[Effectiveness and tolerability of simvastatin in subjects with primary hypercholesterolemia. Multicenter study]

The efficacy and safety of simvastatin were evaluated in an open multicenter study over a 24-week period. One hundred seventy-two patients (91 men, 81 women) with primary hypercholesterolemia (mostly polygenic) were enrolled in 14 Centers in Northern Italy. The mean age was 55.8 +/- 9.7 years and the mean baseline total cholesterol level was 305 +/- 59 mg/dL. After 4 weeks on an AHA step 1 diet, patients who met the inclusion criterion (total cholesterol > or = 250 mg/dL) were given simvastatin 10 or 20 mg in the evening. The dose could be titrated up to a maximum of 40 mg o.d. at week 6 and 12. No dose titration was allowed after week 12. One hundred forty-nine patients (86.6%) completed the study according to the protocol, 2 (1.2%) were withdrawn from the study because of adverse events not related to the drug, 21 (12.2%) were unavailable for follow-up. Simvastatin treatment was associated with a sustained dose-related reduction in total and LDL cholesterol (-28% and -39% respectively at the end of the study). Triglycerides showed a significant descending trend (-16% at week 24) and HDL-C increased by 9%. Apolipoproteins were measured in only 25 patients: apo B was reduced by 30% and apo A1 increased by 9%. Clinical side effects were not relevant. Mean levels of GOT, GPT and CPK significantly increased after 6 weeks on simvastatin, but remained stable and at any rate ioitlin the normal range thereafter. Eight patients (5.4%) experienced small transaminase level elevations (< 3ULN) and six (4%) small CPK elevations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Heart surgery without previous heart catheterization, in pediatric cardiology]

STUDY OBJECTIVE

To determine the influence of echocardiography in the preoperative diagnosis of heart diseases in children.

DESIGN

Retrospective study.

SETTING

Hospitalized children admitted in Departments of Pediatric Cardiology and Cardiothoracic Surgery.

PATIENTS

Children of both sexes, aged from neonate to 14 years old, with heart disease who underwent cardiac surgery.

MATERIAL AND METHODS

From January 1989 to July 1990, 220 consecutive cardiac surgeries were performed in children with heart disease. The initial diagnosis was based on data from clinical examination, electrocardiogram, thorax X-Ray and echocardiogram (M-mode, 2D, conventional and colour Doppler). Patients were separated in three groups according to their ages: newborn infants less than 28 days old; infants less than 12 months old; children more than 1 year old and less than 14 years old. Patients were separated according to the investigations used further for preoperative diagnosis: whether they had or not cardiac catheterization performed prior to surgery.

RESULTS

From 220 surgical interventions performed, 124 were "open heart" surgeries (9 neonates, 28 infants and 87 children) and the remaining had "closed heart" operations (14 neonates, 37 infants and 45 children). Preoperative diagnosis was mainly dependent on echocardiography, dispensing catheterization in 90 cardiac interventions. The diagnosis was confirmed at surgery or at autopsy. There were 9 deaths, 3 of which occurred in patients not submitted to cardiac catheterization.

CONCLUSIONS

Echocardiography is a reliable method for investigation and establishment of the preoperative diagnosis of heart diseases in children. Its use may further reduce the need for diagnostic catheterization in children, particularly in risk groups.

Cefaclor in the treatment of infective exacerbations of chronic bronchitis in cigarette smokers

There is a direct correlation between number of cigarettes smoked and the incidence of lower respiratory tract infection in humans. In studies with smokers suffering from exacerbations of chronic bronchitis, the most common bacterial pathogens found were Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus and Branhamella catarrhalis. Antibiotics should be effective against such possible pathogens. Cefaclor has demonstrated in vitro activity against all these pathogens. We designed the present study to evaluate the efficacy and safety of cefaclor in the treatment of acute exacerbations of chronic bronchitis in cigarette smokers. A total of 106 patients were enrolled in the study. H. influenzae was the most common bacterial species isolated in the sputum (in 23.6% of the total sample), followed by S. pneumoniae (18.9%), S. aureus (17.0%), K. pneumoniae (7.5%) and B. catarrhalis (5.7%), while mixed forms were present in 22.6% of cases and other pathogens in 4.7%. Cefaclor (500 mg) was given orally every 8h for 7 to 16 days (mean 10.73 +/- 2.11). Analysis of clinical response data indicates that 75.5% of patients were cured and 17.0% improved. This finding is important because it demonstrates that cefaclor's spectrum of activity encompasses all the most likely pathogens encountered in smokers. Because of its excellent response rate, cefaclor is of particular value in the treatment of lower respiratory tract infections in cigarette smokers.

