Detection and morphology of thymic remnants after video-assisted thoracoscopic extended thymectomy (VATET) in patients with myasthenia gravis

Thymectomy is often an extremely useful therapeutic procedure in myasthenia gravis (MG) and is usually indicated for adult patients with generalized disease. Because remnants of thymus may remain in extrathymic fat, an extended thymectomy is recommended. A new surgical approach without sternotomy: video-assisted thoracoscopic extended thymectomy (VATET) was performed in 30 MG patients. The weight of removed thymus ranged from 10.8 to 113 grams. The weight of fatty tissue removed from pretracheal, anterior mediastinal and costophrenic areas ranged from 6.3 to 74.8 grams. Histological examination revealed thymic remnants in 14.8% of pretracheal fat samples and in 33.3% of samples from anterior mediastinal plus costophrenic areas. These findings indicate that VATET is a radical procedure and may be the first choice surgery for young female MG patients, since aesthetic sequelae are reduced compared to procedures involving sternotomy.

Somatotype in panic patients

The aim of the study was to test whether an association exists between asthenic somatotype, as measured by the Quetelet index, and panic and or agoraphobia. Ninety-nine cases with panic and/or agoraphobia diagnosed at the psychiatric outpatient clinic of a general teaching hospital were compared to 99 controls with psychiatric conditions other than panic and agoraphobia, and to 64 medical controls, matched by age and gender. No differences in weight, height and raw Quetelet and ponderal indexes were found between panic cases and controls. However, 33.3% of cases, but only 19.2% of psychiatric controls and 18.7% of medical controls, were in the asthenic group as defined by the lower quartile of the Quetelet index (age and sex adjusted odds ratio = 2.33, 95% C.I.: 1.21-4.11). In the entire sample, the asthenic somatotype was associated with lower age and with the presence of hypermobility of joints. Since both panic disorder and mitral valve prolapse may be associated with the joint hypermobility syndrome (JHS), an inherited disorder of collagen synthesis, it is suggested that the relationship found between panic and asthenic somatotype might be mediated through JHS.

Disagreement between hospital medical records and a structured patient interview on the type and date of the first symptom in cancers of the digestive tract

Medical records have often been found to be less reliable than interviews to patients when data on the initial signs and symptoms of cancer, and the out-of-hospital diagnostic process are sought; in spite of this, a large body of research on "diagnostic delay" in cancer is based on clinical records. As part of a study on delay in neoplasms of the digestive tract we analyzed the agreement on the type and date of the initial symptom between hospital records and a structured personal interview. Records were abstracted for a random sample (N = 60) of 183 patients interviewed. Concordance on the date of the first symptom was deemed to exist if the difference was +/- 30 days. The Kappa index (kappa) and the overall proportion of agreement (with its corresponding 95% confidence interval) were used. Medical records and structured personal interviews were concordant on the type of the first neoplastic symptom in only 61% of cases (kappa = 0.50): 67% in esophagus cancer (kappa = 0.49), 60% in stomach cancer (kappa = 0.52), and 61% in colorectal cancer (kappa = 0.50). Records underestimated the occurrence of anorexia as first symptom and overestimated weight loss and dysphagia. Only 56% of cases were date-concordant, the agreement being lower in colorectal cancer (46%) than in esophageal (67%) and stomach cancer (75%). Records indicated the first symptom to have occurred at a later date than interviews in 33% of cases; overall, a study based on hospital records would have underestimated the symptom to diagnosis interval by 2.2 months per patient. Only 40% of cases were totally (symptom and date) concordant. Marked discrepancies may exist between the information contained in medical records and what patients report during a structured interview. The quality of medical records data on the duration and nature of cancer symptoms should be assessed before its use in etiologic and evaluative research.

[Agreement between information supplied by the patient and a family member on medical history, consumption of tobacco, alcohol and coffee and diet in cancer of the exocrine pancreas and extrahepatic biliary tract]

OBJECTIVE

No study on mutations in the K-ras oncogene and cancer of the exocrine pancreas or cancer of the biliary system has analyzed the reliability of clinical and epidemiological information.

METHODS

Agreement between patient and surrogate on factors potentially related to both tumours was evaluated within a multicentre prospective study. Interviews were personally administered to both patient and surrogate (N = 110 pairs). Agreement was examined via the simple kappa index (k), the weighted kappa index (kw), the percentage of simple agreement, and the percentages of positive and negative agreement.

RESULTS

Agreement for medical history was excellent (k between 0.89 and 0.76), as it was for tobacco consumption (k = 0.98). Agreement was moderate for coffee consumption (k = 0.68), frequencies of food groups (kw from 0.66 to 0.38), and consumption of alcoholic drinks (k from 0.66 to 0.32). Surrogates indicated a higher consumption of alcohol than patients.

CONCLUSION

Surrogates can be an alternative source of information when patients cannot be interviewed, but information on alcohol consumption should be treated with caution.

