Intra- and Extra-Hospitalization Monitoring of Vital Signs-Two Sides of the Same Coin: Perspectives from LIMS and Greenline-HT Study Operators

BACKGROUND

In recent years, due to the epidemiological transition, the burden of very complex patients in hospital wards has increased. Telemedicine usage appears to be a potential high-impact factor in helping with patient management, allowing hospital personnel to assess conditions in out-of-hospital scenarios.

METHODS

To investigate the management of chronic patients during both hospitalization for disease and discharge, randomized studies (LIMS and Greenline-HT) are ongoing in the Internal Medicine Unit at ASL Roma 6 Castelli Hospital. The study endpoints are clinical outcomes (from a patient's perspective). In this perspective paper, the main findings of these studies, from the operators' point of view, are reported. Operator opinions were collected from structured and unstructured surveys conducted among the staff involved, and their main themes are reported in a narrative manner.

RESULTS

Telemonitoring appears to be linked to a reduction in side-events and side-effects, which represent some of most commons risk factors for re-hospitalization and for delayed discharge during hospitalization. The main perceived advantages are increased patient safety and the quick response in case of emergency. The main disadvantages are believed to be related to low patient compliance and an infrastructural lack of optimization.

CONCLUSIONS

The evidence of wireless monitoring studies, combined with the analysis of activity data, suggests the need for a model of patient management that envisages an increase in the territory of structures capable of offering patients subacute care (the possibility of antibiotic treatments, blood transfusions, infusion support, and pain therapy) for the timely management of chronic patients in the terminal phase, for which treatment in acute wards must be guaranteed only for a limited time for the management of the acute phase of their diseases.

Casirivimab and imdevimab: Cost-effectiveness analysis of the treatment based on monoclonal antibodies on outpatients with Covid-19

BACKGROUND AND OBJECTIVES

In 2020, the world was profoundly affected by the spread of SARS-CoV-2, a novel coronavirus first identified in December 2019, that was the causative agent of coronavirus disease 2019 (Covid-19), a severe respiratory disease classified as a pandemic by the World Health Organization (WHO) in March 2020. Covid-19 had a significant negative impact on the healthcare facilities and the economies of many countries. A need for pharmacological treatments for Covid-19 patients rapidly emerged to limit the damage caused by the disease and allow for more efficient management of hospital resources. A possible alternative treatment that has achieved encouraging results on Covid-19 is the use of monoclonal antibodies. This research aims to evaluate the cost-effectiveness of a type of monoclonal antibody, specifically the combination of casirivimab and imdevimab, and assess its impact on the Italian healthcare system.

METHODS

The casirivimab and imdevimab treatment efficacy on outpatients with Covid-19 was tested using a predictive Markov model. Research endpoints include hospitalizations, Intensive Care Unit (ICU) admissions, and deaths. This was translated into terms of benefits (savings) and costs for the Italian National Health Service (NHS). The model operates on a predictive time frame of 20 weeks starting from September 2021 until January 2022. The data used to populate the model comes from international academic studies and open-access resources on online databases.

RESULTS

The model estimates the effects that can be achieved by administering casirivimab and imdevimab treatment on outpatients with Covid-19. According to the estimates, the treatment can prevent approximately 4,000 hospitalizations, 3,589 ICU admissions, and 1,500 deaths in the considered 20-week period. The potential cost savings amount to EUR 78 million, mainly attributable to the reduction in the number of hospitalizations and access to ICU. More specifically, a difference of EUR 15,4 million can be observed due to the reduction in the number of hospitalizations, a difference of EUR 59,3 million due to the reduction in the number in intensive care, and a difference of EUR 20,3 million due to the reduction in deaths as a consequence of the reduction of hospitalizations. These results are already very significant, considering that in Italy, only 4.76% of the population is eligible for monoclonal antibody treatment.

CONCLUSION

The administration of casirivimab and imdevimab in outpatients with Covid-19 can accelerate recovery from the disease for patients, make hospital resource management more efficient and significantly reduce costs for healthcare facilities.

Modeling the Potential Impact of Remdesivir Treatment for Hospitalized Patients with COVID-19 in Saudi Arabia on Healthcare Resource Use and Direct Hospital Costs: A Hypothetical Study

Background and Objectives

Coronavirus disease 2019 (COVID-19) has spread rapidly worldwide. Saudi Arabia was significantly impacted by COVID-19. In March 2021, 381,000 cases were reported with 6539 deaths. This study attempts to quantify the impact of remdesivir on healthcare costs in Saudi Arabia, in terms of intensive care unit admissions, mechanical ventilation, and death prevention.

