An adversarial learning approach to generate pressure support ventilation waveforms for asynchrony detection

BACKGROUND AND OBJECTIVE

Mechanical ventilation is a life-saving treatment for critically-ill patients. During treatment, patient-ventilator asynchrony (PVA) can occur, which can lead to pulmonary damage, complications, and higher mortality. While traditional detection methods for PVAs rely on visual inspection by clinicians, in recent years, machine learning models are being developed to detect PVAs automatically. However, training these models requires large labeled datasets, which are difficult to obtain, as labeling is a labour-intensive and time-consuming task, requiring clinical expertise. Simulating the lung-ventilator interactions has been proposed to obtain large labeled datasets to train machine learning classifiers. However, the obtained data lacks the influence of different hardware, of servo-controlled algorithms, and different sources of noise. Here, we propose VentGAN, an adversarial learning approach to improve simulated data by learning the ventilator fingerprints from unlabeled clinical data.

METHODS

In VentGAN, the loss functions are designed to add characteristics of clinical waveforms to the generated results, while preserving the labels of the simulated waveforms. To validate VentGAN, we compare the performance for detection and classification of PVAs when training a previously developed machine learning algorithm with the original simulated data and with the data generated by VentGAN. Testing is performed on independent clinical data labeled by experts. The McNemar test is applied to evaluate statistical differences in the obtained classification accuracy.

RESULTS

VentGAN significantly improves the classification accuracy for late cycling, early cycling and normal breaths (p< 0.01); no significant difference in accuracy was observed for delayed inspirations (p = 0.2), while the accuracy decreased for ineffective efforts (p< 0.01).

CONCLUSIONS

Generation of realistic synthetic data with labels by the proposed framework is feasible and represents a promising avenue for improving training of machine learning models.

Evaluation of the accuracy of established patient inspiratory effort estimation methods during mechanical support ventilation

There is a clinical need for monitoring inspiratory effort to prevent lung- and diaphragm injury in patients who receive supportive mechanical ventilation in an Intensive Care Unit. Different pressure-based techniques are available to estimate this inspiratory effort at the bedside, but the accuracy of their effort estimation is uncertain since they are all based on a simplified linear model of the respiratory system, which omits gas compressibility of air, and the viscoelasticity and nonlinearities of the respiratory system. The aim of this in-silico study was to provide an overview of the pressure-based estimation techniques and to evaluate their accuracy using a more sophisticated model of the respiratory system and ventilator. The influence of the following parameters on the accuracy of the pressure-based estimation techniques was evaluated using the in-silico model: 1) the patient's respiratory mechanics 2) PEEP and the inspiratory pressure of the ventilator 3) gas compressibility of air 4) viscoelasticity of the respiratory system 5) the strength of the inspiratory effort. The best-performing technique in terms of accuracy was the whole breath occlusion. The average error and maximum error were the lowest for all patient archetypes. We found that the error was related to the expansion of gas in the breathing set and lungs and respiratory compliance. However, concerns exist that other factors not included in the model, such as a changed muscle-force relation during an occlusion, might influence the true accuracy. The estimation techniques based on the esophageal pressure showed an error related to the viscoelastic element in the model which leads to a higher error than the occlusion. The error of the esophageal pressure-based techniques is therefore highly dependent on the pathology of the patient and the settings of the ventilator and might change over time while a patient recovers or becomes more ill.

3D printing and 3D bioprinting technology in medicine: ethical and legal issues

Abstract

There has been a surge of interest in new technologies in medicine because of their promising clinical applications. Extensive research on additive manufacturing and its applications in the medical field has been carried out with good results and very high expectations. Due to their disruptive nature and potential, 3D printing and even more 3D bioprinting raise many ethical and safety concerns that need to be adequately addressed to provide good regulation before entering clinical practice. This article aims to highlight the general ethical concerns associated with the use of additive manufacturing in medicine and the lack of current international regulatory directives to guide these experiments. Transparency about how these new medical devices are regulated and approved is a fundamental requirement to promote and improve public trust, efficiency, safety and quality.

The number of risk factors not at target is associated with cardiovascular risk in a type 2 diabetic population with albuminuria in primary cardiovascular prevention. Post-hoc analysis of the NID-2 trial

Background

Nephropathy in Diabetes type 2 (NID-2) study is an open-label cluster randomized clinical trial that demonstrated that multifactorial intensive treatment reduces Major Adverse Cardiac Events (MACEs) and overall mortality versus standard of care in type 2 diabetic subjects with albuminuria and no history of cardiovascular disease. Aim of the present post-hoc analysis of NID- 2 study is to evaluate whether the number of risk factors on target associates with patient outcomes.

Methods

Intervention phase lasted four years and subsequent follow up for survival lasted 10 years. To the aim of this post-hoc analysis, the whole population has been divided into 3 risk groups: 0–1 risk factor (absent/low); 2–3 risk factors (intermediate); 4 risk factors (high). Primary endpoint was a composite of fatal and non-fatal MACEs, the secondary endpoint was all-cause death at the end of the follow-up phase.

Results

Absent/low risk group included 166 patients (52.4%), intermediate risk group 128 (40.4%) and high-risk group 23 (7.3%). Cox model showed a significant higher risk of MACE and death in the high-risk group after adjustment for confounding variables, including treatment arm (HR 1.91, 95% CI 1.04–3.52, P = 0.038 and 1.96, 95%CI 1.02–3.8, P = 0,045, respectively, vs absent/low risk group).

Conclusions

This post-hoc analysis of the NID-2 trial indicates that the increase in the number of risk factors at target correlates with better cardiovascular-free survival in patients with type 2 diabetes at high CV risk.

Clinical Trial Registration

ClinicalTrials.gov number, NCT00535925. https://clinicaltrials.gov/ct2/show/NCT00535925

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01674-7.

Death occurred due to undiagnosed systemic amyloidosis: a case report

Amyloidosis is a disorder related to errors in protein folding. We present a clinical case of systemic amyloidosis manifesting as hypotension, tachycardia, pain, weight loss, asthenia, anorexia, dysphagia, and mood deflection in a 49-year-old-year-old woman with a previous clinical history of articular and muscular pain, correlated to suspected seronegative arthritis. The blood test revealed kidney insufficiency, an electrocardiogram identified low voltages of the peripheral leads and T waves anomalies. A serum protein electrophoresis revealed the presence of high levels of monoclonal kappa free chains. The woman started to have a sense of suffocation, and after one week she was found dead in her bed. After the autopsy, the results of Congo red staining of the myocardium were characteristic of amyloid. According to the autoptic and the histological examination, death occurred due to acute cardiac and respiratory arrest secondary to amyloid cardiomyopathy in a patient with undiagnosed systemic amyloidosis.