Pancreatitis and the risk of pancreatic cancer

To offer quantitative evidence on the association between pancreatitis and pancreatic cancer, we analyzed data from a hospital-based case-control study conducted in northern Italy between 1983 and 1992, including a total of 362 incident cases of histologically confirmed pancreatic cancer and 1,408 controls admitted to hospital for acute, nonneoplastic, nondigestive tract disorders. Information was obtained using a structured questionnaire on sociodemographic characteristics and lifestyle habits (including tobacco and alcohol consumption) and a problem-oriented medical history, which included history of pancreatitis and age at its first diagnosis. Pancreatitis was reported by 24 (6.6%) cases and 18 (1.3%) controls, yielding an age- and sex-adjusted relative risk (RR) of 5.7 (95% confidence interval, 2.9-11.4). The risk of pancreatic cancer was appreciably higher 5 or more years after diagnosis of pancreatitis (RR = 6.9) than in the first 4 years (RR = 2.1), and in subjects below age 60 (RR = 8.3) than in elderly ones (RR = 2.6), but similar in males and females. The time-risk relationship is strongly indicative of a real relationship between pancreatitis and pancreatic cancer. After allowing for tobacco and alcohol, besides area of residence and education, the association between pancreatitis and pancreatic cancer appeared to be partly explained by such covariates (RR = 3.9); however, this may represent some degree of overadjustment if, for instance, alcohol is causally linked to pancreatitis, which, in turn, is causally related to pancreatic cancer. In terms of population attributable risk, pancreatitis would explain approximately 5% of pancreatic cancer cases.

Ki-ras mutations as a prognostic factor in extrahepatic bile system cancer. PANK-ras I Project Investigators

PURPOSE

To assess the prevalence and prognostic significance of Ki-ras codon 12 mutations in extrahepatic biliary system cancer (EBSC).

PATIENTS AND METHODS

Patients diagnosed with EBSC between 1980 and 1990 (N = 111) were selected from two hospitals. DNA was amplified from paraffin-embedded tissues and mutations in codon 12 of Ki-ras were detected using the artificial restriction fragment-length polymorphism (RFLP) technique.

RESULTS

Tissue was available from 68.5% of patients. The prevalence of mutations was 41%. There was no association between mutations and clinical and pathologic characteristics; however, mutations in Ki-ras were associated with survival, with a median survival duration of 7.7 months for patients with wild-type Ki-ras and 1.7 months for patients with mutated tumors (hazards ratio [HR] = 1.67; P = .075). Among patients with stage I to II tumors, the chance of dying of patients with the mutation was 7.8 times higher than that of patients without the mutation (P = .087); the corresponding HR for patients with stage III to IV disease was 2.9 (P = .003). After adjusting for age, tumor site, histology, differentiation, and stage, the HR for Ki-ras mutations was 2.12 (P = .026).

CONCLUSION

Ki-ras codon 12 mutations are an independent prognostic indicator in patients with EBSC. Mutation detection may be of help in the management of these patients.

Pharmacoepidemiology in practice. Current status and future trends

Pharmacoepidemiology is the application of epidemiological reasoning, methods and knowledge to the study of the uses and effects (beneficial and adverse) of drugs in human populations. As referred to by the term 'pharmacoepidemiology', the discipline now enters into its second decade, although its origins go back to the beginnings of this century. This article reviews the opinions of leading pharmacoepidemiologists on the scope and prospects for pharmacoepidemiology, and summarises the most important challenges that the discipline faces on its way towards the next century. The future of pharmacoepidemiology requires the development of research methods more able to cope with the specific problems posed by the study of drugs, notably the issue of confounding by indication and the ability to adjust accurately for severity of disease. Capacity building should also continue during the next years; training of professionals, the optimisation of computerised databases for research purposes and their joint use with more traditional epidemiological methods are major challenges. From a public health perspective, a critical task is to assess the impact that vaccines and drugs have on the overall patterns of disease in well defined populations.

Improvement in survival after myocardial infarction between 1978-85 and 1986-88 in the REGICOR study. (Registre GIroní del COR) registry

Aspirin, intravenous nitrates and fibrinolysis were being used by 1986 in Girona, Spain. These combined factors should be reflected in myocardial infarction patients' outcome. We assessed changes in 28-day and 3-year survival after a first myocardial infarction between 1978-85 and 1986-88 in the REGICOR (Registre GIroní del COR) registry. This included 1216 consecutive patients with a first transmural myocardial infarction (834 in 1978-85 and 372 in 1986-88). Their 28-day and 3-year mortality rates were 14.6% and 8.8% respectively. Although patients admitted in the second period were more frequently hypertensive and diabetic, a history of angina was less common in patients admitted between 1978 and 1985. After adjusting for diabetes, hypertension, age, and sex, the relative risk of 28-day mortality of those admitted in the second period was 0.65 (95% confidence interval 0.42-0.99). The lower severity, as measured by Killip class of patients in the second period, was the main (confounding) variable responsible for this protective effect. Three-year mortality of those surviving 28 days in 1978-85 (8.3%) did not differ from 1986-88 (8.3%). In the second study period hospitalized patients with myocardial infarction in Girona, Spain showed a better 28-day survival. It is possible that therapeutic and diagnostic refinements, together with other factors not controlled in the present study, have resulted in such an improvement. However, 3-year mortality remained unmodified among those surviving 28 days.

Diabetic retinopathy as a cause of blindness in the province of Turin, north-west Italy, in 1967-1991

Diabetes is known to be a major contributor to blindness in industrialized countries but few data are available on the situation in Italy. As an introductory step to the implementation of permanent screening for diabetic retinopathy, a search was carried out on the causes of visual loss in the provincial territory surrounding Turin, the main city of North-West Italy. The case notes of all 4549 residents in the province who were certified blind between 1967 and 1991 were examined with regard to cause, age at onset, and year of onset of visual acuity < or = 1/20. Diabetic retinopathy was the second commonest cause of bilateral blindness (13.1% of cases), preceded by cataract (26.7%) and followed by myopia (11.1%), optic atrophy (8.9%), glaucoma (8.9%), retinitis pigmentosa (7.2%), and senile macular degeneration (4.1%). Diabetic retinopathy was the commonest eye disease among those who became blind between the ages of 50 and 70 and remained the leading cause of visual loss when the age groups 20 to 70 were pooled together. The incidence of diabetic retinopathy-related blindness did not show any trend to decrease over the 25 years investigated. It is concluded that, in spite of widespread availability of facilities for its assessment and treatment, diabetic retinopathy remains a leading cause of blindness in North-West Italy. This fully justifies the implementation of screening programmes and efficient referral chains for the early detection and prompt treatment of this complication of diabetes.

