67Atrial fibrillation and depressive symptoms in the elderly: an association with age, CHA2DS2-VASc score and physical performance

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia found in clinical practice. Its prevalence significantly grows with age. The proportion of elderly individuals with depression varies between 4.2 and 10.6% according to the different criteria used for diagnosis. Interestingly, AF and depression synergistically act to increase mortality.

Purpose. Aim of this study was to identify the clinical variables associated with depressive symptoms in elderly individuals with persistent AF.

Methods. All patients consecutively admitted in a Day-Hospital setting to undergo electrical cardioversion of AF were enrolled in the study. No exclusion criteria were specified. Population was studied with instruments exploring neurocognitive performance (Mini-Mental State Examination - MMSE; range: 0-30; abnormal values <27) and functional status (Short Physical Performance Battery; range: 0-12; abnormal values <10). With these tools, a better condition is expressed by higher scores. The presence of depressive symptoms was assessed with the Geriatric Depression Scale (GDS; 15-item form; abnormal values >5). In this case, lower scores identified a healthier emotional profile.

Results. Between January 2018 and August 2019, 111 patients were evaluated (age: 77 ± 9 years; women: 39.6%; weight: 78 ± 15 Kg; height: 171 ± 11 cm). Lone AF and brady- tachy- syndrome were diagnosed in 12.6% of cases. Hypertension and structural heart disease (coronary artery disease, heart failure, valvular heart disease) were responsible of the arrhythmia in 30.6% and 56.8% of patients, respectively. Left ventricular ejection fraction was 60 ± 12%, with a heart rate equal to 78 ± 17 bpm. MMSE and SPPB score were 28 ± 3 and 8.7 ± 2.9. An abnormal GDS score was observed in 19.8% of cases (mean: 3.0 ± 2.7). Interestingly, in univariate analysis, depressive symptoms increased with age (p = 0.002) and the CHA2DS2-VASc score (< =2: 1.3 ± 1.7; 3: 1.9 ± 2.3; 4: 3.9 ± 3.2; 5: 4.0 ± 2.4; > =6: 4.4 ± 2.8; p < 0.001), and were inversely related to MMSE (p = 0.004) and SPPB (p < 0.001). The type of oral anticoagulation (NOACs: 64.0%) did not exert any effect on GDS score (VKA: 3.2 ± 2.2 vs. NOACs: 3.0 ± 3.0; p = 0.717). In multivariate analysis (R = 0.711; p < 0.001), depressive symptoms were higher in those who lived alone (+1.35 ± 0.48; p = 0.007) and were taking a renin-angiotensin system blocker (+0.93 ± 0.43; p = 0.032). Age (-0.07 ± 0.03 per year; p = 0.026), height (-0.09 ± 0.03 per cm; p = 0.001), glomerular filtration rate (-0.03 ± 0.01 per mL/min; p = 0.013) and SPPB (-0.39 ± 0.09 per each point; p < 0.001) were inversely associated with GDS.

Conclusions. In a population of elderly patients with persistent AF, the prevalence of depression is not negligible. Importantly, depressive symptoms are significantly associated with the CHA2DS2-VASs score, and, at multivariate analysis, with renal function, to live alone and physical performance. Paradoxically, after adjustment for these factors, GDS score decreases with age per se.

Graphical chain models for the analysis of complex genetic diseases: an application to hypertension

A crucial task in modern genetic medicine is the understanding of complex genetic diseases. The main complicating features are that a combination of genetic and environmental risk factors is involved, and the phenotype of interest may be complex. Traditional statistical techniques based on lod-scores fail when the disease is no longer monogenic and the underlying disease transmission model is not defined. Different kinds of association tests have been proved to be an appropriate and powerful statistical tool to detect a ‘candidate gene’ for a complex disorder. However, statistical techniques able to investigate direct and indirect influences among phenotypes, genotypes and environmental risk factors, are required to analyse the association structure of complex diseases. In this paper, we propose graphical models as a natural tool to analyse the multifactorial structure of complex genetic diseases. An application of this model to primary hypertension data set is illustrated.

Survey of tuberculosis drug resistance among Tibetan refugees in India

SETTING

Tuberculosis (TB) is a major health problem among Tibetans living in exile in India. Although drug-resistant TB is considered common in clinical practice, precise data are lacking.

OBJECTIVE

To determine the proportion of drug-resistant cases among new and previously treated Tibetan TB patients.

DESIGN

In a drug resistance survey in five Tibetan settlements in India, culture and drug susceptibility testing (DST) for first-line drugs were performed among all consecutive new and previously treated TB cases from April 2010 to September 2011. DST against kanamycin (KM), ethionamide, para-aminosalicylic acid and ofloxacin (OFX) was performed on multidrug-resistant TB (MDR-TB) isolates.