[Acquired immunodeficiency syndrome associated with infection by HTLV-1 virus: a clinical case]

A 51 year old man with acquired immune deficiency syndrome for 2 years developed a chronic leukemia/T cell lymphoma. Anti HTLV-1 antibodies were confirmed by Western Blot. In the last months he developed hypercalcemia and leukocytosis of 130,000. Necropsy confirmed the diagnosis of Leukemia/T cell lymphoma without cutaneous involvement.

[Primary cutaneous lymphoma: experience with 10 cases]

We report 10 patients with cutaneous lymphoma along with their clinical findings, staging, histopathologic characteristics by light microscopy, and results of anti-HTLV antibody screening. The immunotype was T cell in all. Three patients were diagnosed as having Lymphomatoid papulosis: one of them evolved to Mycosis fungoides, another showed progression to Immunoblastic lymphoma and a third remains as such. Two patients had a long standing Mycosis fungoides and, finally, 5 cases had peripheral T-cell lymphoma. Of the latter, 2 progressed rapidly to death.

Rett's syndrome: a neurophysiological study

Thirteen girls with Rett's syndrome were evaluated with wakefulness and sleep polygraphic records and EMG studies. The main EEG findings were paroxysmal activity during sleep, multifocal in younger and unifocal in older girls, and "pseudorhythmic flattening". In the opinion of the authors, the changes with age are related to evolution of the disease or maturational changes of CNS. The affectation of the peripheral nervous system was demonstrated in almost half the patients.

Effects of plasma exchange (PE) in primary biliary cirrhosis (PBC). A pilot study

Six patients were studied to evaluate the efficacy and safety of plasma exchange (PE) in the treatment of primary biliary cirrhosis (PBC). All patients were affected by PBC at stage III-IV and presented symptoms refractory to pharmacologic therapy. Patients underwent PE for a mean period of 40 weeks (range 10-88). A mean of 33 liters (range 17-64) of plasma per patients was removed. Patients reported less fatigue (4/6), pruritus (5/5), nausea (3/3), Sjogren's syndrome (2/6), and painful neuropathy (2/3). A reduction of xanthomata was noted in one of the three affected patients. Definitive improvement was seen in the patient with Raynaud's phenomenon. A significant reduction was noted for serum cholesterol and gammaglobulins. ALT, AST, gamma-GT, alkaline phosphatase, bilirubin, prothrombin activity, AMA titers were not affected by PE. All patients suffered some mild adverse effects during PE. Two patients (IV stage) developed late edema and ascites after 34 and 44 weeks of treatment. We conclude that PE can be considered effective chronic treatment for advanced symptomatic PBC refractory to pharmacological therapy.

Anaphylactoid reactions to protamine: an often lethal complication in insulin-dependent diabetic patients undergoing vascular surgery

Protamine is used routinely at our institution during arterial surgery to reverse the anticoagulant effect of heparin. Adverse fatal reactions to protamine are generally believed to be rare. However, major anaphylactoid reactions occurred in 11 of the last 1150 patients receiving this drug at our institution. Nine of these reactions occurred in 325 insulin-dependent diabetic patients (incidence, 3%), whereas only two occurred in the 825 patients not receiving insulin (incidence, 0.2%) (p less than 0.001). Ten of these reactions occurred within 10 minutes of protamine administration (15 to 35 mg), whereas one reaction occurred immediately after administration of a 5 mg test dose of protamine. Systolic blood pressure fell below 60 mm Hg in all of the 11 patients, and three patients had to be resuscitated with closed-chest massage. Initial treatment with epinephrine and steroids was successful in seven cases. Four patients required further resuscitative measures, including closed-chest massage. However, one of the patients died as a result of ventricular fibrillation resistant to treatment. Ten of the 11 patients, including the patient who died, had significant preexisting cardiac disease; six of the surviving 10 patients (60%) had perioperative myocardial infarctions and three died. Thus the total mortality rate was 36% (4/11). These data support the implication that neutral protamine Hagedorn (NPH) insulin produces an adverse reaction through immunologic presensitization of the patient. These data also show that, in the older vascular surgery population with a high incidence of significant cardiac disease, protamine reactions can be potentially lethal. Thus routine use of protamine should be avoided in diabetic patients receiving insulin.

