Endometriosis: seeking optimal management in women approaching menopause

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Obesity, Muscular Strength, Muscle Composition and Physical Performance in an Elderly Population

OBJECTIVE

To evaluate the association between BMI levels, muscular strength, muscle composition and physical performance in the elderly.

DESIGN

Italians subjects from the Progetto Veneto Anziani (ProVA) study were analyzed.

SETTING

The ProVa was a population study focused on chronic diseases and functional limitations in Italian subjects aged ≥65 years living in two Northeast Italian cities.

PARTICIPANTS

The ProVa study included 3099 subjects. ProVa participants with unknown information on BMI or disability status were excluded. The final sample was thus represented by 1.188 men, and 1.723 women.

MEASUREMENTS

Physical performance was measured with the Short Physical Performance Battery (SPPB) and leg muscular strength with dynamometry. Fat distribution and skeletal muscle composition were measured in an abdominal single-scan magnetic resonance (MRI) in a randomly selected sample of 348 subjects. Study population was stratified by BMI classes.

RESULTS

An association between BMI levels and SPPB was observed. Normal weight subjects showed the best SPPB scores (8.29±0.03), with significant differences compared to underweight (7.50±0.15; p<0.001), overweight (8.12±0.02; p<0.001), class I (7.72±0.04; p<0.001), class II (6.67±0.09; p<0.001) and class III obesity (5.88±0.24; p<0.001). This pattern was not modified by adjustment for possible confounders. Compared to normal weight subjects (22.9±0.1 kg), leg muscular strength was higher in overweight (23.8±0.1; p<0.001) and in class I obesity (24.5±0.1; p<0.001), but it was reduced in class II (21.4±0.3; p<0.001) and class III (19.8±0.9; p<0.001). The association between BMI and impaired physical performance was not affected by adjustment for muscular strength. An inverse association between SPPB scores and fat infiltration in skeletal muscle was observed in patients with abdominal MRI.

CONCLUSION

A poor physical performance was observed in overweight and obese elderly subjects. Leg strength was reduced only in subjects with severe obesity. Physical performance was negatively influenced by the degree of fat infiltration in skeletal muscle.

Abstract P4-01-21: Head to head comparison of standard echo doppler versus 3D speckle tracking echocardiography for early subclinical cardiotoxicity detection in breast cancer patients treated with anthracycline adjuvant chemotherapy

Background. Anthracycline (ANT)-containing regimens represent the prevalent choice for adjuvant therapy in early breast cancer (EBC) patients. However, cardio toxicity is a major limitation, strongly affecting the quality of life and the overall survival of cancer patients, regardless of the oncologic prognosis.

Aims: To assess the diagnostic power of real-time 3D Speckle Tracking Echocardiography (STE) in comparison with standard echo Doppler (SED) in detection of early subclinical ANT related cardio toxicity in breast cancer patients.

Methods: Fifty-five consecutive patients (F/M = 54/1, mean age = 48 years) with EBC were prospectively enrolled in the study. All patients received three cycles of epirubicin (EPI) based chemo regimen followed by taxanes. Overall, average EPI cumulative dose per patient was 505 ± 68 mg/m2 (range = 360-720 mg/m2). Complete SED exam including determination of 2D ejection fraction (EF) and pulsed Tissue Doppler of the mitral annulus were measured at baseline and at the end of the three cycles of EPI. Three-D determination of left ventricular volumes and EF as well as 3D STE-derived global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) and global radial strain (GRS) were assessed, whenever feasible, at the same time points.

Results: All the patients completed the three cycles of EPI as per protocol. No overt clinical manifestation of heart failure was observed. Standard echo doppler was performed in all the patients. Two-D EF did not significantly change with EPI treatment. However, the E/e’ ratio measured by SED, was significantly increased after EPI administration (6.7±1.7 vs. 7.25±1.8 before and after treatment, respectively; p&lt;0.05). Overall, 3D ventricular volumetric assessment was feasible in the 63.6% (35/55) of patients and 3D STE in the 60% (33/55) of patients due to anatomical or technical problems. Among parameters measured by 3D STE, a reduction of EF (58.8±8% vs. 61.7±7.1%, before and after treatment, respectively; p&lt;0.02) and a significant increase of the left ventricular end-systolic volume (p&lt;0.01) was observed. Importantly, a significant decrease of the following 3D STE parameters: GLS (p&lt;0.01), GRS (p&lt;0.001), GCS (p&lt;0.0001) and GAS (p&lt;0.0001) were observed after EPI therapy.