Treatment of Cushing's disease by interstitial pituitary irradiation: short- and long-term follow-up

Trans-sphenoidal intrasellar implantation of radioactive rods was employed to treat Cushing's disease in our Institution between 1958 and 1981. The patients were followed at regular intervals after the procedure. The aim of this work is to assess retrospectively the results, comparing the short- (1 year) and long-term (average 21.8 years) effects of this treatment. Seventy-six patients received pituitary implantation of 90Y- and one of 198Au-labelled rods, delivering a dose of 100-150,000 rad. Complete remission was obtained in a few weeks to months in 57/76 patients (5 of whom required a second implantation); 2 patients died of meningoencephalitis and 3 of cardiovascular complications associated with hypercortisolism 1 to 2 months after surgery. In 12 patients bilateral adrenalectomy or external pituitary irradiation were required to achieve remission; one of them developed Nelson's syndrome 15 years after implantation. Two were lost at follow-up. Long-term follow-up was possible in 41 patients of the initial series. Of these, 40 were cured of the disease, with hypoadrenalism developing in 25, while recurrence was observed only in the patient treated with 198Au. The incidence of hypothyroidism was 50%, and that of hypogonadism 54%. Permanent diabetes insipidus developed in 1 subject. GH deficiency resulting in retarded growth was found in the youngest patient, who had been operated at the age of 14. In conclusion, interstitial irradiation of pituitary adenomas was a safe and effective procedure for the treatment of Cushing's disease.

Diagnostic certainty and potential for misclassification in exocrine pancreatic cancer. PANKRAS I Project Investigations

Whereas over the last decade epidemiologic studies on exocrine pancreatic cancer (EPC) continued to show a remarkable heterogeneity in diagnostic criteria applied to define caseness, the actual magnitude and consequences of misclassification remain largely unexplored. The objectives were: (1) to estimate the degree of certainty with which cases of EPC are diagnosed in the two participating hospitals (to this end a diagnostic certainty classification (DCC) was developed; (2) to test whether characteristics of cases differed by degree of diagnostic certainty; and (3) to assess what influence different definitions of case might have on risk estimates for tobacco and alcohol. All cases with a discharge diagnosis of EPC who attended at the Hospital del Mar between 1980-90 and at the Hospital Son Dureta between 1983-90 were identified through their respective tumor registries, and their clinical records were reviewed. Only 52% of 140 cases were classified in the group with a higher probability of EPC (group H). Diagnostic certainty appeared somewhat greater among women (age-adjusted odds ratio [ORa] 1.60, p = 0.18). Group H showed a higher proportion of cases with an interval from first symptom to diagnosis < or = 1 month (ORa = 2.38, p < 0.05) and the proportion of adenocarcinomas was slightly higher than in less certain cases (group L) (p = 0.051). A radical treatment was exclusively attempted in group H (p < 0.001). DCC cut-off points had a significant effect on the proportion of smokers and of alcohol drinkers, as well as on the percent of cases with pathological (cytohistological) confirmation. The proportion of cases unlikely to be of pancreatic origin in spite of having pathological confirmation was high enough to cause significant misclassification bias. Because past exposure to certain risk factors may differ among cases with different diagnostic certainty, we suggest to initially include in the case group patients who in spite of lacking pathological confirmation have strong clinical evidence supporting the diagnosis of EPC; subsequently, risk estimates should be computed across strata of diagnostic certainty to assess whether heterogeneity exists. In exocrine pancreatic cancer the impact of misclassification of disease status upon etiologic and prognostic estimates deserves at least as much attention as misclassification of exposure.

Trends in pancreatic cancer mortality in Europe, 1955-1989

Trends in death certification rates from pancreatic cancer over the period 1955-1989 were analyzed for 25 European countries (excluding the former Soviet Union and a few smaller countries). In 1985-1989, rates for males ranged between 5.3/100,000 (age-standardized world population) in Spain and 10.3/100,000 in Hungary and Czechoslovakia. Other high-mortality areas were located in Northern Europe (Finland, Iceland, Ireland, Denmark) and Central Europe (Austria, Poland, Germany), whilst mortality was lower in Southern Europe (Portugal, Greece). Between 1955 and 1989, mortality rates increased in all the countries considered, the change ranging between 6% in Scotland and 279% in Spain; the rises were higher in the Mediterranean and Eastern European countries than in Northern Europe. Among females, Nordic countries such as Iceland, Sweden and Denmark had the highest mortality rates in 1985-1989 (over 6/100,000) and, as for males, Southern Europe (Spain, Portugal, Greece) appeared as a low-mortality area (around 3/100,000). During the 1955-1989 period, upward trends were observed in all the countries studied, with the highest increase in Greece, Italy, Bulgaria, Poland and Spain. A negative correlation was observed between the percent change in mortality rates between 1955-1959 and 1985-1989 and the rate in 1955-1959 among both males (r = -0.95, p < 0.001) and females (r = -0.81, p < 0.001). Thus, a systematic levelling of rates was observed in most countries, with the exception of the UK and some Nordic countries, whose rates were already high in the late 1950s. Tobacco smoking and dietary factors could account for some of the generalized upward trends. Improved diagnostic and death certification of the disease might also partially explain the observed figures.