Methods

A forecasting model was designed to estimate the impact of remdesivir on the capacity of intensive care units and healthcare costs with patients requiring low flow oxygen therapy. The forecasting model was applied in the Saudi context with a 20-week projection between 1 February and 14 June, 2021. Model inputs were collected from published global and Saudi literature, available forecasting resources, and expert opinions. Three scenarios were assumed: the effective pandemic infection rate (Rt) remains at 1, the Rt increases up to 1.2, and the Rt declines from 1 to 0.8 over the study period.

Results

The model estimated that the use of remdesivir in hospitalized patients, in the optimistic and pessimistic scenarios, could prevent between 1520 and 3549 patient transfers to intensive care units and mechanical ventilation, prevent between 815 and 1582 deaths, and make potential cost savings between $US154 million and $US377 million owing to the reduction in intensive care unit capacity, respectively.

Conclusions

The treatment with remdesivir may improve patient outcomes and reduce the burden on healthcare resources during this pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40261-022-01177-z.

Estimation Model for Healthcare Costs and Intensive Care Units Access for Covid-19 Patients and Evaluation of the Effects of Remdesivir in the Portuguese Context: Hypothetical Study

Background and Objectives

In March 2020, the World Health Organization announced a state of emergency due to the appearance of a pandemic caused by the Coronavirus 2 (SARS-CoV-2), a severe acute respiratory syndrome, known as Covid-19. Most governments chose to implement precautionary measures, e.g., physical distancing and use of protective devices, which can in part limit the transmission of the virus. However, the healthcare system experienced numerous structural problems in managing the Covid-19 patients given the limited human and technical resources in critical areas, such as the intensive care units (ICUs). Different therapeutic solutions should therefore be assessed, which can potentially minimize the negative impact of the disease on patients, favoring their recovery and optimizing healthcare resources. The objective of this study is to simulate the impact of remdesivir treatment on the pandemic course in the long term.

Methods

A forecasting model is designed to estimate how remdesivir would impact the ICU capacity and the healthcare costs from the hospital perspective when managing COVID-19 patients. This model is applied in the Portuguese context with a 20-week projection starting on May 1st and concluding on September 18th, 2021. The data inputs were carefully collected by consulting different sources, such as published global literature, official governmental reports, and available infectious diseases databases, i.e., Our World in Data, Portuguese Ministry of Health, and experts’ opinions.

Results

The model showed that the introduction of remdesivir-based treatment in patients with Covid-19 pneumonia requiring supplemental oxygen therapy generates a significant reduction in both the number of ICU admissions and deaths, which would produce more than €23 million in cost savings and avoid more than 261 ICUs admissions and 166 deaths.

Conclusion

It is demonstrated that alternative treatments such as remdesivir can reduce both the health burden for healthcare facilities, optimize their management, and improve patients’ clinical conditions. However, the model is centered on Rt values, which cannot be generalized to the entire country; hence, the results of this research should be considered as a “hypothetical study”.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40261-022-01128-8.

Cognitive Digital Biomarkers from Automated Transcription of Spoken Language

BACKGROUND

Although patients with Alzheimer's disease and other cognitive-related neurodegenerative disorders may benefit from early detection, development of a reliable diagnostic test has remained elusive. The penetration of digital voice-recording technologies and multiple cognitive processes deployed when constructing spoken responses might offer an opportunity to predict cognitive status.

OBJECTIVE

To determine whether cognitive status might be predicted from voice recordings of neuropsychological testing.

DESIGN

Comparison of acoustic and (para)linguistic variables from low-quality automated transcriptions of neuropsychological testing (n = 200) versus variables from high-quality manual transcriptions (n = 127). We trained a logistic regression classifier to predict cognitive status, which was tested against actual diagnoses.

SETTING

Observational cohort study.

PARTICIPANTS

146 participants in the Framingham Heart Study.

MEASUREMENTS

Acoustic and either paralinguistic variables (e.g., speaking time) from automated transcriptions or linguistic variables (e.g., phrase complexity) from manual transcriptions.

RESULTS

Models based on demographic features alone were not robust (area under the receiver-operator characteristic curve [AUROC] 0.60). Addition of clinical and standard acoustic features boosted the AUROC to 0.81. Additional inclusion of transcription-related features yielded an AUROC of 0.90.

CONCLUSIONS

The use of voice-based digital biomarkers derived from automated processing methods, combined with standard patient screening, might constitute a scalable way to enable early detection of dementia.

