Co-occurrence of clozapine-related DRESS syndrome core clinical manifestations: results of a systematic review

Introduction

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome refers to a cluster of clinical symptoms/signs related to drug hypersensitivity. The main clinical features include fever, skin rash, eosinophilia, enlarged lymph nodes, atypical lymphocytosis, and involvement of at least one internal organ. Clozapine-related DRESS syndrome has been rarely reported, but this may be due to a different clinical presentation pattern compared to DRESS for other culprit drugs.

Objectives

We aimed to assess clusters of main clinical features of clozapine-related DRESS.

Methods

We ran a network analysis for clinical manifestations in the pooled sample of all previous published cases of clozapine-related DRESS.

Results

We observed a triad of core symptoms (i.e., organ implication, fever, and eosinophilia) among DRESS criteria co-occurring in 59.3% (n=16) of 27 patients. The organs most likely to be involved in clozapine-related DRESS included lungs, liver, heart, and kidneys. Fever was also present in almost all cases (n=25 patients), while eosinophilia was observed in two thirds of the sample (n=18 patients).

Conclusions

Regarding clinical manifestations clozapine-related DRESS may differ from DRESS for other culprit drugs as skin reaction is not very typical; thus, clinicians need to consider DRESS as a potential diagnosis even in absence of a skin reaction. When managing clozapine-treated patients with the core triad of organ implication, fever, and eosinophilia clinicians should consider guidelines for DRESS treatment.

Disclosure

No significant relationships.

Suicide presentation and the risk at the time of the mandatory quarantine for the SARS-Cov-2 pandemic: medico-legal and forensic aspects

Introduction

COVID-19 pandemic is the most important health emergency of the 21st century. Since the high number of infected people and as there is still no specific therapy worldwide, the pandemic has been countered through the application of prevention measures based on social distancing and home isolation. These elements are known risk factors for the development of various psychiatric conditions. From a forensic point of view, these pathologies are related to a high suicide rate.

Objectives

It is no coincidence that during the previous pandemics that have occurred in history there has been a significant increase in suicides. By this work, we therefore want to highlight the psychological consequences of a pandemic and the importance of preventive strategies.

Methods

It is important to focus not only on physical well-being but also on the psychological aspects that the pandemic produces in the daily life of each individual

Results

If the infecting agent causes the death of millions of people around the world, the socio-economic context that is created indirectly determines as many deaths.

Conclusions

Therefore it is necessary to underline how it is advisable to implement preventive measures in order to significantly reduce deaths from suicide, a problem with an important impact in the social and forensic fields.

Disclosure

No significant relationships.

Real-world effectiveness of long acting aripiprazole: Treatment persistence and its correlates in the Italian clinical practice

OBJECTIVES

To identify the variables that are associated with persistence to Aripiprazole-Long Acting (A-LAI), in adult patients with schizophrenia.

METHODS

Observational, retrospective, non-interventional study involving 261 patients with schizophrenia.

RESULTS

Eighty-six percent of study subjects were persistent for at least 6 months. All subjects with baseline CGI-S of 1 or 2, 95% of subjects with CGI-S of 3, 86% with CGI-S of 4, 82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7 were persistent. A-LAI treatment continuation rate was higher in patients with: 1) baseline CGI score ≤ 4; 2) schizophrenia dimension (LDPS) mania score ≤ 5; 3) psychotic spectrum schizoid score ≤ 11.

CONCLUSIONS

A relatively high number of patients (n = 225, 86%) were persistent to A-LAI for at least 6 months. Not surprisingly, very severe patients were more unlikely to be persistent. However, it is noteworthy that a large number of subjects with high CGI score at the time when A-LAI was started (82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7) were persistent. Larger, controlled, prospective and longer studies are warranted.

Disordered eating behavior and mental health correlates among treatment seeking obese women

BACKGROUND AND OBJECTIVES

Previous research has suggest that obesity is associated with increased risk for psychopathological disorders, however, little is known about which obese patients are most vulnerable to psychopathological disorders. We therefore investigated 126 treatment-seeking obese women to describe eating disorder pathology and mental health correlates, and to identify disordered eating behaviors that may place obese at increased risk for psychopathological disorders.

MATERIALS AND METHODS

The Structured Clinical Interview for DSM-IV (SCID) was used to identify Eating Disorders (ED). A battery of psychological tests, including the Anxiety Scale Questionnaire (ASQ,) Clinical Depression Questionnaire (CDQ), Eating Disorder Inventory-2 (EDI-2) Eating Attitudes Test-26 (EAT-26) scales and structured clinical interview were administered to all the patients. We analyzed the link between psychopathological disorders and eating attitudes by using both multiple regression analysis and non-parametric correlation.

