Prevalence of pulmonary embolism among patients presenting to emergency department for hemoptysis

Background

Although hemoptysis is a well known symptom of presentation of pulmonary embolism (PE), and it is included in different diagnostic scores for PE, the prevalence of PE in patients with hemoptysis and the yield of evidence based PE diagnostic pathway in these patients has not been specifically investigated.

Objectives

To determine the prevalence of PE and the yield (n° of positive tests/n° of tests), the efficiency (the proportion of patients in whom PE could be considered to be excluded) and the failure rate (the false negative rate) of the classic diagnostic algorithm for PE in patients with hemoptysis.

Methods

Unselected patients presenting with hemoptysis to 7 italian EDs were prospectively enrolled in a diagnostic multicenter study. Pre-test clinical probability for PE was assessed using the 2-level Wells score and the results of D-dimer testing using age-adjusted cutoffs. Presence of PE was evaluated by CT pulmonary angiogram (CTPA), when ordered as part of the clinical assessment by the treating ED physician, or by one month follow-up data.

Results

Out of 327 adult patients presenting to ED with hemoptysis, 15 (4.6%) were excluded because of diagnostic protocol violation and absence of one month follow-up. Among 312 included patients, PE was detected at presentation in 15 patients (4.8%; 95% confidence interval [CI]: 2.72–7.81%). During follow-up, 5 patients died (1.6%; 95% CI: 0.52%-3.7%) not due to PE. Among 165 patients with a “likely” score or a high D-dimer, 13 (7.9%; 95% CI: 4.72–13.8%) had PE. The efficiency was 32.8% and the failure rate was 1.7% in patients tested by D-dimer.

Conclusions

PE seems an uncommon cause of hemoptysis among patients presenting to the ED and the yield of classic diagnostic algorithm is low. PE-screening in patients with hemoptysis deserves further investigation aimed at improving the diagnostic yield.

Funding Acknowledgement

Type of funding sources: None.

A fast and safe technique for sperm preparation in ICSI treatments within a randomized controlled trial (RCT)

Recently a novel method based on horizontal sperm migration in injection dishes has been introduced as an additional tool for preparation of semen sample in assisted reproductive technology (ART) procedures. In the present study, we evaluated both timing and reproductive outcomes in a randomized controlled study including 1034 intra-cytoplasmic sperm injection (ICSI) procedures followed by fresh embryo transfer. Couples enrolled were divided into two sub-groups, namely conventional swim-up method (Group A), and horizontal sperm migration in injection dishes (Group B).No significant differences were found between groups with respect to fertilization rate, implantation success, clinical pregnancy outcomes and ongoing pregnancies. On the contrary, both cleavage and blastocyst rates were statistically higher in Group B, suggesting superior efficiency and safety of this innovative technique also including time-saving and cheaper costs as compared to the classical swim-up sperm preparation.Our data support the interpretation of the horizontal sperm migration as a promising procedure for semen preparation in ART cycles.

A comparative assessment of changes in dental arches associated with different activation protocols of rapid maxillary expansion

AIM

The aim of this study is to compare dental arch changes associated with different activation protocols of maxillary expander.

MATERIALS AND METHODS

A sample of 101 subjects with constricted maxillary arches (49 males and 52 females; mean age 10.96 ± 1.91 years) was enrolled in the study. All subjects underwent RME with a stainless steel banded expander cemented to the maxillary first molars and the expansion screw was randomly activated with two different rapid maxillary expansion protocols (one- quarter per day or two quarters per day). The study also involved a control group of 22 subjects (10 females and 12 males, mean age 10.39 ± 1.32 years) who underwent no treatment. A statistical comparison between the dental arch measures obtained before and after treatment in the two groups was performed.

RESULTS

The Wilcoxon rank-sum test shows statistically significant differences of the measurement increases between the two activation protocols (at least p=0.01). Statistically significant differences were also reported in comparison with the control group.

CONCLUSIONS

A faster activation protocol could be able to determine a greater anterior opening of the mid-palatal suture. Moreover, it seems to yield a higher width increase in the molar area.