Carotid pain during percutaneous angioplasty (PTA). Pathophysiology and clinical features

Stretching of the internal carotid artery during percutaneous transluminal angioplasty (PTA) may be associated with transient neck, facial or cranial pain. We report a series of 53 cases who received PTA. Cervical pain occurred in 51% of patients, with a radiation to face and scalp in 33%. Analysis focused on: (a) description of pain intensity, quality, timing and location; (b) investigation about the role of individual and technical parameters that could influence the relative risk of pain onset during PTA; (c) comparison with other available data on pain syndromes related to the carotid artery. Intimal flapping on post-angioplasty angiograms, bradycardia during the procedure and previous history of AMI were associated with a higher risk of painful angioplasty. PTA may also serve as a tool to investigate carotid pain and may add further knowledge to the evidence available about the role of the carotid wall in the pathogenesis of facial and cranial pain.

Economic assessment of drugs in Spain

In order to assess the characteristics and influence on healthcare decision making of the economic assessment of drugs in Spain, pharmacoeconomic studies carried out between 1982 and 1992 were examined. We identified and analysed 16 pharmacoeconomic studies. The commonnest type of economic assessment was cost-effectiveness analysis. Only one study included measures of health-related quality of life. Only one study was carried out in conjunction with a controlled clinical trial. Evidence of influence on decision making was found in 6 studies. Two studies implemented hepatitis vaccination programmes, one set up a telephone follow-up of antituberculosis chemoprophylaxis, one developed the official procedures for using epoetin (recombinant human erythropoietin), one initiated clinical discussion meetings about the cost effectiveness of cholesterol-lowering therapy, and one strengthened the decision to register nebacumab (HA-1A, Centoxin), the monoclonal antibody against endotoxin. The quality of the studies was acceptable according to generally agreed checklists, although somewhat lower than those in other countries with longer traditions in this field. Improvement of the scientific quality of the studies and an increased use of the results for decision making need to be promoted. At present the number of studies of economic assessment of drugs in Spain is low, as is the influence of these studies on healthcare decision making. The movement of the Spanish healthcare authorities towards a selective drugs funding policy is likely to increase the number of studies and their impact on healthcare decision making.

Growth of bovine retinal pericytes and endothelial cells in high hexose concentrations

Selective loss of capillary pericytes occurs early in diabetic and galactosemic retinopathies, at a stage when endothelial cells are still spared. To ascertain whether such loss is directly related to high hexose concentrations, the replication of bovine retinal pericytes and endothelial cells was studied by culturing them in media containing 5.6 mmol/l glucose alone and enriched with extra glucose, mannitol or galactose to achieve final concentrations of 16.7, 27.8 and 50.0 mmol/l. At the end of the incubation there were significantly less pericytes/culture cell in 16.7 mmol/l glucose (341 +/- 78 x 10(3), mean +/- SEM, p = 0.027) and galactose (304 +/- 55 x 10(3), p = 0.046) than in 5.6 mmol/l glucose (417 +/- 98 and 355 +/- 75 x 10(3) for separate experiments, respectively). Mannitol had no such effect (343 +/- 52 vs. 337 +/- 52 x 10(3). Endothelial cells did not change in number, except in 50.0 mmol/l glucose (533 +/- 66 vs. 629 +/- 67 x 10(3) at 5.6 mmol/l; p = 0.026) and 50.0 mmol/l galactose (440 +/- 48 vs. 592 +/- 51 x 10(3); p = 0.013). To verify if these effects are due to decreased replication, the uptake of 3H-thymidine was measured in pericytes and endothelial cells subjected to the same concentrations of glucose, mannitol and galactose. In pericytes, thymidine uptake was reduced in the presence of 16.7 mmol/l glucose (p = 0.003, compared to 5.6 mmol/l) and galactose (p = 0.027) but not mannitol. Pericyte counts and thymidine uptake was reduced for concentrations of glucose, galactose and mannitol higher than 16.7 mmol/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer survival and the duration of symptoms. An analysis of possible forms of the risk function. ISDS II Project Investigators

The time interval between onset of symptoms and the diagnosis of cancer [symptom to diagnosis interval (SDI), or duration of symptoms] is a highly complex variable reflecting patient behaviour, the clinical course, the functioning of the health system and tumour biology. In order to assess possible forms of the risk function of SDI upon cancer survival whilst taking into account the effects of age, sex, tumour site and stage at diagnosis, 1887 symptomatic cases of lung, breast, stomach, colon, rectal, bladder cancer and lymphomas registered in the Tumour Registry of the Hospital del Mar (Barcelona) were analysed by means of survival curves and Cox proportional hazards regression. Subjects (mean age 64 years) were followed for a median length of 15 months after diagnosis (follow-up rate 93.5%). SDI showed a weak relationship with tumour stage at diagnosis and with survival: out of the seven sites studied, only in breast cancer was tumour extension at diagnosis significantly influenced by duration of symptoms, and only lung and rectal cancers showed a detectable form of the risk function of SDI upon survival; neither was linear, and for rectal cancer the relationship was complexly related with tumour stage. Hence, results show that forms of the risk function of duration of symptoms on cancer survival are specific to tumour sites, and that the interval should not be represented as a linear, continuous term. Studies analysing more complex sets of factors, processes and forms of the SDI function are needed.

Consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment: results from cross-sectional studies in 1988 and 1990

We assessed the prevalence of consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment in two cross-sectional studies conducted in 1988 (188 subjects) and in 1990 (197 subjects). Patients were enrolled in one of three different programmes: methadone maintenance programme (MMP), antagonist maintenance programme (AMP) and drug-free programme (DFP). Information given by participants was compared with results of urine screening for drugs. Urine samples were tested using enzyme immunoassay for the detection of heroin, cocaine, dextropropoxyphene, cannabis and benzodiazepines, and radioimmunoassay for buprenorphine. Sixty-six percent of patients in 1988 and 71% of patients in 1990 reported having consumed buprenorphine at some time during their history of drug dependence (period prevalence) and 5.9% and 6.1%, respectively, tested positive to the drug (point prevalence). In over 70% of these patients consumption was by the intravenous route. Consumption of cannabis, cocaine and benzodiazepines was also very high in the study population. Overall, patients in the DFP group consumed the largest number of the drugs tested, while those in the AMP group consumed the smallest number. Abuse of buprenorphine could be more widespread than previously reported.

