A Road Less Traveled: Endoscopic Retrograde Cholangiopancreatography in a Patient with Long-standing Achalasia and Sigmoid Esophagus

Endoscopic retrograde cholangiopancreatography in a patient with achalasia and sigmoid esophagus poses a unique technical challenge, as one must safely guide the side viewing duodenoscope across a severely distorted distal esophagus and non-relaxing lower esophageal sphincter. In such patients, the use of an overtube is a simple solution that allows the safe passage of a duodenoscope and the removal of common bile duct stones.

Hybrid open and endovascular repair of recurrent visceral aortic patch aneurysmal expansion after previous thoracoabdominal aortic aneurysm repair: case report and description of technique

The rate of morbidity and mortality in patients undergoing open repair for thoracoabdominal aortic aneurysm (TAAA) still remains too high, ranging from 2% to 40%. In recent years "hybrid" techniques have been developed (EVAR and retrograde surgical revascularization) for the treatment of TAAA. This procedure has proved to be more effective to reduce the high risks of complication related to this kind of operation resulting in a lower morbidity and mortality rates when compared to traditional surgical techniques. A 77-year old patient who had previously been undergone surgical exclusion of a TAAA by using a straight aorto to aortic bypass graft (end to end fashion) with visceral patch, was referred to our behalf for the presence of a recurrent Crawford Type IV aortic aneurysm expansion of 10.5 cm length on diameter. Considering the serious co-morbidities of the patient and the high risk of mortality related to the traditional redo surgery, the hybrid technique was considered to repair this recurrent aneurysm by using a surgical debranching of the visceral and renal arteries from the aorta associated to the their retrograde revascularization before to perform the endovascular exclusion of the aneurysm at the same time in a single operation. Over a period of 12 months the patient was alive in good health, a follow-up by computed tomography (CT) scan confirmed the correct position of the endograft, without endoleaks, the patency of the bypasses and the reduction on diameter of the aneurysmal sac. The combined hybrid procedure (endovascular and open surgical approach) for treatment of complex TAAA is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required either to validate this procedure or to get a more significant and statistical comparison to the traditional approach.

Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Isolated aneurysm of the inferior thyroid artery repair with coil embolization

A 68-year-old female patient with a suspected aneurysm of the inferior thyroid artery was admitted to the authors' Unit of emergency after an accident. The echography of the thyroid revealed a ''suspected'' aneurismal dilation of the inferior thyroid artery (max. diameter 30 mm.). The patient underwent an angiograph of the supra-aortic trunk, which detected a small round formation at the base of the left inferior thyroid artery (found to be unaffected by aneurismal pathologies), the aneurysm was excluded by coil embolization. The postoperative course was uneventful and the patient was discharged in one day without complications. The follow-up with colour Duplex, at 4-8 months, showed the normal vascularization of the neck arterial vessels and was confirmed the absence of aneurysmal dilations. Aneurysms of the inferior thyroid artery are extremely rare, in scientific literature only 28 cases have been reported of which 32.9% regard ruptured aneurysms in the thyroid artery and 10.7% led to mortality. They may cause dysphagia and/or respiratory difficulties. Therefore, treatment is always recommended, even in asymptomatic cases, by surgical exclusion or coil embolization.

Correlates of bone quality in older persons

PURPOSE OF THE STUDY

In a population-based sample of older persons, we studied the relationship between tibial bone density and geometry and factors potentially affecting osteoporosis.

METHODS

Of the 1260 participants aged 65 years or older eligible for the InCHIANTI study, 1155 received an interview and 915 (79.2%) had complete data on tibial QCT scans and other variables used in the analysis presented here. The final study population included 807 persons (372 men and 435 women, age range 65-96 years) after exclusion of participants affected by bone diseases or treated with drugs that interfere with bone metabolism.

