Search for Gamma-Ray Spectral Lines from Dark Matter Annihilation up to 100 TeV toward the Galactic Center with MAGIC

Linelike features in TeV γ rays constitute a "smoking gun" for TeV-scale particle dark matter and new physics. Probing the Galactic Center region with ground-based Cherenkov telescopes enables the search for TeV spectral features in immediate association with a dense dark matter reservoir at a sensitivity out of reach for satellite γ-ray detectors, and direct detection and collider experiments. We report on 223 hours of observations of the Galactic Center region with the MAGIC stereoscopic telescope system reaching γ-ray energies up to 100 TeV. We improved the sensitivity to spectral lines at high energies using large-zenith-angle observations and a novel background modeling method within a maximum-likelihood analysis in the energy domain. No linelike spectral feature is found in our analysis. Therefore, we constrain the cross section for dark matter annihilation into two photons to ⟨σv⟩≲5×10^{-28}  cm^{3} s^{-1} at 1 TeV and ⟨σv⟩≲1×10^{-25}  cm^{3} s^{-1} at 100 TeV, achieving the best limits to date for a dark matter mass above 20 TeV and a cuspy dark matter profile at the Galactic Center. Finally, we use the derived limits for both cuspy and cored dark matter profiles to constrain supersymmetric wino models.

Bounds on Lorentz Invariance Violation from MAGIC Observation of GRB 190114C

On January 14, 2019, the Major Atmospheric Gamma Imaging Cherenkov telescopes detected GRB 190114C above 0.2 TeV, recording the most energetic photons ever observed from a gamma-ray burst. We use this unique observation to probe an energy dependence of the speed of light in vacuo for photons as predicted by several quantum gravity models. Based on a set of assumptions on the possible intrinsic spectral and temporal evolution, we obtain competitive lower limits on the quadratic leading order of speed of light modification.

The chaperone-like sodium phenylbutyrate improves factor IX intracellular trafficking and activity impaired by the frequent p.R294Q mutation

Essentials Missense mutations often impair protein folding, and thus intracellular trafficking and secretion. Cellular models of severe type I hemophilia B were challenged with chaperone-like compounds. Sodium phenylbutyrate improved intracellular trafficking and secretion of the frequent p.R294Q. The increased coagulant activity levels (∼3%) of p.R294Q would ameliorate the bleeding phenotype.

SUMMARY

Background Missense mutations often impair protein folding and intracellular processing, which can be improved by small compounds with chaperone-like activity. However, little has been done in coagulopathies, where even modest increases of functional levels could have therapeutic implications. Objectives To rescue the expression of factor IX (FIX) variants affected by missense mutations associated with type I hemophilia B (HB) through chaperone-like compounds. Methods Expression studies of recombinant (r)FIX variants and evaluation of secreted levels (ELISA), intracellular trafficking (immunofluorescence) and activity (coagulant assays) before and after treatment of cells with chaperone-like compounds. Results As a model we chose the most frequent HB mutation (p.R294Q, ~100 patients), compared with other recurrent mutations associated with severe/moderate type I HB. Immunofluorescence studies revealed retention of rFIX variants in the endoplasmic reticulum and negligible localization in the Golgi, thus indicating impaired intracellular trafficking. Consistently, and in agreement with coagulation phenotypes in patients, all missense mutations resulted in impaired secretion (< 1% wild-type rFIX). Sodium phenylbutyrate (NaPBA) quantitatively improved trafficking to the Golgi and dose dependently promoted secretion (from 0.3 ± 0.1% to 1.5 ± 0.3%) only of the rFIX-294Q variant. Noticeably, this variant displayed a specific coagulant activity that was higher (~2.0 fold) than that of wild-type rFIX in all treatment conditions. Importantly, coagulant activity was concurrently increased to levels (3.0 ± 0.9%) that, if achieved in patients, would ameliorate the bleeding phenotype. Conclusions Altogether, our data detail molecular mechanisms underlying type I HB and candidate NaPBA as affordable 'personalized' therapeutics for patients affected by the highly frequent p.R294Q mutation, and with reduced access to substitutive therapy.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Differential functional readthrough over homozygous nonsense mutations contributes to the bleeding phenotype in coagulation factor VII deficiency

Essentials Potentially null homozygous Factor(F)7 nonsense mutations are associated to variable bleeding symptoms. Readthrough of p.Ser112X (life-threatening) and p.Cys132X (moderate) stop codons was investigated. Readthrough-mediated insertion of wild-type or tolerated residues produce functional proteins. Functional readthrough over homozygous F7 nonsense mutations contributes to the bleeding phenotype.

