Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis

BACKGROUND AND PURPOSE

Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke.

MATERIALS AND METHODS

We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion).

RESULTS

In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0-2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%-14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%-68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%-35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%-94.6%).

CONCLUSIONS

Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.

Clot Burden Score and Collateral Status and Their Impact on Functional Outcome in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Collateral status and thrombus length have been independently associated with functional outcome in patients with acute ischemic stroke. It has been suggested that thrombus length would influence functional outcome via interaction with the collateral circulation. We investigated the individual and combined effects of thrombus length assessed by the clot burden score and collateral status assessed by a FLAIR vascular hyperintensity-ASPECTS rating system on functional outcome (mRS).

MATERIALS AND METHODS

Patients with anterior circulation acute ischemic stroke due to large-vessel occlusion from the ASTER and THRACE trials treated with endovascular thrombectomy were pooled. The clot burden score and FLAIR vascular hyperintensity score were determined on MR imaging obtained before endovascular thrombectomy. Favorable outcome was defined as an mRS score of 0-2 at 90 days. Association of the clot burden score and the FLAIR vascular hyperintensity score with favorable outcome (individual effect and interaction) was examined using logistic regression models.

RESULTS

Of the 326 patients treated by endovascular thrombectomy with both the clot burden score and FLAIR vascular hyperintensity assessment, favorable outcome was observed in 165 (51%). The rate of favorable outcome increased with clot burden score (smaller clots) and FLAIR vascular hyperintensity (better collaterals) values. The association between clot burden score and functional outcome was significantly modified by the FLAIR vascular hyperintensity score, and this association was stronger in patients with good collaterals, with an adjusted OR = 6.15 (95% CI, 1.03-36.81).

CONCLUSIONS

The association between the clot burden score and functional outcome varied for different collateral scores. The FLAIR vascular hyperintensity score might be a valuable prognostic factor, especially when contrast-based vascular imaging is not available.

Evaluation of synthetic substituted 1,2-dioxanes as novel agents against human leishmaniasis

The treatment of human leishmaniasis is currently based on few compounds that are highly toxic, expensive and have a high rate of treatment failure. A number of recent studies on new drugs focuses on natural or semi-synthetic compounds. Among them, the endoperoxide artemisinin, extracted from Artemisia annua, and some of its derivatives have shown leishmanicidal activity. In the present work, a series of structurally simple, fully synthetic 1,2-dioxanes were evaluated for in vitro antileishmanial activity against promastigotes of Leishmania donovani; the cytotoxicity for mammalian cells was also assessed. The six most promising compounds in terms of activity and selectivity were further investigated for their antileishmanial activity on the promastigote forms of L. tropica, L. major and L. infantum and against L. donovani amastigotes. The good performance in terms of potency and selectivity makes these six hits promising candidates for a preliminary lead optimization as antileishmanial agents.

Endocrine manifestations of chronic HCV infection

Chronic hepatitis C virus (HCV) infection has been associated with a great number of extra-hepatic manifestations (EHMs), including several endocrine disorders. Currently available epidemiological, clinical and experimental data do not show a link between HCV and all EHMs. Thyroid disorders (TD) and type 2 diabetes, for example, are the most frequent endocrine alterations in patients with chronic HCV infection, but there are only weak evidences that HCV could be involved in hypothalamic-pituitary axis perturbation, bone metabolism alteration and sexual dysfunctions induction. Thus, this issue needs further investigation. Prospective studies have also shown that interferon (IFN)-based therapy for chronic HCV infection can induce or worsen EHMs. In particular, IFN has been associated with development of autoimmunity and/or TD in up to 40% of chronic HCV infected patients. Hence, a careful monitoring of thyroid function should be performed in such patients. The recent approval of direct-acting antiviral agents in IFN-free regimens for chronic hepatitis C treatment will dramatically reduce not only liver-related mortality but also morbidity due to EHMs.

PNPLA3 rs738409 I748M is associated with steatohepatitis in 434 non-obese subjects with hepatitis C

BACKGROUND

The PNPLA3/Adiponutrin rs738409 C/G single nucleotide polymorphism is associated with the severity of steatosis, steatohepatitis and fibrosis in patients with non-alcoholic fatty liver disease, as well as the severity of steatosis and fibrosis in patients with chronic hepatitis C (CHC).

AIM

To test in genotype 1(G1)-CHC patients, the putative association between the PNPLA3 variant and histological features of steatohepatitis, as well as their impact on the severity of fibrosis.

