Diogenes syndrome in dementia: a case report

BACKGROUND

Diogenes syndrome is a neurobehavioural syndrome characterised by domestic squalor, hoarding and lack of insight. It is an uncommon but high-mortality condition, often associated with dementia.

AIMS

To describe the clinical features and treatment of Diogenes syndrome secondary to behavioural variant frontotemporal dementia (bvFTD).

METHOD

We describe a case of bvFTD in a 77-year-old man presenting with Diogenes syndrome.

RESULTS

The patient's medical and psychiatric histories were unremarkable, but in recent years he had begun packing his flat with 'art pieces'. Mental state examination revealed confabulation and more structured delusions. Neuropsychological evaluation outlined an impairment in selective attention and letter verbal fluency, but no semantic impairment, in the context of an overall preserved mental functioning. Brain magnetic resonance imaging and positron emission tomography (PET) with fluorodeoxyglucose showed mild bilateral temporo-insular atrophy and hypometabolism in the left-superior temporal gyrus respectively. An amyloid PET scan and genetic analysis covering the dementia spectrum were normal. A diagnosis of bvFTD was made.

CONCLUSIONS

The clinical framing of behavioural symptoms of dementia such as hoarding poses a diagnostic challenge. This case illustrates the importance of a deeper understanding of Diogenes syndrome, leading to timelier diagnosis and effective therapeutic strategies.

A randomized single-blind placebo-controlled study of a Visnadine Emulgel formulation on healthy postmenopausal women

BACKGROUND

There is a growing interest on women' sexual function improvement provided by topical vulvar application of Visnadine, a natural extractive substance with putative vasodilatory properties. Aims of this study were to evaluate: 1) the vasokinetic activity of a Visnadine Emulgel on mucosal genitalia of 15 healthy postmenopausal women clinically and by instrumental non-invasive analysis; 2) the treatment efficacy by volunteers' judgment regarding to subjective comfort, pleasant warmth, lubrication grade, pinching and burning vulvar sensations.

METHODS

Fifteen informed healthy female volunteers with menopause were enrolled in the study, with a single blind controlled study versus placebo corresponding to one single application of the emulgel product (active or placebo) on external genitalia.

RESULTS

Visnadine Emulgel single application determined a significant increase of vulvar hyperemia, evaluated both clinically and instrumentally, accompanied by a significant increase of local turgor versus placebo. The volunteers reported a pleasant comfort sensation.

CONCLUSIONS

The topical use of Visnadine on female external genitalia may increase regional vascularization affecting turgidity and sensorial threshold of the area of application.

Behaviour disorder caused by Cushing's syndrome in an older person

An 81-year-old woman was hospitalised for behavioural disorders that had been progressively emerging over a period of few weeks. The symptoms appeared to worsen over time. A diagnosis of vascular dementia, complicated by psychosis, was initially hypothesised. The inefficacy of the antipsychotic/benzodiazepine medications used, along with the presence of hypertension, hypokalaemia and metabolic alkalosis (resistant to pharmacological attempts of correction), as well as the hirsutism and the development of several infections, led us to consider Cushing's syndrome. Endocrinological analysis suggested ectopic adrenocorticotropic hormone (ACTH) secretion. Although endogenous Cushing's syndrome is rare in older people, it should always be considered among the differential diagnosis of behavioural disorders.

Effectiveness of Erythrocytapheresis in Idiopathic Hemochromatosis. Report of 14 Cases

Thirteen men and one woman (mean age 48.8 yr ± 6.9, range 36–63) with idiopathic hemochromatosis were treated by erythrocytapheresis. Iron depletion followed 9–60 months treatment (median 24), with 21–203 erythrocytaphereses (mean 93 ± 61) and total iron removal of 4.2–40. 6 g (mean 19 ± 11.9). Trasferrin saturation decreased from 90 ± 8.7% to 17 ± 10.6% and serum ferritin from 3164 μg/L ± 1488 to 60.5 μg/L ± 77.5, and liver iron content normalized in all cases. Initial serum ferritin in the patients who were iron-depleted at 18 months (50%, cumulative percentage) was significantly lower than in those still iron loaded at that time (2280 μg/L ± 940 vs 4049 μg/L ± 1444, p<0.02). Clinical improvement was noted in all cases with about a 30% decrease in insulin requirement in most diabetics. Thus erythrocytapheresis appears to be effettive and safe in obtaining iron depletion in idiopathic hemochromatosis.

Early ficolin-1 is a sensitive prognostic marker for functional outcome in ischemic stroke

BACKGROUND

Several lines of evidence support the involvement of the lectin pathway of complement (LP) in the pathogenesis of acute ischemic stroke. The aim of this multicenter observational study was to assess the prognostic value of different circulating LP initiators in acute stroke.

METHODS

Plasma levels of the LP initiators ficolin-1, -2, and -3 and mannose-binding lectin (MBL) were measured in 80 stroke patients at 6 h only and in 85 patients at 48 h and later. Sixty-one age- and sex-matched healthy individuals served as controls. Stroke severity was measured on admission using the National Institutes of Health Stroke Scale (NIHSS). The outcome was measured at 90 days by the modified Rankin Scale (mRS).

RESULTS

Ficolin-1 was decreased in patients compared with controls measured at 6 h (median 0.13 vs 0.33 μg/ml, respectively, p < 0.0001). At 48 h, ficolin-1 was significantly higher (0.45 μg/ml, p < 0.0001) compared to the 6 h samples and to controls. Likewise, ficolin-2 was decreased at 6 h (2.70 vs 4.40 μg/ml, p < 0.0001) but not at 48 h. Ficolin-3 was decreased both at 6 and 48 h (17.3 and 18.23 vs 21.5 μg/ml, p < 0.001 and <0.05, respectively). For MBL no difference was detected between patients and controls or within patients at the different time points. In multivariate analysis, early ficolin-1 was independently associated with unfavorable mRS outcome (adjusted odds ratio (OR): 2.21, confidence interval (CI) 95 % 1.11-4.39, p = 0.023). Early ficolin-1 improved the discriminating ability of an outcome model including NIHSS and age (area under the curve (AUC) 0.95, CI 95 % 0.90-0.99, p = 0.0001).