SUMMARY

Background Whereas the rare homozygous nonsense mutations causing factor (F)VII deficiency may predict null conditions that are almost completely incompatible with life, they are associated with appreciable differences in hemorrhagic symptoms. The misrecognition of premature stop codons (readthrough) may account for variable levels of functional full-length proteins. Objectives To experimentally evaluate the basal and drug-induced levels of FVII resulting from the homozygous p.Cys132X and p.Ser112X nonsense mutations that are associated with moderate (132X) or life-threatening (112X) symptoms, and that are predicted to undergo readthrough with (132X) or without (112X) production of wild-type FVII. Methods We transiently expressed recombinant FVII (rFVII) nonsense and missense variants in human embryonic kidney 293 cells, and evaluated secreted FVII protein and functional levels by ELISA, activated FX generation, and coagulation assays. Results The levels of functional FVII produced by p.Cys132X and p.Ser112X mutants (rFVII-132X, 1.1% ± 0.2% of wild-type rFVII; rFVII-112X, 0.5% ± 0.1% of wild-type rFVII) were compatible with the occurrence of spontaneous readthrough, which was magnified by the addition of G418 - up to 12% of the wild-type value for the rFVII-132X nonsense variant. The predicted missense variants arising from readthrough abolished (rFVII-132Trp/Arg) or reduced (rFVII-112Trp/Cys/Arg, 22-45% of wild-type levels) secretion and function. These data suggest that the appreciable rescue of p.Cys132X function was driven by reinsertion of the wild-type residue, whereas the minimal p.Ser112X function was explained by missense changes permitting FVII secretion and function. Conclusions The extent of functional readthrough might explain differences in the bleeding phenotype of patients homozygous for F7 nonsense mutations, and prevent null conditions even for the most readthrough-unfavorable mutations.

The -308 TNFα and the -174 IL-6 promoter polymorphisms associate with effective anti-TNFα treatment in seronegative spondyloarthritis

The genetic predisposition to a long-term efficacy of anti-tumor necrosis factor (TNF)α treatment in seronegative spondyloarthritis (SpA) was investigated by analysing the possible correlation between several single nucleotide gene polymorphisms and the retention rate of anti-TNFα therapies. We compared patients needing to switch the first anti-TNFα (Sw, No. 64) within at least 12 months of follow-up with patients not needing to switch (NSw, No. 123), observing at least 6 months of treatment to establish anti-TNFα failure, leading to treatment change. Response to treatment was evaluated by standardised criteria (BASDAI for axial involvement, DAS28-EULAR for peripheral involvement). The TNFα -308 A allele and the interleukin (IL)-6 -174GG homozygosis resulted as independent biomarkers predicting survival of the first anti-TNFα therapy in SpA patients (P=0.007, odds ratio (OR): 4.4, 95% confidence interval (CI)=1.5-13.1 and P=0.035, OR: 2.1, 95% CI=1.1-4.4). Also, the male gender (P=0.001, OR: 3.4, 95% CI=1.6-7.1) associated with the NSw phenotype, whereas no association was found either with the specific diagnosis or the predominant joint involvement.

Diabetes outcomes within integrated healthcare management programs

AIM

The aim of this observational study was to assess mortality of patients with type 2 diabetes by type of healthcare delivery system, i.e. through specialist centers or generalist doctors, or integrated care.

METHODS

The study was conducted at the "Vicentino Ovest" Local Health District in the Veneto Region (north-eastern Italy) from January 1, 2008 to December 31, 2010. Patients with diabetes (≥ 20 years old) were identified using different public health databases. They were grouped as: patients followed up by specialists at diabetes clinics (DS); patients seen only by their own general practitioner (GP); and patients receiving integrated care (DS-GP). Cox's regression analysis was used to estimate adjusted hazard ratios for available potential predictors of death by level of care.

RESULTS

The crude mortality rate was highest in the GP group (26.1 per 1000 person-years), the difference being minimal when compared with the DS group (21.7 per 1000 person-years) and more marked when compared with the DS-GP group (8.8 per 1000 person-years). Patients followed up by their GPs had a 2.7 adjusted RR for mortality by comparison with the DS-GP group.

CONCLUSIONS

The findings of the present study could demonstrate that it is safe and cost-effective, after a first specialist assessment at a diabetes service, for low-risk diabetic patients to be managed by family physicians as part of a coordinated care approach, based on the specialist's clinical recommendations; GPs can subsequently refer patients to a specialist whenever warranted by their clinical condition.

Study on the possible role of the -174G>C IL-6 promoter polymorphism in predicting response to rituximab in rheumatoid arthritis

OBJECTIVE

Identification of genetic biomarkers of response to biologics in rheumatoid arthritis (RA) is a relevant issue. The -174G>C interleukin-6 (IL-6) promoter polymorphism was investigated in RA patients treated with rituximab (RTX), being IL-6 a key cytokine for B cell survival and proliferation, thus possibly implicated in rituximab efficacy.