RESULTS

Of 307 patients enrolled in the study, 264 (193 new and 71 previously treated) were culture-positive and had DST available. All patients tested for the human immunodeficiency virus (n = 250) were negative. Among new TB cases, 14.5% had MDR-TB and 5.7% were isoniazid (INH) monoresistant. Among previously treated cases, 31.4% had MDR-TB and 12.7% were INH-monoresistant. Of the MDR-TB isolates, 28.6% of new and 26.1% of previously treated cases were OFX-resistant, while 7.1% of new cases and 8.7% of previously treated cases were KM-resistant. Three patients had extensively drug-resistant TB.

CONCLUSIONS

MDR-TB is common in new and previously treated Tibetans in India, who also show additional complex resistance patterns. Of particular concern is the high percentage of MDR-TB strains resistant to OFX, KM or both.

Adiponectin in outpatients with coronary artery disease: independent predictors and relationship with heart failure

BACKGROUND AND AIMS

Chronic heart failure (HF) is characterised by a neurohormonal dysfunction associated with chronic inflammation. A role of metabolic derangement in the pathophysiology of HF has been recently reported. Adiponectin, an adipose-tissue-derived cytokine, seems to play an important role in cardiac dysfunction. We investigated the variation of circulating adiponectin in patients with coronary artery disease (CAD), with or without HF, in order to identify its independent predictors.

METHODS AND RESULTS

A total of 107 outpatients with CAD were enrolled in the study and divided into three groups: CAD without left ventricular systolic dysfunction (group 1); CAD with left ventricular dysfunction without HF symptoms (group 2) and CAD with overt HF (group 3). Plasma adiponectin was determined by enzyme-linked immunosorbent assay. Adiponectin concentrations increased progressively from group 1 (7.6 ± 3.6 ng ml⁻¹) to group 2 (9.1 ± 6.7 ng ml⁻¹) and group 3 (13.7 ± 7.6 ng ml⁻¹), with the difference reaching statistical significance in group 3 versus 1 and 2 (p < 0.001). A multivariable model of analysis demonstrated that the best predictors of plasma adiponectin were body mass index, N-terminal pro-brain natriuretic peptide and high-density lipoprotein cholesterol. However, even after adjusting for all three independent predictors, the increase of adiponectin in group 3 still remained statistically significant (p = 0.015).

CONCLUSION

Our data confirm the rise of adiponectin in overt HF. The levels of circulating adipokine seem to be mainly predicted by the metabolic profile of patients and by biohumoral indicators, rather than by clinical and echocardiographic indexes of HF severity.

Endometrial metastasis of a primitive neuroendocrine ovarian carcinoma: management and treatment of a case

BACKGROUND

Neuroendocrine tumours are a heterogeneous group of separate clinico-pathological entities which have a common characteristic, i.e., expression of potential endocrine differentiation. In the ovary, the term "neuroendocrine" relates mainly to widely known carcinoids, but it may also be applied to rare neuroendocrine carcinomas as non-small cell type and small cell carcinomas of pulmonary type. In the literature only 11 cases of primary ovarian non-small cell neurendocrine carcinomas have been described and ten of these were associated with a surface epithelial ovarian tumour. Small cell neuroendocrine carcinoma of the ovary is a rare malignant tumour of the ovary. Advanced small cell carcinoma of the ovary is a very aggressive tumour with an overall poor prognosis and unfavourable outcome.

CASE REPORT

The case reported is unique in the literature because the authors describe a rare case of endometrial metastasis of a primary ovarian non-small cell neurendocrine carcinoma without any surface epithelial ovarian tumour association. The tumour invaded up to less than half of the myometrium. The first symptoms were related to endometrial metastasis as metrorrhagia and pelvic pain while the asymptomatic presence of primary ovarian carcinoma was not acknowledged with physical examination, routine biochemistry, tumour markers, blood count and traditional transvaginal greyscale ultrasound.

CONCLUSION

Magnetic resonance and three-dimensional (3D) ultrasonography with power Doppler are a great help in the diagnosis of ovarian localisation but only immunohistochemistry on histological material can provide a correct diagnosis. Immunohistochemistry expression of Ki67 is a useful marker of malignancy. Due to the rarity of this neoplasm, a general consensus for optimal treatment has yet to emerge. The reported biological aggressiveness of these tumours prompts combined treatment with radical surgery and adjuvant polychemotherapy.