RESULTS

Disordered eating behaviors and emotional behavioral aspects related to Anorexia Nervosa, such as ineffectiveness, are strongly linked to the depression and anxiety in obese subjects. No correlation was found between psychopathological disorders and age or anthropometric measurements.

CONCLUSIONS

Findings corroborate earlier work indicating that psychological distress is elevated in obese treatment seeking, bolstering the need for mental health assessment of such individuals. The feeling of ineffectiveness constitutes the major predictor of psychopathological aspects. This is an important result which may inform the development of effective interventions for obese patients and prevention of psychopathological disorders.

Perceived insecurity, mental health and urbanization: Results from a multicentric study

AIMS

This article aims to (1) explore the levels of perceived insecurity in a sample of patients with mood or anxiety disorders and (2) assess whether living in 'big cities' can influence the levels of patients' perceived insecurity and social contacts compared to living in a non-urbanized context.

METHODS

A total of 24 Italian mental health centers (MHCs) have been invited to participate. Twenty patients consecutively accessing the MHC have been recruited. All patients have been assessed using validated assessment tools.

RESULTS

The sample consisted of 426 patients, mostly female, with a mean age of 45 years. Globally, 52.2% of patients had a diagnosis of mood disorders, and 37.8% had anxiety disorders. Half of the sample declared that the main feeling toward life is uncertainty; higher levels of pessimistic views toward life have been detected in patients living in urban areas. A positive association between negative attitudes toward life and higher levels of depressive and anxiety symptoms, poor social functioning and higher levels of perceived psychological distress has been found.

CONCLUSION

Our findings confirm the presence of a common sense of perceived uncertainty among our sample. Such attitude toward life can have a detrimental impact on patients' psychological and physical well-being, contributing to high levels of distress.

Orthorexia nervosa: a frequent eating disordered behavior in athletes

Striving for enhancing athletic performance, many sportsmen undergo rigid dietary habits, which could lead to eating disorders (EDs) or Orthorexia Nervosa (ON), a psychopathological condition characterized by the obsession for high quality food. The aim of the study was to examine the occurrence of ON in athletes and to verify the relationship between ON and EDs. Five-hundred-seventy-seven athletes and 217 matched controls were administered the following tests: ORTO-15, Eating Attitude Test 26 (EAT-26), Body Uneasiness Test (BUT) and Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS). High positivity to ORTO-15 (28%) and EAT-26 (14%) emerged in athletes, whereas a high rate of BUT positivity was evident among controls (21%). Multivariate logistic regression analysis revealed that independent predictors of ON are previous dieting, age, positivity to YBC-EDS, positivity to EAT-26, competition level, and number of YBC-EDS preoccupations and rituals. Sharing many features with both EDs and Obsessive-Compulsive Spectrum, ON represents a crossroad between these pathologic conditions and might compromise the health state of an athlete. Therefore, coaches should consider important to detect symptoms of EDs and ON in their athletes.

The development and validation of the Body Image Dimensional Assessment (BIDA)

AIM

To validate a silhouette-based scale, the Body Image Dimensional Assessment (BIDA), an instrument for the screening of body dissatisfaction in large samples.

MATERIALS AND METHODS

Five-hundred ninety-two both gender non-clinical participants and 57 patients with eating disorders (ED) were administered the BIDA and the Body Dissatisfaction subscale of the Eating Disorder Inventory 2 (BD-EDI2). The BIDA consists of only 4 items to answer with reference to a series of four silhouettes not age- nor gender-related using a numeric scale that allows the quantification of the degree of Body Dissatisfaction, Sexual Body Dissatisfaction, Comparative Body Dissatisfaction and the calculation of the final Body Dissatisfaction Index (BDI).

RESULTS AND CONCLUSIONS

The study has shown that the BIDA has good reliability and validity as well as high predictive capability at a threshold BDI≥30 (sensitivity = 83.3% and specificity = 92.1%). By virtue of the rapid timing of administration, the BIDA can be a useful screening instrument of body dissatisfaction in non clinical populations to detect people at risk for ED and a follow-up instrument in clinical setting.

Demineralizing action of EGTA in endodontics

The demineralization of dentin obtained by treatment with a chelating agent ethylene diamminotetracetic acid (EDTA) or ethylene glycol-bis(beta-aminoethyl ether)-N-tetraacetic acid (EGTA), is a dynamic process involving chelation and solubilization. The actions of the EDTA and EGTA on dentin are influenced by the pH. Increasing mM concentrations of EDTA or EGTA the equivalent pH decreases in a similar slope to 80 mM chelator concentration. Increasing the chelator concentration different data were obtained: with EGTA the pH decreases slightly while with EDTA goes back up to the initial values. After 80 mM, EDTA reduces the activity on the dentin, and EGTA continues to work at higher concentrations. We demonstrated that EGTA solubilized more of 60 percent of dentin while EDTA gives about 20% at the maximal of the solubility.