Cost-Effectiveness Analysis of Tapentadol Versus Oxycodone/Naloxone in both Branded and Generic Formulations in Patients with Musculoskeletal Pain

BACKGROUND AND OBJECTIVES

Current evidence shows that tapentadol hydrochloride prolonged-release is more cost effective than other opioids. However, the introduction into the market of generic formulations of traditional comparators, leading to potential savings due to their lower price, creates space for further research. The objective of this study is to evaluate and compare the efficacy of tapentadol versus oxycodone/naloxone and the economic impact of the two alternatives in both branded and generic formulations.

METHODS

A cost-effectiveness analysis was performed using the third-payer perspective (TPP), with specific reference to the Italian National Health Service. A Markov model was implemented to simulate transitions between states, comparing two arms: The first arm simulated the administration of tapentadol, while the second simulated the administration of oxycodone/naloxone, both branded and generic. The results were reported in terms of net monetary benefit (NMB). The willingness to pay (WPT) was estimated at €35,000/quality-adjusted life year.

RESULTS

Tapentadol was dominant in all scenarios, assuming a population of 1000 individuals over a 1-year time horizon. In all cases, although the prices of oxycodone/naloxone generic formulations were lower, the costs associated with treatment discontinuation were always higher than those associated with tapentadol. The comparison with the branded formulation of oxycodone/naloxone was associated with the highest savings of €431.77 per patient, and with the highest NMB of €1943.77 per patient.

CONCLUSION

The results of this pharmacoeconomic evaluation promote the use of tapentadol in comparison with oxycodone/naloxone, confirming the results obtained in previous studies with reference to the generic formulations.

Hybrid distributed acoustic and temperature sensor using a commercial off-the-shelf DFB laser and direct detection

We demonstrate a hybrid distributed acoustic and temperature sensor (DATS) using a commercial off-the-shelf (COTS) distributed feedback (DFB) laser, a single-mode optical fiber, and a common receiver block. We show that the spectral and frequency noise characteristics of the laser, combined with a suitable modulation scheme, ensure the inter-pulse incoherence and intra-pulse coherence conditions required for exploiting the fast denoising benefits of cyclic Simplex pulse coding in the hybrid measurement. The proposed technique enables simultaneous, distributed measurement of vibrations and temperature, with key industrial applications in structural health monitoring and industrial process control systems. The sensor is able to clearly identify a 500 Hz vibration at 5 km distance along a standard single-mode fiber and simultaneously measure the temperature profile along the same fiber with a temperature resolution of less than 0.5°C with 5 m spatial resolution.

Hybrid Raman/Brillouin-optical-time-domain-analysis-distributed optical fiber sensors based on cyclic pulse coding

We experimentally demonstrate the use of cyclic pulse coding for distributed strain and temperature measurements in hybrid Raman/Brillouin optical time-domain analysis (BOTDA) optical fiber sensors. The highly integrated proposed solution effectively addresses the strain/temperature cross-sensitivity issue affecting standard BOTDA sensors, allowing for simultaneous meter-scale strain and temperature measurements over 10 km of standard single mode fiber using a single narrowband laser source only.

Cyclic pulse coding for fast BOTDA fiber sensors

A cyclic pulse coding technique is proposed and experimentally demonstrated for fast implementation of long-range Brillouin optical time-domain analysis (BOTDA). The proposed technique allows for accurate temperature and strain measurements with meter-scale spatial resolution over kilometers of standard single-mode fiber, with subsecond measurement times.

High-performance hybrid Raman/fiber Bragg grating fiber-optic sensor based on simplex cyclic pulse coding

We propose and experimentally demonstrate the use of cyclic pulse coding to improve the performance of hybrid Raman/fiber Bragg grating (FBG) fiber-optic sensors, for simultaneous measurement of distributed static temperature and discrete dynamic strain over the same sensing fiber. Effective noise reduction is achieved in both Raman optical time-domain reflectometry and dynamic interrogation of time-division-multiplexed fiber FBG sensors, enhancing the sensing range resolution and providing real-time point dynamic strain measurement capabilities. The highly integrated sensor scheme employs broadband apodized low-reflectivity FBGs, a single narrowband optical source, and a shared receiver block.

Hybrid Raman/fiber Bragg grating sensor for distributed temperature and discrete dynamic strain measurements

We propose and experimentally demonstrate a hybrid fiber optic sensing technique that effectively combines Raman optical time domain reflectometry and in-line time-division-multiplexing for fiber Bragg grating (FBG) dynamic interrogation. The highly integrated proposed scheme employs broadband apodized low reflectivity FBGs with a single narrowband optical source and a shared receiver block, allowing for simultaneous measurements of distributed static temperature and discrete dynamic strain, over the same sensing fiber.

