Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience

PURPOSE

The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence.

METHODS

All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database.

RESULTS

Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%.

CONCLUSIONS

This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.

Paratuberculosis, Animal Welfare and Biosecurity: A Survey in 33 Northern Italy Dairy Goat Farms

Paratuberculosis is a notable infectious disease of ruminants. Goats appear to be particularly susceptible. The survey aimed to investigate the spread of paratuberculosis in Italian goat farming and evaluate whether the presence of the disease could be influenced by welfare and biosecurity deficiencies. A serological survey for paratuberculosis in 33 dairy farms in northern Italy was conducted. Contextually, animal welfare and biosecurity were assessed, using a standardized protocol of 36 welfare indicators and 15 biosecurity indicators which assigns to each farm a welfare and biosecurity score from 0 (any application) to 100% (full application). An overall result of less than 60% was considered insufficient. Nineteen farms (58%) tested positive for paratuberculosis, with a mean intra-herd seroprevalence of 7.4%. Total welfare ranged from 39.56 to 90.7% (mean 68.64%). Biosecurity scores ranged from 10.04 to 90.01% (mean 57.57%). Eight farms (24%) showed poor welfare conditions (welfare score < 60%) and 19 (58%) an unsatisfactory biosecurity condition (biosecurity score < 60%). With respect to the explorative character of the study, an indicative association between seven welfare and biosecurity indicators and paratuberculosis seropositivity was identified. The presence of paratuberculosis in northern Italy dairy goat farms was confirmed. The welfare and biosecurity assessment protocol proved to be an accurate tool, capable of identifying critical points for managing health, welfare and productivity.

Accuracy of the fluorescence-aided identification technique (FIT) for detecting tooth-colored restorations utilizing different fluorescence-inducing devices: an ex vivo comparative study

OBJECTIVES

The aim of the present study was to compare the accuracy of the conventional illumination method (CONV) and the fluorescence-aided identification technique (FIT) for distinguishing between composite restorations and intact teeth using different fluorescence-inducing devices commonly used for FIT.

MATERIALS AND METHODS

Six groups of six dentists equipped with one of six different FIT systems each independently attempted to identify composite restorations and intact teeth on a full-mouth model with 22 composite restorations using CONV and, 1 h later, FIT. The entire procedure was repeated 1 week later. Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values, including 95% confidence intervals (CI), were calculated for CONV and FIT overall and for each device. The influence of examiner age, method, and device on each parameter was assessed by multivariate analysis of variance.

RESULTS

The sensitivity (84%, CI 81-86%), specificity (94%, CI 93-96%), PPV (92%, CI 90-94%), and NPV (90%, CI 88-91%) of FIT was significantly higher than that of CONV (47%, CI 44-50%; 82%, CI 79-84%; 66%, CI 62-69%, and 69%, CI 68-71%, respectively; p<0.001). The differences between CONV and FIT were significant for all parameters and FIT systems except VistaCam, which achieved no significant difference in specificity. Examiners younger than 40 years attained significantly higher sensitivity and negative predictive values than older examiners.

CONCLUSIONS

FIT is more reliable for detecting composite restorations than the conventional illumination method.

CLINICAL RELEVANCE

FIT can be considered an additional or alternative tool for improving the detection of composite restorations.

Exploring potential risk factors of antimicrobial use in beef cattle

Livestock species are major contributors to the increase of antimicrobial (AM) resistance which is a worldwide concern for both human and animal health. The over-use of AM is widely acknowledged, however, unlike pigs, poultry and dairy cattle, knowledge on potential risk factors affecting AM usage (AMU) in beef industry is limited. Hence, this study aimed to investigate the impact of farm, breed, sex and season of arrival of purchased beef cattle on AMU in Italian beef cattle. Data on 1063 batches were collected from January 2016 to April 2019 from specialised beef fattening farms located in the north of Italy. Information on breed, sex, date of arrival, performance traits and AM agents used on farm was collected, and the treatment incidence 100 (TI100) indexes per batch were calculated using the defined daily dose animal estimated according to Italian summaries of product characteristics. Factors affecting TI100 indexes were investigated using a cross-classified multilevel model. Farms largely differed in terms of AMU. Males had greater AMU than females (P < 0.001), likely due to their higher susceptibility to disease. Statistically significant differences were observed between seasons of arrival with summer and spring having lower TI100 indexes than winter and autumn (P < 0.001). Indeed, winter is commonly linked to an increase in respiratory diseases in beef cattle. Finally, the TI100it indexes tended to be different among breeds with Blonde d'Aquitaine and Limousine having greater AMU compared to the other breeds. Results of this study provided valuable information on potential risk factors of AMU in beef production which may be useful to address its reduction. For instance, the development of tailored management strategies for specific breeds, targeted approaches to improve the health of males as well as greater care towards batches purchased in winter are possible advice to implement on-farm for a more responsible AM stewardship.