Anticholinergic drug-induced delirium in an elderly alzheimer's dementia patient

Drug-induced delirium is a common matter in the elderly and anticholinergics, together with a number of different drugs, may significantly contribute to the delirium onset, especially in demented people. We report a case of a probable anticholinergic drug-induced delirium in an elderly patient. An 80-year-old man with Alzheimer's dementia presented with wandering, depressed mood with crying, somatic worries, anedonism and suicide recurrent ideas. A first external psychiatric assessment led to the diagnosis of melancholic depression and therapy with haloperidol 2mg/day, orphenadrine 100mg daily, amitriptyline 40 mg/day, lorazepam 2mg/day was started. Two weeks later patient suddenly developed delirium, characterized by nocturnal agitation, severe insomnia, daytime sedation, confusion, hallucinations and persecutory delusions. These symptoms progressively worsened, with the consequent caregiver's stress. A geriatric consultation excluded the main causes of delirium, therefore both Operative Units of Pharmacovigilance and Psychiatry were activated, for a clinical pharmacological and psychiatric assessment. Haloperidol, amitriptyline and orphenadrine were promptly dismissed. The patient began a treatment with quetiapine 25mg/day for two days, then twice a day, and infusion of saline 1000 ml/day for two days; psychiatric symptoms gradually diminished and therapy with galantamine was begun. We postulate that this clinical report is suggestive for an anticholinergic drug- induced delirium since the Naranjo probability scale indicated a probable relationship between delirium and drug therapy. In conclusion, a complete geriatric, pharmacological, and psychiatric evaluation might be necessary in order to reduce the adverse drug reactions in older patients treated with many drugs.

Generalised urticaria in a young woman treated with clomipramine and after ingestion of codfish

We report a case of generalized dermatitis and itch induced by a possible drug-food interaction in a young woman who was consuming clomipramine for Obsessive Compulsive Disorder (OCD). A 33-year-old woman affected by anxiety symptoms presented to our observation for a clinical evaluation. After psychiatric evaluation, the diagnosis of OCD was performed according to DSM-IV-TR and a pharmacological treatment with clomipramine (75-100 mg/day) plus alprazolam (0.5 mg/day) was started. About one month later, the patient developed a severe generalized urticaria with intense itch. A new anamnesis revealed that on the day before the development of the skin rash, no other drug was consumed and the patient had eaten codfish; clomipramine was then gradually discontinued and changed into paroxetine (30 mg/day). At the moment the patient does not show any OCD related symptom and any adverse event to paroxetine treatment has been recorded. We postulate a possible interaction between clomipramine and codfish ingestion. Allergic potential of clomipramine was investigated, while clomipramine de-challenge induced a decrease of the skin rash, the drug re-challenge performed one month later did not induce any adverse event. In contrast, when the combined re-challenge of codfish and clomipramine was performed urticaria was newly observed. The Naranjo Probability Scale Score suggested a probable causal relationship between drug-food interaction and the skin rash. In conclusion, we suggest evaluating also the complete risk of drug-food interaction occurring on clomipramine treatment.

[In vitro antimicrobial activity of glutaraldehyde plus O-phenylphenol association (ratio 2:1)]

BACKGROUND

The correct use of antiseptics, disinfectants and sterilization processes to inactivate or remove micro-organisms is an essential component of an effective infection control program. To reach this result the use of phenolic detergent-disinfectants which work well as a presoak has always been suggested in lieu of sterilization involving submerging instruments in a properly prepared glutaraldehyde solution for about 6 to 10 hrs. This study investigated the in vitro effectiveness of disinfectant solution containing 2% glutaraldehyde and 1% o-phenylphenol.

METHODS

The organisms used were purchased from the American Type Culture Collection (Escherichia coli ATCC 25922, Candida albicans ATCC 10231, Pseudomonas aeruginosa ATCC 27853, Staphylococcus aureus ATCC 25923, Staphylococcus epidermidis ATCC 12228), and from our clinical collection (Proteus mirabilis CH 14, Klebsiella oxytoca CH 22, Serratia liquefaciens CH 90). MIC and MBC were evaluated as testing solution for antimicrobial activity. The contact time studied between disinfectant and bacteria were 30 sec, 1, 2, 5, 10, 20 and 30 min.

RESULTS

The results showed that MIC values for most bacteria were 3.75 mg/ml. The MBC values were similar or higher than the MIC. The disinfectant solution killed E. coli and C. albicans already after 10 min, but for S. aureus 30 min was necessary.

CONCLUSIONS

This study proved that this solution attained the sterilization of surgical instruments in good timing and at low cost.

Root canal treatment in mandibular canines with two roots: a report of two cases

AIM

To highlight anatomical variation in the mandibular canine.