A Model-based Approach to Generating Annotated Pressure Support Waveforms

During pressure support ventilation, every breath is triggered by the patient. Mismatches between the patient and the ventilator are called asynchronies. It has been reported that large numbers of asynchronies may be harmful and may lead to increased mortality. Automatic asynchrony detection and classification, with subsequent feedback to clinicians, will improve lung ventilation and, possibly, patient outcome. Machine learning techniques have been used to detect asynchronies. However, large, diverse and high-quality training and verification data sets are needed. In this work, we propose a model for generating a large, realistic, labeled, synthetic dataset for training and testing machine learning algorithms to detect a wide variety of asynchrony types. Next to a morphological evaluation of the obtained waveforms, validation of the proposed model includes a test with a machine learning algorithm trained on clinical data.

Role of post mortem CT (PMCT) in high energy traumatic deaths

BACKGROUND

Post Mortem Computed Tomography (PMCT) is being increasingly implemented in forensic field and could be an adjuvant to classic autopsies. In this study we evaluated the feasibility of complementation of conventional autopsy in trauma victims with PMCT.

MATERIALS AND METHODS

A total of 21 subjects, who had sustained various types of blunt high-energy trauma, were selected from the casuistry of the Section of Legal Medicine at University of Pisa: before autopsy, a PMCT examination (Toshiba Aquilion 16 CT scanner) was performed, and after the acquisition of the raw images, MPR and VR reconstructions were performed with dedicated software.

RESULTS

PMCT is more sensitive than conventional autopsy in detecting skeletal injuries, whilst autopsy constitutes the method of choice for the detection of thoracic and abdominal visceral injuries.

CONCLUSIONS

PMCT should be considered a useful tool in addition to conventional autopsy in evaluating trauma victims: it detects further bone fractures in body parts difficult to investigate during autopsy (i.e. posterior regions), facilitating the pathologist in the reconstruction of events and in determining the cause of death.

Method for measurement of arterial compliance by fusion of oscillometry and pulse wave velocity

Up until now estimation of arterial compliance has been performed either by analysis of arterial pressure changes with respect to volume changes or by inference based on pulse wave velocity (PWV). In this study we demonstrate the possibility of an approach to assess arterial compliance by fusing the two information sources namely the pressure/volume relationship obtained from oscillography and PWV data. The goal is to assess arterial properties easily and robustly, enhancing current hemodynamic monitoring. The approach requires as input signals: an electrocardiogram (ECG), a photo- plethysmogram (PPG) and the arterial oscillation as measured during non-invasive blood pressure measurements based on oscillometry with a cuff. These signals are fused by an algorithm using Bayesian principles underpinned by a physiological model. In our simulations, we demonstrate the feasibility to infer arterial compliance by our proposed strategy. A very first measurement on a healthy volunteer supports our findings from the simulation.Clinical Relevance- Arterial compliance/stiffness is recognized as a key hemodynamic parameter, which is not easily accessible and not a standard parameter currently. The presented method and obtained results are encouraging for future research in this area.

A machine learning method for automatic detection and classification of patient-ventilator asynchrony

Patients suffering from respiratory failure are often put on assisted mechanical ventilation. Patient-ventilator asynchrony (PVA) can occur during mechanical ventilation, which cause damage to the lungs and has been linked to increased mortality in the intensive care unit. In current clinical practice PVA is still detected using visual inspection of the air pressure, flow, and volume curves, which is time-consuming and sensitive to subjective interpretation. Correct detection of the patient respiratory efforts is needed to properly asses the type of asynchrony. Therefore, we propose a method for automatic detection of the patient respiratory efforts using a one-dimensional convolution neural network. The proposed method was able to detect patient efforts with a sensitivity and precision of 98.6% and 97.3% for the inspiratory efforts, and 97.7% and 97.2% for the expiratory efforts. Besides allowing detection of PVA, combining the estimated timestamps of patient's inspiratory and expiratory efforts with the timings of the mechanical ventilator further allows for classification of the asynchrony type. In the future, the proposed method could support clinical decision making by informing clinicians on the quality of ventilation and providing actionable feedback for properly adjusting the ventilator settings.

TLR2 Signaling in Skin Nonhematopoietic Cells Induces Early Neutrophil Recruitment in Response to Leishmania major Infection

Neutrophils are rapidly recruited to the mammalian skin in response to infection with the cutaneous Leishmania pathogen. The parasites use neutrophils to establish the disease; however, the signals driving early neutrophil recruitment are poorly known. Here, we identified the functional importance of TLR2 signaling in this process. Using bone marrow chimeras and immunohistology, we identified the TLR2-expressing cells involved in this early neutrophil recruitment to be of nonhematopoietic origin. Keratinocytes are damaged and briefly in contact with the parasites during infection. We show that TLR2 triggering by Leishmania major is required for their secretion of neutrophil-attracting chemokines. Furthermore, TLR2 triggering by L. major phosphoglycans is critical for neutrophil recruitment to negatively affect disease development, as shown by better control of lesion size and parasite load in Tlr2^-/- compared with wild-type infected mice. Conversely, restoring early neutrophil presence in Tlr2^-/- mice through injection of wild-type neutrophils or CXCL1 at the onset of infection resulted in delayed disease resolution comparable to that observed in wild-type mice. Taken together, our data show a crucial role for TLR2-expressing nonhematopoietic skin cells in the recruitment of the first wave of neutrophils after L. major infection, a process that delays disease control.

Closed-form solution of the convolution integral in the magnetic resonance dispersion model for quantitative assessment of angiogenesis

Prostate cancer (PCa) diagnosis and treatment is still limited due to the lack of reliable imaging methods for cancer localization. Based on the fundamental role played by angiogenesis in cancer growth and development, several dynamic contrast enhanced (DCE) imaging methods have been developed to probe tumor angiogenic vasculature. In DCE magnetic resonance imaging (MRI), pharmacokinetic modeling allows estimating quantitative parameters related to the physiology underlying tumor angiogenesis. In particular, novel magnetic resonance dispersion imaging (MRDI) enables quantitative assessment of the microvascular architecture and leakage, by describing the intravascular dispersion kinetics of an extravascular contrast agent with a dispersion model. According to this model, the tissue contrast concentration at each voxel is given by the convolution between the intravascular concentration, described as a Brownian motion process according to the convective-dispersion equation, with the interstitium impulse response, represented by a mono-exponential decay, and describing the contrast leakage in the extravascular space. In this work, an improved formulation of the MRDI method is obtained by providing an analytical solution for the convolution integral present in the dispersion model. The performance of the proposed method was evaluated by means of dedicated simulations in terms of estimation accuracy, precision, and computation time. Moreover, a preliminary clinical validation was carried out in five patients with proven PCa. The proposed method allows for a reduction by about 40% of computation time without any significant change in estimation accuracy and precision, and in the clinical performance.

Effects of baked products enriched with n-3 fatty acids, folates, β-glucans, and tocopherol in patients with mild mixed hyperlipidemia

OBJECTIVE

To assess whether a diet containing foods enriched with β-glucans (3.6 g/d), folic acid (1600 μg/d), long-chain (800 mg/d) and short-chain (400 mg/d) n-3 fatty acids, and tocopherols (120 mg/d) is able to modulate positively the cardiovascular risk profile in people at slightly increased cardiovascular risk.

