because EPO levels are increased in the patient group, EPO deficiency does not seem to be the cause of anemia in MDS. Reduced EPO amplitude may be a compensatory mechanism for enhancing its activity in MDS. Finally, the stimulatory therapy in MDS with recombinant human EPO should be administered in the late afternoon hours, in order to respecting and simulating the physiological circadian rhythm of endogenous EPO.

Absent innervation of skin and sweat glands in congenital insensitivity to pain with anhidrosis

OBJECTIVES

A case of a 10-year-old girl with congenital insensitivity to pain with anhidrosis (CIPA) is reported.

METHODS AND RESULTS

Parents referred several hyperpyretic episodes without sweating occurring since birth, and insensitivity to pain, noticed when the child was 2 years old. Her body had many bruises and scars, bone fractures and signs of self-mutilation. Neurological examination was normal except for insensitivity to pain. Her IQ was 52. Electrical and tactile sensory nerve conduction velocities were normal. The patient was unable to detect thermal stimuli. Histamine injection evoked a wheal but not a flare; pilocarpine by iontophoresis did not induce sweat. Microneurography showed neural activity from A-beta sensory fibers while nociceptive and skin sympathetic C fiber nerve activity was absent. No small myelinated fibers and very rare unmyelinated fibers were found in the sural nerve. Immunohistochemistry showed a lack of nerve fibers in the epidermis and only few hypotrophic and uninnervated sweat glands in the dermis.

CONCLUSIONS

The lack of innervation of the skin (C and A-delta fibers) appears to be the morphological basis of insensitivity to pain and anhidrosis, and is consistent with the loss of unmyelinated and small myelinated fibers in the sural nerve biopsy.

[Visual reaction times in a group of patients with single cerebrovascular lesions in rehabilitation]

Approximately fifty percent of stroke survivors have neurological deficits. The evaluation of reaction times permits a study of psychomotor performance, which could be very important for a good rehabilitation outcome.

AIM

The aim of the study was the evaluation of visual reaction times in a group of patients with cerebrovascular lesions, during inpatient hospitalisation in a rehabilitation centre.

MATERIALS AND METHODS

46 right-handed patients (34M, 12F) with unilateral cerebrovascular lesion, confirmed by CT or MRI, were enrolled in the study. In each patients visual Simple Reaction Times (SRT) and Multiple Choice Reaction Times (MCRT) were studied. The patients were asked to react by using the hand ipsilateral to the side of the cerebral lesion. Functional impairment of walking, upper limb and hand were measured by a tailored clinical scale with score ranging from 1 to 12. Depression was measured by a modified version of Hamilton scale, tailored for this kind of patient.

RESULTS

13 of 46 patients (28.2%) showed a pathologic reaction time. There was a lack of correlation between reaction times and age, aphasia, lesion size, time from stroke, functional impairment. Patients with hemorrhagic lesions had significantly lower SRT and MCRT. The subgroup of patients with pathologic reaction times were significantly more depressed than patients with normal reaction times.

CONCLUSION

Judging from the present set of results: a) patients with hemorrhagic lesions have lower reaction times; b) the prolongation of reaction times and post-stroke depression appear to be related in stroke patients. This relationship seems to suggest that post stroke depression can negatively affect functional recovery also by means of an impairment of psychomotor performance.

The effects of parachlorophenylalanine and naloxone on acupuncture and electroacupuncture modulation of capsaicin-induced neurogenic edema in the rat hind paw. A controlled blind study

OBJECTIVE

The aim of this work was to study the effect of pre-treatment with parachlorophenylalanine (PCPA) and posttreatment with naloxone on the modulating action on neurogenic inflammation of manual acupuncture and low intensity (5 mAmp), low frequency (5 Hz) electroacupuncture (EA).

METHODS

Edema was induced by the subcutaneous administration of 50 micrograms capsaicin in rat paws. Pre-treatment with intraperitoneal PCPA was given for 3 days: 200 mg/Kg on the first day and 100 mg/Kg on the second and third days. Naloxone (1 mg/Kg) was administered at the end of the stimulation.

RESULTS

The results show that naloxone and PCPA reduce the anti-edema effect of both manual acupuncture and EA. Combined administration of the two drugs completely eliminated the effect of manual acupuncture, and decreased but did not abolish the effect of electroacupuncture.

CONCLUSION

These results indicate that both the opioid and the serotonergic inhibitory control systems are involved in the modulating action of acupunctural stimulation on neurogenic inflammation.

Two methods for the measurement of voluntary contraction torque in the biceps brachii muscle

Appropriate measurement of maximal voluntary contraction force of a single limb muscle or of a muscle group is important in clinical and research situations. To measure muscle force, one segment of an isometric measuring brace is fixed to a support and force is applied to the other. The output of this arrangement is affected by additional contributions such as pushing or pulling with the whole body. This paper quantifies the differences between measurements of torque produced by the biceps brachii with the brace fixed versus those produced when the elbow joint was isolated by suspending the brace from cables. No statistically significant differences were found between MVC values observed with the two methods within subjects. However, a statistically significant difference in EMG fatigue indices was observed and attributed to a different sharing of force production among different muscles in the two conditions. We conclude that different brace arrangements may lead to the same maximal force but to different rates of myoelectric manifestations of muscle fatigue since the effort may be shared differently among the muscles of synergic or stabilizing groups.