Conclusions: Results from the present study confirm the increased sensitivity of real time 3D STE technique in detecting early subclinical signs of cardio toxicity in patients with EBC treated with EPI adjuvant chemotherapy. However, due to technical problems, STE was not feasible in the entire patient population included in the study. Among parameters measured by SED, the E/e’ ratio identifies early signs of cardiac dysfunction more accurately compared to the standard 2D EF determination.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-21.

Informed consent for tracheostomy procedures in Intensive Care Unit: an Italian national survey

BACKGROUND

Critically ill patients in Intensive Care Unit (ICU), due to their temporary or permanent incompetence, are often not capable to provide informed consent (IC), although required, for not emergency invasive procedures, like elective tracheostomy. By Italian law, a person with partially/temporarily physical/mental impairment needs a legal tutorship appointed by the court (Support Administrator, SA). We performed a national survey in Italy to investigate IC practice for elective tracheostomy procedure in critically ill conscious and unconscious patients in ICU.

METHODS

Questions about IC were included in a survey concerning the clinical practice of tracheostomy in ICU. The survey was approved by the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI, n° 434 - 28 March 2012) and sent by e-mail to all members included in its mailing list. The duration of the survey was three months from April to June 2012. All required information was referred to the year 2011.

RESULTS

The mailed questionnaire correctly fulfilled was sent back by 131/427 (30%) national ICUs. Our data showed 1) in conscious patients, IC was obtained by 82.4% of ICUs; 2) in unconscious patients, IC was obtained in only 61.8% with different procedures not following the current Italian law, 3) for surgical tracheostomy performed in operating room, IC was obtained in conscious and unconscious patients in only 69.8% and 47.2% of ICUs, respectively, 4) risk/benefit informative document was provided in 61.1% ICUs, but available only in 47.2% of ICUs performing tracheostomy in operating room.

CONCLUSION

In Italian ICUs, participating to this study, the procedures related to IC for conscious and unconscious critically ill patients requiring surgical or percutaneous tracheostomy are not in line with current legal rules and procedures.

Obesity treatment in elderly outpatients: predictors of efficacy and drop-out

OBJECTIVE

Obesity is increasing in the elderly and it is associated with an increased risk of medical complications, decline in physical function and disability. Very few studies specifically evaluated the outcome of obesity treatment in the aging patients. Aim of this work is therefore the evaluation of the efficacy of medical therapy in a group of obese patients >or=65 years old.

METHODS

The study has been performed on the clinical records of obese outpatients treated at the medical branch of the Unit for Medical and Surgical Therapy of Obesity at the University of Padova. Patients were recruited from January 1st, 2001 to June 30th, 2006 in order to have patients with at least one year of potential follow-up. In particular two groups were enrolled: 100 patients >or=65 years old and 200 patients <65 years old. The baseline characteristics, the prescriptions and the treatment outcome were compared.

RESULTS

Mean age of the elderly patients was 69.1+/-3.7 years (range 65-80 years). We did not find any significant difference between elderly and adult patients in the sex distribution (female patients 76% in the elderly group and 72% in the adult group; p=0.276) and in the severity of overweight (body mass index: 37.8+/-6.0 kg/m2 in the elderly; 37.2+/-6.3 kg/m2 in adults; p=0.425). The elderly group was characterized by a higher incidence of comorbidities and a lower incidence of eating behavior disorders at baseline. No significant differences in the dietary prescription were found, whereas physical activity was prescribed in 27/100 elderly patients (27%) and in 97/200 (48%) adults patients (p<0.000). Weight loss was evaluated by analyzing the percentage of patients reaching at least a 10% weight loss from baseline after 12 months of treatment. In elderly patients still in active treatment after 12 months, only 5/28 (18%) patients reached the specified goal, whereas in adult patients still in treatment, 18/47 (38%) patients reached the goal (p<0.05). Lower age at baseline, female sex, and lower body mass index were found to be the only significant predictors of 10% weight loss in logistic regression. In our experience, drop-out rate after 12 months was similar in adults (77%) and in older patients (72%). In a multivariate Cox regression model, the risk of drop-out was reduced by married or widowed status, the prescription of physical activity at baseline, and the presence of type 2 diabetes. The risk of drop-out was increased by the presence of osteoarthritis. Even after adjustments for these confounding variables, age did not play any significant role as drop-out predictor.