Natural killer cells in children with acute leukemia. The effect of interleukin-2

The purpose of this study was to determine (1) the number and activity of natural killer (NK) cells in children with acute leukemia at different stages of their disease; and (2) the effect of interleukin-2 (IL-2) in enhancing NK activity of these patients' cells. The mean percentage of Leu 11+ NK cells in patients at diagnosis (5% of peripheral blood (PB) mononuclear cells) was significantly lower than for patients on maintenance (23%), post-treatment (21%) and for normal children (20%). The mean PB NK cell cytotoxicity for patients at diagnosis (16% lysis versus K562) and during maintenance (20%) was significantly lower than for post-treatment (41%) and normal controls (40%). After NK cells were incubated for 5 days with IL-2, NK cells from 82% (36/44) of patients showed enhanced cytotoxicity toward K562 and several acute leukemia cell lines as well as toward autologous leukemic cells. Cytotoxicity toward autologous cells was very low (0% to 5%, 16 hour assay) before IL-2 stimulation, and significantly increased (23% to 69%) after stimulation, suggesting that IL-2 may be a useful agent for enhancing the antileukemic immune response.

[A microanalytical gas liquid chromatography method with a nitrogen-phosphorus detector in the assay of various psychotropic drugs of tricyclic structure and of their N-demethylated metabolites]

Nanogram amounts of chlorimipramine, chlorpromazine and their Nor1- and Nor2-metabolites were detected in plasma by GLC with nitrogen-sensitive detection. Two extraction procedures were compared. The use of Sep Pak C18 cartridges produced a higher degree of accuracy and precision with significant time and materials saving, as compared to the use of organic solvents in a three steps extraction procedure.

Plasma exchange in myasthenia gravis

Results obtained with P.E. therapy on 19 myasthenic patients are reported. 15 of them improved during treatment and 4 remained unchanged. We believe P.E. is an useful therapy in M.G. because it produces a rapid improvement in most patients.

Plasma exchange in radiculopolyneuropathies

The AA. report the results obtained with Plasma Exchange (P.E.) therapy on 24 cases of polyradiculoneuritis; eleven patients had typical Guillain-Barré Syndrome (G.B.S.) ten suffered from a chronic progressive form and three were affected by a relapsing form. The acute patients were selected according to criteria established by the NNCDS Committee (1978) while guidelines laid down by Pineas & Load (1978) were followed in choosing chronic cases. Patients with G.B.S. had four sessions of P.E. at intervals of one or two days while those with chronic forms of polyradiculoneuritis had a total of 6 sessions spaced one to three days apart. P.E. produced no apparent change in chronic progressive patients but two out of three cases with the chronic relapsing form showed rapid and steady improvement resulting in complete cure within a few months. Nine of the eleven G.B.S. patients showed after only one or two sessions a clear and rapid improvement which led to a complete cure within a matter of weeks. The remaining 2 cases showed only partial improvement at first and remained stationary thereafter. The findings confirm the usefulness of P.E. in acute and chronic relapsing radiculopolyneuritis. However, potential side effects and the procedure's high cost suggest that its use should be limited to carefully selected cases, and in particular to those involving respiratory disorders.

Plasma Exchange in Myasthenia Gravis

Results obtained with P.E. therapy on 19 myasthenic patients are reported. 15 of them improved during treatment and 4 remained unchanged. We believe P.E. is an useful therapy in M.G. because it produces a rapid improvement in most patients.

Clozapine inhibition of metenkephalin binding to synaptosome-enriched fractions of rat whole brain and hippocampus

Clozapine has been found to inhibit the binding of [3H]met-enkephalin to synaptosome-enriched fractions prepared from rat whole brain and hippocampus in a Tris-buffered media without added ions. The IC50 value for hippocampus is 28.5 microM. The inhibition constant for whole brain (41.0 microM) was found to be slightly larger than the corresponding value for chlorpromazine, which was measured under similar experimental conditions.

Late embolization of disc occluder of a Beall mitral prosthesis with survival

A case of arterial embolization of a Beall mitral prosthesis disc (model 104) 5 1/2 years after implantation is presented. The patient was referred to use 3 days after the onset of acute symptoms and was immediately operated upon in pulmonary edema and cardiogenic shock. The migrated disc was removed from the abdominal aorta 26 days later, showing marked signs of wear. The postoperative course was complicated and the patient made a slow recovery. It is suggested that patients with models 103 and 104 Beall mitral prostheses be followed very closely and that electric valve substitution should be considered when first signs of prosthetic attrition are noted.