RESULTS

In both sexes, calf cross-sectional muscle area (CSMA) was significantly and independently associated with total bone cross-sectional area (tCSA) and cortical bone cross-sectional area (cCSA) but not with trabecular or cortical volumetric bone mineral density (vBMD). Bioavailable testosterone (Bio-T) was independently associated with both trabecular and cortical vBMD in both sexes. In women, independently of confounders, 25(OH)-vitamin D was positively associated with tCSA and cortical vBMD, while PTH was negatively associated with cortical vBMD. IL-1 beta was negatively correlated with cortical vBMD in women, while TNF-alpha was associated with enhanced bone geometrical adaptation in men.

CONCLUSIONS

Physiological parameters that are generically considered risk factors for osteoporosis were associated with specific bone parameters assessed by tibial QCT. Factors known to be associated with increased bone reabsorption, such as 25(OH)-vitamin D, PTH and Bio-T, affected mainly volumetric BMD, while factors associated with bone mechanical stimulation, such as CSMA, affected primarily bone geometry. Our results also suggested that pro-inflammatory cytokines might be considered as markers of bone resorption.

Definition of a population-specific DXA reference standard in Italian women: the Densitometric Italian Normative Study (DINS)

Osteoporosis is currently defined on the basis of the T-score by dual-energy X-ray absorptiometry (DXA). Despite its limitations, this definition is applied worldwide. However, the normal values provided by manufacturers may not be fully representative of specific local populations. So far, there are no normative data in the Italian population using Hologic densitometers. The Densitometric Italian Normative Study (DINS) is an ongoing multi-center study that aims to establish reference values for bone densitometry with dual-energy X-ray absorptiometry (DXA) in the male and female Italian population. In this paper we report the results of the lumbar vertebrae (L2-L4) and proximal femur in 1,622 women aged 20-79 years. Bone mineral density (BMD) was determined using dual-energy X-ray absorptiometry (DXA) on Hologic bone densitometers (Hologic, Waltham, Mass.). Most of the subjects were examined with a QDR 4500. The BMD of the lumbar vertebrae was virtually constant between 20 and 49 years (test for trend: P=0.66); the BMD values between 20-45 in premenopausal women (mean 1.036; SD 0.109 g/cm(2)) were thus defined as the peak bone mass values, significantly lower compared to the Hologic reference curve (mean 1.079, SD 0.11 g/cm(2)). The mean BMD values of the femoral neck were virtually identical to those of the NHANES study in the first 3 decades; after the age of 50 the BMD values were slightly greater than those of the NHANES subject. The subject classification according to the WHO criteria was similar using the DINS and NHANES reference values for the femur; for the spine, the Hologic reference values classified a larger proportion of women as osteoporotic (21 vs. 16%) or osteopenic (42 vs. 38%) compared to DINS.

Hip fracture in nursing homes: an Italian study on prevalence, latency, risk factors, and impact on mobility

Hip fracture may cause and/or complicate institutionalization. We undertook this study to define its overall prevalence among the residents of four nursing homes in Central Italy as well as its latency and impact on mobility when it occurred within institutions. We also performed a case control analysis with the aim of identifying potential risk factors for hip fracture in nursing home. Among the 211 residents (160 women, mean age 82.2 +/- 9.29 years, and 51 men, mean age 77.1 +/- 8.9 years), 42 were hip fracture cases, with a prevalence of almost 20%, and a female/male ratio of 6/1.23 fractures preceded institutionalization; of these 19 (17 females and 2 males) occurred within the nursing homes (mean age 83.2 +/- 6.3 years). The average interval between institutionalization and fracture was 74.2 months. The impact of hip fracture on mobility was relevant. The percentage of residents ambulating autonomously fell from 95% to 32% among those who had fractured. Fractured subjects were characterized by worse mobility and function than unfractured subjects, while comorbidity, cognitive functions, and use of psychotropic drugs were similar. Prefracture mobility of fractured subjects was better than that of age-and sex-matched residents who had never fractured their hip. Regarding hip fracture in our nursing home population we can conclude that (1) hip fracture is one of the main causes of institutionalization; (2) in most cases hip fracture occurred late in the course of the nursing home stay; (3) the functional impact of the fracture was relevant when it occurred in institutions. We also suggest that preserved mobility may represent an additional risk factor for hip fracture in nursing homes.

