Esophageal food bolus impaction in pediatric age

OBJECTIVES

Esophageal food impaction (EFI) is the sudden onset of dysphagia that occurs when a food bolus becomes lodged in the esophagus, requiring endoscopic removal. Scientific data on the prevalence and causes of EFI in children is lacking. The aim of this study was to provide further insights into EFI episodes in children.

METHODS

We have prospectively enrolled all children admitted for a first episode of EFI between March 2018 and March 2023. A fluoroscopic contrast study was performed in all patients to confirm the boluses and assess their position. Boluses were extracted by esophagogastroduodenoscopies, and esophageal biopsies were routinely obtained for histologic evaluation.

RESULTS

Over the study period, 41 children were admitted for a first episode of food impaction. Drooling was the most commonly reported symptom. Half children experiencing a first episode of food bolus were diagnosed with EoE (20/41, 48.8%). Almost a fourth of the episodes subtended a different condition, such as esophageal anastomotic, peptic or congenital strictures, stricturing caustic esophagitis, esophageal duplication, and achalasia. In the last fourth of patients the cause of EFI was not identified and thus probably related to quick eating and inadequate chewing of food.

DISCUSSION

Our study represents the largest known series of pediatric patients evaluated for food bolus impaction. Our main finding is the high frequency of EoE, which accounts for a half of EFI episodes in pediatric age, especially in older children. This finding highlights the importance of obtaining esophageal biopsies after the endoscopic bolus removal in children with EFI to provide a complete diagnostic evaluation.

Peculiar CADASIL phenotype in monozygotic twins carrying a novel NOTCH3 pathogenetic variant

BACKGROUND

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an autosomal dominantly inherited cerebral small vessel disease caused by Neurogenic locus notch homolog protein 3 (NOTCH3) gene mutations. The main clinical features include migraine with aura, recurrent ischemic strokes and dementia. Brain MRI typically shows multiple small lacunar infarcts and severe, diffuse, symmetrical white matter hyperintensities (WMHs), with characteristic involvement of the anterior temporal pole, external capsule, and superior frontal gyrus. Reports of twins with CADASIL are scarce. Herein we describe a pair of monozygotic twins with peculiar CADASIL phenotype, carrying a new NOTCH3 variant.

CASE PRESENTATION

Twin A was a 45-year-old male suffering from migraine, obesity, arterial hypertension, and polycythemia (with negative genetic analysis), who complained of a transient, short-lasting (~ 5 minutes) episode of speech difficulties. Brain MRI showed diffuse, symmetrical, confluent periventricular WMHs involving frontal, parietal, and temporal lobes and external capsules, with sparing of anterior temporal poles. Genetic analysis of NOTCH3 gene demonstrated the presence of missense c.3329G>A, p.(Cys1110Tyr) variant, confirming CADASIL diagnosis. Twin B, affected by migraine and polycythemia, as well as his monozygotic twin, presented with a 2-month history of trigeminal neuralgia. Brain MRI demonstrated diffuse WMHs with a pattern of distribution like his twin. Genetic analysis revealed the same NOTCH3 pathogenic variant.

CONCLUSIONS

Our monozygotic twins have a strikingly similar neuroimaging picture with sparing of anterior temporal poles. They also have a peculiar phenotype, both presenting polycythemia without genetically confirmed cause. Twin B had trigeminal neuralgia, that is unusual in CADASIL. The possible association of the peculiar findings with the newly reported NOTCH3 variant needs to be confirmed with further observations.

The relevance of MRI blood-sensitive sequences in the diagnostic assessment of late-onset epilepsy

OBJECTIVE

Sporadic cerebral amyloid angiopathy (CAA) is a degenerative brain small vessel disease of ageing resulting from progressive amyloid deposition in small arteries and arterioles of the cortex and leptomeninges. CAA may be diagnosed by the mean of Boston criteria, particularly with the use of the blood-sensitive T2* MRI sequences (GRE and SWI). Epileptic seizures have rarely been reported in CAA.

PATIENTS AND METHODS

We describe two patients with late-onset unprovoked seizures due to CAA. A short literature review on this topic is presented.

RESULTS

In our two patients with late-onset unprovoked seizures as the first manifestation of CAA, only GRE and SWI sequences lead to a correct diagnosis. In literature, only 15 patients with CAA presenting with seizures have been reported. In these subjects, data on seizures semiology and prognosis are scarce.

CONCLUSIONS

Our report highlights the importance to perform blood-sensitive sequences in all subjects with LOE of otherwise unknown etiology, not to miss a diagnosis of CAA.

Multi-center observational study on occurrence and related clinical factors of neurogenic heterotopic ossification in patients with disorders of consciousness

Aims: to assess occurrence and clinical correlates of neurogenic heterotopic ossifications (NHO) in patients with prolonged disorder of consciousness (DoC).Design: multi-center cross-sectional observational study.Setting: 23 intensive neurorehabilitation units.Subjects: 287 patients with prolonged disorder of consciousness (DoC; 150 in vegetative state, VS, and 128 in minimally conscious state, MCS) of different etiology (vascular = 125, traumatic = 83, anoxic = 56, others = 14).Main Measures: clinical evidence of NHO confirmed by standard radiological and/or sonographic evaluation; Coma Recovery Scale-Revised; Disability Rating Scale (DRS); Early Rehabilitation Barthel Index; presence of ventilator support, spasticity, bone fractures and paroxysmal sympathetic hyperactivity.Results: 31 patients (11.2%) presented NHO. Univariate analyses showed that NHO was associated with VS diagnosis, traumatic etiology, high DRS category and total score, and high occurrence of limb spasticity and bone fractures. A cluster-corrected binary logistic regression model (excluding spasticity available in a subset of patients) showed that only lower DRS total score and presence of bone fractures were independently associated with NHO.Conclusions: NHO are relatively frequent in patients with DoC, and are independently associated with functional disability, bone fractures and spasticity. These findings contribute to identifying patients with DoC prone to develop NHO and requiring special interventions to improve functional recovery.

