Development and Validation of Staging Systems for AA Amyloidosis

Key Points

Background

The kidney is involved in almost 100% of cases of AA amyloidosis, a rare disease caused by persistent inflammation with long overall survival but frequent progression to kidney failure. Identification of patients with advanced disease at diagnosis is difficult, given the absence of validated staging systems.

Methods

Patients with newly diagnosed AA amyloidosis from the Pavia (n=233, testing cohort) and Heidelberg (n=243, validation cohort) centers were included in this study. Cutoffs of continuous variables were determined by receiver operating characteristic analysis predicting death or dialysis at 24 months. Prognostic factors included in staging systems were identified by multivariable models in the testing cohort.

Results

Age ≥65 years, eGFR <45 ml/min per 1.73 m2, and elevated natriuretic peptides (type-B natriuretic peptide >130 ng/L and/or N-terminal type-B natriuretic peptide >1000 ng/L) were associated with overall survival and included in the staging system (all with simplified coefficients 1). Mean 36-month overall survival was lower with higher staging system scores (score 0–1: 92%; score 2: 72%; score 3: 32%). These results were confirmed in the validation cohort. For kidney failure, variables selected to enter in the staging system model were proteinuria >3 g/24 hour and eGFR <35 ml/min per 1.73 m2 (both with simplified coefficients 1). The 36-month cumulative incidence of kidney failure was higher with higher staging system scores (score 0: 0%; score 1: 24%; score 2: 51%). Again, similar results were obtained in validation cohort.

Conclusions

We identified and validated biomarker-based staging systems for overall survival and kidney failure in AA amyloidosis.

A wearable inertial system to evaluate Tai Chi training motor effects in patients with Parkinson's disease. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023;2023:1-4. [PMID: 38083600 DOI: 10.1109/embc40787.2023.10340906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Physical therapy is strongly recommended for patients with neurological disorders. Tai Chi-based treatments seem to improve physical functions like gait speed and balance. However, assessments after treatment rely on semi-quantitative clinical scales affected by subjectivity with controversial results. This study aims at investigating whether Tai Chi could be a valid alternative to traditional physiotherapy rehabilitation. We propose a wearable system composed of two inertial devices able to objectively measure the effect of the rehabilitation treatment on the range of movement of the trunk. Seventeen patients with Parkinson's Disease (PD) were recruited and assessed. They have been randomly divided into two groups: group 1 followed a Tai Chi-based treatment, while group 2 underwent a traditional physiotherapy rehabilitation. The two groups have been assessed before (t0) and after the treatment (t1). No statistical differences have been found in the relative range of motion between the upper and lower sensors between the two groups at the baseline. Both treatments resulted in a significant improvement in the trunk range of movement (on the right side). Notably, the improvement in the effect size of the treatment was greater in group 1 than in group 2. In fact, even if both the groups benefited from their treatment group 1 gained larger mobility of the trunk if compared to group 2. Interestingly, no differences have been accounted adopting the traditional UPDRS III for motor symptoms of PD, strengthening the idea that objective measurement coming from wearable biomedical sensors could detect information otherwise neglected by traditional clinical tools.Clinical Relevance- This study preliminary confirms that beneficial motor effects after a Tai Chi rehabilitation program are comparable and quite better than after traditional physiotherapy, promoting Tai Chi as a valid alternative treatment for PD patients.

Lenalidomide-based triplet regimens in first relapsed multiple myeloma patients: real-world evidence from a propensity score matched analysis

Lenalidomide and dexamethasone (Rd)-based triplets, in particular carfilzomib-Rd (KRd) and daratumumab-Rd (DaraRd), represent a standard of care in lenalidomide-sensitive multiple myeloma (MM) patients in first relapse. Meta-analysis of randomized clinical trials (RCT), suggested better outcome with DaraRd. Trying to address this issue in clinical practice, we collected data of 430 consecutive MM patients addressed to Rd-based triplets in first relapse between January 2017 and March 2021. Overall, the most common used regimen was DaraRd, chosen in almost half of the cases (54.4%), followed by KRd (34.6%). Different triplets were used much less commonly. In an attempt to limit the imbalance of a retrospective analysis, we conducted a propensity score matching (PSM) comparison between DaraRd and KRd. After PSM, efficacy of DaraRd versus KRd was similar in terms of overall-response rate (ORR) (OR: 0.9, P=0.685) as well as of very good partial response (VGPR) or better (OR: 0.9, P=0.582). The median progression-free survival (PFS) was significantly longer for DaraRd (29.8 vs. 22.5 months; P=0.028). DaraRd was tolerated better, registering a lower rate of grade 3-4 non-hematological toxicity (OR: 0.4, P<0.001). With the limitations of any retrospective analysis, our real-life PSM comparison between DaraRd and KRd, in first-relapse MM patients, showed better tolerability and prolonged PFS of DaraRd, although with some gaps of performance, in particular of DaraRd, with respect to RCT. Carfilzomib-containing regimens, like KRd, still remain a valid second-line option in the emerging scenario of first-line daratumumab-based therapy.

