Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Prevalence of interstitial pneumonia suggestive of COVID-19 at 18F-FDG PET/CT in oncological asymptomatic patients in a high prevalence country during pandemic period: a national multi-centric retrospective study

PURPOSE

To assess the presence and pattern of incidental interstitial lung alterations suspicious of COVID-19 on fluorine-18-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) ([18F]FDG PET/CT) in asymptomatic oncological patients during the period of active COVID-19 in a country with high prevalence of the virus.

METHODS

This is a multi-center retrospective observational study involving 59 Italian centers. We retrospectively reviewed the prevalence of interstitial pneumonia detected during the COVID period (between March 16 and 27, 2020) and compared to a pre-COVID period (January-February 2020) and a control time (in 2019). The diagnosis of interstitial pneumonia was done considering lung alterations of CT of PET.

RESULTS

Overall, [18F]FDG PET/CT was performed on 4008 patients in the COVID period, 19,267 in the pre-COVID period, and 5513 in the control period. The rate of interstitial pneumonia suspicious for COVID-19 was significantly higher during the COVID period (7.1%) compared with that found in the pre-COVID (5.35%) and control periods (5.15%) (p < 0.001). Instead, no significant difference among pre-COVID and control periods was present. The prevalence of interstitial pneumonia detected at PET/CT was directly associated with geographic virus diffusion, with the higher rate in Northern Italy. Among 284 interstitial pneumonia detected during COVID period, 169 (59%) were FDG-avid (average SUVmax of 4.1).

CONCLUSIONS

A significant increase of interstitial pneumonia incidentally detected with [18F]FDG PET/CT has been demonstrated during the COVID-19 pandemic. A majority of interstitial pneumonia were FDG-avid. Our results underlined the importance of paying attention to incidental CT findings of pneumonia detected at PET/CT, and these reports might help to recognize early COVID-19 cases guiding the subsequent management.

Somatostatin receptors over-expression in castration resistant prostate cancer detected by PET/CT: preliminary report of in six patients

Prostate cancer (PC) is usually characterized by an excellent prognosis, largely due to little biological aggressiveness and the power of hormonal deprivation therapy. In spite of these favorable characteristics, however, a significant quota of patients does not respond to androgen deprivation therapy (ADT) and develop a progressive disease. Castration-resistant prostate cancer (CRPC) is defined by disease progression in spite of ADT. This progression may show any combination of a rise in serum prostate-specific antigen (PSA), clinical and radiological progression of pre-existing disease, and appearance of new metastases. This event is a striking change in the clinical scenario, since the power of treatment for CRPC patients with distant metastases is very limited. Somatostatin is a hormone produced by neuroendocrine cells. Its distant effects are mediated by the binding to five specific receptors, which are the most striking parameter for neuroendocrine. Various synthetic somatostatin agonists able to bind to the receptors have been synthesized during the past two decades for diagnostic and therapeutic purposes. Octreotide, the most popular of these, is widely used to treat patients affected by neuroendocrine tumors. A number of researches carried out in the past evaluated the possible neuroendocrine differentiation (NED) of PC cells in the castration resistant phase. If proved, the presence of a specific class of receptor on cell's surfaces should give a potentially biological target to be used for therapy. However, these studies led to contradictory results. Aim of our phase III diagnostic trial was to study "in vivo" the over-expression of somatostatin receptors (SSTRs) in CRPC patients by PET/CT after the administration of the somatostatin analog [(68)Ga-DOTANOC,1-Nal(3)]-octreotide labeled with (68)Ga. Every area of increased uptake corresponding to a metastasis detected with other methods was considered as SSTRs expressing. False positivity to SSTRs expression was considered those localizations with a suspicious uptake not confirmed by other radiologic procedures. On the other hand, metastatic lesions lacking the radiopharmaceutical's uptake were considered not SSTRs expressing metastases. The preliminary results in 6 of the 67 patients scheduled by our phase III trial showed metastases with a variable SSTRs expression in 2 patients.

Radioguided Parathyroidectomy with Portable Mini Gamma-Camera for the Treatment of Primary Hyperparathyroidism

Background. A proper localisation of pathological parathyroid glands is essential for a minimally invasive approach in the surgical treatment of primary hyperparathyroidism (PHP). The recent introduction of portable mini gamma-cameras (pMGCs) enabled intraoperative scintigraphic scanning. The aim of our study is to evaluate the efficacy of this new method and compare it with the preoperative localisation surveys. Methods. 20 patients were studied; they were evaluated preoperatively by neck ultrasound and (99mm)Tc-sestaMIBI-scintigraphy and intraoperatively with the pMGC IP Guardian 2. The results obtained from the three evaluations were compared. Results. The pMGC presented a sensitivity of 95%, a specificity of 98.89%, and a diagnostic accuracy of 98.18%, which were higher than those of preoperative ultrasound (sensitivity 55%; specificity 95%; diagnostic accuracy 87%) and scintigraphy with (99mm)Tc-sestaMIBI (sensitivity 73.68%; specificity 96.05%; diagnostic accuracy 91.58%). Conclusions. The pMGC can be used effectively as an intraoperative method to find the correct location of the pathological parathyroid glands. The pMGC is more reliable than the currently used preoperative and intraoperative localisation techniques.

Combination of ion beam stabilisation, plasma etching and plasma deposition for the development of tissue engineering micropatterned supports

The performance of biomedical assays at both molecular and cellular level depends greatly on the ability to design new polymer surfaces. Patterns can be created by using materials with contrasted surface properties. In this work we describe in detail the preparation of micropatterned surfaces to be used as tissue engineering supports. Poly(ethylene glycol) (PEG) was used as the 'anti-fouling' polymer in opposition to functional regions covered by acrylic acid (AAc). Since spin-casted PEG films are unstable, ion beam stabilization (IBS) treatment was applied in order to render it insoluble. On the other hand, AAc films were deposited by low-power plasma chemical vapour deposition. Chemical properties of both polymers were monitored by Fourier transform infrared spectroscopy and X-ray photoelectron spectroscopy while topographic features were followed by atomic force microscopy. Finally, a micropattern was produced by using a mask, which isolated the IBS-PEG from the AAc-deposited regions. Endothelial cells cultured on the surface were observed to follow the micropatterns. In fact, for a certain surface density it was observed that the cells present tensile or compressive stresses when forced to remain in the anti-fouling or the functionalised regions, respectively.