Impact of the earthquake of September 26, 1997 in Umbria, Italy on the socioenvironmental and psychophysical conditions of an elderly population

The consequences of natural disasters on the social and health status of older people have not been deeply considered. The aim of this study was to evaluate the socioenvironmental and psychophysical conditions of an elderly population after a devastating earthquake. A randomly selected group of 332 older people (> or =64 years) was selected among 1548 eligible subjects living in the city of Nocera Umbra four months after an earthquake of 5.6 magnitude on the Richter scale. Three geriatricians evaluated the study subjects by means of a structured interview, and standardized scales, which considered physical and mental status, mood and anxiety, and self-perception of well-being, as well as the characteristics of family composition and social interactions. Of the study subjects, 11.1% lived alone, and 33.4% with the spouse only. Most were self-sufficient in the basic activities of daily life. Musculoskeletal diseases and hypertension were the most frequently observed pathologies in this geriatric population. In addition, 47.9% of the subjects lived in temporary houses; this group more frequently suffered from hypertension, and had a higher score of comorbidity as measured by Cumulative Illness Rating Scale (CIRS) compared to people who remained at home. People living in the pre-fabricated huts also showed a higher score on the Geriatric Depression Scale and the Hamilton scale for anxiety, and complained more often of their health status, evaluated as self-perception of well-being, when compared to the home dwellers. Although all the studied subjects suffered from the discomforts caused by the earthquake, the precariousness of living in temporary houses, whose structural characteristics do not take the needs of elderly subjects into account, could justify the higher distress experienced by persons housed in the huts. These observations suggest that, after natural disasters, emergency programs should be more adapted to elderly people, whose needs and expectations are often different from those of young adults.

Manometric investigation of anorectal function in early and late stage Parkinson's disease

Abnormal gastrointestinal function is relatively frequent in Parkinson's disease, and constipation is a disturbing symptom in many patients. However, it remains to be established whether anorectal abnormalities are characteristic of the late stages of the disease. Clinical and anorectal manometric function were investigated in groups of early and late stage parkinsonian patients. Thirty one patients (19 men, 12 women, age range 22 to 89 years) entered the study. The disease severity was assessed by Hoehn and Yahr staging: there were four (12.9%) stage I, seven (22.6%) stage II, 10 (32.2%) stage III, and 10 (32.2%) stage IV patients. Anorectal variables were measured by standard manometric equipment and techniques. Values obtained in early stage patients (Hoehn and Yahr stage I and II) were compared with those obtained in late stage patients (Hoehn and Yahr stage III and IV). Overall, more than 70% of patients complained of chronic constipation, with chronic laxative use reported in more than 30%. Late stage patients were slightly older than their early stage counterparts. Pelvic floor dyssynergia was documented in more than 60% of patients. Manometric variables were not different in the two groups. In conclusion, defecatory dysfunction is frequent in Parkinson's disease, it is not confined to late stage patients, and it is found early in the course of the disease. This has potential implications for a targeted therapeutic approach.

Matrix metalloproteinases. Their role in degenerative chronic diseases of abdominal aorta

BACKGROUND

The main chronic degenerative diseases of the abdominal aorta, namely aneurysmatic and steno-obstructive pathologies, have a common denominator: atherosclerosis. Both pathologies are characterised by the destruction of the structural integrity of the extracellular protein matrix (ME). A number of studies have shown the presence and involvement of a group of enzymes with proteolytic activity towards one or more ME components, the matrix metalloproteinases (MMPs), in the pathogenesis of aneurysms of the abdominal aorta. Other authors have underlined the role of MMPs in the proliferation and migration process of smooth muscle cells into the intima in the pathogenesis of atheromasic plaque. The aim of this study was to evaluate the possible role of these enzymes in the pathogenesis of chronic degenerative diseases of the aorta.