591 SEQUENCE OF DIAGNOSTIC TESTING IN CARDIAC AMYLOIDOSIS: EARLY MONOCLONAL PROTEIN STUDY IS ASSOCIATED WITH BETTER OUTCOMES IN AL AMYLOIDOSIS

Background

Isolated cardiac amyloidosis (CA) is a complex diagnostic scenario, highlighting the need for physician awareness in differential diagnosis. Among the different types of amyloidosis, nearly all cases of CA are caused by light chain (AL) and transthyretin amyloidosis (ATTR). Patients with suspect CA without monoclonal components (MC) in both serum and urine and normal free light chain (FLC) ratio can have a non-biopsy diagnosis of ATTR amyloidosis with bone scintigraphy (1). However, in all suspected CA with a MC (approximately 20% of patients with ATTR amyloidosis), amyloid typing is mandatory. Thus, the diagnostic pathway of CA diverges based on MC-studies. We aim to assess if different sequence of diagnostic tests can affect outcomes in patients with cardiac AL amyloidosis.

Methods

Pavia Amyloidosis prospectively maintained database was searched for patients with isolated cardiac AL amyloidosis referred to our Centre from January 2016 to December 2020. Patients with a known monoclonal gammopathy (MG) and with multiple organ involvement were excluded. We searched for the date of symptom onset and first suspect of CA (i.e. recognition of clinical, imaging or laboratory signs of CA). In addition, we recorded the date of the different diagnostic tests performed: i.e. echocardiogram; serum and urine immunofixation and FLC measurement (MC-study); bone scintigraphy and cardiac magnetic resonance (defined as advanced cardiac imaging). We calculated the interval between those time-points and the final diagnosis: (a) from symptom onset to diagnosis, (b) from first suspect to final diagnosis, (c) from first suspect to MC-study and (d) to advanced cardiac imaging tests. We then searched for possible intervals of time amongst those, that were able to predict death at 3 months, by means of a ROC analysis.

Results

A total of 94 patients were included in the analysis (25% of all patients with cardiac AL amyloidosis diagnosed in the study period). Six (6%) patients died &lt;1 month from diagnosis, and 27 (29%) died &lt;3 months. Median overall survival (OS) of the whole cohort was 8 months, and the median follow-up of living patients was 39 months (range 16-73). The median time from symptom onset to diagnosis was 9 months (range 1-44) and the median time from the first suspect to diagnosis was 2 months (range 0-9). An interval from the first suspect to MC-study ≥6 weeks was the only predictor of death at 3 months. None of the other tested periods were associated with a significant ability to predict survival. A delay in MC-study ≥6 weeks identified patients with more advanced cardiac stage (50% vs. 25% were stage IIIb, P=0.02) and was associated with a significantly worse outcome (median survival 13 months vs. 4 months, P=0.012). In the whole cohort, a total of 76 (81%) patients underwent at least one advanced imaging examination. Amongst those, 37 (49%) performed the imaging tests before MC-study with a higher percentage of patients who had a delay in MC-studies evaluation (69% vs. 27%; P&lt;0.001).

Conclusion

In patients who present with isolated cardiac AL amyloidosis with previously unknown MG, a relatively short delay in identifying the amyloid MC results in a considerable reduction of survival. A delay in MC-study was associated with more advanced cardiac stage. MC studies should be the first step in the work-up of patients with suspected CA to guide biopsy vs. non-biopsy diagnostic approach.

