Challenges of Treating ADHD with Comorbid Substance Use Disorder: Considerations for the Clinician

Adults with attention deficit/hyperactivity disorder (ADHD) often present psychiatric comorbidities and, in particular, substance use disorder (SUD). ADHD-SUD comorbidity is characterized by greater severity of both disorders, earlier age of onset, higher likelihood of polydrug-abuse and suicidal behaviors, more hospitalizations, and lower treatment adherence. At the present stage, research focused on the pharmacological management of ADHD with comorbid SUD in both adolescents and adults is still lacking. Furthermore, while the short-term effects of stimulants are well studied, less is known about the chronic effects of these drugs on dopamine signaling. Current available evidence is consistent in reporting that high doses of stimulant medications in ADHD-SUD subjects have a mild to moderate efficacy on ADHD symptoms. Some data suggest that pharmacological treatment with stimulants may be beneficial for both ADHD symptoms and comorbid cocaine or amphetamine use. However, in the long run, stimulant medications may have a potential risk for misuse. For the absence of potential misuse, atomoxetine is often recommended for ADHD with comorbid cocaine or amphetamine use disorder. However, its efficacy in reducing addictive behavior is not demonstrated. In subjects with other subtypes of SUD, both atomoxetine and stimulant drugs seem to have scarce impact on addictive behavior, despite the improvement in ADHD symptomatology. In this population, ADHD treatment should be combined with SUD-specific strategies.

Adult Attention-Deficit Hyperactivity Disorder/Substance Use Disorder Dual Disorder Patients: A Dual Disorder Unit Point of View

Substance Use Disorders (SUDs) are often associated with Attention-Deficit Hyperactivity Disorder (ADHD) in adult populations due to multiple neurobiological, genetic, and psychosocial risk factors. This chapter provides a picture of the clinical aspects of adults with both ADHD and SUDs at treatment entry into a Dual Disorder Unit introducing the concept of different types of craving that may lead to substance use and abuse. At treatment entry, the presence of different comorbid SUD clusters, characterized by either stimulants/alcohol or by the use of cannabinoids, has not been shown to influence ADHD-specific symptomatology or severity, despite being crucial for the identification of a specific type of craving. We identified four clinical presentations of adult ADHD: Emotional Dysregulation, Substance Use, Core-ADHD Symptoms, and Positive Emotionality variants, that offer a practical guide in diagnosing and managing adult ADHD patients. Although the evidence of an effective medical treatment for Cocaine Use Disorder is insufficient, in our experience, toxicomanic behavior during stimulant treatment is sharply reduced in ADHD patients with cocaine addiction. Moreover, caffeinated compounds in military soldiers with ADHD may help reduce ADHD symptoms, making caffeine a potential pharmacological tool worth further investigation. Finally, substance use comorbidity does not influence treatment retention rate.

Assessing the Magnitude of Risk for ADHD in Offspring of Parents with ADHD: A Systematic Literature Review and Meta-Analysis

The main aim of this study was to examine the body of knowledge on the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in "high-risk" children whose parents are diagnosed with ADHD. This knowledge could aid early identification for children presenting with ADHD symptoms at a young age. We conducted a systematic search of the literature assessing high-risk children. Included were original articles published in English with the main aim to assess prevalence of ADHD in high risk children. In addition, a meta-analysis was conducted to examine this prevalence. Four articles met our inclusion and exclusion criteria all suggesting an increased prevalence of ADHD in children of parents with ADHD. The meta-analysis also confirmed the increased prevalence of ADHD in high-risk children. The literature indicates that children of ADHD parents have an increased risk of developing ADHD compared to control children.

Pilot Study on Dose-Dependent Effects of Transcranial Photobiomodulation on Brain Electrical Oscillations: A Potential Therapeutic Target in Alzheimer's Disease

BACKGROUND

Transcranial photobiomodulation (tPBM) has recently emerged as a potential cognitive enhancement technique and clinical treatment for various neuropsychiatric and neurodegenerative disorders by delivering invisible near-infrared light to the scalp and increasing energy metabolism in the brain.

OBJECTIVE

We assessed whether transcranial photobiomodulation with near-infrared light modulates cerebral electrical activity through electroencephalogram (EEG) and cerebral blood flow (CBF).

METHODS

We conducted a single-blind, sham-controlled pilot study to test the effect of continuous (c-tPBM), pulse (p-tPBM), and sham (s-tPBM) transcranial photobiomodulation on EEG oscillations and CBF using diffuse correlation spectroscopy (DCS) in a sample of ten healthy subjects [6F/4 M; mean age 28.6±12.9 years]. c-tPBM near-infrared radiation (NIR) (830 nm; 54.8 mW/cm2; 65.8 J/cm2; 2.3 kJ) and p-tPBM (830 nm; 10 Hz; 54.8 mW/cm2; 33%; 21.7 J/cm2; 0.8 kJ) were delivered concurrently to the frontal areas by four LED clusters. EEG and DCS recordings were performed weekly before, during, and after each tPBM session.

RESULTS

c-tPBM significantly boosted gamma (t = 3.02, df = 7, p <  0.02) and beta (t = 2.91, df = 7, p <  0.03) EEG spectral powers in eyes-open recordings and gamma power (t = 3.61, df = 6, p <  0.015) in eyes-closed recordings, with a widespread increase over frontal-central scalp regions. There was no significant effect of tPBM on CBF compared to sham.

CONCLUSION

Our data suggest a dose-dependent effect of tPBM with NIR on cerebral gamma and beta neuronal activity. Altogether, our findings support the neuromodulatory effect of transcranial NIR.

Differentiating bipolar disorder from unipolar depression in youth: A systematic literature review of neuroimaging research studies

Differentiating bipolar disorder from unipolar depression is one of the most difficult clinical questions posed in pediatric psychiatric practices, as misdiagnosis can lead to severe repercussions for the affected child. This study aimed to examine the existing literature that investigates brain differences between bipolar and unipolar mood disorders in children directly, across all neuroimaging modalities. We performed a systematic literature search through PubMed, PsycINFO, Embase, and Medline databases with defined inclusion and exclusion criteria. Nine research studies were included in the systematic qualitative review, including three structural MRI studies, five functional MRI studies, and one MR spectroscopy study. Relevant variables were extracted and brain differences between bipolar and unipolar mood disorders in children as well as healthy controls were qualitatively analyzed. Across the nine studies, our review included 228 subjects diagnosed with bipolar disorder, 268 diagnosed with major depressive disorder, and 299 healthy controls. Six of the reviewed studies differentiated between bipolar and unipolar mood disorders. Differentiation was most commonly found in the anterior cingulate cortex (ACC), insula, and dorsal striatum (putamen and caudate) brain areas. Despite its importance, the current neuroimaging literature on this topic is scarce and presents minimal generalizability.