METHODS

Sixteen subjects with mild plasma lipid abnormalities were studied according to a randomized crossover design. After a 2-week run-in period, they followed a diet containing baked products enriched with active nutrients (active diet) or a diet containing the same products but without active nutrients (control diet) for 1 month and then crossed over to the other diet. At the end of each period, a test meal of the same composition as the corresponding diet was administered, and plasma samples were obtained before and for 6 hours after the meal. Hunger and satiety were evaluated by the visual analog scale at fasting and after the meal.

RESULTS

Fasting plasma triglycerides were significantly lower after the active versus the control diet (1.56 ± 0.18 vs 1.74 ± 0.16 mmol/l, p < 0.05), as was the postprandial level of chylomicron triglycerides and the insulin peak (p < 0.05). The active diet also reduced fasting homocysteine (8 ± 0.6 vs 10 ± 0.8 μmol/l, p < 0.05) and the feeling of hunger at the fifth and sixth hour (p < 0.05).

CONCLUSIONS

Baked functional products enriched with n-3 fatty acids, folates, β-glucans, and tocopherols within the context of a balanced diet lower fasting and postprandial plasma triglycerides, fasting homocysteinemia, and the postprandial insulin peak. They induce a greater feeling of satiety with possible beneficial implications on energy intake.

Cell fate following ER stress: just a matter of "quo ante" recovery or death?

The endoplasmic reticulum (ER) is a complex and multifunctional organelle. It is the intracellular compartment of protein folding, a complex task, both facilitated and monitored by ER folding enzymes and molecular chaperones. The ER is also a stress-sensing organelle. It senses stress caused by disequilibrium between ER load and folding capacity and responds by activating signal transduction pathways, known as unfolded protein response (UPR). Three major classes of transducer are known, inositol-requiring protein-1 (IRE1), activating transcription factor-6 (ATF6), and protein kinase RNA (PKR)-like endoplasmic reticulum kinase (PERK), which sense with their endoluminal domain the state of protein folding, although the exact mechanism(s) involved is not entirely clear. Depending on whether the homeostatic response of the UPR is successful in restoring an equilibrium between ER load and protein folding or not, the two possible outcomes of the UPR so far considered have been life or death. Indeed, recent efforts have been devoted to understand the life/death switch mechanisms. However, recent data suggest that what appears to be a pure binary decision may in fact be more complex, and survival may be achieved at the expenses of luxury cell functions, such as expression of differentiation genes.

Telecare Provides comparable efficacy to conventional self-monitored blood glucose in patients with type 2 diabetes titrating one injection of insulin glulisine-the ELEONOR study

BACKGROUND

We compared telecare and conventional self-monitored blood glucose (SMBG) programs for titrating the addition of one bolus injection of insulin glulisine in patients with type 2 diabetes uncontrolled on oral hypoglycemic agents for ≥3 months who were first titrated with basal insulin glargine.

METHODS

This randomized, multicenter, parallel-group study included 241 patients (mean screening glycosylated hemoglobin [HbA(1c)], 8.8% [73 mmol/mol]). In the run-in phase, any antidiabetes medication, except for metformin, was discontinued. Metformin was then up-titrated to 2 g/day (1 g twice daily) until study completion. Following run-in, all patients started glargine for 8-16 weeks, targeting fasting plasma glucose (FPG) ≤5.6 mmol/L using conventional SMBG. Patients with FPG ≤7 mmol/L added a glulisine dose at the meal with the highest postprandial plasma glucose excursion, titrated to target 2-h postprandial plasma glucose level <7.8 mmol/L using telecare or SMBG for 24 weeks. Patients with FPG >7 mmol/L at week 16 were withdrawn from the study.

RESULTS

After glargine titration, 224 patients achieved FPG ≤7 mmol/L, without any difference between telecare and SBMG groups (mean±SD, 6.2±0.8 vs. 6.0±0. 9 mmol/L, respectively). HbA(1c) levels were lower following titration and were similar for telecare and SMBG (7.9±0.9% vs. 7.8±0.9% [63 vs. 62 mmol/mol], respectively). Adding glulisine further reduced HbA(1c) in both groups (-0.7% vs. -0.7%); 45.2% and 54.8% (P=0.14), respectively, of patients achieved HbA(1c) ≤7.0% (≤53 mmol/mol). Weight change and hypoglycemia were similar between groups.

CONCLUSIONS

Patients adding one dose of glulisine at the meal with the highest postprandial plasma glucose excursion to titrated basal glargine achieved comparable improvements in glycemic control irrespective of traditional or telecare blood glucose monitoring.

Ophthalmological aspects of IBD

Ocular manifestations occur in 4-12% of patients with IBD. Uveitis and iritis are more frequently associated with ulcerative colitis while episcleritis is more common in Crohn's disease. Some ocular manifestations in IBD can be secondary to treatment and/or effects of the intestinal disease itself. The specific management of ocular manifestations in IBD requires the use of topical steroids and FANS, cycloplegics, systemic steroids or immunosuppressive drugs. When conventional therapies fail to control the ocular manifestations in IBD, the new biologic drugs can be considered as good alternative treatments. Early diagnosis and effective treatment may avoid the onset of severe and sometimes persisting complications. In some cases, a surgical approach is required to treat eye complications, i.e. cataract, and to improve the patient's quality of life.

Recurrence of cardiovascular events in patients with type 2 diabetes: epidemiology and risk factors

OBJECTIVE

The purpose of this study was to assess incidence of and risk factors for recurrent cardiovascular disease (CVD) in type 2 diabetes.

RESEARCH DESIGN AND METHODS

We estimated the incidence of recurrent cardiovascular events in type 2 diabetic patients, aged 40-97 years, followed by a network of diabetes clinics. The analysis was conducted separately for 2,788 patients with CVD at enrollment (cohort A) and for 844 patients developing the first episode during the observation period (cohort B).

RESULTS

During 4 years of follow-up, in cohort A the age-adjusted incidence of a recurrent event (per 1,000 person-years) was 72.7 (95% CI 58.3-87.1) in men and 32.5 (21.2-43.7) in women, whereas in cohort B it was 40.1 (17.4-62.9) in men and 22.4 (12.9-32.0) in women. After controls were included for potential predictors (familial CVD, obesity, smoking, diabetes duration, glycemic control, microvascular complications, geographic area, and antihypertensive and lipid-lowering treatment), male sex, older age, and insulin use were significant independent risk predictors (cohort A) and serum triglyceride levels >/=1.69 mmol/l emerged as the only metabolic (negative) prognostic factor (cohort B). In both cohorts, a prior CVD episode, especially myocardial infarction, was by far the strongest predictor of recurrent CVD.

CONCLUSIONS

Approximately 6% of unselected diabetic patients in secondary prevention develop recurrent major CVD every year. Those with long-standing previous CVD show a higher incidence of recurrence. Male sex, age, high triglyceride levels, and insulin use are additional predictors of recurrence.