Integrated hybrid Raman/fiber Bragg grating interrogation scheme for distributed temperature and point dynamic strain measurements

We propose and experimentally demonstrate the feasibility of an integrated hybrid optical fiber sensing interrogation technique that efficiently combines distributed Raman-based temperature sensing with fiber Bragg grating (FBG)-based dynamic strain measurements. The proposed sensing system is highly integrated, making use of a common optical source/receiver block and exploiting the advantages of both (distributed and point) sensing technologies simultaneously. A multimode fiber is used for distributed temperature sensing, and a pair of FBGs in each discrete sensing point, partially overlapped in the spectral domain, allows for temperature-independent discrete strain measurements. Experimental results report a dynamic strain resolution of 7.8 nε/√Hz within a full range of 1700 με and a distributed temperature resolution of 1°C at 20 km distance with 2.7 m spatial resolution.

Raman-based distributed temperature sensor with 1 m spatial resolution over 26 km SMF using low-repetition-rate cyclic pulse coding

We experimentally investigate the benefits of a new optical pulse coding technique for long-range, meter and submeter scale Raman-based distributed temperature sensing on standard single-mode optical fibers. The proposed scheme combines a low-repetition-rate quasi-periodic pulse coding technique with the use of standard high-power fiber lasers operating at 1550 nm, allowing for what we believe is the first long-range distributed temperature measurement over single-mode fibers (SMFs). We have achieved 1 m spatial resolution over 26 km of SMF, attaining 3°C temperature resolution within 30 s measurement time.

Wavelet transform analysis of heart rate variability during dipyridamole-induced myocardial ischemia: relation to angiographic severity and echocardiographic dyssynergy

BACKGROUND

Analysis of heart rate variability (HRV) is a valuable noninvasive method for quantifying autonomic cardiac control in humans and has been utilized during dipyridamole echocardiographic test to differentiate positive from negative test results.

HYPOTHESIS

We aimed to evaluate, by means of HRV analysis, the influence of the angiographic severity of coronary artery disease on cardiac autonomic control during dipyridamole-induced myocardial ischemia.

METHODS

We analyzed RR interval variability changes during dipyridamole-induced myocardial ischemia in 31 selected patients (mean age 54 +/- 9 years) with available coronary angiography and positive dipyridamole echocardiographic test. Spectral components of HRV were assessed by means of wavelet transform analysis for the last 5 min before the beginning of the test (baseline) and for 5 min after the onset of ischemia-related events (peak dipyridamole effect).

RESULTS

Patients were divided into three groups according to the number of coronary diseased vessels (Group A, single-vessel disease; Group B, double-vessel disease; Group C, triple-vessel disease). No difference was detectable at baseline among the three groups. After dipyridamole, low-frequency power, a measure of sympathetic modulation of heart rate, increased and echocardiographic wall motion score index worsened in all groups (p < 0.001). The increase in low-frequency power was more evident in Group C patients than in the other two groups (p < 0.005). Furthermore, after dipyridamole, a direct correlation was found between low-frequency power and wall motion score index (r = 0.59; p < 0.001).

CONCLUSIONS

These data suggest that HRV analysis performed during dipyridamole echocardiographic test provides useful information to assess the severity of coronary artery disease.

Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature

OBJECTIVE

To evaluate long-term mortality rate of anorexia nervosa (AN) patients in a southern Italy population compared to the most recent literature.

DESIGN

Retrospective and review setting.

PATIENTS AND INTERVENTIONS

One hundred and forty-seven female AN patients, consecutively admitted from 1994 to 1997 to the Outpatient Unit, were re-examined between June and November 2003. Our data are compared with 10 other studies published since 1988.

RESULTS

One hundred and twenty-three deaths in 2240 patients, amounting to a total mortality rate of 5.25% were reported in the literature. Deaths due to suicide, AN-related and AN-unrelated diseases were 1.20, 3.07 and 0.98%, respectively. After correcting for unrelated deaths, mortality rate was 4.27%. In our 8-year follow-up, we found a mortality rate of 2.72% (1.82% after correcting for unrelated deaths). Standardized mortality ratio was 9.7.

CONCLUSION

We interpret our favourable findings as a consequence of an integrated, clinical-nutritional and psychiatric approach. Finally, considering AN demographic characteristics, that is young female subjects in Westernized societies, mortality rate is confirmed to be dramatically high.

Classical and new proving methodology: Provings of Plumbum metallicum and Piper methysticum and comparison with a classical proving of Plumbum metallicum

OBJECTIVE

To study the reliability of a proving methodology and the reproducibility of proving symptoms.