Diagnosis and treatment of lymph node metastases of a rectal carcinoid tumor using In111-octreotide-scintigraphy and intraoperative gamma probe detection

Carcinoids represent 1-2% of the rectal cancer. We report the case of a woman with a rectal carcinoid and a hypogastric node metastasis. We propose a less invasive treatment of the metastase using In11-octreotide-scintigraphy and intraoperative gamma-probe detector.

¹³¹I treatment of toxic nodular goiter under combined thyrostatic-thyromimetic medication is at low risk of late hypothyroidism

AIM

Treatment of toxic nodular goiter with ¹³¹I is a first-line therapy for hyperthyroidism. To avoid a thyrotoxic storm, ¹³¹I is usually administered after pretreatment with antithyroid drugs, with thyroid-stimulating hormone (TSH) increase and functional recruitment of inhibited normal tissue. Therefore, both autonomous nodule(s) and normal tissue are irradiated. This may be a reason for late hypothyroidism occurring in 15-25% of patients. This study aimed at assessing different pretreatment modalities with combined methymazole and triiodothyronine, achieving euthyroidism with suppressed TSH.

METHODS

After diagnosis of autonomously functioning toxic nodule, patients were subjected to thyrostatic medication. Two months later, TSH was checked; if >0.5 mU/L triiodothyronine treatment was associated. After 2 more months, if the TSH level was suppressed, patients received ¹³¹I-therapy. A total of 149 patients were consecutively enrolled, 41 of whom with uninodular and 108 with multinodular goiter. They were evaluated at diagnosis, pretreatment, 3 and 6 months after therapy and at late follow-up (6.8+/-4.2 years; range: 1-22 years).

RESULTS

Administered activity was calculated according to ¹³¹I uptake and gland weight. Methymazole was discontinued 6 days before treatment and T3 was maintained until administration of ¹³¹I-therapy. Euthyroidism was achieved in 88% of patients. At late follow-up, subclinical hypothyroidism was observed in 10 patients (6.7%) and overt hypothyroidism in 5 patients (3.3%). No pathological consequences or side effects of ¹³¹I-therapy were found during the 6.8+/-4.2 year follow-up period.

CONCLUSION

Treatment of toxic nodular goiter with ¹³¹I-therapy, under combined thyrostatic-thyromimetic treatment is a simple, safe, well-tolerated, and effective procedure.

The I.F.A.S.T. model allows the prediction of conversion to Alzheimer disease in patients with mild cognitive impairment with high degree of accuracy

This paper presents the results obtained with the innovative use of special types of artificial neural networks (ANNs) assembled in a novel methodology named IFAST (implicit function as squashing time) capable of compressing the temporal sequence of electroencephalographic (EEG) data into spatial invariants. The aim of this study is to test the potential of this parallel and nonlinear EEG analysis technique in providing an automatic classification of mild cognitive impairment (MCI) subjects who will convert to Alzheimer's disease (AD) with a high degree of accuracy. Eyes-closed resting EEG data (10-20 electrode montage) were recorded in 143 amnesic MCI subjects. Based on 1-year follow up, the subjects were retrospectively classified to MCI converted to AD and MCI stable. The EEG tracks were successively filtered according to four different frequency ranges, in order to evaluate the hypotheses that a specific range, corresponding to specific brain wave type, could provide a better classification (0.12 Hz, 12.2 - 29.8 Hz; 30.2 - 40 Hz, and finally Notch Filter 48 - 50 Hz). The spatial content of the EEG voltage was extracted by IFAST step-wise procedure using ANNs. The data input for the classification operated by ANNs were not the EEG data, but the connections weights of a nonlinear auto-associative ANN trained to reproduce the recorded EEG tracks. These weights represented a good model of the peculiar spatial features of the EEG patterns at scalp surface. The classification based on these parameters was binary and performed by a supervised ANN. The best results distinguishing between MCI stable and MCI/AD reached to 85.98%.(012 Hz band). And confirmed the working hypothesis that a correct automatic classification can be obtained extracting spatial information content of the resting EEG voltage by ANNs and represent the basis for research aimed at integrating spatial and temporal information content of the EEG. These results suggest that this low-cost procedure can reliably distinguish eyes-closed resting EEG data in individual MCI subjects who will have different prognosis at 1-year follow up, and is promising for a large-scale periodic screening of large populations at amnesic MCI subjects at risk of AD.

F18-FDG-PET/CT in a patient affected by Lynch syndrome

Lynch syndrome (LS) is the most common hereditary syndrome that predisposes patients to colorectal cancer, and it accounts for 2-5% of the total burden of colorectal cancer. We report a case of a 61-year-old female affected by Lynch syndrome who underwent multiple adenocarcinoma resections, studied by F18-FDG-PET/CT for 5 years. This case report suggests a potential role of F18-FDG-PET/CT in the evaluation of patients affected by Lynch syndrome.

Dementia, delusions and seizures: storage disease or genetic AD?

We describe a case of a young patient suffering from a rapidly progressive cognitive decline, associated with delusions, myoclonus and seizures and with no family history for dementia. Clinical features, along with skin biopsy findings were overlapping storage disease; the genetic analysis, however, demonstrated a de novo presenilin 1 mutation. The present report suggests the usefulness of genetic determinations in early-onset cases of dementia, even without an autosomal dominant trait of inheritance; for these cases and their relatives an extensive genetic counselling should be recommended.