593 PRESENTATION AND OUTCOME OF PATIENTS WITH COEXISTING CARDIAC AL AND ATTR AMYLOIDOSIS

Background

Incidence of ATTRwt amyloidosis increased in the last years, especially thanks to the possibility of a non-bioptic diagnosis. However, if a monoclonal component (MC) is detected, amyloid typing is mandatory to rule out AL amyloidosis. Differential diagnosis is even more important now that we have labelled treatment for both types of amyloidosis. In some cases, typing on endomyocardial biopsy (EMB) revealed the presence of both light chains (LC) and transthyretin (TTR) in the heart of the same patient (Sidiqi, et al, Blood Cancer J. 2019). We present a series of patients with coexisting AL and ATTR in the heart. In these cases, we elected to administer treatment for AL amyloidosis due to the more rapid course of this disease and because in Italy and in Germany tafamidis is not prescribable for patients with coexisting AL amyloidosis. Objective: To evaluate the outcome of patients with coexisting AL and ATTR amyloidosis in the heart after treatment for AL amyloidosis. Material & Methods: We identified 17 patients with coexisting AL and ATTR amyloidosis evaluated in a German (n=5) or Italian (n=12) referral center. Typing was performed by immunohistochemistry with custom made antibodies (IHC; N=5) and immunoelectron microscopy (IEM; N=8). In 4 cases, EBM samples were subjected to protein extraction following a new procedure (patent n EP3417295). SDS-PAGE/Western Blot analysis was performed for the main amyloidogenic proteins and its results were validated by mass spectrometry. Cardiac responses and progression were assessed according to AL amyloidosis criteria.

Results

3 patients were excluded because of post-mortem diagnosis and 1 because amyloid deposits were characterized on bone marrow biopsy and it was not possible to unequivocally conclude for the coexistence of LC and TTR in the heart. Thirteen patients were included in the analysis. Four had a positive abdominal fat pad (AFP). Three underwent EMB because typing by IHC was not possible on AFP by IHC. In 1 IEM was positive for TTR only, but given the presence of an abnormal free LC ratio and albuminuria, the patient underwent EBM that was positive both for LC and TTR at IEM. Perugini score 1 was observed in 3 patients, of whom 1 was positive for a TTR mutation (Val40Ile). In 1 case, bone marrow plasma cell infiltrate was ≥60%, in absence of other multiple myeloma defining events. All patients received treatment for AL amyloidosis and 10 had response data. None was treated for ATTR. At 6 months 9 achieved a hematologic response (HR) and 3 a cardiac response. Six patients had a cardiac progression, despite 5 had achieved a HR (complete response [CR] in 2, very good partial response [VGPR] in 2 and partial response in 1 case). After a median follow-up of 33.8 months, 2 patients died of worsening of heart failure after 15 and 48 months from diagnosis, despite the maintenance of CR and VGPR. Both had AL cardiac progression at 6 months.

Summary & Conclusion

This is the largest series of patients with coexisting AL and ATTR amyloid deposits in the heart and the first reporting outcome to AL treatment. The AFP was commonly negative and when positive typing was not possible by IHC. Moreover, IEM did not find AL deposits in 1 case. This was unexpected and may reflect a selection bias: patients with a MC and AL amyloidosis in the AFP are unlikely to be further tested for ATTR. This finding warrants further studies and a possible revision of diagnostic algorithms. Treatment for AL amyloidosis may not be able to stop progression in these patients, who should be granted access to anti-ATTR therapies.

Mastocytosis: Fertility and Pregnancy Management in a Rare Disease

Mastocytosis encompasses a subset of rare diseases, characterized by the presence and accumulation of abnormal neoplastic MC in various organ systems, including skin, bone marrow, spleen and gastrointestinal tract. Clinical manifestations are highly heterogeneous, as they result from both MC mediator release and MC organ infiltration. Both pregnancy, a lifetime dominated by huge physiological changes, and labor can provide triggers that could induce worsening of mastocytosis symptoms. On the other hand, mastocytosis has relevant implications in obstetric management and prenatal care during all the pregnancy. In this review article, current knowledge about the impact of mastocytosis on fertility and pregnancy outcome will be reviewed and discussed, with the aim to provide clinical practice guidance for the evaluation and management of pregnancy and delivery in patients with cutaneous and systemic mastocytosis.

Scoring the Risk of Having Systemic Mastocytosis in Adult Patients with Mastocytosis in the Skin

BACKGROUND

Mastocytosis in adults often presents with skin lesions. A bone marrow biopsy is necessary to confirm or exclude the presence of systemic mastocytosis (SM) in these cases. When a bone marrow biopsy is not performed, the provisional diagnosis is mastocytosis in the skin (MIS). No generally accepted scoring system has been established to estimate the risk of SM in these patients.

OBJECTIVE

To develop a risk score to predict SM in adults with MIS.

METHODS

We examined 1145 patients with MIS from the European Competence Network on Mastocytosis Registry who underwent a bone marrow biopsy. A total of 944 patients had SM and 201 patients had cutaneous mastocytosis; 63.7% were female, and 36.3% were male. Median age was 44 ± 13.3 years. The median serum tryptase level amounted to 29.3 ± 81.9 ng/mL. We established a multivariate regression model using the whole population of patients as a training and validation set (bootstrapping). A risk score was developed and validated with receiver-operating curves.