METHODS

Four hundred and thirty-four consecutively biopsied Caucasian G1-CHC patients were genotyped for PNPLA3 rs738409, its effect evaluated by using an additive model. Histological features of steatohepatitis in CHC were assessed using the Bedossa classification. Hepatic expression of PNPLA3 mRNA was evaluated in 63 patients.

RESULTS

The prevalence of steatohepatitis increased from 16.5% in patients with PNPLA3 CC, to 23.2% in CG and 29.2% in the GG genotype (P = 0.02). By multiple logistic regression, PNPLA3 genotype (OR 1.54, 95% CI 1.03-2.30, P = 0.03), together with age (OR 1.03, 95% CI 1.00-1.05, P = 0.02), BMI ≥ 30 (OR 2.06, 95% CI 1.04-4.10, P = 0.03) and homoeostasis model assessment (HOMA, OR 1.18, 95% CI 1.04-1.32, P = 0.006) were independently linked to steatohepatitis. When stratifying for obesity, PNPLA3 was associated with NASH in non-obese patients only (12.0% in CC vs. 18.3% in CG vs. 27.3% in GG, P = 0.01), including after correction for metabolic confounders (OR 2.06, 95% CI 1.26-3.36, P = 0.004). We showed an independent association between steatohepatitis (OR 2.05, 95% CI 1.05-4.02, P = 0.003) and severe fibrosis. Higher liver PNPLA3 mRNA was associated both with the severity of steatosis (adjusted P = 0.03) and steatohepatitis after adjusting for gender, age, BMI and HOMA (P = 0.002).

CONCLUSION

In patients with genotype 1 hepatitis C, the PNPLA3 G variant is associated with a higher risk of steatosis severity and steatohepatitis, particularly among non-obese subjects.

[Contribution of arterial spin labeling to the diagnosis of sudden and transient neurological deficit]

MRI is the gold standard exploration for sudden transient neurological events. If diffusion MRI is negative, there may be a diagnostic doubt between transient ischemic attack and other causes of transient neurological deficit. We illustrate how sequence arterial spin labeling (ASL), which evaluates cerebral perfusion, contributes to the exploration of transient neurological events. An ASL sequence was performed in seven patients with a normal diffusion MRI explored for a transient deficit. Cortical hyperperfusion not systematized to an arterial territory was found in three and hypoperfusion systematized to an arterial territory in four. ASL helped guide early management of these patients.

Broca's area damage is necessary but not sufficient to induce after-effects of cathodal tDCS on the unaffected hemisphere in post-stroke aphasia

BACKGROUND

The inter-individual variability of behavioral effects after tDCS applied to the unaffected right hemisphere in stroke may be related to factors such as the lesion location.

OBJECTIVE/HYPOTHESIS

We investigated the effect of left Broca's area (BA) damage on picture naming in aphasic patients after cathodal tDCS applied over the right BA.

METHODS

We conducted a study using pre-interventional diffusion and resting state functional MRI (rsfMRI) and two cross-over tDCS sessions (TYPE: sham and cathodal) over the right homologous BA in aphasic stroke patients with ischemic lesions involving the left BA (BA+) or other left brain areas (BA-). Picture naming accuracy was assessed after each session. Inter-hemispheric (IH) functional balance was investigated via rsfMRI connectivity maps using the right BA as a seed. Probabilistic tractography was used to study the integrity of language white matter pathways.

RESULTS

tDCS had different effects on picture naming accuracy in BA+ and BA- patients (TYPE × GROUP interaction, F(1,19): 4.6, P: 0.04). All BA- patients except one did not respond to tDCS and demonstrated normal IH balance between the right and left BA when compared to healthy subjects. BA+ patients were improved by tDCS in 36% and had decreased level of functional IH balance. Improvement in picture naming after cathodal tDCS was associated with the integrity of the arcuate fasciculus in BA+ patients.

CONCLUSIONS

Behavioral effects of cathodal tDCS on the unaffected right hemisphere differ depending on whether BA and the arcuate fasciculus are damaged. Therefore, IH imbalance could be a direct consequence of anatomical lesions.