Raised serum apolipoprotein (a) in active diabetic retinopathy

Progressive capillary occlusion often leads to severe retinopathy within 15-20 years of the onset of Type 1 (insulin-dependent) diabetes mellitus. Lipoprotein(a), a complex formed by apolipoprotein(a), apo B-100 and lipids, is considered an independent, genetically determined, predictor of cardiovascular disease. It may have antifibrinolytic properties in view of its similarity to plasminogen. To test the hypothesis that circulating lipoprotein(a) is associated with the process that leads to clinically active diabetic retinopathy, we measured the circulating levels of apolipoprotein(a) (which are strictly correlated with those of lipoprotein(a)) in two groups of patients with Type 1 diabetes of at least 15 years duration: 25 with active retinopathy and 27 without clinically detectable retinal lesions. Thirty-eight healthy subjects of the same age and sex served as controls. Serum apolipoprotein(a) was higher in the patients with active retinopathy (36(2-193) U/dl, geometric mean and range) than in those without clinically detectable retinal lesion (17(1-160)) and the control subjects (14(0-115)), p < 0.01 in both cases. The distribution of apolipoprotein(a) levels was skewed to the left, as expected, in the patients without clinically evident retinal lesions and the control groups, but there was a bimodal trend of distribution among those with active retinopathy. The levels of glycated haemoglobin were similar in the two groups of diabetic patients, and no significant differences were found for total and HDL cholesterol, triglycerides or apolipoproteins A1 and B between them and the control subjects. These preliminary results suggest that serum apolipoprotein(a) is elevated in patients with active retinopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Anxiety disorders in the joint hypermobility syndrome

A case-control study was designed to test the association between joint hypermobility syndrome (JHS), an inherited disorder of collagen synthesis, and anxiety and phobic disorders. One hundred fourteen cases of JHS diagnosed at the rheumatology outpatient clinic of the Hospital del Mar (Barcelona) were compared to 59 control subjects randomly selected from patients seen at the same clinic. Both cases and controls were examined by a psychologist who used the Structured Clinical Interview for DSM-III-R and who was unaware of their medical diagnoses. DSM-III-R diagnoses of panic disorder, agoraphobia, and simple phobia, but not generalized anxiety disorder, dysthymic disorder, or major depression were found to be highly associated with JHS (age- and sex-adjusted odds ratio = 10.7). Mitral valve prolapse (MVP) was present only among JHS cases. Among cases of JHS, subjects with MVP were almost three times more likely to suffer from anxiety than subjects without MVP (odds ratio = 2.95), although the association was not statistically significant. The strong association between panic anxiety and JHS appears to occur at a higher level than the association between panic and MVP, and provides a new basis for further studies on the genetic background of panic-anxiety.

The role of endothelium in the pathogenesis of diabetic microangiopathy

Damage caused to the vessel wall by diverse mechanisms may lead to diabetic microangiopathy. Consequently, research work is more and more focusing on the pathophysiology of vascular cells, with particular emphasis on endothelium. This paper reviews the present knowledge on the alterations of small vessel endothelium in diabetes. The most important risk factors for diabetic microangiopathy are the duration of disease and the degree of metabolic control maintained throughout the years. However, genetic factors may also contribute. These are examined first, followed by the presumed roles played by increased protein glycation and the production of Advanced Glycosylation End Products, the "polyol pathway" and free radical generation. Endothelium is a widespread, extremely active organ which regulates complex physiologic functions and its structure and function are discussed in the second section of this review. The third part deals with how diabetes can affect endothelium and describes observations on endothelial metabolism in vitro as well as morphologic and functional alterations in the patients. Unfortunately, the mechanisms leading to progressive degeneration of the microcirculation and organ damage in diabetic patients remain largely unaccounted for.

Pericyte mitogenic activity is reduced in the blood of type 1 diabetic patients with and without retinopathy

Selective loss of capillary pericytes occurs early and specifically in diabetic retinopathy. We have investigated whether blood derivatives from patients with long-term type 1 (insulin-dependent) diabetes and no retinopathy differ from those with retinopathy and/or non-diabetic controls in their ability to stimulate DNA synthesis in cultured bovine retinal pericytes and endothelial cells. As a general trend, whole blood serum, platelet-rich plasma and platelet-free plasma from patients without and with retinopathy stimulated thymidine incorporation in both cell types less than derivatives from controls. Serum, 0.1% v/v final concentration in culture medium, from patients without retinopathy was less active (114.5 +/- 24.5% of a standard stimulus produced by 0.1% fetal calf serum) than that from patients with the complication (132.6 +/- 20.8%, P = 0.003) and both were less potent than control sera (143.6 +/- 28.0%, P < 0.001 and P = 0.013, respectively). Lack of support from circulating factor(s) may contribute to the disappearance of pericytes from the capillary wall in diabetes but further investigations are necessary to clarify the mechanisms that prevent the development of microangiopathy in some patients.