Analysis of protease-activated receptor-1 and -2 in human scar formation

Protease-activated receptor (PAR)-1 and PAR-2 are reported to contribute to the fibrotic process in a number of organs, including lung, liver, pancreas, and kidney. The aim of this study was to localize expression and biological activity of PAR-1 and PAR-2 in normal and pathological cutaneous scars. First, we investigated the immunohistochemical expression of PAR-1 and PAR-2 proteins in a series of human normal scars (NS, n = 10), hypertrophic scars (HS, n = 10), and keloids (K, n = 10). Expression of PAR-1 and PAR-2 was observed in all types of scar. Specifically, in HS and K, diffuse PAR-1 and PAR-2 positivity was found in dermal cellular areas composed of myofibroblasts, while no or minor staining was observed in the scattered fibroblasts embedded in abundant extracellular matrix in the context of the more collagenous nodules, irrespective of the type of scar. The hyperplastic epidermis overlying K was also found to be strongly PAR-1 and PAR-2 positive, whilst in most NS and HS the epidermis was faintly to moderately stained. Second, ribonuclease protection assay on paraffin-embedded specimens showed overexpression of PAR-1 and PAR-2 mRNA in K compared to NS and HS. Third, cultured human fibroblasts exposed to TGF-beta1 expressed a myofibroblast phenotype associated with overexpression of PAR-2, while PAR-1 expression was unaffected. Intracellular Ca(2+) mobilization by PAR-2 agonists in myofibroblasts was increased as compared to fibroblasts, whereas the effect of PAR-1 agonists was unchanged. Our in vivo study indicates that PAR-1 and PAR-2 are expressed in cells involved in physiological and pathological scar formation and suggests that in vitro overexpression and exaggerated functional response of PAR-2 may play a role in the function of myofibroblasts in scar evolution from a physiological repair process to a pathological tissue response.

A new approach to vulvar squamous cell carcinoma: two-year follow-up of a case report

BACKGROUND

Vulvar carcinoma is relatively rare gynaecologic malignancy. The most prevalent vulvar cancer is squamous cell carcinoma. It is not uncommon for patients to delay seeking medical attention or for physicians to delay diagnosing the condition. This delay results in many cases being diagnosed in advanced stage. The sentinel lymph node "concept" is attractive in vulvar cancer because it has the potential to avoid a radical vulvectomy associated with uni- or bilateral inguinofemoral lymphadenectomy and, thus, to avoid the morbidity associated with formal groin dissection.

CASE REPORT

A case of an 88-year-old woman with advanced local vulvar cancer is presented. A study of the inguinal-femoral lymph nodes was also conducted with intraoperative vital blue dye peritumoral injection and as the sentinel node was found to be negative for malignant metastasis, a radical vulvectomy without bilateral inguinofemoral lymphadenectomy and without additional treatment (chemotherapy and/or radiotherapy) was performed. Follow-up was performed at one, three, six, nine, 12, 18 and 24 months. No local recurrence or distant metastasis was found.

CONCLUSION

The sentinel lymph node procedure allows a less aggressive treatment to be carried out in patients with invasive vulvar cancer thus reducing the complications and morbidity of treatment. Moreover, reducing the operative stress can change the overall survival and reduce the mortality linked to complications and postoperative stress.

Unusual case of cervical pregnancy after curettage for a presumptive diagnosis of intrauterine blighted ovum

A case of cervical pregnancy after curettage for presumptive intrauterine blighted ovum is presented. The woman was successfully treated by vacuum evacuation and curettage. A 29-year-old woman, gravida 2, nulliparous, was admitted to our department at ten weeks and two days of gestation after a diagnosis of cervical pregnancy. She had been treated by curettage five days before for an initial diagnosis of intrauterine blighted ovum. Ultrasound scan examination revealed a gestational sac without foetus in the cervix four days after the first curettage. Vacuum evacuation and curettage of the cervical canal were performed and a Foley catheter was also inserted and left in place for three days. The patient was discharged in good condition on the fourth postoperative day.

[Atelectasis following cesarean section. Personal experience]

Purpose of this paper is to evaluate the risk of ateletasis in patients that underwent surgery of the abdomen (cesarean section), since the reflex of cough in these patients is notably altered for the limitation of the diaphragmatic excursions, due to analgesic contracture. The inhibition of cough's reflex causes retention of secretions with consequent bronchial obstruction and atelectasis. Personal experience in 6 cases of atelectasis following cesarean section is reported.

Renal adaptive mechanisms in aged and hypertensive humans: possible effects of treatment

BACKGROUND

In the aging kidney renal blood flow and glomerular filtration rate are reduced due to glomerulosclerosis. On this regard, hypertension has synergistic effects and may lead to end-stage renal disease in a significant proportion of cases.