Atmospheric bulk deposition to the lagoon of Venice Part I. Fluxes of metals, nutrients and organic contaminants

First available data on atmospheric fall-out were provided by sampling monthly bulk depositions in four sites inside the Lagoon of Venice (550 km2). Sampling was carried out monthly during the period July 1998-July 1999, in one site near an industrial area (Porto Marghera; site D), another site in the city of Venice (site A), and the remaining two in the southern- and northernmost ends of the Lagoon (Valle Figheri, site C; Valle Dogà site B). The following determinations were carried out for each samples: pH, conductivity, grain-size, particulate load, and dissolved nutrients (N, P). Samples were then subdivided into soluble and insoluble fractions, and Al, Ca, Na, K, Mg, Si, Mn, Fe, Zn, Ni, Cr, Cu, Pb, Cd, As, Hg, Ti, V, S, P, Se and Sb were analysed on both fractions. Total organic micropollutants (PAH, PCB, HCB, DDT, PCDD/F) were measured. As regards particle size distribution, there was great variability among sampling sites. The percentage of the < or =2 microm grain-size fraction was higher in the southern and northern ends of the Lagoon. Small differences were found among sites for major elements, whereas higher variability was observed for inorganic and organic micropollutants, with standard deviations between 20% and 60% of the fluxes measured. Major differences in annual fluxes between the most polluted sites (mostly D and A) and background (site B) were seen for Cd (0.26 vs. 0.06 mg m(-2) year(-1)), Hg (41 vs. 15 microg m(-2) year(-1)), PCB ( approximately 2500 vs. approximately 500 ng m(-2) year(-1)) and HCB ( approximately 8000 vs. approximately 1000 ng m(-2) year(-1)). Comparisons with previous data, collected in the periods 1993-1994 and 1995-1997, were only available for a few trace metals. A definite decline in the annual Pb flux in the city of Venice was detected, from 18 to 13 mg m(-2) in 1996/1997 and 1995/1996 respectively, to approximately 5 mg m(-2) in the present study. Total annual deposition was calculated by means of two different methods, which gave very similar results: (i) the mean value of deposition in the four sites was multiplied by lagoon area (550 km2); (ii) the monthly rain isopleths were combined to normalize deposition values. The figures are: 15-34 kg of Hg and Sb, approximately 200 kg of As, approximately 100 kg of Cd and PAH, 0.7-1.3 tons of Cr, Ni and V, more than 2 tons of Cu and Pb, 17 of Zn, 55 of total P, approximately 200 of Al, and 3900 of DIN. Total fluxes of organics inside the lagoon were: PAH approximately 100 kg; HCB approximately 1 kg; DDT approximately 0.4 kg. PCB and PCDD/F fluxes were approximately 500 g and approximately 10 g, corresponding respectively to 0.1 and 0.4 g I-TE. The correlations between fluxes of inorganic micropollutants and grain-size were significant. Multivariate statistical analysis was applied to investigate more accurately relationships between the insoluble and dissolved fractions of inorganic micropollutants and grain-size fractions. In particular, significant correlations were highlighted between the dissolved fraction of As and the < or =1 mum particle size fraction. Relations between levels of SigmaPCDDF, SigmaPCDD, PCB and PAH congeners and grain-size revealed significant correlation coefficients for the remote sites (B, C), and none in the urban and industrial sites (A, D). In particular, significant correlations were highlighted between SigmaPCDDF, SigmaPCDD and particle size fraction < or =2 mum, and between benzo(a)pyrene and PCB 167 and particle size fraction 4-8 mum.

Atmospheric bulk deposition to the Lagoon of Venice Part II. Source apportionment analysis near the industrial zone of Porto Marghera, Italy

Multivariate statistical analyses were applied to measurements of atmospheric deposition of total particulate (TSP), inorganic elements (Al, Ca, Na, K, Mg, Si, Mn, Fe, Zn, Ni, Cr, Cu, Pb, Cd, As, Hg, V and S) and organic compounds (PAH, PCB, HCB and PCDD/F) collected in four stations, all located in the Lagoon of Venice. Aerosols at the scale of the basin (i.e., within a distance of 20 km) were mainly characterised by two end-members, one natural (composed of mineral particulate and marine spray) and one anthropogenic (with at least two different source components), affecting the sites in various ways. Variability at the two distant (>20 km) sites (Valle Dogà, Valle Figheri) was mainly due to natural components, whereas the other two stations (city of Venice, Dogaletto, approximately 5 km) were mainly impacted by industrial (and urban) sources. Total annual inputs were compared with the limits recently set by law (maximum allowed discharge=MAD). In the year of study, MAD values were exceeded for total As, Cd, Hg, Pb, dissolved Zn, PAH and PCDD/F. These results indicate that industrial sources gave rise to a quasi-permanent compositional (background) effect near the industrial area. The risk associated with atmospheric deposition should be quantified within the DSPIR framework to avoid future negative consequences in populations living in the vicinity of Porto Marghera.

Value of gated SPECT in the analysis of regional wall motion of the interventricular septum after coronary artery bypass grafting

PURPOSE

The aim of this study was the evaluation of septal wall motion, perfusion and wall thickening after CABG in two groups of consecutive patients, one with grafted left anterior coronary artery and no history of myocardial infarction, and the other with previous anteroseptal myocardial infarction and impaired septal motion before surgery. The issue addressed was the ability of gated SPECT to differentiate between true paradoxical septal motion, characterised by paradoxical wall motion, depressed ejection fraction (EF), poor viability and compromised wall thickening, and pseudo-paradoxical motion, characterised by abnormal wall motion and regional EF but preserved perfusion and wall thickening.

METHODS

One hundred and thirty-two patients with previous anterior myocardial infarction, 82 patients with left anterior descending coronary disease and no history of myocardial infarction and 27 normal subjects underwent rest gated SPECT after 99mTc-sestamibi injection, according to the standard QGS protocol. Quantitative regional EF, regional perfusion, regional wall motion and regional wall thickening were determined using a 20-segment model.

RESULTS

Despite the presence of similar regional wall motion impairment in patients with and patients without septal infarction, in terms of regional EF (2.5%+/-3% vs 1.9%+/-4.9% p=NS) and inward septal motion (3+/-4.9 mm vs 2.3+/-6.1 mm p=NS), significant differences were observed in both perfusion (74.7%+/-6.2% vs 63.3%+/-13%, p>0.0001) and regional wall thickening (17.2%+/-7.4% vs 12.6%+/-7.2%, p>0.0001).