A study of the effects of human blood derivatives and individual growth factors on [3H]thymidine uptake in bovine retinal pericytes and endothelial cells

Pericytes disappear early, selectively and specifically from retinal capillaries in diabetic microangiopathy, but little is known of their growth and turnover in health and disease. We have studied the effects of human blood derivatives and of a panel of individual growth factors on [3H]thymidine incorporation in bovine retinal pericytes and endothelial cells. Human serum and platelet-rich plasma stimulated incorporation of the nucleotide in a dose-dependent manner in both cell types, and did so more potently than platelet-free plasma. Consistent and significant stimulation of DNA synthesis in pericytes was observed with basic fibroblast growth factor (ED50 = 1.8 x 10(-13) mol/l), acidic fibroblast growth factor (7.4 x 10(-12) mol/l), insulin-like growth factor 1 (8.6 x 10(-10) mol/l), insulin (158 microU/ml) and endothelin-1 (6.1 x 10(-10) mol/l). Transforming growth factor beta 1 inhibited DNA synthesis (ID50 = 3.6 x 10(-10) mol/l) and so did heparin (1.4 x 10(-6) mol/l) and low molecular weight heparin (2.9 x 10(-6) mol/l). Retinal endothelial cells were stimulated by basic fibroblast growth factor (3.2 x 10(-13) mol/l) and acidic fibroblast growth factor (1.3 x 10(-9) mol/l), and inhibited by transforming growth factor beta 1 (1.6 x 10(-12) mol/l). Neither cell type was stimulated by platelet-derived growth factor (A + B chain heterodimer), epidermal growth factor, growth hormone, or nerve growth factor (7S complex). The characteristics and active concentrations of the above growth factors suggest that none is solely responsible for the pericyte mitogenic activity of platelets, serum or plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of prostatic disorders in the city of Barcelona

Although disorders of the prostate are among the most prevalent problems in elderly males, little is known about their epidemiological characteristics. The 1986 Barcelona Health Interview Survey (BHIS), a cross-sectional study of a random sample of the noninstitutionalized population of the city, was used to estimate the prevalence of prostatic disorders (PD) and to analyse sociodemographic characteristics, self-perceived health, and use of health services among males reporting PD. Ninety-eight out of 1218 males over 45 years old (8%) reported having PD, the prevalence increasing substantially with age. A pattern of increasing prevalence with decreasing occupational class was found. As compared to subjects not reporting PD, individuals reporting PD reported slightly more restricted activity days (prevalence odds ratio [POR] = 1.28; 95% confidence interval [CI]: 0.52-2.80), more chronic disorders (POR = 4.75; 95% CI: 2.04-13.53), and worse self-perceived health (POR = 1.55; 95% CI: 0.92-2.58). Medical visits and hospitalizations were also higher in the prostatic group (P < 0.05). Men reporting PD appear to constitute a subgroup with increased morbidity and health services use.

Myelodysplastic syndromes and malignant solid tumors: analysis of 21 cases

We studied the association between myelodysplastic syndromes (MDS) and malignancies in a cohort of 155 patients with MDS, 21 of whom presented malignant solid tumors. Myelodysplasia was present after the diagnosis of cancer in eight patients (interval between the diagnosis of both conditions 18 months, median survival 49.5 months), simultaneously with diagnosis in 11 (median survival 8 months), and before malignancy in two patients (interval between the diagnosis of both conditions 47 and 7 months). One patient was given chemotherapy for lung cancer, and three patients received radiotherapy for adenocarcinoma of the kidney and cancer of the prostate. At the time of diagnosis of MDS, nine patients already presented metastatic spread. Fourteen patients died, ten as a result of tumor-related complications and four because of transformation to acute nonlymphocytic leukemia. The analysis of the incidence of malignancy in patients with MDS was statistically significant for males, and the relative risk was significant in both sexes. The results of this study show that MDS patients present a higher incidence of malignant tumors than the general population, that MDS may be of real paraneoplastic significance, and that the occurrence of MDS in cancer patients may be considered to be related to the malignancy rather than an independent phenomenon.

[Sequential nimodipine-reduced glutathione treatment in alcoholic abstinence syndrome. Preliminary experience]

Alcohol abstinence syndrome (AAS) occurs in alcohol dependent patients a few hours after ceasing to drink, first in the form of gastrointestinal and dysvegetative signs, then with the involvement of neurological functions. The results obtained in 15 patients selected according to DSM III criteria, treated with nimodipine (calcium entry blocker) in the acute phase and with reduced glutathione in the subacute phase are presented. All patients who, during treatment, did not take other drugs, showed a definite, fast improvement in symptoms, especially in neurovegetative symptoms. Administration of nimodipine, which seems capable of reducing the catecholaminergic drive, was very well tolerated. Treatment with reduced glutathione is justified by the fact that the inadequate intake of alcohol is responsible for liver changes and, particularly, for a significant reduction in liver levels of glutathione, a condition that makes the cell more exposed to attack on the part of substances that activate lipoperoxidation processes. The results obtained seem to confirm a protective action on the part of reduced glutathione.

Sjögren's syndrome: a stepwise approach to the use of diagnostic tests

One hundred and forty two patients (62 with definite Sjögren's syndrome, 24 with probable Sjögren's syndrome, and 56 in whom Sjögren's syndrome was finally ruled out) were studied. Schirmer's test and rose bengal staining for the diagnosis of keratoconjunctivitis sicca and salivary scintigraphy and a labial biopsy sample for the diagnosis of xerostomaia were studied in all patients. Rose bengal staining showed high specificity (98%) but low sensitivity (55%). All patients with positive rose bengal staining results had associated xerostomia. In the rose bengal staining positive patients, scintigraphy had 100% specificity. A labial biopsy sample showed high sensitivity in the rose bengal staining, salivary scintigraphy positive group, and high specificity in the rose bengal staining positive, salivary scintigraphy negative group. In patients with negative rose bengal staining, salivary scintigraphy showed 96% specificity and 36% sensitivity. A labial biopsy sample had a sensitivity and specificity greater than 90% in rose bengal staining negative patients. Only 29 biopsy samples were needed to achieve a diagnosis of Sjögren's syndrome in 142 patients (20%). Hence the suggested approach may make it unnecessary to take biopsy samples in approximately 80% of patients with suspected Sjögren's syndrome. Using the stepwise approach of first rose bengal staining, then salivary scintigraphy, and eventually a labial biopsy sample in patients with suspected Sjögren's syndrome, the diagnosis is relatively simple.

