Vascular Access for Chronic Haemodialysis in Lombardy

To evaluate the organisation of vascular access surgery, the techniques used to monitor surgical access and the central catheters, a survey was conducted amongst dialysis Units of Lombardy. A questionnaire was sent out to the 43 dialysis centres in Lombardy, 96% of which replied.

In almost 90% of dialysis units nephrologists perform vascular access albeit in close cooperation with vascular surgeons for the more complex cases.

First choice access is by distal arteriovenous fistula (AVF): 36% end-to-end, 31.7% side-to-end, and 19.5% side-to-side with distal ligature of the vein.

As second choice proximal AVF is more widely used than AV grafts, which are implanted only when all native vessels and related surgical procedures are exhausted.

Central venous catheters offer valid solutions not only as temporary access, but also as an alternative permanent one. In both cases the jugular vein is the most frequent site of insertion. Despite the documented incidence of related episodes of stenosis/obstruction, the subclavian vein is used as a temporary access in quite a high percentage of cases.

Only in selected cases are diagnostic procedures (mainly Venography and Doppler studies) performed prior to permanent access choice. Similarly vascular access is monitored mainly using a recirculation test albeit not routinely. In case of vascular access thrombosis, surgical revision is the most common approach.

Model-Based Assessment of Alternative Study Designs in Pediatric Trials. Part II: Bayesian Approaches

This study presents a pharmacokinetic‐pharmacodynamic based clinical trial simulation framework for evaluating the performance of a fixed‐sample Bayesian design (BD) and two alternative Bayesian sequential designs (BSDs) (i.e., a non‐hierarchical (NON‐H) and a semi‐hierarchical (SEMI‐H) one). Prior information was elicited from adult trials and weighted based on the expected similarity of response to treatment between the pediatric and adult populations. Study designs were evaluated in terms of: type I and II errors, sample size per arm (SS), trial duration (TD), and estimate precision. No substantial differences were observed between NON‐H and SEMI‐H. BSDs require, on average, smaller SS and TD compared to the BD, which, on the other hand, guarantees higher estimate precision. When large differences between children and adults are expected, BSDs can return very large SS. Bayesian approaches appear to outperform their frequentist counterparts in the design of pediatric trials even when little weight is given to prior information from adults.

Model-Based Assessment of Alternative Study Designs in Pediatric Trials. Part I: Frequentist Approaches

Alternative designs can increase the feasibility of pediatric trials when compared to classical parallel designs (PaD). In this work we present a model-based approach based on clinical trial simulations for the comparison of PaD with the alternative sequential, crossover, and randomized withdrawal (RWD) designs. Study designs were evaluated in terms of: type I and II errors, sample size per arm (SS), trial duration (TD), treatment exposures, and parameter estimate precision (EP). The crossover requires the lowest SS and TD, although it implies higher placebo and no treatment exposures. RWD maximizes exposure to active treatment while minimizing that to placebo, but requires the largest SS. SS of sequential designs can sometimes be smaller than the crossover one, although with poorer EP. This pharmacometric framework allows a multiscale comparison of alternative study designs that can be used for design selection in future pediatric trials.

[Malignant mesothelioma: analysis of a hospital case series]

The 2000-2010 case record of our Institute includes 77 cases of malignant mesothelioma (MM) [67 pleural (40 males, 27 females; mean age 63.9 years), 9 peritoneal (7 males, 2 females; 67.9 years) and one testicular (38 year-old man)], often associated, with various degree of probability, to previous asbestos exposure (occupational or environmental). Twenty-four patients with pleural MM had undergone surgery (12 pleural decortication and 12 pneumonectomy), with median survival, respectively, of 14 +/- 4.33 (standard error) and 38 +/- 4.27 months, longer than that recorded without surgery (8 +/- 0.94 months). Four peritoneal cases underwent peritonectomy with hyperthermic intraoperative chemotherapy: one is still alive 20 months after diagnosis, the others died at 8, 18 and 36 months. The testicular case is still living 6 years after radical orchidectomy. In conclusion, due to past asbestos use, MM is often observed in the current clinical practice. Patients treated surgically present longer survivals.

Determinants of Risk Infection During Therapy with Anti TNF-Alpha Blocking Agents in Rheumatoid Arthritis

The use of TNF-alpha antagonists (infliximab, etanercept, adalimumab) has changed the course of many rheumatic diseases including rheumatoid arthritis (RA). Since their approval, some questions regarding their safety including infections have been observed. The aim of the study was to evaluate the changes in cytokines levels and cells subsets in patients with RA during anti TNF blocking agents treatment and the possible effect on infections’ development. We evaluated in 89 RA patients [39 treated with etanercept (ETN), 29 with adalimumab (ADA) and 21 with infliximab (IFN)] at baseline and after 6 months the following parameters: procalcitonin, ESR, CRP, cytokines as TNF, IL-6, IL-10, IL-8 and the TNF/IL-10 ratio, and peripheral mononuclear cells as CD3+, CD3+/CD4+, CD3+/CD8+, CD19+, CD3- /CD16+/56+, CD14+HLADR+, CD20+, CD19+/CD38+. Peripheral mononuclear cells were detected by flow cytometric system Cytomics FC500 and cytokines circulating levels by a quantitative sandwich enzyme immunoassay technique (Human IL-8 Instant ELISAe Bioscience, Human IL-6 Instant ELISA e Bioscience, Human IL-10 Instant ELISAe Bioscience and Human TNF-a Quantikine immunoassay RD system). A lower reduction of CD14+HLADR+ in ADA group 54.6±10.4% vs ETA 48.4±15.7% vs INF 40.7±16.5%, p<0.039 was found. No differences in all three groups on peripheral mononuclear cells CD3+, CD3+/CD4+, CD3+/CD8+, CD19+, CD 20+, CD19+/CD38+, CD3-/CD16+/56+, and cytokine circulating levels were found. The number of infections at 6 months was: 10.3% in ADA group, 12.8% in ETN group and 19.04% in IFN group. A correlation was found between the reduction in CD14+HLADR+ cells and IFN treatment. Our data showed that the level of CD14+HLADR+ cells was reduced during therapy with IFN. ADA and ETN don’t reduce lymphocyte populations and their subsets such as CD14+HLADR+ cells that play an important role host defence.

Impact of the new european paediatric regulatory framework on ethics committees: overview and perspectives

AIM

To evaluate the impact of the new European paediatric regulatory framework on the activities of Ethics Committees operating in Europe and to assess their involvement and interest in paediatric research.