Sagittal dentoskeletal modifications associated with different activation protocols of rapid maxillary expansion

AIM

The aim of this study is to compare the sagittal dentoskeletal changes associated with different activation protocols of maxillary expander.

MATERIALS AND METHODS

A total of 101 subjects with constricted maxillary arches (49 males and 52 females; mean age 10.08 ± 1.57 years) were enrolled in the study. The study comprised also a control group of 20 subjects (11 females and 9 males, mean age 10.27 ± 1.24 years) who were not treated during the observation period. All the subjects underwent rapid maxillary expansion with a stainless steel banded expander cemented to the maxillary first molars. The expansion screw was randomly activated with two different rapid maxillary expansion protocols (one-quarter per day or two-quarters per day). A statistical comparison between the sagittal cephalometric variations obtained in the two expansion groups was made, and compared with the untreated control group. Data were then stratified for skeletal maturation of each subject.

RESULTS

The Wilcoxon rank-sum test shows statistically significant differences between the two RME activation protocols only for overjet. Statistically significant differences were reported in comparison with the control group.

CONCLUSIONS

This study suggests that the increase in overjet after RME could be associated with faster activation protocols especially in subjects with lower skeletal maturation.

Analysis of errors in following the rapid maxillary expansion activation protocol: An observational study

AIM

The aim of this study is to analyse the correspondence between the reported number of activations and the number of prescribed activations.

MATERIALS AND METHODS

A total of 114 subjects with constricted maxillary arches (58 males, 56 females; mean age 10.26 ± 1.92 years) were enrolled in the study. The subjects underwent RME and all the parents were provided with a screw activations report form in order to remind them the number of prescribed activations. At the removal of the expander, the screw was turned back in order to count the effective number of activations applied.

RESULTS

In 46 cases, out of a total of 114 patients, an involuntary error during the activation procedure was presumably made. A slight statistically significant correlation between the number of activations prescribed, and the number of incorrect activations was found. The errors consisted in added or missed activations, compared to the prescribed number but more frequently in missed activations with statistical significance.

CONCLUSION

Errors in following the rapid palatal expansion activation protocol are not uncommon. These errors could consist in missed or added activations to the number prescribed by the orthodontist, more often in missed ctivations.

[Do initial experience with an enhanced recovery program after surgery (ERAS) improve postoperative outcomes after cystectomy?]

OBJECTIVE

To estimate the feasibility and the impact of an ERAS program after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

This was a retrospective study comparing a historical pre ERAS group, including all the patients undergoing cystectomy for bladder cancer from January 2013 to December 2015 with a classic procedure, and an interventional ERAS group after introducing an enhanced recovery protocol before, during and after surgery, from February 2016. The principal outcome was the postoperative length of stay. Secondary outcomes mesures were impact on perioperative complication rate (Clavien classification≥3B), readmission rate, reanimation length of stay, ileus rate and adherence to the ERAS protocol.

RESULTS

There were no differences between the 2 groups as far as demographics characteristics are concerned. In total, 97 patients were included, 56 in the control group, and 41 in the ERAS group. The adherence to the protocol was about 65.8%. The ERAS group had statistically significantly shorter median length of stay (D19 versus D14; P: 0.021). The major complications rate (Clavien≥3B) were about 23.2% for the control group and 12.1% for the ERAS group (P: NS). The reinsertion of nasogastric tube were higher in the control group (39.3% vs 21.9%; P: NS) and the readmission rate was about 7.1% in the control group versus 14.6% in the ERAS group (P: NS).

CONCLUSION

In conclusion, introduction and application of an enhanced recovery protocol (ERAS) after cystectomy for bladder cancer allowed for better management of postoperative outcomes. It is clearly feasible in cystectomy, and improve significantly the median postoperative length of stay. Moreover, it may be effective in terms of faster return of bowel function and reduction of majors complications.

LEVEL OF EVIDENCE

4.

