Sex difference in the impact of smoking on Clinical outcomes following LVAD implantation

Background

Smoking would have a negative impact on clinical outcomes following left ventricular assist device (LVAD) implantation. However, its impact on male and female cohorts separately remains uninvestigated.

Purpose

We aimed to investigate the association between smoking and post-LVAD outcomes among male and female cohorts separately.

Methods

Data of consecutive patients who received LVAD implantation at our institute between Jan 2013 and Sep 2018 were retrospectively reviewed. Clinical outcomes were compared between the never smokers and the current smokers among male and female cohorts separately. Those with former smoking were excluded.

Results

Of all, 85 male patients (median 56 years old) and 45 female patients (median 56 years old) were included. Among the male cohort, total readmission rate was higher in the current smokers than never smokers (incidence rate ratio 1.51, p=0.09). Rates of gastrointestinal bleeding, stroke, and hemolysis trended to be higher in current smokers (Figure 1A). Among the female cohort, these rates were not different irrespective of the smoking status (Figure 1B). Survival was not different irrespective of smoking status among both male and female cohorts.

Conclusion

The impact of smoking on post-LVAD outcomes seems to be different between males and females. Different therapeutic strategy might be required for the LVAD candidates with active smoking between male and female cohort.

Figure 1

Funding Acknowledgement

Type of funding source: None

Brain MRI white matter lesions in migraine patients: is there a relationship with antiphospholipid antibodies and coagulation parameters?

Brain magnetic resonance imaging (MRI) studies in migraine patients have demonstrated lesions consisting of focal regions of increased signal intensity within the white matter. Antiphospholipid antibodies are known to have a role in many diseases including migraine. The aim of the present study was to ascertain the relationship between MRI-visualized cerebral focal hyperintense lesions and serum antiphospholipid antibody levels, as well as blood coagulation parameters in migraine patients. One hundred and two (77 females, 25 males, mean age 33.8 +/- 11.1) consecutive migraine patients and a control group of 94 (70 females, 24 males, mean age 33.2 +/- 10.8) healthy subjects were enrolled. All individuals underwent brain MRI. Complete blood examinations, autoantibodies, antiphospholipids antibodies including anticardiolipin and lupus anticoagulant (aCL, LAC), antithrombin III, Protein C and S serum levels were ascertained in the subjects who presented white matter lesions on MRI. Twenty-seven (26.4%) migraine patients and six (6.3%) healthy subjects in the control group showed focal regions of increased intensity signal within cerebral white matter (odds ratio 5.3, 95% CI: 1.98-16.36). In migraine patients with white matter lesions, antiphospholipid antibodies were not detected and serum levels of antithrombin III, and proteins C and S were normal. White matter lesions in migraine patients are fairly common. This finding is not associated with antiphospholipid antibodies or abnormal coagulation parameters. The significance of such lesions at present remains unclear.

Tumor necrosis factor alpha serum levels and inflammatory response in acute ischemic stroke patients

Experimental evidence indicates that tumor necrosis factor alpha (TNF-alpha) is involved in brain damage following ischemic injury. The present study was designed to monitor serum TNF-alpha levels in acute stroke patients and to correlate TNF-alpha levels with lesion size, neurological impairment and vascular risk factors. In 41 patients with ischemic stroke, serum TNF-alpha levels were serially measured by a solid enzyme amplified sensitivity immunoassay (EASIA) in the first 10 days after stroke onset. Serum fibrinogen and C-reactive protein (CRP), white blood cell (WBC) and neutrophil counts were determined on the same days to monitor acute phase response changes. Lesion size was calculated on computed tomograms by a computer-assisted procedure. Neurological impairment was evaluated on the Canadian Neurological Scale. Forty age-matched subjects were used as controls. Compared to baseline, TNF-alpha levels significantly increased during the study ( p=0.0001), peaking on day 7. Peak TNF-alpha levels did not correlate with neurological impairment or lesion size. Multivariate analysis showed that sex, age, vascular risk factors and infectious complications did not influence TNF-alpha levels. Fibrinogen, CRP, WBC and neutrophil concentrations increased, indicating an acute phase response occurred after stroke. In conclusion, serum TNF-alpha levels showed an early and prolonged increase after stroke onset, unrelated to lesion size, neurological impairment, age, sex, vascular risk factors or infectious complications. Serum increase of TNF-alpha may be explained as part of the acute phase response occurring in stroke patients.