METHODS

Task-force in Europe for Drug Development for the Young Network of Excellence and Relating Expectations and Needs to the Participation and Empowerment of Children in Clinical Trials project set up an inventory of Ethics Committees existing in Europe and conducted a survey on their approach to paediatric trials.

RESULTS

Ethics Committees operating in 22 European Countries participated in this survey. Results showed a high lack of knowledge, understanding and awareness of the current European paediatric regulatory framework and a lack of involvement of Ethics Committees in paediatric research, especially in terms of training and education, demonstrated also by the decreasing number of Ethics Committees answering exhaustively to the whole questionnaire. The majority of participating Ethics Committees expressed interest in future initiatives related to paediatric research.

CONCLUSIONS

Despite a limited knowledge and understanding of the current paediatric regulatory framework, a significant number of Ethics Committees operating in Europe show interest in initiatives related to paediatric research. Networking may be an essential tool to be used to enhance Ethics Committees role in supporting paediatric research. Any initiative should be undertaken at European level in collaboration with European Union Institutions.

Efficacy and safety of leflunomide or methotrexate plus subcutaneous tumour necrosis factor-alpha blocking agents in rheumatoid arthritis

Several smaller retrospective case series have concluded that leflunomide (LEF) in combination with anti-TNF-alpha blocking agents appears to be effective and safe. Prospective case series and cohort studies have generally confirmed the efficacy of this combination. Overall, there is currently no evidence from controlled trials that an anti-TNF-alpha combination with LEF is as effective as an anti-TNF-alpha combination with methotrexate (MTX). We compared the effectiveness and safety of a therapeutic regimen associating subcutaneous anti-TNF-alpha agents, etanercept (ETN) and adalimumab (ADA), with leflunomide (LEF) or methotrexate (MTX), in a two year open-label study performed in clinical practice. We evaluated 96 patients with active rheumatoid arthritis undergoing therapy with ADA at the dose of 40 mg every other week, or with ETN at the dose of 50 mg/week for two years added to prednisolone (PDN) at the mean dose of 5.2±2.6 mg/day. Fifty-four of these patients were also undergoing therapy with MTX at the mean dose of 11.7±2.6 mg/week, while 42 patients were undergoing therapy with LEF at the daily dose of 20 mg. At 12 months, the analysis of variance showed an improvement of DAS28 in both groups (p<0.001), with a reduction in 33.3% of the patients in treatment with LEF and in 51.8% of the patients in treatment with MTX (p = 0.20). At 18 months, improvement was present in 33.3% of the patients in the LEF group and in 81.5% of the patients in the MTX group (p=0.001). This improvement seems to be independent of the anti-TNF-alpha agent, even if MTX produces the highest DAS28 reduction when used in association with ETN (p<0.078). We found no difference in drug discontinuation rates or in effectiveness measures between anti-TNFalpha+MTX and anti-TNFalpha+LEF. Our data showed a greater reduction of DAS28 in the MTX group and, in combination with ETN, better results after two years of therapy.

In-label and off-label use of respiratory drugs in the Italian paediatric population

AIM

To evaluate the prescription rate of respiratory drugs (ATC code R03) in an Italian community setting and to estimate the extent of off-label use by both age and indication.

METHODS

A cohort study aimed at evaluating prescriptions of drugs with ATC code R03 was conducted for the period 2002-2006. Data source was the PEDIANET Database.

RESULTS

Ninety percent of R03 prescriptions are covered by 11 active substances or combinations, corresponding to 67 medicinal products. Inhaled corticosteroids are the most prescribed anti-asthmatic agents, followed by short-acting beta2 mimetics. The mean off-label rate is 19 and 56%, by age and indication respectively. The majority of off-label uses is among children under the age of 2. Five active substances are used at dosages not supported by adequate dose-finding studies.

CONCLUSION

In Italy, many respiratory drugs are approved for the treatment of paediatric respiratory diseases, but a remarkable percentage of their prescriptions is off-label. This pharmaco-utilization study demonstrates that there is a need to perform clinical studies aimed at increasing the current knowledge on marketed paediatric drugs, and to revise and re-label the existing regulatory documents to reduce their off-label uses.

The Economic Burden of Biological Therapy in Rheumatoid Arthritis in Clinical Practice: Cost-Effectiveness Analysis of Sub-Cutaneous Anti-TNFα Treatment in Italian Patients

Rheumatoid arthritis (RA), with a prevalence of 0.46%, is found in about 272,004 patients in Italy. The socioeconomic cost of rheumatoid arthritis in Italy in 2002 has been estimated at €1,600 million. Cost-effectiveness evaluations have been based on the concept that, with treatment, patients will not progress to the next level(s) of disease severity or will take a longer time to progress, thus avoiding or delaying the high costs and low utility associated with more severe disease. Many cost-effective studies have been based on the variation of Health Assessment Questionnaire (HAQ) in clinical trials. The objective of this study is to perform a cost-effective analysis of 86 patients with rheumatoid arthritis in therapy with adalimumab 40 mg every other week and etanercept 50 mg/week for two years in a population of patients observed in clinical practice. The group of patients in therapy with adalimumab had also taken methotrexate, mean dose 12.4±2.5 mg/week (22 patients) or leflunomide 20 mg/day (16 patients). The group of patients in therapy with etanercept had also taken methotrexate, mean dose 11.7±2.6 mg/week (24 patients) or leflunomide 20 mg/day (24 patients). Incremental costs and QALYs (quality adjusted life years) gains are calculated compared with baseline, assuming that without biologic treatment patients would remain at the baseline level through the year. Conversion HAQ scores to utility were based on the Bansback algorithm. The results after two years showed: in the group methotrexate+adalimumab the QALY gained was 0.62±0.15 with a treatment cost of €26,517.62 and a QALY/cost of €42,521.13. In the group methotrexate+etanercept the QALY gained was 0.64±0.26 with a treatment cost of €25,020.96 and a QALY/cost of €39,171.76. The result of using etanercept in association with methotrexate is cost-effectiveness with a QALY gained under the acceptable threshold of €50,000. These are important data for discussion from an economic point of view when we choose a biologic therapy for rheumatoid arthritis in clinical practice.

Effects of monthly intramuscular neridronate in rheumatic patients in chronic treatment with low-dose glucocorticoids

OBJECTIVES

To assess the effects of intramuscular (im) neridronate (NE) on lumbar and femoral neck BMD and on markers of bone turnover in rheumatic patients under chronic low-dose glucocorticoids (GC) therapy.