Adult attention-deficit hyperactivity disorder and clinical correlates of delayed sleep phase disorder

The purpose of the study was to assess the prevalence and clinical correlates of Delayed Sleep Phase Disorder (DSPD) in adults with Attention-Deficit/Hyperactivity Disorder. Participants were 102 adults (Female= 27), aged 18-65 (mean age= 28.2 years), with ADHD diagnosed in adulthood. ADHD and DSPD diagnosis were made according to DSM-5 criteria. Assessing instruments included the Morningness-Eveningness Questionnaire, the brief Temperament Evaluation of Memphis, Pisa, Paris and San Diego Questionnaire, the Barratt Impulsiveness Scale, the Reactivity Intensity Polarity Stability Questionnaire-40 and the World Health Organization Disability Assessment Schedule 2.0. Epidemiological and Clinical features were compared in patients with and without DSPD. 34 out of 102 patients were classified as having a Delayed Sleep Phase Disorder. As expected, DSPD patients reported a more frequent evening chronotype. In the multivariate logistic regression analysis, Delayed Sleep Phase Disorder was significantly associated with young age, cannabis use, cyclothymic temperamental traits and severe global impairment. An early diagnosis with a proper treatment targeted to both disorders may be fundamental in order to improve the overall functioning and the outcome of adult ADHD patients.

Misperceptions and hallucinatory experiences in ultra-trailer, high-altitude runners

BACKGROUND

The Mountain Activities Neuro-behavioural Research Programme is a research project born in the 2 nd Unit of Psychiatry, Department of Clinical and Experimental Medicine at the University of Pisa to investigate the effects of altitude on the mental and neuro-behavioural aspects of people performing activities in mountainous areas.

METHODS

In this study, after elaborating a standardised data collection form, based on traditional psychopathology notions, to classify the misperceptions reported by the athletes taking part, we investigated the various types of these misperceptions in 21 athletes (including only one female), with a mean age of 44.90 ± 8.51 (min 33 and max 58).

RESULTS

The athletes reported different kinds of misperceptions. It was possible to highlight three different clusters of athletes, based on the similarities between the kinds of misperceptions reported in each cluster: (a) anomalies in the intrinsic characteristics of perceptions (i.e. depersonalisation and derealisation), (b) illusions and (c) hallucinations.

CONCLUSIONS

This study supports the concept that anomalous perceptual experiences may occur independently of the context of psychiatric or neurological disorders. The chance of observing hallucinatory phenomena outside the context of psychiatric disorders and in extreme environmental conditions among ultra-trail runners may offer a unique opportunity to those intending to study psychopathological conditions in a 'para-physiological' context.

Transcranial Photobiomodulation with Near-Infrared Light for Generalized Anxiety Disorder: A Pilot Study

Objective: Our aim was to test the anxiolytic effect of transcranial photobiomodulation (t-PBM) with near-infrared light (NIR) in subjects suffering from generalized anxiety disorder (GAD). Background: t-PBM with NIR is an experimental, noninvasive treatment for mood and anxiety disorders. Preliminary evidence indicates a potential anxiolytic effect of transcranial NIR. Methods: Fifteen subjects suffering from GAD were recruited in an open-label 8-week study. Each participant self-administered t-PBM daily, for 20 min (continuous wave; 830 nm peak wavelength; average irradiance 30 mW/cm2; average fluence 36 J/cm2; total energy delivered per session 2.9 kJ: total output power 2.4 W) broadly on the forehead (total area 80 cm2) with an LED-cluster headband (Cerebral Sciences). Outcome measures were the reduction in total scores of the Hamilton Anxiety Scale (SIGH-A), the Clinical Global Impressions-Severity (CGI-S) subscale and the Pittsburgh Sleep Quality Index (PSQI) subscales from baseline to last observation carried forward. Results: Of the 15 recruited subjects (mean age 30 ± 14 years; 67% women), 12 (80%) completed the open trial. Results show a significant reduction in the total scores of SIGH-A (from 17.27 ± 4.89 to 8.47 ± 4.87; p < 0.001; Cohen's d effect size = 1.47), in the CGI-S subscale (from 4.53 ± 0.52 to 2.87 ± 0.83; p < 0.001; Cohen's d effect size = 2.04), as well as significant improvements in sleep at the PSQI. t-PBM was well tolerated with no serious adverse events. Conclusions: Based on our pilot study, t-PBM with NIR is a promising alternative treatment for GAD. Larger, randomized, double-blind, sham-controlled studies are needed.

Reconstruction of vertebral body in thoracolumbar AO type A post-traumatic fractures by balloon kyphoplasty. A series of 85 patients with a long follow-up and review of literature

BACKGROUND

Traumatic fractures of the thoracolumbar spine are common injuries, accounting for approximately 90% of all spinal traumas. Optimal management of these fractures still gives rises to much debate in the literature. Currently, one of the treatment options in young patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improved physical function with early return to work activity. The aim of the study is to report VAS, ODI scores, and kyphosis correction following treatment.

METHODS

This is a retrospective study to investigate the clinical and radiological results 10 years after percutaneous balloon kyphoplasty followed by cement augmentation with polymethylmethacrylate (PMMA) or calcium phosphate cements (CPC), according to age, in 85 consecutive patients affected by 91 AOSpine type A traumatic fractures of the thoracolumbar spine (A1, A2, and A3). Clinical follow-up was performed with the Visual Analogic Scale (VAS) at the preoperative visit and in the postoperative follow-up after 1 week, 1, 6, 12 months, and each year up to 10 years. Additionally, the Oswestry Disability Index (ODI) improvement was calculated as the difference between the ODI scores at the preoperative visit and at final follow-up. Finally, the Cobb angle from this cohort was assessed before surgery, immediately postoperatively, and at the end of follow-up.

RESULTS

Kyphoplasty markedly improved pain and resulted in statistically significant vertebral height restoration and normalization of morphologic shape indexes that remained stable for at least 10 years following treatment.

CONCLUSIONS

The present study showed that kyphoplasty and cement augmentation are an effective method of treatment for selected type A fractures.