Incidence of first-ever ischemic and hemorrhagic stroke in a well-defined community of southern Italy, 1993-1995

Most epidemiological surveys in the Italian population, have concentrated on areas of northern and central Italy. The incidence of the first-ever ischemic and hemorrhagic strokes in a well-defined population of the province of Foggia, a rural area of southern Italy, over a 3-year period has been investigated, to compare the occurrence of stroke by type in this and other areas. A retrospective study in a local health district (USL FG3) in the province of Foggia was conducted and all cases of first-ever cerebral infarction (CI) and intracerebral hemorrhage (ICH) in the local population (41 269) from January 1, 1993 to December 31, 1995 have been investigated. Case ascertainment was performed by a chart review in the two local hospitals and examination of death certificates. General practitioners were also asked to report on non-hospitalized cases suffering a stroke during the study period. Patients with recurrent stroke, unclassifiable stroke, transient ischemic attacks and subarachnoid hemorrhage were excluded. Risk factors for stroke and 30-day mortality were investigated. The rates were standardized to the Italian population (57 138 489, 1991 census). During the 3-year study period, 202 patients had a first-ever ischemic or hemorrhagic stroke (66 in 1993, 69 in 1994 and 67 in 1995). Of these, 174 (86.1%) had cerebral ischemia, accounting for 57, 60 and 57 cases in the three index years. The overall crude annual incidence of CI and ICH was 1.60, 1.67 and 1.62 of 1000 for 1993, 1994 and 1995, respectively. The corresponding standardized incidences rates were 2.0, 2.10 and 2.06 of 1000. The rate was 0.11 in patients <55 years of age, and 1.97, 7.01, 13.52, and 25.34 at ages 55-64, 65-74, 75-84, and 85+ years for the entire period; the 30-day mortality was 27.2, 21.7, and 15% for 1993, 1994, and 1995, respectively. Hypertension (45.9%), diabetes (26.4%) and atrial fibrillation (16.6%) were the most common risk factors. The incidence of CI and ICH was similar to that of most other Italian studies. It was constant during the 3-year period, and mostly involved older people.

Arterial hypertension as a risk factor for chronic symmetric polyneuropathy

OBJECTIVE

To assess whether arterial hypertension (AH) is an independent risk factor for chronic symmetric polyneuropathy (CSP) in the elderly.

BACKGROUND

A strong relationship has been detected between AH and distal symmetric polyneuropathy in insulin-dependent and non-insulin-dependent diabetes. However, the correlation between AH and polyneuropathy caused by other clinical conditions has not yet been studied.

METHODS

Four thousand one hundred and ninety-one subjects aged > or = 55 years seen in office consultations by 25 general practitioners (GPs) from two separate areas in Italy were interviewed, using a pretested semistructured questionnaire covering conditions commonly associated with neuropathy and symptoms of peripheral nerve disease. A neurologist later visited individuals with > or = 2 symptoms of polyneuropathy and a diagnosis of CSP was made in the presence of bilateral, fairly symmetric impairment of at least two among strength, sensation and tendon reflexes. AH was ascertained when known to the GP and/or if the patient was being treated with antihypertensive drugs.

RESULTS

One hundred and fifty one subjects had CSP (3.6%). Diabetes was the commonest associated condition (18%). AH was present in 47 patients with CSP (31%). The odds ratio (OR) of AH in patients with CSP was 4.5 [95% confidence interval (CI) 3.1-6.6]. The OR of AH was 3.2 (95% CI 1.5-6.9) in patients with diabetes, and 5.7 (95% CI 3.6-9.3) in those without diabetes. The OR of AH was 4.8 (95% CI 4.4-5.2) after adjusting for the commonest risk factors for CSP.

CONCLUSION

AH may be an independent risk factor for CSP in the elderly.

Occurrence of factor V Leiden mutation (Arg506Gln) and anticardiolipin antibodies in migraine patients

The occurrences of factor V Leiden mutation (Arg506Gln) and antiphospholipid antibodies (APA) in migraine patients have been reported, but the findings are controversial. We investigated the presence of factor V Leiden and the serum level of anticardiolipin antibodies (aCL) in a consecutive series of 70 migraine patients (47 women; mean age, 34.1 years). Of these, 40 patients had migraine with aura. A matched sample of 70 healthy people was considered as the control group. Heterozygous genotype for factor V Leiden mutation was detected in 4 (5.7%) migraine patients (of which 2 had migraine with aura) and in 2 (2.8%) subjects of the control group. Although proportionally more migraine patients harbored the factor V Leiden mutation, this difference was not statistically significant, perhaps due to the small number of patients involved. We found normal serum levels of aCL in all migraine patients. Further studies and a long-term follow-up are warranted to determine the significance of this genetic abnormality in migraine.