Re-excision Rates and Local Recurrence in Breast Cancer Patients Undergoing Breast Conserving Therapy

Background: Controversy continues over the impact of re-excision (RE) on local recurrence (LR) in patients with invasive breast cancer. Patients and Methods: We investigated factors which could effect RE rates in patients undergoing breast-conserving or oncoplastic surgery. Between 2000 and 2003, 489 patients with stage pT1-pT2 or pN0/1 tumors were evaluated. 74 patients fulfilled the inclusion criteria. Patients were categorized into 3 groups: no RE (n = 25), RE during primary surgery (n = 28), and RE performed during secondary or even tertiary procedure (n = 21). All tumor slides were re-evaluated by a pathologist specializing in breast cancer. Results: Mean follow-up was 70 months with an overall LR rate of 4.1 %. Binary logistic regression revealed no tumor-specific risk factors for RE. There was no LR in the group of patients who did not have RE. There was one case of LR in the group of patients who had RE during primary surgery. Two cases of LR were observed in the group of patients who had two or more surgical procedures. Conclusion: New risk factors for increased RE rates were not observed, reflecting the inconsistent data on risk factors for RE. However, breast cancers should be excised in a single procedure and oncoplastic procedures should be considered.

Design and manufacture of a novel system to simulate the biomechanics of basic and pitching shoulder motion

Objectives

Cadaveric models of the shoulder evaluate discrete motion segments using the glenohumeral joint in isolation over a defined trajectory. The aim of this study was to design, manufacture and validate a robotic system to accurately create three-dimensional movement of the upper body and capture it using high-speed motion cameras.

Methods

In particular, we intended to use the robotic system to simulate the normal throwing motion in an intact cadaver. The robotic system consists of a lower frame (to move the torso) and an upper frame (to move an arm) using seven actuators. The actuators accurately reproduced planned trajectories. The marker setup used for motion capture was able to determine the six degrees of freedom of all involved joints during the planned motion of the end effector.

Results

The testing system demonstrated high precision and accuracy based on the expected versus observed displacements of individual axes. The maximum coefficient of variation for displacement of unloaded axes was less than 0.5% for all axes. The expected and observed actual displacements had a high level of correlation with coefficients of determination of 1.0 for all axes.

Conclusions

Given that this system can accurately simulate and track simple and complex motion, there is a new opportunity to study kinematics of the shoulder under normal and pathological conditions in a cadaveric shoulder model.

Hyperglycemia and the fate of apparent diffusion coefficient-defined ischemic penumbra

BACKGROUND AND PURPOSE

Previous data have shown the feasibility of identifying ischemic penumbra in patients with acute stroke by using a semiautomated analysis of ADC maps. Here, we investigated whether the fate of ADC-defined penumbra was altered by HG. We also examined the interaction between HG and arterial recanalization on infarct growth.

MATERIALS AND METHODS

We examined 94 patients by using MR imaging within 6 hours of stroke onset and a follow-up MR imaging within 7 days. The ADC-defined tissue-at-risk was calculated from the early MR imaging. Patients were classified according to high (>7 mmol/L; n = 34/94, HG) or normal (n = 60/94) baseline SGL. The impact of HG status on infarct growth was assessed by using multiple regression models and analysis of the slopes of regression lines for each group. Interaction between HG status and arterial recanalization on infarct growth was investigated by using multiple regression analysis.

RESULTS

The slope of the predicted versus observed infarct growth regression line was steeper in HG than non-HG patients (P = .0008), suggesting that infarct growth within ADC-defined tissue-at-risk was increased in HG patients. The effect was 2.8 times more severe in nonrecanalized patients (P = .01) than in patients with recanalization (P = .001).

CONCLUSIONS

ADC-defined tissue-at-risk may represent ischemic penumbra because part of this area may be salvaged in normal SGL patients. The toxicity in HG patients seems to be more related to penumbra-infarction transition than reperfusion injury in humans because the effect was larger in nonrecanalized than in recanalized patients.

Postthrombolysis hemorrhage risk is affected by stroke assessment bias between hemispheres

OBJECTIVE

Stroke symptoms in right hemispheric stroke tend to be underestimated in clinical assessment scales, resulting in greater infarct volumes in right as compared to left hemispheric strokes despite similar clinical stroke severity. We hypothesized that patients with right hemispheric nonlacunar stroke are at higher risk for secondary intracerebral hemorrhage after thrombolysis despite similar stroke severity.

METHODS

We analyzed data of 2 stroke cohorts with CT-based and MRI-based imaging before thrombolysis. Initial stroke severity was measured with the NIH Stroke Scale (NIHSS). Lacunar strokes were excluded through either the presence of cortical symptoms (CT cohort) or restriction to patients with prestroke diffusion-weighted imaging (DWI) lesion size >3.75 mL (MRI cohort). Probabilities of having a parenchymal hematoma were determined using multivariate logistic regression.