METHODS

Fragments of aortic wall were removed from patients undergoing elective aortic surgery for aneurysms (14 patients) or aortic steno-obstruction (4 patients). The samples obtained were treated appropriately and then subject to immunohistochemical analysis. The preparations were incubated with specific anti-MMP antibodies and were also incubated with substrate and chromogen, forming a pigmented precipitate on the site of the antigen, before being observed using an optic microscopic at an enlargement of 250x. Nuclear positivity linked to the presence of the antigen testified the validity of staining. Lastly, the MMP INDEX, or in other words the number of positive cells out of 100, was stained in the adventitia and in the tunica media in each preparation.

RESULTS

MMPs were divided into three main groups: interstitial collagenase (MMP1) which degrade type I and III native collagen; gelatinases (MMP9, MMP2) which act on elastin and type IV collagen; stromelysins (MMP3) with specific proteolytic action towards proteoglycans, fibronectin and laminine. In our experience, those preparations obtained from aorta affected by steno-obstructive pathologies (4 patients) revealed the presence of MMPs with a preferential localisation on the intimal side of the tunica media. In particular, the increased activity of gelatinases MMP9 in atherosclerotic aorta might be responsible for destroying the internal elastic lamina and fostering the proliferation and migration of smooth muscle cells and the formation of atheromasic plaque. On the other hand, preparations obtained from aneurysmatic aorta (14 patients) showed an opposite situation with a preferential localisation within the adventitia and on the adventitial side of the media. Above all, the loss of elastin represents an essential stage in the formation of aortic aneurysms.

CONCLUSIONS

This study concords with numerous authors who have demonstrated the involvement of proteinase MMPs in the development of aortic aneurysms and their possible role in the pathogenesis of atheromasic plaque. The different origin of these enzymes (inflammatory cells and macrophages or endothelial cells) may be the result of different pathogenetic mechanisms. Although they present different pathogenetic features, aortic aneurysms and steno-obstructions have a common denominator in atherosclerosis. The mechanisms responsible for their evolution towards one or other form are not known. The different expression of MMPs in the context of the aortic wall represents a field for future research.

Short-term reproducibility of proximal femur bone mineral density in the elderly

Densitometric measurements are prone to imprecision in elderly subjects and the present study was primarily designed to dissect out the effects of age and bone mineral density on proximal femur dual energy x-ray absorptiometry (DXA) reproducibility. The study comprised 17 elderly women (mean age 74.6 years, range 65-84 years), 13 early postmenopausal women with osteopenia (mean age 56.2 years, range 50-63 years), and 17 elderly men (mean age 73.8 years, range 65-86 years). Each subject was given triplicate proximal femur scans by a QDR 2000 Densitometer (Hologic Inc., Waltham, MA) with repositioning between scans. Because of subject selection in the early postmenopausal women there were no significant differences in bone mineral density (BMD) at any site among the three groups. Despite this, reproducibility errors expressed as either coefficient of variation (CV) % or mean standard deviation (SD) were greater in the elderly subjects, regardless of gender, when compared with the younger female subjects. The variability in measurement errors with age were least marked for the total hip and trochanteric sites. Within the elderly subjects, BMD appeared to exert little influence on measurement errors. We conclude that short-term proximal femur reproducibility is dependent on age-related factors other than BMD. There is no influence of gender on the measurement errors. It is likely that local factors (e.g., hip osteoarthritis) or general frailty may influence repositioning but this needs further exploration. In the meantime, the total hip and trochanteric sites should be used as they provide the most reproducible measurements in the elderly.

Physical activity and cardiovascular health in the elderly

People over the age of 65 constitute a growing proportion of the world population both in western and in developing countries. A unique feature of this group is the high prevalence of cardiovascular diseases, which negatively affect its quality of life as well as its life expectancy. Among the interventions able to reduce the health burden of cardiovascular diseases is physical activity. The benefits of physical activity have been demonstrated both in healthy and chronically ill elderly subjects, while the risks have been found to be modest. Physicians should recommend moderate-intensity physical activity to sedentary older subjects, who are still the majority within the elderly population.