Towards a psychopathology specific to Substance Use Disorder: Should emotional responses to life events be included?

INTRODUCTION

The severity of emotional responses to life events (PTSD spectrum) as part of Post Traumatic Stress Disorder (PTSD) in Substance Use Disorder (SUD) patients has often been considered from a unitary perspective. Light has also been shed on the possible definition of a specific psychopathology of SUD patients. This psychopathology has been proved to be independent of treatment choice, of being active in using substances, of lifetime psychiatric comorbidity and primary substance of abuse (heroin, alcohol, cocaine).

METHODS

To further support this unitary perspective, in this study we have compared the severity and typology of the five psychopathological dimensions found in SUD patients, by dividing 93 HUD patients (77.4% males and 22.6% females), characterized by the lifetime absence of exposure to actual or threatened death, serious injury, or sexual violence, on the basis of the severity of their PTSD spectrum. We used the cut-off that differentiated people developing (High PTSD spectrum; H-PTSD/S) or not developing (Low PTSD spectrum; L-PTSD/S) a PTSD after the earthquake that hit L'Aquila, Italy, in April 2009.

RESULTS

Using a canonical correlation analysis, the significant (p<0.001) canonical variate set-one (psychopathology) is saturated negatively by "panic anxiety" and positively by the "worthlessness-being trapped" and "violence-suicide" dimensions. Set-two (PTSD spectrum) is saturated negatively by "emotional, physical and cognitive responses to loss and traumas", and positively by "grief reactions", "re-experiencing numbing", "arousal symptoms" and "personality traits". When comparing the two groups, all five psychopathological dimensions were significantly more severe in H-PTSD/S patients, who were distinguished by higher values of worthlessness-being trapped, sensitivity-psychoticism and violence-suicide symptomatology. No differences were observed regarding the typology of psychopathology.

CONCLUSIONS

This study further supports the SUD-PTSD spectrum unitary perspective and argues in favor of the inclusion of the PTSD spectrum in the psychopathology of SUD.

The long-term outcome of patients with heroin use disorder/dual disorder (chronic psychosis) after admission to enhanced methadone maintenance

BACKGROUND

Over-standard methadone doses are generally needed in the treatment of heroin use disorder (HUD) patients that display concomitant high-severity psychopathological symptomatology. A flexible dosing regimen may lead to higher retention rates in dual disorder (DD), as we demonstrated in bipolar 1 HUD patients, leading to outcomes that are as satisfactory as those of HUD patients without high-severity psychopathological symptomatology.

OBJECTIVE

This study aimed to compare the long-term outcomes of treatment-resistant chronic psychosis HUD patients (PSY-HUD) with those of peers without dual disorder (HUD).

METHODS

85 HUD patients who also met the criteria for treatment resistance-25 of them affected by chronic psychosis and 60 without DD-were monitored prospectively for up to 8 years while continuing to receive enhanced methadone maintenance treatment.

RESULTS

The rates of endurance in the treatment of PSY-HUD patients were 36%, compared with 34% for HUD patients (p = 0.872). After 3 years of treatment, these rates tended to become progressively more stable. PSY-HUD patients showed better outcome results than HUD patients regarding CGI severity (p < 0.001) and DSM-IV-GAF (p < 0.001). No differences were found regarding good toxicological outcomes or the methadone dosages used to achieve stabilization. The time required to stabilize PSY-HUD patients was shorter (p = 0.034).

CONCLUSIONS

An enhanced methadone maintenance treatment seems to be equally effective in patients with PSY-HUD and those with HUD.

Patent foramen ovale and cryptogenic stroke: from studies to clinical practice: Position paper of the Italian Chapter, International Society Cardiovascular Ultrasound

BACKGROUND

Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists.

AIMS

This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO.

METHODS

All studies published in the literature on PFO and cryptogenic stroke are considered and discussed.

RESULTS

We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke.

CONCLUSION

After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.

An exceptional case of complete lumbosacral spine duplication and open myelomeningocele in adulthood

The authors describe the case of a 47-year-old woman with a wide (14 × 12-cm) ulcerated lumbosacral myelomeningocele. The patient had sought medical attention for a sudden copious CSF leak from the lumbosacral sac followed by clinical signs of CSF leakage. After admission, neuroradiological assessment (spinal MR and 3D CT imaging) revealed the uncommon finding of a complex malformation characterized by a complete spine duplication originating at the L2-3 level, both hemicords having a separate dural sac. The myelomeningocele sac originated medially at the L-2 level. Surgical repair of the lumbosacral myelomeningocele was performed. The placement of a ventriculoperitoneal shunt became necessary to treat secondary hydrocephalus. After reviewing accredited classifications on spinal cord malformations, the authors believe that, to date, complete duplication and separation of the spine and dural sac seems exceptional, and its report in adulthood appears exceedingly rare.

[Hypercoagulability during pregnancy: evidences for a thrombophilic state]

AIM

The development of thrombotic disorders is a major threat for young women during pregnancy. It is one of the main causes of pregnancy-related disorders, which may also result in harm for the conceptus. Successful pregnancies require an even balance of coagulation and fibrinolysis, in order to secure stabilization of the basal plate as well as adequate placental perfusion. Broad spectrum assays which measure a range of thrombin/fibrin formation in serum have become an established means of identifying activation of blood coagulation and/or fibrinolysis. There is considerable interest in the application of these assays to the diagnosis of other hypercoagulable states, such as thrombophilia during pregnancy. We investigated coagulation/fibrinolysis parameters for significant differences between pregnant women during their gestation (first, second and third trimester) with or without pregnancy loss and healthy nonpregnant women.

METHODS

Thirty-nine pregnant women, aged 24-39 years, were studied. They were subdivided according to pregnancy trimester: 15 patients in the first trimester; 13 in the second and 11 in the third. The selection of patients was carried out in cooperation with the Transfusion Center of the Second University of Naples in order to obtain a homogeneous sample group. The control group included 400 healthy patients. Biochemical and blood coagulation tests were performed for each patient and the results obtained were compared with the control group.

RESULTS

A decrease in free protein S (PS) and fibrinolysis (t-PA/PAI-1) activities and an increase in Factor VII, Factor VIII, prothrombin fragment 1+2 (F1+2), D-dimer (D-dimer) were observed in pregnant women during the follow-up of gestation. However, there were statistical differences between the groups of women with one or more pregnancy loss where it was found the lowest values in t-PA and PAI and the highest values in FVII and F1+2. Among subjects with more than one abortion, coagulation/fibrinolysis derangements before the partum were more prominent. A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions.