DNAJC17 is localized in nuclear speckles and interacts with splicing machinery components

DNAJC17 is a heat shock protein (HSP40) family member, identified in mouse as susceptibility gene for congenital hypothyroidism. DNAJC17 knockout mouse embryos die prior to implantation. In humans, germline homozygous mutations in DNAJC17 have been found in syndromic retinal dystrophy patients, while heterozygous mutations represent candidate pathogenic events for myeloproliferative disorders. Despite widespread expression and involvement in human diseases, DNAJC17 function is still poorly understood. Herein, we have investigated its function through high-throughput transcriptomic and proteomic approaches. DNAJC17-depleted cells transcriptome highlighted genes involved in general functional categories, mainly related to gene expression. Conversely, DNAJC17 interactome can be classified in very specific functional networks, with the most enriched one including proteins involved in splicing. Furthermore, several splicing-related interactors, were independently validated by co-immunoprecipitation and in vivo co-localization. Accordingly, co-localization of DNAJC17 with SC35, a marker of nuclear speckles, further supported its interaction with spliceosomal components. Lastly, DNAJC17 up-regulation enhanced splicing efficiency of minigene reporter in live cells, while its knockdown induced perturbations of splicing efficiency at whole genome level, as demonstrated by specific analysis of RNAseq data. In conclusion, our study strongly suggests a role of DNAJC17 in splicing-related processes and provides support to its recognized essential function in early development.

Comparison between "early" or "late" intravitreal injection of dexamethasone implant in branch (BRVO) or central (CRVO) retinal vein occlusion: six-months follow-up

AIM

The aim of this study was to compare early and late injections of intravitreal dexamethasone implant in patients affected by central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with a six-months follow-up. We assessed whether an earlier treatment start (within seven days from diagnosis) could be more beneficial than a delayed (or late) treatment start (after seven days).

MATERIALS AND METHODS

The study included 81 patients (81 eyes) affected by retinal vein occlusion. Best corrected visual acuity was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS) while central macular thickness (CMT) was measured by spectral-domain optical coherence tomography.

RESULTS

Both types of patients had a positive therapeutic response to dexamethasone, with an increase in visual acuity (ETDRS) and CMT reduction. CRVO patients were characterized by lower ETDRS values at baseline and at the end of the follow-up as compared to BRVO. CRVO patients showed higher CMT values at baseline, after three and six months from injection. No significant differences in therapeutic response to dexamethasone were observed between patients treated early or late, regardless of RVO type.

CONCLUSIONS

This study demonstrates that the therapeutic properties of dexamethasone implant are not significantly influenced by an early or late treatment start in patients affected by BRVO and CRVO, although its therapeutic efficacy seems greater in the former type.

Three episodes of non-arteritic posterior ischemic optic neuropathy in the same patient treated with intravenous prostaglandin E1

Non-arteritic posterior ischemic optic neuropathy (NA-PION) is a disorder involving reduced blood flow to the retrobulbar portion of the optic nerve. This disorder usually develops acutely, and research has suggested that high-dose steroid therapy soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator could help to restore ocular blood flow. This case report describes the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat three separate episodes of NA-PION over five years in the same patient. A 68-year-old white male was first seen in June 2009 with NA-PION in the left eye, and the condition was treated with steroids and PGE1. The patient had a subsequent episode in July 2010 that was treated with steroids and PGE1 and another in May 2014 that was treated with PGE1 alone. Visual acuity improved from 4/10 to 11/10 in 2009, from 4/10 to 11/10 in 2010, and from 5/10 to 10/10 in 2014. No complications due to the use of PGE1 were noted. PGE1 should be considered as a treatment for NA-PION to immediately restore blood flow and potentially improve vision.

Degenerative events in retina and optic nerve induced by inhibition of carnitine transport

Biochemical and pharmacological evidence supports the hypothesis that the mechanism of action of mildronate [3-(2,2,2-trimethylhydrazinium)propionate dihydrate] is based on its regulatory effect on carnitine concentration. The present study demonstrates that carnitine acts as a neuroprotective agent both in optic nerve head and in retinal ganglion cell (RGC) by means of antioxidant and antiradical activities. In fact, carnitine normalized the increase in caspase-3, cellular apoptosis susceptibility protein (CAS) and inducible nitric oxide synthase (iNOS) expression by stabilizing mitochondrial membranes, as assessed by quantitative and qualitative analysis. This research shows that the neuroprotective effects of carnitine result, at least partially, from anti-neurodegenerative (anti-apoptotic) and anti-inflammatory mechanisms. It is suggested that the molecular conformation of carnitine can facilitate its easy binding to mitochondria, and regulate the expression of different signal molecules, hence maintaining normal cellular signaling and survival by modulating caspase-3 activity.