Effect of welfare standards and biosecurity practices on antimicrobial use in beef cattle

Antimicrobial use (AMU) in livestock species and the associated antimicrobial resistance are a global concern, thus strategies for their reduction and a more judicious use are needed. Previous research has revealed a link between improved animal welfare, biosecurity and AMU reduction in pig and dairy sectors, however, little is known about the beef sector. This study aimed to investigate the impact of welfare standards and biosecurity on AMU in beef cattle. Data on performance traits and AMU were collected over a 3.5 year time from 27 specialised beef farms and a treatment incidence was calculated using the defined daily dose for animals. An on-farm assessment was carried out by assigning a score from 0 (very poor) to 100% (very good) to 3 sections: welfare, biosecurity and emergency management. The highest average score was obtained for the welfare section (76%) followed by emergency management (39%) and biosecurity (24%). This suggests that major focus on strategies for the implementation of biosecurity measures and emergency management is needed, due to the low scores reported. A statistically significant lower AMU was observed with improved level of welfare. These results may be helpful for farm benchmarking and highlight the importance of improved animal welfare for an efficient antimicrobial stewardship.

Use of antimicrobials in beef cattle: an observational study in the north of Italy

Antimicrobial resistance is a worldwide issue whereby a more prudent use of medications is needed, especially for those antimicrobials (AM) classified as 'highest priority critically important antimicrobials' (HPCIAs) which are likely contributors to the development of resistance. So far, data on antimicrobial use (AMU) in EU are mainly reported at sales level while information on real use, mostly in beef production, is poor. The most reliable indicator to measure AMU is the treatment incidence (TI100) calculated by using the Defined Daily Dose Animal (DDDA) as stated by the European Medicines Agency (EMA). Although Italy ranks second among EU countries with regard to the AM sales in livestock production, data on AMU of the Italian beef production is still lacking, whereby the aim of this study was to provide information on the current scenario of AMU in Italian beef cattle. Data were collected from January 2016 to April 2019 from specialized beef fattening farms located in the north of Italy yielding a final dataset of 1376 batches. Data on performance and AM agents used in the study were collected and TI100 indexes per batch were calculated according to both Italian and EMA's DDDA. A Kruskal-Wallis test was used to check for differences between years and seasons. Results showed a significant variation between years and seasons with a reduction of TI100 based on Italian DDDA as time progressed (P < 0.05). However, about 40% of the total amount of treatments administered were HPCIAs with macrolides accounting for the 27.7% of the total amount. The most common reasons of administration of AM were respiratory diseases (68.9%) and lameness (17.6%). Penicillins was the class of AM used on the highest proportion of batches (84.4%) showing that broad-spectrum AM were widely exploited among herds. In summary, despite a general reduction of AMU in beef cattle over time, a great use of HPCIAs was still observed suggesting that AM stewardship for Italian beef production should pay particular emphasis on the reduction of HPCIAs use. This shows how overall knowledge on where efforts need to be optimized is important to develop targeted strategies for a more responsible AM stewardship. Results of the current study may also contribute to define national and EU benchmark criteria for AMU, as a comparison with studies carried out in other countries or on other food-producing sectors is still challenging to achieve.

The Mid-Term Effects of Radiotherapy on T and B Lymphocytes: An Evaluation of Cellular Immunity with Standard Methods and Monoclonal Antibodies

The mid-term effects of radiotherapy on T and B peripheral lymphocytes of 15 patients treated for various malignancies were evaluated. All patients had a significant impairment of lymphocyte functions, as measured by blastogenesis after stimulation with phytohemagglutinin and pokeweed mitogen. Such impairment lasted for 1 year after the completion of radiotherapy, when numerical variability of T and B subpopulations, observed during and after radiation treatment, was restored to initial values.