CONCLUSIONS

These findings suggest that an excessive hypercoagulable state is associated with the termination of pregnancy resulting into a moderate risk for thrombosis during the different trimesters of pregnancy. The follow-up of fibrinolytic markers could represent a useful diagnostic tool for termination of pregnancy.

[Arrhythmic risk in essential hypertension: late potentials]

AIM

A higher incidence of cardiac death exists in patients with essential hypertension, and it is higher still in those with ventricular arrhythmia. The purpose of noninvasive diagnostic imaging in hypertensive patients is to determine those with a greater risk for arrhythmia. In previous studies on hypertension, one of the inclusion criteria is diastolic blood pressure <95 mmHg, which, however, is a low selectivity criterion. Instead, our study emphasizes the need to evaluate the incidence of ventricular arrhythmia in hypertensive patients not yet receiving drug therapy and to formulate the diagnosis based on 24-h ambulatory arterial blood pressure monitoring, which represents a more selective criterion than the diastolic pressure value proposed by the World Health Organization (WHO).

METHODS

A total of 128 consecutive patients with essential hypertension classified according to WHO criteria underwent 24-h monitoring, 85 (66.4%) of which presented with a mean 24-h arterial pressure >135/85 mmHg. These patients were then evaluated using mono- and two-dimensional echocardiography and 24-h dynamic Holter monitoring to detect arrhythmias and the presence of left ventricular later potentials.

RESULTS

Left ventricular hypertrophy was present in 60 (70.6%) patients and absent in 25 (29.4%). Based on the Lown classification of ventricular arrhythmia, 20 (23.5%) patients had Grade I arrhythmia, 5 (5.9%) Grade II, 4 (4.7%) Grade III, 9 (10.6%) Grade IVA, 20 (23.5%) Grade IVB, 12 (14.1%) Grade V, 15 (17.6%) clinically unremarkable arrhythmia, and 17 (20%) had late potentials because they tested positive to at least 2 out of three criteria, and 2 patients were positive to all 3 criteria.

CONCLUSION

Our study findings demonstrated a significant correlation between left ventricular hypertrophy and grade of arrhythmia (r=0.552; p<0.0001) and late potentials (r=0.405; p<0.001). The presence of late potentials was also found to correlate significantly with grade of arrhythmia (r=0.593; p<0.001). These patients present with a more severe stage of the disease and should therefore receive more aggressive treatment to prevent sudden cardiac death resulting from arrhythmia.

Heat-shock protein 70 favours human liver recovery from ischaemia-reperfusion

BACKGROUND

Pringle's manoeuvre controls excessive bleeding, but results in ischaemia-reperfusion injury during liver surgery. Activation of the heat-shock protein system of cell defense has been demonstrated after ischaemia-reperfusion injury in animal tissues. The aim of the present study was to determine whether the ischaemia-reperfusion accompanying hepatic surgery induces heat-shock protein 70 (HSP70) in human liver and whether the induction of HSP70 is related to the recovery of liver function.

METHODS

Heat-shock protein 70 and gamma-actin mRNAs were assayed in the liver biopsies of 10 subjects undergoing partial hepatectomy for localized lesions. Measurements were performed before the Pringle's manoeuvre and at the end of the surgery. Transaminases and fibrinogen were measured before and at 12, 24 and 36 h following hepatectomy.

RESULTS

After an average 40 +/- 8-min period of warm ischaemia, a significant increase of HSP70 mRNA (187 +/- 67%, 2P < 0.05) was observed. The acute increase of HSP70 mRNA correlates with the decrease of transaminases (AST: rs -0.964, ALT: rs -0.891, P < 0.002) and the increase of fibrinogen (rs -0.7, P < 0.02) observed between 12 and 24 h following surgery.

CONCLUSIONS

Heat-shock protein 70 is induced by ischaemia-reperfusion injury in human liver. Its induction seems to have beneficial effects, including a prompt reduction of transaminases and a rapid recovery of fibrinogen synthesis.

Cooperative inhibitory effect of ZD1839 (Iressa) in combination with trastuzumab (Herceptin) on human breast cancer cell growth

BACKGROUND

Co-expression of the epidermal growth factor receptor (EGFR) and of ErbB-2 is found in a subset of primary human breast cancer.

MATERIALS AND METHODS

The antiproliferative effects of anti-EGFR and anti-ErbB-2 agents were evaluated using a monolayer assay. The effects of these agents on the activation of EGFR, ErbB-2, AKT and p42/p44 MAP kinases (MAPK) were investigated by western blot analysis.

RESULTS

We found that both ZD1839 (Iressa), a specific EGFR tyrosine kinase inhibitor, and trastuzumab (Herceptin) (TRA), a humanized anti-ErbB-2 monoclonal antibody, were able to inhibit the growth of SK-Br-3 and BT-474 breast carcinoma cells, which express both EGFR and ErbB-2. Treatment of breast carcinoma cells with a combination of ZD1839 and TRA resulted in a synergistic inhibitory effect. Treatment of SK-Br-3 cells with ZD1839 produced a significant, dose-dependent reduction of the tyrosine phosphorylation of both EGFR and ErbB-2. Phosphorylation of MAPK and AKT were significantly reduced in SK-Br-3 cells following treatment with ZD1839, whereas treatment with TRA produced a reduction of AKT but not MAPK phosphorylation. Finally, treatment with ZD1839, but not with TRA, produced a significant increase in fragmented DNA in breast carcinoma cells. However, a more pronounced increase in the levels of fragmented DNA was observed following combined treatment with ZD1839 and TRA.

CONCLUSIONS

These data suggest that combined treatment with drugs that target EGFR and ErbB-2 might result in an efficient inhibition of tumor growth in those breast carcinoma patients whose tumors co-express both receptors.

[Silent ischemia and ventricular arrhythmias in essential hypertension]

BACKGROUND

Silent ischemia episodes rate is 4-5% among over fifty aged people. Patients affected by hypertension have higher coronary artery disease rate than people with normal blood pressure. An increased mortality is present among patients affected by essential hypertension, especially if affected by silent ischemia and /or ventricular arrhythmias. In all previous study about hypertension, the inclusion criterion was a diastolic blood pressure >95 mmHg, that is a low selective one. The aim of study is to evaluate ventricular arrhythmias rate, in hypertensive patients, without pharmacological therapy, and diagnosed by 24 hours ambulatory blood pressure monitoring (ABPM), so using a more selective criterion than WHO rules.