Impaired inotropic response in type 2 diabetes mellitus: a strain rate imaging study

BACKGROUND

Left ventricular (LV) concentric geometry and hypertrophy, depressed wall mechanics, and abnormal diastolic properties have been described in the diabetic heart. However, the cardiac response to dynamic exercise in diabetic patients remains controversial. The present study assessed strain rate (SR) imaging during dobutamine stress, to investigate inotropic response in patients with type 2 diabetes mellitus and without coronary artery disease.

METHODS

Twenty-four diabetics and 16 controls, both free of coronary artery disease, underwent Doppler echocardiography at rest and during dobutamine stress. Tissue Doppler systolic (S(m)) and early diastolic (E(m)) velocities, SR, and strain of middle posterior septum were measured at rest, low-dose, and high-dose dobutamine.

RESULTS

Diabetics had higher LV mass and relative wall thickness, lower midwall shortening, and transmitral pattern of abnormal LV relaxation. At rest, E(m) was significantly lower but S(m), SR, and strain were similar between the two groups. At low-dose and high-dose dobutamine, without difference of S(m), SR and strain were significantly lower in diabetics. At every level of dobutamine, strain increased with increasing heart rate (HR) in either group (both P < .0001), but the slope of the overall relation between HR and strain was lower in diabetics (b = -0.08) than in controls (b = -0.14) (P < .01).

CONCLUSIONS

In type 2 diabetes SR imaging allows detection of reduced longitudinal mechanics during dobutamine stress. The blunted slope of the relation between HR and regional strain suggests the impairment of the myocardial force-frequency relation, indicating altered contractile reserve in uncomplicated diabetes.

Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location

OBJECTIVE

Cardiovascular disease (CVD) is the main cause of morbidity/mortality in diabetes. We set forth to determine incidence and identify predictors (including microvascular complications and treatment) of first coronary heart disease (CHD) event in CVD-free type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

A cohort of 6,032 women and 5,612 men, sampled from a nationwide network of hospital-based diabetes clinics, was followed up for 4 years. Baseline assessment included retinopathy, nephropathy, and foot ulcers. First CHD events (myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and electrocardiogram-proven angina) were analyzed for 29,069 person-years.

RESULTS

The age-standardized incidence rate (per 1,000 person-years) of first CHD event (n = 881) was 28.8 (95% CI 5.4-32.2) in men and 23.3 (20.2-26.4) in women. Major CHD (myocardial infarction, coronary artery bypass grafting, and percutaneous transluminal coronary angioplasty) was less frequent in women (5.8 [4.3-7.2]) than in men (13.1 [10.9-15.4]; a sex ratio of 0.5 [0.4-0.6]). Incidence rates of all outcomes were higher in patients with microvascular complications (for major CHD, age-adjusted rate ratios were 1.6 [1.2-2.21] in men and 1.5 [1.0-2.2] in women). By multivariate Cox analysis, age and diabetes duration were risk predictors common in both sexes. In men, glycemic control and treated hypertension were additional independent risk factors, but residing in the south was associated with a significant 29% risk reduction. In women, higher triglycerides/lower HDL cholesterol and microvascular complications were independent risk factors.

CONCLUSIONS

In CVD-free patients with type 2 diabetes, risk of first CHD event depends on sex, geographic location, and presence of microvascular disease. Hyperglycemia and hypertension, particularly in men, and diabetic dyslipidemia, especially in women, are risk factors amenable to more aggressive treatment.

Incidence and risk factors for stroke in type 2 diabetic patients: the DAI study

BACKGROUND AND PURPOSE

Type 2 diabetes mellitus is a strong predictor of cerebrovascular disease, yet few studies have assessed the incidence of stroke and the role of other risk factors in unselected type 2 diabetes mellitus populations.

METHODS

We prospectively followed-up 14,432 type 2 diabetes mellitus patients, aged 40 to 97 years, with and without a history of cardiovascular disease at enrollment, and we estimated the incidence of stroke and the hazards ratios with respect to clinical variables.

RESULTS

During a 4-year follow-up, 296 incident stroke events were recorded. In persons with no history of cardiovascular disease, the age-standardized incidence of stroke (per 1000 person-years) was 5.5 (95% confidence interval, 4.2 to 6.8) in men and 6.3 (95% confidence interval, 4.5 to 8.2) in women. In persons with a history of cardiovascular disease, it was 13.7 (95% confidence interval, 7.5 to 19.8) in men and 10.8 (95% confidence interval, 7.3 to 14.4) in women. The hazards ratios of stroke incidence varied according to age, sex, and history of cardiovascular disease. Among men with no history, HbA1c and smoking were predictors of stroke. Among patients with a history, the risk factors were, in men, therapy with insulin plus oral agents, treated high total cholesterol and low HDL cholesterol, whereas in women microvascular complications were a risk factor. Previous stroke was a strong predictor of stroke in both sexes.

CONCLUSIONS

Age and previous stroke are the main predictors of stroke in diabetes. The combined role of Hba1c, microvascular complications, low HDL cholesterol, and treatment with insulin plus oral agents highlights the importance of diabetic history and clinical background in the development of stroke.

Early detection of diabetic cardiomyopathy: usefulness of tissue Doppler imaging

OBJECTIVE

The aim of the study was to evaluate whether tissue Doppler imaging (TDI) detects a pre-clinical impairment of diastolic function in subjects with Type 2 diabetes with short duration of disease and normal cardiac function with conventional echocardiography (CE), and whether echocardiographic parameters are related to metabolic abnormalities.

PATIENTS AND METHODS

We studied 40 non-obese, normotensive, uncomplicated Type 2 diabetic subjects with short duration of disease and 20 control subjects. All participants underwent both CE and TDI echocardiography. With TDI, early velocity (Ea), atrial velocity (Aa), their ratio (Ea/Aa) and systolic velocity (Sa) were measured at the lateral corner of mitral annulus. Glycosylated haemoglobin, fasting plasma glucose and insulin were determined and homeostasis model assessment (HOMA-IR), as an index of insulin resistance, was calculated.

RESULTS

Cardiac function with CE was similar in the two groups. Using TDI, diabetic subjects showed a lower Ea velocity (15.5+/-3.9 vs. 19.4+/-3.5 cm/s, P<0.0001), an increased Aa velocity (15.5+/-2.4 vs. 14.1+/-2.4 cm/s, P<0.05) and a reduced Ea/Aa ratio (1.00+/-0.2 vs. 1.39+/-0.3, P<0.0001), compared with control subjects. Linear regression analysis in the diabetic group showed that only HOMA-IR was negatively associated with Ea/Aa ratio (P=0.026). No significant association was observed with other metabolic variables.

CONCLUSION

An early stage of diabetic cardiomyopathy can be evidenced by TDI in Type 2 diabetic subjects even in the presence of a normal cardiac function with CE. This abnormality is associated with insulin resistance.