Procedure-dependence and Tissue Factor-independence of Hypercoagulability during Orthopaedic Surgery

The increased risk for deep vein thrombosis (DVT) after orthopaedic surgery has been well documented as well as hypercoagulable state during both total hip arthroplasty (THA) and total knee replacement (TKR). To investigate the influence of the surgical procedure [postero-lateral (PL) or lateral (L) approach for THA, use of tourniquet (TQ) or not use of TQ for TKR] on the hypercoagulability and the role of extrinsic pathway activation and endothelial stimulation during orthopaedic surgery we have examined 40 patients (20 patients undergoing primary THA – 10 with PL approach and 10 with L approach – and 20 patients undergoing TKR – 10 with TQ application and 10 without TQ). Thrombin-antithrombin complexes (TAT), tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombomodulin (TM) and von Willebrand factor antigen (vWF:Ag) were analyzed before and during the orthopaedic surgery. During THA, TAT plasma levels increased more markedly in patients assigned to the L than PL approach (p <0.05); during TKR an elevation of TAT of higher degree (p <0.05) was observed when TQ was not applicated. Blood clotting activation was significantly (p <0.001) more relevant during THA than TKR. No changes in TF and vWF:Ag plasma levels were observed in all patients undergoing THA and TKR. TFPI plasma levels significantly (p <0.05) decreased 1 h after the end of the THA in group PL and group L, whereas they remained unaffected in the two groups of patients undergoing TKR. Similarly TM plasma levels significantly decreased during THA, but not during TKR. In conclusion, these results show that: 1) the site of surgical procedures and the type of approach affect the degree of hypercoagulability, 2) the blood clotting activation takes place in the early phases of orthopaedic surgery, without signs of extrinsic pathway and endothelial activation.

The difficult primary total knee arthroplasty: a review

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Analysis of rapid maxillary expansion effects on nasal soft tissues widths

AIM

The aim of this study was to analyze the variations in nasal dimensions in prepubertal patients associated with RME therapy compared with an untreated age matched control group.

METHODS

A group of 61 subjects (26 F, 35 M; mean age 10.5±1.8 years) was enrolled in the study to undergo a rapid maxillary expansion therapy; 41 subjects (26 F, 15 M; mean age 10.7±2.2 years) were enrolled as a control group. Both groups underwent nasal soft tissues width measurements using a caliper at three separate time points: T0 - prior to the placement of RME; T1 - after completion of active expansion phase; T2 - at the removal of the expander (nearly 6 months after T1).

RESULTS

The ANOVA showed statistically significant increments (P<0.0001) of the greater alar cartilage (GAC) measurement (0.8±0.2 mm) in the study group, differences for the AB measurements were not statistically significant (P=0.0784).

CONCLUSION

The treatment of rapid maxillary expansion can induce an increase in GAC soft tissues width of about 1 mm in prepubertal patients. This increase could not be considered of clinical impact. The alar base width increase less than GAC, this increase is without statistical significance.

Injuries in Youth and National Combined Events Championships

In major track and field competitions, the most risky discipline is the combined event. Therefore, we aimed to record and analyze the incidence and characteristics of sports injuries incurred during the Youth and National Combined Events Championships. During the French Athletics Combined Events Championships in 2010, all newly occurred injuries were prospectively recorded by the local organising committee of physicians and physiotherapists working in the medical centres at the stadium, in order to determine incidence and characteristics of newly occurred injuries. In total, 51 injuries and 9 time-loss injuries were reported among 107 registered athletes, resulting in an incidence of 477 injuries and 84 time-loss injuries per 1,000 registered athletes. Approximately 72% of injuries affected lower limbs and 60% were caused by overuse. Thigh strain (17.6%) was the most common diagnosis. 14 dropouts were recorded, 8 were caused by an injury (57.1%). During the National and Youth Combined Events Championships, over one third of the registered athletes incurred an injury, with an injury incidence higher than in international elite track and field competitions. Interestingly, this higher injury risk concerned the younger population affecting immature musculoskeletal structures. In combined events, preventive interventions should mainly focus on overuse and thigh injuries.