An ischemic diabetic eye treated with intravenous prostaglandin E1

PURPOSE

To present the use of intravenous prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, in the treatment of an ischemic diabetic eye.

METHODS

A 27-year-old diabetic man with ischemic diabetic retinopathy and glaucoma had a decreased visual acuity of no light perception in his right eye and hand motions in his left eye. He was started on intravenous PGE1 and has been treated for over 4.5 years.

RESULTS

The visual acuity in his right eye remained unchanged and in his left eye improved gradually to 1.5/30. He has been stable for 4.5 years.

CONCLUSION

Intravenous PGE1 may be useful in ischemic diabetic eyes to improve the ocular blood flow and visual acuity. It is safe and tolerated well.

Smith Lemli-Opitz syndrome: a contribution to the delineation of a cognitive/behavioral phenotype

AIM

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive congenital malformation syndrome caused by an inborn error of cholesterol biosynthesis. The incidence is around 1:20000-1:70000. SLOS phenotype is very broad: severe phenotypes show exitus in perinatal period while milder phenotypes only show behavioral and learning problems. The purpose of this study is to further contribute to the delineation of a cognitive and behavioral phenotype in SLOS.

METHODS

Nine patients with SLOS aged between 22 months and 25 years have been followed at the Department of Pediatrics, University of Naples "Federico II" for 2 years. A neuropsychologic study has been carried out in order to assess motor development, adaptive skills, social behavior, communication and language, temperament, aggressive behavior, symptoms typical of autism spectrum disorders (ASDs).

RESULTS

The overall assessment of cognitive/behavioral phenotype showed severe / profound mental retardation in most of them (8/9) with a quite homogeneous neuropsychological profile. The language area was deficient both in expressive and receptive skills. Adaptive skills were in line with mental development. The presence of behavior problems (self-injury and stereotypies) was detected in 6 patients. The study of temperament showed a trend towards a sedentary lifestyle, lack of inhibition against novelty and danger, and reduced interest in the stimuli. None of our patients could be diagnosed as having ASDs.

CONCLUSION

Although a specific behavioral phenotype for SLOS has gained support in the literature, we believe that many of the features described in individuals with SLOS are common to other mental retardation syndromes.

Idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysm treated with indocyanine green dye-enhanced photocoagulation

This case report presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of idiopathic juxtafoveal retinal telangiectasis and a retinal macroaneurysm. A 35-year-old male with 20/20 vision had been followed for 5 years for a retinal macroaneurysm with retinal telangiectasis outside the macular area. He then presented with a recently decreased vision in his right. He had macular edema with a new area of idiopathic juxtafoveal retinal telangiectasis. After 4 focal argon laser treatments, angiographic closure of the lesions was not obtained and the retinal edema remained. After 3 sessions of ICG-DEP, the lesions were closed and the edema absorbed. The 810 nm infrared laser with ICG-DEP should be considered for the treatment of idiopathic juxtafoveal retinal telangiectasis and retinal macroaneurysms. In this case the procedure appears to be safe and well tolerated. It may allow for more direct energy absorption than that of the argon laser to these types of retinal lesions with better tissue closure.

Epilepsy in inherited metabolic disorders: a pediatric series

AIM

Our study aims at further defining the characteristics of epilepsy in Inherited Metabolic Disorders (IMDs).

METHODS

We reviewed the medical records of 345 patients with IMDs followed at the Metabolic Diseases Unit of our Department of Pediatrics and found the presence of an epileptic syndrome in 45 cases. An overview is given based on various criteria such as pathogenetic background, seizure type, age of onset, EEG, neuroimaging data, treatability. Seizure types were: focal (24 patients), generalized (13 patients), febrile (3 patients), and hypoglycemic (8 patients with glycogenoses). Some patients presented with more than one type of seizures. Age of onset was mainly during the first year of life (N.=19), between 2 and 6 years in 13 patients, and after the 6th year in 9 patients.

RESULTS

Available EEGs showed either focal (N.=21) or generalized epileptiform abnormalities (N.=11); multifocal paroxysms were evident in 3 patients while the remaining 3 patients had normal findings. Available neuroimages (CT/MRI) showed either normal findings (N.=6) or white matter abnormalities (N.=6), cerebral and/or cerebellar cortical atrophy (N.=11), hydrocephalus (N.=1), corpus callosum hypoplasia (N.=2), pontocerebellar hypoplasia (N.=1), gliosis in trigone area (N.=4). Most patients showed a favorable response to antiepileptic treatment (AEDs) with either complete control or reduced seizure frequency.

CONCLUSION

IMDs are a relatively rare cause of epilepsy in children but their diagnosis is very important with respect to treatment, prognosis and genetic counselling.

Arteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E(1) and steroids

Arteritic anterior ischemic optic neuropathy (AAION) is an acute ischemia of the posterior ciliary arteries and/or ophthalmic artery due to inflammation. Therapy is immediate intervention with systemic steroids, especially to protect against vision loss in the other eye. The addition of a potent vasodilator to the steroids could help restore ocular blood flow and improve visual acuity. The objective of the current report was to present the use of prostaglandin E(1) (PGE(1)) - a powerful vasodilator of the microcirculation - in the treatment of AAION. Two patients with AAION were treated with intravenous steroids and PGE(1). The visual acuity improved from 4/50 (less than 20/200) to 6/10 (20/35) in one patient and from 1/50 (20/400) to 1/10 (20/200) in the second patient. The visual fields in both patients maintained small central islands of vision. No complications due to the use of PGE(1) were seen. Intravenous PGE(1) should be considered in addition to steroids in cases of AAION to immediately restore blood flow to the optic nerve and improve visual acuity while the steroids reduce the inflammation.