Propofol EEG burst suppression in carotid endarterectomy

BACKGROUND

The results of randomized trials indicate that carotid endarterectomy, performed with a low morbidity-mortality perioperative risk, is the best therapeutic option both for patients with high-grade symptomatic and asymptomatic stenosis. Since the main operative risk is represented by embolic or hemodynamic cerebral ischemia, it appears necessary to maintain an adequate intraoperative cerebral blood flow and to carry out a meticulous endarterectomy.

METHODS

On the basis of these considerations we prospectively studied a series of 100 consecutive patients operated on for high-grade carotid stenosis, by using a protocol based on: 1) an accurate selection of patients for surgery; 2) meticulous surgical technique without any shunt; 3) perioperative cerebral protection by barbiturate or propofol; 4) pre- and postoperative medical treatment of risk factors. All patients of our series performed preoperatively brain CT scan, transcranial Doppler, carotid duplex scanning, four vessel angiography, brain 99mTc-HMPAO SPECT. Eighty-two patients had symptomatic carotid stenosis ranged between 70 and 90%, 18 had carotid stenosis higher than 90%.

RESULTS

In this series there have been one postoperative death due to myocardial infarction and one major stroke.

CONCLUSIONS

We think that this protocol can significantly minimize risks of endarterectomy and probably maximize the benefits of surgery, also in patients with asymptomatic high-grade carotid stenosis.

Laparoscopic cholecystectomy in cirrhosis: contraindication or privileged indication?

Until recently, cirrhosis has been considered to be an absolute or relative contraindication of laparoscopic cholecystectomy. An evaluation of benefits and risks of laparoscopic cholecystectomy in the treatment of gall bladder lithiasis in cirrhotic patients is presented. Thirty-three consecutive laparoscopic cholecystectomies in patients with cirrhosis were performed between March 1990 and March 1997. During the same period, no open cholecystectomy was performed in patients with cirrhosis. There was no morbidity or mortality; the conversion rate was 6% (2/33). No patient received blood transfusion, and the mean hospital stay was 2.8 days. These results favorably compare with the results of open cholecystectomy. Specific advantages of laparoscopic cholecystectomy in patients with cirrhosis include the absence of wound infection and a lower rate of postoperative hepatic failure. Finally, laparoscopic surgery reduces the risk of viral contamination (the hepatitis B virus, the hepatitis C virus, or the human immunodeficiency virus) of the surgical staff.

The international classification of the epilepsies and epileptic syndromes. An algorithm for its use in clinical practice

An algorithm has been structured as a guided reading of the international league against epilepsy (ILAE) syndromic classification to be used in clinical practice by less experienced physicians in newly diagnosed patients. The algorithm followed the original structure of the classification, which identifies major syndromic groups, subgroups, and specific syndromes. Validation required two raters, a resident and a board-certified neurologist, to apply the algorithm with different techniques (direct or recorded interview, medical record consultation) to 19 children and 18 adults with epilepsy with information available at the time of diagnosis. The two raters' diagnoses were compared with those of the caring physicians, and cases where disagreement arose were discussed in conference to achieve consensus. The kappa statistic was used as a measure of inter-rater agreement. Caring physicians and both raters agreed in 51% of cases. Substantial agreement (kappa = 0.75) was obtained between the resident and the neurologist on major diagnostic groups and subgroups, mostly in adults. Agreement with the caring physician was slightly more satisfactory for the resident (kappa=0.67) than for the neurologist (kappa = 0.60). Agreement was better with direct or indirect interview than with record consultation, and improved further after discussion. Agreement was obtained after discussion in 32% of cases, in some of which the caring physician agreed on the resident's diagnosis. Agreement was less satisfactory for specific syndromes. On this basis, an algorithm of the ILAE classification is a fairly reliable instrument only for making a broad syndromic classification of epilepsy at the time of diagnosis. The limits of the algorithm tend mostly to reflect the intrinsic limitations of the classification itself.