SUMMARY

Two clinical case reports are presented to illustrate anatomical variation in the human mandibular canine. Endodontic treatment may sometimes fail because morphological features of the tooth adversely affect the treatment procedures. Many investigators have reported the anatomical variations associated with mandibular canines. Mandibular canines are recognized as usually having one root and one root canal in most cases, although approximately 15% may have two canals or sometimes two roots. This paper describes two clinical cases of mandibular canines with two roots and two canals.

KEY LEARNING POINTS

Failure to control infection in the root canal system has an adverse impact on outcome. Clinicians should be aware of anatomical variations in the teeth they are managing, and should never assume that canal systems are simple. The majority of mandibular canines have one root and root canal, but 15% may have two canals, and a smaller number may have two distinct roots.

RB2/p130 gene-enhanced expression down-regulates vascular endothelial growth factor expression and inhibits angiogenesis in vivo

Angiogenesis is an essential step in the progression of tumor formation and development. The switch to an angiogenetic phenotype can occur as a distinct step before progression to a neoplastic phenotype and is linked to genetic changes such as mutations in key cell cycle regulatory genes. The pathogenesis of the angiogenetic phenotype may involve the inactivation of tumor suppressor genes such as the "guardian of the genome," p53, and the cyclin-dependent kinase inhibitor p16. Retinoblastoma family member RB2/p130 encodes a cell cycle regulatory protein and has been found mutated in different tumor types. Overexpression of RB2/p130 not only suppresses tumor formation in nude mice but also causes regression of established tumor grafts, suggesting that RB2/p130 may modulate the angiogenetic balance. We found that induction of RB2/p130 expression using a tetracycline-regulated gene expression system as well as retroviral and adenoviral-mediated gene delivery inhibited angiogenesis in vivo. This correlated with pRb2/p130-mediated down-regulation of vascular endothelial growth factor protein expression both in vitro and in vivo.

Localization of the e-NOS enzyme in endothelial cells and odontoblasts of healthy human dental pulp

Nitric oxide synthases (NOS) are important enzymes present in different cells such as endothelial cells, macrophages, etc. Recently, it has been found that nitric oxide (NO) is responsible for vasodilation, blood pressure regulation, platelet aggregation, cardiac contractility, and the mediation of immunity during bacterial infections and inflammation. However, the production and role of NO in various structures of the oral cavity have not been investigated extensively. The aim of this study was to evaluate the presence of e-NOS in healthy human odontoblasts and endothelial cells of the dental pulp. Twenty healthy human dental pulps were collected and frozen and pulp slices were obtained using a cryostat. The e-NOS enzyme was revealed by immunohistochemical analysis and the enzyme level was detected by Western blotting and mRNA expression by RT-PCR. The immunohistochemical results demonstrated, for the first time, the presence of e-NOS in odontoblasts and in endothelial cells. The presence of e-NOS m-RNA was confirmed by RT-PCR and the expression of the protein by Western blotting. These results clearly show that the e-NOS enzyme is present in both odontoblasts and endothelial cells of healthy human pulp. The presence of e-NOS in the odontoblast and endothelial cells of the dental pulp may mediate local vasodilation and cell proliferation.

TCR and immunophenotype changes in dimethyl sulfoxide-dependent programmed cell death

In the thymus most deleted cells are immature thymocytes and the high rate of cell death within the thymus is involved in the development of the initial T-cell receptor repertoire. Functional T-cell receptor recognition units are created by somatic rearrangements of gene segments, and the expression of successfully assembled TCR complex is the key to molecular events that culminate in T-cell activation, growth and differentiation. Previously, we reported that DMSO induces apoptosis in RPMI-8402 human pre-T cells. Here we examine the fate of pre-T cells undergoing negative selection analysing the responsiveness to DMSO-enforced TCR expression and immunophenotype modulation. Our results demonstrate that DMSO induces cell growth inhibition, cell phenotype changes, with down-regulation of CD2 and CD7, and increases in alpha/beta or gamma/delta TCR chains led by TdT, RAG-1 and RAG-2 activity. These modifications are associated with an apoptotic program. Taken together, these data suggest the existence of an early checkpoint that ensures in vivo the effective intrathymic differentiation supported from another point of view, the linkage between immunophenotypes and TCR regulation in T-cell differentiation and programmed cell death.