METHODS

Sixty-nine osteopoenic and osteoporotic patients, affected by rheumatic diseases and gastric or esophageal conditions which contraindicated treatment with oral bisphosphonates (BPs), were randomly assigned to: Group A (23 patients) administered with daily calcium 1 g and vitamin D 800 UI; Group B (46 patients) receiving daily calcium 1 g, vitamin D 800 UI and im NE 25 mg monthly.

RESULTS

After 12 months of therapy (M12) lumbar BMD was reduced of 2.97% in Group A, and improved of 3.34% (p=0.001) in Group B; at M12, femoral neck BMD was reduced of 2.40% in Group A and improved of 1.78% in Group B (p=0.010). After 6 (M6) and 12 months of therapy, the bone resorption markers were significantly reduced in Group B: OHPr-41.64% at M6 (p<0.001) and -37.91% at M12 (p<0.001); DPD-33.4% at M6 (p<0.001) and -33.18% (p<0.001) at M12: NTX -57.08% (p<0.001) at M6 and -55.95% (p<0.001) at M12; OC-11.62% (p=0.05) at M6 and -12.62% at M12 (p=0.06); B-ALP -13.95 % at M6 (p=0.04) and -0.85% at M12 (NS).

CONCLUSION

A twelve-month intramuscular NE treatment in rheumatic patients under GCs therapy improves lumbar and femoral BMD and mainly reduces the markers of bone resorption.

Correlation between atopy and hypersensitivity reactions during therapy with three different TNF-alpha blocking agents in rheumatoid arthritis

OBJECTIVE

The use of TNF-alpha antagon-ists (infliximab, etanercept, adalimumab) has changed the course of many rheumatic diseases including rheumatoid arthritis (RA). Since their approval, some questions regarding their safety have been raised. Both acute and delayed reactions have been described.

METHODS

The aim of our work was to detect if there is a different incidence of hypersensitivity reactions - infusion reactions to infliximab or injection site reactions with etanercept or adalimumab - in atopic patients versus non- atopic patients. In 90 patients (82 females, 8 males) with rheumatoid arthritis we evaluated, during the first year of therapy with three different TNF-alpha blocking agents, total serum IgE (normal value <100 KU/L) (method ImmunoCAP PHADIA) and serum specific IgE performing a qualitative multi-allergen test for inhal-ant allergens (PHADIATOP, method ImmunoCAP PHADIA). In all patients we evaluated injection site reactions (ISR) to etanercept and adalimumab - erythema, edema and itching at the site of subcutaneous administration - and infusion reactions to infliximab - hypotension/hypertension, chest pain, dyspnea, laryngospasm, fever, urticaria angioedema.

RESULTS

We obtained the following results: patients with high value of tot-al IgE were 15/90 (16.6 %), patients with total IgE in normal range were 75/90 (83.4.%), reactions in patients with high total IgE were 6.7% and in patients with normal total IgE were 18.7% (p=0.255 ns). As regards serum specific IgE, patients with specific IgE were 17/90 (18.8%) patients without specific IgE were 73/90 (81.2%), reactions in patients with specific IgE were 11.8% and in patients without specific IgE were 17.8% (p=0.547 ns). Also, when the data were divided for the three groups, the differences were not statistically significant.

CONCLUSION

Adverse reactions to biological agents have been categorized into five types. In hypersensitivity reactions - the Beta type reactions - an immune mechanism is suspected. Our data showed that there was no correlation between the atopic status and the incidence of hypersensitivity reactions during the first year of therapy with three different TNF-alpha blocking agents.

Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) remains a common cause of disability, death and hospital admission. Several investigations support the usefulness of programs of disease management for improving clinical outcomes. However, the effect of home-based telemanagement programs on the rate of hospital readmission is still unclear and the cost-effectiveness ratio of such programs is unknown. The aim of the study was to determine whether a home-based telemanagement (HBT) programme in CHF patients decreased hospital readmissions and hospital costs in comparison with the usual care (UC) follow-up programme over a one-year period.

METHODS AND RESULTS

Four hundred-sixty CHF patients (pts), aged 57+/-10 years were randomised to two management strategies: 230 pts to HBT programme and 230 pts to UC programme. The HBT pts received a portable device, transferring, by telephone, a one-lead trace to a receiving station where a nurse was available for interactive teleconsultation. The UC pts were referred to their primary care physicians and cardiologists. The primary objective of the study was one-year hospital readmission for cardiovascular reasons. During one-year follow-up 55 pts (24%) in HBT group and 83 pts (36%) in UC group had at least one readmission (RR=0.56; 95% CI: 0.38-0.82; p=0.01). After adjusting for clinical and demographic characteristics, the HBT group had a significantly lower risk of readmission compared with the UC group (HR=0.50, 95% CI: 0.34-0.73; p=0.01). The intervention was associated with a 36% decrease in the total number of hospital readmissions (HBT group: 91 readmissions; UC group: 142 readmissions) and a 31% decrease in the total number of episodes of hemodynamic instability (101 in HBT group vs 147 in UC group). The rate of hearth failure-related readmission was 19% (43 pts) in HBT group and 32% (73 pts) in UC group (RR=0.49, 95% [CI]: 0.31-0.76; p=0.0001). No significant difference was found on cardiovascular mortality between groups. Mean cost for hospital readmission was significantly lower in HBT group (euro 843+/-1733) than in UC group (euro 1298+/-2322), (-35%, p<0.01).

CONCLUSIONS

This study suggests that one-year HBT programme reduce hospital readmissions and costs in CHF patients.

Efficacy of pulmonary rehabilitation in chronic respiratory failure (CRF) due to chronic obstructive pulmonary disease (COPD): The Maugeri Study

While the effectiveness of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) is well established, its effectiveness in the most severe category of COPD, i.e. patients with chronic respiratory failure (CRF), is less well known.

OBJECTIVE

To verify the effects of PR in patients with CRF, and compare the level of improvement with PR in these patients to that of COPDs not affected by CRF.

METHODS

A multi-centre study was carried out on COPD patients with versus without CRF. The PR program included educational support, exercise training, and nutritional and psychological counselling. Lung function, arterial gases, walk test (6MWT), dyspnoea (MRC; BDI/TDI), and quality of life (MRF(28); SGRQ) were evaluated.

RESULTS

Thousand forty seven consecutive COPD inpatients (327 with CRF) were evaluated. In patients with CRF all parameters improved after PR (0.001). Mean changes: FEV(1), 112 ml; PaO(2), 3.0 mmHg; PaCO(2), 3.3 mmHg; 6MWT, 48 m; MRC, 0.85 units; MRF(28) total score, 11.5 units. These changes were similar to those observed in patients without CRF.