Acute hyperglycemia does not affect the reactivity of coronary microcirculation in humans

OBJECTIVE

There is some evidence that acute hyperglycemia (H) may cause vascular dysfunction in normal subjects. This study investigates whether acute, short-term H affects coronary vasodilatory function in healthy subjects.

DESIGN

Diastolic peak flow velocity in the left anterior descending coronary artery was measured at rest and after dipyridamole (0.56 mg/kg over 4 min) using transthoracic color Doppler echocardiography in 13 healthy men. Coronary flow reserve (CFR) was defined as the ratio of dipyridamole-induced coronary peak diastolic to resting peak diastolic flow velocity. CFR was measured both in euglycemia (E) and after 3 h H ( approximately 14 mmol/liter) by a variable infusion of glucose and octreotide (0.4 mg/h) to prevent increase in insulin concentration.

RESULTS

Fasting plasma glucose increased to 14.3 +/- 0.33 mmol/liter during the study and maintained variability within less than 10%. Plasma insulin remained nearly stable during H. Resting diastolic flow velocity was 18.5 +/- 0.6 cm/sec in E and increased to 20.0 +/- 0.7 cm/sec during H (P < 0.005). Dipyridamole infusion produced a marked increase in coronary flow velocity, which reached values of 50.8 +/- 2.9 cm/sec in E and 51.8 +/- 2.1 cm/sec in H (P = not significant). CFR was 2.78 +/- 0.16 in E and 2.59 +/- 0.12 in H (P = not significant).

CONCLUSION

Our study indicates that short-term hyperglycemia does not affect the vasodilatory response of coronary microcirculation in healthy subjects.

Vestibular evaluation in Behçet's disease. Personal experience

Few reports have appeared in the literature concerning vestibular findings in Behçet's disease. In the present study, extensive vestibular testing, performed in 14 patients (8 male, 6 female; mean age: 32 years; range: 12-51) presenting definite Behçet's disease, revealed a high prevalence of central vestibular dysfunctions (78%). Data reported here suggest that an otoneurological evaluation of Behçet's disease patients may be helpful in identifying unexpected vestibular dysfunctions and central nervous system involvement different from the classical manifestations of the neuro-Behçet's syndrome.

[Treatment of curved canals: from stainless steel to nickel titanium]

Endodontic treatment of curved canals is always more difficult than straight canals, especially for the apical zone preparation: root canals may present several curvatures in different space directions. From an anatomical point of view root canals with accentuated curvatures are a very frequent event (more than we might think); radiological exams, in fact, give us only a 2D image, and we can observe mesial or distal curvatures but not those in the oral or buccal direction. However, all root canals have curvatures of some degrees; even those that appear straight. Because of this, endodontitis have made many attempts to overcome these problems and manage to have a good preparation in curve canal. The authors analyse all endodontic techniques (step back, step down, crown down, balanced forces) codified in the course of the years, to prepare curved canals; they both in shape or in materials. It's fundamental for the endodontist to have a specific technique to treat curved canals to allow a good, wide preparation; in this way it's possible to make a better and tridimensional filling of the endodontic space above all in the tipical zone.

Secondary prevention of coronary artery disease in high-risk diabetic patients

BACKGROUND AND AIM

To compare guideline implementation and the actual delivery of secondary prevention for coronary artery disease in the cohort of Italian diabetic patients enrolled in the DAI study.

METHODS AND RESULTS

The DAI study is a multicentre cohort study of the prevalence and incidence of macroangiopathic events among 19,570 type 2 diabetic patients attending 201 Diabetic Care Units. For this study, we selected 1,475 subjects with a history of myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty at enrollment. Only 25% of the coronary patients in secondary prevention were receiving lipid-lowering drugs, and 20% were receiving beta-blockers. None of the patients in 54/185 Diabetic Care Units were on statins, and none in 82/185 Units were on beta-blockers. Multivariate analysis showed a positive correlation between the number of treatments and the taking of statins, and a negative correlation with age.

CONCLUSION

Our data highlight a gap between the therapeutic guidelines and actual treatment, with wide variability in the delivery of secondary prevention across Units. The out-of-pocket cost of medication, daily treatment burden and geographic area can be ruled out as possible explanatory factors. Physicians' prescription attitudes may be a possible reason.

Selected food intake and risk of multiple pregnancies

In order to explore the association between multiple birth risk and diet, data were analysed from a case-control study on risk factors for multiple births conducted in Italy between 1988 and 1998. A total of 185 cases (median age 30 years) were interviewed: 36 women delivered monozygotic and 149 delivered spontaneous dizygotic multiple births. The control group comprised 498 women who gave birth at term (>37 weeks gestation) to healthy infants on randomly selected days at the same clinic. Women were specifically excluded if they reported a history of multiple pregnancy or they had received treatment for infertility for the index pregnancy. No marked differences emerged in daily intake between cases and controls and a total of 35 foods items, including the major sources of beta-carotene, retinol, ascorbic acid, vitamin D, E, methionine folate and calcium in the Italian diet. Likewise intake of selected micronutrients was largely similar in dizygotic cases, monozygotic cases and controls, with the only exception of a slightly lower intake of folates in dizygotic pregnancies in comparison with controls: this difference was statistically significant (P < 0.05), but limited in quantitative terms (mean daily intake of folate 192.4, 183.2 and 191.4 microg respectively in monozygotic, dizygotic cases and controls). In conclusion, the results of this study do not support the role of diet in the development of multiple births.

Effect of treatment with acarbose and insulin in patients with non-insulin-dependent diabetes mellitus associated with non-alcoholic liver cirrhosis

AIM

Non-insulin-dependent diabetes mellitus (type 2 diabetes) not responding to dietary treatment alone in patients with non-alcoholic liver cirrhosis is characterized by high postprandial hyperglycaemia. The control of postprandial hyperglycaemia in such patients, is generally achieved by the means of progressively higher doses of insulin, with an increasing risk of hypoglycaemia in the late postprandial period. The aim of this study was to evaluate the use of acarbose for the control of postprandial hyperglycaemia in 100 patients with well-compensated liver cirrhosis and type 2 diabetes treated with insulin.

METHODS

The study was double blind with randomization of treatments into acarbose (52 patients) vs. placebo (48 patients) with parallel branches over a period of 28 weeks.

RESULTS

All patients tolerated the treatments well and no significant variations in liver function tests were observed (< 5% vs. pretreatment). A significant reduction of several parameters was observed only after acarbose treatment: fasting glycaemia (173 +/- 28 vs. 146 +/- 19 mg/dl; p < 0.01), postprandial glycaemia (230 +/- 24 vs. 148 +/- 20 mg/dl; p < 0.01), mean glycaemia (206 +/- 20 vs. 136 +/- 13 mg/dl; p < 0.01), mean variation (180 +/- 14 vs. 51 +/- 10 mg/dl; p < 0.01), HbA1c (8.9 +/- 0.8 vs. 7.2 +/- 0.5; p < 0.05), C-peptide 2 h after a standard meal (4.5 +/- 1.9 vs. 2.8 +/- 1.7 ng/ml; p < 0.05), whereas the parameters did not change significantly after the placebo. After acarbose treatment a significant increase of intestinal voiding/week (+116% vs. +10%; p < 0.01) and a parallel reduction of blood ammonia levels (-52 +/- 9% vs. -9 +/- 5%; P < 0.01) were observed.