[Central core disease. Report of 2 cases in adults]

"Central core disease" (CCD) is a rare disease of infancy and childhood and represents the prototypic member of a group of muscular disorders known as "congenital, benign (non progressive) myopathies". It is very uncommon to diagnose cases affected by CCD in youth and adulthood. The disease is mainly familial with a dominant autosomal pattern of inheritance, but sporadic cases are known to occur. The candidate gene has been localized on chromosome 19q13.1, and is allelic with RYR-1 ("ryanodine receptor" [calcium release channel gene]), the gene responsible of the susceptibility to malignant hyperthermia. In some familial cases of CCD a susceptibility to malignant hyperthermia was also recognized. The diagnosis is only made based on muscular biopsy, which documents some peculiar morphological abnormalities, i.e. focal losses of oxidative enzyme activities, exclusively in type I muscular fibres. The basis for the loss of such activities is represented by an almost total absence of mitochondria and sarcoplasmic reticulum in those focal regions of muscle fibres. Cores may be "structured" and "unstructured" based on the reactivity with myosin ATPases, which ultrastructurally means preservation or destruction of myofilaments. Both structured and unstructured cores qualify this disease in the same way. The authors have observed two cases of CCD in patients in their non infantile age. Both diagnoses were accomplished by means of muscular biopsy, and the results of their studies in both cases are herein presented and discussed.

Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia

We investigated the long-term efficacy and safety of intrasphincteric injections of botulinum toxin (100 U) in 57 patients with esophageal achalasia. One month after treatment, 50 patients had improved (88%); both symptom score and LES pressure were significantly reduced (P < 0.001). After a mean follow-up of 24+/-15 months (range 6-48), 43 patients (75%) are still in remission, although repeat injections of toxin were needed to achieve a stable effect on symptoms.

Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia

We investigated the long-term efficacy and safety of intrasphincteric injections of botulinum toxin (100 U) in 57 patients with esophageal achalasia. One month after treatment, 50 patients had improved (88%); both symptom score and LES pressure were significantly reduced (P < 0.001). After a mean follow-up of 24+/-15 months (range 6-48), 43 patients (75%) are still in remission, although repeat injections of toxin were needed to achieve a stable effect on symptoms.

Bilateral periventricular nodular heterotopia associated with coeliac disease and palatoschisis

Periventricular nodular heterotopia (PNH) is considered a distinct entity in relation to the other forms of neuronal migration disorders (NMD), because PNH patients usually have normal neurological and mental examination results. We report the case of a 48-year-old woman with bilateral periventricular nodular heterotopia associated with epilepsy, coeliac disease, palatoschisis and other dysmorphic features. Her intelligence quotient (I.Q.) and the results of a neurological examination were normal, but she suffered from a drug-resistant epileptic syndrome characterised by predominantly generalised and sporadic partial seizures. It has recently been suggested that an X-linked dominant inheritance may play a role in bilateral periventricular nodular heterotopia, and it is thought that a genetic defect is probably responsible for coeliac disease. In our patient, a genetic disorder may have produced both diseases and the dysmorphic syndrome, although the coexistence of PNH, epileptic seizures, coeliac disease and palatoschisis could be coincidental. Further observations are needed to ascertain whether the simultaneous presence of these disorders is simply an unusual association of unrelated pathologies or a new and distinct pathological entity.

Surgical treatment of anterior callosal tumors

OBJECTIVE

Thirteen patients with neoplasm of anterior corpus callosum have undergone our observation during the last two years.

METHODS

For the diagnosis, all the patients underwent TC, NMR and stereotactic biopsy. In 6 cases with glioblastomas, a radiation treatment was adopted. The other 7 patients underwent total surgical treatment in 5 cases, and partial in 2 cases, as documented by postoperative contrast-enhanced CT scanning. Histologically, there were: 3 glioblastomas, 1 grade III astrocytoma, 1 neuroblastoma (PNET), 2 pilocytic astrocytomas.

RESULTS

Neuropsychological tests carried out on the 5 patients still living showed persistent disturbances of verbal memory in all five and disturbances of verbal phonological fluency in 3 cases. No patient presented apraxia, dysgraphia and dyslexia.

CONCLUSIONS

Thus, no severe neuropsychological deficits developed after surgical treatment of anterior callosal tumors.

[The use of type A botulin toxin in the treatment of detrusor-sphincter dyssynergia]

The detrusor-sphincter dyssynergia (DSD) is a common and significant problem for patients with spinal cord lesions. If not treated, DSD can lead to severe and potentially lethal complications (urinary tract infections and renal damage). BTX inhibits acetylcholine release at the neuromuscular junction, producing muscle chemical denervation in the site of injection. The aim of this preliminary study was to test the safety and the effects of BTX injection in the spastic urethral rhabdosphincter in patients with DSD. Five patients (3 M, 2 F; mean age 43 years, range 22-56) with DSD entered the study. Videourodynamic parameters were controlled before BTX injection at 10 days, at 3 and 6 months after infiltration. The aim of this preliminary study was to test the safety and the effects of BTX injection in the spastic urethral rhabdosphincter in patients with DSD. The post void residual urine volume, the maximum pressure of emptying and the maximum pressure of urethral closure are reported in Tab. II-III-IV. Patients reported subjective improvement of bladder emptying and improved quality of life. No adverse effects related to pharmacological activity of BTX or to infiltration procedures were observed.

Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia

BACKGROUND & AIMS

Intrasphincteric injection of botulinum toxin has been suggested as an alternative treatment modality in esophageal achalasia. A controlled trial comparing botulinum toxin, placebo, and pneumatic dilation is reported.

METHODS

Sixteen patients received random intrasphincteric injections of either botulinum toxin or saline. The efficacy of treatment was assessed by symptom score, esophageal manometry, and scintigraphy. In case of failure, pneumatic dilation was performed.

RESULTS

One month after injection, symptoms had improved in all patients treated with botulinum toxin (symptom score, 0.9 +/- 0.6 vs. 5.5 +/- 1.4; P < 0.02). In the placebo group, symptoms were unchanged in all patients, who were all dilated. Lower esophageal sphincter pressure decreased by 49% after treatment with botulinum toxin (P < 0.03) and by 72% after dilation (P < 0.01). Similarly, esophageal retention decreased by 47% after treatment with botulinum toxin (P < 0.02) and by 59% after dilation (P < 0.02). No significant difference in symptom score and esophageal function test results was found between patients treated with botulinum toxin injections and those undergoing dilation. However, 7 of the 8 patients in the botulinum toxin group required a second injection because of recurrent dysphagia.

CONCLUSIONS

Treatment of achalasia with botulinum toxin was as effective as pneumatic dilation in relieving symptoms and improving esophageal function. The effect of the first injection was temporary, but the effect of the second injection lasted longer.

Raised plasma fibrinogen concentrations in subjects attending a metabolic ward--relation to family history and vascular risk factors

We have evaluated plasma fibrinogen levels in 171 subjects attending a metabolic ward. As in the general population, a significant difference in plasma fibrinogen concentrations (p < 0.05) was found between subjects with diabetes mellitus or hypertension and those without. However, fibrinogen was also abnormally high (p < 0.05) when evaluated according to the presence of a family history of ischemic complications of atherosclerosis (p < 0.05). In this setting, fibrinogen correlated with diabetes mellitus or hypertension as well as with familial risk, and the latter interacted with hypertension (p < 0.05) in accounting for plasma fibrinogen. The relationships between certain fibrinogen genotypes and familial risk have then been evaluated. Analysis of a locus (1.3 kb, HAE III digestion) of the promoter region of the B beta fibrinogen gene, identified a polymorphic cutting site. The allele with the alternative restriction site (H1) was associated with mean fibrinogen levels which were 0.1-0.3 g/l lower than those associated with the other allele (H2). This difference was not statistically significant. No obvious association was found between the familial risk and the presence of the H2 allele. We conclude that in a group of subjects from a metabolic ward, a positive family history for ischemic complications of atherosclerosis is consistently associated with high plasma fibrinogen levels. Interaction with hypertension significantly strengthens the association.

[Survival and mortality in a cohort of heroin addicts in 1985-1994]

Between 1985 and 1994, 138 intravenons drug addicts were observed, 62 were HIV ab positive. 26 patients died (10 overdose and 9 AIDS). AIDS is, at present, the most frequent cause of death.

Peripheral and abdominal adiposity in childhood obesity

The aim of this work was to evaluate peripheral and abdominal adipose tissue (AT) content detected by MRI in normal weight and obese children, to compare MRI data with simple anthropometric indexes and to estimate intrabdominal adipose tissue (IAT) influence on cardiovascular risk factors. The subjects were 23 obese and 21 normal weight children aged 10 to 15 years. The following measurements were carried out: MRI analysis at lumbar level with definition of subcutaneous adipose tissue (SAT) area and IAT area; arm fat area (AFA); thigh fat area (TFA) and waist/hip ratio from anthropometry. SAT (353 +/- 94 cm2) was predominant compared with IAT (49 +/- 21 cm2) in obese as well as in controls (SAT: 79 +/- 61 cm2; IAT: 22 +/- 11 cm2). No differences in SAT/IAT ratio were found for sex and puberty, either in obese subjects or in controls. SAT and IAT were significantly related in controls (r = 0.77, P < 0.0001), but not in obese subjects (r = 0.12, P = 0.59). IAT was related to total and LDL cholesterol and triglycerides levels (r = 0.54, P < 0.02, r = 0.60, P < 0.01, r = 0.46, P < 0.04, respectively) in obese children. AFA and TFA from anthropometry significantly underestimated AT compared with MRI in both groups. Methods agreement analysis showed unacceptable results for anthropometry. It was concluded that childhood obesity has a subcutaneous adipose pattern with no differences between the sexes. IAT already begins to have clinical significance since it has a relationship to some cardiovascular risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormally high circulation levels of tissue plasminogen activator and plasminogen activator inhibitor-1 in patients with a history of ischemic stroke