CONCLUSIONS

The ficolins are consumed within 6 h after stroke implicating activation of the LP. Early ficolin-1 is selectively related to 3-month unfavorable outcome.

Exposure of the petrous segment of the internal carotid artery through the extradural subtemporal middle cranial fossa approach: a systematic anatomical study

The relationships between the horizontal segment of the internal carotid artery (ICA) and other petrous apex structures was studied in 14 anatomical specimens obtained from routine autopsies and on 10 magnetic resonance images obtained from healthy volunteers. The dissection was performed under an operating microscope using the middle fossa transpetrous approach. A pentagonshaped area of 67.91 mm(2) posterior to the trigeminal nerve and bordered by anatomical structures was identified inside the petrous apex. The results suggest a method for exposing the ICA when the artery is not visible after dural elevation.

A spontaneous decrease of blood pressure occurs in acute ischemic stroke with favourable neurological course

BACKGROUND

In the acute phase of ischemic stroke the relationship between blood pressure (BP) and clinical outcome remains not clear. The aim of our study was to evaluate the association of stroke severity and BP measurements in the acute phase of stroke, and whether early variation of neurological status affects BP profiles.

METHODS

BP on admission was obtained with mercurial sphygmomanometer and 24h-ambulatory BP monitoring (ABPM) was performed on days 1(st) and 6(th). Enrolled patient were grouped according to the neurological deficit at onset (graded by the NIHSS) in group A, (NIHSS score ≤ 10, mild/moderate) and group B (NIHSS score > 10, moderate/severe) and according to the occurrence of early neurological improvement, defined as a NIHSS score reduction of at least 4 points at the 6(th) day in group C (improved) and in group D (not improved).

RESULTS

A total of 57 patients were enrolled. On admission sphygmomanometric systolic BP values were higher in group A with respect to group B (158,5 mmHg ± 26,9 vs 147,7 mmHg ± 15,5 respectively; p = 0.6) whereas no difference was found in ABPM. On admission sphygmomanometric BP and ABPM were similar in group C and group D. At the 6(th) day ABPM, both systolic BP and diastolic BP values were significantly reduced in clinically improved patients (Δ systolic BP 1(st) to 6(th) day = 9,9±13,3 in group C vs 0,5±17,6 in group D, p < 0,05; Δ diastolic BP 1(st) to 6(th) day = 5,1± 8,4 mmHg in group C vs 1,3 ± 9,7 mmHg in group D, p = ns) whereas no change in the 24-h BP profile was observed in patients without early improvement.

CONCLUSION

BP on admission in not related to the stroke severity and does not predict early neurological outcome and patients that show an early neurological improvement show also a reduction of the BP profile.

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region

The partial labyrinthectomy petrous apicectomy (PLPA) approach is a transpetrous route that provides the advantages of the labyrinthine removal but with hearing preservation. Using seven temporal bone tissue blocks and three formaldehyde-fixed cadaveric heads we have made a morphometric and comparative study on this approach that summarizes the invasiveness, the optimal surgical exposure, the anatomic complexity of the skull base approaches and, on the other hand, the spirit of preservation that is the constant aim of modern neurosurgery. The morphometric analysis is designed to make the bony phase of the PLPA approach safer and to define the relationship between petrous landmarks. The comparative study is made between the PLPA and other neurosurgical routes enhancing the potentiality of the PLPA approach that permits a wider angle of incidence towards the brainstem than with the retrosigmoid routes.

Minor stroke and major vascular occlusion. A case report

Occlusion of middle cerebral artery (MCA) is generally associated to severe stroke and poor prognosis; however a few patients with mild to moderate presentation and long-term reversibility of neurological deficits have been reported. A 66-year-old male presented with left-side weakness and dysarthria (NIHSS score 7), which progressively resolved within a few days; ischaemic lesion of the anterior arm of the right internal capsule was found at brain CT obtained 72 h after presentation. Transcranial Colour Doppler showed absence of flow of the right MCA. Cerebral angiography showed occlusion of the right MCA that was retrogradely revascularised by leptomeningeal collaterals. Non-invasive intracranial vascular examinations could identify major intracranial artery lesions in patients who present with mild to moderate stroke symptoms. These patients could be identified and followed to clarify their best treatment and prognosis.

Vertebral arterio-venous fistula presenting with intracranial hemorrhage

Vertebral arteriovenous fistulas are rare lesions consisting of an abnormal shunt between the extracranial vertebral artery and the neighboring veins. The authors present a case of post-surgical high-flow left vertebral arteriovenous fistula presenting with intracranial hemorrhage. The patient underwent endovascular balloon occlusion of the fistula: after endovascular treatment a reduction of the flow was evident but the patient presented neurological deterioration related the occurrence of intraventricular-subarachnoid hemorrhage. Intracranial hemorrhage is a potential manifestation of high-flow vertebral AVF and a possible complication of endovascular fistula balloon occlusion. Direct endovascular occlusion of the vertebral artery may be primarily considered in selected cases.