Clinical Relevance of Bone Marrow Biopsy in Staging and Follow-Up of Breast Cancer

Bone marrow biopsies by Jamshidi needle were performed in 106 breast cancer female patients. Sixty-four of them were in follow-up after mastectomy, and neoplastic involvement of marrow was found in 21 patients (32.8%). Among the 42 women undergoing staging before mastectomy, the incidence of marrow involvement was 11.9% (5 women, all with radiographic positivity). Of the 37 women, either in follow-up or in the staging phase, with bone metastases detected by roentgenographic and isotopic examination, the bone biopsy was positive in 23 (62.1%), and 7 histologically had micrometastases. Three women, without any radiographic or isotopic sign of metastases, had positive biopsies. A good correlation was found between the hydroxyproline:creatinine ratio and neoplastic involvement of bone marrow.

Cisplatin, etoposide and continuous infusion bleomycin in patients with testicular germ cell tumors: efficacy and toxicity data from a retrospective study

We retrospectively reviewed medical charts of 54 patients who underwent orchidectomy for germ cell tumors (GCT) and received a regimen, given every 3 weeks, consisting of cisplatin 100 mg/m2 day 4 intravenous (i.v.), bleomycin 15 Units (U) day 1 i.v. push; bleomycin 10 U days 1-3 24 h i.v. continuous infusion (c.i.) and etoposide 100 mg/m2 days 1-5/i.v. (PEB). 53 of 54 patients achieved a complete remission without adjunctive surgery. At a median follow-up of 48.2 months (95%CI 41.7 - 54.8 months) all patients but one are alive with no evidence of disease recurrence. Patients receiving PEB experienced no pulmonary toxicity, nephrotoxicity nor neurological adverse events. PEB with c.i.bleomycin is an active regimen with a low rate of acute and late toxicity. The main limitations of our study are related to the retrospective analysis, the limited number of patients and the restricted follow-up time. A prolonged follow-up is necessary to evaluate long term toxicity and outcome.

Octatropine methyl bromide and diazepam combination (Valpinax) in patients with irritable bowel syndrome: a multicentre, randomized, placebo-controlled trial

OBJECTIVE

To investigate the efficacy and tolerability of octatropine methyl bromide plus diazepam (Valpinax) in patients with irritable bowel syndrome (IBS).

MATERIALS AND METHODS

We conducted a randomized, double-blind, multicentre study in 186 patients aged 18-65 years with IBS diagnosed according to Rome II criteria. Following a 2-week washout period, patients received octatropine plus diazepam 40 mg/2.5 mg twice daily or placebo for 6 weeks. The primary efficacy endpoint was response to a weekly question: "did you have satisfactory relief of your abdominal pain and discomfort during the last week?" Other endpoints included abdominal swelling, abdominal pain and discomfort, symptom severity, and the number of bowel movements. A prespecified subgroup analysis was conducted in patients with an abdominal pain and discomfort score > or = 3.

RESULTS

The primary efficacy endpoint showed a tendency towards a statistically significant benefit for octatropine plus diazepam over placebo among patients with a baseline abdominal pain and discomfort score of > or = 3 (3 vs. 0 patients; p = 0.059). Octatropine plus diazepam demonstrated significant improvements from baseline in all parameters assessed, but not compared with placebo. Adverse events were reported in 15.1% of patients receiving octatropine plus diazepam.

CONCLUSIONS

Patients with IBS and an abdominal pain and discomfort score of > or = 3, who may be considered in the active phase of the disease, may derive some benefits from octatropine plus diazepam. This study highlights that Rome II criteria should be considered with particular care in the design of a clinical trial, since it does not consider disease activity level on admission.

Epidermal growth factor receptor serum (sEGFR) level may predict response in patients with EGFR-positive advanced colorectal cancer treated with gefitinib?

PURPOSE

Epidermal growth factor receptor-overexpression reported in colorectal cancer, justifies therapeutic use of EGFR-inhibitors. We have recently conducted a phase II study in 57 patients with EGFR-positive advanced colorectal cancer (ACC) who received gefitinib-FOLFOX6 followed by gefitinib-single agent as maintenance. Main biological objective was to assess sEGFR as surrogate marker of tyrosine kinase inhibition and as predictor of response.

METHODS

sEGFR, evaluated by quantitative ELISA, was investigated as predictive factor both taking into account the basal value only, and its whole pattern over time. sEGFR was collected at baseline and at every 2-months assessment in 42 cases. Thirty-three patients reported CR/PR as best objective response (BOR), while nine showed SD/PD.