METHODS

The study was conducted in a real-life retrospective cohort of 142 unselected RA patients (120F/22M) treated with RTX and referred to 7 rheumatologic centres in the north of Italy. One hundred and thirteen (79.6%) patients were rheumatoid factor (RF)-positive and 112 (78.9%) were anti-CCP antibodies positive. The response to therapy was evaluated at the end of the sixth month after the first RTX infusion, by using both the EULAR criteria (DAS28) and the ACR criteria. The IL-6 -174G>C promoter polymorphism was analyzed by RFLP following previously reported methods.

RESULTS

Lack of response to RTX at month +6 by EULAR criteria was more prevalent in RA patients with the IL-6 -174 CC genotypes (9/21, 42.8%), than in the GC/GG patients (23/121, 19.0%) (OR 3.196, 95% CI=1.204-8.485; p=0.0234). Similar results were found when evaluating the response by ACR criteria. No differences were found in RA duration, baseline DAS28, baseline HAQ, RF status, anti-CCP status according to the different IL-6 -174 genotypes.

CONCLUSION

IL-6 promoter genotyping may be useful to better plan treatment with RTX in RA. Larger replication studies are in course to confirm these preliminary results.

[Rheumatoid factor positivity rather than anti-CCP positivity, a lower disability and a lower number of anti-TNFalpha agents failed are associated with response to rituximab in rheumatoid arthritis]

OBJECTIVE

Predictors of response to biologics in rheumatoid arthritis (RA) is an important issue in the current era. Rituximab (RTX) has been demonstrated effective and safe in active RA, resistant to traditional or biologic DMARDs.

METHODS

Fifty-seven patients with active longstanding RA were treated with RTX after traditional DMARD or anti-TNF alpha therapy failure.

RESULTS

Number of anti-TNF treatment previously failed (p=0.005), HAQ (p=0.013), rheumatoid factor (RF) (p=0.0002) and anti-CCP (p=0.006) were associated with an ACR response > or =50 at the end of 6th month by univariate analysis. Multivariate analysis confirmed that the number of anti-TNF previously failed, baseline HAQ and RF, but not anti-CCP were associated with an ACR response > or =50. EULAR moderate/good response was associated with ESR value (p=0.036), HAQ (p=0.032), and RF (p=0.01) by univariate analysis, while only RF positivity was associated with EULAR moderate/good response by multivariate analysis.

CONCLUSIONS

RF positivity rather than anti-CCP positivity is a predictor of response to RTX, suggesting that RF-positive patients with low disability may obtain a clinical response when treated to RTX after the first anti-TNF agent failure or after traditional DMARD therapies. Larger studies are required to confirm these results.

[Recycle of jute bags; asbestos in agriculture, exposure and pathology ]

During the last four years, a deeper examination of malignant mesothelioma (MM) cases occurred within non asbestos textile industry highlighted asbestos past exposure in several textile industrial divisions. In spite of that, poor information about recycled textile bags previously containing asbestos fibres is available to the National Mesothelioma Registry, although holding a remarkable data bank on more than 3500 work histories and sources of asbestos exposures. Besides the analysis of the exposure circumstances and the registered health effects of the past exposure within the recycling activity, the aim of this research was to relate the possible involvement of the agricultural sector, where the use of recycled jute bags was very diffused. The MM cases were collected from the Mesothelioma Registry of Brescia, asbestosis, pleural plaques and lung cancer cases were collected from the Occupational Diseases Archive of the Local Public Occupational Health Service of the Province of Brescia. During the 1977-2006 period, 8 cases of MM, 4 cases of pulmonary asbestosis, 4 of isolated bilateral pleural plaques and I of lung cancer in pulmonary asbestosis, were observed among workers employed in bags recycling activity in 4 small companies, one of them still operating, employing about 50 workers. Even more, among the 65 MM cases classified by the Registry with "unknown asbestos exposure" (UAE), the most relevant frequency of working histories concerned the agriculture sector. Confirming a past signalling, the investigations underlined the cross linkage between this working activity and the diffusion of recycled bags in the agriculture sector. In the Province of Brescia, the activities of these small jute bags recycling plants were linked, even geographically, to the asbestos cement manufacture plant using a huge number of bags, roughly until mid seventies. Therefore, a large number of these recycled bags, previously containing asbestos, were generally used for harvesting and trading agricultural typical products of northern Italy. According to the 2003 National Mesothelioma Registry Guide Lines, MM in agricultural workers are still classified as UAE due to poor information available. In the light of these new findings, it looks reasonable to review the UAE within agriculturalists attributing a new classification of "possible" occupational asbestos exposure, although other exposure circumstances might have occurred in the past.