Gastroduodenal lesions in polycythaemia vera: frequency and role of Helicobacter pylori

The prevalence of gastroduodenal lesions is higher in polycythaemia vera (PV) than in the general population. However, the role of Helicobacter pylori (H. pylori) in the pathogenesis of such lesions is unknown. The aim of our study was to evaluate the prevalence of gastroduodenal lesions in PV patients and dyspeptic controls, and to assess the role of PV and H. pylori infection in inducing them. Thirty-five PV patients fulfilling selection criteria and 73 age- and sex-matched controls underwent upper gastrointestinal endoscopy. Six gastric mucosal biopsies were taken in all patients and controls, and analysed for presence of H. pylori; serum anti-CagA was assayed by Western blot. Data were analysed with descriptive statistics and multivariate regression analysis. Compared with controls, PV patients showed a significantly higher frequency of erosions (46% versus 12%), ulcers (29% versus 7%), H. pylori positivity (83% versus 57%), and anti-CagA positivity (66% versus 37%). Fourteen out of 20 (70%) asymptomatic PV patients had gastroduodenal lesions. At multivariate analysis, H. pylori, presence of PV alone, and both PV and anti-CagA were significantly and strongly associated with a higher frequency of gastroduodenal lesions (P < 0.05, P < 0.01 and P < 0.05 respectively). Both PV and H. pylori infection were independent risk factors for gastroduodenal lesions; the underlying pathogenetic mechanism responsible for gastroduodenal lesions in PV possibly involves blood mucosal flow and trophism. The higher susceptibility of H. pylori infection and the high frequency of asymptomatic gastroduodenal lesions in PV patients suggest a surveillance of these patients.

Surgical excision of clival tumors via the enlarged transcochlear approach. Indications and results

BACKGROUND

The results of the surgical resection of 9 clival tumors using the enlarged transcochlear approach (ETCA) are evaluated. The literature is reviewed to compare the ETCA with other approaches to the clival and petroclival region; the surgical indications are discussed.

METHODS

Between June 1996 and June 1997, 9 patients were operated on through the ETCA either alone or combined with other approaches. Only meningiomas and chordomas with a significant involvement of the clivus and huge extension into the posterior fossa were included into this study.

RESULTS

Gross total tumor removal was achieved in 5 cases and in 4 cases a residual meningioma was left in place inside the cavernous sinus and treated by radiosurgery. No postoperative mortality or major neurological morbidity were recorded. The postoperative facial nerve function was good in 75% of cases. No tumor recurrence was recorded (mean follow-up = 45.9 months).

CONCLUSIONS

The indications to the ETCA should be as strict as possible. The ETCA is an effective procedure in the treatment of large clivopetrous tumors. Tumor characteristics like consistency, vascularity, encasements of vertebro-basilar vessels, bone erosion and previous surgery are also indicative. The transient postoperative facial nerve palsy and deafness should be considered as major disadvantages related to this approach.

Desmopressin stimulation test before and after pituitary surgery in patients with Cushing's disease

OBJECTIVE

The desmopressin test has been proposed as a useful tool for the differential diagnosis of Cushing's disease. The aim of our study was to investigate, in a large series of patients with Cushing's disease, the incidence of a positive ACTH and cortisol response to desmopressin. Moreover, we repeated the test soon after surgery to verify its usefulness in the assessment of early and late surgical results.

PATIENTS AND METHODS

One hundred and seven consecutive patients with Cushing's disease, 89 female and 18 male patients, with a mean age of 37.2 +/- 1.3 years, were studied. All patients, except three, repeated the test 5-6 days after surgery. Desmopressin (10 microg) was injected i.v. and blood samples were drawn 15, 30, 45 and 60 minutes thereafter. Plasma ACTH and serum cortisol were measured in duplicate by commercially available immunoassays. A positive response to desmopressin was considered to be a plasma ACTH and serum cortisol increment of at least 30% and 20% above baseline, respectively.

RESULTS

Mean basal plasma ACTH level was 17.3 +/- 1.7 pmol/l and rose to a peak level of 42.7 +/- 4.9 pmol/l at 15 minutes Mean basal serum cortisol level was 574 +/- 19 nmol/l and rose to a peak level of 814 +/- 28 nmol/l at 45 minutes. ACTH and cortisol incremental changes were inversely correlated with their respective basal levels. Ninety patients (84.1%) had an ACTH and 84 patients (78.5%) had a cortisol response to desmopressin. Several clinical and demographic characteristics were not significantly different among desmopressin responders and non responders, except that basal ACTH and cortisol levels were significantly higher in desmopressin non responders (27.2 +/- 8.3 pmol/l, 781 +/- 86 nmol/l) than in desmopressin responders (15.4 +/- 1.2 pmol/l, 535 +/- 14 nmol/l). Disappearance of the ACTH and cortisol response to desmopressin after surgery occurred in 50 of 87 (57%) ACTH responders and in 57 of 81 (70.4%) cortisol responders, respectively. However, concordance between the desmopressin test and surgical outcome was not complete. Indeed, 18 patients considered in remission still showed an ACTH increase after desmopressin and, on the contrary, four patients with disappearance of the ACTH response had persistence of hypercortisolism. During follow-up monitoring, three patients, who had persistence of the ACTH response to desmopressin, relapsed 24, 38 and 54 months after surgery.

CONCLUSIONS

Desmopressin administration elicits a significant rise in ACTH and cortisol levels in the majority but not all patients with Cushing's disease. There is a good, but not complete, concordance between the response to the desmopressin test and the surgical outcome. Our preliminary data show that persistence of the ACTH response to desmopressin in the early postoperative period might be associated with a higher risk of late relapse.

Chondrosarcoma of the thoracic spine: total en bloc sagittal resection. A case report

Chondrosarcomas located in the spine are uncommon tumors and are challenging to manage. A case of a 65-year-old man with a T3-T4 spine chondrosarcoma is reported. The onset of symptoms consisted in progressive dorsal pain with sometimes a girdle-like radiation and, successively, in dysaesthesia and paresthesia from the lower limbs to the thoracic region. After preoperative oncologic and surgical planning the patient underwent a total en bloc resection of the mass. No postoperative adjunctive neurological deficits were recorded. An adjuvant radiation therapy with a dose of 5.500 centigrays (cGy) over four weeks was performed. At one year follow-up the patient is alive with no signs of recurrence on computed tomographic scans and magnetic resonance imaging. We discuss this case with particular emphasis on the preoperative planning, the surgical procedure and related prognosis.