METHODS

Two homeopathic medicines and placebo were given, in a double-blind randomized design, to 31 healthy volunteers (13 Piper methysticum 30C, 11 placebo and 7 Plumbum metallicum 30C), 5 drops 4 times daily, until the onset of unbearable symptoms, or at most for 1 week. The primary outcome measure was the number of phrases containing unusual or new symptoms selected by supervisors (SEL) from unstructured diaries and the number of these symptoms (SYM) present in SELs. The secondary outcome measures were the number of symptoms with modalities of both verum groups concordant with symptoms reported in a previous proving of Plumbum 12C. Other parameters evaluated were repeated and crossed symptoms in SELs.

RESULTS

Both medicines showed qualitative and quantitative differences from placebo. Piper: 146 SELs (median: 5), Plumbum: 118 SELs (16), placebo: 48 SELs (2), containing 260 (8), 199 (29) and 58 (2) SYMs, respectively. There was a significant difference from placebo in Plumbum but not in Piper SELs and SYMs (P < 0.05). 31, 24 and 4 'repeated' and 18, 22 and 2 'crossed' symptoms were found in Piper, Plumbum and placebo. 8 and 30 symptoms concordant with the classical proving of Plumbum were found for Piper and Plumbum, corresponding to about 10% and 45% of their total SELs.

CONCLUSIONS

Open diaries, supervision and double-blind placebo are useful methods in homeopathic pathogenetic trials. Estimates of concordance should be introduced in proving methodology.

Outcome predictors in the short-term treatment of anorexia nervosa: an integrated medical-psychiatric approach

OBJECTIVES

Factors predicting clinical outcome in the short-term treatment of anorexia nervosa.

DESIGN

Longitudinal follow-up study.

SETTING

Department of Clinical and Experimental Medicine, "Federico II" University of Naples.

PARTICIPANTS

Fifty-eight young anorectic women consecutively attending the outpatient Unit between January 1997 and December 2000.

MAIN OUTCOME MEASURES

Body weight changes over six months' follow-up.

RESULTS

Body weight changes in the short term was exclusively predicted by the prevalent underlying psychiatric disorder, being increased in the patients with prevalently depressive traits, decreased in those with psychotic features and unchanged in those with a prevalently narcissistic personality.

CONCLUSIONS

The prevalent psychiatric disorder seems to predict clinical outcome in the short term. Body weight gain per se cannot always be the main target of medical intervention, at least in the early phase of the treatment of malnutrition secondary to major eating disorders.

[Rationale for the building of a new hospital]

The "Azienda Ospedaliera Ospedali Riuniti di Bergamo" has completed the preliminary planning of the building of a new, great hospital, after a long and deep debate about the role and the significance of a modern hospital, thought to support, during the next century, the activity of a "hospital of national relevance and high specialization". The main aspects about the number of beds in the new hospital are debated and considered in the new conditions following the new programming acts of health planning in Italy and Lombardy and the needs of demography and emerging health demands The choice between new building or restructuring the existing hospital is discussed and the debate is referred to international scientific bibliography. Risk management is also considered as a must in a new hospital building.

[Theory of training and quality of safety in health]

This article aims to define the concept of security, particularly in relation to concepts of risk, error, danger and adverse events. The authors go on to analyse the latest theory of adult training, applying it to healthcare safety whilst recognising that this is a complex facility. By using tools such as guidelines and risk management, the authors propose a new kind of corporate culture that enables certain initiatives, such as clinical governance and therefore learning organisation, to develop. This strategic organisation the company allows vital knowledge and experience, which lead to problem-solving and an increased guarantee of security for both internal and external clients, to become the common knowledge and property of the company as a whole and of all who operate in and around it.

Intensified chemotherapy supported by DMSO-free peripheral blood progenitor cells in breast cancer patients

BACKGROUND

The majority of high-dose chemotherapy (HDC)-related complications results from bone marrow aplasia, but the graft infusion per se may cause adverse reactions due to the injection of both dimethyl sulfoxide (DMSO) and cell lysis products. We evaluated the feasibility of a two-step chemotherapy regimen with peripheral blood progenitor cell (PBPC) support in association with a novel procedure to remove DMSO and products of cell lysis from the cryopreserved cells.