RESULTS

A total of 392 patients in the CT cohort and 400 patients in the MRI cohort were evaluated. Although NIHSS scores were similar in strokes of both hemispheres (median NIHSS: CT: 15 vs 13, MRI: 14 vs 16), the frequencies of parenchymal hematoma were higher in right hemispheric compared to left hemispheric strokes (CT: 12.4% vs 5.7%, MRI: 10.4% vs 6.8%). After adjustment for potential confounders (but not pretreatment lesion volume), the probability of parenchymal hematoma was higher in right hemispheric nonlacunar strokes (CT: odds ratio [OR] 2.3; 95% confidence interval [CI] 1.08-4.89; p = 0.032) and showed a borderline significant effect in the MRI cohort (OR 2.1; 95% CI 0.98-4.49; p = 0.057). Adjustment for pretreatment DWI lesion size eliminated hemispheric differences in hemorrhage risk.

CONCLUSIONS

Higher hemorrhage rates in right hemispheric nonlacunar strokes despite similar stroke severity may be caused by clinical underestimation of the proportion of tissue at bleeding risk.

Reliability of the ECASS radiological classification of postthrombolysis brain haemorrhage: a comparison of CT and three MRI sequences

BACKGROUND

Postthrombolysis brain haemorrhagic transformations (HT) are often categorized with the CT-based classification of the European Cooperative Acute Stroke Study (ECASS). However, little is known about the reliability of this classification and its extension to MRI. Our objective was to compare the inter- and intraobserver reliability of this classification on CT and 3 MRI sequences.

METHODS

Forty-three patients with postthrombolysis HT on CT or at least 1 of the 3 MRI sequences: fluid-attenuation inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and T2* gradient recalled echo (T2*GRE) were selected. Twelve control patients without any bleeding were added to avoid a bias based on a pure HT-positive cohort. Each series of images were independently classified with the ECASS method by 6 blinded observers. Inter- and intraobserver reproducibility was categorized from poor to excellent depending on kappa values.

RESULTS

The inter- and intraobserver overall concordance of the classification was good for T2*GRE, DWI and CT (kappa > 0.6) and moderate for FLAIR (kappa < 0.6). The interobserver concordance for parenchymal haematomas was excellent for T2*GRE (kappa > 0.8) and moderate for CT, FLAIR and DWI.

CONCLUSION

The T2*GRE sequence is the most reproducible method to categorize postthrombolysis HT and has an excellent reliability for the severe parenchymal haematoma category, suggesting that this sequence should be used to assess HT in thrombolytic therapy trials.

Risk of symptomatic intracerebral hemorrhage in patients treated with intra-arterial thrombolysis

BACKGROUND

In intra-arterial (IA) thrombolysis trials, higher rates of symptomatic intracerebral haemorrhage (sICH) were found than in trials with intravenous (IV) recombinant tissue plasminogen activator (tPA); this observation could have been due to the inclusion of more severely affected patients in IA thrombolysis trials. In the present study, we investigated the rate of sICH in IA and combined IV + IA thrombolysis versus IV thrombolysis after adjusting for differences in clinical and MRI parameters.

METHODS

In this multicenter study, we systematically analyzed data from 645 patients with anterior-circulation strokes treated with either IV or IA thrombolysis within 6 h following symptom onset. Thrombolytic regimens included (1) IV tPA treatment (n = 536) and (2) IA treatment with either tPA or urokinase (n = 74) or (3) combined IV + IA treatment with either tPA or urokinase (n = 35).

RESULTS

44 (6.8%) patients developed sICH. sICH patients had significantly higher scores on the National Institutes of Health Stroke Scale (NIHSS) at admission and pretreatment DWI lesions. The sICH risk was 5.2% (n = 28) in IV thrombolysis, which is significantly lower than in IA (12.5%, n = 9) or IV + IA thrombolysis (20%, n = 7). In a binary logistic regression analysis including age, NIHSS score, time to thrombolysis, initial diffusion weighted imaging lesion size, mode of thrombolytic treatment and thrombolytic agent, the mode of thrombolytic treatment remained an independent predictor for sICH. The odds ratio for IA or IV + IA versus IV treatment was 3.466 (1.19-10.01, 95% CI, p < 0.05).

CONCLUSION

In this series, IA and IV + IA thrombolysis is associated with an increased sICH risk as compared to IV thrombolysis, and this risk is independent of differences in baseline parameters such as age, initial NIHSS score or pretreatment lesion size.