We evaluated 106 subjects with and 109 subjects without a history of ischemic stroke. All were attending a metabolic ward. The two groups were compared for major risk factors for ischemic events. A positive family history for ischemic complications of atherosclerosis was more common in subjects with a history of stroke than in those without; moreover, plasma levels of plasminogen activator inhibitor-1 (PAI-1) and tissue-type plasminogen activator (TPA) were higher in patients with documented previous events. A strong positive significant correlation was found between TPA and PAI-1 levels, and an interaction between age and TPA was observed when the sample was stratified according to ages being above or below 70 years. When the patient population was analyzed according to the number of ischemic events, it was found that 62 of the 106 subjects with a history of stroke had experienced more than one ischemic event. Under these conditions, the levels of TPA and PAI-1 still correlated with the occurrence of previous ischemic episodes. As in the whole patient sample, TPA was the strongest discriminator. We conclude that in subjects attending a metabolic ward, TPA and PAI-1 levels consistently help identify subjects with a history of cerebral ischemic episodes and that TPA is the strongest discriminator.

The prevalence of parkinsonism in Italy: an epidemiological survey of the disease in general practice. The Italian General Practitioner Study Group (IGPSG)

The prevalence and characteristics of parkinsonism have been assessed in two separate geographic areas in Italy (Arcisate and San Giovanni Rotondo). A total of 28,377 patients of 23 general practitioners (GPs) were the reference population. Fifty-eight patients were traced by the GP as having typical parkinsonian features or being treated with antiparkinson drugs. Among 53 subjects, 21 of them untreated, parkinsonism was subsequently confirmed neurologically. The overall crude prevalence rate was 1.87 cases per 1,000 (Arcisate 1.81; San Giovanni Rotondo 2.01). The age- and sex-adjusted prevalence rates were 1.84 in Arcisate and 2.04 in San Giovanni Rotondo. After exclusion of drug-related parkinsonism, the rates were 1.48 and 1.90, respectively. Even with some inconsistencies within the two study areas, the prevalence tended to be higher in San Giovanni Rotondo, to prevail in women, and to increase significantly with age. Presumed etiological factors for parkinsonism were recorded in 34% of the cases (mostly drugs). In two thirds of the cases the disease ran a mild course. The present study shows that the GP proves a valuable reference for surveys of parkinsonism in Italy.

Physiological basis of voluntary activity inhibition induced by transcranial cortical stimulation

Apart from exciting corticospinal cells and evoking a motor response, electrical or magnetic transcranial cortical stimulation (TCCS) delivered during voluntary activity produces a prolonged inhibition of activity, a silent period (SP), that can last up to 280 msec. The SP duration after TCCS is directly proportional to stimulus intensity. To determine the anatomic substrate and underlying physiological properties of the SP from TCCS, we (1) compared the SP from TCCS with the SP from cutaneous and mixed nerve stimulation, (2) studied the excitability cycle of spinal motor neurons in 3 double stimulus conditions: (a) after paired peripheral nerve stimulation, (b) after TCCS and peripheral nerve stimulation, and (c) after paired electrical TCCS, (3) investigated the timing of the excitability of the sensorimotor cortex measuring long latency responses from median nerve stimulation delivered inside the SP from TCCS. We found that after TCCS, spinal motor neuron segmental excitability is reduced for a period up to 100 msec. Inhibition at a suprasegmental, possibly cortical, level was even more prolonged for a period up to 160 msec, suggesting that at least the late part of the SP after TCCS is due to supraspinal inhibition. Determining the nature of the supraspinal inhibition such as the possible role of cortical inhibitory mechanisms may be useful in further understanding central mechanisms of voluntary motor control and sensorimotor processing.

[Cholecystectomy by video celioscopy in the elderly. An obligatory choice?]

The videocelioscopic technique is becoming increasingly widely used in the treatment of cholelithiasis. In view of the results obtained, the authors underline the advantages of this method in geriatrics.

[The diagnosis and treatment of renal oncocytoma. Our experience]

Personal experience of the treatment of renal oncocytoma is compared with reported data. Furthermore the problems relating to the diagnosis and treatment of this tumour, characterised, in many cases, by its lack of symptoms and tricky histopathological classification, are examined in greater depth.