Clinical assessment of hypermobility of joints: assembling criteria

We carried out a prospective study to determine the validity of different sets of criteria to define the hypermobility syndrome (HMS), as well as the frequency, reliability and clinical features of HMS items. All consecutive cases of HMS attending the rheumatological outpatient clinic of Hospital del Mar (Barcelona, Spain) constituted the index group (n = 114). A control group of non-HMS rheumatological patients (n = 59) was randomly selected to assess suitable cutoff points and particular HMS item prevalences. Beighton's, Carter's and Rotés' HMS scores correlated very highly among them. Both the correlation coefficients obtained between each pair of sets of HMS criteria and the predictive efficiencies were uniformly high, suggesting high concurrent and predictive validity. All but 2 of the major items were more frequent among women. A basic set of criteria to define HMS is proposed. In relation to previous criteria the new scale shows better internal reliability and homogeneity. Results suggest that it may be suitable for screening studies and in clinical rheumatological settings.

Influence of "diagnostic delay" upon cancer survival: an analysis of five tumour sites

STUDY OBJECTIVE

The aim was to assess the relationship between survival, tumour stage, and the interval from first symptom to diagnosis (SDI, or duration of symptoms).

DESIGN

This was a retrospective follow up study of a cohort of patients registered in the tumour registry of the Hospital del Mar (Barcelona).

SETTING

Hospital based tumour registry, with patients derived mainly from the City of Barcelona.

PARTICIPANTS

1247 cases of lung, breast, stomach, colon, or rectal cancer were analysed using survival curves and Cox proportional hazards regression. Subjects (mean age 63.6 years) were followed for a median length of 12.9 months after diagnosis. At the time of diagnosis one fourth of patients had disseminated disease.

MEASUREMENTS AND MAIN RESULTS

Based on clinical records, a physician registered the onset time of the first symptom attributable to cancer (from which the SDI is computed), as well as the tumour stage at diagnosis. Other measurements followed standard tumour registry procedures. Overall, the crude mean SDI was 5.15 months (SD 8.03, median 2.03); only 24.5% of cases had an SDI less than a month. Crude mean SDIs by anatomical site were as follows: lung cancer 3.07 months; breast 7.44; stomach 5.34; colon 5.74; rectum 5.03. Tumour extension did not appear to be significantly influenced by SDI, only breast cancer showing a distinct pattern of increased extension with increasing SDI. As expected, the probability of survival decreased monotonically with increasing stage in all sites. Tumour site was also a significant predictor of survival, which at one year ranged from 93% for breast cancer to 28% for lung cancer. However, a longer SDI tended sometimes to be associated with a better chance of survival, a fact that was most apparent in colon cancer. All Cox proportional hazards models showed a consistent picture: SDI was not a significant predictor of survival (age and sex adjusted hazard ratios ranging from 0.97 to 1.01), neither was sex; age did predict survival, and so did site and stage.

CONCLUSIONS

The results provide further evidence of a very weak relationship between SDI and tumour stage at diagnosis (except for breast cancer), and between SDI and survival, thus emphasising some limitations within which early clinical detection operates. They also suggest that in addition to reflecting patient and physician behaviour, as well as the functioning of the health system, SDI may be influenced by the biological behaviour of the tumour.

Emerging strategies for the prevention and treatment of diabetic eye disease

Diabetic retinopathy (DR) is the major cause of blindness in the working age groups of industrialized countries, and a programme has been launched by the World Health Organization (WHO) and the International Diabetes Federation (IDF) to reduce its morbidity in Europe. Retinopathy progresses slowly, and even when it becomes sight-threatening, may not present visual symptoms. When symptoms do occur, it is often too late to restore full vision or to stop further deterioration by retinal photocoagulation. For photocoagulation to be maximally effective, treatable sight-threatening retinopathy must be identified while still asymptomatic by means of regular fundus examination of all diabetic patients. Given the absence of effective medical treatment, prevention of retinopathy depends on mass screening. The WHO and IDF recommend that internists in charge of diabetic patients perform a fundus examination at least every two years if retinopathy is absent, or as frequently as necessary otherwise. Patients at risk should be referred for assessment and treatment to ophthalmic facilities. Either direct ophthalmoscopy or retinal photography are suitable methods. The setting up of nation-wide screening programmes is essential for coordinated action. Pilot studies have proven that screening is an effective means for decreasing diabetes related blindness and the human and social costs attached to it.

von Willebrand factor and endothelial abnormalities in diabetic microangiopathy

We briefly summarize current knowledge on 1) the abnormalities of von Willebrand factor (vWF) as an indicator of endothelial cell (EC) dysfunction in diabetes and 2) the modifications induced in the growth of cultured ECs by high glucose in the incubation media. A MEDLINE search (1986 through Sept. 1989) was performed to update previous relevant references on vWF and ECs in healthy and diabetic subjects. Main data in the literature and personal contributions were scrutinized. Study quality, information, and relevance to the subject were assessed. vWF is synthesized and stored mainly in ECs. Its plasma levels are increased in diabetic microangiopathy but are not influenced by circulating glucose, insulin, or growth hormone, nor do they acutely affect platelet function in diabetes. Supraphysiological concentrations of glucose inhibit the replication of cultured ECs from large vessels via different possible mechanisms but appear to stimulate pathways involved in the activation of capillary ECs. vWF is a possible marker of EC damage in diabetes, and prospective studies will ascertain its role as a predictor for the development of microangiopathy. The possible dichotomy in the response of cultured ECs from large and small vessels to high glucose in the culture media may help explain some of the lesions observed in the walls of arteries and capillaries in diabetes.