MATERIAL AND METHODS

To study the effects of antihypertensive drugs in an acute setting, we expressly designed an acute experiment to assess the renal response to mental stress (MS). In healthy elderly, the response was characterized by a prolonged and pronounced renal vasoconstriction, due to a reduction in renal autacoid modulatory capacity, particularly of prostaglandins. In older patients with isolated systolic hypertension, the response to MS was impaired, being characterized by a passive vasodilation with hyperfiltration. The effects of antihypertensive drugs were evaluated twice in adults patients with mild to moderate essential hypertension: after two weeks of pharmacological wash-out and after two weeks of treatment with the ACE-inhibitor trandolapril (4 mg), or the non-dihydropyridinic Ca2+ channel blocker verapamil (240 mg), or both (2 mg + 180 mg).

RESULTS

While the three antihypertensive regimens reduced blood pressure to a similar extent, their effects on the renal response to MS were different. Each regimen re-established a renal vasoconstrictive response to adrenergic activation. However, with trandolapril, renal vasoconstriction was limited, as it occurs physiologically, to the period of blood pressure rise, while verapamil, or the combination of the two drugs, were associated with more prolonged vasoconstriction.

CONCLUSIONS

Further studies are needed to confirm the nephroprotective effects of these drugs, particularly of ACE-inhibitors. These data may be a pathophysiological basis for future clinical trials.

Soluble Jagged 1 represses the function of its transmembrane form to induce the formation of the Src-dependent chord-like phenotype

We have previously demonstrated that the expression of the soluble extracellular domain of the transmembrane ligand for Notch receptors, Jagged 1 (sJ1), in NIH 3T3 cells results in the formation of a matrix-dependent chord-like phenotype, the loss of contact inhibition of growth, and an inhibition of pro-alpha 1(I) collagen expression. In an effort to define the mechanism by which sJ1 induces this phenotype, we report that sJ1 transfectants display biochemical and cytoskeletal alterations consistent with the activation of Src. Indeed, cotransfection of sJ1 transfectants with a dominant-negative mutant of Src resulted in the loss of matrix-dependent chord formation and correlated with the restoration of type I collagen expression and contact inhibition of growth. We also report that the sJ1-mediated induction of Src activity and related phenotypes, including chord formation, may result from the inhibition of endogenous Jagged 1-mediated Notch signaling since it was not possible to detect an sJ1-dependent induction of CSL-dependent transcription in these cells. Interestingly, NIH 3T3 cells transfected with dominant-negative (but not constitutively active) mutants of either Notch 1 or Notch 2 displayed a similar Src-related phenotype as the sJ1 transfectants. These data suggest that the ability of sJ1 to mediate chord formation is Src-dependent and requires the repression of endogenous Jagged 1-mediated Notch signaling, which is tolerant to the destabilization of the actin cytoskeleton, a mediator of cell migration.

Changes in renal autacoids in aged human hypertensives

The aging process determines several modifications of the kidney, that, however, do not provoke any dysfunction in normal conditions. But in the elderly--in the presence of stressful situations and particularly when adrenergic activation is present--the kidney is more vulnerable than in the young, and renal failure may arise. Variations typical of the aging kidney are accelerated when hypertension overlaps the physiological renal process, because both senescence and hypertension weight on the same structures, i.e. glomeruli. We studied renal hemodynamic adaptation capacity both in the healthy elderly and in patients affected by isolated systolic hypertension, in an acute experiment which requires the application of a mental stress-induced adrenergic activation. In hypertensive patients we have already demonstrated a total lack of renal adaptation capacity. In fact, while the elderly normotensives react with a prolonged and pronounced vasoconstriction, in those with isolated systolic hypertension, adrenergic activation induces a passive renal vasodilation and glomerular hyperfiltration. The anomalous adaptation capacity of renal hemodynamics is probably due to an impairment in the paracrine response of renal vasculature. Indeed in the hypertensive elderly, unlike in the normotensive one, no variations of autacoid production occur during the adrenergic activation. Following on from this, pattients affected by isolated systolic hypertension passively suffer the many hypertensive peaks which characterize their every day life. The altered renal autoregulation of the elderly with isolated systolic hypertension may explain the accelerated glomerulosclerosis and the greater incidence of renal damage and end-stage renal disease which characterize this condition. These aspects underline the primary role of the antihypertensive treatment of isolated systolic hypertension, not only for the prevention of cardiovascular mortality but also of renal damage and/or end-stage renal disease.