Topotecan hydrochloride effects on retinal vessels in newborn rats

A physiological system, i.e. rodent retina during vessel formation and hierarchical organization, was utilised for assaying antiangiogenic properties of Topotecan, a topoisomerase I inhibitor, capable of inhibiting tumoral growth in animal models of retinoblastoma. In particular we analysed possible differences in effectiveness and side effects among different drug dosages and ways of administration. In the present research only qualitative analyses were undertaken. After preliminary experiments, in which suckling animals subcutaneously treated with Topotecan dosages comprised between 9 and 3 mg/kg underwent high lethality and extremely severe systemic damages, 7 day-old rats were subcutaneously, intravenously or peribulbary injected with a single dose of 1 mg/kg; retinal vessels were visualized in retinal fluorangio-graphies taken 1 and 2 weeks after treatment. The most important and frequent alterations were found to affect radial vessels, which showed non-perfused and/or regionally mislocated segments, together with abnormal branching and enlargements in retinal periphery; persistence of capillary-free periarteriolar regions, non-vascularised regions and spots of extravascular FITC were also detected. Despite the high individual variability the alterations were substantially similar among the different ways of drug administration, while they appeared milder in 21 day-old rats, with respect to younger ones. The extensive vascular remodelling found after Topotecan administration, besides demonstrating the antiangiogenic properties of this chemioterapic drug, confirms the rodent retina as a highly valuable model system for studying angiogenesis modulation.

Nonarteritic anterior ischemic optic neuropathy treated with intravenous prostaglandin E1 and steroids

BACKGROUND

Acute nonarteritic anterior ischemic optic neuropathy (NAION) is considered to be acute ischemia of the posterior ciliary arteries. Prostaglandin E1 (PGE1), a powerful microcirculation vasodilator, has been shown to improve ocular blood flow.

DESIGN

A nonrandomized, comparative trial.

METHODS

Eight consecutive cases of NAION were treated with intravenous steroids and PGE1. Seven control cases of NAION were treated with acetylsalicylic acid and oral steroids. Fisher's exact test was used for statistical analysis.

RESULTS

The visual acuity improved in seven cases of NAION treated with PGE1 and was unchanged in one. Of the seven control cases, four had no change in vision and three lost further visual acuity on follow-up visits.

CONCLUSIONS

Intravenous PGE1 and steroids should be considered in cases of NAION to immediately restore blood flow to the optic nerve and improve visual acuity.

Developmental evolution in a patient with multiple acyl-coenzymeA dehydrogenase deficiency under pharmacological treatment

PURPOSE

evaluate the psychomotor evolution of a child with Multiple acyl-CoA dehydrogenase deficiency after treatment with L-carnitine, ubiquinone and riboflavin.

METHODS

an assessment of psychomotor development was performed before the start of farmacological treatment using the Assessment Scale of Mental Development Griffiths (GMDS-R, 0-2 years). The same assessment was performed after a month and after six months of treatment to evaluate the possible benefits of treatment.

RESULTS

we noticed a quick and dramatic improvement in muscular tone and motor performances after pharmacological treatment. We also observed a substantial improvement in the personal/social and hearing/language areas, suggesting the presence of intellectual/cognitive improvement. The clinical improvement correlated with the biochemical response.

CONCLUSION

In our patient early therapy resulted in a optimal response in psychomotor development, motor function and muscole hypotonia. Evaluation with GMDS-R, a simple, non-invasive and multidimensional tool, represents a useful instrument to monitor the clinical response to treatment.

Ocular and optic nerve ischemia: recognition and treatment with intravenous prostaglandin E1

Ischemia of the optic nerve, the retina and the choroid are common problems in ophthalmology. This paper presents the different types of ischemia and their treatment with prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation. This is a review article of various previously published case reports and studies presenting patients with different types of ocular and optic nerve ischemia. Their treatment with intravenous (IV) PGE1 is described. Treatment for acute and chronic problems is presented. The visual acuity and/or the visual fields improved in almost all the treated patients. When measured, the blood flow velocities also improved. No complications due to the use of PGE1 were seen. Treatment with IV PGE1 should be considered in cases of ocular and optic nerve ischemia to immediately restore blood flow to these structures and improve the visual acuity. Intravenous prostaglandin E1 is an effective treatment for ocular and optic nerve ischemia leading to immediate visual improvement.