CONCLUSIONS

This study, featuring the largest cohort so far reported in the literature, shows that PR is equally effective in the more severe COPD patients, i.e. those with CRF, and supports the prescription of PR also in these patients.

Bronchoalveolar lavage, sputum and exhaled clinically relevant inflammatory markers: values in healthy adults

Bronchoalveolar lavage (BAL), induced sputum and exhaled breath markers (exhaled nitric oxide and exhaled breath condensate) can each provide biological insights into the pathogenesis of respiratory disorders. Some of their biomarkers are also employed in the clinical management of patients with various respiratory diseases. In the clinical context, however, defining normal values and cut-off points is crucial. The aim of the present review is to investigate to what extent the issue of defining normal values in healthy adults has been pursued for the biomarkers with clinical value. The current authors reviewed data from literature that specifically addressed the issue of normal values from healthy adults for the four methodologies. Most studies have been performed for BAL (n = 9), sputum (n = 3) and nitric oxide (n = 3). There are no published studies for breath condensate, none of whose markers yet has clinical value. In healthy adult nonsmokers the cut-off points (mean+2sd) for biomarkers with clinical value were as follows. BAL: 16.7% lymphocytes, 2.3% neutrophils and 1.9% eosinophils; sputum: 7.7 x 10(6).mL(-1) total cell count and 2.2% eosinophils; nitric oxide: 20.2 ppb. The methodologies differ concerning the quantity and characteristics of available reference data. Studies focusing on obtaining reference values from healthy individuals are still required, more evidently for the new, noninvasive methodologies.

Medicines for children licensed by the European Medicines Agency (EMEA): the balance after 10 years

OBJECTIVE

The 1995-2005 balance of EMEA activities in the field of paediatric medicines was evaluated, taking into account the number both of drugs authorised for children and paediatric studies supporting the Marketing Authorisation (MA).

METHODS

Data on drugs authorised by EMEA were extracted from EPARs (European Public Assessment Reports). Active substance, year of approval, anatomical, therapeutic and chemical (ATC) code, indication, orphan status, ages, and registrative clinical studies characteristics were assessed.

RESULTS

The percentage of authorised substances for paediatrics is 33.3%. This percentage decreased or increased when different subsets of medicines were considered [medicines for children under 2 years (23.4%), N-ATC code drugs (6%) and orphan drugs (46.4%)]. A total of 165 trials were included in the MA dossiers of 51 drugs at the time of approval, and additional 22 studies were added to the dossiers of 12 active substances submitted for paediatric variations. PK and Efficacy/Safety studies were performed for 32 (52%) active substances, while either one PK or one Efficacy/Safety study was carried out for 43 (69%) and 45 (73%) substances, respectively.

CONCLUSIONS

This report demonstrates that the total number of paediatric medicines approved by EMEA is stable over the 10-year period, while an increase in drugs to treat serious or orphan diseases has been observed. In addition, under the Centralised Procedure, a valuable number of paediatric trials have been submitted to support drug approval.

[A group therapy assessment tool (GrETha-Q)]

This paper presents a questionnaire designed to assess the aspecific treatment efficacy and subjective perceived efficacy of group therapy. A preliminary version of the instrument was administered to a sample of 151 subjects undergoing group therapy. The psychometric properties of the instrument were evaluated by means of the Rasch model, and showed a good score range, good reproducibility and adequate coherence. The hierarchy of difficulty of the items remained stable among the respective categories of sex, age and professional level.

Predictors of mortality in patients with Eisenmenger syndrome and admission to the lung transplantation waiting list

Background. Patients with Eisenmenger Syndrome (ES) have very severe irreversible pulmonary hypertension but the criteria for admitting such patients to a lung transplantation waiting list (LTWL) is not clear. Indeed it has been demonstrated that the natural survival of patients with ES is better than the survival achieved through lung transplantation: it follows that no guidelines are available for these patients’ admission to an LTWL. The aim of our study was to identify possible predictors of mortality in ES patients in order to reserve admission to the LTWL solely for those patients who would otherwise have the lowest probability of survival. Methods. Since 1991, 57 patients with ES from our rehabilitative centre were admitted to the LTWL of the Division of Cardiac Surgery at San Matteo Hospital, University of Pavia. At the time of the retrospective analysis, patients were divided into a group of non-transplanted survivors (27 patients - 47% of the total) and a group who had died prior to transplantation (16 patients - 28% of the total). The 14 transplanted patients (25% of the total) were not considered in the statistical analysis, considering transplantation as an “external event”. Unpaired t tests were used to compare the following factors in the survivors and in those who died: sex, “complexity” of the congenital heart disease underlying the ES, previous cardiac surgery, arterial blood gases, pulmonary function and hemodynamic parameters. Moreover, a stepwise discriminant analysis was performed in order to define a possible set of prognostic factors. Results. PaCO2 was higher in those who subsequently died (36.15±7.42 mmHg) compared with those who survived (32.5±5.33 mmHg), although this difference did not reach a statistical significance (p=0.08). Discriminant analysis defined a model in which a) complexity of the congenital heart disease, b) sex (male) and c) cardiac output were predictive of a higher risk of mortality. Conclusions. This new knowledge can be used in the decision of admission to LTWL in ES patients.

Role of galanin receptor 1 in peristaltic activity in the guinea pig ileum

Galanin effects are mediated by distinct receptors, galanin receptor 1 (GAL-R1), GAL-R2 and GAL-R3. Here, we analyzed 1) the role of GAL-R1 in cholinergic transmission and peristalsis in the guinea-pig ileum using longitudinal muscle-myenteric plexus preparations and intact segments of the ileum in organ bath, and 2) the distribution of GAL-R1 immunoreactivity in the myenteric plexus with immunohistochemistry and confocal microscopy. Galanin inhibited electrically stimulated contractions of longitudinal muscle-myenteric plexus preparations with a biphasic curve. Desensitization with 1 microM galanin suppressed the high potency phase of the curve, whereas the GAL-R1 antagonist, RWJ-57408 (1 microM), inhibited the low potency phase. Galanin (3 microM) reduced the longitudinal muscle contraction and the peak pressure, and decreased the compliance of the circular muscle. All these effects were antagonized by RWJ-57408 (1 or 10 microM). RWJ-57408 (10 microM) per se did not affect peristalsis parameters in normal conditions, nor when peristalsis efficiency was reduced by partial nicotinic transmission blockade with hexamethonium. In the myenteric plexus, GAL-R1 immunoreactivity was localized to neurons and to fibers projecting within the plexus and to the muscle. GAL-R1 was expressed mostly by cholinergic neurons and by some neurons containing vasoactive intestinal polypeptide or nitric oxide synthase. This study indicates that galanin inhibits cholinergic transmission to the longitudinal muscle via two separate receptors; GAL-R1 mediates the low potency phase. The reduced peristalsis efficiency could be explained by inhibition of the cholinergic drive, whereas the decreased compliance is probably due to inhibition of descending neurons and/or to the activation of an excitatory muscular receptor. Endogenous galanin does not appear to affect neuronal pathways subserving peristalsis in physiologic conditions via GAL-R1.