RESULTS

In the multivariate model, the tryptase level (P < .001), constitutional/cardiovascular symptoms (P = .014), and bone symptoms/osteoporosis (P < .001) were independent predictors of SM (P < .001; sensitivity, 90.7%; specificity, 69.1%). A 6-point risk score was established (risk, 10.7%-98.0%) and validated.

CONCLUSIONS

Using a large data set of the European Competence Network on Mastocytosis Registry, we created a risk score to predict the presence of SM in patients with MIS. Although the score will need further validation in independent cohorts, our score seems to discriminate safely between patients with SM and with pure cutaneous mastocytosis.

Clinical course and outcome of essential thrombocythemia and prefibrotic myelofibrosis according to the revised WHO 2016 diagnostic criteria

The recently revised World Health Organization (WHO) classification of myeloid neoplasms recognizes prefibrotic myelofibrosis (prePMF) as a distinct entity, characterized by well-defined histopathologic features together with minor clinical criteria (leukocytes, anemia, increased LDH, splenomegaly). The aim of the study was to examine the clinical relevance of distinguishing prePMF from essential thrombocythemia (ET). We identified in our database all patients affected with ET, prePMF and primary myelofibrosis (PMF) diagnosed according to 2008 WHO criteria with a bone marrow fibrosis grade 0-1 at diagnosis and one DNA sample to define the mutational status. The bone marrow morphology of all 404 identified patients was reviewed by an expert pathologist and patients were reclassified according to the 2016 WHO criteria. After reclassification, our cohort included 269 ET, 109 prePMF, and 26 myeloproliferative neoplasm unclassificable. In comparison with ET, patients with prePMF had higher leukocyte count, lower hemoglobin level, higher platelet count, higher LDH values, and higher number of circulating CD34-positive cells; they showed more frequently splenomegaly (all P values < ·001). CALR mutations were more frequent in prePMF than in ET (35·8% vs 17·8%, P < ·001). PrePMF patients had shorter overall survival (P < ·001) and a trend to a higher incidence of leukemic evolution (P ·067) compared to ET patients, while they did not differ in terms of thrombotic and bleeding complications. In conclusion, ET and prePMF diagnosed according to 2016 WHO criteria are two entities with a different clinical phenotype at diagnosis and a different clinical outcome.

Protein kinase CK2 is widely expressed in follicular, Burkitt and diffuse large B-cell lymphomas and propels malignant B-cell growth

Serine-threonine kinase CK2 is highly expressed and pivotal for survival and proliferation in multiple myeloma, chronic lymphocytic leukemia and mantle cell lymphoma. Here, we investigated the expression of α catalytic and β regulatory CK2 subunits by immunohistochemistry in 57 follicular (FL), 18 Burkitt (BL), 52 diffuse large B-cell (DLBCL) non-Hodgkin lymphomas (NHL) and in normal reactive follicles. In silico evaluation of available Gene Expression Profile (GEP) data sets from patients and Western blot (WB) analysis in NHL cell-lines were also performed. Moreover, the novel, clinical-grade, ATP-competitive CK2-inhibitor CX-4945 (Silmitasertib) was assayed on lymphoma cells. CK2 was detected in 98.4% of cases with a trend towards a stronger CK2α immunostain in BL compared to FL and DLBCL. No significant differences were observed between Germinal Center B (GCB) and non-GCB DLBCL types. GEP data and WB confirmed elevated CK2 mRNA and protein levels as well as active phosphorylation of specific targets in NHL cells. CX-4945 caused a dose-dependent growth-arresting effect on GCB, non-GCB DLBCL and BL cell-lines and it efficiently shut off phosphorylation of NF-κB RelA and CDC37 on CK2 target sites. Thus, CK2 is highly expressed and could represent a suitable therapeutic target in BL, FL and DLBCL NHL.

[The mechanism of operation of the malaria therapy]

This article intends to synthetically introduce a meaningful Italian monographic contribution to the debate of the years '30 relatively to the mechanism of operation of the malariatherapy on the "paralytic" subjects to the light of the laboratory investigation own of neuropsychiatric medicine in that age.

[The painful hemiplegic shoulder: effects of exercises program according to Bobath]

AIM

To verify whether a shoulder exercises program according to Bobath reduced the shoulder pain in hemiplegic patients.

METHODS

We studied a total of 20 patients with pain shoulder. Ten patients are assigned to group R (submitted to rehabilitation) and ten to group R+E (submitted to rehabilitation and shoulder exercises program according to Bobath). Shoulder exercises program was self-performed by the patients after training in occupational rehabilitation unit. The assessment of patients was performed at admission to hospital, at discharge and three months after discharge. Shoulder pain (VAS), shoulder range of motion, disability (FIM), motor function (Fugl-Meyer scale) and spasticity (Ashworth scale) of paretic arm were evaluated in all patients.