CONCLUSIONS

The results clearly document the good tolerability and the absence of toxic effects of acarbose on liver, due to the lack of both intestinal absorption and hepatic metabolism of the drug at doses in the therapeutic range. In fact, acarbose increases the peristalsis movements of the gut, stimulates the proliferation of the saccarolytic bacteria and simultaneously reduces the proliferation of proteolytic bacteria, thus resulting active in the reduction of blood ammonia levels. These effects of acarbose may be advantageously exploited in the treatment of type 2 diabetic patients with well-compensated non-alcholic liver cirrhosis.

Comparative efficacy study of atorvastatin vs simvastatin, pravastatin, lovastatin and placebo in type 2 diabetic patients with hypercholesterolaemia

Although there is little information from primary or secondary prevention trials on cholesterol-lowering medication in diabetic patients, the reduction of elevated cholesterol is widely recommended for this group. The American Diabetes Association (ADA) recommends drug therapy in diabetic patients if low density lipoprotein (LDL)-cholesterol remains at > 130 mg/dl, or > 100 mg/dl in patients with macroangiopathy, after dietary intervention. When cholesterollowering medication is indicated, the choice of the drug must take into account the other lipid abnormalities that are often present and the need to maintain optimal glycaemic control. In the present study we compared the efficacy and safety of the novel HMG-CoA reductase inhibitor atorvastatin at the dose of 10 mg/day with simvastatin , lovastatin and pravastatin at doses of 10, 20 and 20 mg/day, respectively, and placebo, in type 2 diabetic patients with moderate elevation of LDL-cholesterol with or without elevation of triglycerides. All the quoted agents are enzyme inhibitors effective in lowering LDL-cholesterol in humans. The efficacy endpoints were the mean per cent changes in plasma LDL-cholesterol (primary), total cholesterol, triglycerides, and high-density lipoprotein (HDL)-cholesterol concentrations from baseline to the end of treatment (24 weeks). Atorvastatin at a dose of 10 mg/day produced: (1) a significant reduction in LDL-cholesterol (-37%) in comparison with equivalent doses of simvastatin (-26%), pravastatin (-23%), lovastatin (-21%), and placebo (-1%); (2) HDL-cholesterol increases (7.4%) comparable to or greater than those obtained with simvastatin (7.1%), pravastatin (3.2%), lovastatin (7.21%), and placebo (-0.5%); (3) a significantly greater reduction in total cholesterol (- 29%) than that obtained with simvastatin (-21%), pravastain (-16%), lovastatin (-18%), and placebo (1%); and (4) a significantly greater reduction in triglycerides than that obtained with all the other drugs and placebo. In all treatment groups no significant variation in fibrinogen concentration was observed. All reductase inhibitors studied had similar levels of tolerance. There were no incidents of persistent elevations of serum aminotransferases or myositis.

Effects of insulin-glucose infusion on left ventricular function at rest and during dynamic exercise in healthy subjects and noninsulin dependent diabetic patients: a radionuclide ventriculographic study

OBJECTIVES

The aim of this study was to evaluate: 1) the effects of insulin administration on left ventricular ejection fraction (LVEF) during exercise, and 2) the eventual impairment of the cardiovascular response to insulin in noninsulin dependent diabetes mellitus.

BACKGROUND

Insulin influences the cardiovascular system, but its effect on left ventricular function has yet to be established.

METHODS

The effects of normal saline (test A) and insulin-glucose (insulin = 1.7 mU x kg(-1) x min(-1); glucose = 6 mg x kg(-1)min(-1)) (test B) infusions on systolic and diastolic functions at rest and during dynamic exercise were examined by radionuclide ventriculography. Twenty-two noninsulin-dependent diabetic patients and 22 gender, age and body mass index matched healthy subjects were investigated.

RESULTS

Both groups had normal scintigraphic parameters at rest and during dynamic exercise. Rest- and stress-LVEF as well as rest- and stress-peak filling rate were significantly (p < 0.001) lower in diabetic than in healthy subjects, both in test A and B. Rest-LVEF was significantly higher during test B than it was in test A only in diabetic subjects (p < 0.01). Stress-LVEF was significantly higher (p < 0.05) during test B than it was in test A, in both groups. Insulin-glucose infusion did not modify rest- and stress-peak filling rate in either group. No difference in left ventricular end diastolic volume and in mean blood pressure was found between test A and B at rest and during exercise in either group. A significant linear correlation between LVEF and the index of insulin sensitivity was found in diabetic patients.

CONCLUSIONS

In both normal and diabetic humans, insulin induces a very important rise in LVEF after submaximal work. However, the rise is significantly lower in diabetic than in nondiabetic subjects. The increase in exercise-LVEF on insulin is likely due to an enhancement of ventricular contractility. Insulin resistance could justify the lower angioscintigraphic indexes in diabetic subjects.

Predictors of home death in palliative care cancer patients

With recent changes in health care there is greater emphasis on providing care at home, including the support of families to enable more home deaths. Since a home death may not be practical or desirable in every family situation, there is a need for an objective way to assess the viability of a home death in each individual family situation. The purpose of this study was to describe the relative role of predictors of home death in a cohort of palliative care patients with advanced cancer. A questionnaire was created as a means of assessing the viability of a home death. Five questions were included. Ninety questionnaires were administered by home care coordinators. A follow-up questionnaire was administered to record the place of death. Of the 73 evaluable patients, 34 (47%) died at home and 39 (53%) died in hospital or hospice. The desire for a home death by both the patient and the caregiver, support of a family physician, and presence of more than one caregiver were all significantly associated with a home death. Logistic regression identified a desire for home death by both the patient and the caregiver as the main predictive factor for a home death. The presence of more than one caregiver was also predictive of home death. The questionnaire is simple and, if our results are confirmed, it can be used for predicting those who will not have a home death.

Efficacy and safety of acarbose in the treatment of Type 1 diabetes mellitus: a placebo-controlled, double-blind, multicentre study

AIMS

The aim of the study was to evaluate the efficacy and safety of acarbose in patients with Type 1 diabetes mellitus (DM).

METHODS

A multicentre double-blind, randomized, placebo-controlled study was performed. After a 6-week run-in, 121 patients were randomized to acarbose or placebo and to high- or low-fibre diet for 24 weeks. Acarbose dose was 50 mg t.d.s. for the first 2 weeks and 100 mg t.d.s. for the subsequent weeks.