Risk for cardiovascular events in an Italian population of patients with type 2 diabetes

BACKGROUND AND AIM

This study aims to analyse the risk of cardiovascular events in a local cohort of patients with type 2 diabetes, and to evaluate the prognostic accuracy of four algorithms used to estimate cardiovascular risk: the Framingham study, United Kingdom Prospective Diabetes Study (UKPDS), Riskard study and Progetto Cuore.

METHOD AND RESULTS

We analysed clinical charts of the Diabetes Clinics of Modena for the period 1991-95. Patients in the age range of 35-65 with type 2 diabetes and no previous cardiovascular disease were eligible. The incidence of new cardiovascular disease was compared with estimated rates deriving from the different functions. A stratification was obtained in subgroups at different cardiovascular risk, allowing comparison between the algorithms. A total of 1532 patients were eligible; women presented a worse cardiovascular risk profile. An absolute 10-year rate of cardiovascular events of 14.9% was observed. Comparing patients with events with event-free subjects, we found significant differences in systolic blood pressure, age at visit, smoking, high-density lipoprotein (HDL)-cholesterol, duration of diabetes, glycosylated haemoglobin (HbA1c) and co-morbidities. Comparing the estimated risk rate according to the different functions, Italian algorithms were more consistent with observed data; however, Progetto Cuore and Riskard show underestimation of events when applied to females.

CONCLUSIONS

Estimation of cardiovascular risk is dependent on the algorithm adopted and on the baseline risk of the reference cohort. Functions designed for a specific population, including risk variables peculiar for diabetes, should be adopted to increase the performance of such functions which is clearly unsatisfactory at present.

Pancreas transplantation inside Emilia-Romagna, Italy: referral pattern, demand forecasting, and organ availability

In Italy, referral of diabetic patients for pancreas transplantation (PT) is an unstructured process, resulting in a low rate of activity and late referrals, often when the patient has already undergone dialysis. In addition, the continuous improvement in pancreas transplant alone, offering the opportunity to reduce cardiovascular risk due to proteinuria and reduced glomerular filtration rate (GFR), is rarely appreciated. We therefore analyzed (1) referral activity to PT during the time frame 2001-2005 in Emilia-Romagna, Italy (four million inhabitants), by collecting ICD 9 CM codes (55.69 + 52.80; 52.86 and 52.80 alone) by residence of the patient; (2) demand for PT among a sample population of 1670 diabetes patients, whose charts were reviewed for the type of diabetes and presence of overt diabetic nephropathy (DN: proteinuria >300 mg/24 h and/or GFR <60 mL/min); (3) potential pancreas availability as the ratio between pancreas and hearts utilized (UP/HR) in different areas of our country. As a results, (1) referral activity reached 8.4 PT per million people in 5 years in the whole region, ranging from 2.6 in the province where a PT program is active, to a maximum value of 20.7 in the province where a devoted outpatient clinic is operated by nephrologists. (2) Prevalence of overt DN was 6% in our cohort, corresponding to 510 D1 patients worthy of evaluation for PT inside Emilia-Romagna region. (3) During 2006, UP/HR was 0.58 in Associazione Inter-Regionale Trapianti agency, 1.16 in Tuscany, 0.30 in Piedmont, and 0.26 in our region. Taken together, our data showed that (1) the referral of D1 to PT has to be empowered, keeping in touch with all patients suffering from diabetic nephropathy; (2) the outpatient clinic devoted to evaluation and recruitment of D1 with nephropathy plays the key role in this program of timely and widespread referral; (3) the availability of pancreata can be increased by utilizing broader criteria for harvesting, increased consent rate to donation and increased the demand for PT (recipient pool). Pancreas grafts need to increase, since the current low demand produces underutilization of the pancreas resource, due to the frequent lack of a suitable recipient.

Normalization of load and clearance effects in ball-in-socket-like replacements

A normalizing loading parameter useful in summarising the mechanical response of plane pin-in-plate-like contacts is extended to axisymmetric ball-in-socket-like contacts. An example addressing a compliant layered artificial hip joint is presented, and the usefulness of the normalizing loading parameter is evidenced.