Immunocytological and mineralogical study of bronchoalveolar lavage in a group of subjects exposed to asbestos

Twenty-five subjects (24 males and 1 female, mean age 57.4 years) who have been exposed to asbestos underwent chest radiography, high resolution computed tomography (HRCT) of the chest, lung function tests and bronchoalveolar lavage (BAL) for evaluation of cell components (total cell count, percentages of macrophages, lymphocytes, neutrophil and eosinophil granulocytes and the lymphocyte subpopulations CD3+, CD4+, CD8+, CD19+ and HLADR+), soluble factors (IL-8, IL-10, IL-12 and MCP-1 in the supernatant) and concentration of asbestos fibre. The subjects were subdivided according to the degree of their exposure, to the concentration of asbestos fibres in the BAL and to chest X-ray findings using the I.L.O. classification (0/0pl, 0/1 and 1/0 and above). According to the exposure index, we showed statistically significant (p < 0.05) higher lymphocytes percentage in the BAL of subjects with moderate exposure and significantly higher levels of IL-10 (p < 0.05) in the supernatant of subjects showing an absence of asbestos fibres in their BAL. In the group of subjects with a 0/0 and 0/1 radiological profile, the cellular component of the BAL was characterised by a higher percentage of lymphocytes (p < 0.02), whereas a trend toward an increase in the number of neutrophils was noted in subjects with obvious pulmonary fibrosis. The percentage of neutrophils was inversely correlated with some parameters of respiratory function such as vital capacity (p = 0.03) and the partial pressure of oxygen (p = 0.05) in the blood. Investigating the cytokines in the supernatant of the BAL, we found a trend toward lower concentration of IL-10 in the group showing the worst radiological picture (I.L.O. > or = 1/0), and a statistically significant negative correlation between this cytokine and pO2 (p = 0.048). Concerning the other cytokines and chemokines studied (MCP-1, IL-8 and IL-12), no significant differences were found to be associated with the radiological profiles. There were, however, positive correlations between the concentration of IL-8 and the percentage of neutrophils (p = 0.038) and between the concentration of MCP-1 and the percentage of lymphocytes (p = 0.006). A negative relationship between the concentrations of IL-12 and IL-10 has been also observed (p = 0.028). This research allows us to hypothesise that IL-10 may have a pathogenetic role in the evolution of asbestosis.

Medicines for children licensed by the European Agency for the Evaluation of Medicinal Products

OBJECTIVE

. The aim of this study was to evaluate the number and the characteristics of medicines approved for children in Europe by the European Agency for the Evaluation of Medicinal Products (EMEA) and whether the paediatric studies supporting the authorisation were in accordance with the Note for Guidance on the Clinical Investigation of Medicinal Products in children (CPMP/ICH/2711/99). We also considered any possible difference between the EMEA and the Food and Drug Administration (FDA) paediatric medicines evaluations.

METHODS

. We examined the drugs authorised by the EMEA through the centralised procedure from January 1995 to September 2001 deriving information from the "European Medicines - Database" (EMD) set up in 1998 by the Italian Group for Pharmacoeconomic Studies (GISF) and sponsored by the Italian Ministry of Health. The analysis of paediatric data has been managed by experts belonging to the Clinical Pharmacology Working Group of the Italian Paediatric Society. The following parameters were assessed: active substance, year of approval, anatomical therapeutic and chemical (ATC) code, therapeutic indications, age for which the drug is authorised, interest to children and paediatric studies supporting a paediatric authorisation. European Public Assessment Reports (EPARs) were considered as reference sources.

RESULTS

. The median percentage of drugs authorised for children from 1995 to 2001 (September) is 35% of the total of commercially available drugs; only 16 medicines have been approved for children under 2 years of age (11%), ten of these being vaccines. Medicines for children shared out 9 ATC classes, 24 belonging to the J- (anti-infective agents) -ATC class. Thirty-nine medicines were authorised on the basis of at least one clinical trial (27 phase III, 6 phase II, 6 phase I) while eight active substances have been licensed without any paediatric investigation.

CONCLUSIONS

. Under the EMEA centralised procedure, several active substances have been licensed for children. Consequently serious and life-threatening diseases as AIDS and diabetes are now treatable, in a legal framework overcoming the orphan status of the past years. Despite the reported encouraging results, the number of drugs devoted to children remain low and important ATC classes, as L-(oncology) or N-(neurology), are still 'orphans' of innovative medicines. At the same time few medicinal products are specifically studied in children. Consequently, more efforts have to be made to increase the number of drugs assessed and licensed for the paediatric population, and manufacturers should be required to supply data on the effects of new drugs in children when the products are expected to offer a benefit over existing therapies.

Clinical validation of an anxiety and depression screening test for intensive in-hospital rehabilitation

Routine hospital psychological care must necessarily make use of a clinically reliable screening instrument for the identification of the patients to be referred for a clinical interview with a psychologist. This study compared two tests for the evaluation of anxiety and depression that are widely used in the hospital setting: the Hospital Anxiety and Depression Scale (HADS) and Form A-D, consisting of the State-Trait Anxiety Inventory (STAI-X1) for the evaluation of anxiety, and the Depression Questionnaire (DQ) for measuring depression. The aim of the study was to identify which of these instruments is the most suitable for screening a population admitted at in-hospital intensive rehabilitation using the clinical interview-based psychological evaluation as the gold standard. Both of the tests showed a concordance with the clinical opinion expressed by the psychologist, whose judgement was guided by the use of the validation study evaluation form. The analyses confirmed the good correlation of the two instruments in measuring anxiety and depression. The sensitivity of the STAI-X1 (52%) was less than that of HADS section A (72%), but its specificity (99%) was greater than that observed with the application of the HADS Anxiety subscale (84%). Analysis of the ROC curves showed that the STAI-X1 percentages of sensitivity and specificity tended to balance at higher level with a cut-off point equal to the 80th percentile. The results of the analysis of the DQ demonstrated equivalence with the results obtained using HADS section D, with a cut-off point of the 90th percentile. On the basis of these results, and given that both the STAI-X1 and the DQ have a broadly based Italian normative population, we feel that they can be recommended for psychological screening of patients in an in-hospital intensive rehabilitation.