CONCLUSION

Advanced age seems to be a predictor of poor response to treatment in obese outpatients treated by conventional medical therapy. Drop-out rate was not significantly influenced by age.

Audit of litigation against the accident and emergency radiology department

PURPOSE

The aims of this study were to reduce and monitor litigation due to failure to diagnose a fracture, to evaluate whether the cases were due to radiological error or other problems in the diagnostic and therapeutic management of patients and to identify organisational, technical or functional changes or guidelines to improve the management of patients with suspected fracture and their expectations.

MATERIALS AND METHODS

We analysed the litigation database for the period 2004-2006 and extracted all episodes indicating failure to diagnose a fracture at the accident and emergency radiology department of our centre. The radiographs underwent blinded review by two experts, and each case was jointly analysed by a radiologist and a forensic physician to see what led to the compensation claim.

RESULTS

We identified 22 events (2004 seven cases; 2005 eight cases; 2006 seven cases). Six cases were unrelated to radiological error. Six were due to imperceptible fractures at the time of the examination. These were accounted for by the presence of a major lesion distracting the examiner's attention from a less important associated lesion in one case, a false negative result in a patient examined on a incompletely radiolucent spinal board and underexposure of the coccyx region in an obese patient. Six cases were related to an interpretation error by the radiologist. In the remaining cases, the lesion being referred to in the compensation claim could either not be established or the case was closed by the insurance company without compensation. Corrective measures were adopted. These included planning the purchase of a higher performance device, drawing up a protocol for imaging patients on spinal boards, reminding radiologists of the need to carefully scrutinise the entire radiogram even after having identified a lesion, and producing an information sheet explaining to patients the possibility of false negative results in cases of imperceptible lesions and inviting them to return to the department if symptoms persist.

CONCLUSIONS

We believe the clinical and administrative analysis we performed is useful. It reviewed some administrative practices and identified critical features. We identified tools that we trust will reduce litigation.

The legal implications of error in radiology

Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.

Fat depot-related differences in gene expression, adiponectin secretion, and insulin action and signalling in human adipocytes differentiated in vitro from precursor stromal cells

AIM/HYPOTHESIS

The distinct metabolic properties of visceral and subcutaneous adipocytes may be due to inherent characteristics of the cells that are resident in each fat depot. To test this hypothesis, human adipocytes were differentiated in vitro from precursor stromal cells obtained from visceral and subcutaneous fat depots and analysed for genetic, biochemical and metabolic endpoints.

METHODS

Stromal cells were isolated from adipose tissue depots of nondiabetic individuals. mRNA levels of adipocyte-specific proteins were determined by real-time RT-PCR. Insulin signalling was evaluated by immunoblotting with specific antibodies. Glucose transport was measured by a 2-deoxy-glucose uptake assay. Adiponectin secretion in the adipocyte-conditioned medium was determined by a specific RIA.

RESULTS

With cell differentiation, mRNA levels of PPARG, C/EBPalpha (also known as CEBPA), AP2 (also known as GTF3A), GLUT4 (also known as SLC2A4) were markedly upregulated, whereas GLUT1 (also known as SLC2A1) mRNA did not change. However, expression of C/EBPalpha, AP2 and adiponectin was higher in subcutaneous than in visceral adipocytes. By contrast, adiponectin was secreted at threefold higher rates by visceral than by subcutaneous adipocytes while visceral adipocytes also showed two- to threefold higher insulin-stimulated glucose uptake. Insulin-induced phosphorylation of the insulin receptor, IRS proteins, Akt and extracellular signal-regulated kinase-1/2 was more rapid and tended to decrease at earlier time-points in visceral than in subcutaneous adipocytes.