Non-arteritic Posterior Ischaemic Optic Neuropathy Treated with Intravenous Prostaglandin E1 and Oral Corticosteroids

Intravenous prostaglandin E1 and oral corticosteroids were used to treat the ischaemic phase of a non-arteritic posterior ischaemic optic neuropathy with immediate visual improvement. Non-arteritic posterior ischaemic optic neuropathy is a disorder of reduced blood flow to the retrobulbar optic nerve, usually of acute onset. It has been suggested that high-dose steroid therapy given soon after the onset of visual loss can result in significant visual improvement. This treatment, however, is not universally successful. The addition of a potent vasodilator to the corticosteroids could help restore ocular blood flow and improve visual acuity. This paper presents the use of prostaglandin E1 (PGE1), a powerful vasodilator of the microcirculation, to treat non-arteritic posterior ischaemic optic neuropathy. In this case report a 68-year-old white male with hereditary haemochromatosis was seen 8 hours after sudden loss of visual acuity in his left eye (OS) to 4/10. The diagnosis of non-arteritic posterior ischaemic optic neuropathy was made and he was immediately given oral corticosteroids. Intravenous PGE1 was given the next morning, 24 hours after the sudden loss of vision, once ischaemia of the optic nerve was confirmed by colour Doppler imaging. The visual acuity in the OS improved from 4/10 to 11/10 within 1 day. A visual field (VF) post treatment showed a peripheral scotoma without a central scotoma. At 12 months post treatment the vision OS remained 11/10. No complications due to the use of PGE1 were seen. The authors conclude that PGE1 should be considered in addition to steroids in cases of NA-PION to immediately restore blood flow to the optic nerve and improve visual acuity.

Branch retinal arterial occlusion treated with intravenous prostaglandin e1 and steroids

PURPOSE

To present the use of 6-methylprednisolone IV and prostaglandin E1 IV, a powerful vasodilator of the microcirculation, in the treatment of a branch retinal arterial occlusion.

METHODS

A 63-year-old man presented with a 3-hour history of a sudden loss of vision in the right eye. On ophthalmic examination, the diagnosis of a superior temporal branch retinal arterial occlusion was made. The patient was immediately given 40 mg of 6-methylprednisolone IV for more than 5 minutes followed by 80 μg of prostaglandin E1 with 2 milliequivalents of potassium IV for more than 3 hours. The same treatment was repeated the following morning.

RESULTS

The visual acuity in the right eye improved from 2/10 at presentation to 7/10 at the end of the second day of treatment. Clinically, there was a reduction of the posterior pole edema. Eleven days after treatment, the visual acuity was 9/10 with no retinal edema.

CONCLUSION

Immediate prostaglandin E1 IV and steroids should be considered in cases of recent-onset branch retinal arterial occlusion to restore retinal blood flow and improve visual acuity.

Retinal Angiomatous Proliferation Successfully Treated with Indocyanine Green Dye-Enhanced Photocoagulation

This case series presents the use of indocyanine green dye-enhanced photocoagulation (ICG-DEP) for the treatment of retinal angiomatous proliferation (RAP). Five RAP lesions in 4 eyes of 3 patients were identified by fluorescein and indocyanine green dye angiography. The RAP lesions were treated with focal ablation of the intraretinal component using a ICG-DEP protocol. The 810-nm infrared laser in the pulsed millipulsed mode was used. The visual acuity and angiographic findings in the 3 patients with a follow-up from 18 months to 4 years are reported. The five RAP lesions were closed angiography in the 4 eyes of the 3 patients. All of the eyes had visual improvement for at least 8 months. In one stage 3 RAP lesion, there was visual improvement for 8 months until the choroidal neovascular membrane grew again. In this limited series, the procedure appeared to be safe and well tolerated with stable or improved visual acuity.

Risk factors for type 2 diabetes in women attending menopause clinics in Italy: a cross-sectional study

OBJECTIVE

To analyze risk factors for type 2 diabetes among women attending menopause clinics in Italy for counselling about the menopause.

SUBJECTS

Women attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms.

METHODS

Cross-sectional study with no exclusion criteria. Type 2 diabetes was defined according to National Diabetes Data Groups Indications and the fasting blood glucose at an oral glucose tolerance test within the previous year.

RESULTS

Out of the 44 694 considered in this analysis, 808 had a diagnosis of diabetes type 2 (1.8%). In comparison with women aged < 50 years, the multivariate odds ratios (OR) of type 2 diabetes were 1.31 (95% confidence interval (CI), 0.99-1.74) for women aged 50-52 years, 1.66 (95% CI, 1.27-2.17) at 53-56 years and 2.84 (95% CI, 2.20-3.67) in women aged > or = 57 years. Type 2 diabetes was less frequently reported in more educated women (OR high school/university vs. primary school = 0.44 (95% CI, 0.36-0.55)). Being overweight was associated with an increased risk of type 2 diabetes. In comparison with women reporting a low level of physical activity, the multivariate OR of type 2 diabetes was 0.67 (95% CI, 0.54-0.84) for women reporting regular physical activity. In comparison with premenopausal women, the multivariate OR of type 2 diabetes was 1.38 (95% CI, 1.03-1.84) in women with natural menopause. This finding was present also after allowing for the potential confounding effect of age. The multivariate OR of diabetes for users of hormonal replacement therapy was 0.58 (95% CI, 0.46-0.73).

CONCLUSIONS

This large cross-sectional study suggests that postmenopausal women are at higher risk of type 2 diabetes after allowance for the effect of age. Other main determinants of risk of type 2 diabetes in women around menopause were low socioeconomic status and being overweight. Diabetes was found less frequently in those taking hormone replacement therapy.

Photodynamic therapy for nonsubfoveal choroidal neovascularization in 100 eyes with pathologic myopia

PURPOSE

To evaluate the visual and anatomic outcome of photodynamic therapy (PDT) in eyes with nonsubfoveal choroidal neovascularization (CNV) associated with pathologic myopia (PM).

DESIGN

Interventional, noncomparative cases series.