[Sickness Impact Profile: the Italian version]

The Sickness Impact Profile (SIP) is one of the questionnaires most widely used for the generic evaluation of functional health status. Besides measuring functional status or quality of life, it is also a precious font of information for the psychologist in the inpatient-rehabilitative context when planning an intervention focused on the most dysfunctional areas indicated by the subject. In producing the Italian version of the SIP, attention was duly paid in the translation to maintain equivalence in terms of idioms, grammar and syntax, so as to render it free of erroneous translations or possible. misunderstandings. Since the SIP employs "weighted" items, in order to obtain the weights corresponding to each individual statement a 3-phase procedure was followed: A) each subject "judge" was asked to express on a scale his/her own dysfunctionality judgement for each item; B) statements with the highest and lowest mean weight for each category were identified; C) the same "judges" were then asked to reclassify the statements which had obtained the highest and lowest weights, respectively, on a scale of 15 equidistant intervals; subsequently the same subjects completed the SIP a second time (retest). Results show that the judges were coherent in their estimation of the specific weights for each item. In the judges' second completion of the SIP it was found that the majority of the test-retest correlations fell almost always within the r = 0.70-0.90 range. Moreover, given the marginal difference between Italian and United States weights, both methods may be used for the calculation of the scores. One thus concludes that the SIP questionnaire can be applied in the Italian context.

Three conventional-drug combination (ifosfamide, carboplatin, etoposide--ICE regimen) in advanced non-small cell lung cancer (NSCLC)

Fifty consecutive patients with stage IIIB-IV non-small cell lung cancer (NSCLC) received the ICE regimen at intermediate doses (ifosfamide 1 g/m2, carboplatin 120 mg/m2, etoposide 80 mg/m2, day 1 to 3, q.4 weeks, for a maximum of 6 cycles). Overall 2 complete response (CR) and 10 partial response (PR) (overall response, OR: 24%, 95% C.I. 14-37%) were observed. An additional 7 patients had stable disease (SD) lasting more than 6 months, therefore a clinical benefit (CR+PR+SD >6 mos) was achieved in 19 patients (38%). Median time-to-progression (TTP) was 7 months and median overall survival (OS) was 11 months; 1- and 2-year survival rates were 36% and 10%. The ICE regimen was well tolerated and devoid of any cardiac, hepatic or neurologic toxicity. Moderate nausea and vomiting were easily manageable, grade 2 alopecia was universal, while hematological toxicity was mild (grade 2 leuko- and thrombocytopenia). Due to its efficacy and safety profile, this 3-drug regimen can be considered for routine community use.

[Assessment of problems associated with caregiving: the family strain questionnaire]

Our study concerns a questionnaire for the evaluation of caregiving-related problems: the Family Strain Questionnaire. The questionnaire, which is composed by a structured interview and 47 dychotomous items, was administered to 409 caregivers of patients with different kinds of chronic diseases. Factorial analysis shows a structure of 5 factors named: emotional strain, social involvement, knowledge of the disease, family relationships and thoughts about death. The FSQ is sensible in discriminating different groups of caregivers. This paper presents the psychometric properties as well as the clinical advantages evidenced by the FSQ.

A computerized guideline for pressure ulcer prevention

This paper illustrates the implementation of a computerized guideline for pressure ulcer prevention. In particular, it describes the aspects related to the site-specification of a guideline delivered by the Agency for Health Care Policy Research (AHCPR), to its integration with the electronic patient record, and to its implementation within the clinical routine. The primary goal of the system is both to facilitate nurses assessing the risk of ulcer development, and to manage patients at risk by producing daily prevention work-plans. Concerning this functionality, particular attention has been paid to manage nurse's non-compliance with the guideline suggestions and to collect data for evaluating the guideline impact. Moreover, since it is well known that nurses are often over-loaded, the human computer interaction has been studied in such a way to optimise the time spent for data input. An additional functionality of the system is the novice nurses' education - they can browse a graphical representation of the guideline, asking details about the different tasks, and they can simulate patients to obtain real-time advice. The educational tool is written in Java and it is based on a representation of the guideline as a relational database. A preliminary evaluation of the system has been performed and the results are presented on the management of about 40 patients.

Lesson learnt from a halt of the hospital information system

The present paper deals with an experience of blackout of the hospital information system at our Medical Centre, trying to evaluate the impact on internal users (physicians, nurses, clerks) and patients population. Limited inconveniences have occurred to out-patients in terms of delay in collecting medical reports after diagnostic test execution. As regards direct users, impact was evaluated through a structured interview. Administrative personnel, that have been using computer-based system for at least ten years, have not declared particular inconveniences, accepting the overtime or the extra-work as simply unavoidable. On the contrary, health-care personnel reported a heavy negative impact of the system failure on their activity. After a great effort to achieve the system acceptance and direct physicians usage, the blackout of the system has pointed out that the situation has changed since a few years ago: now the HIS, and particularly its clinical core, is considered mission critical.

A computerised guideline for pressure ulcer prevention

This work illustrates the implementation of a computerised guideline for the pressure ulcers prevention. In particular, we describe the site-specification of a guideline delivered by the Agency for Health Care Policy Research, its integration with the electronic patient record, and its introduction within the clinical routine. The system facilitates trained nurses in the patient management by producing daily workplans, and novice nurses by running as an educational tool.

The effects of aging on enzyme activities and metabolite concentrations in skeletal muscle from sedentary male and female subjects

Aging affects the metabolic capacity of skeletal muscle, in particular the glycolytic and respiratory capacities. The purpose of this study was to quantify biochemical alterations due to aging in muscular metabolic capacity in human skeletal muscles in sedentary subjects. The activities of various marker enzymes and metabolites related to glycolysis, Krebs' cycle and the electron transfer chain and high energy phosphate compounds were measured in muscle biopsies from the rectus abdominis, vastus lateralis, and gluteus maximus muscles of 76 sedentary subjects (32 males and 44 females) between 15 and 91 yr. No significant differences between males and females were found, but changes related to age were: a decrease in hexokinase and lactate dehydrogenase activities in the rectus abdominis; a decrease in citrate synthase activity and citrate in the vastus lateralis; an increase in pyruvate kinase activity and a decrease in ATP and creatine phosphate concentrations in the gluteus maximus. These data suggest that distinct muscles may respond differently to aging regardless of sex in sedentary subjects.