Prevalence and risk factors for Chlamydia trachomatis infection in young women in north-west of Italy

AIM

The aim of the study was to estimate the prevalence of Chlamydia trachomatis infection, risk factors and best predictors of infection in young sexually active women in north-west of Italy.

METHODS

One thousand one hundred and eighty 18-24 years old women of family planning clinics and three STI Clinics over Turin city area underwent vaginal swabs to detect infection and completed a questionnaire. Logistic regression and multivariate analysis identified risk factors and a receiver operating characteristic (ROC) curve was used to assess the model accuracy.

RESULTS

Overall prevalence of infection was 10.4% 2.71 times higher (P<0.001) among women afferent to STI clinics than family planning clinics. Higher among women of Eastern European, Asian and South American ethnic origin (P=0.012) compared to Western European or African ethnic origin. Age at first intercourse (P=0.006), absence of a stable partner (P<0.001) partner with urogenital complaints (P<0.001), number of lifetime partners (P<0.001) number of partners in the last 6 months (P<0.001) history of occasional intercourse (P<0.001) and of IST (P<0.007) resulted associated with chlamydial infection. Multivariate analysis showed setting, partner with urogenital complaints and number of lifetime partners as best predictors of infection. ROC curve on variables from multivariate analysis showed an AUC of 0.732.

CONCLUSION

The study showed high rates of Chlamydial infection among sexually active women between 18-24 years in north-west area of Italy. Predictors of infection are related to sexual activity and to population sub-groups. Selective screening protocols should be supported by wider and more representative studies in order to increase knowledge and involve public opinion.

Restless legs syndrome is frequently overlooked in patients being evaluated for polyneuropathies

Restless legs syndrome (RLS) often presents with paresthesias and dysesthesisas. We have investigated the prevalence and clinical features of RLS in a cohort of patients referred for clinical suspicion of peripheral neuropathy (PN). Sixty-four patients with sensory symptoms, and 101 age-matched controls were prospectively evaluated for RLS, PN and causes of both conditions. In the 64 patients (60 +/- 14 years), none were referred with a suspicion of RLS. Forty-one had a sensori-motor PN of which 22 had a definite RLS (54%). When excluding other causes of RLS, 8 of 41 patients had a RLS associated with a neuropathy (20%). The proportion of RLS in the healthy controls was 10%, lower than in the cohort of patients. In patients without PN, 57% had a RLS, and 55% in the whole cohort, a higher proportion than in the healthy controls (P < 0.0001). Patients with PN and RLS had more sleep disorders (P < 0.04), and legs and calves symptoms (P = 0.09) than patients with PN without RLS. Toes symptoms were more frequently observed in patients with PN but without RLS (P < 0.02). We conclude that RLS frequently presents with symptoms suggestive of peripheral neuropathy, and therefore, is often overlooked.

Diffusion-weighted MR imaging characteristics of an acute strokelike form of multiple sclerosis

The characteristics of multiple sclerosis (MS) lesions on diffusion-weighted sequences and apparent diffusion coefficient (ADC) mapping at the very early phase of symptoms have not been clearly described. We report the case of a young woman who presented with a sudden pseudostroke form of MS resulting in hemiplegia and sudden aphasia. MR imaging showed a lesion of the left internal capsule with reduced ADC, which suggests an ischemic stroke. This case shows that very acute MS lesions may have reduced ADC on MR imaging, reflecting cytotoxic and not vasogenic edema.

Hydrocephalus and racemose cysticercosis

BACKGROUND AND PURPOSE

Hydrocephalus is a frequent and potentially serious complication of neurocysticercosis. Its treatment often requires ventricular shunting. The complication rate is high due to obstruction or material infection, which may justify endoscopic third ventriculostomy (ETV).

OBSERVATION

We report a case of obstructive hydrocephalus in a 46-year-old man in the context of racemose cysticercosis, presenting with headaches and transient disorders of consciousness. Imaging showed cystic lesions of the cisterna magna, responsible for hydrocephalus which was treated effectively by ETV. Treatment with albendazole decreased the volume of the cisterna magna cysts.

RESULTS

The patient was followed for 6 years after ETV with no recurrence of hydrocephalus despite two more symptomatic episodes of the disease with extension of the cysts into the lumen of the fourth ventricle and into the perispinal subarachnoid spaces, effectively treated by albendazole each time.

CONCLUSIONS

Treatment of obstructive hydrocephalus secondary to cerebral racemose cysticercosis by ETV seems to be an effective and safety technique. The role of ETV should be evaluated in this indication.