Variable Very-High-Energy Gamma-Ray Emission from the Microquasar LS I +61 303

Microquasars are binary star systems with relativistic radio-emitting jets. They are potential sources of cosmic rays and can be used to elucidate the physics of relativistic jets. We report the detection of variable gamma-ray emission above 100 gigaelectron volts from the microquasar LS I 61 + 303. Six orbital cycles were recorded. Several detections occur at a similar orbital phase, which suggests that the emission is periodic. The strongest gamma-ray emission is not observed when the two stars are closest to one another, implying a strong orbital modulation of the emission or absorption processes.

Friedreich's ataxia: clinical heterogeneity in two sisters

Diagnostic evaluation of two sisters affected by ataxia, with similar age of onset, revealed a characteristic trinucleotide expansion in the Friedreich's ataxia (FRDA) locus and two different phenotypic presentations. At onset the elder sister had retained deep tendon reflexes (FARR), while the younger sister presented classic FRDA. The GAA expansion in the patients' alleles proved to be similar in both siblings, ruling out that age at onset and clinical heterogeneity could be due to different FRDA mutations. On the whole, clinical and genetic data on these patients confirmed that FARR is a variant phenotype of FRDA.

Assessment of cyclin D1 overexpression as a prognostic factor in soft tissue sarcomas: role of laparoscopy and core needle biopsy

BACKGROUND

This study was designed to test cyclin D1 as a prognostic marker in patients with soft tissue sarcomas (STS), and to evaluate the usefulness of laparoscopy for determining cyclin D1 overexpression.

METHODS

The records of 62 patients with STS were collected: 28 with retroperitoneal STS (RSTS) and 34 with extremity STS (ESTS). A total of 51 patients underwent surgical resection, whereas 11 did not undergo surgery because of advanced tumor stage. Preoperative-intraoperative laparoscopic staging was performed for patients judged to be resectable at preoperative imaging.

RESULTS

Cyclin D1 was overexpressed in 30 (58.8%) of 51 resected patients and in 10 (90.9%) of 11 nonresected patients. Laparoscopy avoided unnecessary laparotomy in 9 (32.1%) of 28 RSTS patients.

CONCLUSIONS

High tumor grade, positive surgical margins, local recurrence, distant metastases, and cyclin D1 overexpression were related to poor survival. Multivariate analysis demonstrated cyclin D1 to be the only independent factor. Laparoscopy was shown to be useful for avoiding useless laparotomies.

[Epithelial naso-sinusal cancer incidence and the role of work in 100 cases diagnosed in the Province of Brescia (northern Italy), in the period 1978-2002]

BACKGROUND

Naso-sinusal cancers (NSC) cover a group of rare tumours in Italy for which the role of occupational risk has been established. The systematic survey of NSC in the province of Brescia made it possible to analyse the jobs of the cases occurring in the area.

OBJECTIVES

The aims of the research were: estimation of epithelial NSC incidence both in the general population and among wood and leather workers, description of the frequency and type of occupational exposure to substances or manufacturing processes.

METHODS

The epithelial type cases were obtained from the Naso-sinusal Cancer Register (population-based) operating in the Province of Brescia since 1994. Work histories were obtained via a standardized questionnaire.

RESULTS

The annual incidence ofepithelial NSC (for 100,000) in the entire population (1,090,000 inhabitants, ISTAT census 1991) from 1993 to 1997 and from 1998 to 2002 was nearly the same, 0.82 and 0.90 for men, 0.37 and 0.37 for women, respectively. The nasal cavity was the most affected anatomic site (45%) and squamous cell carcinoma was the most frequent histotype (44%) among the first 100 cases whose case histories were appropriate; in the ethmoidal sinus adenocarcinoma represented 62% of the cases; 25% of all cases were exposed to occupational carcinogens (list A) and particularly to wood dust (17%), even if only of softwood species (30%), and leather dusts (7%) especially in the shoe repair. The average latency period was 47 years (SD 7.4) and 44 years (SD 5.6) respectively; 71% of these epithelial NSC cases involved the ethmoid and 85% were adenocarcinomas. Only 1% of the cases was exposed to chromium and nickel and occurred in galvanization processes. Among the exposures to occupational risks with limited epidemiological evidence (list B) there was one case exposed to formaldehyde and 42 cases occurring in the building, agricultural, metallurgic and textile sectors. Thus all the exposures to occupational risks, both certain and probable (lists A and B) reached 84% among men and 17% among women. Epithelial NSC annual incidence rates (for 100,000) estimated among the wood and leather workers for the period 1985-2002 were 13 and 6.5 respectively.

CONCLUSION

The results confirm the meaning of sentinel event for these tumours in occupational health and justify maintaining an active surveillance programme for the cases occurring in the area.