RESULTS

Retrospectively, on average, the sEGFR values reported by both responders (CR/PR) and not responders (SD/PD) were already different at baseline (49.4 +/- 6.2 and 42.4 +/- 8.4 ng/ml respectively). This difference was statistically significant (p = 0.042). Although sEGFR trend over time confirmed the basal difference (p = 0.032), this result should be taken with caution, due to the small number of patients reporting EGFR values besides the basal one.

CONCLUSIONS

Higher sEGFR at baseline was associated to BOR and may be considered a significant predictor of outcome in patients with ACC.

Optimizing clinical care of patients with metastatic breast cancer: a new oral vinorelbine plus trastuzumab combination

BACKGROUND

Trastuzumab (T) combined with i.v. vinorelbine (i.v.VNR) is an active regimen for patients with advanced breast cancer (ABC). In order to further improve quality of life of patients undergoing treatment for ABC, a new regimen using oral vinorelbine (oVNR) (d1 + d3) plus q3wks T was tested (ToVNR).

PATIENTS AND METHODS

Thirty-nine patients with ABC, human epidermal growth factor receptor 2/neu 3+ or FISH positive received 288 treatment cycles with T 6 mg/kg (loading dose, 8 mg/kg) on d1 and oVNR 55 mg/m(2) on d1 + d3, q3wks until disease progression or unacceptable toxicity.

RESULTS

Thirty-seven patients and 286 treatment cycles were evaluated (two patients were lost to follow-up). Treatment was very well tolerated. Two patients had complete response (CR), 14 partial response (PR), 17 stable disease (SD) and four disease progression (PD) (overall response rate: 43%). Clinical benefit rate (CR + PR + SD >24 months) was 73%. Median time to progression was 8.9 months (range 2-27) and median duration of response was 10.9 months (range 2-27).

CONCLUSIONS

The ToVNR combination is active and very well tolerated. It favorably compares with the combination of T and weekly i.v. administered VNR, allowing a more convenient once every three weeks hospital admission and leaving patients and care providers free from the unpleasant effect of i.v.VNR.

Antitumour and biological effects of letrozole and GnRH analogue as primary therapy in premenopausal women with ER and PgR positive locally advanced operable breast cancer

Preoperative endocrine therapy is effective in postmenopausal patients with breast cancers expressing oestrogen receptor. We investigated the activity of primary therapy with letrozole in combination with GnRH analogue in premenopausal women with T2-T4 N0-N2 breast cancer, whose tumours expressed oestrogen and progesterone receptors. We measured the expression of molecular factors involved in responsiveness to endocrine agents including ERalpha, EGFR, HER2, MAP kinases (and phosphorylated forms) ER-beta1, both at initial biopsy and at the time of surgery. Thirty-five patients were included and 32 patients were evaluable for response. Sixteen patients (50%, 95% CI 32-68%) obtained a partial response, 16 patients were stable. One patient showed pathological complete response (3%, 95% CI 0-16%). Response was significantly associated with younger age (P<0.05) and a longer duration of treatment (P<0.05). Treatment significantly decreased ERalpha-p-Ser(118) and upregulated ER-beta1, independently of response. No or negligible overexpression of EGFR was observed at baseline or after treatment in this population. Preoperative letrozole and GnRH analogue are effective in premenopausal women. A biological response in terms of downregulation of phosphorylated ERalpha was observed in all patients. Future investigations might focus on treatments of longer duration.

Brain metastases in patients with advanced breast cancer

BACKGROUND

The incidence of brain metastases (BM) is apparently rising in patients with advanced breast cancer (ABC). We performed a case control study to define current features of breast cancer related to central nervous system (CNS) metastases.

PATIENTS AND METHODS

From March 1999 to May 2006, we identified 72 patients with symptomatic BM of breast cancer. A comparison group was randomly selected assigning to each case two patients with primary breast cancer and no BM, matched for year of diagnosis, age and tumour stage (pT status and nodal status).

RESULTS

Cases had a significantly higher rate of negative estrogen receptors (ERs) (60% in cases vs. 29% in controls), negative progesterone receptors (PgRs) (79% vs. 43%), HER2/neu over expression (44% vs. 13%) and immunostaining for Ki-67 > or =20% (84% vs. 55%), with p-value <0.001 for all four parameters in univariate analyses. On multivariate analysis, HER2/neu over expression and Ki-67 -20% were independent predictive factors of brain relapse (Odds Ratio (OR) 2.55, 95% confidence intervals (CI) 1.10-5.94 and OR 2.97, 95% CI 1.01-8.73, respectively). Endocrine unresponsive tumours (both ER and PgR <10%) showed an increased risk of relapse with BM of borderline significance (OR 1.91, 95% CI 0.87-4.12).