Surgical management of thyrotropin-secreting pituitary adenomas

The reported cases of hyperthyroidism due to a TSH-secreting pituitary adenoma have steadily increased in previous years; however, information about the results and long term outcome after pituitary surgery is scanty. Twenty-four patients with a TSH-secreting adenoma underwent pituitary surgery at our department in the last 15 years. Hypersecretion of other pituitary hormones was diagnosed in 7 patients. Three patients were euthyroid at the time of surgery because of previous ablative thyroid therapies. The success rate of surgery strictly depends on the criteria used. Normalization of elevated FT3 and FT4 levels occurred in 17 of the 21 patients with preoperative hyperthyroidism: however, only those with early postoperative undetectable TSH level (12 cases) had no recurrence of disease during follow-up and no residual tumor tissue on postoperative MRI, whereas recurrence of hyperthyroidism occurred in 3 of the 5 patients without postoperative TSH inhibition. All 3 euthyroid patients had a subtotal removal of the tumor, as judged by postoperative MRI. Surgical removal is the therapy of choice of TSH-secreting adenomas, whereas radiotherapy and medical treatment with somatostatin analogues are usually reserved to patients with incomplete tumor removal. A thorough postoperative evaluation is necessary to discriminate between complete and partial remission of disease.

Treatment of Helicobacter pylori and Chlamydia pneumoniae infections decreases fibrinogen plasma level in patients with ischemic heart disease

BACKGROUND

Chronic Chlamydia pneumoniae and Helicobacter pylori infections could be a risk factor for ischemic heart disease (IHD), possibly by increasing fibrinogen levels. The aim of our study was to evaluate changes in fibrinogen level in patients with IHD and H pylori and/or C pneumoniae positivity randomly assigned to antibiotic treatment.

METHODS AND RESULTS

Eighty-four patients with chronic IHD, H pylori and/or C pneumoniae antibodies, and normal acute-phase reactants were randomly assigned to treatment or no treatment. Treatment consisted of omeprazole, clarithromycin, and tinidazole in H pylori-positive patients and clarithromycin alone in C pneumoniae-positive patients. The effect of treatment and other baseline variables on fibrinogen levels, determined at 6 months, was evaluated by multivariate analysis. Treatment significantly reduced fibrinogen level at 6 months in the overall study population and in the groups of patients divided according to H pylori or C pneumoniae positivity. In the 43 treated patients, mean (+/-SD) basal fibrinogen was 3.65+/-0.58 g/L, and mean final fibrinogen was 3. 09+/-0.52 g/dL (P<0.001), whereas in the 41 untreated patients, mean basal and final fibrinogen levels were 3.45+/-0.70 and 3.61+/-0.71 g/L, respectively. The largest decrease was observed in patients with both infections. Fibrinogen changes were also significantly and negatively correlated with age.

CONCLUSIONS

Our data suggest that a short, safe, and effective course of antibiotic therapy might be suggested as a means of interacting with an "emerging" risk factor.

Portal hypertension and iron depletion in patients with genetic hemochromatosis

Clinically, portal hypertension has been considered to be less common and less severe in patients with cirrhosis resulting from iron overload in homozygotes for genetic hemochromatosis than in patients with cirrhosis of other causes. To characterize the prevalence and progression of portal hypertension in genetic hemochromatosis (GH), 120 cirrhosis and iron-overloaded patients were compared with a control group of 120 patients with postnecrotic cirrhosis (PNC) who were matched for gender, age, Child's class, and alcohol abuse. Gastroesophageal endoscopy and abdominal ultrasonography were performed at diagnosis and repeated every 12 months and every 6 months, respectively, to evaluate the presence and severity of varices, the caliber of the portal vein and its collaterals, and splenic size. At diagnosis a similar frequency of varices was observed in patients with GH (25%) and in PNC (24%), as well as of portal vein abnormalities and spleen enlargement. During the follow-up period, all but two of the patients with GH were treated by phlebotomy and depleted of excess iron. After a mean of 6 +/- 4.3 (SD) years of observations (range, 2 to 10 years), varices were improved or completely reversed in 26% of patients with cirrhosis and GH but in only 5% of those with PNC (P < .01). Bleeding from varices was observed in only one patient with GH but in five patients with PNC. Of 22 patients with GH in whom portal hypertension was unmodified or worsened, 16 had coexistent hepatic viral infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of DNA ploidy and ERB-B2 oncogene expression in the prognosis of endometrial carcinoma

Seventy-three patients with endometrial carcinoma have been retrospectively evaluated in this paper. Stage, grade, depth of myometrial invasion, flow cytometric DNA ploidy and ERB-B2 oncogene expression by immunohistochemical method have been analyzed on paraffin embedded tissue. Results showed the existence of a significant correlation between stage and grade of neoplasia and between DNA ploidy and course of disease; it has been observed that patients with aneuploid tumor tend to have a shorter time before relapse of disease. No significant correlation between depth of myometrial invasion and survival was found. Besides, it has been shown that tumours with ERB-B2 oncogene hyperexpression seem to have a more aggressive evolution.