METHODS

Ninety-seven patients (100 eyes) who were treated with PDT at three centers and followed up for three to 44 months (mean 16.5 months). Outcome measures were visual acuity, lesion size, and the occurrence of subfoveal invasion.

RESULTS

Median baseline visual acuity was 20/40(-2) and ranged from 20/20 to 20/160(+2). On average, visual acuity was stable throughout follow-up after a modest increase of about 0.5 lines between three and six months. The probability of losing 3 or more lines was 10% to 15% during the second year. Lesion size (median: 710 microns) slightly decreased after the first PDT and tended to increase later, but not to a statistically significant extent compared with baseline. The probability of developing subfoveal CNV stabilized at 10% in the second year. The mean number of PDTs per individual was 2.9 in the first year and 0.6 in the second.

CONCLUSIONS

Visual and anatomic outcomes of PDT, in this large group of patients with nonsubfoveal myopic CNV and good visual acuity, suggest that it may halt the progression of the disease in most cases.

Factors associated with climacteric symptoms in women around menopause attending menopause clinics in Italy

OBJECTIVE

To obtain data on correlates of climacteric symptoms in women around menopause attending menopause clinics in Italy.

METHODS

Since 1997 a large cross sectional study has been conducted on the characteristics of women around menopause attending a network of first level menopause outpatient's clinics in Italy. A total of 66,501 (mean age 54.4 years) women are considered in the present paper.

RESULTS

The odds ratios of moderate and severe hot flashes/night sweats were lower in more educated women and (for severe symptoms only) in women reporting regular physical activity. Depression, difficulty to sleep, forgetfulness and irritability tended to be less frequent in more educated women and (depression only) in women reporting regular physical activity. Parous women reported more frequently these symptoms.

CONCLUSIONS

This large study confirms in Southern European population that low education, body mass index and low physical activity are associated with climacteric symptoms. Parous women are at greater risk of psychological symptoms.

Macular Function after PDT in Myopic Maculopathy: Psychophysical and Electrophysiological Evaluation

PURPOSE

To evaluate the effects of photodynamic therapy (PDT) on macular function in myopic subfoveal choroidal neovascularization (CNV).

METHODS

Fourteen eyes of 14 patients (mean age, 48.1 +/- 13.3 years) with myopic CNV (myopia ranging from -6.50 to -20 D) were enrolled. In each eye, at baseline and at 15 and 90 days after PDT with verteporfin, logMAR visual acuity (logarithm of the minimum angle of resolution VA), macular sensitivity by scanning laser ophthalmoscope microperimetry, and focal (central 9 x 9 degrees ) ERGs (FERGs) and pattern ERGs (PERGs) were assessed.

RESULTS

At 15 days after PDT, myopic CNV eyes showed, in relation to baseline values, a significant (ANOVA, P < 0.01) reduction in the diameter of the lesion that correlated (Pearson test, P < 0.01) with the significant (ANOVA, P < 0.01) increase in FERG and PERG amplitudes, VA, and scanning laser ophthalmoscopy (SLO) microperimetry results obtained from the central 1 degrees to 2 degrees of the macular area (SLO-CM). At 90 days after PDT, myopic CNV eyes showed, in comparison with baseline values, a nonsignificant (ANOVA, P > 0.01) reduction in the diameter of the lesion, a nonsignificant increase in VA and SLO-CM, and a still significant increase in FERG and PERG amplitudes.

CONCLUSIONS

In myopic CNV eyes, PDT induces an increase, though not significant, in VA and macular sensitivity. These changes may be related to a reduction in the diameter of the lesion, with an improvement in the function of both ganglionic and preganglionic elements of the macular region, as suggested by the improvement in FERG and PERG responses.

Relapse of low-grade gastric MALT lymphoma after Helicobacter pylori eradication: true relapse or persistence? Long-term post-treatment follow-up of a multicenter trial in the north-east of Italy and evaluation of the diagnostic protocol's adequacy

The effect of eradication of Helicobacter pylori on early stage gastric low-grade MALT lymphoma in 76 patients with follow-up of at least 1 year (12-63 months, mean 28) is reported. No regression was found in five cases after 12-48 months. In one case surgical resection detected the involvement of perigastric lymph nodes overlooked by endoscopic ultrasonography (EUS). Neither progression of the disease nor a high-grade component was documented by repeated gastric mappings, EUS and complete stagings in the other four cases. After histological remission five relapses of low-grade and one relapse of high-grade MALT lymphoma were found 12-48 months after eradication. Subsequent histological remission, without any additional therapy, was found in three relapsed cases. A rapid and persistent histological remission was obtained in 56 patients (73%). A late remission was observed in six cases. Monoclonal remission was found in half of the patients and was frequently delayed. Persistent monoclonality was associated with histological remission in the vast majority of patients. Our data confirm H. pylori eradication as the first choice therapy for early stage gastric low-grade MALT lymphoma and recommend extensive bioptic mapping and endoscopic sonography both in the local staging and in the regression evaluation. The rare cases of late remission encourage us to wait for at least 1 year after eradication of H. pylori. Longer follow-up studies will clarify the meaning of histological relapse/persistence and late remission. The study of non-responder cases could show us a step in lymphomagenesis.