RESULTS

VAS was similar in both groups at admission and decreased in group R+E at discharge without reaching significant differences (p=0.253). On the contrary, VAS and Shoulder range of motion improved statistically in group R+E (p=0.0001, p<0.04 respectively) after three months. The others variables measured did not change.

CONCLUSIONS

This study showed that a shoulder exercises program according to Bobath reduces shoulder pain of patients with hemiplegia if it is performed daily and for a long period of time.

[Disability and rehabilitation outcome in hemiplegia with global aphasia and neglect]

PURPOSE

Global aphasia and neglect are considered to be the neuropsychological disorders mostly affecting the hemiplegia outcome. The aim of this study is to examine which of the two disorders is making worse the recovery from hemiplegia.

METHODS

The study was conduced on 45 patients suffering from hemiplegia: 15 subject with global aphasia, 15 with neglect and 15 without neuropsychological disorders (control group). All patients were subject to rehabilitation treatment. Before and after rehabilitation, the assessment of patients was made using neuropsychological tests, Fugl-Meyer scale and Functional Independence Measure (FIM). At admission, all patients were not self-sufficient.

RESULTS

At the end of the rehabilitation period the recovery of motor function was poor in both groups. The damage on limbs motion was severe in 93.4% and marked in 6.6% of both patients with global aphasia and neglect. At discharge, the FIM motor score of patients with global aphasia (44.6 +/- 13) was higher than in those with neglect (37.2 +/- 10) and was not statistically different from control group (51.2 +/- 18) (p = 0.493). The FIM motor score of patients with neglect was significantly lower than control group (p = 0.036). In patients with global aphasia effectiveness was 35.5% and efficiency 0.40 while in patients with neglect effectiveness was 18% and efficiency 0.22. The final disability was lower in patients subject to global aphasia than neglect.

CONCLUSIONS

The study showed that neglect limits the recovery from stroke more than global aphasia.e.

Effects of chronic lithium treatment on the peripheral nervous system

BACKGROUND

Although lithium carbonate is widely used in the treatment of mood disorders, symptoms suggesting toxic effects on the peripheral nervous system may emerge even in subjects whose serum lithium levels remain within the recommended therapeutic range.

METHOD

Electroneuronographic (ENG) parameters (motor nerve conduction velocity of peroneal and median nerves, sensory nerve conduction velocity of sural and median nerves, amplitude of motor potential of peroneal and median nerves, and amplitude of sensory action potential of the median nerve at the wrist and the sural nerve) were investigated in 2 groups (N = 34) of patients suffering from bipolar affective disorder (DSM-III-R, DSM-IV) undergoing maintenance treatment with lithium carbonate for at least 1 year (mean = 2.06 years) in monotherapy. For 12 patients, ENG results were compared with pretreatment values, whereas in the other 22 cases, only data relevant to posttreatment were available. Fifty-four healthy subjects and 20 patients with recurrent major affective disorder (unipolar and bipolar) never treated with lithium made up the comparison groups.

RESULTS

Compared with the 2 comparison groups, patients on chronic lithium treatment showed significant reduction of motor nerve conduction velocity of peroneal and median nerves, sensory nerve conduction velocity of sural and median nerves, amplitude of motor potential of peroneal and median nerves, and amplitude of sensory action potential of the median nerve at the wrist and the sural nerve. The comparison with the assessment made prior to lithium treatment also showed significant changes; after a period of treatment with lithium varying from 2 to 8 years (mean = 5.2 years), significant reductions were found on motor and sensory nerve conduction velocity and on amplitude motor potentials and sensory action potentials.

CONCLUSION

Chronic maintenance treatment with lithium affects the peripheral nerves, even if the impairment rarely is such as to warrant discontinuation of treatment. Monitoring of ENG results could be useful for the early detection of neurotoxicity of lithium.

The Edinburgh Postnatal Depression Scale: validation for an Italian sample

A sample of 113 women has been recruited for the Italian validation of Edinburgh Post Natal Depression Scale (EPDS). These women, between the eighth and the twelfth week after delivery, were admnistered the EPDS and diagnosed according the DSM-III-R criteria using the MINI Interview. At the 8/9 cut-off score the sensitivity is 94.4%, specificity 87.4% and PPV 58.6%. The internal consistency of the EPDS Italian version was tested using Chronbach's alpha coefficient (0.7894) and Guttman split-half coefficient (0.8191). Finally a receiver operating characteristic (ROC) analysis was carried out to evaluate the global functioning of the scale: the area under ROC curve AUC is 0.7470 and the logistic estimate for the threshold score of 11/12 fitted the model sensitivity at 75% and model specificity at 67%. Our data confirm the validity of EPDS in identifying postnatal depression also in its Italian version and the scale could be used as an useful instrument in the clinical practice.