PATIENTS AND METHODS

Stage III and IV breast cancer patients received induction chemotherapy with three cycles of CEF (cyclophosphamide 600 mg/m2, epirubicin 100 mg/m2, 5-fluorouracil 600 mg/m2) followed by three cycles of HDC consisting of escalating doses of cyclophosphamide (dose range 1200 3000 mg/m2) and carboplatin (dose range 600-1000 mg/m2), supported by DMSO-free PBPC reinfusion. DMSO was removed by a washing/enzymatic digestion procedure.

RESULTS

Twenty patients received induction chemotherapy and eighteen completed the entire chemotherapy program; a total of fifty-four cycles of HDC were administered. Dose limiting toxicity of HDC was long-lasting grade 4 neutropenia associated with documented infection. The maximum tolerated dose (MTD) was cyclophosphamide 3000 mg/m2 and carboplatin 600 mg/m2. No side effects related to PBPC reinfusion were observed.

CONCLUSIONS

The proposed two-step chemotherapy regimen, associated with a novel washing/enzymatic digestion procedure, is feasible in advanced breast cancer patients in the absence of complications related to the specific toxicity of PBPC reinfusion.

Hospital admission and mortality rates in anorexia nervosa: experience from an integrated medical-psychiatric outpatient treatment

OBJECTIVES

To evaluate the effectiveness of an integrated medical-psychiatric treatment of major eating disorders.

DESIGN

Historical cohort study.

SETTING

Outpatient Unit for Protein Energy Malnutrition of the Department of Clinical and Experimental Medicine, "Federico II" University of Naples, time of study: January 1994 to December 1997 PARTICIPANTS: 147 female patients with restrictive or bulimic anorexia nervosa (mean age 19.8 +/- 13.7, BMI 14.7 +/- 2.1 Kg/m2) consecutively attending the outpatient unit between January 1994 and December 1997.

MAIN OUTCOME MEASURES

Hospitalization and mortality rates were evaluated up to Jan 1999 with a minimum follow-up of 18 months.

RESULTS

There were 23 admissions to the Clinical Nutrition ward for 19 patients (i.e. 12.9%) mostly due to severe protein energy malnutrition, and 2 deaths, only 1 strictly related to anorexia (mortality rate 0.7%).

CONCLUSIONS

Integrated outpatient medical-psychiatric treatment for major eating disorders is an effective and inexpensive procedure that reduces mortality and admissions due to medical complications in the medium term.

Limited value of sonohysterography for endometrial screening in asymptomatic, postmenopausal patients treated with tamoxifen

OBJECTIVES

Sonohysterography (SHG) has been proposed as a useful tool for the surveillance of the endometrium in patients receiving tamoxifen. This study aimed to assess the value of SHG in asymptomatic patients who would have been biopsy candidates because of abnormal transvaginal ultrasound (TVUS) results.

METHODS

The study population included postmenopausal breast cancer patients receiving adjuvant tamoxifen who had asymptomatic abnormalities at TVUS (endometrial thickness >/=8 mm or endometrial echo not adequately visualized). SHG was performed with an Aloka SSD 680 system using a 5-MHz vaginal probe, with sterile saline solution as contrast medium.

RESULTS

Forty-one patients entered the study. A regular endometrial echo was identified by SHG in 9 patients (21.9%). Histology was obtained in the remaining 32 patients with positive (n = 27, 65.8%) or unsuccessful (n = 5, 12.2%) SHG. Benign polyps (n = 15, 36.6%) and endometrial atrophy (n = 14, 34.1%) were the most common findings; 3 patients (7.3%) had simple hyperplasia.

CONCLUSIONS

Breast cancer patients with asymptomatic, tamoxifen-associated TVUS abnormalities have little additional benefit from SHG. More than 23 remain candidates for biopsy, which usually yields benign or insignificant findings.

Toremifene as a substitute for adjuvant tamoxifen in breast cancer patients

BACKGROUND

Toremifene is a new antiestrogen, which in nonclinical studies appears less carcinogenic than tamoxifen. Clinical trials of adjuvant toremifene vs. tamoxifen in breast cancer patients are ongoing. This study aimed to evaluate the short-term effects of changing from adjuvant tamoxifen to toremifene.

PATIENTS AND METHODS

Twenty postmenopausal breast cancer patients receiving adjuvant tamoxifen, 20 mg/day, were switched to toremifene 60 mg/day. The effects on the uterus were evaluated prospectively by transvaginal ultrasound; tolerability was assessed clinically.

RESULTS

In 14 patients who had uterine abnormalities (endometrial thickening or polyps) under tamoxifen, no significant changes occurred during a median of 18 months (range 7-24) of toremifene treatment. Out of six patients who had entered the study due to intolerance to tamoxifen, however, 3 tolerated toremifene well.