CONCLUSION

Gated SPECT with perfusion tracers can reliably differentiate pseudo-paradoxical from true paradoxical septal motion in patients with previous CABG, and it may be the method of choice for evaluating left ventricular performance in this patient population.

Measurement of atmospheric deposition of polychlorinated dibenzo-p-dioxins and dibenzofurans in the Lagoon of Venice, Italy

Data on atmospheric fall-out of polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) were provided by collecting bulk deposition in four stations inside the Lagoon of Venice. A total of 44 monthly samples was collected during the period July 1998-July 1999 in one site near an industrial area (Porto Marghera), one site in the city of Venice, and two sites in the southern- and northernmost ends of the Lagoon. Fluxes of PCDD/Fs were between 0.1 and 470 pg m(-2) d(-1), corresponding to 0-9.2 pg of 2,3,7,8-TCDD equivalents (TEQ) m(-2) d(-1), with a gradient increasing from remote to urban/industrial stations. Thus, annual deposition of PCDD/Fs to the Lagoon (total area=550 km2), calculated with various methods, turned out to be approximately 12 g, corresponding to approximately 400 mg TEQ. Significant differences were found among the stations, with a clear fingerprinting signature (PCDF/PCDD>1) of the deposition collected near Porto Marghera, and a reversed pattern (PCDF/PCDD<1) in the rest of the Lagoon, which pattern was similar to the sediments collected in the same locations. Lastly, the amount of bulk sigmaTEQ of all stations was compared with the guide values for dioxins in depositions proposed by De Fré et al. [Organohalogen Compounds 45 (2000) 324].

Prevalence of the E1317Q variant of the APC gene in Italian patients with colorectal adenomas

Loss of APC is an initial, rate-limiting event in inherited and sporadic colorectal tumorigenesis. Rare germline APC mutations have been identified in patients with multiple colorectal adenomas. Recently, the E1317Q APC variant has been associated with a predisposition to the development of multiple colorectal adenomas. In this study, the prevalence of the E1317Q variant was examined in 182 patients with single or multiple colorectal adenomas, and in 235 controls. In all, E1317Q was identified in two of 182 patients with adenomatous polyps (1.1%) and in two of 235 controls (0.8%) (p = 0.59). The risk of harboring adenoma(s) among subjects bearing the E1317Q variant was 1.29 (95% CI 0.09-18.0). No difference in the prevalence of E1317Q between cases with single (2.0%) or multiple colorectal adenomas (0.7%) and controls (0.8%) was found. None of the subjects with a family history of colorectal cancer carried the E1317Q variant. In conclusion, our results confirm that only a very small fraction of colorectal adenomas may be associated with the presence of E1317Q.

[Topical anesthesia for cataract surgery with phacoemulsification: lidocaine 2% vs ropivacaine 1%. Preliminary results]

BACKGROUND

The safety, tolerability and efficacy of ropivacaine 1% vs lidocaine 2% for phacoemulsification using topical anesthesia during cataract surgery, are compared.

METHODS

A prospective, randomized, double-blind study comparing two agents for topical anesthesia is reported.

ENVIRONMENT

Operative Unit of Ophthalmology, general Hospital. 1893 consecutively patients were studied (ASA 1-3, 738 males, 1155 females, age 71.8+/-9.7 years, range 35-90 years) undergoing routine phacoemulsification under topical 2% lidocaine (group I) and 1% ropivacaine (group II). The mains outcome measures of the study were: - the total dose of local anesthetic for obtaining a reduction of corneal sensation measured with the Cochet-Bonnet esthesiometer (value>3); - the pain recorded with visual analogic scale and verbal scale at: T1 = the first injection of local anesthetic; T2 = corneal incision; T3 = the end of surgery; T4 = 1h after surgery; T5 = the first postoperative day; - any requirement for additional intraoperative injection anesthesia and systemic sedation when needed; - surgeon assessments of operative conditions and patient cooperation; - patients' subjective level of comfort; - complications.

RESULTS

Topical anesthesia using lidocaine 2% was significantly more painful than the ropivacaine 1%. The onset of anesthesia adequate for surgery was similar in all two groups. There were differences between the groups with respect to perioperative analgesia because the VAS was significantly higher in lidocaine group than in ropivacaine group. There were no statistically differences between the two groups at the follow-up. Inadequate anesthesia was seen in 8.05% (74/919 patients) cases of group I vs 0.9% (22/974 patients) of group II. Sedation was needed only in 10 patients and 6 patients of group I and II respectively. The surgeon assessment showed more patient cooperation in the ropivacaine group (83%). Satisfactory comfort (level 1) was reported by 60.4% in the lidocaine group and 86.8% in the ropivacaine group. In both groups there were cases of postoperative epithelial edema (29 patients in group I vs 36 patients in group II) although it decreased after the first postoperative day. No other significant side-effects were observed with the use of either formulations.

CONCLUSIONS

Lidocaine 2% and ropivacaine 1% were safe and effective agents in patients having phacoemulsification with IOL implantation. However, ropivacaine provides more good operative conditions than lidocaine for the surgeon and comfortable surgical circumstances for the patient.

Clarithromycin in rheumatoid arthritis patients not responsive to disease-modifying antirheumatic drugs: an open, uncontrolled pilot study

OBJECTIVE

In 1996 we found by serendipity that 2 patients with rheumatoid arthritis (RA) who were taking clarithromycin (CM) to eradicate Helicobacter pylori experienced a regression of their RA symptoms. Following this observation, we tested the hypothesis that this reduction in symptoms could have been caused by CM administration.

METHODS

We performed a 6-month, open, uncontrolled pilot study on 18 patients (14 females and 4 males, mean age 62 yrs.) with RA who had previously received DMARDs (mean 2.6) and discontinued the treatment at least one month earlier because lack of efficacy or severe side effects. Patients were treated with CM at the dose of 500 mg twice per day for the first 10 days, followed by a daily maintenance dose of 250 mg twice per day.