An Italian model of dementia special care unit: results of a pilot study

A small feasibility study was performed in Italy to evaluate whether the special care unit (SCU) model could minimize behavioral disturbances in demented patients. In a nursing home an area was selected to provide an appropriate environment for individuals with dementia. The physical environment was adapted, and the staff was trained to meet the needs of demented patients. Sixteen residents were transferred from traditional wards to the SCU. Functional status, cognitive performance, behavioral symptoms, and use of psychotropic drugs or physical restraints were assessed before and 6 months after admission to the SCU. Our findings show that transferring demented persons from traditional nursing home wards to an SCU significantly lessens behavioral problems but does not improve functional abilities or cognitive status after a short period of follow-up. Changes in caring strategies (in particular the use of physical restraints) seem to be important in reducing behavioral problems. The regional government of Lombardia (8.5 million inhabitants) decided to open small (20-bed) SCUs in 60 nursing homes (corresponding to 3.5% of the total nursing home beds in our region) and to reserve these units for demented patients with a high level of behavioral disturbances.

The psychosis of fatherhood: a clinical study

The psychosis of fatherhood is classified as an acute delusional disorder. It has been psychodynamically correlated with preoedipal conflicts. Common elements were identified in 6 men who were about to become fathers for the first time. Their personal histories and their clinical pictures were very similar. It is our hypothesis that up to the moment of facing the impact of becoming fathers themselves, these subjects had managed to avoid the oedipal conflict. As a consequence of this avoidance, they failed to identify with the father figure and to incorporate the paternal function into their symbolic universe. Once they accepted the concrete reality of fatherhood, these men underwent an acute psychotic crisis having inadequately interiorized paternal role models for themselves. We believe that this sort of psychopathological behavior becomes clinically manifest only when triggered by impending fatherhood.

[Progressive pneumoperitoneum in the surgical treatment of conspicuous ventral hernias. Importance of the procedure to restore a good respiratory function]

A recent clinical report regarding a patient with a voluminous laparocele treated using progressive pneumoperitoneum justifies this short paper on the use of this method as a preparatory act to reparative surgery. The paper emphasises the undoubted advantages deriving from the use of this technique, especially in the case of those subjects with a particularly poor respiratory function secondary to hernia.

[Therapeutic approach in ventral hernia]

Laparoceles are diseases of the abdominal wall and their repair does not usually involve technical problems which are difficult to resolve. The use of classic surgical methods, such as direct suture and plastic surgery, enables the parietal defect to be easily repaired in most case. However, cases do occur in which the surgeon is faced with considerable technical and tactical difficulties largely due to anatomopathological causes: the "loss of the right of domicile" of herniated viscera and the loss of musculo-aponeurotic substance. In the former case it is necessary to prepare the peritoneal cavity using pneumoperitoneum. In the event of the extensive destruction of the muscular component, or when the parietal breech is located next to bone or cartilagenous structures, it is essential to use a prosthesis. The paper goes on to describe the indications for the use of various techniques and their respective methods of use under different anatomo-clinical conditions.

[Pneumoperitoneum in preparation for surgery of large ventral hernia]

Reparative surgery of ventral hernia may be relatively simple or, on the other hand, the surgeon may be confronted with a number of tactical and technical problems. Many of these are caused by the "loss of the right of domicile". In order to avoid this particular condition it is useful to resort to preoperative pneumoperitoneum. This method entails the gradual and progressive introduction of air into the peritoneal cavity. In this way abdominal capacity is increased and it is therefore possible to re-insert all the viscera into their natural cavities avoiding all the harmful consequences for respiratory and cardio-circulatory organs following forced replacement. Preoperative pneumo-peritoneum is a relatively well consolidated surgical technique in large scale eventration. The methods is simple to perform and has a low incidence of complications.

[Progressive pneumoperitoneum in the preparation for surgical intervention for voluminous ventral hernias]

The paper report three patients suffering from voluminous ventral hernias who were treated using progressive pneumoperitoneum as a preparative method prior to reparative surgery. On the basis of the results obtained, the authors sustain the rationality, safety and efficacy of the procedure, in particular given its ability to reestablish good respiratory and circulatory function in those cases where the latter were severely affected by hernia. Since this method needs a longer application time and therefore involves a greater economic burden, pneumoperitoneum should probably be reserved for selected cases, and alternative techniques should be used in patients where hernia is more easily resolved.