Conventional and new antidepressant drugs in the elderly

Depression in the elderly is nowadays a predominant health care problem, mainly due to the progressive aging of the population. It results from psychosocial stress, polypathology, as well as some biochemical changes which occur in the aged brain and can lead to cognitive impairments, increased symptoms from medical illness, higher utilization of health care services and increased rates of suicide and nonsuicide mortality. Therefore, it is very important to make an early diagnosis and a suitable pharmacological treatment, not only for resolving the acute episode, but also for preventing relapse and enhancing the quality of life. Age-related changes in pharmacokinetics and in pharmacodynamics have to be kept into account before prescribing an antidepressant therapy in an old patient. In this paper some of the most important and tolerated drugs in the elderly are reviewed. Tricyclic antidepressants have to be used carefully for their important side effects. Nortriptyline, amytriptiline, clomipramine and desipramine as well, seem to be the best tolerated tricyclics in old people. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose and include the so called atypicals, such as selective serotonin reuptake inhibitors, serotonin noradrenalene reuptake inhibitors and noradrenaline reuptake inhibitors. Monoamine oxidase (MAO) inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy; the last generation drugs (reversible MAO inhibitors), such as meclobemide, seem to be very successful. Mood stabilizing drugs are widely used for preventing recurrences of depression and for preventing and treating bipolar illness. They include lithium, which is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients for its side effects, the anticonvulsants carbamazepine and valproic acid. Putative last generation mood stabilizing drugs include the dihydropyridine L-type calcium channel blockers and the anticonvulsants phenytoin, lamotrigine, gabapentin and topiramate, which have unique mechanisms of action and also merit further systematic study. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide or drug resistant forms.

Broken instrument removal--two cases

This paper reports two clinical aids for the removal of broken instruments in root canals using a combination of hand instrumentation and ultrasonic devices. This technique is based on two phases: hand instrumentation with stainless-steel K-file instruments for bypassing the fragments, and K-files mounted on an ultrasonic handpiece for loosening and retrieval of the broken instruments. This method offers the following advantages: conservation of the remaining dentin wall of the root canal and elimination of the necessity for surgical treatment.

Nuclear matrix provides linkage sites for translocated NF-kappa B: morphological evidence

In response to the binding of extracellular ligands to cell surface receptors, multiple transcription factors are activated in the cytoplasm and translocated into the nucleus where they exert positive or negative control over cellular genes. The human transcription factor NF-kappa B family regulates the expression of a large number of genes involved in the host defence mechanism. They are typically present in the cytoplasm bound to the inhibitory I kappa B proteins. The activation of NF-kappa B involves the signal-induced degradation of these proteins, allowing NF-kappa B to translocate to the nucleus. In this study, by multiparametric analysis, we recognise in RPMI-8402 DMSO-activated cells the intracellular movement of transcription factor NF-kappa B providing its definite intranuclear collocation. Intact cells, purified nuclei and nuclear matrix preparations after 4 h of treatment were processed for morphological and biochemical analyses. Light and electron microscope observations show, in untreated cells, the presence of NF-kappa B protein homogeneously retained in the cytoplasm. Treated cells display a massive presence of NF-kappa B at the nuclear level bound to the interchromatin region. Immunoblotting of the same specimens confirms the strong association of NF-kappa B with the nuclear scaffold. Taken together, the data presented in this manuscript support a model where DMSO treatment provokes the cleavage and translocation of NF-kappa B from the cytoplasm to the nucleus and, in particular, in the proteinaceous network of the nuclear matrix sustaining the active role of this subcellular structure on regulation of eukaryotic gene expression.

bcl-2, p53, and MIB-1 in human adult dental pulp

Little is known about the renewal of some groups of cells in dental pulp, and the occurrence and significance of physiological cell death in dental pulp is not yet understood. The possibility of odontoblast disappearance by apoptosis has been proposed, and the presence of apoptotic cells in the rat and human odontoblastic and subodontoblastic layers has been recently described. bcl-2 and p53 are proteins involved in the apoptotic pathway, whereas MIB-1 is a proliferating cell marker. The aim of our study was an immunohistochemical evaluation of bcl-2, p53, and MIB-1 in healthy normal pulps of young human subjects. With bcl-2 immunostaining, some positive cells were found in the odontoblastic and subodontoblastic layers, whereas with MIB-1, only a few stromal cells were positive, and all odontoblasts were consistently negative. No cells were positive to p53. The bcl-2 immunoreactivity of the cells of the odontoblastic and subodontoblastic layers could help to explain the presence of apoptotic cells found in these regions.

An evaluation of the action of different root canal irrigants on facultative aerobic-anaerobic, obligate anaerobic, and microaerophilic bacteria

The aim of this study was to test the effect of different concentrations of sodium hypochlorite, chlorhexidine, and cetrimide on the following bacterial strains: Facultative aerobes-anaerobes: Candida albicans ATCC 10231; Enterococcus faecalis ATCC 29212; Escherichia coli ATCC 25,922; Pseudomonas aeruginosa ATCC 27,853; Streptococcus mitis ATCC 9811; Streptococcus mutans ATCC 35668; Streptococcus salivarius ATCC 13419; and Streptococcus sanguis ATCC 10556. Microaerophiles: Actinobacillus actinomycetemcomitans ATCC 29522. Obligate anaerobes: Actinomyces odontolyticus ATCC 17929; Fusobacterium nucleatum ATCC 25,586; Porphyromonas gingivalis ATCC 33277; and Prevotella melaninogenica ATCC 25845. Each irrigant was kept in contact with the bacterial species used for the experiment for 10, 20, or 30 min. Results showed that all irrigants had a bactericidal effect on both facultative aerobes-anaerobes and on microaerophilic and obligate anaerobic strains, in all concentrations and even after short periods of contact.