Changes in renal autacoids and hemodynamics associated with aging and isolated systolic hypertension

The aging kidney is characterized by a decrease in renal blood flow and glomerular filtration rate mainly due to glomerulosclerosis. Nevertheless, even in the presence of these changes, the kidney maintains its functionality until advanced age. However, there is a tendency towards greater renal vasoconstriction in the elderly as compared with young individuals. This occurs either in physiological circumstances such as physical exercise, or in disease manifestations, such as the effective circulatory volume depletion that develops, for example, in heart failure. This tendency may be secondary to the reduction of renal autacoid modulatory capacity, particularly at the vasodilating prostaglandin level. In an acute experimental model we could demonstrate that, in the healthy elderly, the renal response to adrenergic activation by mental stress is characterized by a prolonged and pronounced vasoconstriction. In addition to this, in elderly patients affected by isolated systolic hypertension, we demonstrated an impairment of renal hemodynamic and humoral adaptation capacity in response to adrenergic activation and blood pressure increase. In the presence of sudden blood pressure increase, the kidney of these patients responds with a passive vasodilation and a glomerular filtration rate increase without any activation of humoral modulatory substances. The impairment in renal adaptation capacity may predispose these patients to renal injury, particularly in the presence of the many hypertensive peaks which characterize everyday life of elderly individuals. In conclusion, these results show that renal adaptation capacity of elderly patients with isolated systolic hypertension is completely lost. Further studies will elucidate whether antihypertensive treatment per se, or specific classes of antihypertensive drugs, are able to revert this impairment.

Impaired renal adaptation to stress in the elderly with isolated systolic hypertension

The aim of this study was to evaluate the renal response in the elderly with isolated systolic hypertension (ISH) when an adrenergic activation, as induced by mental stress, is applied. Renal hemodynamics and kidney neurohumoral response to mental stress were studied in 8 elderly patients with ISH (aged 63 to 82 years) along with 8 elderly normotensive subjects. The study encompassed four 30-minute experimental periods (baseline, mental stress, and recovery I and II). In these patients, the mental stress-induced blood pressure rise was associated with a significant increase in both effective renal plasma flow ((131)I-labeled hippurate clearance) and glomerular filtration rate ((125)I-labeled iothalamate clearance) (+42% and +29%, respectively; P<0.01 for both), without variations in filtration fraction, while elderly normotensives reacted to adrenergic stimulation with renal vasoconstriction but with the glomerular filtration rate constant. Variations in renal vasoactive substances, which paralleled hemodynamics of the kidney, differed in the 2 groups. In normotensives, excretion (radioimmunoassay) of endothelin-1, prostaglandin E(2), and cGMP increased during the stimulus (+50%, +54%, and +59%, respectively; P<0.05). In ISH patients the release of these autacoids did not vary in any of the experimental periods. In conclusion, in patients with ISH the renal adaptive capacity to sympathetic activation is impaired, and the data may suggest that the glomerulus passively suffers the blood pressure increase, probably because of the insufficiency of the neurohumoral response, particularly in regard to the increase of endothelin-1. This hemodynamic pattern may predispose ISH patients to a higher risk of renal injury.

Successful outcome of pregnancy in a thyroidectomized-parathyroidectomized young woman affected by severe hypothyroidism

Severe hypothyroidism was discovered in a young woman in her 29th week of pregnancy. Previously, at the age of 12 years, she had undergone thyroid surgery for Graves' disease that resulted in persistent hypothyroidism and hypoparathyroidism. After surgical excision, the patient started levothyroxine replacement therapy and had regular control of thyroid function with normal findings throughout the years. The dose of levothyroxine had not been adjusted when the pregnancy started, and at the 29th week of gestation the patient had a thyrotropin (TSH) of 72.4 microU/mL. Ultrasound studies were performed in order to monitor fetal development. The fetal parameters analyzed before the adjustment of levothyroxine therapy showed growth retardation of various degrees. All analyzed fetal parameters (biparietal diameter, cranial and abdominal circumference, humerus and femur length) improved during the last 6 weeks of gestation, showing a good correlation with the newly achieved euthyroid state of the mother. The infant was clinically euthyroid at birth and was found normal at all evaluations of the neonatal hypothyroidism screening program (1, 5, 30 days).