Puerperal psychoses: a clinical case study with follow-up

Thirty cases of post-partum psychotic disorders occurred between 1973 and 1987 and hospitalized at the Psychiatric Ward of Florence University were studied and followed up. A structured diagnostic interview was used, which explored DSM Ill-R diagnosis both for mood disorders and for psychotic features. The psychotic symptoms had started within 8 weeks of parturition in all cases. Only 36.7% of the patients showed no subsequent pathology after the puerperal symptoms. The diagnoses, both at the index episode and at the follow-up, revealed a great predominance of mood disorders and the absence of schizophrenia. The follow-up survey showed a greater proportion of bipolar disorders than it appeared at the puerperal onset of the disease. A high frequency of puerperal psychotic relapses has also occurred after subsequent deliveries during the follow-up period.

[A case of anomalous outlet of the cystic duct]

The paper reports a case of anomaly affecting the extrahepatic biliary tract. Brief comments are made regarding the practical importance of this pathology.

[Malignant tumors of the small intestine. Comments concerning 21 observed cases]

Patients affected by malignant tumors of the small intestine observed by the Department of Clinical and Pathological Surgery at the University of Florence were studied from 1964 to 1989. The most important aspects of the disease were studied, on the one hand emphasising its low incidence and on the other the poor prognosis which accompanies it. Greater attention should be focused on these lesions in order to enable an early diagnosis to be made since this currently represents the sole possibility for carrying out an efficacious therapy.

[Endometriosis]

On the basis of two recently treated cases of endometriosis, the main aspects of this unusual pathology are examined; in particular its aetiopathogenesis, clinical picture and treatment still provide reasons of uncertainty. On the basis of an albeit limited experience, stress is laid on the importance of radical surgery, the only way to resolve the situation. Medical or conservative surgical measures are left to the early stages of the disease.

[Frequency and clinical significance of ectopic pancreas]

Ten cases of ectopic pancreas are presented. The literature on the subject is reviewed and the more controversial aspects of the disorder are discussed, in particular the clinical and anatomic-pathological significance, its diagnostic recognition, and the necessary treatment.

[Knowledge and attitudes regarding family clinics on the part of women who use or do not use them]

Thanks to large civil participation and to the women's movement in 1975 a law has been approved that institutes family health clinics. This law is dedicated in particular to health and general services for women and to family planning. The Hygiene Department of University of Perugia has studied during this time: the family health clinics (FHC) activity in order to determine how well it is meeting the institutional aims. The knowledge and the attitudes of women with respect their use of FHC which have been projected onto the community. Health Education has a very important role because it is quite often basis for acceptance of FHC by women. The identification of all aspects of cultural resistance is very important. To this point a research project has been completed. The focal point of this research concerns women and their ability to profit from available information, as well as their attitudes and evaluation of the FCH. This study has been using a representative sample of Umbrian women, aged 16-50 ys old, at March 1987; the sampling method was of two stage. On the whole 1647 observations have been made by means of a mail questionnaire. The responders were very low (about 25%), so the results obtained must be considered with extreme caution. Generally there is a positive opinion on family health clinic: women are linked to a service of the community. They express satisfaction with the service. They express opinions on both positive and negative aspects. Even if the first approach is generally determined by a gynecological visit, the users redefine the service in a less ambulatory manner and into a more consultative one. In fact, users consider the FHC as a reference for women's problems. They underline the lack of sexual and health consulting service. There is demand for counseling for infancy problems, sterility, health education and sexual education. Even the non-users have a sufficiently clear idea of the family health clinics. Non-users view the FHC as a service for women's problems as well as relationship problems.

[Abortion and the man. Psychological and psychopathological manifestations in the face of lost fatherhood]

This study examines the psychological and psychopathological reactions that may appear in a man when his partner aborts. The small amount of literature that exists on the subjects was examined, and several men were, interviewed at the time their partners aborted voluntarely. It turns out that in spite of the man's lack of recognition of any reactions (reinforced by current attitudes and by the scant psychological and medical interest in the subject), there is considerable emotional involvement in the lost parenthood, both for the man and the woman. As revealed by the interviews, this involvement may manifest itself in persecutory or depressive anxiety and psychosomatic symptoms. Moreover, but very rarely, real and typical psychopathological symptoms may appear, such as depression and behavioural disorders. The appearance of these reactions is linked to the problems and conflicts aroused by prospective fatherhood, leading to a comparison between the experiences of fuliwed fatherhood and those of fatherhood lost.