Human recombinant interleukin-1 beta induces thromboxane A2 release in polymorphonuclear leukocytes, macrophages and platelets: effect of IL-1 receptor antagonist

Prostaglandins and thromboxanes (Txs) are produced by polymorphonuclears (PMNs) and macrophages (Mphis) in response to various stimuli. PMNs were separated from other human blood cells and Mphis were separated from rat peritoneal lavage. In this paper we show that human recombinant interleukin-1 (hrIL-1) can stimulate the release of thromboxane B2 (TxB2) by PMNs and Mphis. In addition, we have shown that aggregation of PMNs may occur when calcium ions (7 mM) and hrIL-1 (100 ng/ml) are added to the cell preparation, but not when Ca2+ alone, hrIL-1 alone, or first hrIL-1 then calcium are added to the cell preparation. The treatment of human platelets with hrIL-1 shows that after 15 min incubation TxB2 is released. In addition, we compared the aggregation of platelets caused by ADP with that caused by hrIL-1. Human recombinant IL-1 at a concentration of 100 ng/ml also causes little aggregation of platelets, in this case the aggregation is reversible. In conclusion, hrIL-1 beta stimulates TxB2 release in PMNs, Mphis and platelets and this effect increases with addition of Ca2+ ions. The mixture of hrIL-1 and Ca2+ causes little aggregation of PMNs. In monocyte suspensions, pretreated with human recombinant IL-1 receptor antagonist (IL-1ra) 500 ng/ml for 10 min and then treated with LPS or hrIL-1 beta 10 micrograms/ml, the release of TxB2 was partially inhibited. IL-1ra may play a significant role in the control of IL-1 and LPS induction in the release of TxB2.

Dental health and treatment needs in institutionalized psychiatric patients in Italy

The caries prevalence, oral hygiene status, periodontal health and the treatment needs were assessed in a group of institutionalized psychiatric patients in Catanzaro, Italy. Of the total sample of 297 subjects, 165 (55.6%) were males, the mean age was 55.1 yr, the great majority (90.6%) was able to care for themselves, on average they had been institutionalized for 12.9 yr, and almost two-thirds were schizophrenic (65%). They did not receive any assistance in daily oral hygiene procedures, only 7.4% had visited a dentist and exclusively for emergency care. A total of 33 (11.1%) patients were edentulous, and the multiple logistic regression analysis showed a highly significant increase of edentulousness with increasing age (P < 0.001). No caries-free subjects were found and among the dentate the DMFT and DMFS scores for all age groups were respectively 15.5 and 88.6. The stepwise linear regression analysis showed that the mean DMFT index increased with age (t = 6.86; P < 0.001), and in the partly or totally helpless patients it was significantly higher than in the self-sufficient patients (t = 2.78; P = 0.006). Of the 264 dentate subjects, only 25 (9.5%) had no need of dental treatment; 213 (80.7%) required extractions with a mean number per person of 6.3 and the need for conservative dental care was recorded in 154 (58.3%) patients with a mean need for patient of 2.8. Mean OHI-S score was 4.2 and the stepwise linear regression analysis showed that it increased with age (t = 5.73; P < 0.001) and with the length of institutionalization (t = 3.42; P < 0.001). Only 0.9% of the entire sample was found with healthy periodontal tissue; bleeding on probing or a higher score was found in 4.6% of examined sextants; calculus in 10.1%; shallow pockets and deep pockets in 19.6% and 64.8% of all sextants. The results of the multiple logistic regression analysis indicated that the number of subjects with deep pockets as highest score increased with increasing age (P<0.001), and with the increasing length of institutionalization (P=0.005). The findings of this study demonstrate high caries prevalence, poor oral hygiene and periodontal health, and extensive unmet needs for dental treatment. More coordinated efforts between the social and dental care sector must be maintained to serve adequately the need of this disadvantaged group.