The prediction of total body water from body impedance in young obese subjects

Almost all formulae for the prediction of total body water (TBW) from body impedance are based on the assumption of a constant conductor configuration--i.e. a constant subject section. In this paper we report on data obtained for a group of 19 young obese subjects (relative weight greater than 120%) and 10 young normal subjects (relative weight 80-110%). In obese subjects, the application of two different formulae generated from normal children gave biased results and led to an underestimation of TBW with respect to the reference value obtained by deuterium oxide dilution. Body mass index accounted for more than 40% of the inter-individual variability, suggesting that body size was not taken sufficiently into consideration by the predictive formulae used. We have used the body surface area as the anthropometrical parameter for the prediction of TBW from body impedance. The regression formula that we propose (TBW = 1.156 x (surface area/body impedance) - 2.356; R = 0.96), although requiring further validation on external populations, seems to provide a more realistic assessment of TBW in young obese subjects. We therefore suggest that the assessment of TBW in young obese subjects requires specifically designed prediction formulae.

[Spontaneous rupture of the spleen caused by primary amyloidosis. Description of a clinical case]

Spontaneous rupture of the spleen in primary amyloidosis is an uncommon event. After a review of the pertinent literature (10 case-reports between 1948 and 1987) a case of spontaneous splenic rupture with hemoperitoneum is presented. The diagnosis depends on the demonstration of amyloid deposit in splenic and hepatic tissues.

[Effect of somatostatin and salmon calcitonin on carcinoid syndrome. A clinical case]

In carcinoid syndrome, calcitonin administration proved to have an effective action in reducing symptomatology. During the perioperative period, treatment with somatostatin, thanks to the ease of administration of the drug and the reductive action of gastroenteric secretion, demonstrated its usefulness in countering the action of serotonin. In the present case, the data reported in the most recent literature on the use of the two drugs in the carcinoid syndrome are confirmed.

[Angiodysplasia of the colon]

Ascending colon angiodysplasia is a cause of colorrhagia, particularly if the patients are more than 55 years old. Therapy is primarily surgical and it consists generally in right hemicolectomy. Two cases personally observed are reported and a survey of the literature is made.

[Carcinoma of the gallbladder. Our experience]

A series of 14 patients (6 males and 8 females) suffering from gallbladder cancer has been examined. Postoperative mortality, mean survival, quality of life understood as time free from symptomatology, and the incidence of early postoperative complications in relation to the various types of radical and palliative intervention performed were evaluated.

[Human sparganosis. A clinical case]

After reviewing the international literature, the Authors report an uncommon case of sparganosis localized in a submandibular gland.

[CA 15-3 in the diagnosis and monitoring of carcinoma of the breast and its correlations with CEA]

The effectiveness of marker CA 15-3 is assessed for the purposes of early diagnosis of breast cancer and its monitoring and data are compared with that of CEA. The results obtained in a series of 71 breast tumours show that CA 15-3 presents high positivity for T2 (66.2%) and possesses greater diagnostic sensitivity and accuracy than CEA.

Polyneuropathy in an adult hospital population. Assessment of the prevalence through a simple screening procedure

An epidemiological survey has been conducted during a 3-month period in the Regional Hospital of S. Giovanni Rotondo, a small city in Southern Italy. A total of 1,878 patients aged 12 years and over admitted to the hospital were randomized during the study period. Each patient was asked 7 specific questions focusing on symptoms most likely due to polyneuropathy. The sensitivity and specificity of the screening procedure were tested separately and found to be high. All cases who gave affirmative answers to at least 2 questions were carefully investigated in search of a polyneuropathy. Of the 20 cases which gave an affirmative answer to 2 or more questions, 19 (1% or 10 cases per 1,000 hospital population) had a neurological examination fitting with the diagnosis of polyneuropathy. There were 3 males and 16 females with a median age of 61 years. Diabetes was the commonest associated disorder. The disease ran a mild course in 12 cases and was severe in only 1. The screening model used in the current study seems a valuable and simple approach for case ascertainment in epidemiological investigations of polyneuropathy.

Evaluation of a new bronchodilating compound (broxaterol) administered as a pressurized aerosol

The bronchodilating activity and the tolerability of a new beta 2-agonist, broxaterol hydrochloride, administered in single doses of 200 and 400 micrograms as pressurized aerosol were studied in 12 adult patients with reversible airway obstruction, taking placebo as a control. A double-blind three-way cross-over design using a series of randomly chosen latin squares was employed. FVC, FEV1, MMEF, heart rate, and blood pressure were measured immediately before and 7.5, 15, 30, 60, 120, 180, and 240 min after each treatment. Our results show that broxaterol is an effective bronchodilating drug with a dose-related activity. The areas under the curves of the changes in FVC, FEV1, and MMEF after the 400 micrograms dose were found to be significantly greater as compared to the 200 micrograms dose. Both broxaterol doses produced significant increases in all the spirometric indices already at the first measurement, i.e., 7.5 min after treatment. Broxaterol 400 micrograms induced significant increases in FVC, FEV1, and MMEF through at least 4 h. The tolerability of the new compound was good.