Prevalence of cholelithiasis in alcoholic and genetic haemochromatotic cirrhosis

The prevalence of cholelithiasis and possible related factors was evaluated in 350 consecutive patients with alcoholic cirrhosis (218 cases, 174 male and 44 female, mean age 58 +/- 9 years) or genetic haemochromatotic cirrhosis (132 cases, 115 male and 17 female, mean age 53 +/- 10 years). At enrollment patients with alcoholic cirrhosis were significantly older than those with genetic haemochromatotic cirrhosis (P < 0.01), and their clinical status was more severe (Child's class B/C in 99 alcoholic cirrhosis cases versus 27 genetic haemochromatotic cirrhosis cases, P < 0.01). The overall frequency of cholelithiasis was 31% (67 cases) in the alcoholic cirrhosis group and 30% (40 cases) in the genetic haemochromatotic cirrhosis group, without differences according to gender, classes of age (< or = 49, 50-59, > or = 60 years), or HBsAg positivity in either group. In addition, in the genetic haemochromatotic cirrhosis group the presence of diabetes (45 cases), alcohol misuse (38 cases) and beta-thalassemia trait (13 cases) did not influence the prevalence of cholelithiasis. Body mass index, serum cholesterol and triglycerides, and the severity of the underlying liver disease (Child's class) did not distinguish patients with or without cholelithiasis. In conclusion, the frequency of cholelithiasis was high in both alcoholic cirrhosis and genetic haemochromatotic cirrhosis, and was three times higher than that reported in controls from the general population of the same area.

[Color-Doppler semiology in transplanted kidney]

Color-encoded duplex ultrasonography (CEDU) makes a more accurate technique in kidney graft monitoring by combining real-time US with pulsed Doppler studies of renal vasculature. It is a non-invasive and easy technique. Suitable to study the whole renal artery and vein, CEDU also allows the qualitative and quantitative assessment of the intrarenal vasculature and therefore the easy diagnosis of such vessel dysfunctions as arteriovenous fistulas following biopsy. Moreover, Doppler spectral analysis can be used to distinguish among different causes of renal allograft dysfunction--i.e. rejection, cyclosporine nephrotoxicity or acute tubular necrosis. The value of the resistive index for the differential diagnosis is discussed. CEDU allows a more reliable measurement of renal blood flow thanks to the more precise evaluation of renal artery diameter and mean flow velocity.

Saturability of hepatic iron deposits in genetic hemochromatosis

The relationship of pretreatment serum ferritin and hepatic iron concentration to body iron removed by venesections was evaluated in 33 patients with genetic hemochromatosis. The median values of the three variables considered were 1,950 micrograms/L (range = 255 to 10,000), 1,175 micrograms/100 mg dry weight (range = 270 to 4,310) and 10 gm (range = 2 to 41), respectively. At basal liver biopsy 18 patients had cirrhosis, 6 patients had fibrosis and 9 patients had a normal pattern; siderosis was degree 3 in 6 patients and degree 4 in 27 patients. The results of fitting a polynomial regression of second degree showed that the curve of serum ferritin on iron removed was a straight line (R2 = 0.79, with a significant coefficient of linearity, p less than 0.01, and a nonsignificant coefficient of curvature), whereas that of hepatic iron concentration on iron removed showed a curvature (R2 = 0.62, with significant coefficient of linearity and curvature, p less than 0.01) and reached a plateau. The sigmoid model fit the curve of hepatic iron concentration on iron removed (R2 = 0.61), which suggested a saturation of hepatic iron storage capability; the asymptote corresponded to a hepatic iron concentration of about 2,000 micrograms/100 mg. In alcoholic patients (17 cases) the location of the sigmoid was greater than in nonalcoholic patients. Our results suggest that iron deposition occurs in the liver before other organs are involved and that with massive iron overload hepatic deposits reach saturation, after which hepatic iron concentration does not always reflect the amount of total stores. Alcohol consumption could slow the saturation of hepatic iron deposits.

Survival and prognostic factors in 212 Italian patients with genetic hemochromatosis

Two hundred twelve Italian patients with genetic hemochromatosis (181 men, mean age 50 +/- 11 yr; and 31 women, mean age 49 +/- 10 yr) were followed for a median period of 44 mo (range = 3 to 218 mo). Alcohol abuse was present in 31 subjects (15%), and chronic HBV and HCV infection were seen in 19 (9%) and 35 (24%) of 145 cases tested, respectively. Twenty-four patients (11%) had concomitant beta-thalassemia trait. Liver biopsy revealed cirrhosis in 146 and a noncirrhotic pattern in the other 66. Perls' stain was degree III in 37 patients and IV in 171 patients. One hundred eighty-five patients underwent weekly venesection, and iron depletion was achieved in 122 cases after total iron removal of 3 to 41 gm. Death occurred in 44 patients after 3 to 198 mo and was due to hepatocellular carcinoma in 20 cases, liver failure in 10, extrahepatic cancer in six, heart failure in three and hemochromatosis unrelated causes in five. Cancer has developed in seven other patients still alive (hepatocellular in five and extrahepatic in two). No deaths were observed among noncirrhotic patients; cumulative survival rates in cirrhotic patients were 85%, 75%, 60% and 47% at 3, 5, 8 and 10 yr, respectively. Univariate analysis in the 146 cirrhotic patients showed that age greater than 60 yr, alcohol abuse, cardiomyopathy, skin pigmentation, portal hypertension, hypoalbuminemia, hypergammaglobulinemia and Child class B or C had significant negative prognostic value. At multivariate analysis, only alcohol abuse, gamma-globulins greater than 2.0 gm/dl and Child class B or C maintained their negative prognostic values (p less than 0.01, hazard ratio 2.7; p less than 0.001, hazard ratio 2.8; and p less than 0.001, hazard ratio 4.3, respectively).

