[Genetics of type 1 neurofibromatosis]

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterised by cafè au lait spots, multiple neurofibromas and Lisch nodules of the iris, with marked variability of expression. The NF1 gene is located at 17q11.2, spans 350 kb genomic DNA and comprises 60 exons encoding a 11-13 kb transcript (Viskochil et al.). Four alternatively spliced NF1 transcripts have been identified and they show differential expression in various tissues. NF1 gene is a member of the tumor suppressor gene family. The protein encoded by NF1, neurofibromin, has a domain homologous to the GTPase activating protein (GAP) family, and downregulates ras activity. Neurofibromin is involved in the control of cellular growth and differentiation and germline mutation analysis has shown that around 82% of all the fully characterised NF1 specific mutations so far predict severe truncation of neurofibromin. The current demand for molecular diagnosis of NF1 is low. Many couples would probably request a prenatal diagnosis if it could predict disease severity. Molecular prediction of disease severity and prognosis may either be very complicated or even impossible. Presymptomatic DNA diagnosis is probably not going to be in huge demand because the clinical diagnosis of NF1 is usually straightforward, even in early childhood. Further knowledge of the gene function may also lead to the development of new therapy for the disease.

Short report: Schistosoma mansoni miracidia are killed by the defense system of an Argentine strain of Biomphalaria straminea

Biomphalaria straminea snails from Argentina fail to shed cercariae even if exposed to high doses of Schistosoma mansoni EC miracidia. Alternative explanations for this failure are that miracidia are unable to penetrate the snail's epithelium or that the miracidia are killed by the snail's defense system. To discriminate between these 2 possibilities, B. straminea snails were individually exposed to increasing doses of miracidia. Susceptible B. glabrata were used as controls. Exposed snails were fixed 12 hr after exposure, and histological sections of the whole specimens were examined. Miracidia were seen to penetrate the epithelium of B. straminea and B. glabrata at similar rates (14.7%), independent of the exposure level. Regardless of the miracidial dose, 94% of the penetrating miracidia appeared encapsulated by the B. straminea defense system, whereas in B. glabrata, only 42% of the miracidia underwent encapsulation. These results show that resistance of B. straminea to S. mansoni EC strain is due to an efficient defense system that destroys miracidia once they have penetrated.

Characteristics of violent behaviour in acute psychiatric in-patients: a 5-year Italian study

OBJECTIVE

In order to examine prospectively the characteristics of violence among psychiatric patients, a 5-year study was carried out in an acute psychiatric unit.

METHOD

All assaultive behaviour occurred in the ward during the study period were assessed routinely using the Staff Observation Aggression scale (SOAS).

RESULTS

Of 1534 patients admitted to the unit during the study period, 116 were responsible for 329 aggressive episodes (prevalence of violence=7.5%, 2.8 incidents/patient). Most violent patients had an ICD-9 diagnosis of schizophrenia and/or delusional syndromes (55.1%), a history of violence (80.7%) and previous psychiatric admissions (92%). Approximately half of the incidents had no specific cause, occurred during daytime and the first week of admission and, in most cases, were directed towards individuals (77.8%).

CONCLUSION

Although confirming the low rate of violence among Italian psychiatric in-patients, the study indicates the need for more attention to the problem of aggression in general hospital psychiatric units.

Analgesia, sedation, and memory of intensive care

PURPOSE

The purpose of this article was to investigate the relationship between analgesia, sedation, and memory of intensive care.

PATIENTS AND METHODS

One hundred fifty-two adult, cooperative intensive care unit (ICU) patients were interviewed 6 months after hospital discharge about their memory of intensive care. The patient was considered to be cooperative when he/she was aware of self and environment at the interview. The patients were grouped as follows: A (45 patients) substantially no sedation, B (85) morphine, and C (22) morphine and other sedatives.

RESULTS

The patients having no memory of intensive care were 38%, 34%, and 23% respectively, in the three groups. They were less ill, according to SAPS II (P <.05), and had a shorter ICU stay (P <.01). Group C patients were more seriously ill according to SAPS II, duration of mechanical ventilation, and length of stay in ICU and in hospital (P <.001). The incidence of factual, sensation, and emotional memories was not different among the three groups. Females reported at least one emotional memory more frequently than males (odds ratio 4.17; 95% CI 10.97-1.59).

CONCLUSIONS

The patients receiving sedatives in the ICU are not comparable with those receiving only opiates or nothing, due to the different clinical condition. The lack of memory of intensive care is present in one third of patients and is influenced more by length of stay in ICU than by the sedation received. Sedation does not influence the incidence of factual, sensation, and emotional memories of ICU admitted patients. Females have higher incidences of emotional memories than males.