Prevention of fog-induced bronchospasm by nedocromil sodium

A single dose double-blind crossover study was performed to compare the efficacy of nedocromil sodium (4 mg) and placebo administered from pressurized aerosols against bronchoconstriction induced by the inhalation of ultrasonically nebulized distilled water (fog) in twelve asthmatic subjects. Neither active nor placebo pre-treatment produced any significant change in baseline FEV1 and SRaw. Nedocromil sodium significantly attenuated fog-induced falls in FEV1 (P less than 0.001) and increased specific airways resistance (SRaw, P less than 0.01). The results provide further evidence of the potential therapeutic usefulness of nedocromil sodium in the management of chronic obstructive airways disease.

Prevention of fog-induced bronchospasm by high doses of ipratropium bromide in asthmatics

In 12 adult asymptomatic, relatively stable adult asthmatics the protective effect of 3 doses (200, 1,000 and 2,000 micrograms) of ipratropium bromide against bronchospasm induced by an ultrasonic mist of distilled water was functionally (sRaw, FEV1) assessed. Ipratropium bromide and placebo were administered as an inhalation powder via a special inhaler in random order and under double-blind conditions at the same time on 4 usually consecutive days 90 min prior to the challenge. A considerable protective effect (clearly inferior, in any case, to that previously observed by us with fenoterol) was demonstrated (% protection approximately equal to 50) without any striking difference among the 3 doses. Mouth dryness (dose-related) was the sole complaint in some patients.

Prevention of fog-induced bronchospasm by Duovent and its components (fenoterol, ipratropium bromide) in asthmatics

16 hyperreactive asthmatics were challenged with an ultrasonic mist of H2O at the same time of day on 4 usually consecutive days 2 h after premedication with placebo, fenoterol (200 micrograms), ipratropium bromide (80 micrograms) and Duovent (fenoterol 200 micrograms + ipratropium bromide 80 micrograms), given in random order and double-blind conditions. The challenge test consisted of 3 exposures of 30, 60 and 120 s with 4-min intervals. Specific airway resistance (sRaw) was measured under basal conditions and 1, 2 and 3 min after each exposure. FEV1 was measured under basal conditions and immediately after the last sRaw measurement. Fenoterol afforded a good protection; ipratropium bromide alone was ineffective but enhanced the protective effect of fenoterol when the two drugs were given in combination (Duovent). A similar effect was also observed after a second challenge performed 1 h (9 patients) or 3 h (6 patients) after the first one, which was performed 2 h after premedication.

Tolerance of carprofen in patients with asthma caused by non-steroidal anti-inflammatory drugs

Eight asthmatics with respiratory intolerance to NSAIDs and two subjects (one asthmatic, one healthy) only sensitive (asthma) to pyrazolone drugs were challenged under single-blind conditions with a new NSAID, carprofen. No adverse effects were observed in patients sensitive to pyrazolones. Among the other patients, only three developed considerable bronchial obstruction which was rapidly reversed by inhalation of a beta 2-stimulant (fenoterol: 2 puffs). Two subjects developed nasal obstruction with rhinorrhoea: in conjunction with bronchoconstriction in one patient and alone in the other. In conclusion, acute administration of carprofen in patients with respiratory intolerance to NSAIDs, in contrast to most other NSAIDs, never creates a situation of real danger even though in some patients it may considerably increase nasal and bronchial resistance.

Pharmacokinetic study on intravenous rifampicin in man

A pharmacokinetic study was carried out in 18 male patients in order to assess the blood concentrations of rifampicin after intravenous administration of 3 different doses (600, 900 and 1200 mg) over 3 different periods of infusion (1, 2 and 3 hours). The results show that, by increasing the dose and the rate of infusion higher and earlier peak concentrations are obtained. A kinetic analysis based on a one-compartment open model gives a good fitting of the data obtained experimentally. From these data one obtains for the volume of distribution a value of 48.1 +/- 17.2 liters and for the serum disappearance rate the value of 0.212 +/- 0.070 h-1 in adult subjects. It is possible to predict the time course of serum kinetics of the drug by using the equation (formula; see text).