RESULTS

4/18 patients did not complete the treatment, 2/18 were not responsive to the treatment and 2/18 discontinued the treatment. Following ACR criteria the improvement was: 10 patients ACR 20; 6 patients ACR 50; and 2 patients ACR 70. The remaining 4 patients did not reach ACR 20 since either the number of tender or swollen joints was not to the level required. Reductions in PGE2 and soluble phospholipase A2 plasma levels were closely related to CM plasma levels.

CONCLUSIONS

Ourfindings suggest that CM treatment can be beneficial in those patients who are not responsive to or cannot tolerate DMARDs. No definitive conclusions can be drawn based on the present study, due to the small sample size involved.

Effect of estradiol valerate alone or in association with cyproterone acetate upon vascular function of postmenopausal women at increased risk for cardiovascular disease

OBJECTIVES

a large body of evidence has been accumulated suggesting that impairment of vascular endothelial function is an initial step in the development of atherosclerosis. Recent studies have shown that estrogen replacement therapy in postmenopausal women (PMW) improves endothelium-dependent, flow-mediated dilatation (FMD) while the cyclical adjunct of a progestin may reverse this effect.

METHODS

the purpose of this study was to evaluate endothelium-dependent, FMD in the brachial artery and the plasma levels of Endothelin-1 in menopausal females treated with estradiol valerate with and without cyclical cyproterone acetate in 20 PMW (mean age 64+/-6 years) with more than one risk factor for coronary artery disease. After a baseline evaluation, PMW entered a double-blinded, placebo controlled single cross-over study and were randomized to receive either estradiol valerate (2 mg) for 21 days or estradiol valerate (2 mg) for 11 days and estradiol valerate (2 mg) and cyproterone acetate (1 mg) for 10 days. Patients were crossed-over the complementary treatment 7 days after completing the first treatment phase. The study of forearm blood flow was repeated at the end of each treatment period.

RESULTS

estradiol valerate significantly increased FMD as compared with baseline (12+/-3 vs. 7+/-4%, P<0.01) the adjunct of cyproterone acetate did not affect the effect of estradiol valerate upon FMD (12+/-3 vs. 11+/-4%, P=NS). Similarly reactive hyperemic flow increased after estradiol valerate alone (24%) or in association with cyproterone acetate (24%) compared with baseline. Plasma levels of Endothelin-1 were significantly reduced by estradiol valerate alone or in association with cyproterone acetate.

CONCLUSIONS

in conclusion hormone replacement therapy with estradiol valerate and cyproterone acetate improves endothelial function and reduces plasma levels of Endothelin-1 in PMW at risk of coronary artery disease. These effects may be relevant for cardioprotection.

How progestins influence the cardiovascular effect of hormone replacement therapy

Hormone replacement therapy aims to protect against osteoporosis and alleviate fastidious menopausal symptoms such as hot flushes, depression, sleep disturbances and vaginal dryness. In view of the acknowledgement of estrogen deficiency as a major trigger for the acceleration of cardiovascular risk after menopause, hormone replacement therapy may also be proposed as a substantial beneficial cardioprotective agent. The effects of progestins on lipoprotein profile and vasomotor tone are dependent on the chemical structure and the scheme of administration of progestins, with androgenic progestins and cyclical therapy having a potential detrimental effect. Prospective primary and secondary prevention studies, however, suggest that the adjunct of non-androgenic progestins to estrogen therapy is at least as effective as estrogen replacement therapy in reducing cardiovascular mortality and morbidity. Data from recent randomized secondary prevention studies have to be viewed with caution.

Usefulness of histological examination for the diagnosis of onychomycosis

BACKGROUND

[corrected] Direct microscopy and culture tests currently used in the diagnosis of nail mycosis can yield false-negative results, and confirmation of the pathogenic agent, especially in non-dermatophyte infections, is often a lengthy process.

OBJECTIVE

The aim of this study was to investigate the usefulness of the histological examination of nail clipping samples in supplementing the standard microscopic and culture techniques for the diagnosis of onychomycosis.

PATIENTS AND METHODS

One hundred and seventy-two subjects affected by nail alterations suggestive of onychomycosis were evaluated. Nail specimens were studied with 3 different techniques: direct microscopic examination of a 40% KOH clarified preparation, fungal culture and histological examination. Patients positive for fungal infection were re-evaluated with the same techniques after treatment with oral terbinafine, fluconazole or itraconazole and topical application of bifonazole or ciclopirox for 2 months.

RESULTS

Direct microscopy was positive in 102 (59.3%) nail specimens. The culture test was positive in 90 cases (52.9%), showing a dermatophyte in 45, a yeast in 23 and a mould in 22 samples. The histological examination was positive in 94 (54.6%) samples. In 4 cases, it was the only investigation confirming the clinical diagnosis of nail mycosis. In most of the cases, the morphological aspect of the hyphae and/or spores suggested also to which group of pathogens (dermatophytes, yeasts or moulds) the mycetes observed in the histological sections could be ascribed. The concurrent presence of a dermatophyte and a mould was evidenced in a few specimens. The control histological examination at the end of the treatment showed negative results or residual non-vital hyphae and/or spores.

CONCLUSIONS

Results of the present study indicate that the histological examination of nail clipping specimens is a relatively inexpensive, rapid and easily performed procedure. It is useful to confirm or refute the results of routine microscopy and culture tests. Moreover, nail histopathological observation may help in ascribing a pathogenic role of non-dermatophyte isolates and evaluating the effectiveness of antifungal treatment.

Organic pollution in a Ramsar site (Piallassa Baiona, northern Adriatic Sea)

A core collected in the Piallassa Baiona lagoon, a salt-marsh area already studied for Hg contamination related to nearby industrial sites, was analysed for organic micropollutants. Surface sediments show high concentrations of total PCBs (1148 ng g-1), PCDD/Fs (64 ng g-1) and PAHs (4801 ng g-1). According to a sedimentation rate of 0.4 cm y-1, the high increases in total PAH, PCB and PCDD/F concentrations began in the 1960s and peaked in the 1970s, in parallel with the highest Hg concentrations. Instead, the recent contamination, which primarily involves PCBs and PCDD/Fs, has been observed to be unrelated to Hg concentrations. Organic micropollutant concentrations in the sample core were compared with the sediment quality criteria provided by international guidelines, and revealed high toxic potential. This heavy contamination was also confirmed by comparison with similar environments, particularly the Lagoon of Venice. Further investigations are needed to understand better the sources of the recent contamination and to explain the different transfer pathways involved during sedimentation of the "old" material, dumped 20-30 years ago.