Difficult hospital discharges in internal medicine wards

OBJECTIVE

Investigate the prevalence of difficult hospital discharges (DHD), describe clinical and social patients' characteristics as potential reasons for discharge delays in an internal medicine ward and implement tailored post-discharge care.

METHODS

During the year 2005 we analysed, in a middle-sized country hospital, all the patients for which some delay for discharge, owing to their whole complexity, was presumable. Comprehensive multidimensional assessment, clinical-social risk score, specific needs of care, mean of stay and outcomes were evaluated.

RESULTS

68.5% of DHD patients were >/=80 years old, with 3.8 the mean number of diseases per patient; 57.5% presented a loss of autonomy (ADL) just before acute deterioration; 80% were functionally and/or cognitively impaired. Only 5% had suitable family support; 5.1% were living at a nursing home; 2% were living alone. The most frequent causes of admission were stroke, cognitive impairment-dementia, cardiovascular diseases, fractures and cancer. Mean length of stay was 12 days. Fifty-two percent of patients were discharged home, 30% were admitted to a long-term care facility, 1% to hospice and 17% died during their hospital stay.

CONCLUSIONS

The aim of "coordinated care" (i.e., targeting "at-risk" patients with assessment of medical, functional, social and emotional needs; provision of optimal medical treatment, self-care education, integrated services, monitoring of progress and early signs of problems) is to improve health outcomes and reduce costs. More than 80% of DHDs patients, with specific tailored programmes, may be discharged from hospital, with satisfactory solutions for them and their families.

Quadriceps-sparing versus mini-subvastus approach in total knee arthroplasty

In a prospective randomized double-blind study we compared the postoperative recovery and early results of two groups of 30 patients having total knee arthroplasty with minimally invasive techniques using either a mini-subvastus or a modified "quadriceps-sparing" approach. All knees were implanted with the same posterior-stabilized prosthesis (LPS-Flex, Zimmer, Warsaw, IN) by the same surgeon with the same dedicated set of downsized instruments. Epidural anesthesia with the same postoperative analgesia and rehabilitation protocol was used in all patients. Evaluation was performed preoperatively, postoperatively in the first week, and at 1 and 3 months. In five cases in the "quadriceps- sparing" group, the incision was extended a few cm to facilitate exposure. Tourniquet time, estimated blood loss, and postoperative pain were similar in the two groups. Active straight leg raising was achieved half a day earlier, on average, in the mini-subvastus group (1.9 vs 1.4 days). Average maximum active flexion was similar in the two groups at each interval, and reached 117 degrees and 119 degrees at 3 months for the mini-subvastus and "quadriceps-sparing" group, respectively. We believe there was no difference between the mini-subvastus and "quadriceps-sparing" approach in relation to short term recovery or early results.

Value of routine measurement of serum calcitonin concentrations in patients with nodular thyroid disease: A multicenter study

BACKGROUND

The routine measurement of serum calcitonin (CT) has been proposed for patients with nodular thyroid disease (NTD), to detect unsuspected medullary thyroid carcinoma (MTC) before surgery.

OBJECTIVE

To assess the prevalence of hypercalcitoninemia and MTC in NTD patients; to compare the ability of CT measurement and fine needle aspiration cytology (FNAC) to predict MTC; to identify age groups of NTD patients who should be better candidates than others to undergo routine measurement of CT.

PATIENTS AND METHODS

1425 consecutive patients, referred from April 1, 2003, through March 31, 2004, to four Italian endocrine centers due to NTD, were grouped depending on age, and underwent basal and, in some cases, pentagastrin (Pg)-stimulated CT measurement, FNAC and, when indicated, surgery. Serum CT concentrations were measured by an immunoluminometric assay (ILMA).