Suicide probability and psychological morbidity secondary to HIV infection: a control study of HIV-seropositive, hepatitis C virus (HCV)-seropositive and HIV/HCV-seronegative injecting drug users

BACKGROUND

Suicide ideation and psychological morbidity among HIV-positive patients has been the object of intense research. No study has investigated this area among injecting drug users (IDUs) infected with HIV and those infected with the hepatitis C virus (HCV), which has the same patterns of transmission of the HIV and may favour HIV replication and, possibly, HIV disease progression.

METHODS

In order to examine the prevalence and characteristics of suicide ideation and psychological morbidity associated with HIV and HCV infection in IDUs, a sample of HIV+ (n=81), HIV-/HCV+ (n=62) and HIV-/HCV- (n=152) subjects completed the Suicide Probability Scale (SPS), The Brief Symptom Inventory (BSI) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

No difference was found between the groups as far as the mean scores on SPS and the risk of suicide (no-low risk category: 70.7% HIV+, 56.09% HCV+, 65.6% HIV-/HCV-). Estimated psychological morbidity (BSI) (26.9% HIV+, 27.1% HCV+, 25.4% of HIV-/HCV-) and BSI and HADS scores were comparable across the groups.

CONCLUSIONS

Suicide ideation, psychological morbidity and anxiety and depression symptoms seemed not to be directly influenced by HIV-serostatus. Careful assessment of psychological symptoms and suicide ideas among IDUs, as a vulnerable segment of population at risk of HIV and HCV infections, needs to be routinely carried out in clinical settings.

Knowledge about HIV transmission and prevention among Italian patients with psychiatric disorders

For a study designed to examine the accuracy of information about HIV transmission, risk behavior, and preventive measures among individuals with psychiatric disorders in Italy, 214 psychiatric patients-114 outpatients and 100 inpatients-and 88 nonpsychiatric patients completed the AIDS Risk Behavior Knowledge Test. Levels of knowledge were lower among psychiatric patients than among control subjects. Patients with chronic illness and a diagnosis of schizophrenia were found to have less knowledge than other patients about HIV transmission. These findings confirm the need for HIV-related educational and behavior-modification programs for patients with chronic and severe mental illness in the community in Italy.

Day-night variation in aggressive behavior among psychiatric inpatients

Self-directed aggressive behaviors of human beings show a 24h pattern. The aim of this study was to evaluate if violence of psychiatric inpatients against one another and hospital staff varies over the 24h. The clock time occurrence of 334 episodes of assault behaviors by 119 psychiatric inpatients (78 males and 41 females, mean age 34.8+/-11.3 years) committed during a 5-year span in the psychiatric unit of the university-based hospital of Ferrara, Italy, was evaluated. The clock time of each event was categorized by hour during the 24h and into one of four 6h intervals for analysis of temporal variation by cosinor and chi2 tests, respectively. A significant 24h variation, characterized by an early afternoon peak, was detected irrespective of gender and number (single vs. repeated) of episodes committed. Changes during the 24h in ward activity, patient contact, and endogenous circadian rhythms are likely to contribute to the observed 24h pattern, although further study is needed to confirm our findings and to define causal factors.

Assessing delirium in cancer patients: the Italian versions of the Delirium Rating Scale and the Memorial Delirium Assessment Scale

To validate the Italian versions of the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS), 105 cancer patients consecutively referred for neurological or psychiatric consultation for mental status change were evaluated using the Confusion Assessment Method (CAM), the DRS, the MDAS, and the Mini-Mental State Examination (MMSE). According to the CAM criteria and clinical examination, 66 patients were delirious, and 39 received diagnoses other than delirium. The DRS and the MDAS scores significantly distinguished delirious from non-delirious patients. The MDAS and the DRS were mutually correlated. When using the proposed cut-off scores for the two scales, the MDAS had higher specificity (94%) but lower sensitivity (68%) than the DRS (sensitivity = 95%, specificity = 61% for DRS cut-off 10; sensitivity = 80%, specificity = 76%, DRS cut-off 12). The MMSE showed high sensitivity (96%) and very low specificity (38%). Exploratory factor analysis of the DRS and the MDAS suggested a three-factor and two-factor structure, respectively. Both instruments in their Italian version proved to be useful for the assessment of delirium among cancer patients. Further research is needed to examine the use of the DRS and the MDAS in other clinical contexts.