Immunocytochemical detection of factor XIII A--subunit in acute leukemia

Factor XIII (FXIII) is a plasma pro-transglutaminase consisting of A and B subunits in a tetrameric structure. A cellular form of FXIII consisting exclusively of A subunits exists in platelets and monocytes: monocyte FXIII may be involved in connective tissue organization. To evaluate the expression and diagnostic significance of FXIII A subunit (FXIIIA) in acute leukemia, we performed an immunocytochemical study (PAP technique) with rabbit antiserum against FXIIIA on leukemic blasts of 48 cases. FXIIIA was detected only in myelomonocytic (M4), monocytic (M5) and megakaryocytic (M7) cases: in M4 and M5 samples the amount of blast cytoplasmic FXIIIA was closely correlated with the expression of monocyte-specific antigenic and cytochemical markers. Our data show immunocytochemical detection of FXIIIA to be useful for acute leukemia characterization.

[Anticipatory anxiety and interpersonal relations with the radiologist of patients undergoing diagnostic imaging]

A pilot study has been carried out with the aim of evaluating the impact of updated imaging techniques (CT and MRI) versus "simple" examinations (tomography, X-rays, US, and nuclear medicine) on the anticipatory anxiety of the patients, as well as on the radiologist-patient relationship. Ninety consecutive patients undergoing diagnostic imaging modalities were examined according to the following schedule: 1) preliminary interview and anxiety assessment according to HRSA; 2) diagnostic imaging investigation, and 3) filling out an "ad hoc" questionnaire. The collected data have been divided into two groups: the "simple" group (52 patients submitted to X-rays, tomography, US, and nuclear medicine), and the "complex" group (38 patients submitted to CT and MRI). Anticipatory anxiety was observed in all subjects and attained psychopathological rates in more than half of them. Anxiety proved to be related to the completion of the examination rather than to its complexity. The questionnaire has pointed out the need for a more interactive relationship between radiologist and patient during diagnostic imaging examinations.

[Condensation of gutta percha after McSpadden]

The Authors have studied the efficacy of the sealing effect of thermomechanical compaction of guttapercha according to McSpadden with an in vitro analysis on undecalcified tooth sections and with a clinical evaluation of ten patients with periapical lesions. The analysis of the results has shown a good sealing capacity of the McSpadden technique.

Immunocytochemical detection of ferritin in human bone marrow and peripheral blood cells using monoclonal antibodies specific for the H and L subunit

We have used the monoclonal antibodies 2A4 (specific for the H subunit of human ferritin) and LO3 (specific for the L subunit) for immunocytochemical detection of ferritin in bone marrow and peripheral blood cells from normal subjects and patients with various haematological disorders. Formalin-fixed slides were stained by the immunoalkaline phosphatase procedure (APAAP). In normal subjects, ferritin could be found only in bone marrow smears and appeared to be largely confined to erythroid precursors and reticuloendothelial cells. The more immature erythroid precursors contained higher concentrations of cellular ferritin. Although evaluation could be only semiquantitative, erythroblast ferritin appeared to be more reactive with the monoclonal 2A4 (15 +/- 7% positive erythroblasts) than with the monoclonal LO3 (6 +/- 5% positive erythroblasts), indicating that H-type ferritin was predominant, particularly in proerythroblasts and basophilic erythroblasts. By contrast, the ferritin present in reticuloendothelial cells appeared to be predominantly of L-type. Patients with iron deficiency showed low levels of positive erythroblast, whereas the reverse was true in patients with transfusional iron overload. Intense positivity for reticuloendothelial cell ferritin was found in patients with anaemia of chronic disease. In myelodysplastic syndromes and acute myeloid leukaemia (AML), ferritin positivity was generally very strong at any stage of erythroblast development, particularly with the monoclonal antibody 2A4. Perls-positive perinuclear granules of ring sideroblasts were not stained, confirming that mitochondrial iron deposition is not in the form of ferritin. In AML and myelodysplastic syndromes with excess of blasts, ferritin could be detected also in immature myeloid cells. These data indicate that: (a) in normal conditions ferritin is mainly expressed in red cell precursors and reticuloendothelial cells, and this is in keeping with the peculiar role of these cells in iron metabolism; (b) abnormal cell ferritin contents can be observed in both iron overload and malignancy.

Tumor necrosis factor alpha down-regulates c-myc mRNA expression and induces in vitro monocytic differentiation in fresh blast cells from patients with acute myeloblastic leukemia

We have studied tumor necrosis factor alpha (TNF-alpha) for its capacity to induce differentiation and to modulate c-myc and c-fms protooncogene mRNA expression in fresh blasts from 10 patients with acute myeloblastic leukemia (AML). Bone marrow blast cells were grown in suspension cultures in the presence of 500 U/ml (62 ng/ml) of TNF-alpha for 7 days. Induction of differentiation was assessed by means of morphology, cytochemistry, immunophenotyping (CD11b, CD13, CD14, CD33), and nitroblue tetrazolium reduction. In all cases, exposure of leukemic blasts to TNF-alpha resulted in phenotypic changes consistent with induction of differentiation, although a marked variability in degree and type of response was observed. The majority of cases developed monocytic morphology and showed significant increases (chi 2 test, p less than 0.05) in phagocytic activity and/or expression of ANAE and myelomonocytic differentiation antigens (CD11b, CD14). TNF-alpha reduced c-myc mRNA level over a period of 24 hr in four of six cases studied: the two cases with no down-regulation were the least responsive in terms of myelomonocytic differentiation. These results confirm those obtained with leukemic cell lines, suggesting that TNF-alpha can induce differentiation of fresh AML blasts, mainly toward the monocytic lineage, and that induction of differentiation seems to be closely linked to down-regulation of c-myc mRNA expression over the first 24 hr rather than to attenuation of cellular proliferation per se.