RESULTS

Hypercalcitoninemia was found in 23 out of 1425 patients. MTC was discovered in 9 patients, all >40 yr old and showing high CT levels. Sensitivity of basal and Pg-stimulated CT to predict MTC before surgery was 100% for both tests, whereas specificity was 95 and 93%, respectively. CT specificity reached 100% when a cutoff value of 20 pg/ml was taken. FNAC showed an overall 86% sensitivity. When >10 mm MTC nodules were considered, FNAC sensitivity approached 100%. On the contrary, a correct cytological diagnosis was obtained in only one out of five patients with <10 mm MTC nodules (microMTC); in one patient with histologically proved microMTC, FNAC even demonstrated a benign lesion. Hypercalcitoninemia or MTC were associated with chronic thyroiditis in 30 or 33% of cases, respectively. C-cell hyperplasia was found in 57% of hypercalcitoninemic patients without MTC.

CONCLUSIONS

Basal CT measurement detects elevated CT values in 1.6% of NTD patients. Although CT is not a specific marker of MTC, its routine measurement represents a useful tool in the pre-operative evaluation of NTD patients, particularly those >40 yr old presenting with nodules <10 mm, even when FNAC does not show malignant features. To our knowledge, this is the first trial using ILMA to assess the ability of pre-operative CT measurement to predict MTC in a large series of NTD patients.

Flexion-extension gap changes during total knee arthroplasty: effect of posterior cruciate ligament and posterior osteophytes removal

Flexion and extension gap heights were measured in 50 consecutive primary posterior-stabilized total knee arthroplasties (TKAs) to determine whether posterior cruciate ligament (PCL) release or re-establishment of the posterior condylar recess increased gap width. After PCL release, a slight symmetrical increase was noted in both gaps. In extension, gap width increased on average 1.3 mm and 1 mm in the medial and lateral compartments, respectively. The same pattern was observed in flexion, averaging 1.3 mm medially and 1.3 mm laterally. Another increase in the two gaps was observed after the posterior condylar osteophytes were removed and the posterior recess was re-established. The gaps in extension increased, with respect to the base-line value, on average 1.8 mm medially and 1.8 mm laterally, whereas flexion increased an average 2 mm medially and 2.2 mm laterally. No statistical differences were noted between flexion and extension gaps. No independent differences between the flexion and extension gaps were found in any surgical phase. Posterior cruciate ligament removal and re-establishment of posterior condylar recess does not require additional consideration in gap balancing during posterior-stabilized TKA.

The Insall-Burstein II prosthesis: a 5- to 9-year follow-up study in osteoarthritic knees

We prospectively studied 100 Insall-Burstein Posterior Stabilized II total knee arthroplasties (Zimmer Inc, Warsaw, IN) consecutively implanted in 91 patients with osteoarthritis. We reviewed 92 knees in 85 patients at a mean follow-up of 7.5 years (range, 5.3-9.5 years). According to the Knee Society score, 78 (85%) results were excellent, 11 (12%) were good, and 3 (3%) were fair or poor. The unsatisfactory results were attributed to patellofemoral pain with a low patella (2 knees) and to valgus alignment and medial laxity (1 knee). Flexion at follow-up averaged 116 degrees. Nonprogressive radiolucent lines were present around 30% of the tibial components. There was only 1 small osteolytic lesion around the tibial plateau. We observed no aspetic loosening, infection, or patella stress fracture. Survivorship analysis in the worst-case scenario showed a 90.9% success rate at 8 years.

Phase I, dose-finding study of capecitabine in combination with docetaxel and epirubicin as first-line chemotherapy for advanced breast cancer

PURPOSE

Capecitabine is an oral fluoropyrimidine with considerable activity and minimal myelosuppression and alopecia. This phase I study evaluated the addition of capecitabine to epirubicin/docetaxel combination therapy as first-line treatment for advanced breast cancer.

PATIENTS AND METHODS

Twenty-three female patients with advanced breast cancer received capecitabine (765-1060 mg/m2 twice daily on days 1-14 of a 3-week treatment cycle) in combination with epirubicin and docetaxel (75 mg/m2 i.v. on day 1).

RESULTS

The maximum tolerated dose of capecitabine was 985 mg/m2 and the principal dose-limiting toxicity was febrile neutropenia. No grade 3/4 anemia or thrombocytopenia occurred. There were no grade 4 non-hematological events and grade 3 events other than alopecia were rare. Alopecia occurred in all patients and treatment cycles, and asthenia occurred in all patients and in 84% of treatment cycles. Other frequent adverse events included nausea, vomiting, fever, paresthesia and elevated transaminase levels. An objective response to treatment was observed in 91% (95% confidence interval 72% to 99%) of patients.