Survival and prognostic factors in 212 Italian patients with genetic hemochromatosis

Two hundred twelve Italian patients with genetic hemochromatosis (181 men, mean age 50 +/- 11 yr; and 31 women, mean age 49 +/- 10 yr) were followed for a median period of 44 mo (range = 3 to 218 mo). Alcohol abuse was present in 31 subjects (15%), and chronic HBV and HCV infection were seen in 19 (9%) and 35 (24%) of 145 cases tested, respectively. Twenty-four patients (11%) had concomitant beta-thalassemia trait. Liver biopsy revealed cirrhosis in 146 and a noncirrhotic pattern in the other 66. Perls' stain was degree III in 37 patients and IV in 171 patients. One hundred eighty-five patients underwent weekly venesection, and iron depletion was achieved in 122 cases after total iron removal of 3 to 41 gm. Death occurred in 44 patients after 3 to 198 mo and was due to hepatocellular carcinoma in 20 cases, liver failure in 10, extrahepatic cancer in six, heart failure in three and hemochromatosis unrelated causes in five. Cancer has developed in seven other patients still alive (hepatocellular in five and extrahepatic in two). No deaths were observed among noncirrhotic patients; cumulative survival rates in cirrhotic patients were 85%, 75%, 60% and 47% at 3, 5, 8 and 10 yr, respectively. Univariate analysis in the 146 cirrhotic patients showed that age greater than 60 yr, alcohol abuse, cardiomyopathy, skin pigmentation, portal hypertension, hypoalbuminemia, hypergammaglobulinemia and Child class B or C had significant negative prognostic value. At multivariate analysis, only alcohol abuse, gamma-globulins greater than 2.0 gm/dl and Child class B or C maintained their negative prognostic values (p less than 0.01, hazard ratio 2.7; p less than 0.001, hazard ratio 2.8; and p less than 0.001, hazard ratio 4.3, respectively).

[Survival and development of neoplasms in 56 patients with idiopathic hemochromatosis]

Fifty-six patients with idiopathic hemochromatosis (50 men and 6 women, mean age 49.7 +/- SD 11.1 and 60.8 +/- SD 10.3 years respectively) were studied and followed up for a median period of 44 months (range 3-168). At basal liver biopsy 44 patients had cirrhosis and 12 fibrosis. Iron depletion was achieved in 39 of the 46 cases who underwent iron removal by erythrocytapheresis. Eighteen patients died, 11 from malignancy and 7 from other causes. A total of 14 malignant neoplasms were observed (6 hepatocellular and 8 extrahepatic), of which 6 (5 hepatocellular and 1 pancreatic) were already evident at enrollment. Cumulative survival rates at 3, 5 and 8 years were 75.4%, 64.2% and 54.4% respectively, significantly lower than those in the general population. Probabilities of developing cancer in the 50 patients without cancer at diagnosis were 5.5%, 14.9% and 44.4% at 3, 5 and 8 years respectively.

Cholelithiasis in cirrhosis: analysis of 500 cases

The prevalence of cholelithiasis (gallstones or previous cholecystectomy) was evaluated in a series of 500 cirrhotic patients from Northern Italy (329 males and 171 females, mean age 58 +/- 11 (SD) yr and 61 +/- 10 yr, respectively). Cirrhosis was related to chronic alcohol abuse in 180 cases, non-A non-B (NANB) hepatitis in 160, hepatitis B virus (HBV) in 94 (including 38 with concomitant alcohol abuse), idiopathic hemochromatosis in 44, and miscellaneous causes in the remaining 22 (including 15 with primary biliary cirrhosis). One hundred and sixteen patients (23.2%) had gallstones, and 31 others (6.2%) had previously undergone cholecystectomy, with an overall prevalence of cholelithiasis of 29.4%. The frequency was similar in both sexes (91/329 males, 27.7% vs. 56/171 females, 32.7%; p = NS), showed a slight increase with age, and differed significantly according to etiology (p less than 0.05), with the highest prevalence in the miscellaneous group and the alcoholics (36.4% and 33.3%, respectively). No significant difference was found in the prevalence of cholelithiasis according to Child's A, B, or C class.

Prevalence of HIV infection in 646 heroin addicts and outcome of HIV-related conditions in the 266 followed up

In a series of 646 heroin addicts anti-HIV was detected in 428 (66.2%) and HBsAg in 53 (8.2%). Forty-eight (90.5%) of the latter had concomitant chronic HDV infection. Markers of past HBV infection were found in 481 (74.4%). The prevalence of anti-HIV was significantly higher in the 534 subjects with HBV markers than in the other 112 without markers (69.8% versus 49.1%, p less than 0.001). Of the 266 anti-HIV positive subjects followed for 3-48 months (median 12), nine progressed from no disease to persistent generalized lymphadenopathy (PGL), 52 from PGL to AIDS-related complex (ARC) or AIDS (30 and 22 cases respectively), and six from ARC to AIDS. Baseline T4 + cell count was significantly lower and reduction during follow-up significantly greater in heroin addicts with disease progression than in those without.

T4+ cell depletion as a major risk factor for AIDS-related complex and AIDS. Longitudinal study of 253 HIV-antibody positive heroin addicts from northern Italy

We enrolled 253 HIV-antibody positive heroin addicts without HIV-related disease (n = 81) or with persistent generalized lymphadenopathy (n = 172) in a prospective study to evaluate clinical progression to AIDS related complex (ARC) or AIDS and to identify factors of possible prognostic relevance. Follow-up lasted between 6 and 40 months (median 12 months). According to the non-parametric Cox's model the only significant (P less than 0.001) prognostic variable was T4+ cell count considered in three classes: greater than 800/microliters (no depletion), 400-800/microliters (moderate depletion) and less than 400/microliters (absolute depletion). Subjects with T4+ cell count of less than 400/microliters had a risk of developing ARC or AIDS that was 6.46 and 1.98 higher than those with values of greater than 800/microliters or between 400 and 800/microliters respectively. The estimated probability of progression to ARC or AIDS was 0.029, 0.056 and 0.172 at one year in subjects with T4+ cell count of greater than 800/microliters 400-800/microliters and less than 400/microliters, respectively, and 0.296, 0.501, and 0.896 at two years.