[Psychosexual problems in patients with neoplasms]

The Author's aim is to highlight the importance of psychic dynamics which play a role when a patient, suffering from cancer, turns to a therapist for sexual rehabilitation.

[The "small penis": considerations about subjective penile deficiency]

In sexology clinical practice you can see quite frequently patients who make complaints about their penis not being big enough. The Authors suggest that the subjective feeling of penis deficiency is a symptom which needs to be properly diagnosed and understood, in order to be able to make effective therapeutic interventions, from a psychotherapeutic, psychopharmacologic or surgical point of view.

[Diabetes, hypothyroidism and celiac disease in Down's syndrome. A case report]

It is well known that Down's syndrome patients frequently suffer from immune system diseases leading to the production of autoantibodies and the onset of correlated pathologies. These disorders become increasingly frequent as the patients grow older and the onset of one autoimmune disease often predisposes the development of others. Autoimmune thyroiditis is the most frequent disorder and appears to affect 39% of adult patients. Over the past years a number of reports have been published regarding the coexistence of various autoimmune diseases in DS patients, but little is still known about the relationship between these pathologies and celiac disease. In order to contribute to knowledge regarding the prevalence of this association, the authors report a case of a DS patient who developed diabetes mellitus, hypothyroidism and celiac disease at different times. This case provides further confirmation of the association between Down's syndrome and autoimmune pathologies. The authors feel that follow-up programmes for DS patients should include an evaluation of thyroid function and antithyroid antibodies given that the onset of glandular hypofunction may be very subtle. Furthermore, they should also include tests to assay glycemia, anti-pancreatic insula and anti-insulin antibodies for diabetes and AGA and EMA for celiac disease.

Use of the Oximeter-539 WTW, equipped with a sensor Trioxmatic-300, for the functional analysis of dilute solutions of human Hb-A

Dissociation curves for oxygen of dilute samples of human adult Hb-A were evaluated on this occasion, by using the Oximeter-539 WTW with its sensor, and a suitable spectrophotometer. At this purpose, Hb samples were desaturated in oxygen upon given experimental conditions, by bubbling pure nitrogen in them, and their re-oxigenation in air was followed, step by step, by multiple oximetries. In addition, all the spectrophotometric measurements of the saturation of Hb-O2%, corresponding to each individual oximetry, were carried out parallely but separately. Dilution of Hb-A was maintained at 0.1 mM in heme. The p50 at pH 7.3 was 4.435 +/- 0.299 Torr, with the n-value of 2.7 +/- 0.2; Bohr effect was -0.55 +/- 0.08, within a pH range between 6.8, 7.3 and 7.8, whereas chloride and DPG effects at pH 7.3 (the most useful value) were 0.42 +/- 0.44 and 0.453 +/- 0.0187 respectively. In conclusion, these results are similar to those obtained with automated procedures, upon comparable experimental conditions, but do not require expensive and sophisticated instruments. Such a technique could be very useful in the hemoglobinopathies, which are common in Italy, and it could be easily adapted to perform comparative studies on animal hemoglobins not far from human species.

[Penile prosthesis]

In this article the Authors, after describing the history of the penile prosthesis surgery and analyzing the technical progresses made in the last twenty years, offer their personal experience and data from the most recent literature about treatment of erectile dysfunction through the application af penile prosthesis, about the indications for the operation and the choice of the type of prosthesis. They also explain all the possible complications and eventual mechanical failures, which have considerably decreased in the last few years.

[Psychosexual interventions combined with biologic therapy of erectile dysfunction]

The authors, beginning from che concept of erectile disorder with mixed pathogenesis, describe its clinical dimension. The psychic variables which prevent the use of biologic-andrologic therapy (FIC, penis prosthesis) are then considered: 1) psycho-sexual difficulties before the onset of the organic lesion; 2) the partner's relationship with the biologic-andrologic therapy; 3) the patients' relationship with the biologic therapy. A model of intervention (Group Psycho-sexologic Intervention) on the psychic variables interfering with the use of the biologic-andrologic therapy is then described. The authors end by considering the psychological impact and the possible psychoiatrogenicity of biologic-andrologic therapies.

Penile prostheses: Progress and present situation

After having shown the progress made in the last twenty years in the treatment of erectile dysfunction through the application of penile prostheses, the Authors define the actual situation on the basis of their personal experience as well as data from the most recent literature. The Authors dwell in particular on indications for the operation in different types of erectile dysfunction and on the choice of prosthesis. The Authors examine all the possible complications and eventual mechanical failures, which have considerably decreased in the last few years. Finally the Authors analyse the degree of patient satisfaction after the operation and conclude that it depends mostly on correct indication, choice of the most appropriate prosthesis and the information given to the patient and his partner.