CONCLUSION

Patients with ER and PgR negative tumours either with or without HER-2/neu over expression should be considered at higher risk of BM.

Epidermal growth factor receptor (EGFR) serum level may predict response in patients with advanced colorectal cancer (ACC) treated with gefitinib

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Background: EGFR-overexpression reported in colorectal cancer, justifies use of EGFR inhibitors. We conducted a phase II study (ESMO 2005) in ACC with the aim to assess efficacy of gefitinib plus oxaliplatin containing regimen. Main biological objective was to assess serum EGFR extra-cellular binding domain as surrogate marker of tyrosine-kinase inhibition and as predictor of outcome. Methods: 57 patients with EGFR-positive ACC,received gefitinib 250 mg/day combined with simplified FOLFOX-6 for at least 4 cycles,for a maximum of 10 courses.In not progressive disease, gefitinib was continued as maintenance treatment. Tumour assessment by RECIST criteria was performed at baseline and every 4 cycles.Serum EGFR extracellular binding-domain was evaluated by quantitative enzyme-linked immunoadsorbent.Serum EGFR as predictive factor was evaluated both taking into account the basal value only,and the whole EGFR pattern over time.The analyses were performed by logistic and Cox’s regression model with time-dependent covariate respectively;both models included centre, gender,age and site of primary tumours as adjusting factors. Results: Serum samples for EGFR were obtained at baseline and at every assessment.During mono-therapy phase the patients with serum samples decreased. Over treatment,34 patients reported a CR or PR as best objective response (BOR),while 9 patients showed SD or PD. Higher serum EGFR was associated to BOR both at baseline and over time.This result was confirmed by a similar analysis,which considered the whole EGFR profile,instead of the basal value only. Conclusions: Serum EGFR at baseline can be considered a significant predictor for the BOR.This observation is in line with data reported on lung cancer (Gregorc V, 2004).Although the EGFR trend over time seems to confirm the basal difference,this result should be taken with caution,due to the little number of cases reporting EGFR values besides the basal one.

[Table: see text]

No significant financial relationships to disclose.

Monolithic triglyceride matrices: a controlled-release system for proteins

Matrices made of glyceryl trimyristate as a bioerodible and biocompatible material were manufactured by compression in dimensions that would still allow an application via injection. Pyranine, as a low molecular hydrophilic compound with a low detection limit, and tetramethylrhodamine labeled bovine serum albumin (TAMRA-BSA), as a high molecular weight (66 kDa) protein compound, served as model drugs for release investigations. In vitro studies with pyranine revealed that release depends substantially on the gelatin content of the matrices, which proved to be a useful tool as a release modifier. The duration of the drug release period can be adjusted to a desired time interval ranging from days to weeks by choosing the right gelatin content. Moreover, results illustrated the importance of the molecular weight and the nature of the compound to be incorporated into such matrices, since investigations with TAMRA-BSA showed a more pronounced burst release and altered release profiles and periods. Experiments with hyaluronidase, which served as a model enzyme to assess the problem of protein integrity in such matrices, suggested that proteins may display sufficient stability during the manufacturing procedure of the cylinders or while in contact with the triglyceride matrices. In addition to in vitro investigations, a study in mice revealed that after 15 days of subcutaneous implantation the matrices showed a good in vivo stability. The main conclusion that could be drawn from these results was that triglycerides are a promising alternative to biodegradable polymers for the development of parenteral release systems for protein and peptide drugs.

A transcultural study of agitation in dementia

Agitation is one of the most troublesome behaviors in demented patients. It is etiologically heterogeneous and has varied associated behaviors. To explore the transcultural differences in the manifestation of agitation, we evaluated 50 consecutive Alzheimer's disease (AD) patients in three countries (Taiwan, Italy, and the United States) using the Neuropsychiatric Inventory (NPI) and the Mini-Mental State Examination (MMSE). In a focused analysis, only patients with composite NPI scores > 2 for agitation were selected, with similar levels of disease severity as measured by the MMSE, from the three groups (n = 15 per group) to evaluate culturally specific correlates of agitation. Agitated Taiwanese had significantly more hallucinations than either Italian or American patients. Agitated Italian patients had significantly more apathy than both Taiwanese and American patients. Cultural factors may influence the manifestation of agitation more than a common underlying neuropathology. Management strategies targeting unique behavioral instigators of agitation may be specific for different ethnic groups.