Paclitaxel, ifosfamide, and carboplatin for the treatment of stages IIIB and IV non-small cell lung cancer: preliminary results

We have treated 26 consecutive chemotherapy-naive patients with stage IIIB/IV non-small cell lung cancer with an innovative regimen based on a 1-hour infusion of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) 125 to 250 mg/m2, ifosfamide 3 g/m2 (with mesna), and carboplatin dosed to an area under the concentration-time curve of 5, every 21 days for a total of six cycles in responding or stabilized patients. Among 22 fully evaluable patients, 14 (64%) achieved a partial remission, six had disease stabilization, and two had disease progression. Hematologic toxicity was remarkably mild; only one patient had grade 3 neutropenia (on day 21). Arthralgias/myalgias (grade 3 in nine patients, grade 4 in one patient) and neurologic toxicity (a cumulative sensory neuropathy of grade 3 or 4 in five patients) were the most common side effects and seem to be dose related. To date, few patients are fully evaluable and survival data are clearly immature. Nevertheless, this regimen seems highly active and quite well tolerated, and deserves further evaluation.

Clinical features, treatment and outcome in a series of 93 patients with low-grade gastric MALT lymphoma

The purpose of this paper is to report the clinical characteristics and treatment outcome following different therapeutic approaches in a large series of patients with primary low-grade MALT lymphoma of the stomach. A total of ninety-three patients (median age 63 years) were reviewed. The patients were treated by different modalities (local treatment alone, combined treatment, chemotherapy, antibiotics alone); seven patients refused any treatment. The antibiotic-treated group of patients was prospectively followed with regular endoscopic biopsies, and their responses were histologically evaluated. The 5-years projected overall survival is 82% (95% C.I.; 67%-91%) in the series as a whole. Second tumors were observed in 21.5% of the patients in this series (95% CI 14%v to 31%). There was no apparent difference in overall survival and event-free survival between patients who received different treatments. In the antibiotic-treated group histologic regression of MALT lymphoma was documented in 67% of patients (95% CI 51% to 80%). In conclusion the indolent nature of the disease justifies a conservative approach. The use of antibiotics as first-line therapy may avert or at least postpone the indication for surgical resection in the majority of patients.

High incidence of other neoplasms in patients with low-grade gastric MALT lymphoma

BACKGROUND

Low-grade gastric MALT lymphoma is an uncommon tumour for which a close association with chronic Helicobacter pylori infection has been suggested. However, given the rarity of MALT lymphoma of the stomach despite the high prevalence of H. pylori infection, it seems plausible that genetic host factors might play a fundamental role in gastric lymphomagenesis.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 83 patients with low-grade gastric MALT, all of whom resided in a geographic area (southern Switzerland and northern Italy) where the incidence of gastric tumours appears to be uncommonly high.

RESULTS

One or more additional cancers were observed in 17 of 83 patients (20%, 95% CI 12% to 31%) for a total of 23 tumours. Of these, 5 were diagnosed prior to, 12 concomitantly with, and 7 after the gastric MALT lymphoma. Eleven patients had a single additional solid tumour (13%, 95% CI 7% to 22%); 3 patients had non-Hodgkin's lymphoma and one had Hodgkin's disease. Multiple additional cancers were present in 3 cases. Nine of 83 patients have died and 8 of them of a second cancer.

CONCLUSIONS

Unexpectedly an extraordinarily large number of patients with other malignancies was observed in this series. The reasons for this finding are still unknown, but genetic alterations are speculated to play an important role.

Low-dose cytosine arabinoside in patients with acute myeloid leukemia not eligible for standard chemotherapy

The results of treatment with low dose cytosine arabinoside (LDARA-C) in 131 AML patients ineligible for standard regimens were analyzed retrospectively. Eighty-seven were previously untreated, 25 were refractory to conventional chemotherapy and 19 were relapsed patients. The median age was 66 years (15-84). An antecedent hematological disorder (AHD) was documented in half of the patients. Overall, 22 (17%) achieved complete remission, 14 (11%) partial remission, 77 (59%) had resistant leukemia and 18 died during induction. Median disease free survival was 57 weeks and median survival, for the 87 previously untreated patients, was 22.5 weeks. The prognostic value of initial parameters was analyzed for response. Bone marrow cellularity was the only significant factor. We observed 33% vs 81% (p < 0.01) of responses in patients with normo-hypercellular and hypocellular marrow, respectively. Accordingly, there was a trend to more responses in patients with leukocyte counts of less than 10 x 10(9)/L. M4-M5 FAB subtypes were frequently resistant to LDARA-C, resulting in a lower response rate compared to M0-M2 (18% vs 32%). Other parameters, including age, sex, hemoglobin, platelet count, AHD and fever at diagnosis, had no prognostic value. Our findings suggest that LDARA-C may be an effective treatment for some patients who are not eligible for first line conventional chemotherapy. However, this schedule is not advised in patients with monocytic leukemia or those with an hypercellular marrow.

Eradication of Helicobacter pylori infection in primary low-grade gastric lymphoma of mucosa-associated lymphoid tissue

OBJECTIVE

To determine the effect of eradicating Helicobacter pylori infection on the course of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.

DESIGN

Prospective cohort study.

SETTING

University internal medicine clinics, a referral oncology center in southern Switzerland, and a gastroenterology referral center in northern Italy.

PATIENTS

26 patients with localized primary low-grade gastric MALT lymphoma.

INTERVENTION

Treatment for H. pylori infection (bismuth or omeprazole or both, amoxicillin, and metronidazole for 14 days).

MAIN OUTCOME MEASURES

Endoscopic biopsy specimens of the gastric mucosa were obtained every 3 to 6 months after treatment for H. pylori infection.