CONCLUSIONS/INTERPRETATION

Subcutaneous and visceral adipocytes, also when differentiated in vitro from precursor stromal cells, retain differences in gene expression, adiponectin secretion, and insulin action and signalling. Thus, the precursor cells that reside in the visceral and subcutaneous fat depots may already possess inherent and specific metabolic characteristics that will be expressed upon completion of the differentiation programme.

Bipedicled skin flaps for reconstruction of the abdominal wall in newborn omphalocele

Despite technical refinements in surgery and advances in postoperative intensive care, abdominal wall closure in giant omphalocele remains a difficult endeavor. In this respect, bipedicled skin flaps obtained with longitudinal incisions along the margins of the rectus abdominis muscle may represent a good alternative solution to achieve a complete, tension-free midline closure. Incisional areas can subsequently be easily covered with split-thickness thigh grafts. Two neonatal cases were treated with this technique with good results. This has enabled avoidance of palliative coverage as well as complex musculo-cutaneous reconstructions at a later age.

Y-chromosome haplotypes in Italy: the GEFI collaborative database

A sample of 1176 males from 10 Italian regions have been typed for DYS19, DYS389-I, DYS389-II, DYS390, DYS391, DYS392, DYS393, and DYS385. Individual haplotype data are available on line. A low degree of variation is present among regions. Use of this database is specifically recommended for forensic applications in Italy.

Autografting followed by nonmyeloablative immunosuppressive chemotherapy and allogeneic peripheral-blood hematopoietic stem-cell transplantation as treatment of resistant Hodgkin's disease and non-Hodgkin's lymphoma

PURPOSE

To investigate the use of a nonmyeloablative fludarabine-based immunosuppressive regimen to allow engraftment of HLA-sibling donors' mobilized stem cells and induction of a graft-versus-lymphoma effect for patients with advanced resistant Hodgkin's disease and non-Hodgkin's lymphoma.

PATIENTS AND METHODS

Fifteen patients with Hodgkin's disease (n = 10) and non-Hodgkin's lymphoma (n = 5) were studied. All patients received cyclophosphamide and granulocyte colony-stimulating factor to mobilize autologous hematopoietic stem cells (HSCs). Subsequently, they received high-dose therapy with carmustine, etoposide, cytarabine, and melphalan and reinfusion of HSCs. At a median of 61 days after engraftment, patients were given fludarabine 30 mg/m(2) with cyclophosphamide 300 mg/m(2) daily for 3 days. Donor-mobilized HSC collections were prepared for fresh infusion and were not T-cell depleted. Methotrexate and cyclosporine were used to prevent graft rejection and as graft-versus-host disease (GVHD) prophylaxis.

RESULTS

Combined treatment was well tolerated. After mini-allografting, hematologic recovery was prompt. Thirteen patients had 100% donor cell engraftment. Eleven patients achieved complete remission (CR) after the combined procedure. Nine patients, who were in partial remission after autografting, achieved CR after mini-allografting. Seven patients developed >/= grade 2 acute GVHD (aGVHD) and two developed extensive chronic GVHD (cGVHD). Three patients who received the highest number of donor lymphocyte infusions (DLIs) developed grade 3 GVHD (two patients) and extensive cGVHD (one patient). Ten patients are currently alive, and five are in continuous CR. Seven patients received DLI, with five CRs. Five patients died: one of progressive disease, two of progressive disease combined with aGVHD or cGVHD, one of extensive cGVHD, and one of infection.

CONCLUSION

Fludarabine/cyclophosphamide was well tolerated and allowed consistent engraftment in lymphoma allografted patients. Response rates were high in this group of refractory and heavily pretreated patients. This dual procedure seems to be most promising in patients with end-stage malignant lymphomas.