Prevalence of inherited ataxias in the province of Padua, Italy

Few population studies are available on epidemiological indexes of hereditary ataxias. An investigation on the prevalence rate of these movement disorders is in progress for the Veneto region, the main area of northeast Italy with a population of 4,490,586 inhabitants. The first results of this epidemiological survey concern the province of Padua, which numbers 845,203 residents (January 1, 2002). The prevalence rate of inherited ataxias has been estimated at 93.3 cases per million inhabitants. The most common types appeared to be the autosomal dominant forms, namely spinocerebellar ataxia type 1 and 2, with a prevalence of 24 per 1,000,000. In the same population, with a prevalence rate of 6 per 1,000,000, Friedreich's ataxia was defined as the prominent recessive autosomal form. There were very rare cases of ataxia telangiectasia, ataxia with vitamin E deficiency and cerebellar ataxia with congenital muscular dystrophy, a recently identified autosomal recessive disease.

A review of natural CO2 accumulations in Europe as analogues for geological sequestration

Natural geological accumulations of carbon dioxide occur widely throughout Europe, often close to population centres. Some of these CO2 deposits leak, whereas others are sealed. Understanding these deposits is critical for selecting and designing underground storage sites for anthropogenic CO2. To provide confidence that the potential risks of geological CO2 storage are understood, geologists are required to predict how CO2 may behave once stored underground. Natural CO2 accumulations provide a unique opportunity to study long-term geochemical and geomechanical processes that may occur following geological storage of anthropogenic CO2. In addition, natural CO2 springs and gas vents can provide information on the mechanisms of gas migration and the potential effects of CO2 leakage to the surface. This paper provides a description of some natural, European CO2 occurrences.

CO2 accumulations occur in many basins across Europe. In addition, volcanic areas and seismically active areas allow CO2-rich fluids to migrate to the near surface. Many of these occur in areas that have been populated for hundreds and thousands of years.

Stratigraphic traps have allowed CO2 to accumulate below evaporite, limestone and mudstone caprocks. Comparisons between reservoir sandstone and equivalent nearby sandstones that contain no CO2 indicate that reservoir sandstones may experience increased secondary porosity development through feldspar dissolution. Where fracture reactivation allows CO2-rich fluids to migrate, limited self-sealing may take place through calcite precipitation. Gas migration experiments indicate that, due to geochemical interactions, fine-grained seals would be able to trap smaller volumes of CO2 compared to, for example CH4. In natural systems most leakage from depth occurs along fractures and is typically extremely localized on a metre-scale.

The Metabolic Syndrome is an independent predictor of cardiovascular disease in Type 2 diabetic subjects. Prospective data from the Verona Diabetes Complications Study

AIMS

To evaluate the cardiovascular risk associated with the presence of the Metabolic Syndrome in Type 2 diabetic subjects.

METHODS

Subjects with the Metabolic Syndrome, defined by WHO criteria, were identified in a large sample of non-insulin-treated Type 2 diabetic patients examined within the Verona Diabetes Complications Study (n = 946). At baseline and after a mean of 4.5 years follow-up, cardiovascular disease (CVD) was assessed by medical history, physical examination, electrocardiogram (ECG) and echo-duplex of carotid and lower limb arteries. Death certificates and medical records of subjects who died during the follow-up were scrutinized in order to identify CVD deaths. In statistical analyses, CVD was considered as an aggregate end-point, including fatal and non-fatal coronary, cerebrovascular and peripheral vascular disease as well as ischaemic ECG abnormalities and vascular lesions at the echo-duplex.

RESULTS

The proportion of subjects with the Metabolic Syndrome was very high (92.3%). At the baseline, 31.7% of subjects were coded positive for CVD, which was more prevalent in subjects with the Metabolic Syndrome (32.9 vs. 17.8%, P = 0.005). Among subjects free of CVD at the baseline (n = 559), CVD events during the follow-up were significantly increased in patients with the Metabolic Syndrome as compared with those without it (19.9% vs. 3.9%, P < 0.001). Multiple logistic regression analysis showed that, along with sex, age, smoking and HbA1c, the presence of the Metabolic Syndrome independently predicted prevalent (OR 2.01, P = 0.045) and incident CVD (OR 4.89, P = 0.031).

CONCLUSIONS

In Type 2 diabetes, the presence of the Metabolic Syndrome is associated with an almost 5-fold increase in CVD risk.

[Video-assisted surgery of the thyroid: outlines of the technique and analysis of the results]

INTRODUCTION

The authors described the technique of the video-assisted approach to thyroid surgery (MIVAT: minimally invasive video-assisted thyroidectomy), selection criteria of the patients and evaluated the technical feasibility of this method.

MATERIALS AND METHODS

Patients selection is based on many parameters. Exclusion criteria are: nodules greater than 35 mm, presence of thyroiditis, thyroid volume greater than 20 mL, previous neck surgery and irradiation. The surgical procedures are conducted through a minimal substernal skin incision (1-3 cm); the procedure performed using external retractors and needlescopic instruments.