Left-sided inferior vena cava. Report of a case occasionally encountered while performing an aorto bifemoral bypass and review of the literature

We present a case of left-sided inferior vena cava unexpectedly observed during an operation of aorto bifemoral bypass in a patient with severe Leriche syndrome and almost complete obstruction of the infrarenal aorta. This very rare congenital malformation (0.2-0.5%) was not recognized by the duplex scanner performed preoperatively, probably because of the low level of suspicion carried on by an experienced operator. AngioCT or angioMR, which would have surely shown us the anomaly, were not done because, in the lack of an aneurysmal disease or other abdominal pathological situations, these investigations were not required before operation. The possible hazards of such an unrecognized malformation are great, mostly in terms of incontrollable intraoperative hemorrhages, but the final outcome of this case was positive.

[Effectiveness of mesoglycan therapy in patients with ischemia of the lower limbs. Preliminary results of a new therapeutic protocol]

BACKGROUND

Mesoglycan is a natural glycosaminoglycans preparation, with antithrombotic and pro-fibrinolytic activities, which has been shown to be clinically effective in a number of vascular atherosclerotic disorders with thrombotic risk.

METHODS

In the present investigation we studied the effect of mesoglycan in patients with acute episodes of relative lower limb ischemia (Stage IIb according to Leriche-Fontaine classification) coming to our observation. Mesoglycan was administered according to the following schedule: a 10-days period of endovenous mesoglycan (90 mg/day), given in day-hospital regimen, followed by a 20-days period of oral mesoglycan (100 mg/day). The treatment schedule was repeated for two months and then patient continued with oral mesoglycan. We present the preliminary results obtained on 36 patients which were followed for a mean period of 12 months.

RESULTS

From February 1995 thirty-six patients, 24 males and 12 females, aged between 45 and 83 years (mean +/- SD: 69.8 +/- 7.5) coming to our observation for acute relative lower limb ischemia were enrolled. At baseline, the diagnosis was Fontaine's IIb stage (walking distance < or = 200 m) in all patients, 17 patients presenting walking distance < 100 m. After 3 and 6 months of mesoglycan treatment a significant improvement of symptoms and signs was observed in all patients but one. At the end of the 6-months period, 29 patients (81% of the study population) became to a Fontaine's IIa degree, with a significant increase in walking distance (in 70% three times their basal value) and improvement of symptoms and recovery time. After treatment, Winsor Index was not significantly modified. Similar results were obtained after 12 months of follow-up. During the study period only one patient included in the trial needed surgical revascularisation. The administration of mesoglycan was well tolerated, with only minor complaints in two patients (one case of headache and one of diarrhea). During the endovenous administration of mesoglycan most patients (81%) presented values of aPTT almost double than baseline, which returned to normal values at the end of the administration.

CONCLUSIONS

The present preliminary results show that, in patients with acute episodes of relative lower limb ischemia, mesoglycan (administered according to the described protocol) is an effective and safe agent able to improve symptoms (walking distance, pain, leg appearance) and to possibly delay the need of surgical interventions.

A new device for prevention of postoperative haematoma in the surgery of varicose veins

The objective of this article is the presentation of a new device, simple, easy to use, at low cost, for the prevention of postoperative haematoma following surgery of varicose veins of the lower limbs. It consists in a two-part device that functions as an elastic and pneumatic bandage, that wraps thigh and leg, with the knee articulation free and that is placed immediately before the stripping of the saphenous vein when all the surgical wounds are closed, except the supramalleolar one. While the head of the stripper is pulled, the device is inflated by air with a compression of 40-50 mmHg and the last surgical wound is sutured. Pneumatic compression is held for 24-36 hours, allowing the patients to walk and, in the meantime, to control the colour and the temperature of the foot. The advantages of this device are: easy use and low costs; compression on the area of the saphenous vein and of the main collaterals; uniform but moderate pressure on all the limb circumference.