Gene expression profiling of human colon cancer cells following inhibition of signal transduction by 17-allylamino-17-demethoxygeldanamycin, an inhibitor of the hsp90 molecular chaperone

A number of molecular therapeutic agents, derived from exploiting our knowledge of the oncogenic pathways that are frequently deregulated in cancer, are now entering clinical trials. One of these is the novel agent 17-allylamino-17-demethoxygeldanamycin that acts to inhibit the hsp90 molecular chaperone. Treatment of four human colon cancer cell lines with iso-effective concentrations of this agent resulted in depletion of c-raf-1 and akt and inhibition of signal transduction. We have used gene expression array analysis to identify genes responsive to treatment with this drug. The expression of hsp90 client protein genes was not affected, but hsc hsp70, hsp90beta, keratin 8, keratin 18 and caveolin-1 were deregulated following treatment. These observations were consistent with inhibition of signal transduction and suggested a possible mechanism of resistance or recovery from 17-allylamino-17-demethoxygeldanamycin treatment. The results shed light on the molecular mode of action of the hsp90 inhibitors, and suggest possible molecular markers of drug action for use in hypothesis testing clinical trials. Oncogene (2000) 19, 4125 - 4133

Long-term follow-up of two children with a variant of mild autosomal recessive osteopetrosis undergoing bone marrow transplantation

Malignant autosomal recessive (AR) osteopetrosis represents an absolute indication for bone marrow transplantation (BMT). Over the last 15 years, almost 100 BMTs for osteopetrosis have been reported. The median age at transplant of most patients is 4 months. Very few cases of mild AR osteopetrosis have been described. Here, we report the good outcome of two cases of mild AR osteopetrosis with a follow-up of 5 and 6 years, respectively, after an HLA-identical sibling transplant undergone at 5 and 12 years of age, respectively. At the time of BMT, severe visual impairment was present in both children. Bone biopsy demonstrated hypermineralization with virtual obliteration of the medullary spaces, rare microfoci of hematopoiesis and marked deficiency in osteoclastic activity. Successful engraftment was complicated by hypercalcemia, controlled by a combination of bisphosphonate, phosphate infusions, vigorous hydration and calcitonin. Following BMT, radiological and histological findings showed extensive bone resorption with marked augmentation of the osteoclasts in normalized marrow. No improvement was observed in visual acuity, despite complete remodeling of skeletal abnormalities. We conclude that allogeneic BMT is the only chance of curing mild AR osteopetrosis.

[Flaccid paralysis surveillance in the Latium Region]

The goal of World Health Organization is to reach the global eradication of poliomyelitis during the first decade of the third millennium. To achieve the certification of the eradication of the disease the main strategy is the Acute Flaccid Paralysis (AFP) surveillance. In Italy the active AFP surveillance was performed at national level since 1997. In the Latium region the active surveillance was performed since January 1997 by the laboratory of virology of Institute of Hygiene G Sanarelli which established a regional hospital network. During the years of survey 7 cases were found in 1997 (0.87/100,000), 4 in 1998 (0.5/100,000), 2 in 1999 (0.25/100,000) and 2 in 2000. No wild polioviruses were detected.

Evidence of cytogenetic and molecular remission by allogeneic cells after immunosuppressive therapy alone

An immunosuppressive but not myeloablative regimen followed by HLA-matched donor mobilized haemopoietic stem cell transplantation was employed in two high-risk patients. The first patient had refractory anaemia with excess blasts (RAEB) and cytogenetic evidence of translocation 1;3(p36;q21). The second patient had Philadelphia-negative but p190 BCR-ABL chimaeric gene positive chronic myelogenous leukaemia in accelerated phase (AP-CML). The conditioning regimen consisted of fludarabine (30 mg/m2/d, days 1-3) with cyclophosphamide (300 mg/m2/d, days 1-3). Cyclosporine and methotrexate were employed for acute graft-versus-host disease (aGVHD) prophylaxis. In both cases the engraftment of donor cells was demonstrated by cytogenetics and short tandem repeat polymorphisms via PCR. Both patients are alive with normal cytogenetic (RAEB) and molecular (AP-CML) remissions, 100 and 150 d after allografting, respectively. In particular, in the AP-CML patient, the BCR-ABL became undetectable and the BCR-ABL/ABL ratio was <0.0001.