Atmospheric input of organic pollutants to the Venice Lagoon

The atmospheric deposition of dioxins and furans (PCDD-Fs), dioxin-like polychlorobyphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs) and hexachlorobenzene (HCB) was determined in the Lagoon of Venice. Sampling was carried out monthly, for a total of 13 months (July 1998-July 1999) using "bulk" samplers (passive collectors of wet and dry depositions) at four sites, inside the lagoon and close to its edge. Calculated PCDD-F loadings to the Lagoon turned out to be quite homogeneous, their range being approximately 10-20 ng m-2 y-1, whereas in the station located close to the industrial zone of Porto Marghera the value was approximately 50 ng m-2 y-1. PCB deposition in the industrial fallout sampling site and in the city centre of Venice was approximately 2500 ng m-2 y-1, that is, almost five times higher than the values measured at the northern and southern lagoon stations. HCB annual loading (approximately 8000 ng m-2 y-1) was almost six times higher in the industrial zone than in the other sites (approximately 1500 ng m-2 y-1). PAH loadings in the city centre of Venice and at Porto Marghera were 314 and 389 micrograms m-2 y-1, respectively. The amount of 2,3,7,8-TCDD equivalents (TEQ) of PCDD-Fs and PCBs in the Venice and Porto Marghera bulk depositions was compared with the guideline value of 15 pg m-2 d-1 for dioxins in depositions proposed by De Fré et al. (1998). Moreover, as some of the effects which drive the risk assessment of dioxin-like compounds were also observed after exposure to other molecules, the TEQs of PAHs and HCB were also calculated: nine out of 13 samples exceeded the guideline value. Lastly, an atmospheric emission source related to vinyl chloride monomer production, which may affect atmospheric deposition on the whole Lagoon, is reported in the industrial zone of Porto Marghera.

Mapping of early and late human somatosensory evoked brain potentials to phasic galvanic painful stimulation

In the present study, we modeled the spatiotemporal evolution of human somatosensory evoked cortical potentials (SEPs) to brief median-nerve galvanic painful stimulation. SEPs were recorded (-50 to +250 ms) from 12 healthy subjects following nonpainful (reference), slight painful, and moderate painful stimulations (subjective scale). Laplacian transformation of scalp SEPs reduced head volume conduction effects and annulled electric reference influence. Typical SEP components to the galvanic nonpainful stimulation were contralateral frontal P20-N30-N60-N120-P170, central P22-P40, and parietal N20-P30-P60-P120 (N = negativity, P = positivity, number = latency in ms). These components were observed also with the painful stimulations, the N60, N120, P170 having a longer latency with the painful than nonpainful stimulations. Additional SEP components elicited by the painful stimulations were parietomedian P80 as well as central N125, P170 (cP170), and P200. These additional SEP components included the typical vertex negative-positive complex following transient painful stimulations. Latency of the SEP components exclusively elicited by painful stimulation is highly compatible with the involvement of A delta myelinated fibers/spinothalamic pathway. The topography of these components is in line with the response of both nociceptive medial and lateral systems including bilateral primary sensorimotor and anterior cingulate cortical areas. The role of attentive, affective, and motor aspects in the modulation of the reported SEP components merits investigation in future experiments.

Gated blood pool tomography for the evaluation of global and regional left ventricular function in comparison to planar techniques and echocardiography

BACKGROUND

Multigated radionuclide ventriculography (MUGA) is a simple and reliable tool for the assessment of global systolic and diastolic function and in several studies it is still considered a standard for the assessment of left ventricular ejection fraction. However the evaluation of regional wall motion by MUGA is critical due to two-dimensional imaging and its clinical use is progressively declining in favor of echocardiography. Tomographic MUGA (T-MUGA) is not widely adopted in clinical practice. The aim of this study was to compare T-MUGA to planar MUGA (P-MUGA) for the assessment of global ejection fraction and to transthoracic echocardiography for the evaluation of regional wall motion.

METHODS

A 16-segment model was adopted for the comparison with echo regional wall motion. For each one of the 16 segments the normal range of T-MUGA ejection fraction was quantified and a normal data file was defined; the average value -2.5 SD was used as the lower threshold to identify abnormal segments. In addition, amplitude images from Fourier analysis were quantified and considered abnormal according to three different thresholds (25, 50 and 75% of the maximum).

RESULTS

In a study group of 33 consecutive patients the ejection fraction values of T-MUGA highly correlated with those of P-MUGA (r = 0.93). The regional ejection fraction (according to the normal database) and the amplitude analysis (50% threshold) allowed for the correct identification of 203/226 and 167/226 asynergic segments by echocardiography, and of 269/302 and 244/302 normal segments, respectively. Therefore sensitivity, specificity and overall accuracy to detect regional wall motion abnormalities were 90, 89, 89% and 74, 81, 79% for regional ejection fraction and amplitude analysis, respectively.

CONCLUSIONS

T-MUGA is a reliable tool for regional wall motion evaluation, well correlated with echocardiography, less subjective and able to provide quantitative data.

Recurrent proximal white subungual onychomycosis associated with a defect of the polymorphonuclear chemotaxis

Proximal white subungual onychomycosis (PWSO) is a rare form of nail infection that occurs almost exclusively in immunocompromised patients. Initially, in several reports, PWSO was described in ARC and AIDS patients. Later this pattern of onychomycosis was observed in patients with renal transplants, who received immunosuppressive therapy, and recently in a woman with active systemic lupus erythematosus (SLE) treated with systemic steroid therapy. We report a case of recurrent PWSO in a woman affected by a defect of polymorphonuclear chemotaxis. The association between PWSO and a defect of neutrophil chemotaxis, not yet described in the literature, suggests a point of discussion about the role of polymorphonuclear leucocyte functions in the defense mechanisms of the host affected by dermatophytosis. In this report the close association between PWSO and an immunocompromised condition is once again described. For this reason the authors emphasize the importance of investigating the common and uncommon causes of immunodeficiency in all patients affected by PWSO.