Age-related cortical bone loss at the metacarpal

In order to evaluate in vivo the entity of endosteal and periosteal changes with age in the two sexes, and their relative contribution to age-related cortical bone loss, we undertook a cross-sectional study on a population of normal Caucasian subjects. The group included 189 women and 107 men who were studied by photodensitometry and radiogrammetry of the second metacarpal bone, derived from the same standard hand X-ray. Of the subjects, 134 were 65 years of age or older (75 women and 59 men). Metacarpal bone mineral density (BMD) correlated with age in both sexes, with an annual bone loss rate of 0.5% in women and 0.15% in men. In the over 65 group, correlation was significant only in women, who underwent an acceleration in the rate of bone loss (1% per year). Marrow cavity width (M), cortical index at the second metacarpal shaft (MI) and external width (W) all correlated with age in both sexes, although generally better in the female than in the male sex. M almost doubled from the fourth to the ninth decade in women and increased 50% in men. In the same age interval, MI showed an annual decrease of 0.49% in females and 0.33% in males. In the over 65 group, cortical thinning rate was significant in women (0.39% per annum) but not in men (0.14% per annum), whereas correlation of W was not significant in either sex. Finally, MI correlated with BMD in the whole study population and in the over 65, with a female prevalence in correlation strength maintained throughout life. The following conclusions can be derived for metacarpal aging: (1) an acceleration in cortical bone loss occurs in females after age 65; (2) age-related growth in periosteal diameter, although significant in the whole population, is negligible in the elderly of both sexes; (3) age-related cortical bone loss is generally more dependent on cortical thinning in women than in men.

Post stenotic aneurysm of the inferior mesenteric artery: case report and discussion

A case of post stenotic aneurysm of the inferior mesenteric artery (IMA) is reported. This case underlines the importance of a correct diagnosis by instrumental methods such as Duplex Scanner, CT and Arteriography, mainly when the first diagnosis is aneurysm of the abdominal aorta (AAA). Our patient showed, furthermore, the occlusion of the celic axis, of the superior mesenteric artery and of both hypogastric arteries; thus his intestinal vascularization was represented, from the gastric fundus until the rectum, only by the inferior mesenteric artery and its collateral network. The operation consisted in the resection and reimplantation of the vessel on the left side of the terminal abdominal aorta, after removal of the dilated segment. This location was chosen because of the coexistence of a mild dilatation of the aorta of 2.8 cm and considering possible aortic surgery for AAA in the future.

Cathepsin B activity in normal human osteoblast-like cells and human osteoblastic osteosarcoma cells (MG-63): regulation by interleukin-1 beta and parathyroid hormone

Cathepsin B activity and its regulation by interleukin 1 beta (IL-1 beta) and parathyroid hormone (PTH) was investigated in normal human osteoblast-like cells (hOB) and in the human osteoblastic osteosarcoma cell line MG-63. Cathepsin B activity was measured using a fluorescent synthetic substrate, 7-N-benzyloxycarbonyl-L-arginyl-L-arginylamide-4-methylcoumarin, and its specificity was checked with E-64, a specific inhibitor of cysteine proteinases and CA074, a specific inhibitor of the enzyme. Cathepsin B activity was detected in crude extracts of cell monolayers and in conditioned media. In both cell types, basal activity was detected essentially in cell extracts, since in media only approximately 1.2% (hOB) and approximately 6% (MG-63) of the total activity was released. IL-1 beta (1-100 U/ml) and PTH (10(-9) M-10(-6) M) significantly stimulated cathepsin B activity in cell extracts and in conditioned media. In both cell types, the increase in proteolytic activity appeared to require RNA and protein synthesis after adding IL-1 beta or PTH. Using the above substrate, we also evaluated some biochemical properties of the enzyme, and its pH-stability and pH-optimum. In both cell types, intracellular cathepsin B activity was not resistant to neutral or slightly alkaline pH, whereas extracellular cathepsin B activity was stable. This study provides evidence that osteoblast-like cells produce and secrete active cathepsin B. The production and secretion was stimulated by IL-1 beta and PTH. The physiological role of cathepsin B produced by osteoblasts and stimulated by the bone resorbing agents remains to be elucidated. Since extracellular activity is stable under relatively physiological conditions, it is possible that the extracellular as well as intracellular form of the enzyme may play a role in matrix turnover.