RESULTS

At the end of 24 weeks of treatment the intention to treat analysis showed that acarbose compared with placebo decreased 2 h postprandial plasma glucose levels (12.23 +/- 0.83 vs. 14.93 +/- 0.87 mmol/l; F = 6.1, P < 0.02) (least square means +/- SEM). No significant effect of acarbose was recorded on HbA1c or on the number of hypoglycaemic episodes. The effect of acarbose on blood glucose control was not influenced by the amount of carbohydrate and/or fibre intake. The incidence of adverse events were 75% and 39% in acarbose and placebo groups, respectively; they were mild and confined to the gastrointestinal tract.

CONCLUSIONS

The use of acarbose in combination with insulin reduces postprandial plasma glucose levels in Type 1 diabetic patients who are not satisfactorily controlled with insulin alone but without significant effect on HbA1c.

[Non-insulin-dependent diabetes mellitus associated with nonalcoholic liver cirrhosis: an evaluation of treatment with the intestinal alpha-glucosidase inhibitor acarbose]

Non-insulin-dependent diabetes mellitus not responding to diet only in patients with non-alcoholic liver cirrhosis is characterized by high post-prandial hyperglycemia. The aim of this study was to evaluate the safety and efficacy of 24 weeks of treatment with 300 mg acarbose per day in 76 consecutive outpatients affected by type 2 diabetes and well-compensated liver cirrhosis. The study design was double-blind cross-over vs placebo. All patients tolerated both treatments well, and no significant variations in liver function tests were observed (< 5% vs pre-treatment). A significant reduction of several parameters was observed only after acarbose: fasting glycemia (19 +/- 6 vs 2 +/- 0.5%; p < 0.01), post-prandial glycemia (41 +/- 9 vs 3 +/- 0.6%; p < 0.01), mean glycemia (30 +/- 8 vs 14 +/- 5%; p < 0.01), daily glycemic variation (52 +/- 8 vs 8 +/- 1%; p < 0.01), HbA1c (16 +/- 1 vs 2 +/- 0.5; p < 0.05), incremental area of C-peptide after a standard meal (80 +/- 19 vs 200 +/- 36 ng/mL/300 min; p < 0.01). After acarbose a significant increase of intestinal voiding/week (98 vs 28%; p < 0.01) and a parallel reduction of blood ammonia levels (52 +/- 9 vs 9 +/- 5%; p < 0.01) were observed. Results clearly document the good tolerability and the absence of toxic effects of acarbose on the liver, due to a theoretic absence of both absorption by the gut and hepatic metabolism of the drug. In fact, acarbose increases peristaltic movement of the gut, stimulates the proliferation of saccharolytic bacteria and simultaneously reduces proteolytic bacterial proliferation, thus actively reducing blood ammonia levels. These unexpected effects of acarbose may be used to advantage for the treatment of type 2 diabetes mellitus in patients with well-compensated liver cirrhosis.

The role of autonomic neuropathy as a risk factor of Helicobacter pylori infection in dyspeptic patients with type 2 diabetes mellitus

A high prevalence of upper gastrointestinal symptoms is described in diabetic patients and, at least in part, this has been attributed to abnormal emptying of the stomach. In an unselected small series of dyspeptic patients with Type 2 diabetes mellitus (DM2), we previously described a higher prevalence of Helicobacter pylori (Hp) infection associated with autonomic neuropathy (AN) than in non-diabetic subjects. To evaluate the prevalence of Hp and its relationship with AN, we studied 164 DM2 patients, matched for sex, age ( +/- 5 years) and body weight ( +/- kg) to 164 non-diabetic subjects, all affected with dyspepsia of unknown origin. Results document that the prevalence of peptic ulcer is similar in both groups of patients (20.1 vs 29.3% P = n.s.); chronic gastritis was 50% in the control group and 35.4% in the DN2 group (P < 0.01) and dyspepsia without ulcer and gastritis (simple dyspepsia) was significantly more frequent in DM2 patients than in non-diabetics (44.5 vs 20.7%, P < 0.01). Hp infection was documented by histology of gastrointestinal mucosa in 74.4% of the DM2 patients and in 50% of the controls (P < 0.01) (ulcer: 97 vs 71%, P < 0.05; gastritis: 72 vs 43.5%, P < 0.05; simple dyspepsia: 66 vs 35%, P < 0.01, respectively). Autonomic neuropathy was found in 65.2% of the DM2 patients (90.9% of patients with ulcer, 65.5% with gastritis and 53.4% with simple dyspepsia). A significant concordance (84.7%, P < 0.001) was found between the presence of AN and Hp infection. Data provide, for the first time, direct evidence for a higher frequency of Hp infection in dyspeptic patients affected with DM2 than in non-diabetic subjects. In addition, in diabetic patients the frequency of non-ulcer, non-gastritis dyspepsia is two times higher than in non-diabetics and is strictly associated with autonomic neuropathy, acting as a favoring factor for occurrence and recurrence of gastrointestinal disease.

Soluble CD8 antigen, stimulated C-peptide and islet cell antibodies are predictors of insulin requirement in newly diagnosed patients with unclassifiable diabetes

To evaluate the predictive factors of insulin requirement in newly diagnosed patients with unclassifiable diabetes, 54 consecutive patients, aged less than 35 years, were prospectively followed for 3 years or more. At entry, haemoglobin HbA1c, basal and stimulated C-peptide concentrations, HLA phenotype, islet cell antibodies (ICA) status, and serum levels of soluble CD8 antigen (sCD8) were evaluated. After a median time of 9 (range 2-32) months, 31 patients (group 1) required insulin therapy, whereas 23 patients (group 2) remained non-insulin-requiring after 36 months. Group 1 patients were younger (P < 0.05) and had higher HbA1c and sCD8 serum levels (P < 0.0001), respectively), a higher frequency of ICA positivity and of HLA DR3 and/or DR4 phenotype (P < 0.005 and P < 0.0001, respectively), and lower C-peptide concentrations (P < 0.005 and P < 0.0001, basal and stimulated, respectively) than group 2. The sensitivity, specificity, positive and negative predictive value, and overall accuracy for the subsequent insulin requirement were: sCD8 serum levels (> 737 U/ml), 100%, 65%, 79%, 100% and 85%, respectively; stimulated C-peptide (< 0.60 nmol/l), 71%, 96%, 96%, 74% and 81%, respectively; and ICA positivity (> 20 JDFU), 45%, 91%, 87%, 55% and 65%, respectively. Thus, higher sCD8 serum levels, low stimulated C-peptide concentrations and ICA positivity are the most powerful predictors of subsequent recourse to insulin therapy in young, newly detected patients with unclassifiable diabetes.