METHODS

128 consecutive patients with hypertension diagnosis by WHO rules, were screened for 24 hours ambulatory blood pressure measurement (ABPM); 85 of them (66.4%) had 24 hours mean blood pressure >135/85 mmHg. These 85 patients were screened for M-mode, B-mode echocardiography and 24 hours electrocardiogram monitoring by Holter.

RESULTS

Sixty patients (70.6%) were affected by left ventricular hypertrophy, 25 were free (29.4%) According to the Lown and Wolf classification for ventricular arrhythmias 20 patients (23.5%) had a Grade I arrhythmia, 5 (5.9%) had a Grade II, 4 (4.7%) had a Grade III, 9 (10.6%) had a Grade IV A, 20 (23.5%) had a Grade IV B, 12 (14.2%) had a Grade V and 15 patients (17.6%) were free from premature ventricular complexes. 40 patients (47%) had one or more ST depression episodes longer than 60 . The range of episodes number is 1-22, mean 6.8; their duration range is 1-16 minutes, mean 7.6 minutes. In our study, left ventricular hypertrophy correlate significantly with arrhythmia Lown score, r=0.552 for p<0.0001 and also with silent ischemia as ST depression r=0.51, p<0.004. The correlation, between arrhythmia score and ST depression, r=0.042, p<0.021 is not highly significant.

CONCLUSIONS

The conclusion is drawn that using a more selective criterion for the diagnosis of hypertension, it is possible to identify patients affected by a more severe stage of disease, and detect them for primary prevention of coronary events.

Increased prevalence of microthromboses in retinal capillaries of diabetic individuals

In diabetic retinopathy, capillary nonperfusion and eventual obliteration can lead to retinal ischemia and sight-threatening neovascularization. The occurrence of retinal microthrombosis in human diabetes has long been suspected and occasionally observed but never systematically demonstrated. We used trypsin digestion to isolate the intact vascular network from retinas obtained postmortem from nine diabetic donors (age 64 +/- 11 years, duration of diabetes 6 +/- 4 years; mean +/- SD) and eight age-matched nondiabetic donors. Topographically matched sectors (each one-sixth of retina) of diabetic and nondiabetic retinas were tested sequentially with antibodies to fibrin cross-linking factor XIII and platelet glycoprotein (GP)-IIIa to identify fibrin-platelet thrombi. In some trypsin digests, we also examined vascular cell apoptosis. The retina from a nondiabetic donor, 24 years of age, who had died of trauma, was used to exclude confounding influences caused by the postmortem period. When compared with those of nondiabetic donors, the retinas of diabetic donors showed double the number of capillary segments with colocalized immunostaining for factor XIII and GPIIIa (P = 0.02). The total area of the positive segments was fourfold greater in the diabetic than in the nondiabetic donors (P = 0.02) and correlated with the duration of diabetes (r = 0.71, P < 0.05). Large thrombi were six times more frequent in the diabetic donors (P = 0.03), and there was a significant topographical association of microthrombosis with apoptotic cells in both diabetic and nondiabetic vessels (P = 0.0001). Hence, diabetes of short duration was found to be associated with a greater than normal number and size of platelet-fibrin thrombi in the retinal capillaries. These thrombi can contribute to capillary obliteration and retinal ischemia and may be a practical target for early drug intervention.

Ventricular arrhythmias and left ventricular hypertrophy in essential hypertension

BACKGROUND

Patients with essential hypertension and/or left ventricular hypertrophy and ventricular arrhythmias suffer from an increased mortality rate. In all previous studies on hypertension, the criterion for inclusion was diastolic blood pressure > 95 mmHg. This is a low selective threshold. Our study attempted to evaluate the incidence of ventricular arrhythmia in hypertensive patients not receiving pharmacological treatment and diagnosed by 24-h ambulatory blood pressure monitoring (ABPM), therefore using a more selective criterion than WHO guidelines.

METHODS

Hundred-twenty-height consecutive patients with hypertension diagnosed on the basis of WHO guidelines were screened for 24-h ambulatory blood pressure measurement. Eighty-five (66.4%) presented a 24-h mean blood pressure > 135/85 mmHg. All 85 patients were screened for M-mode, B-mode echocardiography, PW Doppler and 24-h ECG Holter recordings.

RESULTS

Sixty patients (70.6%) were affected by left ventricular hypertrophy and 25 were free (29.4%). Thirty-six patients (42.4%) had left ventricular diastolic dysfunction, 49 were free (57.6%). According to Lown and Wolf's classification of ventricular arrhythmia, 20 patients (23.5%) presented Grade I arrhythmia, 5 (5.9%) presented Grade II, 4 (4.7%) Grade III, 9 (10.6%) Grade IVA, 20 (23.5%) Grade IVB, 12 (14.1%) Grade V and 15 patients (17.6%) were free from premature ventricular complexes, namely Grade 0 arrhythmia. Left ventricular hypertrophy was found to correlate significantly with the arrhythmia score, r = 0.552 for p < 0.0001. Moreover, left ventricular diastolic dysfunction correlated significantly with the arrhythmia score, r = 0.495 for p < 0.0001. There was also a good correlation between left ventricular hypertrophy and left ventricular diastolic dysfunction, r = 0.616 for p < 0.0001. Among patients affected by left ventricular diastolic dysfunction and left ventricular hypertrophy, the correlation with the arrhythmia score was even closer, r = 0.586 for p < 0.0007.

CONCLUSIONS

We conclude that by using a more selective criterion for the diagnosis of hypertension, we can identify patients with a highly significant statistical correlation between left ventricular hypertrophy and ventricular arrhythmia score, and also between diastolic dysfunction and the ventricular arrhythmia score, due to a more severe stage of disease. It is useful to detect those patients affected by ventricular arrhythmias for the primary prevention of major cardiovascular events.