Psychiatric morbidity and burnout in the medical profession: an Italian study of general practitioners and hospital physicians

BACKGROUND

Burnout and psychological stress symptoms represent a major problem among health care professionals. The aim of this study was to investigate the prevalence of and the relationship between psychiatric morbidity and burnout among a convenience sample of Italian primary care physicians (GPs) and hospital physicians (HPs).

METHOD

The sample consisted of 328 physicians (182 GPs and 146 HPs) who completed the 12-item version of the General Health Questionnaire and the Maslach Burnout Inventory (MBI).

RESULTS

The global prevalence of psychiatric morbidity was 22.3% (20.3% among GPs and 24.6% among HPs). Symptoms of emotional exhaustion were reported by 27.5% of the participants (GPs: 32.4%; HPs: 21.2%), depersonalization by 25.6% (GPs: 27.4%; HPs: 22.6%) and low personal accomplishment by 12.8% (GPs: 13.1%; HPs: 12.3%). No significant difference was found between the two groups, except higher levels of emotional exhaustion among GPs. Female GPs reported lower scores on MBI depersonalization and female HPs lower scores MBI personal accomplishment than male GPs and HPs, respectively.

CONCLUSIONS

The study underscores the significant problem of stress among physicians and indicates the need for supporting health professionals in order to improve their psychological well-being and, possibly, the quality of their relationship with the patients.

Illness behavior, emotional stress and psychosocial factors among asymptomatic HIV-infected patients

BACKGROUND

Over the last years the way in which patients with chronic physical illness respond to their illness (illness behavior) has been explored by several studies. This study sought to examine characteristics of illness behavior and to investigate the association between illness behavior and psychosocial and clinical variables among asymptomatic HIV-infected subjects.

METHODS

Seventy-three asymptomatic HIV+ outpatients completed self-report questionnaires to evaluate illness behavior (Illness Behavior Questionnaire), psychological stress symptoms (Brief Symptom Inventory), personality variables (External Locus of Control and Courtauld Emotional Control Scales) and social support (Social Provision Scale).

RESULTS

Psychological morbidity ('caseness' = 34%) was associated with a pattern of illness behavior characterized by conviction of disease progression, irritability, dysphoria, psychological perception of illness and low denial. Individual capacity to express emotions, adequate levels of social support and low levels of depression, as well as clinical variables (high number of CD4+ cells, recent notification of HIV infection and nonintravenous drug use category) influenced a more adaptive illness behavior. Psychological stress and low CD4+ cell count were the main predictors of the affective dimension of illness behavior.

CONCLUSIONS

Psychosocial variables resulted to influence the tendency to interpret illness in a nonadaptive way in asymptomatic HIV-infected subjects. Such variables merit to be routinely examined within the doctor-patient relationship in AIDS clinics.

Microsatellite instability and frameshift mutations in genes involved in cell cycle progression or apoptosis in ovarian cancer

The loss of mismatch repair enzymes increases the mutation rate in microsatellites and coding regions of the genome and appears to be involved in drug resistance. The replication error (RER+) phenotype, associated with microsatellite instability, has been widely described for both familial and sporadic colon cancers and for gastric and endometrial tumors. For ovarian cancer, the incidence of RER+ cases among sporadic tumors is still uncertain. We analyzed epithelial ovarian tumors and ovarian carcinoma cell lines for microsatellite instability and for mutations in the coding regions of different genes, including the recently discovered human CHK-1 gene, which has an important role in controlling cell cycle progression and whose coding region contains a poly(A)9 tract. Microsatellite instability and frameshift mutations in coding regions of BAX, TGFbetaRII, IGFIIR, E2F-4, ICE, and CHK-1 genes were analyzed in ovarian cancer samples and cell lines by polymerase chain reaction (PCR). Approximately 26% of patients showed microsatellite instability in two or more loci. BAT-26 locus showed no alteration in primary tumors. We detected a BAX mutation in one tumor sample and a TGFbetaRII mutation in one cell line. Our findings confirm the presence of the RER+ phenotype in sporadic ovarian cancer. The low rate of mutation in genes previously reported to be altered in colon and gastric cancer suggests that other not yet identified genes might be altered and could play a role in tumor progression and response to treatment in RER+ ovarian tumors.

Social support and psychological distress in primary care attenders. Ferrara SIMG Group

BACKGROUND

Growing evidence has been collected about the high prevalence of psychological distress in primary care. The role of psychosocial variables, namely the role of support from the patients' interpersonal ties, has not been extensively explored.

METHODS

The study investigated the relationship between perceived social support, as evaluated by the Multidimensional Scale of Perceived Social Support, and psychological distress, as measured by the Brief Symptom Inventory, in 1,341 primary care attenders.