Excessive vasoconstriction after stress by the aging kidney: inadequate prostaglandin modulation of increased endothelin activity

The adaptive capacity of the aging kidney to stimulation of the sympathetic nervous system, as induced by a 30-minute mental stress (MS), was assessed in 8 elderly healthy women (68 to 82 years of age) and compared with that of 8 younger women (24 to 40 years of age). The study encompassed 4 consecutive 30-minute periods (baseline, mental stress, recovery 1, and recovery 2). In the elderly subjects, baseline effective renal plasma flow (ERPF)(iodine 131-labeled hippurate clearance) was lower and glomerular filtration rate (GFR)(iodine 125-labeled iothalamate clearance) was proportionally less reduced than in the younger group; the filtration fraction (FF) was higher. The elderly group excreted more endothelin 1 (ET-1) (P < .05), prostaglandin E2 (PGE2), and 6-keto-prostaglandin F1alpha (6-keto PGF1alpha)(P < .001 for both)(radioimmunoassay). Mental stress induced similar increases in blood pressure, heart rate, and plasma catecholamines in the 2 age groups, limited to the stimulation period. In the elderly group, mental stress caused a prolonged decrease in ERPF that reached its maximum 60 minutes after mental stress (-33%, P < .05), while GFR remained constant during the whole experiment, so that FF increased. In the younger subjects, renal hemodynamic changes were limited to the mental stress period. ET-1 increased during mental stress and the first recovery period in the elderly group (+50% and +25%, P < .05) as it did in the younger group, but the elderly group differed from the younger in that vasodilating prostaglandins increased only during mental stress. In conclusion, the aging kidney reacts to adrenergic stimulation with more-pronounced and -prolonged vasoconstriction that is probably caused by a defect in prostaglandin modulation of endothelin activity. Autoregulation of GFR is maintained at the expense of increased intraglomerular pressure.

Renal adaptation to stress: a possible role of endothelin release and prostaglandin modulation in the human subject

The aim of this study was to define the neurohumoral response associated with the renal hemodynamic perturbations induced by mental stress acting as an adrenergic stimulus. In 8 healthy women, the effects of mental stress were studied during four consecutive 30-minute periods (baseline, mental stress, recovery I, recovery II). Mental stress induced sympathetic activation as evidenced by increases in blood pressure, heart rate, and plasma norepinephrine level. Effective renal plasma flow (iodine 131-labeled hippurate clearance) decreased only during mental stress (-22%, p < 0.05 vs baseline); glomerular filtration rate (iodine 125-labeled iotalamate clearance) remained constant during the entire experiment; the filtration fraction increased significantly during mental stress and recovery I (+30% and +22%, respectively, p < 0.02 for both). Complex neuroendocrine responses were associated with the hemodynamic changes. Urinary excretion of endothelin-1 and 6-keto-PGF(1alpha) increased during mental stress (+53%, p < 0.01, and +20%, p < 0.01, respectively) and recovery I (+49% and +29%, respectively, p < 0.01 for both). Urinary cyclic guanosine monophosphate rose only during mental stress (+77%, p < 0.05), whereas excretion of PGE2 showed a stepwise increase throughout recovery I and II (+292%, p < 0.01, and +360%, p < 0.001, respectively). In conclusion, the present experiments demonstrate that renal hemodynamic response induced by mental stress is a complex reaction in which endothelin-1, prostaglandins, and presumably nitric oxide take part.

Increased renal formation of thromboxane A2 and prostaglandin F2 alpha in heart failure

Renal formation of the vasoconstrictor prostaglandins thromboxane A2 (TXA2) and prostaglandin F2 alpha (PGF2 alpha) was investigated in 25 patients with cardiac failure, divided into New York Heart Association functional classes I to IV, and in eight healthy control subjects. Plasma renin activity (PRA) and hemodynamic parameters were also investigated. Renal vasoconstrictor eicosanoid formation, measured in urinary daily excretion, was not different between patients in class I and control subjects. Class II to IV patients showed progressively increasing production of PGF2 alpha (F = 49.8, p < 0.001, analysis of variance) and TXA2 (F = 37.8, p < 0.002). PGF2 alpha excretion peaked in class IV (+ 1266% vs class I, p < 0.001). Compared with class I, urinary excretion of thromboxane B2 was + 816% in class III and + 1561% in class IV (both p < 0.001). PRA was significantly increased only in class IV (+ 1558%, p < 0.001). The current results indicate a progressive increase in renal production of vasoconstrictor eicosanoids directly related to New York Heart Association class and suggest that these prostanoids may have a role in deterioration of renal function.

The protective impact of a covariate on competing failures with an example from a bone marrow transplantation study

Starting from an applied Bone Marrow Transplantation (BMT) study, the problem of "unexpected protectivity" in competing risks models is introduced, which occurs when one covariate shows a protective impact not expected from a medical perspective. Current explanations found in the statistical literature suggest that unexpected protectivity might be due to the lack of independence between the competing failures. Actually, in the presence of dependence, the Kaplan-Meier curves are not interpretable. Conversely, the cumulative incidence curves remain interpretable, and therefore seem to be a candidate for solving the problem. We discuss the particular nature of dependence in a competing risks framework and illustrate how this dependence may be created via a common frailty factor. A Monte Carlo experiment is set up which accounts also for the association between the observable covariates and the frailty factor. The aim of the experiment is to understand whether and how the bias showed by the estimates could be related to the omitted frailty variable. The results show that dependence alone does not cause false protectivity, and that the cumulative incidence curves suffer the same bias as the survival curves and therefore do not seem to be a solution to false protectivity. Conversely, false protectivity may occur according to the magnitude and the sign of the dependence between the frailty factor and the covariate. The paper ends with some suggestions for empirical research.