Basal synthesis of heat shock protein 70 increases with age in rat kidneys

The heat shock protein (HSP) system is a mechanism of cell defense induced by stress, constitutively expressed during basal conditions and essential to the maintenance of cellular integrity. Acutely induced HSP synthesis decreases with aging, but the effect of age on the basal expression of HSP70 has not been specifically addressed so far. The aim of this work is to study the age-dependent basal concentrations of HSP70 mRNA in rat kidneys. In 8 young (2-3 months), 6 adult (6-11 months) and 6 old male Wistar rats (22-27 months), steady-state concentrations of HSP70 and gamma-actin mRNA and of rRNA were measured. Pentosidine was measured by HPLC. The basal, unstimulated HSP70 mRNA is increased in young and old rats compared with adult subjects [young: 182% of adult levels (100-299), old: 167% of adults (142-209); p < 0.005]. The amount of pentosidine increases with age (young: 0.6 +/- 0.1; adult: 1.65 +/- 0.15; old: 2.3 +/- 0.3 pmol/mg of protein; p < 0.0001). It seems likely that different mechanisms are responsible for the increased HSP70 basal synthesis in both the young and old animals. The prevalence of anabolic activity can trigger the increased basal production of HSP70 in young rats. The accumulation of posttranslational modified proteins, documented by pentosidine, can chronically enhance HSP70 synthesis in aged animals. The suppression of the synthesis of other proteins accompanying HSP-selective production might contribute to the impairment of specific cell functions in aging.

Removal of tumours of the orbital apex via a postero-lateral orbitotomy

BACKGROUND

The surgical management of pure apical tumours of the orbit may be problematic with traditional approaches. A postero-lateral approach, specifically designed for apical growths, provides a more favourable angle of vision through a relatively small bone opening.

METHODS

A series of 103 consecutive cases of intraorbital tumours, operated on in a community-based institution, was retrospectively reviewed. Out of this series, 8 patients, harbouring lesions located in the posterior intraconal space, underwent a postero-lateral orbitotomy. This approach, through a small opening on the orbital and temporal portions of the greater wing of the sphenoid, with the lesser sphenoidal wing, the orbital plate of the frontal bone, the lateral rim of the orbit being maintained intact, allowed adequate exposure of the orbital apex and successful extirpation of the tumours. In four patients the histological examination disclosed a cavernoma; the other patients had, respectively, a dermoid cyst, a lymphoma, a hemangiopericytoma and a metastatic melanoma.

RESULTS

No recurrences were observed in a follow-up period ranging from 1 to 7 years postoperatively (the patient with melanoma died 16 months after operation for systemic complications of her illness). One patient showed transient weakness of lateral rectus muscle due to surgical manipulation, which subsided in few months.

CONCLUSIONS

The postero-lateral orbitotomy represents a reliable alternative to other traditional surgical approaches when dealing with tumours of the orbital apex, providing excellent exposure of this region with a low rate of operative morbidity.

Intrarenal arteriosclerosis and impairment of kidney function in NIDDM subjects

It is currently under debate whether the pathogenesis of end-stage renal failure in non-insulin-dependent diabetes mellitus (NIDDM) is a consequence of microangiopathy alone. The aim of this study was to investigate intrarenal arteriosclerosis and its correlation with kidney function in NIDDM. In 36 diabetic subjects, and in 10 age- and sex-matched healthy control subjects we measured kidney volume and resistive index of the interlobar arteries by duplex Doppler ultrasonography. Clinical and metabolic parameters, renal function and vascular sequelae of the disease were also evaluated. In diabetic subjects resistive index (median 0.72, range 0.54-0.79) was higher than in control subjects (median 0.62, range 0.57-0.66) (2p < 0.002). Kidney volume and resistive index correlated with age (p < 0.004), body mass index (p < 0.001), mean blood pressure (p < 0.001), total and LDL cholesterol (p < 0.01) and creatinine clearance (p < 0.001 and < 0.01, respectively). Kidney volume also correlated with HbA1 (p < 0.01) and resistive index with uric acid (p < 0.01). Lower body macroangiopathy was associated with increased resistive index and reduced kidney volume (2p < 0.05), while upper body macroangiopathy and microangiopathy were not. Our data suggest that macroangiopathy rather than microangiopathy is mainly responsible for impairment of kidney function in NIDDM. The resistive index of interlobar arteries seems to be a reliable marker of intrarenal arteriosclerosis and can be used as a non-invasive, easily available parameter of its evolution.

Lateral ventricle subependymomas. Case report taking into particular consideration the aspects of magnetic resonance and review of the literature

Subependymomas are rare neuroectodermic tumours. The authors report a case of a patient he had a subendymoma in the left lateral ventricle, with particular attention to the MR aspects on these lesions and review of the literature.

Surgical treatment of fractures of the thoracic and lumbar spine via the transpedicular route

Sixty-seven consecutive patients with burst or dislocation fractures of the thoracic or lumbar spine were submitted to early surgical reduction, via the transpedicular route, over a 5-year period. The first 22 patients received Harrington instrumentation, while transpedicular devices were applied in the last 44 cases, at either the thoracic or the lumbar level. One patient did not receive any spinal instrumentation. This surgical approach was found to be reliable in achieving a near-anatomical reconstruction of the fractured spinal segment. The rate of post-operative complications was low. Placement of transpedicular devices proved to be a safe and effective procedure. The overall results were consistent with the thesis that the transpedicular approach compares favourably with alternative surgical methods.

Delayed worsening of the surgical correction of angular and axial deformity consequent to burst fractures of the thoracolumbar or lumbar spine

Forty-one patients with burst fractures of the thoracolumbar junction, or the lumbar spine (T12 to L5), were followed for 6-48 months (mean follow-up = 19.9 months) after early surgery (usually within 24 hours). Preoperative, early postoperative, and late postoperative degrees of kyphosis, as well as percent reduction of the height of the vertebral body were calculated and compared. Early postoperative radiologic evaluations showed a statistically significant difference (p < 0.0001) between the mean values of both parameters calculated respectively before and after surgery. The decrease of the surgical correction, from the initial postoperative radiographs to follow-up, was statistically significant (p < 0.0001). However, the final values were better when compared with the preoperative features (p < 0.003 and p < 0.0001, respectively for degree of kyphosis and reduction in vertebral height.