Engraftment of HLA-matched sibling hematopoietic stem cells after immunosuppressive conditioning regimen in patients with hematologic neoplasias

BACKGROUND AND OBJECTIVE

The main objective of this pilot study was to assess the possibility of achieving engraftment of HLA-matched sibling donor mobilized hematopoietic stem cells after immunosuppressive non-myeloablative therapy. The second objective was to verify whether high-dose therapy with autologous stem cells rescue followed by allografting conditioned by only an immunosuppressive regimen, can be combined in order to achieve the reduction of tumor burden after autografting and the control of residual disease with immune-mediated effects after allografting.

DESIGN AND METHODS

To enter the pilot study the patients had to fulfil the following criteria: advanced resistant disease, presence of an HLA matched sibling donor, no general contraindications to stem cell transplantation. Our data refers to 9 patients: Hodgkin's disease (n = 4), non-Hodgkin's lymphoma (n = 2), advanced chronic myelogenous leukemia (n = 2) (one patient with accelerated phase Ph-negative but p190 BCR-ABL gene positive by RT-PCR and one with Ph-positive blastic phase), refractory anemia with excess of blasts t(1;3) (p36;q21) (n = 1). All patients but one received the combined approach. At a median of 40 days (range 30-96), after high-dose therapy and autologous stem cell engraftment, the patients were treated with immunosuppressive therapy consisting of fludarabine and cyclophosphamide (Flu-Cy protocol) and then HLA matched donor mobilized stem cells were infused into the patients. GvHD prophylaxis consisted of cyclosporin and methotrexate.

RESULTS

To date, with a median observation period of 4 months (range, 2-10), complete chimerism (100% donor cells) has been achieved in 6 patients. Three patients did not achieve complete chimerism: one patient died of progressive Hodgkin's disease when he reached 55% of donor cells, another patient is now in increasing phase of donor cell engraftment and the last patient (blastic phase-CML) was the only case who appears to have had autologous recovery. Two of the Hodgkin's disease patients, who were in partial remission after autografting, achieved complete remission after allografting and both are disease free 2 and 6 months after. Another Hodgkin's disease patient is alive at 10 months but she has progressive disease. One of the two patients with non-Hodgkin's lymphoma, who achieved partial remission after autografting, obtained complete remission and he is disease free 2 months after allografting. The other patient maintains partial remission obtained after autografting. The accelerated phase-CML patient obtained hematologic and molecular remission; the RAEB patient achieved hematologic and cytogenetic remission. In two patients severe aGVHD (grade II-III) was the single major complication but neither patient died of it. Mild aGVHD was seen in another patient. In only one patient did the ANC decrease to below 1 x 10(9)/L and in no case did platelets decrease below 20 x 10(9)/L. No patients required a sterile room or any red cell or platelet transfusions.

INTERPRETATION AND CONCLUSIONS

Immunosuppressive therapy with a Flu-Cy protocol allowed engraftment of HLA-matched sibling donor stem cells without procedure-related deaths; moreover, we have demonstrated that this combined procedure can be pursued in safety in a serious ill population and some of these patients achieved a complete remission. This procedure is not likely to be curative, but a fascinating step along the path to curing these diseases. Of course, the follow-up is too short to document the incidence of cGvHD.

A 'de novo' point mutation of the low-density lipoprotein receptor gene in an Italian subject with primary hypercholesterolemia

Severe hypercholesterolemia was found in an 11-year-old boy with no family history of familial hypercholesterolemia. The reduced LDL-receptor activity in cultured skin fibroblasts (40% 125I-LDL degradation as compared with a control cell line) indicated the presence of an LDL-receptor defect. The analysis of the promoter region and the exons of LDL-receptor gene by single strand conformation polymorphism revealed an abnormal migration pattern in exon 1, which was due to a T --> A transversion at nucleotide 28 of the cDNA. This novel mutation causes an arginine for tryptophane substitution at position - 12 of the signal peptide (W-12R) and introduces an AviII restriction site in exon 1. Screening of the mutation by polymerase chain reaction (PCR) amplification of exon 1 and AviII digestion revealed that none of the proband's family members carried the mutation. Non-paternity was excluded after the analysis of a battery of 14 short tandem repeats located in 13 different chromosomes. These results are consistent with the hypothesis that the proband is heterozygous for a 'de novo' mutation of the LDL-receptor gene producing a non-conservative amino acid substitution. We suggest that the change in the net charge of the signal peptide, caused by the addition of a positively charged amino acid, impairs the co-translational translocation of the nascent receptor protein across the endoplasmic reticulum membrane.