Monolithic glyceryl trimyristate matrices for parenteral drug release applications

Monolithic lipid matrices were developed that allow parenteral drug release for days, weeks or even months. The cylindrical matrices consist of triglycerides or triglyceride/cholesterol mixtures and allow, due to their small dimensions, an application via injection. Pure triglyceride matrices showed less than 3%, triglyceride matrices containing 70% and more cholesterol less than 10% water uptake over 30 weeks. This swelling behavior would allow the use of such matrices even for sophisticated applications such as interstitial drug delivery to the brain where excessive swelling is highly undesirable. The drug release kinetics were found to depend strongly on the fatty acid chain length of the triglyceride and the cholesterol content of the matrices. Increasing the chain length from C(12) to C(18) allowed an increase in the release of pyranine, a low molecular weight model compound, from approx. 60 days to more than 120 days. Adding cholesterol to glyceryl trimyristate matrices made it possible to adjust the release within a time span varying from days to weeks. While matrices containing 50% cholesterol released pyranine within 8 days, cholesterol contents of 90% allowed a release of the dye for more than 3 weeks.

Regulation of endothelial cell shape and barrier function by chromogranin A

We have found that chromogranin A (CgA), a protein released in circulation by neuroendocrine cells and neurons, prevents the vascular leakage induced by tumor necrosis factor (TNF) in a mouse model. Studies of the mechanism of action showed that CgA and its NH(2)-terminal fragments inhibit TNF-induced vascular permeability by preventing endothelial cytoskeleton rearrangements. We propose that neuronal/endocrine secretion of CgA could contribute to the regulation of endothelial barrier function and the protection of vessels against plasma leakage in inflammatory diseases.

Spinal dysraphism in an elderly patient

Spinal dysraphisms are diagnosed more frequently at birth or in infancy. We report a spinal malformation compatible with lipomyeloschisis in an elderly patient presenting with symptoms and signs of myelopathy. Magnetic resonance imaging revealed an intraspinal mass continuous with a subcutaneous lipoma. Three-dimensional computed tomography reconstructions better showed the spinal dysraphism; dermal sinus was also evident. Neuroimaging can define the precise diagnosis also in elderly patients presenting with myelopathy and can provide valuable structural details.

Roles of tumor necrosis factor p55 and p75 receptors in TNF-alpha-induced vascular permeability

We have investigated the role of p55 and p75 tumor necrosis factor receptors 1 and 2 (TNFR1 and TNFR2, respectively) in TNF-induced alteration of endothelial permeability in vitro and in vivo. Stimulation of TNFR1 with an agonist antibody or a receptor-selective TNF mutein increased the flux of (125)I-albumin through endothelial cell monolayers. An antagonist anti-TNFR1 antibody, but not antagonist anti-TNFR2 antibodies, blocked the activity of TNF in vitro. Stimulation of TNFR1, but not TNFR2, induced cytoskeletal reorganization associated with increased permeability. SB-203580, a p38 mitogen-activated protein kinase inhibitor, blocked TNFR1-induced cytoskeletal reorganization and permeability. A selective mouse TNFR1 agonist and human TNF, which binds to murine TNFR1, increased the leakage of trypan blue-albumin from liver vessels in mice. These results indicate that stimulation of TNFR1 is necessary and sufficient to increase endothelial permeability in vitro and in vivo. However, an antagonist anti-murine TNFR2 antibody partially inhibited the effect of murine TNF on liver vessels, suggesting that TNFR2 also plays a role in the regulation of TNF-induced vascular permeability in vivo.

Programmable biodegradable implants

Pulsatile release implants were developed that release substances up to 58 days post implantation. With a cylindrical size of 2 mm diameter and 1.8 mm height the matrices can carry as much as 1 mg of drug and allow even for intracranial implantation into a rodent model. The matrices are made of materials that have been used for parenteral applications in humans before such as surface eroding polyanhydrides and bulk eroding poly(D,L-lactic acid) or poly(D,L-lactic acid-co-glycolic acid). The onset of drug release is controlled by the degradation of bulk eroding polymers which are known to exhibit a certain stability over a defined period of time and which start eroding after they reach a critical degree of degradation. The time of drug release onset was found to depend on the molecular weight and the chemical state of the carboxylic acid end of the polymer chain. For testing the onset of release in vivo a nude mouse model was developed where the release of Evan's blue could be observed visually after subcutaneous application. By combining individual matrices with different release onset, a therapeutic system can be composed that releases drugs after implantation at predetermined time points in a preprogrammed way. Potential applications for such matrices is vaccination and local tumor therapy.