Polyclonal haemopoieses associated with long-term persistence of the AML1-ETO transcript in patients with FAB M2 acute myeloid leukaemia in continous clinical remission

The t(8;21) (q22;q22) translocation is a recurring chromosomal abnormality observed in about 20-40% of AML patients with subtype FAB M2 (AML-M2). The molecular facet of this translocation is represented by the formation of a new hybrid gene, the AML1-ETO, which is regularly transcribed in a chimaeric mRNA and translated into a new fusion protein believed to have a key role in the pathogenesis of this type of leukaemia. We looked for the presence of AML1-ETO transcripts, by RT-PCR, in 49 unselected patients affected by AML-M2 diagnosed at various Italian Institutions. A hybrid transcript was detected in 11 cases (23%). Minimal residual disease status was investigated in three patients in continuous complete remission (CCR) after a median follow-up of 44 months; at least one sample from each subject was found positive for the AML1-ETO transcript suggesting a long-term persistence of t(8;21) leukaemic cells. In two female patients in CCR a 'clonality' analysis was performed on peripheral blood DNA by exploiting the X chromosome inactivation pattern of the human androgen-receptor gene (HUMARA); in both cases the results were consistent with the presence of a polyclonal haemopoiesis. Our data confirm that the persistence of residual cells expressing the AML1-ETO transcripts is a frequent occurrence even in patients with long-term remission; on the other hand, clonality assays indicate that in t(8;21) leukaemias long-term remission haemopoiesis is sustained by a polyclonal bone marrow reconstitution.

[Perforated endometriosis of the sigmoid. Report of a case]

The term endometriosis means the presence in an ectopic site of normal functioning endometrial tissue, the ectopic endometrial tissue, as the normal uterine mucosa, undergo hormonal stimulation and follow the proliferative and functional changes along the menstrual course; this evolution, characterize the clinical story of patients affected by endometriosis. Endometriosis is considered to be one of the most common gynecologic disorders, occurring in about 10% of women in fertile age. An involvement of adjacent organs such as the pelvic colon and rectum by endometriosis is not uncommon and may cause symptoms difficult to distinguish from malignant or inflammatory disease located in the pelvic region. The purpose of the following case report is to elucidate certain diagnostic and therapeutic problems of a disease concerning both the surgeon and gynecologists. Our case concerns a 44 year old patient with two children and a negative previous clinical gynecological history; the patients reports the occurrence in the last two years of alterations of colic evacuation consisting in a period of constipation lasting 5-7 days. The patient reached us in emergency with a sub-occlusive state that has lasted for 5 days, in the last 12 hours the appearance of a violent trafictive pain referred to the lower abdomen configure the clinical picture of a acute abdomen. The patient underwent surgery and the laparotomy demonstrated the presence of a perforated tumours located at the recto-sigmoid junction. We proceed to perform an Hartman's resection and a right ovariectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Psychological problems related to the sexual stimulation video (SSV) test in the diagnosis of erectile disorders]

The Authors analyze scientific community's attitude towards VSS test. Related psychological problems are examined: the doctor's fear to be accused of voyeurism, the doctor's inadequacy in "invading" patient's field of intimacy, the doctor's relationship with his own erotic fantasies and with pornography, the "castrating" aspects in hospital environment and so on.

Human peripheral blood granulocytes and myeloid leukemic cell lines express both transcripts encoding for stem cell factor

Stem cell factor (SCF), the ligand for the c-kit proto-oncogene, has been shown to play a critical role in the migration of melanocytes and germ cells during embryogenesis as well as in the proliferative control of the hematopoietic compartment. In this study we investigated the expression of both the soluble and transmembrane SCF forms in purified peripheral blood populations and in several hematopoietic cell lines. Expression of both transcripts, though in different ratios, was identified in whole bone marrow, in bone marrow stromal cells and in human peripheral blood. In peripheral blood, SCF expression could be ascribable to polymorphonuclear leukocytes (PMN), whereas no SCF expression was detected in isolated lymphocytes, monocytes and in some T lymphoid cell lines. Conversely, some hematopoietic myeloid cell lines, such as HL-60, KG1 and K562, express SCF with similar patterns.