5' Nucleotidase in chronic B cell leukemias: a cytochemical and ultrastructural study

We studied by cytochemical means the distribution of 5' nucleotidase (5' NT), a purine degradative enzyme, in the circulating lymphocytes of 24 healthy donors and 41 cases of chronic lymphoid leukemias, classified according to morphological and immunological criteria. About half the normal circulating lymphocytes were 5'NT positive and exhibited variable degrees of enzyme activity. Among chronic B lymphocytic leukemias we found high percentages of positive cells only in the phenotypically more mature cases. Moreover all cases of hairy cell, follicular cell, lymphoplasmacytic, and plasma cell leukemia showed moderate or weak 5' NT reactivity. Also one case of chronic T lymphocytic leukemia, CD8 positive, was moderately positive, while another, with large granular lymphocyte morphology, was completely negative. Electron microscopy revealed a discontinuous, granular plasma membrane reaction pattern, varying in intensity from case to case. In conclusion, our results confirm the usefulness of the 5' NT cytochemical reaction for identification of lymphoid populations at different stages of maturation in chronic B cell disorders.

Biological and clinical features of acute lymphoblastic leukaemia with cytoplasmic granules or inclusions: description of eight cases

We describe eight patients (four children and four adults) with an acute lymphoblastic leukaemia (ALL) with cytoplasmic granules or inclusions. The incidence of this variant of acute leukaemia in our whole series of patients with ALL is 1.8%. The granules or inclusions were usually positive for aspecific esterases (ANAE) and/or acid phosphatase, and the immunophenotype was in all cases typical of a CALLA positive B-lineage ALL (CD10+, CD19+ and/or CD24+, DR+, TdT+, anti-T-, anti-My-, SIg-). In one paediatric case, CD33 was unusually coexpressed. Ultrastructural investigations were performed in one case and demonstrated large granules containing vesicles, usually membrane bound, in the majority of blast cells. In the two cases analysed, Ig heavy chain gene rearrangement was detected. In this series of patients prognosis was poor since three never achieved a complete remission, four relapsed and only one is still in first continuous remission.

[Calcium oxide therapy of periapical lesions. A clinical contribution]

The use of calcium oxide as intermediate canal medication prior to definitive filling is described and followed by a report on the heating of periapical lesions in 6 particularly significant clinical cases.

Reactive hemophagocytosis in Ki-l positive large cell lymphoma: a case study

A case of large cell lymphoma presenting with hemophagocytic syndrome is reported. The clinicopathological findings suggested a diagnosis of malignant histiocytosis, but on the basis of immunohistological studies Ki-l lymphoma was diagnosed. Neoplastic cells expressed activation antigens such as HLA-DR, IL 2R, T10 and Ki-l, and showed high proliferative activity, but were devoid of T and B cell markers. The high percentage of reactive macrophages found in the bone marrow and lymph node probably reflected the release of lymphokines by the tumor population. The patient was treated with aggressive chemotherapy and is in complete remission at 8 months from diagnosis.

Tetrahydrofolate dehydrogenase cytochemistry in acute lymphoblastic leukemia

We studied the cytochemical distribution of tetrahydrofolate dehydrogenase (FH4D), an enzyme involved in nucleic acid metabolism and thus in cell proliferation and differentiation processes, in bone marrow blasts from 37 cases of acute lymphoblastic leukemia (ALL), of whom 23 were pediatric patients. 26 cases were analyzed at onset, 11 in relapse. The ALL cases were immunologically classified as T (10), common (20), B (3) and null (4). In each subgroup the majority of lymphoblasts were positive, with heterogeneous positivity patterns and variable degrees of enzyme activity. Most T lymphoblasts were characterized by focal localization of FH4D, whereas in common blasts reactivity - usually less strong - was either focally localized or scattered with several fine granules. Finally, many B and null blasts showed diffuse positivity. A quantitative evaluation of FH4D activity using cytophotometric technique (Vickers M86) demonstrated higher degrees of reactivity in leukemic blasts than in normal lymphocytes. Moreover, slightly different levels of reactivity were observed in relation to immunological phenotype, age and stage of the disease. Therefore we think that FH4D is a useful additional marker for ALL characterization.