RESULTS

MIVAT was accomplished in 20 patients (15 female and 5 men). One cervicotomy was required to perform total thyroidectomy (positive frozen section). Mean operative time was 70 min. Two patients have reported transient hypoparathyroidism; one patient has reported transient recurrent nerve palsy.

DISCUSSION

MIVAT has not yet met the favor of most endocrine surgeons; nevertheless we think that this technique is safe and feasible for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results Conversion to conventional surgery is required generally for local bleeding and to perform total thyroidectomy for positive frozen section.

CONCLUSIONS

MIVAT is feasible and may improve cosmetic outcome. The indications are limited at present, but the results are encouraging for the future.

Predictors of insulin sensitivity in Type 2 diabetes mellitus

AIMS

To identify the independent predictors of insulin sensitivity in Type 2 diabetes, and to establish whether isolated Type 2 diabetes (i.e. diabetes without overweight, dyslipidaemia and hypertension) is a condition of insulin resistance.

METHODS

We examined 45 patients with non-insulin-treated Type 2 diabetes undergoing a 4-h euglycaemic hyperinsulinaemic clamp (20 mU/m2 per min) combined with 3H-3-D-glucose and 14C-U-glucose infusions and indirect calorimetry. We also examined 1366 patients with non-insulin-treated Type 2 diabetes randomly selected among those attending the Diabetes Clinic and in whom insulin resistance was estimated by Homeostasis Model Assessment (HOMA-IR).

RESULTS

In the 45 patients undergoing glucose clamp studies, insulin-mediated total glucose disposal (TGD) was independently and negatively associated with systolic blood pressure (standardized beta coefficient = -0.407, P = 0.003), plasma triglycerides (beta= -0.355, P = 0.007), and HbA1c (beta= -0.350, P = 0.008). The overall variability of TGD explained by these variables was 53%. Overweight diabetic subjects with central fat distribution, hypertension, hypertriglyceridaemia and poor glycometabolic control had insulin-mediated TGD values markedly lower than their lean counterparts without hypertension, with normal triglycerides, and with good glycometabolic control (16 +/- 5 vs. 31 +/- 10 micromol/min per kg lean body mass, P < 0.01). Nevertheless, the latter still were markedly insulin-resistant when compared with sex- and age-matched non-diabetic control subjects (31 +/- 10 vs. 54 +/- 13 micromol/min per kg lean body mass, P < 0.01). In the 1366 Type 2 diabetic patients of the epidemiological study, HOMA-IR value was independently associated with HbA1c (beta = 0.283, P < 0.0001), plasma triglycerides (beta = 0.246, P < 0.0001), body mass index (beta = 0.139, P < 0.001), waist girth (beta = 0.124, P < 0.001) and hypertension (beta = 0.066, P = 0.006).

CONCLUSION

Overweight, central fat distribution, dyslipidaemia, hypertension and poor glycometabolic control are strong independent predictors of insulin resistance in Type 2 diabetes. However, reduced insulin sensitivity can be found even when Type 2 diabetes is isolated and well controlled.

An assessment of gas emanation hazard using a geographic information system and geostatistics

This paper describes the use of geostatistical analysis and GIS techniques to assess gas emanation hazards. The Mt. Vulsini volcanic district was selected for this study because of the wide range of natural phenomena locally present that affect gas migration in the near surface. In addition, soil gas samples that were collected in this area should allow for a calibration between the generated risk/hazard models and the measured distribution of toxic gas species at surface. The approach used during this study consisted of three general stages. First data were digitally organized into thematic layers, then software functions in the GIS program "ArcView" were used to compare and correlate these various layers, and then finally the produced "potential-risk" map was compared with radon soil gas data in order to validate the model and/or to select zones for further, more-detailed soil gas investigations.

Plasma glucose levels throughout the day and HbA(1c) interrelationships in type 2 diabetes: implications for treatment and monitoring of metabolic control

OBJECTIVE

To evaluate the extent of plasma glucose excursions with meals, the relations between plasma glucose levels at different times of the day, and the relations between the latter and HbA(1c) in non-insulin-treated type 2 diabetic subjects.

RESEARCH DESIGN AND METHODS

Daily glucose profiles were assessed in non-insulin-treated type 2 diabetic patients. Outpatients at the diabetes clinic (n = 371; one daily plasma glucose profile) and at home (n = 30; five daily blood glucose profiles over 1 month) as well as inpatients (n = 455; profile of plasma glucose on the day of admission) were examined. Subjects had plasma/blood glucose assessment before and 2-3 h after breakfast, lunch, and dinner. HbA(1c) was also measured.