Appendicular cortical bone loss after age 65: sex-dependent event?

Distal radius photodensitometric and second metacarpal radiogrammetric measurements were obtained from computerized analyses of standard hand X-Ray films of 296 Caucasian subjects (189 women and 107 men). This sample included 134 subjects > or = 65 years old (75 women and 59 men). Distal radius bone density and metacarpal index showed a significant linear decrease with age in both sexes. Rates of bone loss, calculated from the regression curves, were -0.7% per year in women and -0.5% per year in men by distal radial photodensitometry, and -0.49% per year in women and -0.33% per year in men by metacarpal radiogrammetry. In the elderly subgroup, women > or = 65 years of age showed an even faster bone loss, with an annual decrease of -1.4% by distal radial photodensitometry. Conversely, men > or = 65 years of age had no significant bone loss, not even by metacarpal radiogrammetry. In conclusion, these data suggest that appendicular cortical bone loss occurs at a higher rate in elderly females than in the elderly males, both at the distal radial and at the metacarpal site.

[Malignant fibrohistiocytoma arising at a femoral dacron vascular prosthesis. Case report and review of the literature]

In a recent publication, reporting the sixth case of aortic angiosarcoma, probably induced by the implantation of a dacron vascular prosthesis, Weiss et al. have done a literature review concerning the association between the presence of vascular prostheses and the onset of mesenchymal neoplasms. Although they consider the incidence of this association very low, they also point out the hypothesis, largely supported by experimental studies, that vascular prostheses can play the role of aetiological co-factor or factor in the onset of these tumors. We consider useful to report a case of malignant fibro histiocytoma arising around a femoral vascular prosthesis in a patient operated on for aneurysm of the femoral artery.

[Intraoperative microbiological monitoring in abdominal aortic aneurysms in elective surgery. A review of the literature and the authors' personal experience]

Thirty-one patients, ranging in age from 57 to 78 years (mean 66), with the exclusion of cases with doubtful possible results, underwent abdominal aortic aneurysmectomy for asymptomatic AAA and had cultures from the aneurysmal wall and endovascular thrombus to identify possible microbiological source of future graft infection; 5 (16%) of 31 cultures yielded bacterial growth and the most common organism isolated was staphylococcus epidermidis. During an average follow-up of 15.4 months no graft infection was noted in patients with positive or negative aortic cultured. A literature review stresses the same disparity between positive cultures obtained at the aneurysmectomy and subsequent low graft-infection rate. It is concluded that the aneurysm wall itself does not represent an important source of early or late graft infection and it's suggested that the bacterial presence both in the wall and thrombus could be explained by an exogenous contamination at the operation time.

Effect of estrogen and calcitonin on vertebral bone density and vertebral height in osteoporotic women

Estrogen and calcitonin increase bone density of osteoporotic women, particularly on the axial skeleton. To verify whether the effect of these drugs might in part be biased by spurious increases in bone density due to radiologically irrelevant microfractures, and consequent subtle decreases in vertebral height, we followed the changes in vertebral bone density (VBD), assessed by quantitative computed tomography, in relation to vertebral height (VH) in 60 osteoporotic women. VH was measured as the sum of anterior, central and posterior heights of L1-L3 vertebral bodies on lateral radiographs. Patients received either salmon calcitonin (sCT: 50 IU subcutaneously three times per week, n = 18), hormonal replacement therapy (HRT: conjugated estrogen 0.625 mg/day, days 1-25, plus medroxyprogesterone acetate 10 mg/day, days 16-25 of each month; n = 21) or calcium alone (Ca: 1000 mg/day, n = 21). After 1 year, VBD increased in the HRT group (+5.0 +/- 1.9%, p = 0.010), did not change significantly in the sCT group (+3.3 +/- 2.3%, p = 0.167), and decreased by 6.1 +/- 1.0% (p less than 0.001) in the Ca group. By analysis of variance, the changes induced by HRT and sCT were significantly different from those observed in the Ca group (F = 7.982, p less than 0.001). VH decreased slightly in all three subsets of patients (-0.9 +/- 0.5% in sCT, -1.5 +/- 0.3% in HRT, -0.1 +/- 0.5% in Ca), but these changes were not significantly different between groups (F = 2.545, p = 0.081).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of surgical menopause and estrogen replacement on cytokine release from human blood mononuclear cells