Clinical and laboratory manifestations of elderly onset psoriatic arthritis: a comparison with younger onset disease

OBJECTIVE

Although the influence of age on clinical and laboratory features has been widely demonstrated in many arthropathies, studies on elderly onset (> 60 years) psoriatic arthritis (EOPsA) are rare. This study compares manifestations at onset and two year outcome of EOPsA with those of younger onset PsA (YOPsA).

PATIENTS AND METHODS

Sixty-six consecutive PsA patients with disease duration < 1 year, 16 EOPsA (> 60 years) and 50 YOPsA (< or = 60 years) were admitted to a prospective study. Clinical, laboratory, and radiographic assessment were carried out at admission and after two years. HLA class I and bone scintigraphy were also recorded. In 10 patients with EOPsA and 24 with YOPsA it was possible to obtain synovial fluid, which was subsequently analysed for local inflammatory indices, including interleukin (IL) 1 beta, IL6, and IL8.

RESULTS

Presenting manifestations of EOPsA differed from YOPsA in number of active joints (mean (SD)) (12.2 (6.3) v 6.7 (4.6), p < 0.001), foot bone erosions (2.7 (1.2) v 1.1 (1.1), p < 0.001), erythrocyte sedimentation rate (64.2 (35.3) v 30.5 (30.0) mm 1st h, p < 0.001), C reactive protein (3.9 (2.0) v 1.3 (1.3) mg/dl, p < 0.001) and synovial fluid IL1 beta (8.0 (4.7) v 3.0 (3.0) pg/ml, p < 0.001) and IL6 (828.2 (492.6) v 469.3 (201.4) pg/ml, p < 0.005). No differences were found in the number of subjects with dactylitis, pitting oedema, HLA-B27, or signs of sacroiliac and sternoclavicular joint involvement at bone scintigraphy. After two years, progression was more evident in EOPsA than in YOPsA, as the number of new erosions in the hands and also the C reactive protein were higher in EOPsA patients.

CONCLUSION

PsA has a more severe onset and a more destructive outcome in elderly people (onset > 60 years) than in younger subjects. This behaviour may be influenced by immune changes associated with aging, as suggested by the higher concentrations of IL1 beta and IL6 found in the synovial fluid of EOPsA than in YOPsA.

Spectral analysis of intercycle heart fluctuations in the diethyl-ether-anaesthetized or pithed rat treated with prazosin, dl-propranolol, endothelin-1, alpha-r atriopeptin and ACE-inhibitors

1. Frequency-domain spectral analysis of stationary ECG R-R intervals was made by fast Fourier transformation (FFT) in conditions of monitored arterial blood pressure and respiratory activity in diethyl-ether-anaesthetized and pithed adult rats. This technique yields a number of parameters which allow quantitative evaluation of the non-random distribution of the mean values obtained in time-domain studies. The frequency-analysis method enables the overall heart rate variability to be broken down into its various constituents, which are differently affected by physiological loading and capable of selective reactivity to pharmacological agents. 2. The low-frequency spectral component obtained by breaking down the total spectral density power, i.e. the appropriate variability signal (band width < 0.15 Hz) and a higher-frequency band corresponding to spontaneous (0.80-1.60 Hz) or artificially imposed (0.75 Hz) respiratory activity were estimated and their integrated areas evaluated as absolute powers or normalized fractional values. 3. The power of the high-frequency spectral component increased in all animal preparations under treatment with prazosin, dl-propranolol, endothelin-1 and the angiotensin converting enzyme (ACE) inhibitors captopril, lisinopril, quinapril and ramipril. The power of the low-frequency band increased under alpha-r atriopeptin and ACE inhibitors in the pithed preparations only, and decreased in the anaesthetized animals. 4. The new power spectrum features and trends detected indicate that these time-independent, model-dependent cardiovascular and respiratory markers are subject to some form of complex peptidergic control. 5. The relative roles of the various factors operating in the genesis of these short-term changes in spectral power in the low- and high-frequency bands cannot be interpreted as indicating a reciprocal push-pull relationship between sympathetic and parasympathetic control. 6. The study findings, however, can be interpreted as providing evidence of a different and to some extent alternative form of integrative cardiovascular control persisting in the pithed rats (i.e. in the 'peripheral', CNS-destroyed preparations). 7. New areas of theoretical and applied research are being developed in the (auto)classification of (iso)receptors and drug analogues through exploration of multiple physiological and pharmacokinetic parameters in the frequency-domain. Furthermore, model-independent frequency-domain methods not requiring stationary data will afford scope for even more significant developments by separating the overlapping dynamic processes from a whole series of correlated effects.

Clinical, laboratory and immunogenetic aspects of post-traumatic psoriatic arthritis: a study of 25 patients

OBJECTIVE

In a previous study we demonstrated that the prevalence of trauma preceding arthritis was higher in patients with psoriatic arthritis (PsA) than in patients with rheumatoid arthritis (RA) or ankylosing spondylitis (AS); of 300 consecutive patients with PsA, 25 (8%) had a history of trauma before (< 3 months) the onset of the disease. The present study was carried out to characterize the clinical, laboratory and immunogenetic profiles of post-traumatic (PT)-PsA.

PATIENTS AND METHODS

The clinical and laboratory features of 25 patients with PT-PsA were studied at onset (first 6 months) and after a follow-up period of 1-7 years, and were compared with those of 275 PsA patients without any history of trauma (nonPT-PsA). HLA typing was performed in PT-PsA patients, and synovial fluid (SF) analysis, including interleukin (IL)-1 and IL-6 determinations, was carried out in 12 subjects with PT-PsA and in 32 with nonPT-PsA.