Plasma levels of arginine vasopressin in hepatorenal syndrome

BACKGROUND

The etiology of hepatorenal syndrome is still incompletely understood, but the non-osmotic release of arginine vasopressin (AVP) seems to have an important role in its pathogenesis. The aim of the study was to investigate the circulating plasma concentrations of AVP in patients with hepatorenal syndrome, compared with healthy controls, in relation with plasma osmolality.

METHODS

Venous blood samples were drawn in 20 healthy subjects and in 20 patients with HRS for the determination of the plasma levels of AVP by radio-immunoassay and of plasma osmolality. The comparison between the two groups was carried out by the Student "t"-test for unpaired data; the plasma AVP levels were correlated with the values of plasma osmolality by linear regression analysis.

RESULTS

The patients presented significantly (p < 0.001) higher plasma AVP levels in respect to controls; on the contrary, plasma osmolality was significantly lower in patients than in controls (p < 0.005). Whereas a significant (r = 0.83; p < 0.001) relationship was demonstrated between plasma AVP and osmolality in controls, no significant (r = 0.23; p > 0.05) correlation was found in patients.

CONCLUSIONS

These results confirm the existence of an activation in the release of AVP in hepatorenal syndrome, due to the activation of the sympathetic adrenal system and to hyponatriemia. The contraction of diuresis in hepatorenal syndrome, on the other hand, is not due to a deficiency in plasma AVP. AVP release occurs despite low plasma osmolality, which normally inhibits its secretion. This great upset in functional organization, together with that of the atriopeptin-renin-angiotensin-aldosterone system, could play an important role in promoting and/or in the maintenance of the hydro-electrolyte imbalance that characterizes the syndrome.

[The clinical evaluation of conservative treatment in patients with the thoracic outlet syndrome]

Conservative treatment of thoracic outlet syndrome is frequently recommended but few studies reporting conservative management are present in literature. Thirteen out-patients with thoracic outlet syndrome (4 males, 9 females) were admitted to a conservative treatment (massage and kinesitherapy) involving the cervical spine and shoulder girdle. All the patients were satisfied with the outcome of the treatment. In particular rest symptoms completely disappeared after treatment in all patients. This study confirms the efficacy of physical therapy in the conservative treatment of patients with thoracic outlet syndrome. Further studies on long-term outcome are needed.

Early development of EMG localized muscle fatigue in hand muscles of patients with chronic heart failure

BACKGROUND

Patients with chronic heart failure (CHF) frequently complain of fatigue and exercise intolerance that are not directly related to the severity of cardiac failure. A not well-defined muscle function impairment is generally considered the cause of such symptoms. The frequency compression of electromyographic (EMG) signal power spectrum during isometric contractions is commonly accepted as an index of the fatigue occurring in the muscle (localized muscle fatigue).

PURPOSE AND METHODS

The purpose of the study was to evaluate muscle fatigue development in a selected group of CHF patients by studying the compression of the EMG signal power spectrum. The first dorsal interosseus of the right, dominant hand was investigated at two levels of contraction: 40% and 80% of the maximal voluntary contraction (MVC).

RESULTS

In CHF patients there was early development of localized muscle fatigue during the high level of contraction (80% of MVC).

CONCLUSION

This study demonstrates the presence of an early development of localized muscle fatigue in CHF patients and confirms the possibility of an increased glycolytic metabolism. Moreover, the changes seem to show that muscle impairment is not limited to large muscles, but also occurs in small muscles of the hands, frequently used during daily activities. Finally, this study confirms the validity of EMG spectral analysis techniques in evaluating muscle fatigue of CHF patients, suggesting a possible use in the rehabilitation of such patients when the technique is correctly used.

Daily distribution of episodes of acute cardiogenic pulmonary edema

Many fatal or potentially fatal cardio-cerebrovascular diseases present a definite circadian distribution in their onset. In order to verify if episodes of acute cardiogenic pulmonary edema have a significant daily periodicity in their occurrence, a retrospective analysis of 1,204 episodes has been conducted. In all cases, the hour of the day of onset has been identified with certainty; all episodes occurred in hospitalized patients. The rhythmometric circadian inferential statistical analysis by means of the single cosinor method demonstrates that the episodes of acute cardiogenic pulmonary edema present a significant (p < 0.002) circadian distribution, with a peak at 1:00 a.m. (from 10:00 p.m. to 4:00 a.m.). No significant differences (p > 0.05) were found in the circadian distribution regarding sex, age (less or more than 60 years), absence or presence of arterial hypertension and coronary artery disease. Several factors may contribute to this behavior, especially the relationships between several endogenous circadian rhythms, sleep and disease. The knowledge that acute pulmonary edema is a high chronorisk disease could be of interest for the better understanding of its pathophysiology and for a better causative control and prevention.