Family needs after traumatic brain injury: a factor analytic study of the Family Needs Questionnaire

The present investigation examined the empirical and theoretical validity of an instrument developed to assess family members' perceptions of needs following the brain injury of a relative. The Family Needs Questionnaire (FNQ) consists of 40 items reflecting commonly reported family needs. The development of the items was based on the literature describing family reactions to brain injury and other medical disabilities. A principal-components factor analysis was executed based on the FNQ responses of 178 family members. A six-factor solution was selection as the best fit for the data, yielding the following independent subscales: (1) Need for Health Information; (2) Need for Emotional Support; (3) Need for Instrumental Support; (4) Need for Professional Support; (5) Need for a Support Network; and (6) Need for Involvement with Care. Further analysis indicated at least adequate internal reliability for each scale. Overall, the measure appears to offer unique information relevant to family members' needs after brain injury.

Validation of a neurobehavioral functioning inventory for adults with traumatic brain injury

OBJECTIVE

To examine the validity of a neurobehavioral inventory for adults with traumatic brain injury.

DESIGN

Construct validity was examined by applying principal components and confirmatory factor analytic procedures. Internal consistency of factors was examined using Cronbach's alpha. Criterion-related validity was examined by comparing inventory scale scores with neuropsychological and personality test variables.

SETTINGS

Medical center outpatient clinic.

PARTICIPANTS

520 consecutive adult patients with traumatic brain injury were administered psychological and neuropsychological tests; 520 informants, primarily family members, completed the neurobehavioral inventory.

MAIN OUTCOME MEASURE

Neurobehavioral inventory with items describing symptoms and daily living problems; scale scores were compared with a set of neuropsychological measures and Minnesota Multiphasic Personality Inventory scores.

RESULTS

Principal components and confirmatory factor analytic procedures identified six scales with a total of 70 items. The primary scale inclusion criterion required a minimum factor loading of .40. Chronbach's alpha analysis revealed acceptably high internal reliability for all scales ranging from .86 to .95. Scale scores were statistically compared with patients' scores on neuropsychological and personality tests. Poor neuropsychological test performance and greater levels of psychopathology were associated with greater frequency of perceived neurobehavioral problems.

CONCLUSIONS

Findings suggest that the neurobehavioral inventory is a promising means of investigating informants' perceptions of outpatients' everyday problems. Such information can serve as a complement to historical information, test results, and information from standardized interviews to develop a holistic perspective of patients. Differential weighting of items, association of scales with other measures, and validation with other neurological patient populations are recommended avenues for future research.

Molecular characterization of rhizosphere and clinical isolates of Burkholderia cepacia

Four Burkholderia cepacia strains isolated from the rhizosphere and pathological samples of infected human patients were characterized at the molecular level by different methodologies, including the determination of 16S ribosomal rDNA sequence, restriction endonuclease analysis of total DNA, random amplified polymorphic DNA fingerprinting and Southern hybridization with gene probes for nitrogen fixation and siderophore synthesis. The results indicate that the four strains cluster together within genus Burkholderia, but differ from one another. The DNA from the four strains hybridized to the nifA gene probe from Klebsiella pneumoniae, and an appreciable homology with the nifHDK structural genes of Azospirillum brasilense was demonstrated for one rhizosphere strain. Although the four isolates produced an ornibactin-like siderophore, they did not give hybridization with the pvdA probe for hydroxamate biosynthesis from Pseudomonas aeruginosa.

Identification of Azospirillum strains by restriction fragment length polymorphism of the 16S rDNA and of the histidine operon

DNA fingerprints of several Azospirillum strains, belonging to the five known species A. amazonense, A. brasilense, A. halopraeferens, A. irakense and A. lipoferum, were obtained by restriction analysis of the amplified 16S rDNA and by restriction fragment length polymorphism of the histidine biosynthetic genes. Data obtained showed that amplified rDNA restriction analysis is an easy, fast, reproducible and reliable tool for identification of Azospirillum strains, mainly at the species level, whereas restriction fragment length polymorphism could, in some cases, differentiate strains belonging to the same species. Moreover, both analyses gave congruent results in grouping strains and in the assignment of new strains to a given species.