Researching a differential impairment of frontal functions and explicit memory in early Parkinson's disease

An impairment at tasks sensitive to frontal lobe damage has been repeatedly reported in Parkinson's disease, but the exact nature of these deficits has not yet been clarified. Similarly, deficits of visuo-spatial functions have been frequently observed, but it is still debated whether verbal and visuo-spatial memory can be differentially affected. In this study we have compared the performance of 20 mild Parkinson's disease patients (I-II Hoehn and Yahr stage) and 18 matched normal controls, at tasks assessing frontal functions and explicit memory. We detected a selective deficit in set shifting and maintaining, without impairment in categorization and set formation. The lack of a selective increase in perseverative errors might indicate that perseverations either measure something different from set shifting or that they do not represent an index sensitive enough to set shifting impairment. Parkinson's disease patients were also significantly impaired at Raven's Progressive Matrices, a task assessing both frontal and visuo-spatial aspects. However, they did not show any differential impairment of visuo-spatial memory. Indeed, despite a trend of lower performance in visuo-spatial learning, memory performance of Parkinson's disease patients was significantly different from that of controls only at a free recall test which involved both verbal and visuo-spatial memory. We suggest the exploration of set shifting and maintaining to detect 'frontal' deficits in mild Parkinson's disease. We argue that Raven's Progressive Matrices is a valuable task for detecting subclinical cognitive deficits in Parkinson's disease, even if it does not show a specific profile of impairment in these patients. According to our results, a differential evaluation of verbal vs. visuo-spatial memory is not necessary in clinical practice, whilst free recall confirms its usefulness to detect subclinical impairments of memory functions.

Superficial siderosis of the central nervous system and anticoagulant therapy: a case report

Superficial siderosis of the central nervous system is a rare condition characterized by deposition of haemosiderin in the leptomeninges and in the subpial layers of the brain and spinal cord. With the widespread use of magnetic resonance imaging, an increasing number of cases of superficial siderosis are being discovered, secondary forms being more frequent than idiopathic ones. We report a 78-year-old man in oral anticoagulant therapy, who presented neurosensory hearing loss, gait ataxia and spastic paraparesis. Magnetic resonance imaging suggested the diagnosis of superficial siderosis of the central nervous system, without an evident bleeding source.

Behavioral disorders in Alzheimer disease: a transcultural perspective

OBJECTIVES

To compare 2 samples of patients with Alzheimer disease (AD), from Italy and the United States, in order to determine transcultural differences in the manifestation of noncognitive symptoms. To analyze the concurrent validity, internal consistency reliability, between-rater reliability, and test-retest reliability of the Neuropsychiatric Inventory Scale (NPI).

METHODS

The NPI was given to 50 Italian and 50 US patients with AD. To demonstrate the validity and reliability of the Italian version of the instrument, several different methods of analysis were used. The total score on the NPI and the score of single items in the different stages of the disease were compared in the 2 samples of patients.

RESULTS

A high level of internal consistency reliability was confirmed, the between-rater reliability was very high, and the test-retest reliability was significantly correlated. Apathy was the most frequently recorded behavior in the Italian sample. Five of 10 NPI item scores showed a significant relation with the Mini-Mental State Examination scores in both samples. The Italian patients showed an increasing and significantly higher mean NPI total score at all levels of dementia severity when compared with the US patients. The scores on some NPI subscales, such as apathy, aberrant motor behavior, disinhibition, and agitation, were significant higher in Italian patients at different levels of severity covarying with educational level.

CONCLUSIONS

These results indicate that NPI is a reliable instrument with which to study transcultural differences in the presentation of neuropsychiatric disturbances in patients with AD. The described similar pattern of behaviors between Italians and US patients with AD suggests a biological origin of the disorders. However, cultural influences must be taken in account when the focus of the study is on psychopathological aspects of dementia.

Visual and spatial perception in the early phase of Alzheimer's disease

A battery of visuospatial perception tests was administered to 27 mild probable Alzheimer's disease (AD) patients; 21 were reassessed after 8 months. At the first evaluation, AD patients were impaired only in an object-naming task. After 8 months, the performance in the subtests of object perception was unchanged, while there was a significant decline in the total score of the items tapping space perception. A significant worsening was also observed in the Rey's figure copy score and was correlated with the decrease in the spatial perception score. This study confirms that an impairment in visual perceptual tests requiring access to semantic and lexical knowledge is present in the earliest phase of AD, whereas visuospatial and constructional impairments became evident only later. This pattern of progression may represent the clinical correlate of increasing pathological involvement of posterior associative cortex.