Bone involvement in primary hemochromatosis and alcoholic cirrhosis

Biochemical indexes of bone metabolism, bone mineral density, and histomorphometry were evaluated in 14 male patients with noncholestatic cirrhosis due to primary hemochromatosis (six cases) or to chronic alcohol abuse (eight cases), and in 30 male controls of similar age. Alkaline phosphatase in alcoholic patients was significantly higher than in controls (mean +/- SD 50.4 +/- 33.7 vs 33.0 +/- 7.1 U/L, p less than 0.01), as was urinary hydroxyproline in both hemochromatotics and alcoholics (mean +/- SD, 44.3 +/- 8.4 and 40.4 +/- 16.8, respectively, vs 30.1 +/- 4.5 mg/g, p less than 0.001 and p less than 0.005). Bone mineral density was significantly lower in hemochromatotics than in alcoholics and controls (mean +/- SD, 591 +/- 90 vs 765 +/- 87 and 759 +/- 34 mg/cm2, respectively, p less than 0.005 and p less than 0.001). At bone biopsy, trabecular osteoporosis was observed in two hemochromatotics and four alcoholics, and osteomalacia was seen in another alcoholic. Overall densitometric and histomorphometric findings indicate a derangement of trabecular bone in both alcoholic and hemochromatotic cirrhosis, whereas cortical osteoporosis seems limited to hemochromatotic patients.

HLA typing in 67 Italian patients with idiopathic hemochromatosis and their relatives

The frequency of HLA A3 and B7 antigens was significantly higher in 67 unrelated patients with idiopathic hemochromatosis (IH) than in 700 controls (62.7% vs 22.5%, p less than 10(-8) and 26.9% vs 9.3%, p less than 10(-3), respectively). A3 B7, A3 B35 and A3 B5 were significantly more frequent in 72 haplotypes linked to IH gene than in 278 control haplotypes. The prevalence of B35 and A3 B35 was significantly higher in IH patients from North-Eastern Italy than from other regions (60% vs 21%, p less than .05 and 54.5% vs 8.2%, p less than 0.0001, respectively). All 15 siblings HLA identical to the respective proband were homozygous for IH with variable expression of the disease, whereas minor abnormalities of iron-related indexes were present in 23% of heterozygous relatives. Homozygous-heterozygous mating probably occurred in three of 40 families, accounting for the overt disease in three offspring and in one HLA semi-identical sibling; however, in this last case the possibility of a recombination event cannot be excluded.

Concomitant primary hemochromatosis and beta-thalassemia trait: iron depletion by erythrocytapheresis and desferrioxamine

Six men and one woman with mild anemia due to beta-thalassemia trait and major iron overload attributable to concomitant primary hemochromatosis were treated by erythrocytapheresis to remove iron, combined with subcutaneous desferrioxamine in the four cases with greater iron load. Depletion was achieved by iron removal of 4.5-15.1 g after 9-24 months' treatment. No side effects were observed, suggesting that such a regimen is effective and safe in this particular subgroup of hemochromatotics.

Effectiveness of erythrocytapheresis in idiopathic hemochromatosis. Report of 14 cases

Thirteen men and one woman (mean age 48.8 yr +/- 6.9, range 36-63) with idiopathic hemochromatosis were treated by erythrocytapheresis. Iron depletion followed 9.60 months treatment (median 24), with 21-203 erythrocytaphereses (mean 93 +/- 61) and total iron removal of 4.2-40.6 g (mean 19 +/- 11.9). Trasferrin saturation decreased from 90 +/- 8.7% to 17 +/- 10.6% and serum ferritin from 3164 micrograms/L +/- 1488 to 60.5 micrograms/L +/- 77.5, and liver iron content normalized in all cases. Initial serum ferritin in the patients who were iron-depleted at 18 months (50%, cumulative percentage) was significantly lower than in those still iron loaded at that time (2280 micrograms/L +/- 940 vs 4049 micrograms/L +/- 1444, p less than 0.02). Clinical improvement was noted in all cases with about a 30% decrease in insulin requirement in most diabetics. Thus erythrocytapheresis appears to be effective and safe in obtaining iron depletion in idiopathic hemochromatosis.

HBV, HDV and HIV infections in 242 drug addicts: two-year follow-up

Of 242 north Italian heroin addicts, 24 (9.9%) were HBsAg positive. HBeAg was positive in two of them (8.3%), anti-HBe in 16 (66.6%) and anti-HDV in 21 (87.5%). Of the 218 HBsAg negative, 182 (83.5%) had anti-HBc, 72 (33.0%) anti-HBe and 97 (44.5%) anti-HBs. One-hundred-eighty-five drug addicts were anti-HIV positive (76.4%); 77 of these (41.6%) were asymptomatic, 93 (50.3%) had PGL and 15 (8.1%) ARC. T4+ cell count was significantly lower in subjects with ARC as was T4+/T8+ ratio in subjects with PGL and ARC. During a median follow-up of 9.5 months (range 4-25), we observed three new cases of hepatitis (two caused by NANBV and one by HBV with HDV coinfection) and one new HIV infection. Ten anti-HIV positive subjects developed PGL and one AIDS.