CONCLUSION

Toremifene does not modify previous uterine changes induced by tamoxifen. For some patients who do not tolerate tamoxifen, however, switching to toremifene may allow the continuation of adjuvant antiestrogenic therapy.

[Organization of health and safety activities in health care centers]

The paper proposes a model for health and safety organization in health care units and hospitals which takes account of the risk assessment procedures required by law and the quality assessment of the measures thus taken. A redefinition is given of the role of Medical Director and of the functions, aims and standards on which health and safety service and the services of an authorized occupational health physicians must be based.

Comparison of verapamil versus felodipine on heart rate variability in hypertensive patients

OBJECTIVE

We evaluated the effect of two calcium channel blockers, verapamil and felodipine, on heart rate variability in hypertensive patients.

DESIGN

Time and frequency domain measures of heart rate variability were obtained from 24 h Holter recording in 25 previously untreated hypertensive patients without left ventricular hypertrophy, before and after 3 months of verapamil slow-release treatment (240 mg once daily) or felodipine extended-release treatment (10 mg once daily).

RESULTS

Blood pressure values decreased with both drugs. Measures of heart rate variability, comparable at baseline in the two groups, were unchanged after felodipine. After verapamil, the average RR interval, the square root of the mean of the squared differences between all adjacent normal RR intervals (r-MSSD) and the percentage of differences between all adjacent normal RR intervals > 50 ms (pNN50), measures of vagal modulation of heart rate, increased (from 735 +/- 67 to 827 +/- 84 ms, P < 0.001; from 30 +/- 10 to 44 +/- 15 ms, P < 0.001; and from 3 +/- 2 to 7 +/- 6%, P < 0.01, respectively) and were higher than after felodipine. The coefficient of variation, a measure that compensates for heart rate effects, increased only after verapamil (from 5.8 +/- 1.3% to 6.6 +/- 1.0%; P < 0.05). High frequency power and its coefficient of component variance, both representing the vagal modulation of heart rate, increased after verapamil (from 5.33 +/- 0.29 to 5.80 +/- 0.27 In units, P < 0.001 and from 1.9 +/- 0.3 to 2.2 +/- 0.25%; P < 0.05). Finally, the low to high frequency power ratio, an indicator of sympathovagal balance, with a high value suggesting a sympathetic predominance, decreased after verapamil (from 2.16 +/- 0.41 to 1.36 +/- 0.35; P < 0.001), confirming the improvement in vagal modulation of heart rate.

CONCLUSION

In hypertensive patients, despite a comparable anti-hypertensive effect, verapamil, but not felodipine, has favourable effect on cardiac autonomic control.

A scientific reappraisal of the 'principle of similarity'

In the history of therapeutics, the 'principle of similarity'--the treatment of 'same by same' or of 'like by like'--may be traced back to a number of medical traditions, including the systems of Hippocrates, Paracelsus and Hahnemann. Although in recent years we have witnessed a renaissance of interest in traditional medicines and 'holistic' medical practices, the reliability of the principle of similarity has still to be demonstrated on experimental grounds, and very few studies have been conducted to understand the underlying mechanism(s). Acceptance of this phenomenon requires supporting evidence of possible mechanisms and high-quality studies exploring its effectiveness in clinical medicine. The aim of this work is to provide a rational approach to the analysis of the various aspects of this historical yet also modern medical principle, in order to construct a plausible framework of ideas capable of facilitating further basic and clinical research into this field.

Apoptosis of Burkitt's lymphoma cells induced by specific interaction of surface IgM with a self-antigen: implications for lymphomagenesis in acquired immunodeficiency syndrome