Cytokine stimulated endothelin release from endothelial cells

Endothelin release from bovine endothelial cells of the aorta, pulmonary artery, and retinal microvessels was measured in response to various cytokines. Transforming growth factor beta (0.05-5 ng/ml) was found to be a potent stimulator (3-4 fold increase) of endothelin secretion in all three cell types. Tumour necrosis factor alpha (0.1-10 ng/ml) and interferon gamma (8-800 U/ml) had a small (1.5-2 fold increase) but significant effect on endothelin secretion from endothelial cells of large vessels but not the retinal microvessels. Interleukin-1 beta, Interleukin-6 and interleukin-8 at various doses did not affect endothelin secretion. These effects were observed at various time points from 6-24 hrs and indicate that of the cytokines tested, only transforming growth factor beta has a potent effect on endothelin release from endothelial cells of different organs.

Production of endothelin by vascular smooth muscle cells

Endothelin (ET) production by cultured vascular smooth muscle cells isolated from rat and rabbit aortae was measured by a specific radioimmunoassay. Vascular smooth muscle cells released ET at a rate of 0.6 (range of 0.1-1) fmol/10(5) cells/24 h compared to 45 (range of 10-80) fmol/10(5) cells/h for endothelial cells. ET immunoreactivity was confirmed as ET-1 by fast protein liquid chromatography. Calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) suppressed basal release of ET by 24-66% from both rat and rabbit vascular smooth muscle. Forskolin and dibutryl-cAMP similarly suppressed ET release by 33-86%, suggesting that increased intracellular cAMP may account for the mechanism of action of CGRP and VIP. In contrast, CGRP and VIP did not have any effect on ET release from endothelial cells. The characteristics and regulation of ET binding sites on vascular smooth muscle cells were measured using [125I]ET-1 as the radioligand. Pretreatment with CGRP, VIP, forskolin, and dibutryl-cAMP increased the ET receptor density on both smooth muscle cell types. The low level production of ET-1 by vascular smooth muscle cells may have an important autocrine function and may be under regulation of neuropeptides localized to perivascular nerves.

Nimodipine in human alcohol withdrawal syndrome--an open study

The aim of this study was to evaluate the efficacy and tolerability of the DHP Ca2+ antagonist nimodipine in human AWS and post-AWS. Ten hospitalized alcoholics of both sexes with a diagnosis of AWS according to the DSM-III criteria were treated for 3 weeks in monotherapy with nimodipine p.o. at flexible daily dosages. Evaluation of AWS symptoms was performed at baseline and after 3, 5, 7, 10, 14 and 21 days. A statistically significant improvement of AWS was seen at evaluation on day 3, particularly in neurovegetative and psychopathological symptoms, and lasted up to the end of the study. The treatment was well tolerated and no side effects were observed or reported. In this pilot, open study nimodipine proved effective in the treatment of mild-to-moderate AWS. If these data are confirmed in a double-blind study nimodipine could be a rational alternative to benzodiazepines in the treatment of AWS.

Efficacy of clonidine, guanfacine and methadone in the rapid detoxification of heroin addicts: a controlled clinical trial

The efficacy of clonidine, methadone, and guanfacine in rapid detoxification of heroin inpatients was assessed in a randomized controlled clinical trial. Signs and symptoms of abstinence and of side effects were analysed in 90 heroin addicts successfully completing a 12-day inpatient trial. All patients fit DSM-III criteria for opioid dependence, the age range being 18 to 36 years. All three drugs were effective in controlling abstinence; however, the course of abstinence was different in the methadone group as compared to the adrenergic agonists, the latter showing limitations in their ability to suppress withdrawal manifestations. While mean number of withdrawal signs and symptoms was significantly lower during days 2 to 5 in the methadone group (p less than 0.01), adrenergic agonists were slightly more effective at the end of the trial. Incidence of side effects was closely related to the dose administered. Hypotensive action of adrenergic agonists was more marked in orthostatic position. The present results suggest that methadone is superior to adrenergic agonists. Between these drugs clonidine appears to be less effective than guanfacine in controlling some withdrawal manifestations, and causes more side effects, mainly of cardiovascular nature.

Antibiotic prophylaxis with cefotaxime in gastroduodenal and biliary surgery

In a multicenter prospective, randomized study, the efficacy of a single preoperative dose of 1 g of cefotaxime for avoiding wound infections was compared with four 2-g doses of cefoxitin. In the study, 1,451 patients with infection risk factors who underwent gastroduodenal or biliary surgery were included, of whom 722 received cefotaxime and 729 cefoxitin. The characteristics of both groups were comparable. The frequency of wound infections in the cefotaxime group was 3.3 percent and in the cefoxitin group, 7.6 percent. The difference was statistically significant. The lowest rate of wound infection (0.63 percent) was achieved when cefotaxime was administered during the last hour before surgery. In both groups, the frequency of infections was directly related to the duration of operation. Hospital stay was, on average, 3 days longer in patients with wound infections. After cost-benefit analysis, we have concluded that cefotaxime treatment results in substantial reduction of costs derived from antibiotic prophylaxis.