RESULTS

After the meals many subjects had glucose levels >8.9 mmol/l (160 mg/dl) and/or glucose excursions >2.2 mmol/l (40 mg/dl). This was also often found when HbA(1c) was satisfactory (<7%). The coefficients of simple correlation among plasma/blood glucose at different times of the day ranged from 0.52 to 0.88. Correlations between HbA(1c) and plasma/blood glucose at different times of the day ranged from 0.44 to 0.67. The strongest correlation was between HbA(1c) and mean daily glucose (r = 0.57-0.69). Multiple regression analyses showed that premeal but not postmeal plasma/blood glucose levels were independent predictors of HbA(1c).

CONCLUSIONS

These results suggest that 1) the majority of non-insulin-treated type 2 diabetic patients have exaggerated plasma/blood glucose excursions with meals, and many of them have higher-than-recommended glucose concentrations 2 h after the meals; 2) plasma/blood glucose levels throughout the day are not as strongly interrelated as one might believe; and 3) HbA(1c) is more related to preprandial than postprandial plasma/blood glucose levels. These findings have potential implications for treatment and monitoring of metabolic control in type 2 diabetes.

[Long-term evaluation of the endoscopic treatment of gastric polyps]

BACKGROUND

The authors intend to evaluate the long-term efficacy of endoscopic treatment of gastric polyps.

METHODS

They report their experience in 5000 upper gastro intestinal endoscopies performed between 1985 and 1998. The method used aimed to evaluate the distribution of polyps by sex and age, the frequency of various histological types and the incidence of complications in relation to histological type and the size of the polyps. The authors also analysed the indications and criteria of choice between endoscopic treatment and surgery and they calculated the incidence of malignant neoplasm and complications in relation to the endoscopic method used, as well as the incidence of relapse at the medium and long-term follow-up. They searched for the presence of neoplasms in the follow-up and compared their personal experience with data from international literature.

RESULTS

The results obtained show that non-surgical treatment of gastric polyps is resolutive in most cases. The endoscopic resection of polyps was performed using a polypectomy loop. In patients converted to surgery, the necessity for the operation was caused by an unexpected hemorrhage that could not be controlled using endoscopic treatment. In this case, the operation consisted of resecting the entire wall of the lesion, including an extemporary histological analysis.

CONCLUSIONS

The authors' experience allows them to state that endoscopic treatment of this gastric pathology is efficacious and free from risks and complications if stringent patient selection criteria are used (dimensions, morphological characteristics of the lesion) and control procedures over time suited to the potential malignancy of each histological type are carried out.

[Incidence of malignant mesothelioma (1980-1999) and asbestos exposure in 190 cases diagnosed among residents of the province of Brescia]

Several cases of malignant mesothelioma (MM) previously unknown to the Occupational Health and Safety Service were recognised in the Province of Brescia after an active surveillance program carried out during the first nineteen years of operation; a large proportion of the cases involved workers occupationally exposed to asbestos. A local Mesothelioma Register was subsequently set up in 1993 and by the end of 1999, 190 MM cases had been collected. The annual incidence ratio (standardized on the Italian population, census 1981, x100,000 person-years) was calculated in the 1980-1999 period and showed an increasing trend for location in the pleura in both sexes; in the 1996-1999 period the incidence ratio was 2.95 for males and 1.35 for females. In the same period, this trend was not observed for peritoneal location, with an incidence ratio of 0.17 and 0.37 for males and females respectively. 161 pleural MM (84.7%) and 28 peritoneal MM (14.7%) are described; histopathologic diagnosis was performed in 161 cases (84.7%). Anamneses were collected for 88% of the cases but with direct information from patients only in 65% of these in the recent period. Only 7 cases of asbestosis were diagnosed in the MM cases, whereas 31 cases of pleural abnormalities were observed but only 17 of these were observed in workers occupationally exposed to asbestos. Occupational asbestos exposure was evaluated as certain, probable or possible in 45% of total cases and in 54% of recently (1996-1999) observed cases, which were ten times more frequent in males. Exposure occurred in sectors works where asbestos was not used as raw material, such as construction, iron and steel and metal working. MM's from environmental and non-occupational exposure to asbestos were very few, 1.5% and 0.5% respectively. In 65 MM's asbestos exposure was unknown (34.2%); 50% of these concerned females; for whom the industry and jobs are discussed. The distribution of histologic types of MM was similar in asbestos exposed and non exposed cases. No association between peritoneal mesotheliomas and heavy exposure to asbestos was observed. Ten cases of MM were diagnosed in subjects under 45 years old (5.2%) with only one case occupationally exposed. 2 cases were exposed to radiation therapy (1%) and 2 cases to thoracic trauma (1%). Although in Italy MM has been included in the list of compensatable occupational diseases by law since 1994, a large number of cases occupationally exposed to asbestos are still not recognised by the National Insurance Institute (INAIL). A number of problems limiting work of the Mesothelioma Register and its usefulness are discussed. The Lombardy Mesothelioma Register set up in January 2000 should be able to overcome the limits identified in the past.