RESULTS

In comparison with highly supported patients, lowly supported subjects showed higher scores on distress dimensions (e.g. depression, anxiety, phobia) and a higher prevalence of psychological morbidity ('caseness' = 37.3 vs. 11%).

CONCLUSION

The findings suggest that, in the setting of primary care, the GPs' assessment of their patients' social support system may be useful in identifying those more vulnerable to psychological stress.

Psychosocial problems secondary to cancer: an Italian multicentre survey of consultation-liaison psychiatry in oncology. Italian Consultation-Liaison Group

Data relative to consultation-liaison psychiatry (C-L) in oncology are lacking. In order to examine this area, a multicentre investigation was conducted in 17 general hospitals in Italy. All psychiatric consultation requests for cancer patients referred to C-L during a 1-year period were evaluated. Only 5% (n=217 referred patients: 114 men and 103 women) of all C-L activity were for cancer patients. Most were 'routine' consultations (72%) for current psychiatric symptoms (69%) or coping/compliance problems (12%). Previous psychological or psychiatric disorders were shown in 32% of cases. Approximately 40% of patients were not informed of their referral to C-L. The most frequent ICD-10 psychiatric diagnoses were adjustment disorders (27%) and major affective disorders (23%). Transfer to psychiatric units was low (1%). These findings indicate the need for improvement of referral criteria to C-L and closer attention to continuity of psychosocial care of cancer patients during hospitalisation and post-discharge.

[Usefulness of opposed-phase gradient-echo technique in the diagnosis of occult lesions of the knee and comparison with traditional T1-weight sequences (in-phase)]

PURPOSE

To investigate the usefulness of opposed-phase gradient-echo (GRE) technique in detecting occult posttraumatic bone injuries in the knee. Occult injuries account for pain and, if not properly treated, may progress to severe chondral and bone damage. An early diagnosis provided by MRI can help avoid interventional procedures.

MATERIAL AND METHODS

We submitted to MRI of the knee 51 patients (32 men and 19 women) with negative plain radiographic findings and at least one traumatic bone injury at MRI. MR examinations were performed with a 0.5 T unit and included a conventional SE or GRE T1-weighted sequence and an opposed phase GRE sequence on the coronal or sagittal plane (2-3 minutes acquisition). To assess the lesion number and conspicuity, images were retrospectively reviewed by two readers. Injury conspicuity was graded as: 0 (poorly visible), 1 (visible), and 2 (well visible). Marrow-to-injury signal intensity ratio was calculated in 30 patients: a ROI was positioned in the site of highest signal intensity and adjacent bone marrow and the ratio analyzed with Student's "t"-test.

RESULTS

In-phase and out-of-phase images showed 71 injuries in 51 patients. Conventional (in-phase) imaging missed 6/71 lesions. Injury conspicuity on out-of-phase images was of grade 2 in 58 cases (81.6%) and of grade 1 in 13 cases (18.3%), versus 23 (32.3%) and 42 (59.1%), respectively, on conventional images. Injury conspicuity was graded as 0 in 6 cases (8.4%) on conventional images. Quantitative analysis of marrow-to-injury signal intensity ratio showed higher values for out-of-phase GRE than conventional images.

CONCLUSION

Opposed-phase GRE are quick sequences available on all MR systems which appear superior to conventional T1-weighted images in detecting occult injuries in the knee. Injuries are more conspicuous because their signal intensity is lower due to the simultaneous presence of fat and water protons, which is typical of bone trauma, GRE sequences make a useful and rapid complement to T1-/T2-weighted fat saturation acquisitions in the study of the post-traumatic knee.

Physicians' attitudes to and problems with truth-telling to cancer patients

Disclosure of a diagnosis of cancer to patients is a major problem among physicians in Italy. The aim of the study was to assess physicians' attitudes to and opinions about disclosure. A convenience sample of 675 physicians in Udine (North Italy) completed a ten-item questionnaire. About 45% indicated that, in principle, patients should always be informed of the diagnosis, but only 25% reported that they always disclosed the diagnosis in practice. Physicians with a surgical specialization employed in general hospitals endorsed disclosure of the diagnosis more frequently than GPs and older physicians. One third of the responding physicians persist in the belief that the patients never want to know the truth. Hospital doctors considered the hospital, rather than the patient's home, was the most appropriate place to inform the patients. The opposite result was found among GPs. Almost all the physicians endorsed the involvement of family members when disclosing the diagnosis, but, at the same time they also indicated that families usually prefer their ill relative not to be informed. Ninety-five per cent of physicians believed that the GP should always be involved in the processes of diagnosis and communication, and 48% indicated that the GP should communicate the diagnosis to the patient (as opposed to the physician who made the diagnosis). Having guidelines for breaking bad news to patients was indicated as an important need by 86% of the responding physicians. Despite changes in medical education, improvement of communication skills in dealing with cancer patients and their families represents an important need in healthcare settings.