In a previous study, we described a cell line (BRG-P) derived from a woman with Burkitt's lymphoma (BL) and acquired immunodeficiency syndrome that shared the same characteristic cytogenetic abnormalities as the patient's malignant cells. This cell line contained subclones that displayed an isotype switch from IgM to IgA1 and an accumulation of point mutations in the Vh region genes. Because these two features suggested an antigen-driven process, we began a search for the antigen responsible for the stimulation of the malignant B cells. Specifically, we hypothesized that because the patient's tumor had presented as a lymphomatous infiltration of the breast, the malignant B cells were recruited to this site because of the reactivity of their surface lg with breast tissue. A hybridoma (BRG-H) was obtained by fusing BRG-M cells (an IgM producing subclone of the BRG-P cell) with an appropriate cellular partner. The monoclonal antibody (BRG MoAb) produced by this hybridoma reacted strongly with two of five breast cancer cell lines and stained normal and malignant ductal epithelial cells on breast tissue sections. The antigen recognized by the BRG MoAb consisted of a single, minimally glycosylated polypeptide chain of 45 kD (p45). The BRG MoAb failed to react with a panel of human cell lines from different tissues, except for one cell line from a uterine cervical carcinoma. No reactivity was detected for a panel of exogenous antigens from various pathogens, including human immunodeficiency virus and self-antigens frequently recognized by polyspecific antibodies. Experiments were performed to investigate the functional consequences of the interaction of surface IgM with its specific ligand. Coculture of BRG-M cells with p45+, but not with p45-, breast cells caused apoptosis of BRG-M cells. The specificity of the interaction was shown by the observation that apoptosis was prevented by pretreatment of BRG-M cells with a monovalent F(ab') fragment of rabbit IgG antibody to human mu chains. Moreover, only BRG-M cells, but not other BL cells, underwent apoptosis after exposure to p45+ breast cells. The interaction between the CD40 molecule expressed by BRG-M cells and its specific ligand (CD40L) prevented p45-induced cell apoptosis. Because this interaction mimics that occurring in vivo between T and B cells during immune responses, our data suggest that various events contributed to the emergence of the BL, in this particular patient, including antigenic stimulation possibly assisted by T-cell help.

Neurobehavioral functions in operating theatre personnel exposed to anesthetic gases

Neurobehavioral functions in paramedical operating theatre personnel were assessed in a cross-sectional survey. Sixty-two subjects (40 males and 22 females) occupationally exposed to anesthetic gases were examined and compared to 46 unexposed hospital workers (18 males and 28 females). The Simple Reaction Time (SRT) test was selected from the MANS battery (Milan Automated Neurobehavioural System). In order to evaluate acute and subacute types of effects on performance, the test was administered before and after the work shift, at the beginning and at the end of the working week. In addition, the complete battery was administered during one working day without exposure to anesthetic gases. On the last day of the working week, atmospheric nitrous oxide (N2Oa) ranged from 7 to 553 ppm (geometric mean 62.6), atmospheric ethrane (ETHa) ranged from 0.1 to 18.8 ppm (geometric mean 1.3), and urinary N2O (N2Ou) ranged from 4 to 297 micrograms/l (geometric mean 26.8). An impairment of performance on the SRT test was observed at the end of the working week in subjects exposed to anesthetic gases compared to controls. This alteration was observed also considering only the subjects exposed to less than 55 micrograms/l (which is the Italian exposure limit for N2Ou, equivalent to 100 ppm for N2Oa). No significant differences were observed for the other psychometric tests. No dose-effect relationships where found between SRT test score and the indicators of exposure (N2Oa, ETHa, N2Ou).(ABSTRACT TRUNCATED AT 250 WORDS)

[Proposal of a health education program]

Since 1987 at the Spedali Civili of Brescia the problem of anaesthetic gases pollution in operating surgery rooms was managed by means of periodical environmental monitoring and maintenance of the anaesthesiological equipments. The mean nitrous oxide concentrations were generally reduced to values below the limits indicated by the Italian Ministry of Health. On the contrary, a low participation of the operating room personnel was observed in the health surveillance program and this phenomenon is clearly evidenced by the progressive decrease of the number of medical examinations. In order to clarify the usefulness of health surveillance programs and to promote the adoption of "less pollutant" behaviour, a Health Education Program was planned by the Medical Administration, in collaboration with the Occupational Health Service and the Department of Anesthesiology and Intensive Care. This program will be performed at different times, including the administration of a questionnaire, the participation at information meetings, the distribution of brochures and the evaluation of environmental and biological exposure data before and after the education program.

Microtubule assembly in Friend erythroleukemia cells spread on fibronectin- and lectin-coated substrates

A comparison was carried out between parental Friend Erythroleukemia cells (FLC, 745 A clone) and highly fibronectin (FN)-sensitive clones of FLC for their ability to adhere, spread and organize microtubular (MT) apparatus, when seeded on FN- or lectin-coated plastic substrates. While FN was able to induce the spreading only in the FN-sensitive FLC clones (further referred to as FF clones) and not in the parental 745 A cells, the lectins Concanavalin A (ConA) and Leukoagglutinin (LeuA) promoted the spreading of both 745 A and FF cells, with no differences between the two cell lines. Wheat germ agglutinin (WGA), instead, is almost ineffective in triggering cell spreading in both cell clones. The spreading of FLC, either 745 A or FF, on any of the ligands tested, is always accompanied by a massive reorganization of the MT apparatus of the cell. Possible mechanisms involved in the selective spreading effect, exerted by FN, are discussed.