CONCLUSIONS

The addition of capecitabine to docetaxel/epirubicin combination therapy provides a well-tolerated and active first-line chemotherapy regimen in patients with advanced breast cancer, and merits phase II/III evaluation.

Mice deleted for the DiGeorge/velocardiofacial syndrome region show abnormal sensorimotor gating and learning and memory impairments

Del22q11 syndrome is caused by heterozygous deletion of an approximately 3 Mb segment of chromosome 22q11.2. Children diagnosed with del22q11 syndrome commonly have learning difficulties, deficits of motor development, cognitive defects and attention deficit disorder. They also have a higher than normal risk for developing psychiatric disorders, mainly schizophrenia, schizoaffective disorder and bipolar disorder. Here, we show that mice that are heterozygously deleted for a subset of the genes that are deleted in patients have deficits in sensorimotor gating and learning and memory. The finding of sensorimotor gating deficits is particularly significant because patients with schizophrenia and schizotypal personality disorder show similar deficits. Thus, our deletion mouse models at least two major features of the del22q11-associated behavioral phenotype, and as such, represents an animal model of this complex behavioral phenotype. These findings not only open the way to pharmacological analyses that may lead to improved treatments, but also to the identification of gene/s that modulate these specific behaviors in humans.

Patella resurfacing in total knee replacement: functional evaluation and complications

Three different knee replacements, with three trochlear designs, were prospectively evaluated clinically and radiographically for patellar function and presence of patellar complications. They included the Insall-Burstein (IB) I and the IB-II (posterior cruciate ligament substituting) and the Meniscal Bearing Knee (MBK; posterior cruciate ligament recession). The trochlea of the IB-I was short and shallow with an anterior sharp edge of the intercondylar box (later modified to a smoother edge) and the femoral component had a prominent "shoulder." In the IB-II the trochlea was deeper to allow for soft tissue clearance. In the MBK the trochlea was more prolonged, with R and L components and the "shoulder" was less prominent. In all the cases the patella was resurfaced with an all polyethylene dome prosthesis. Knees with tibiofemoral problems were excluded. From the data of the present study the following conclusions can be drawn: (a) The most frequent problem was impingement (clunks) with the early version of the IB-I. Smoothening of the anterior edge significantly reduced the incidence of clunks to 5% in the modified IB I. (b) With the IB-II deepening the trochlea for soft tissue clearance improved the degree, not the incidence of clunks (4.5%), compared to the modified IB I. (c) With the MBK clunks were very rare and patellar function improved. (d) Throughout the three series patellar stress fractures and instability were rare and loosening or wear not evident. (e) Normal function (including stairs ascending and descending) can be expected in over 80% of category A patients. (f) Of the various radiological parameters only patella baja was correlated with symptoms in the IB prostheses. (g) We still prefer the dome design because is more tolerant and with cold flow may better conform to the trochlea increasing contact area.

Cloning and chromosome mapping of human and chicken Iroquois (IRX) genes

Three highly homologous homeobox genes (caupolican, araucan and mirror) have been identified in Drosophila. These genes belong to the novel Iroquois complex, which acts as a pre-pattern molecule in Drosophila neurogenesis. Recently several vertebrate Iroquois homologues (Irx) were isolated and found to be involved in pattern formation of various tissues. Here we report cytogenetic mapping of four human and five chicken Iroquois genes by FISH. Our findings revealed that vertebrate Irx genes are clustered at two different loci.