Effects of vanadyl sulfate on carbohydrate and lipid metabolism in patients with non-insulin-dependent diabetes mellitus

The safety and efficacy of vanadyl sulfate (VS) was tested in a single-blind, placebo-controlled study. Eight patients (four men and four women) with non-insulin-dependent diabetes mellitus (NIDDM) received VS (50 mg twice daily orally) for 4 weeks. Six of these patients (four men and two women) continued in the study and were given a placebo for an additional 4 weeks. Euglycemic-hyperinsulinemic clamps were performed before and after the VS and placebo phases. VS was associated with gastrointestinal side effects in six of eight patients during the first week, but was well tolerated after that. VS administration was associated with a 20% decrease in fasting glucose concentration (from 9.3 +/- 1.8 to 7.4 +/- 1.4 mmol/L, P < .05) and a decrease in hepatic glucose output (HGO) during hyperinsulinemia (from 5.0 +/- 1.0 pre-VS to 3.1 +/- 0.9 micromol/kg x min post-VS, P < .02). The improvement in fasting plasma glucose and HGO that occurred during VS treatment was maintained during the placebo phase. VS had no significant effects on rates of total-body glucose uptake, glycogen synthesis, glycolysis, carbohydrate (CHO) oxidation, or lipolysis during euglycemic-hyperinsulinemic clamps. We conclude that VS at the dose used was well tolerated and resulted in modest reductions of fasting plasma glucose and hepatic insulin resistance. However, the safety of larger doses and use of vanadium salts for longer periods remains uncertain.

Left ventricular systolic and diastolic function in severe obesity: a radionuclide study

To verify the impact of sever obesity (defined as body mass index > 31 kg/m2) on left ventricular (LV) function, 32 asymptomatic obese but otherwise healthy subjects (16 men; age 38 +/- 11 years) voluntarily underwent first-pass and equilibrium 99mTc radionuclide angiography at rest and, in 22 of them, during bicycle supine exercise. Data were compared to those obtained from 10 normal volunteers (age 48 +/- 13; p < 0.05, vs. obeses). End-diastolic and stroke volumes did not differ between the two groups, whereas end-systolic volume was significantly higher in obese subjects (67 +/- 20 vs. 49 +/- 20 ml; p < 0.05), and, as a consequence, LV ejection fraction at rest was decreased in obese subjects (59 +/- 7%) compared to normals (65 +/- 6%; p < 0.05). Due to the higher heart rate in obese subjects (81 +/- 13 vs. 69 +/- 10 pbm, respectively; p < 0.05) cardiac output was significantly greater compared to normals (7.1 +/- 0.8 vs. 6.2 +/- 0.2 liters/min, respectively; p < 0.01). During exercise, ejection fraction normally increased in normals (70 +/- 7%; p < 0.001, vs. baseline) but not in obese subjects (60 +/- 9%; p = nonsignificant vs. baseline). In addition, systolic blood pressure/end-systolic volume ratio was significantly decreased in obese subjects (23 +/- 1.3) compared to normals (2.8 +/- 1.6; p < 0.05). Peak filling rate, normalized to end-diastolic counts per second, was significantly lower in obese subjects (2.2 +/- 1.3) compared to normals (2.8 +/- 1.6; P < 0.05). This difference was also true when peak filling rate was computed in stroke counts per second (3.8 +/- 0.8 in obeses vs. 4.4 +/- 0.4 in normals; p < 0.05). Repeat analysis in a subgroup of 10 young obese subjects (age < or = 30 years) confirmed decreased ejection fraction at rest (60 +/- 4%; p < 0.05) and peak filling rate (2.4 +/- 0.4 end-diastolic counts/s; p < 0.05), as well as the lack of ejection fraction increase during exercise (59 +/- 9%). Thus, these data indicate a subclinical impairement of LV systolic and diastolic function at rest and during exercise in asymptomatic severely obese but otherwise healthy subjects.

Simplified diagnostic criteria for diabetic distal polyneuropathy. Preliminary data of a multicentre study in the Campania region. S.I.M.S.D.N. Group

The diagnostic procedures recommended for diabetic neuropathy are rather complex and there is the risk that they may be applied only in highly specialized research centres and not in other more basic health service centres that recruit large numbers of diabetic patients. This consideration highlights the need for rapid and precise diagnostic procedures for the screening and follow-up of diabetic patients. In this paper we describe a simplified diagnostic protocol for distal polyneuropathy (DP), which is the most common form of peripheral neuropathy associated with diabetes. We performed an electroneurographic examination (ENG) based on a five-nerve evaluation in 204 diabetic subjects, and took it as the standard. Its reproducibility preliminarily assessed with a test--retest evaluation was 100%. DP was found in 47 of the 204 diabetic patients on the basis of an alteration in at least two nerves. Other clinical parameters, including a questionnaire on symptoms, a clinical neurological examination (NE), and the vibration perception threshold (VPT) were evaluated. The variability coefficient was not significant for all clinical parameters in a selected group of diabetic patients (questionnaire = 21.2%, NE = 5%, VPT = 16.5%). The sensitivities and specificities of the questionnaire, NE, and VPT in comparison with ENG were 87% and 60% for the questionnaire, 94% and 92% for NE, and 64% and 97% for VPT, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation of virulence genes directing GPI synthesis by functional complementation of Leishmania

Recent advances in molecular genetics of Leishmania parasites prompted us to develop methods of functional genetic complementation in Leishmania and apply them to the isolation of genes involved in the biosynthesis of the virulence determinant LPG, an abundant GPI-anchored polysaccharide. LPG1, the gene product identified by complementation of our R2D2 LPG- mutant, may be a glycosyltransferase responsible for the addition of galactofuranose to the nascent chain. As galactofuranose is not found in mammalian cells, inhibition of the addition of this sugar could be exploited for chemotherapy. Overall, the success of the functional complementation approach opens the way to the identification of a variety of genes involved in pathogenesis and parasitism.

Comparison of left ventricular function in insulin- and non-insulin-dependent diabetes mellitus

Diabetes mellitus has been reported to have controversial effects on left ventricular (LV) function in patients with no evidence of coronary artery disease. In this study, LV function at rest was evaluated in 2 groups of diabetic patients, with insulin-dependent (IDD; n = 16) and non-insulin-dependent (NIDD; n = 23) diabetes mellitus, with no evidence of coronary artery disease. All patients underwent an electrocardiographic stress test, and first-pass and equilibrium radionuclide angiography at rest and during supine exercise. Data in each group of diabetic patients were compared with those obtained from age- and sex-matched normal subjects. In both groups of diabetic patients plasma catecholamine levels were significantly greater than in control subjects. Ejection fraction at rest and during exercise did not differ between each group of diabetic patients and their respective control group. In patients with IDD, peak ejection rate (4 +/- 1 end-diastolic count/s) was significantly greater than in control subjects (2.6 +/- 0.1 end-diastolic count/s; p < 0.001); similarly, peak filling rate (4.3 +/- 1.0 end-diastolic count/s) was significantly greater than in controls (3.0 +/- 0.2 end-diastolic count/s; p < 0.001). Cardiac output and systemic vascular resistances did not differ between patients with IDD and control subjects. In contrast, patients with NIDD had significantly reduced cardiac output compared with that of control subjects (5.7 +/- 0.2 vs 5.9 +/- 0.2 liter/min; p < 0.01), and increased systemic vascular resistances (1,422 +/- 137 vs 1,314 +/- 68 dynes.s.cm-5; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)