Low transplant mortality in allogeneic bone marrow transplantation for acute myeloid leukemia: a randomized study of low-dose cyclosporin versus low-dose cyclosporin and low-dose methotrexate

Sixty patients undergoing allogeneic bone marrow transplant for acute myeloid leukemia (AML) in first remission (CR1; n = 49) or more advanced phase (n = 11) were entered in a prospective trial of graft-versus-host disease (GvHD) prophylaxis: low-dose cyclosporin A (IdCSA; 1 mg/kg/d from day -1 to +20 day; n = 28) or IdCSA plus low-dose methotrexate (IdMTX; 10 mg/m2 for day +1, 8 mg/m2 for days +3, +6, and +11; n = 32). Primary end points were acute GvHD (aGvHD) and transplant-related mortality (TRM); secondary end points were relapse and survival. The conditioning regimen consisted of cyclophosphamide (120 mg/kg) and fractionated total body irradiation (3.3 Gy/d for 3 consecutive days). The actuarial risk of developing aGvHD grade II-III was 61% for IdCSA alone and 34% for IdCSA + IdMTX (P = .02). The actuarial risk of TRM at 1 year was 11% versus 13%, respectively, and older patients (>/= 29 years) had higher TRM than younger patients (22% v 5%, P = .01). The age effect was significant in the IdCSA group (P = .04) but not in the IdCSA + IdMTX group (P = .1). The median follow-up is 4.4 years, with an overall actuarial survival of 78% for CR1 patients and 36% for patients with advanced disease. For patients in CR1 the outcome of the two regimens was as follows: survival 77% versus 80% (P = .6), relapse 20% versus 9% (P = .1), and TRM 13% versus 17% (P = .6). This study suggests that TRM can be reduced in AML patients undergoing allogeneic marrow transplants with a mild conditioning regimen and low-dose immunosuppression, and this translates in a 78% 5-year survival for CR1 patients. Beyond CR1 the major obstacle remains leukemia relapse, which is not prevented by low-dose in vivo immunosuppression.

Treatment of allergic diseases during pregnancy

Pregnancy may variously modify the natural history of allergic disorders through occurring endocrinologic, functional and immunological changes. A pharmacologic treatment of allergic diseases (mainly asthma) is often necessary during pregnancy. On the other hand, a drug should be not potentially teratogenic and should not have serious side effects, both for the mother and the fetus. This paper reviews current knowledge about allergic diseases during pregnancy, considering the points of view of the different specialists involved in their management. Topical mucosal agents seem to be the safest, due to their minimal or absent absorption which should reflect reduced side effects. Preferred agents should be topical antihistamines (for rhinitis and conjunctivitis), and cromones and topical steroids (for asthma), as they are both safe and effective.

Analysis of a short tandem repeat locus on chromosome 19 (D19S253)

A tetranucleotide tandem repeat locus on chromosome 19 (D19S253) was analysed. PCR products were detected by denaturing polyacrylamide gels with fluorescent-based technology. This study has confirmed a polymorphism with 9 alleles ranging from 209 to 241 bp with a simple repeat structure arranged from 7 to 15 repeats. Family studies confirmed mendelian inheritance of alleles. The efficiency on DNA extracted from bloodstains and cigarette butts has been evaluated. The protocol has shown sensitivity and reproducibility.

Forensic evaluation of HUMCD4: an Italian database

The YTTTC pentanucleotide short tandem repeat polymorphism HumCD4 was studied in an Italian population sample. PCR products were compared to an allelic ladder by manual PAGE and silver staining. A total of 6 alleles ranging from 5 to 12 repeats were represented in the analysed sample, of which 3 alleles (10, 6 and 5 repeats) were predominant and displayed a combined frequency of 0.91. Successful amplification was obtained from different sources such as blood and urine stains, teeth and paraffin embedded tissues. Results were also determined in cases of severely degraded DNA. We consider that the HUMCD4 polymorphism may be a useful tool for individual identification, paternity testing, population studies and have also employed this locus to monitor engraftment of bone marrow transplantation.