Influence of fluoxetine and litoxetine on 5-HT4 receptor-mediated relaxation in the rat isolated oesophagus

The influence of two selective serotonin reuptake inhibitors (SSRIs), litoxetine and fluoxetine, has been studied on 5-HT4 receptor-mediated relaxation in the rat isolated oesophageal muscularis mucosae. In carbachol-precontracted oesophageal tissues, 5-hydroxytryptamine (5-HT) (0.1 nM-1 microM) induced concentration-dependent relaxations. Concentration-response curves were monophasic and reproducible. Litoxetine at concentrations without antimuscarinic properties (10 nM-1 microM) caused concentration-dependent relaxations, which reduced carbachol tone up to 37%. Higher litoxetine concentrations (3 microM-300 microM) were associated with marked relaxation up to the abolition of carbachol tone. The overall curve profile of litoxetine was biphasic in nature with a high (10 nM-1 microM) and a low (3 microM-300 microM) potency phase. Unlike 5-HT, the second curve of litoxetine was not reproducible, with a reduction involving mainly the low potency phase. Compared to litoxetine, fluoxetine caused minimal relaxation (less than 10% at 1 microM). Treatment of rats with parachlorophenylalanine (pCPA: 375 mg kg-1 per day, for two days), to deplete endogenous 5-HT stores, did not modify the relaxant effect of 5-HT, while it significantly reduced the high potency phase of litoxetine. In tissues from untreated rats, this phase was reduced by the 5-HT4 receptor antagonist GR 125487 (10 nM) to an extent similar (P = 0.20: ANOVA for continuous-by-class effects) to that induced by pCPA treatment. However, in tissues from pCPA treated animals GR 125487 (10 nM) exerted a slight but significant antagonism of litoxetine response (P = 0.037: ANOVA for continuous-by-class effects) mainly involving the high potency phase. In tissues from untreated rats, litoxetine (1 microM) increased the relaxant effects of 5-HT, while in tissues from pCPA treated animals it exerted a small but significant depression of the maximal response to 5-HT, without changing its potency value. Fluoxetine (1 microM) slightly, but significantly, antagonized the relaxant effect of 5-HT in an unsurmountable manner. In conclusion, litoxetine up to 1 microM relaxed the rat isolated oesophageal muscularis mucosae through a mechanism involving release of endogenous 5-HT, which in turn activates 5-HT4 receptors. However, based on results with GR 125487 in tissues from pCPA treated rats, a small component of litoxetine-induced relaxation may involve a direct activation of 5-HT4 receptors. It is unlikely that blockade of 5-HT reuptake can participate in the action of litoxetine, since fluoxetine, a 5-HT reuptake inhibitor equipotent to litoxetine, was ineffective in the same range of concentrations. The antimuscarinic activity of litoxetine, previously demonstrated in the isolated guinea-pig intestine, played a role at concentrations greater than 1 microM. The 5-HT-releasing action of litoxetine could account for the potentation by litoxetine of 5-HT-induced relaxation in tissues from untreated rats, which was reversed by pCPA treatment. Under these conditions, litoxetine depressed relaxations to high 5-HT concentrations only. In tissues from untreated rats, fluoxetine slightly but unsurmountably antagonized 5-HT-induced relaxations, thus confirming previous observations in the guinea-pig small intestine.

Soluble interleukin 2 receptor (sIL2R) in monitoring advanced lung cancer during chemotherapy

STUDY OBJECTIVES

To evaluate the usefulness of measuring sIL2R for diagnostic and prognostic purposes and for monitoring disease during a 6-month period of chemotherapy, and to investigate the clinical significance of sIL2R serum concentrations.

METHODS

The serum concentration of sIL2R, TPA and lymphocyte subsets CD4, CD8, CD25, CD16 were measured at diagnosis and then 1 and 6 months after the start of chemotherapy.

PATIENTS

There were 39 patients (three females, 36 males; mean age 61.6 years) with lung cancer (LC), treated with chemotherapy and 22 control subjects (six females, 16 males; mean age 50.1 years) with non-neoplastic lung diseases.

RESULTS

No significant differences in sIL2R serum concentrations were observed at diagnosis between the control and LC group or when comparing the different histotypes, disease stages (IIIa-b vs IV) and survival (survival < or = 12 vs > 12 months). On comparing the sequential variations of the examined parameters a significant increase in sIL2R (P < 0.007) after 1 and 6 months versus basal value was observed only in patients surviving less than 12 months and in those who did not respond to chemotherapy. Moreover a negative correlation was observed between sIL2R serum concentrations and CD25+ and CD16+ lymphocyte subsets. Evaluation of survival curves of patients with basal sIL2R > or < or = 700 U/ml showed a slightly lower survival rate in the former group.

CONCLUSIONS

The present results, confirming the poor utility of sIL2R in the diagnostic phase of the disease, show its usefulness in prognostic evaluation and in the clinical surveillance of patients with advanced lung cancer submitted to polychemotherapy. In this case any variations in sIL2R serum levels are likely to relate to the spread of the neoplasia rather than to the host immune response.

Altered muscle energy metabolism in post-absorptive patients with chronic renal failure

Skeletal muscle biopsies were performed on 12 healthy sedentary subjects and on 22 non-dyalized chronic renal failure patients (CRF) on a free diet and after overnight fasting. Parathormone, glucagon and insulin were determined at the same time of biopsies. CRF patients showed significantly low ATP and creatine phosphate levels. Regarding enzyme activities, a high hexokinase Vmax was found, while the pyruvate kinase activity was lower than in the control group. For the tricarboxylic acid cycle, citrate synthase, succinate dehydrogenase and malate dehydrogenase activities were higher; total NADH cytochrome c reductase activity was also high, while cytochrome oxidase activity was slightly lower. Both alanine aminotransferase and aspartate aminotransferase activities were considerably high in comparison with the control group. In conclusion, our study revealed a hypermetabolic TCA cycle, but impaired oxidative phosphorylation, which partly explained the reduced ATP concentration. Excessive protein intake and hormonal derangements may play a role in these metabolic changes.

Spreading the clinical information system: which users are satisfied?

The present study deals with the assessment of the perceived usefulness and perceived ease of use of the clinical core of the HIS we are building, and progressively spreading into the medical centre, through the use of two questionnaires. The differences in subjective perception among clinical units and professional roles have been analyzed. Results show that the system, in use on a mandatory basis, has been accepted. Most of the users are satisfied, and probable removable causes of dissatisfaction have been identified.