HIV and HBV infection in intravenous drug addicts from northeastern Italy

Three hundred and two intravenous drug addicts (IVDA) from five towns in Northeastern Italy were studied. Of the males, 37/249 (14.8%) were homosexuals and of the females, 29/53 (54.7%) were prostitutes; 118 (39.0%) were alcoholics. AST levels were abnormal in 31.8%, ALT in 45.7%, GTP in 36.4%, and bilirubin in 14.6%. The prevalence of HBsAg (13.9%) and HBeAg (21.4% of HBsAg positive) was significantly higher than in 2,983 controls (4.2% and 6.3%, p less than .001 and p less than .02, respectively). Of the HBsAg positive subjects, 51.7% had anti-HDV antibodies. Among 260 HBsAg negative cases, 146 (56.2%) were anti-HBs and anti-HBc positive, 76 (29.2%) were anti-HBc positive and anti-HBs negative (25 anti-HBe positive and 51 anti-HBe negative), and 38 had no HBV markers. Anti-HIV ELISA positive subjects came to 70.5% (triplicate determination with absolute concordance) and Western blot analysis confirmed the results in 99.1% of ELISA positive and 100% of ELISA negative subjects. The prevalence of anti-HIV was significantly higher in anti-HBc positive than negative cases (p less than .02), even excluding HBsAg positive subjects. Cases negative for HIV and HBV had a significantly lower median duration of drug abuse than those with past or present infection (36 vs 60 months, p less than .001). HIV-related diseases were present in 56.3% of the cases (120/213; PGL in 94, ARC in 24, and AIDS in two).(ABSTRACT TRUNCATED AT 250 WORDS)

Stainable iron in gastric and duodenal mucosa of primary hemochromatosis patients and alcoholics

The presence of iron in gastric and duodenal mucosa was investigated with Perl's stain in endoscopic biopsies from 13 patients with overt primary hemochromatosis, 10 chronic heavy alcohol abusers, and 10 patients with nonulcer dyspepsia. In the primary hemochromatosis patients marked iron deposition was found in cells at the base of glands in the gastric body and antrum in nine cases, and in crypt cells and Brunner gland cells of the duodenum in six. Iron was detected in the lamina propria of the stomach in five and duodenum in four cases. A similar distribution of iron overload, usually of lesser degree, was also observed in five alcoholics. Serum ferritin levels and the degree of gastric and/or duodenal iron deposits did not correlate in either hemochromatosis patients or alcoholics. No gastric or duodenal siderosis was observed in nonulcer dyspepsia cases. The absence of gastric and duodenal stainable iron in some hemochromatosis patients and its presence in some alcoholics suggests that the diagnostic value of upper gastrointestinal biopsy in primary hemochromatosis is limited.

On surveillance methods for congenital malformations

This paper presents an 'optimal' procedure for the use of the 'sets' method, a system proposed for surveillance of congenital malformations. Comparisons over a number of examples shows that the given procedure represents a clear improvement over the one originally proposed, and, in some conditions, is more efficient than the cusum scheme.

Clinical, biochemical and histological features of primary haemochromatosis: a report of 67 cases

In 67 patients (mean age 51 years, range 26-79), at diagnosis of primary haemochromatosis (PH), grade III or IV liver iron overload was present in all cases, cirrhosis in 85%, transferrin saturation greater than 80% in 75%, serum ferritin greater than 1000 micrograms/l in 84%, and overt diabetes in 48%. Alcohol intake was greater than 150 g/day in 11 patients; six were chronic hepatitis B surface antigen (HBsAg) carriers. HLA-A3 and B7 antigens were present in 64% and 23% versus respectively 22% (p less than 0.01) and 9% (p less than 0.025) in controls. Iron overload was found in the stomach, duodenum, skin and bone marrow in 57, 43, 45 and 59% of the patients studied. Sixty-three patients were followed for 1-260 months (median 24); 43 received regular iron-depleting treatment and 20 did not because of liver failure, cancer or refusal. Cumulative survival was 79%, 67% and 61% at 1, 4 and 10 years, respectively. Ten patients died from hepatocellular carcinoma and two from extrahepatic cancer. The early high mortality rate was due to some cases of advanced disease or cancer. Cumulative survival in the regularly treated group was 95% at 1 year and 91% at 4 and 10 years, which was higher than in the untreated group.

Beneficial effects of defibrotide against myocardial ischemia and decline of beta-adrenoceptor function in the rabbit

Defibrotide is a polydeoxyribonucleotide of mammalian origin which possesses profibrinolytic effect and PGI2-releasing capacity. Because of these properties, defibrotide has antithrombotic effects which are demonstrated in various experimental models of venous and arterial thrombosis. The present study indicates that defibrotide clearly protects against myocardial damage in the rabbit 3 days after total coronary artery occlusion. Furthermore, defibrotide prevents the decline of beta-adrenergic receptor function, a phenomenon related to excessive circulating catecholamines that occurs during the myocardial infarct. Defibrotide prevents the dramatic fall of creatine phosphokinase activity in the ischemic ventricle: metabolic changes which reflect changes in the cells affected by prolonged ischemia. Assumptions about the mode of action of defibrotide are given particularly in consideration of the interaction between the fibrinolytic activity and the PGI2-releasing capacity of this substance.

Effect of ascorbic acid on desferrioxamine-induced urinary iron excretion in idiopathic hemochromatosis

The effect on urinary iron excretion (UIE) of vitamin C administered orally 2 h after the start of an 8-hour desferrioxamine (DF) i.v. infusion was studied in 12 patients with untreated idiopathic hemochromatosis (IH). Mean +/- SEM basal UIE of 324.6 +/- 84.6 micrograms/24 h increased after a 1-gram i.v. DF infusion to 8,778.5 +/- 1,191.4 micrograms/24 h; when vitamin C 1 or 2 g were added to DF i.v. infusion, there were further increases to 11,241.5 +/- 1,486.1 (p less than 0.01) and 13,531.2 +/- 1,697.2 micrograms/24 h (p less than 0.05 versus the last value), respectively. Basal UIE did not significantly increase after oral vitamin C administration alone. No side effects were observed.