RESULTS

Helicobacter pylori was completely eradicated in 25 of 26 patients, but 4 patients needed second-line antibiotic treatment to eradicate the microorganism. Disappearance or almost total regression of the lymphomatous tissue was observed in 15 of the 25 evaluable patients (60%; CI, 39% to 79%); however, disappearance or almost total regression was evident in the first biopsy specimen after treatment for H. pylori infection in only 8 of the 15 patients.

CONCLUSIONS

Our study confirms recent anecdotal reports of regression of gastric MALT lymphoma after eradication of H. pylori and indicates that the growth of these extranodal lymphomas may depend on H. pylori.

Attenuated-dose idarubicin in acute myeloid leukaemia of the elderly: pharmacokinetic study and clinical results

AML in the elderly is characterized by intrinsic biological features implying an enhanced chemoresistance. Intensive chemotherapy should be the treatment of choice, but the standard doses could induce unacceptable rates of aplastic deaths. We evaluated the efficacy of an induction protocol with attenuated-dose idarubicin (IDA) 8 mg/m2 for 3 d plus cytarabine and etoposide in 26 AML patients aged > 60. 18 patients (69%) achieved CR, five (19%) were non-responders and three (12%) died during induction. To compare the pharmacokinetics of IDA between elderly and young patients, we assayed daily the serum level of the drug and of its metabolite (idarubicinol, IDAol) in a group of eight elderly patients who received a dose of 8 mg/m2 (group A) and in a group of nine younger AML patients treated with 12 mg/m2 (group B). The apparent terminal half-life of IDAol was significantly longer in the elderly than in the younger patients (mean half-life 59.7 h versus 41.4 h, P < 0.05). The values of the area under the serum concentration curve of IDAol indicated that the two patient groups received a very similar exposure to the drug despite the different doses. In conclusion, this protocol, based on attenuated doses of IDA, compares well with the results obtained previously in similar age-matched patient series.

CD34 expression fails to predict the outcome in adult acute myeloid leukemia

BACKGROUND

The expression of the CD34 antigen on the blast cells of acute myeloid leukemia (AML) has been regarded as an unfavorable prognostic factor for the achievement of complete remission (CR). However, clinical reports on this issue still remain controversial. We evaluated the relationship between CD34 expression, some clinical characteristics and outcome in 80 consecutive adult AML patients.

METHODS

Immunophenotyping was performed with a FACSCAN flow cytometer and CD34 was tested by HPCA-1 (My10, Becton-Dickinson). Samples were considered positive when at least 20% of cells were labeled. Promyelocytic leukemias were excluded from the study. Sixty-six patients were designed to receive intensive induction chemotherapy; 14 "low-dose" ARA-c.

RESULTS AND CONCLUSIONS

Forty percent of AML were CD34 positive. In this group there was a higher incidence of less differentiated FAB subtypes (p = 0.03), but not of pre-existing myelodysplasia. No differences were found in complete remission (CR) rate, remission duration or survival. Excluding induction deaths from the analysis, the CR rate was slightly lower in CD34+ AML (55 vs 65%), without any impact on survival. We could not confirm the prognostic relevance of CD34 in adult AML, but larger studies are needed.

Ceftriaxone plus conventional or single-daily dose amikacin versus ceftazidime/amikacin as empiric therapy in febrile neutropenic patients

Results of antibiotic treatment in 144 febrile episodes during drug-induced granulocytopenia are reported. 63 episodes were treated with ceftazidime plus amikacin and 81 with ceftriaxone (CFX) using single daily doses combined with amikacin either divided in three doses (CFX-1 group) or administered as single doses (CFX-2 group). The response rates were 51, 80, and 57% respectively. In this study CFX was more effective than ceftazidime and amikacin provided better results when administered using the standard 8-hour scheduling.

The orientation of a parallel-line texture between the verticals can modify the strength of the Poggendorff illusion

In the present experiments, we attempted to evaluate the modification of the strength of the Poggendorff illusion as a function of the different orientation of a parallel-line texture filling the space between the vertical lines. In Experiment 1, the standard version of the Poggendorff configuration was tested against four different parallel-line textures oriented at 0 degrees, 45 degrees, 90 degrees, and 135 degrees with respect to the obliques. The results showed that the illusory effect was a linear function of the progressive discrepancy between the angle of the lines of the texture and that of the obliques. In Experiment 2, we tested the same textures used in Experiment 1 after the elimination of the two vertical lines. The data obtained approximated a linear function, as in the previous experiment, but the alignment errors were consistently lower. The statistical analysis performed on the data of all eight experimental conditions shows that both factors--texture and presence/absence of verticals--were significant, but most of the effect was due to the texture factor. The results may be interpreted through the "perceptual compromise hypothesis," originally proposed for the bisection forms of the Poggendorff illusion, but with important modifications. The data are also discussed in terms of their implications for other theories proposed for the Poggendorff illusion.

Effects of tryptophan depletion on Poggendorff illusion, corner Poggendorff illusion, and attention

The effects of a tryptophan-free amino acid mixture on Poggendorff illusion, corner Poggendorff illusion, and attention were investigated with 12 male subjects who ingested either a balanced amino acid mixture or a tryptophan-free mixture, the latter known to cause a marked depletion of brain tryptophan and serotonin. No significant difference between the two mixtures on the perceptual illusions was found.