Use of statistical classifiers as support tools for the diagnosis of iron-deficiency anemia in patients on chronic hemodialysis

Discriminant analysis, logistic regression and neural network models were applied to the diagnosis of iron-deficiency anemia in hemodialyzed patients. The ability of the three quantitative approaches to distinguish between subjects suffering or not from iron-deficiency anemia was compared by re-substitution and cross-validation testing. Methods performance was evaluated by means of sensitivity, specificity and accuracy. All the methods performed globally well (sensitivity and specificity > 0.85), revealing that the problem is classifiable. Neural networks showed the highest accuracy, both in the re-substitution (models developed and tested on the complete data set) and 3-way cross-validation (data set randomly splitted into 3 developmental and validation data sets) testing. These preliminary results suggest that the correct classification of iron status in the hemodialytic population can be treated as a pattern classification problem, for which neural networks and traditional statistical modelling can be a valuable aid to the clinical diagnosis of iron-deficiency anemia. A better performance of the neural network model must be confirmed through prospective testing on a larger data set.

Assessing users' satisfaction through perception of usefulness and ease of use in the daily interaction with a hospital information system

The present study deals with the assessment of the subjective perception of the clinical core of the hospital information system (HIS) we are building. This HIS is not in use on a voluntary basis, but physicians and nurses use it for all the aspects of their inpatient care that have been informatized. Two questionnaires, aimed at the assessment of users perceived usefulness and ease of use of information technology, were utilized to: obtain feedback of the actual users' satisfaction as a predictive factor for the future life of the system, assess the real influence of the often-mentioned problems of age and unfamiliarity with computers of potential users, learn about the aspects which would enhance users' acceptance. The analysis of answers to the questionnaires has indicated a substantially positive perception of the system in terms of both usefulness and ease of use. This constitutes a good reason to keep on investing in the project. Even though this study has the intrinsic limit of the small dimension of the inquired population (53 users, equivalent to 98% of the personnel of the assessed clinical units), our data confirm the inconsistency of the relationship between perception of usefulness and age, and show "unfamiliarity with computers" as commonplace. On the other hand, it seems that the keystone for usefulness perception is the knowledge the users have of the system. An effort by the technical personnel in establishing a broader collaboration with the users, and in providing more exhaustive training and support may well be worthwhile.

Heterogeneity of cholinergic muscarinic receptors coupled to phosphoinositide metabolism in immature rat brain

The effects of muscarinic agonists and antagonists on phosphoinositide (PtdIns) metabolism were examined in the cerebral cortex and brainstem of 7-day-old rats, in order to evaluate the role of muscarinic receptor subtypes in this process. Additionally, comparative experiments were performed in cortices from adult animals. Accumulation of [3H]inositol phosphates ([3H]InsPs) in [3H]inositol pre-labeled brain slices was taken as an index of PtdIns hydrolysis. In neonatal cortex, maximal stimulation induced by the full agonists acetylcholine, carbachol and methacholine was 8-10 fold over basal [3H]InsPs accumulation. The effect of the partial agonists bethanechol, pilocarpine and oxotremorine varied from 3 to 4 fold over basal. Smaller responses to cholinergic stimulation were found in the brainstem and in the adult cortex. In neonatal cortex, muscarinic antagonists inhibited the stimulatory responses with the following order of potency: 4-DAMP > pirenzepine > AF-DX 116 approximately p-F-HHSiD. Pirenzepine inhibition of full agonist-induced [3H]InsPs accumulation showed biphasic curves, with two thirds of the response being inhibited with high affinity. When partial agonists were used, the resulting pirenzepine curves were better described by interaction at one high affinity site. No differences were found between immature and adult rats in the effect of pirenzepine on [3H]InsPs accumulation induced by carbachol, methacholine, or bethanechol. Inhibition by pirenzepine of PtdIns hydrolysis induced by carbachol or methacholine showed biphasic curves also in the brainstem. In this area, only one third of the response was inhibited with high affinity, and p-F-HHSiD was more potent as an antagonist.(ABSTRACT TRUNCATED AT 250 WORDS)

Interaction and dialogue between the users and the patient record core of hospital information system: looking for a solution

The lack of good user interface, in terms of both modality of dialogue and system behaviour is the major impediment to the acceptance and routine use of the computer based patient record (CPR) core of a hospital information system. We describe here the adopted approach to face the daily users' needs, overcoming the pitfalls of the paper based patient record (PPR), and giving the physicians an exhaustive modality for CPR inspection.

Does renal tubular dysfunction account for the enhanced CAm/CCr ratio in acute pancreatitis?

To verify whether renal tubular dysfunction may account for the CAm/CCr enhancement in acute pancreatitis (AP), we have measured the renal excretion of amylase, lysozyme, and gamma-glutamyl-transpeptidase (GGTP) in 22 patients with AP and in 8 with acute tubular necrosis. While the CAm/CCr ratio was elevated in most patients with AP, the CLys/CCr ratio fell within the normal range in 60% of these patients. The subdivision of patients with AP in subgroups with elevated and normal CLys/CCr ratios revealed a mean CAm/CCr not statistically different. Moreover, no correlation was present in AP between amylase vs. both lysozyme and GGTP clearances. These data suggest that tubular dysfunction does occur in some but not in all the patients with AP and seems not to play a major role in the pathogenesis of the increased CAm/CCr ratio in this condition.

Amylase to creatine clearance ratio in renal diseases

In order to assess to what extent glomerular or tubular function is involved in the renal handling of amylase and the lysozyme to creatine clearance ratios (CAm/CCr and CLys/CCr) were evaluated in 22 healthy volunteers and in 71 patients with different renal diseases. In normal controls, the mean CAm/CCr was 2.55 +/-1.54 SD, with an upper normal limit of 5.56. A normal ratio was found in patients with glomerulonephritis, with or without a nephrotic syndrome, and in patients with pyelonephritis. A significantly elevated ratio (P less than 0.001) was instead found in patients with uremia and in patients with uremia and in patients with either chronic or acute tubular damage. The CLus/CCr ratio was elevated in all the groups, except in patients with glomerulonephritis and minimal proteinuria. These results show that in humans, as in animals, the amylase filtered load undergoes partial tubular reabsorption. In renal diseases, an increase of the CAm/CCr is caused by either a marked reduction of functioning nephrons or a severe tubular damage, while the glomerular permeability does not seem to be involved. Some other mechanism is probably involved in the elevation of the CAm/CCr during acute pancreatitis.