Ataxia and congenital muscular dystrophy: the follow-up of a new specific phenotype

Cerebellar hypoplasia may, at neuroimaging studies, be found in association with congenital muscular dystrophy (CMD), although it is an extremely rare occurrence. We here report on three CMD patients who underwent a longitudinal evaluation of clinical and neuroimaging features for a mean period of 18 years. Case 1, a 22-year-old woman, and cases 2 and 3, brothers aged 26 and 20 years, respectively, had presented a mild to moderate muscular weakness and increased serum creatine kinase (CK) levels since birth. All cases were diagnosed in the first years of life, with identification of evident dystrophic changes at muscle biopsy and moderate to severe cerebellar hypoplasia at brain computed tomography (CT) scan. Subsequently, all the patients underwent a second muscle biopsy, with immunostaining and immunoblot analysis, which showed normal values for merosin, dystrophin and dystrophin-related proteins. During the longitudinal study, the patients underwent repeated neurological and psychiatric examinations, serum CK controls, intellectual ability assessments and neuroimaging evaluations (CT and/or magnetic resonance imaging (MRI)). In all cases, these investigations indicated a mild to moderate deficit in the proximal muscles and a clear-cut cerebellar syndrome which, it was assumed, had been present since the first years. The patients also presented some intellectual difficulties, with an IQ of 0.69 in case 1, 0.83 in case 2 and 0.61 in case 3. The clinical course of all the patients was static, and all symptoms of the combined muscle and brain involvement persisted. Nor were any changes in the cerebellar hypoplasia observed at repeat MRIs. Findings obtained by us on the longitudinal study and a review of the literature indicate that cerebellar hypoplasia and merosin-positive CMD constitute a particular clinical phenotype, mainly characterized by an ataxic syndrome associated with a non-severe muscular involvement and a possible mild intellectual impairment.

Systemic inflammatory pseudotumor, an unusual cause of fever of unknown origin mimicking a malignant lymphomatous process: case-report and review of the literature

BACKGROUND AND OBJECTIVE

In recent years, a new pathologic condition Eth called inflammatory pseudotumor Eth has been occasionally described to involve many different tissues or organs. However, evidence for systemic involvement is lacking and a review of the topic potentially useful, also considering the clinical features mimicking hematologic malignancies or other clinically relevant conditions. We report a case of systemic inflammatory pseudotumor and review the literature concerning the etiopathogenesis, differential diagnosis and treatment modalities of this particular pathology.

DATA SOURCES AND METHODS

The data source for this topic was MEDLINE , searching all fields for inflammatory pseudotumor, inflammatory pseudotumor and lymph node or fever of unknown origin, pertaining to humans, published between 1970 and 1999.

RESULTS AND CONCLUSIONS

Inflammatory pseudotumor should be considered in the differential diagnosis of malignant hematologic processes and of fever of unknown origin.

Increased neutrophil adhesive capability in Cohen syndrome, an autosomal recessive disorder associated with granulocytopenia

BACKGROUND AND OBJECTIVE

Cohen syndrome is a multiple congenital anomalies-mental retardation syndrome associated with granulocytopenia. To date, the mechanisms involved in causing the neutropenia are unknown. In order to get insight into the mechanisms of neutropenia, we studied both the bone marrow and the functional properties of neutrophils obtained from peripheral blood (PB) or skin window (SW) exudate of a patient affected by Cohen syndrome.

DESIGN AND METHODS

Assays of superoxide anion release (as reduction of cytochrome C) and cell adhesion (quantified by measuring membrane acid phosphatase) were carried out according to a microplate method whereby both parameters can be evaluated (Bellavite et al., 1992). Neutrophil surface integrins and CD62L (selectin) were evaluated by flow cytometry.

RESULTS

Bone marrow did not show relevant morphological abnormalities in either erythroid or myeloid precursors. Cohen neutrophils exhibited a greater adhesive capability than control leukocytes in all the conditions studied (PB or SW, unstimulated or agonist-stimulated leukocytes). Cytofluorometric evaluation of neutrophil beta 2 integrin (CD11b) and selectin (CD62L) showed a lower mean fluorescence intensity and a lower percentage of fluorescence conjugate monoclonal Ab-positive cells in the patient than in control subjects. Moreover, a double population of neutrophils, with different affinities to the specific monoclonal antibody anti-CD11b, was observed in the patient. Superoxide anion release, expression and distribution of fluorescence conjugate MoAb anti-human CD11a were normal.

INTERPRETATION AND CONCLUSIONS

Neutrophil adhesive capability was greatly increased in a case of Cohen syndrome. Cytofluorimetric expression of CD11b and CD62L molecules was consistent with a generalized neutrophil activation in vivo.