[The pharmaco-erection test]

Intracavernous administration of vasoactive drugs induces an erection in absence of erotic stimuli; we can use this property in the study of impotent patients, inducing the appearance on an erection to examine it in all its phases (FIC Test). In case of the appearance of a good erection, the test should rule out the presence of a penile arterial disease or of a corpora-veno-occlusive deficiency. When the administration of the drug does not cause complete tumescence, it is very probable that the erectile dysfunction is caused by arterial vascular alterations or by organic disorders of veno-occlusion mechanism, but we cannot exclude for a certainty a psychogenic dysfunction. In fact an excessive noradrenergic autonomic control, as during stress condition, may limit FIC Test response. Therefore we hope that more efficacious molecules will be available in a near future. Nevertheless, we consider the opportunity of enclosing tests in the diagnostic algorithm of impotent patients to reveal an excessive adrenergic tone, such as, for example, psychological tests, study of cavernous potential, or intracavernous catecholamine dosage.

Inhibition of c-myc expression induced by 4-hydroxynonenal, a product of lipid peroxidation, in the HL-60 human leukemic cell line

4-Hydroxynonenal is a highly reactive aldehyde, produced by cellular lipid peroxidation, able to inhibit cell proliferation "in vitro" and "in vivo". Its concentration in non proliferating cells ranges up to 1 microM, whereas in the highly undifferentiated tumour cells, it is very low or undetectable. We have now demonstrated that micromolar concentrations of 4-hydroxynonenal inhibit c-myc but not N-ras expression in HL-60 human leukemic cells. This inhibitory effect is observed after an incubation of 1 hour with both 1 and 10 microM aldehyde. Moreover, we report that down-regulation of c-myc expression increases when repeated additions of 1 microM 4-hydroxynonenal are performed, to maintain the cells in presence of aldehyde for 7.5 hours. These results indicate that not only the concentration but also the length of exposure to the aldehyde is important in determining the extent of the c-myc expression inhibition and suggest a role of lipid peroxidation products in the control of gene expression.

Expression of GATA-1 mRNA in human myeloid leukemic cells

Expression of the transcription factor GATA-1, which regulates several erythroid specific genes and possibly also some megakaryocytic genes, has been previously detected in normal erythroblasts, megakaryocytes, and basophils, and in some myeloid cell lines. It has been suggested that GATA-1 may be first expressed in a common progenitor and then further activated during erythroid-megakaryocytic and basophilic differentiation and repressed during myeloid maturation. We investigated GATA-1 mRNA expression in highly purified leukemic blasts representing different lineages and stages of myeloid differentiation and in a recently established leukemic cell line, GF-D8, which exhibits morphological, cytochemical and immunophenotypic characteristics of early myeloid progenitor cells. We found GATA-1 expression in five of five myeloid and in one megakaryocytic blast crisis of CML, in four of six cases of myelomonocytic leukemias (M4 according to FAB classification), in one case of erythroleukemia (M6), whereas lymphoid blast crisis of CML and all other FAB groups were completely negative. In addition, a low level of GATA-1 mRNA was also expressed by the GF-D8 cell line. These data further support the hypothesis that GATA-1 expression may occur not only in erythroid and megakaryocytic progenitors, but also in early myeloid progenitors, and then be further regulated during lineage-specific maturation.

Repeated PCR in CML during IFN-alpha therapy

Repeated PCR analysis was performed on bone marrow and/or peripheral blood samples from 4 CML patients in complete cytogenetic remission during treatment with IFN-alpha. Two patients became PCR-negative. One was negative for the analyses carried out from the 9th to the 30th months, but reverted to PCR positivity 10 months after IFN was reduced from 1.5 x 10(6) IU/day to 1 x 10(6) IU and given on alternate days. Although the dose was again raised to 3 x 10(6) IU/day, 8 months later her peripheral blood cells were still PCR-positive, but remained persistently Ph'-negative. Another patient became PCR-negative at the 42nd month and remained so at the last analysis performed 3 months later. Two patients were persistently PCR-positive. Cytogenetic relapse was documented in both, in one while still on full therapy. Ph'-positive metaphases reappeared in the other patient 7 months after discontinuing IFN-alpha therapy.

[Intervention models in andrology in adult-elderly patients with psychogenic erectile dysfunction]

The Authors deals of the principal models of management in andrologic ambit on patients adult-elder affected by psychogenic impotence. Yet they made a critic remark of these models and show a different management model named "within treatment". The authors presents the results achieved using this model in the S. Luigi Gonzaga Hospital surgery for male sexual diseases.