To determine whether mononuclear cell secretory products contribute to the changes in bone turnover that characterize the development of postmenopausal osteoporosis, we evaluated the effects of oophorectomy and subsequent estrogen replacement on the spontaneous secretion of interleukin 1 (IL-1) and tumor necrosis factor alpha (TNF-alpha) and on the phytohemagglutinin A-induced secretion of granulocyte-macrophage colony-stimulating factor (GM-CSF) from peripheral blood mononuclear cells. In 15 healthy premenopausal women who underwent oophorectomy, increases in GM-CSF activity were observed as early as 1 week after surgery, whereas elevations in IL-1 and TNF-alpha and in hydroxyproline/creatinine and calcium/creatinine ratios, two urinary indices of bone resorption, were detectable 2 weeks after the surgical procedure. Six of the oophorectomized women received no estrogen therapy after surgery and in these subjects hydroxyproline/creatinine and calcium/creatinine ratios plateaued 6 weeks postoperatively, and all three cytokines reached the highest levels 8 weeks after oophorectomy, when the study ended. In the remaining 9 women, who were started on estrogen replacement therapy 4 weeks after oophorectomy, decreases in the indices of bone resorption paralleled decreases in the secretion of the cytokines, with lower levels detected after 2 weeks of therapy. In the women who did not receive estrogen therapy, circulating osteocalcin, a marker of bone formation, increased beyond preoperative levels 8 weeks after oophorectomy, whereas in the estrogen-treated subjects osteocalcin remained unchanged in the entire study period. In 9 female controls who underwent simple hysterectomy, cytokine release and biochemical indices of bone turnover did not change after surgery. These data indicate that changes in estrogen status in vivo are associated with the secretion of mononuclear cell immune factors in vitro and suggest that alterations in the local production of bone-acting cytokines may underlie changes in bone turnover caused by surgically induced menopause and estrogen replacement.

Catecholamines and pituitary function. VI. Effect of different dopamine doses on TRH-induced prolactin release in women with pathological hyperprolactinemia

The present study was designed to examine the effect of low-dose dopamine (DA) infusion rates (0.02 and 0.1 microgram/kg X min) on both basal and TRH-stimulated prolactin release in normal and hyperprolactinemic individuals. Sixteen normally menstruating women in the early follicular phase of a cycle and 23 hyperprolactinemic patients were studied. 0.1 microgram/kg X min DA was infused in 8 normal women and 15 patients with pathological hyperprolactinemia, while 8 normal controls and 8 patients received 0.02 microgram/kg X min DA TRH (200 micrograms, i.v.) was administered alone and at the 180th min of the 5-hour DA infusion in all controls and patients. A significant reduction in serum PRL levels, which was similar in normal women (-59.5 +/- 4.0%, mean +/- SE) and hyperprolactinemic patients (-48.2 +/- 5.5) was observed in response to 0.1 microgram/kg X min DA. In normal cycling women DA infusion significantly (P less than 0.02) reduced the PRL response to TRH with respect to the basal TRH test (delta PRL 45.0 +/- 7.0 vs. 77.9 +/- 15.4 ng/ml). On the contrary, the PRL response to TRH was significantly higher during 0.1 microgram/kg X min DA than in basal conditions in hyperprolactinemic patients, both in absolute (delta PRL 91.8 +/- 17.6 vs. 38.4 +/- 6.8, P less than 0.03) and per cent (198.5 +/- 67.6 vs. 32.1 +/- 7.5, P less than 0.02) values. A normal PRL response to TRH, arbitrarily defined as an increase greater than 100% of baseline, was restored in 11 out of 15 previously unresponsive hyperprolactinemic patients.(ABSTRACT TRUNCATED AT 250 WORDS)