Increased expression of basement membrane collagen in human diabetic retinopathy

Basement membrane thickening is the most prominent and characteristic feature of early diabetic microangiopathy. Unknown is not only the causative process but also whether the thickening reflects increased synthesis of specific components. Because collagen type IV is uniquely present in basement membranes and represents their predominant structural element, we studied its expression in retinas obtained postmortem from five patients with 8 +/- 3 yr of diabetes and six nondiabetic controls. The collagen IV transcript proved to be rare in adult human retina and undetectable by Northern analysis. We thus identified a set of primers and conditions to detect the transcript by the reverse transcriptase polymerase chain reaction and to measure its level relative to an endogenous internal standard (beta-actin mRNA). In the diabetic patients the levels of collagen IV mRNA were increased twofold over levels in controls, whereas the actin mRNA levels were similar in the two groups. Hence, the collagen IV/actin ratio was 0.53 +/- 0.15 in diabetic samples and 0.24 +/- 0.09 in control samples (P = 0.004). These results indicate that diabetes induces a twofold increase in the expression of collagen IV by the cells that synthesize basement membranes in the adult retina (vascular cells). Insofar as high ambient glucose in vitro elicits the same effect, it may be proposed that basement membrane thickening in diabetes results from enhanced synthesis of specialized component molecules sustained by hyperglycemia.

Spinal cord stimulation for the treatment of progressive systemic sclerosis and Raynaud's syndrome

Progressive Systemic Scleroderma (PSS) is a generalized disease of connective tissue involving the skin, as well as other internal organs. The cutaneous signs are characterized by a progressive sclerosis and loss of function or dexterity in the hands. Between 1987 and 1992, 15 patients affected by scleroderma were treated by means of spinal cord stimulation (SCS) in order to reduce signs and symptoms related to vascular damage. The follow-up ranged from 12 months to 6 years. The study confirms that SCS is an effective therapy in patients with PSS and Raynaud's phenomenon because of its beneficial effects on the Raynaud episodes, ulcers, pain, vascular sclerosis and hand function. This method may have a primary role in the treatment of this chronic disorder because of the high probability of failure of other medical or surgical therapy.

Transpedicular decompression and stabilization of burst fractures of the lumbar spine

Twenty-seven consecutive patients with neurological impairment due to burst fractures of the lumbar spine were operated upon, via the postero-lateral route, over a 38-month-period. Transpedicular fixation devices [posterior segmental fixator (PSF) or variable screw placement system (VSP)] were applied in all cases, in order to achieve short-segment fusion of the fractured spinal segment. Return to useful motor power or neurological normality (median follow-up: 18.7 months) occurred in 22 cases (81% of the whole series), with this outcome resulting in all but one of the cases with preoperative incomplete neurological deficit. Postoperative encroachment of the spinal canal, degree of kyphotic deformity, and reduction of the vertebral height showed statistically significant differences compared with the corresponding preoperative values.

Increased expression of tissue plasminogen activator and its inhibitor and reduced fibrinolytic potential of human endothelial cells cultured in elevated glucose

In diabetic patients, elevated plasma levels of t-PA and PAI-1 accompany impaired fibrinolysis. To identify mechanisms for these abnormalities, we examined whether vascular endothelial cells exposed to high glucose upregulate t-PA and PAI-1 production and whether ambient PA activity is decreased concomitantly. In 17 cultures of human umbilical vein endothelial cells grown to confluency in 30 mM glucose, the t-PA antigen released to the medium in 24 h was (median) 52 ng/10(6) cells (range 10-384) and the PAI-1 antigen was 872 ng/10(6) cells (range 217-2074)--both greater (P less than 0.02) than the amounts released by paired control cultures grown in 5 mM glucose--29 ng/10(6) cells (range 7.5-216) and 461 ng/10(6) cells (range 230-3215), respectively. In the presence of high glucose, the steady-state levels of t-PA and PAI-1 mRNAs were increased correspondingly (median 142 and 183% of control, respectively, P less than 0.05); high glucose per se and hypertonicity contributed to the upregulation in additive fashion. The PA activity of conditioned medium from cultures exposed to high glucose was 0.4 IU/ml (range 0.2-0.6), which was significantly lower (P less than 0.02) than the PA activity of control medium (0.5 IU/ml, range 0.2-0.9). No difference was observed when comparing the PA activities of acidified conditioned media, expected to be depleted of inhibitors. Thus, high glucose coordinately upregulates endothelial t-PA and PAI-1 expression through effects exerted at the pretranslational level and enhanced by even mild degrees of hypertonicity.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of genes related to the extracellular matrix in human endothelial cells. Differential modulation by elevated glucose concentrations, phorbol esters, and cAMP

To identify agents and mechanisms responsible for the thickened basement membranes characteristic of diabetic angiopathy we examined the effects of high glucose (30 mM) on the expression of genes related to extracellular matrix composition and turnover and investigated whether the changes induced by high glucose were mimicked and sustained by activation of protein kinase C or A. In human umbilical vein endothelial cells high glucose increased fibronectin, collagen IV, tissue plasminogen activator (tPA), and plasminogen activator-inhibitor 1 (PAI-1) mRNA levels 2-fold but did not affect type IV and interstitial collagenase expression. Acute treatment with phorbol esters resulted in increased collagen IV, tPA, PAI-1, and interstitial collagenase mRNAs; the type IV collagenase mRNA levels were instead suppressed to 50% of control. Upon longer exposure to phorbol esters (48 h) suppression of fibronectin and PAI-1 mRNAs also occurred. Intracellular elevation of cAMP led to over-expression of fibronectin and type IV collagenase and potentiated the effects of phorbol esters on collagen IV, tPA, and interstitial collagenase expression. The mRNA changes induced by high glucose occurred in the absence of protein kinase C activation or cAMP elevation. These studies indicate that events other than activation of protein kinase C or A bridge high ambient glucose to changes in endothelial cell gene expression that may contribute to diabetic angiopathy.

Malondialdehyde (MDA) level in diabetic subjects. Relationship with blood glucose and glycosylated hemoglobin

The relationships between plasma malondialdehyde (MDA) and metabolic parameters in type I and II diabetic subjects have been studied at different levels of glycemic control. In 67 diabetics (20 type I, 47 type II, aged 53 +/- 1.2) and 40 healthy subjects (aged 47 +/- 1.75), triglycerides (TG), total cholesterol (CT) and C-HDL, fasting blood glucose (FBG), glycosylated hemoglobin (GHb) and MDA were measured. Diabetic population as a whole showed higher MDA plasma levels compared to controls, together with higher FBG, TG, GHb. MDA showed a significant correlation with both FBG and GHb, but was not correlated to plasma lipids. The patients with a poor metabolic control showed the highest plasma MDA concentrations, significantly different from the group with a better control: GHb less than 10% = MDA 2.77 +/- 0.28 nmol/ml - GHb greater than 10% = MDA 4.22 +/- 0.39 nmol/ml (z = 2.10, a less than 0.02); FBG less than 150 mg/dl = MDA 2.74 +/- 0.32 nmol/ml - FBG greater than 150 mg/dl = MDA 4.15 +/- 0.37 nmol/ml (z = 2.22, a less than 0.02). Glycemic equilibrium seemed to influence plasma MDA, increasing free radical production. This phenomenon probably occurred either because of enhanced glycosylation and platelet aggregation, or impairment of cellular antioxidant protective systems. The increased free radical production may play a role in the pathogenesis of metabolic vasculopathy.