Use of random amplified polymorphic DNA (RAPD) for generating specific DNA probes for microorganisms

We report the rapid generation of DNA probes for several Azospirillum strains. This method does not require any knowledge of the genetics and/or the molecular biology of the organism (genome) to be investigated. The procedure is based on the generation of random amplified polymorphic DNA (RAPD) fingerprints using primers with an embedded restriction site. The amplification product(s) peculiar to one strain or common to two or more strains can be purified, cloned, sequenced and used as molecular probes in hybridization experiments for the detection and identification of microorganisms. We have tested this methodology in the nitrogen-fixing bacterium Azospirillum by amplyfing the total DNA extracted from several Azospirillum strains. We have used amplification bands with different specificity as molecular probes in hybridization experiments performed on amplified DNA. Results obtained have demonstrated the usefulness of this methodology for Azospirillum. Its use in microbial ecology studies as a general strategy to generate specific DNA probes is also discussed.

[The role of prolactin in endometrial lesions]

The Authors examine serum levels of HPRL in basal conditions and after TRH and sulpiride test in 15 patients with endometrial lesions (hyperplasia) and in 15 patients with endometrial adenocarcinoma included in a age range between 44 and 62 years, in which 7 patients present obesity, 10 patients present hypertension and 2 patients are hyperglycemic. The same examination is carried out in a control group of 30 healthy patients. Then the 15 patients with adenocarcinoma and 3 patients with adenomatosa hyperplasia are subjected to surgery and they estimate HPRL levels in endometrium. The results prove that there is no correlation between HPRL plasma levels and endometrium lesions and between endometrium HPRL. The Authors conclude that HPRL does not play a significant role in the pathogenesis of endometrial lesions; use of HPRL plasma levels as a marker of endometrial lesions is not possible.

[Endometrial carcinoma with simultaneous endometrioid carcinoma of the ovary. Report of two clinical cases]

The paper reports two cases of simultaneous endometrial carcinoma and endometrioid carcinoma of the ovary. The clinical and pathological characteristics are examined. Both patients underwent radical surgery with an intraoperative examination for metastatic involvement of the lumbo-aortic, iliac and infundibulo-ovarian lymphonodes. Surgery was followed by antiblastic (cisplatin, adriamycin, cyclophosphamide), hormonal (progestogens) and immuno-modulating (thymostimulin treatment). The two patients (respectively approximately 10 and 7 years after the operation) both enjoy good health.

[Carcinoma of the vulva. Report of a case originating from Bartholin's gland]

A case of vulvar carcinoma arising from Bartholin's gland is described. At admission the patient showed a large suppurated swelling of the left labium maior. The neoformation reached the groin of the same side. Malignant cells were detected in biopsy specimens of both the vulvar swelling and the lymphonodes. The histological test showed a vulvar carcinoma arising from Bartholin's gland. The vulvar swelling and the ulcerated lesion were removed and the patient was treated with radiotherapy, chemotherapy (bleomicina) and immunomodulant therapy (Timostimoline). Pulmonary methastases were detected eighteen months after the operation and the patient died two years later.

[Ascites and carcinoma of the endometrium]

The authors exopound three cases of women affected by endometrial carcinoma in which the ascithis has represented the first clinic manifestation in absence of metrorrhage (first two cases); in the third case, instead, the ascithis has appeared four years after the surgical operation of total laparohysterectomy with bilateral annexiectomy and telecobaltotherapy. The association of the malign ascithis with endometrial adenocarcinoma is of rare observation. The Authors think very likely that the intraperitoneal semination in the cases they examined, is due to the infiltration of the myometry, of the regional and iuxtaregional lymphonoids with formation of ascithis.

[Correlation of carcinoembryonic antigen (CEA) and serum and tissue alpha-fetoprotein (AFP) in malignant tumors of the female genital tract]

The Authors have carried out determinations of AFP in the serum and of CEA in serum and in surgically removed tissue of 67 patients with genital tract's malignant tumors. As the results obtained among values of pre and post operatory CEA and tissue concentrations are incongruous, they believe useful, within the monitoring of patients with gynecological cancer, dosing CEA in the serum and also on the surgical section trying to reduce so the minimum positive false and negative false. Finally the repeated dosage of these antigens allows to follow the local replaced or the metastasis after some month, before the symptoms are clear.

Laparoscopy for screening and early diagnosis of ovarian cancer

Authors examined validity of laparoscopy for early diagnosis of ovarian cancer. They studied 144 cases of patients with benign neoplasia diagnosed by clinical examination and found ten cases of ovarian cancer by laparoscopy. They point out validity of laparoscopy indicated as a present day essential technique for early diagnosis of ovarian cancer.