Monoclonal gammopathy of undetermined significance evolving directly in primary plasma cell leukemia

A case of monoclonal gammopathy of undetermined significance (MGUS) which evolved directly into primary plasma cell leukemia (PCL) is reported. Even if MGUS and PCL represent the opposite aspects of the same immunoproliferative disorder, no previous cases of this direct evolution have been described, as stated by an accurate review of the specific literature. The patient abruptly developed PCL after five months from the discovery of a serum monoclonal spike, without any other clinical, laboratory and radiological abnormalities. The practical conclusions of this case report indicate that a patient with MGUS must be followed periodically and over an indefinite period, and that PCL must be considered into the possible evolution of MGUS.

[The use of neurophysiopathological technics in assessing pain syndromes in industrial medicine and rehabilitation]

The use of neurophysiopathological techniques in the assessment of pain syndromes in occupational and rehabilitative medicine. Pain is one the major causes of disability. In occupational medicine this is translated into a loss of working days or the need to change jobs. In rehabilitation pain limits treatment and often lengthens recovery time. Neurophysiopathological techniques can be used to improve neuroalgological diagnosis and gain better understanding of pathogenic mechanisms thus allowing therapy to be targeted more precisely aiding the subject's social and occupational recovery.

Diurnal rhythm of serum erythropoietin circulating levels in chronic obstructive pulmonary disease

OBJECTIVE

Since erythropoietin (Epo) presents a diurnal rhythm in its circulating serum levels and it is reported increased in patients with chronic obstructive pulmonary disease (COPD), the circadian rhythm of Epo was investigated in a group of 40 normocytemic patients with chronic obstructive pulmonary disease compared with 40 clinically healthy subjects.

METHODS

Venous blood samples were drawn in each subject during the span of a whole day every four hours, starting from midnight, for the determination of serum Epo levels by RIA. Statistical analysis was carried out by chronograms and by means of the "cosinor" method.

RESULTS

The control group presents a significant (p < 0.001) circadian rhythm in serum Epo levels, with maximum in the afternoon, whereas no rhythm (p > 0.05) is detected in the patient group. This has significantly (p < 0.05) higher mean daily levels and lower diurnal variations of serum Epo than the control group; a significant (p < 0.05) difference exists between the two groups regarding the peaks of rhythms.

CONCLUSION

These data confirm the presence of circadian rhythm in serum Epo levels and suggest that the COPD, by daytime hypoxemia with associated severe nocturnal desaturation, is associated with increased serum Epo levels both by day and by night, so that the physiological circadian rhythm is lost in these patients.

Systemic sclerosis (scleroderma): an integrated challenge in rehabilitation

Systemic sclerosis (SSc), a multisystem disease involving the microvascular system and the connective tissue, is considered one of the most difficult rheumatic diseases to treat. The natural history of the disease evolves from an edematous to a scleroatrophic phase following two different temporal patterns: acute or chronic. The former leads to early death, and the latter evolves slowly toward severe disability that deserves rehabilitative intervention. Despite the poor prognosis, recent improvements in diagnosis and treatment have led to longer patient survival, thus increasing the need to intervene against the development of tissue fibrosis and contractures by using appropriate integrated rehabilitation programs. This article does not review the medico-pharmacological management of visceral manifestations of the disease. Rather, it is divided into six parts, which include analyses of the changes in skin, joints and tendons, and muscle induced by SSc; examination of the existing literature on rehabilitation strategies and treatments; discussions of the pain and peripheral sensory-motor system involvement that are present to a greater or lesser extent in almost all patients and influence not only the duration and outcome of rehabilitation but also the patient's family, social life, and working ability; and consideration of ergonomic and occupational interventions. No controlled studies have been done on the few rehabilitation guidelines and specific protocols identified, so it must be emphasized that this article is a summary of opinions expressed in the literature and the authors' own findings. Particularly lacking are studies on such aspects as ergonomics, work intervention, or the management of sexual dysfunction. Experience gained in the rehabilitation of skin burns and other rheumatic diseases forms the basis for a logical approach to SSc patients.

Tobacco smoking and risk of haematological malignancies in adults: a case-control study

A retrospective study was conducted in 1216 cases to investigate the possible association between tobacco smoking and the risk of haematological malignancies. A small, but not significant, increase in malignancy was observed in smokers. Significant association was demonstrated between tobacco smoking and acute nonlymphoblastic leukaemia, and myelodysplastic syndromes. The duration and amount smoked increased the risk; heavy smokers presented significant positive associations with overall malignancies, acute nonlymphoblastic leukaemia, myelodysplastic syndromes, and monoclonal gammopathy of undetermined significance, whereas light smokers did not present any significant association. These data support a causal relationship between certain haematological malignancies and tobacco smoking. Further research is needed to examine the risk according to dose-response effect, and the variation in risk according to the histological subtype of the malignancy.