[Evaluation of alexithymic traits in bronchial asthma patients. Use of the Schalling Sifneos Personality Scale]

The authors investigate the alexithymia phenomenon and the possibility of quantifying it by administering the Schalling-Sifneos Personality Scale on four groups of subjects: asthmatics, psychosomatics other than bronchial asthmatics, patients afflicted with non-psychosomatic chronic illnesses and healthy subjects. The questionnaire permits a quantitative evaluation of the alexithymia phenomenon that appears significantly more evident in asthmatics than in patients afflicted with chronic illnesses and healthy subjects. The patients afflicted with psychosomatic illnesses other than asthma attain higher scores than asthmatic patients. The authors identify certain items on the scale as being particularly associated with the alexithymia phenomenon, enough to be able to construct a partial alexithymia score, indicative in itself of the presence of alexithymia personality traits, even in the absence of particularly high total alexithymia scores. Variations in age and educational level influence scores obtained by healthy subjects and patients afflicted with chronic illnesses, while this does not occur in asthmatics and other psychosomatic patients. This seems to indicate that the higher scores of the latter are not influenced by social or statistical types of factors, but rather by illness-related factors.

[Long-acting neuroleptics in the therapeutic relationship. I. General considerations]

In spite of their recognized effectiveness with psychotic pathologies and their unquestionable therapeutic advantages, long-acting neuroleptics, in use for more than a decade, still generate more bewilderment and resistance than other medicines. Within the profession, it is assumed that the difficulties associated with their use are related to the interference of subjective experience in the rational motivations of therapy. The strictly inherent aspects to the therapeutic relationship are taken into consideration in an attempt to systematize the subjective implications of the psychiatrist who prescribes the medicines and the patient who takes them. Experiences of rejection and/or total acceptance of the drugs are traced in the patient: these experiences are often determining factors in the progress of the therapy. These observations lead to an evaluation of the importance of the therapeutic relationship and the psychotherapeutic aspects this takes on during the course of chemotherapy. Thus the use of long-acting neuroleptics presents special difficulties connected with the fact that they create new means of communication in the patient, means which the psychiatrist must take into consideration in his relationship with the patient.

[Psychopathologic decompensation in paternity and the couvade syndrome]

Paternity, like maternity, provides an occasion for profound modifications of an individual's social role and internal world. Such modifications may be defined as "the job of becoming a parent". The authors examine psychological symptoms that appear at the advent of paternity, with special attention given to acute disorders and the couvade syndrome. Recalling the anthropological meaning of the term "couvade", this syndrome is regarded as a sort of "individual defense rite" from various conflicting elements that are stimulated by paternity. In the majority of these cases, this syndrome, fairly rare on the whole, is considered a "physiological" paternity symptom which through somatic symptoms expresses the father's conflicting drives toward his wife and child. In detail, the authors examine certain cases of acute disorder in which psychopathological symptoms are preceded by a somatic symptomology identifiable as a couvade syndrome. A hypothesis that a connexion exists between the psychosomatic symptomatology of couvade and acute disorders on a neurotic and psychotic level of paternity is formulated, analogous to what is observed in certain psychosomatic illnesses during whose course somatic symptoms alternate with psychotic symptoms.

[The task of becoming a parent: problems and failures]

The reactions of father and/or mother at the time of the birth of the first son are here analysed (post partum "blue", "couvade", paternal acting and neurotic depressions). These manifestations are considered as masked depressive states. Analogies between the freudian concept of the mourning work and the work of becoming parents are seen as an internal process for both parents to consider all their losses (the role of the son, the privileged role of the pregnant woman, the exclusive relationship with the partner . . .). Two aspects are emphasised which correspond to different levels of involvement and to different clinical manifestations. An incapacity to establish a dual relationship is expressed in both father and mother with psychosis as an escape from the work of parenthood; problems and failures in such work are expressed as depressive manifestations which testify the obstacles to this elaboration.

[Lithium in the prophylaxis of recurrent affective disorders. Effectiveness of low plasma levels and predictors to clinical response (author's transl)]

Thirty-eight patients suffering from recurrent affective disorder were treated at the Lithium Clinic of the Department of Clinical Psychiatry, University of Florence, with lithium carbonate for a period of 3-8 years; twenty-four (76%) had good response. The latter was defined as a decrease of at least 50% of recurrences during the period of treatment when compared with those of the period preceding treatment. This improvement was obtained in spite of the fact that plasmatic lithium was maintained within 0.40-0.80 mEq/l, a range lower than recommended. However, patients who sometimes let this value fall below 0.40 had significantly increased relapses. No marked toxic effect was recorded. Some factors (bipolar illness, typical symptom pattern and, probably, family history of affective disorder) were associated with a favourable outcome. However, the absence of these did not predict a poor response in more than 40% of the cases. The authors therefore conclude that it is worthwhile to start a lithium treatment whenever a diagnosis of recurrent affective disorder is met.