Individual identification of flood victims by DNA polymorphisms and autopsy findings

On September 23rd 1993 Genova was flooded by heavy rainstorms and 4 people disappeared, including an elderly couple. Four days later a partially skeletonized body was found floating near the coast. No visual identification was possible. Autopsy findings were consistent with the medical history of a possible victim. DNA was extracted from a muscle sample and compared to paraffin embedded prostatic gland fragment taken by surgery. A positive identification could be made. On October 11th the body of a decomposed and partially skeletonized female was found. The visual identification was also uncertain and no clinical records were available. A blood sample from the son was obtained for maternal identification by the polymerase chain reaction.

HLA-DQA1 and amelogenin coamplification: a handy tool for identification

A protocol for HLA-DQA1 and gender identification by single amplification is described. The use of the commercial HLA-DQA1 amplification kit (Perkin Elmer) permits a positive response for sex determination by adding primers for a short sequence on the first intron of Amelogenin gene. The suggested amplification protocol results in PCR products easily and clearly detectable on ethidium bromide stained agarose gel or silver stained polyacrylamide gel. In both gels the HLA-DQA1 observations at 242-239 bp are accomplished with a single band at 106 bp in females and a doublet 112-106 bp in males. HLA-DQA1 reverse dot-blot hybridization is unaffected by the presence of X and Y amplified fragments.

HLA-DQA1 allele and genotype frequencies in a northern Italian population

HLA-DQA1 typing of 227 randomly selected Northern Italian people by the use of polymerase chain reaction are reported. The combined use of commercial Amplitype HLA-DQalpha system and four sequence-specific oligonucleotide probes allows the definition of 8 alleles and 36 genotypes, arranged according to World Health Organisation nomenclature. Seven of these genotypes are not observed among the analyzed samples. Allele frequencies range from 1.5 to 35.7% and genotype observations do not deviate significantly from Hardy-Weinberg equilibrium; observed heterozygosity is 0.8238 with an allelic diversity value of 0.79 and the power of discrimination is 0.925. Our Italian population sample shows differences from other Caucasian samples both for allele and genotype frequencies. This locus typing for the 8 defined alleles provides a rapid and sensitive method in individual identification and paternity investigation.

Forensic applications of molecular genetic analysis: an Italian collaborative study on paternity testing by the determination of variable number of tandem repeat DNA polymorphisms

Several variable number of tandem repeat (VNTR) DNA polymorphisms detecting different loci (YNH24/MspI or TaqI, CMM101/MspI or MLJ14/MspI, EFD64.2/RsaI or HinfI, YNZ22/TaqI, AW101/EcoRI, EKMDA2.1/PvuII and 3'-HVR/PvuII) were used in the analysis of 27 cases of disputed paternity in the Italian population. Fourteen exclusions and 17 attributions were performed. The results were compared with those obtained with immunohematologic analyses. Four exclusions and 2 attributions were made possible only by the combined use of several DNA polymorphisms, as the analyses of red-blood-cell antigens and isoenzymes, serum proteins and HLA group determinants were inconclusive. With the DNA test, 10 exclusions and 15 attributions were confirmed, with increased overall probability. In conclusion, VNTR polymorphisms were more informative, accurate and sensitive than the immunohematologic tests. Therefore, DNA analysis is the method of choice for testing genetic relationships.

A Method for the Analysis of Chlorinated Benzenes in Clams (Mercenaria mercenaria) and Oysters (Crassostrea virginica)

A method of analysis for mixtures of chlorinated benzenes in clam (Mercenaria mercenaria) and oyster (Crassostrea virginica) samples is reported. The method involves Soxhlet extraction with n-hexane-isopropanol (1:1) for 6 hours followed by gas chromatographic separation on a Silicone gum column with an electron affinity detector. Quantities as small as 10-10 g are detectable. Average recovery of added Polystream (a mixture of chlorinated benzenes) was 99% for clam samples and 104% for oyster samples. Recoveries were based on reading the 1,2,3,4-tetrachlorobenzene peak. The relative precision for triplicate chromatograms, averaged over all levels, was ± 5%.