Visual and spatial perception in the early phase of Alzheimer's disease

A battery of visuospatial perception tests was administered to 27 mild probable Alzheimer's disease (AD) patients; 21 were reassessed after 8 months. At the first evaluation, AD patients were impaired only in an object-naming task. After 8 months, the performance in the subtests of object perception was unchanged, while there was a significant decline in the total score of the items tapping space perception. A significant worsening was also observed in the Rey's figure copy score and was correlated with the decrease in the spatial perception score. This study confirms that an impairment in visual perceptual tests requiring access to semantic and lexical knowledge is present in the earliest phase of AD, whereas visuospatial and constructional impairments became evident only later. This pattern of progression may represent the clinical correlate of increasing pathological involvement of posterior associative cortex.

Neuropsychological deficits in asymptomatic atrial fibrillation

OBJECTIVE

To assess the preclinical effects on cognitive functions of nonrheumatic atrial fibrillation (NRAF) in patients with negative history for cerebrovascular disease.

MATERIALS AND METHODS

The study included 37 consecutive patients with chronic (n=16, mean age 65.3+/-6.6 years) or paroxysmal (n=21, mean age 58.3+/-9.5 years) NRAF and an equal number of control subjects in sinus rhythm, who were matched for age, education and presence of hypertension. A comprehensive neuropsychological battery including tests of attention, memory, language and visuospatial skills was administered.

RESULTS

Patients with chronic NRAF showed significantly poorer performances in tasks exploring attention and verbal memory functions, while the paroxysmal group was significantly impaired in a long-term memory task. The neuropsychological findings were confirmed excluding from both groups patients with CT evidence of cerebrovascular damage. A small subgroup of patients was also submitted to cerebral MRI.

CONCLUSION

Neurologically asymptomatic NRAF is related to a subclinical but significant impairment in attention and memory. These deficits could be produced by minor ischemic lesions due to microembolization, or by diffuse hypoxic damage due to hypoperfusion.

Procedural memory stimulation in Alzheimer's disease: impact of a training programme

The study evaluates the efficacy of a procedural memory stimulation programme in mild and mild-moderate Alzheimer's disease (AD). Twenty basic and instrumental activities of daily living have been selected, and divided into two groups, comparable for difficulty. Ten normal elderly subjects (age 68.0 +/- 4.8 years; MMSE score: 28.7 +/- 0.9; education: 7.6 +/- 3.5 years) were asked to perform the two groups of daily activities and the time required to perform the tasks of each group was recorded and used as a reference. Ten mild and mild-moderate AD patients (age 77.2 +/- 5.3 years; MMSE score: 19.8 +/- 3.5; education: 7.3 +/- 4.7 years) without major behavioural disturbances constituted the experimental group. Patients were evaluated in all 20 daily activities and the time employed was recorded at baseline and after a 3-week training (1 h/d, 5 d/week) period. Five patients were trained during the 3 weeks on half of the 20 daily activities and the other five patients were trained on the remainder. This procedure was adopted in order to detect separately the improvement in "trained" and "not trained" activities, allowing to control better the effects of the intervention. The assessment of the functional impact of the training was directly measured, through the variation of time employed to perform tasks before and after training. After 3 weeks of training a significant improvement was observed for the trained activities, from 3.6 to 1.9 standard deviations below the performance of the normal elderly controls (P < 0.05). AD patients improved also in not-trained activities from 3.5 to 2.7 standard deviations below the controls' performance (P < 0.05). The rehabilitation of activities of daily living through developing procedural memory strategies may be effective in mild and mild-moderate AD patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of mortality and institutionalization in demented patients with delusions

Delusions are a common symptom during the course of dementia. Despite their clinical relevance, however, it is still unclear whether they are of prognostic value. This longitudinal study involving, at baseline, 99 demented Alzheimer disease (AD) and multi-infarct dementia (MID) patients, investigates the risk of mortality and institutionalization at 2 years after discharge from a dementia unit in patients with and without delusions at baseline. Results indicate that the presence of delusions is a significant predictor of future institutionalization (odds ratio 3.6, confidence interval 1.3-9.6), even when confounding factors such as age, educational level, and severity of cognitive and functional impairment are statistically controlled. No significant impact on survival was found.