Modification of tissue-factor mRNA and protein response to thrombin and interleukin 1 by high glucose in cultured human endothelial cells

Because diabetic vascular disease is accompanied by a state of hypercoagulability, manifested by increased thrombin activity and foci of intravascular coagulation, we investigated whether a specific procoagulant property of the endothelium--production and surface expression of tissue factor--is modified by elevated glucose concentrations. In unperturbed human vascular endothelial cells, tissue factor mRNA and expression of the functional protein were undetectable and were not induced by 10-12 days of exposure to 30 mM glucose. In thrombin-stimulated cultures, tissue-factor expression was related inversely to cellular density, with confluent cultures producing (per 10(5) cells) half the amount of tissue factor measured in sparse cultures. Cells exposed to high glucose and studied when cell number and thymidine incorporation were identical to control cells manifested increased tissue-factor mRNA level and functional protein production in response to thrombin (P = .002). This effect was not attributable to hypertonicity and was not observed after short exposure to high glucose. In contrast, the tissue-factor response to interleukin 1, a modulator of endothelial function in the context of host defense, was decreased in cells cultured in high glucose (P = .04). These findings indicate that exposure to high glucose can alter tissue-factor gene expression in perturbed vascular endothelium. The reciprocal effects of high glucose on the tissue-factor response to thrombin and interleukin 1 points to different pathways of tissue-factor stimulation by the two agents and suggests functional consequences pertinent to the increased thrombin activity and compromised host-defense mechanisms observed in diabetes.

Increased expression of basement membrane components in human endothelial cells cultured in high glucose

Although the degree of hyperglycemia is a powerful and independent risk factor for diabetic microvascular disease, it has not been established if and how high glucose per se can induce the typical lesions of microangiopathy. We have investigated in human vascular endothelial cells the expression of messenger RNA (mRNA) for collagen type IV and fibronectin, the two glycoproteins characteristically increased in diabetic basement membranes. In 12 confluent primary cultures exposed for 11 +/- 1 d (mean +/- SD) to 30 mM glucose and exhibiting cell number and thymidine incorporation similar to control cultures, the levels of collagen IV and fibronectin mRNA were, respectively, 238 +/- 140 and 221 +/- 231 percent of control (P less than 0.01). The effects of high glucose were selective (the levels of collagen I and c-myc mRNA remained unchanged), independent of the proliferative activity of the cultures and of the plating substratum, and maintained throughout multiple passages. However, several days of exposure to high glucose were required before their appearance. These observations establish that high glucose is a perturbation sufficient to mimic the effects of diabetes on the regulation of basement membrane components and propose that modifications in gene expression may pertain to the chain of events leading to diabetic angiopathy.

Influence of cell age and ketoaminic linkage on rapid glycosylation of hemoglobin in human red cells in vitro

In vitro the rate of synthesis of the aldiminic linkage between Hb and glucose depends on glucose concentration, length of incubation and some other physiological factors. To understand better the regulation of this synthesis and to verify the role of cell age and of basal HbA1 levels on the rate of synthesis of pre-A1, we studied red cells from 7 normal controls and 7 diabetics, with high HbA1 levels. We found that the content of HbA1 (stable glycosylated hemoglobin) is able to negatively affect the rate of synthesis of new pre-A1, according to a curvilinear model. These results suggest that in vitro the glycosylation process is saturable, and that elevated values of HbA1 are able to slow the synthesis of pre-A1 in vitro.

[A method for the assay of fibrinopeptide in plasma]

Fibrinopeptide A (FPA) levels have been assayed in 10 normal subjects using a radioimmunoassay (RIA-mat FPA Mallinckrodt). Mean values were 0,97 +/- 0,46 ng/ml. The variation coefficient of the test was 4,82%. The method is well standardized and seems to be useful in the diagnosis of venous thrombosis and in the control of heparin treatment. It seems to be also useful in the evidentiation of an activation af the coagulation system in some diseases (cardiovascular diseases, diabetes etc.)

[A method for erythrocyte filtration]

Erythrocyte deformability is one of the most important factors on determining blood viscosity. Many microcirculation damages are caused by alteration of viscosity. We propose a method for evaluate erythrocyte filtration using Nucleopore membranes, to study erythrocyte deformability. Normal ranges are calculated in young healthy subjects. Mean filtration time is determined on 5 filtrations for every subject. Filtration rate is expressed by sec/ml and correlated whit haematocrit. The method is not easily utilizable, but it can be useful in the knowledge of the role of the erythrocyte deformability in the altered microcirculation.

[Euthyroid exophthalmos: evaluation of 6 patients]

To determine if "euthyroid Graves' exophthalmopathy" is a separate autoimmune disorder, we have examined 6 clinically euthyroid male patients (aged 30-50 yrs) who have never had thyrotoxicosis, with recently developed bilateral exophthalmos (classes 2-4 in the A.T.A. classification). We have evaluated T4 and T3 levels, FTI, TSH response to TRH (200 micrograms i.v.), antithyroglobulin and antimicrosomal antibodies (Tgab and Mab) titres and thyroid stimulating antibody (TSab) activity of patients' IgG. In 5 patients we performed also orbital computerized axial tomography (CAT). The T4 and T3 levels ranged 5.6-7.9 micrograms/d1 and 1.2-2.1 ng/ml respectively; FTI ranged 7-9.7 U. 5 patients showed an impaired TSH response to TRH; only one had a normal TSH increase. The Tgab and Mab titre was undetectable in 5 patients; only one showed high autoantibody titre and developed a clear hypothyroidism 8 months later. TSab activity was detectable in the overall group. The CAT revealed a consistent infiltrative involvement of extraocular muscles in 4 patients; the 5th showed evidence of increased density of retroorbital fat, without any muscle involvement. In conclusion, the presence of TSab activity (6/6), the impaired TRH test (5/6) and the infiltrative retroorbital muscle involvement (4/5) seem to suggest an autoimmune thyroid disease even if apparently normal iodothyronine levels were found.