RESULTS

No differences were observed between PT-PsA and nonPT-PsA patients with regard to their clinical evolution. ESR (p < 0.0001) and CRP (p = 0.005) were higher in PT-PsA than in nonPT-PsA patients at disease onset but not after follow-up. No differences were found in the other blood indices. SF analysis revealed higher IL-6 levels in PT-PsA than in nonPT-PsA patients (p < 0.0005).

CONCLUSION

Our study demonstrates that the prevalence of trauma preceding arthritis is higher in PsA than in RA or AS. Clinical and laboratory findings in patients with PT-PsA differed from those with nonPT-PsA only at disease onset (first six months), however, showing an abrupt clinical presentation and a more acute phase response. This pattern may be related to the higher levels of IL-6 found in the SF of PT-PsA than in nonPT-PsA patients. However, during the follow-up period the two groups became indistinguishable, and no difference was observed between PT-PsA and nonPT-PsA regarding the evolution of the disease.

Teaching sign language to hearing children as a possible factor in cognitive enhancement

We describe an educational experience designed to teach Italian Sign Language (LIS) to a group of hearing children. The hypothesis underlying this experience was that learning a visual-gestural language such as LIS may improve children's attentional abilities, visual discrimination, and spatial memory. To examine this hypothesis, we conducted two studies. The first involved an educational experience lasting two years with a group of hearing children attending a Sign Language class from first to second grade. The Raven PM 47 TEST was administered at the beginning and at the end of each school year to children attending the LIS classes and to a control group of children enrolled in the same school but not exposed to LIS. The second study involved an educational experience in first grade. The Raven PM 47 and Corsi's block tapping tests were administered at the beginning and at the end of the school year to the children attending the LIS classes, to children enrolled in the same school but at tending an English class, and to children not exposed to a second language. We found that in both studies the LIS group performed better than the other groups. These results suggest that learning a sign language may lead to a cognitive advancement in hearing children.

(ECTO) nucleotidase kinetics observed by 31P-NMR spectroscopy: resolution of signals

We used 31P-NMR to study the action of the drug ouabain, a digitalis glycoside, on the ecto-nucleotidase catalysed reaction pathway: [formula: see text] Even under conditions where it was impossible to resolve all resonances from the individual species, the rate constants for the individual steps may be evaluated by a chi 2 fit of equations describing the global kinetics to the NMR data. The fitted values of the reaction rate constants show no inhibition of any step in the reaction pathway, confirming previous results. This improved kinetic method can be used to evaluate the effect of different substrates, ions and drugs, both in intact or pathologically altered organs and in tissue subcellular fractions.

Spectral analysis of intercycle heart fluctuations in Xenopus laevis, conscious or spinalized, treated with calcium channel blockers. Part I

1. In this study, electrocardiographic second lead tracings were recorded and analyzed online and offline in the conscious and spinalized Xenopus laevis under control conditions and after treatment with at least two effective doses of racemic diltiazem, nifedipine and racemic verapamil hydrochlorides. 2. Heart rates (HR) and intercycle heart rate power spectra (IHRPS) were calculated in the various experimental conditions. 3. Dose-dependent bradycardia was found in most cases, which was associated with dose-related increases in the overall dynamic range of the largest peak of HR variability (increased IHRPS), this being particularly marked at the higher nifedipine dose. The frequency position of the largest peak was unchanged in the spinalized preparation, as well as in the various treatments. 4. These findings may contribute toward a more complete pharmacodynamic definition of calcium channel blockers in their current therapeutic use.

Spectral analysis of intercycle heart fluctuations in the diethyl-ether-anaesthetized or pithed rat treated with l-hyoscyamine

1. Within the context of neural regulation of the activity of sinus node pacemaker cells, the study of heart rate variability, as explored in the frequency domain by spectral analysis, was proposed about 15 years ago as a quantitative tool for the evaluation of short-term autonomic cardiovascular control. It has since been postulated that the two main oscillations observed, one at low and the other at high frequency, may respectively be markers of sympathetic vs. vagal efferent cardiac activity, and that the low- and high-frequency signals may reflect a reciprocal or 'push-pull' relationship between sympathetic and parasympathetic control. 2. In our power spectra assessment, ECG R-R intervals were submitted to fast Fourier transformation analysis in order to study the mechanisms underlying the control of heart beats in rats. Data were acquired in conditions of steady arterial blood pressure and cardiac and respiratory activity (spontaneous or artificially stimulated) in diethyl-ether-anaesthetized and pithed rats, as well as in a group of control rats, all in the presence and absence of l-hyoscyamine. 3. With increasing doses of the parasympathetic antagonist, the fractal dimension of the time-series structure remained stable in most cases. The low-frequency spectral component narrowed with increasing drug doses and the high-frequency band underwent either no, or only very slight, changes. 4. In these rodent assays, the low- and high-frequency signals cannot be interpreted as a push-pull relationship between sympathetic and parasympathetic control.

Value of synovial fluid interleukin-1 beta determination in predicting the outcome of psoriatic monoarthritis

OBJECTIVE

To investigate the value of synovial fluid analysis in predicting the outcome of psoriatic monoarthritis.

METHODS

In synovial fluid from knee joints of 18 patients with psoriatic monoarthritis lasting less than six months, white blood cell count, acid phosphatase, lysozyme, and interleukin (IL)-1 beta were determined. ESR and serum C reactive protein were also measured. To define the outcome, the patients were monitored for at least three years and then subdivided into those with polyarthritis and those without.

RESULTS

Among the blood and synovial fluid indices considered, synovial fluid IL-1 beta was the only variable which differed between the patients who developed polyarthritis, within three years and those without polyarthritis after this time, at 20.82(SD 8.79) v 4.19(4.73) pg ml-1, P < 0.0001). A correlation was found between synovial fluid IL-1 beta concentrations and the number of affected joints after three years (r = 0.739, P < 0.0001).

CONCLUSIONS

Determination of synovial fluid IL-1 beta at disease onset may be useful in revealing the outcome of psoriatic monoarthritis since, among the variables considered in our study, this was the only one capable of predicting the evolution of monoarticular psoriatic arthritis to polyarthritis.