Use of medical resources and quality of life of patients with chronic heart failure: a prospective survey in a large Italian community hospital

AIMS

To assess the prevalence, clinical characteristics, use of medical resources and quality of life in consecutive patients with chronic heart failure (CHF) hospitalized in a large community hospital during 3 months.

METHODS AND RESULTS

The study group included 354 patients with CHF, admitted in the Departments of Internal Medicine (97%) and Cardiology. Median age was 78 years [72;85], 45% were males. CHF was the main diagnosis in 72%; 28% were in NYHA class III and 49% in class IV; 42% had atrial fibrillation. The median hospital stay was 8 days [5;14], in-hospital mortality 9% in those admitted for CHF and 19% in those admitted primarily for other diseases. Patients with CHF occupied 15% of the beds; 1330 ECGs, 389 chest X-rays, 112 echocardiograms and 10 coronary angiograms were performed. A quality of life questionnaire revealed that 82% had problems with mobility, 54% with self-care and 88% with everyday activity. Thirty-nine percent of patients had at least one hospitalization during the previous year.

CONCLUSIONS

Ninety-seven percent of hospitalized patients with CHF are admitted in the Internal Medicine wards and occupy 15% of beds. The majority of the patients are 72 years or older, with severe heart failure. The frequency of rehospitalization(s) and mortality rate in this population remains high. Echocardiography is performed only in 27% of patients.

Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients

Among Italian hospital physicians and general practitioners, 17.9% endorsed euthanasia or assisted suicide for terminally ill patients and 79.4% endorsed withholding or withdrawal of treatment. Need for attention to quality of life and pain control also emerged.

A multicenter investigation of consultation-liaison psychiatry in Italy. Italian C-L Group

In order to evaluate the extent and quality of consultation-liaison (C-L) activity in Italy, a multicenter investigation was conducted in 17 general hospitals. All of the hospitalized patients referred to C-L psychiatry during a 1-year period were assessed by means of a specific instrument (Patient Registration Form, PRF-SF). Of 518,212 patients, 4182 were referred to C-L services (referral rate = 0.72%). Typical consultations were for female patients (60.1%), admitted to medical wards (71.5%), aged 55-75 years. Most interventions were carried out within 2 days; a minority (22%) were urgent requests. Gastrointestinal and cardiovascular disorders, and unexplained medical symptoms were the most frequent ICD-9 somatic diagnoses at admission. One-third of the patients were not informed of having been referred to C-L and half of them had a lifetime history of psychiatric disturbances. Most frequent ICD-10 psychiatric diagnoses were neurotic, stress-related, and somatoform syndromes (33.1%), affective syndromes (19.4%), and organic mental syndromes (10.7%). Two-thirds of the patients were given only one consultation whereas the reminder received two to four follow-up visits. The rate of transfer to psychiatric wards was low (2.1%). Psychopharmacological treatment was suggested in 65% of cases, and 75.5% of the patients were referred to community psychiatric care at discharge. The implications of the findings are discussed.

Dissociative disorder after traumatic brain injury

Several episodes of dissociative disorder, including depersonalization and multiple personality, have been observed in a 32-year old man during a period of a few months following a mild traumatic brain injury. The psychogenic or organic aetiology of these psychiatric disorders remains undetermined. This case highlights the need to consider dissociative disorder among the possible (temporary) outcomes of a brain injury.

Human immunodeficiency virus-related risk behavior among Italian psychiatric inpatients

This study evaluated at-risk behavior for human immunodeficiency virus (HIV) infection among Italian psychiatric inpatients. One hundred patients with mental disorders consecutively admitted to an acute psychiatric unit over a 1-year period were studied using a self-report questionnaire. In these patients, 53.1% reported sex with multiple partners, 35.4% with occasional partners, 57% with prostitutes, and 6.7% with intravenous (i.v.) drug users (i.v.DUs). Forty-three percent never used condoms during sexual intercourse, 23% used drugs intravenously, and 20% shared needles. Only one third of the patients were tested for HIV, and two tested seropositive ([HIV+] prevalence, 5.8%). Most patients (62%) reported no concern about the risk of HIV infection. The rate of HIV risk behaviors was higher among psychiatric patients versus a control group of 90 healthy people. These findings indicate an alarming rate of HIV risk behaviors among Italian psychiatric inpatients and the need for closer attention to HIV assessment and education in mental health settings.