Recovery from arterial growth delay reduces penetrance of cardiovascular defects in mice deleted for the DiGeorge syndrome region

Chromosome 22q11.2 heterozygous deletions cause the most common deletion syndrome, including the DiGeorge syndrome phenotype. Using a mouse model of this deletion (named Df1) we show that the aortic arch patterning defects that occur in heterozygously deleted mice (Df1/+) are associated with a differentiation impairment of vascular smooth muscle in the 4th pharyngeal arch arteries (PAAs) during early embryogenesis. Using molecular markers for neural crest, endothelial cells and vascular smooth muscle, we show that cardiac neural crest migration into the 4th arch and initial formation of the 4th PAAs are apparently normal in Df1/+ embryos, but affected vessels are growth-impaired and do not acquire vascular smooth muscle. As in humans, not all deleted mice present with cardiovascular defects at birth. However, we found, unexpectedly, that all Df1/+ embryos have abnormally small 4th PAAs during early embryogenesis. Many embryos later overcome this early defect, coincident with the appearance of vascular smooth muscle differentiation, and develop normally. Embryos born with aortic arch patterning defects probably represent a more severely affected group that fails to attain sufficient 4th PAA growth for normal remodelling of the PAA system. Our data indicate that Df1/+ embryos are able to overcome a localized arterial growth impairment and thereby reduce the penetrance of birth defects.

Tbx1 haploinsufficieny in the DiGeorge syndrome region causes aortic arch defects in mice

DiGeorge syndrome is characterized by cardiovascular, thymus and parathyroid defects and craniofacial anomalies, and is usually caused by a heterozygous deletion of chromosomal region 22q11.2 (del22q11) (ref. 1). A targeted, heterozygous deletion, named Df(16)1, encompassing around 1 megabase of the homologous region in mouse causes cardiovascular abnormalities characteristic of the human disease. Here we have used a combination of chromosome engineering and P1 artificial chromosome transgenesis to localize the haploinsufficient gene in the region, Tbx1. We show that Tbx1, a member of the T-box transcription factor family, is required for normal development of the pharyngeal arch arteries in a gene dosage-dependent manner. Deletion of one copy of Tbx1 affects the development of the fourth pharyngeal arch arteries, whereas homozygous mutation severely disrupts the pharyngeal arch artery system. Our data show that haploinsufficiency of Tbx1 is sufficient to generate at least one important component of the DiGeorge syndrome phenotype in mice, and demonstrate the suitability of the mouse for the genetic dissection of microdeletion syndromes.

Identification and molecular characterization of de novo translocation t(8;14)(q22.3;q13) associated with a vascular and tissue overgrowth syndrome

Klippel-Trenaunay syndrome (KTS) is a disorder primarily characterized by capillary-venous vascular malformations associated with altered limb bulk and/or length. We report the identification of a balanced translocation involving chromosomes 8q22.3 and 14q13 in a patient with a vascular and tissue overgrowth syndrome consistent with KTS. We demonstrated that translocation t(8;14)(q22.3;q13) arose de novo. These data suggest that a pathogenic gene for a vascular and tissue overgrowth syndrome (KTS) may be located at chromosome 8q22.3 or 14q13. Fluorescence in situ hybridization (FISH) analysis was used to define the breakpoint on chromosome 8q22.3 to a <5-cM interval flanked by markers AFMA082TG9 and GATA25E10, and the 14q13 breakpoint within a 1-cM region between STSs WI-6583 and D14S989. This study provides a framework for the fine-mapping and ultimate cloning of a novel vascular gene at 8q22.3 or 14q13.

Disease severity and health-related quality of life across different chronic conditions

OBJECTIVES

Measurements of health-related quality of life (HRQL) are an essential component in overall assessment of health status, particularly in older patients. Nevertheless, how measures of HRQL relate to measures of disease severity is largely unexplored. This study was carried out to explore the relationship between a measure of HRQL and measures of severity of ischemic stroke, Parkinson's diseases (PD), or chronic coronary heart disease (CHD).

DESIGN AND SETTING

Cross-sectional analysis of three groups (54 subjects each) of patients aged > or = 65 years consecutively referred to outpatient clinics for stroke, PD, or CHD, excluding those with cognitive impairment and severe comorbidity.

MEASUREMENTS

Severity of stroke, PD, and CHD assessed by Fugl-Meyer Scale (FMS), Webster Rating Scale (WBRS), and total work capacity (TWC, from graded exercise test), respectively. HRQL was determined by the Sickness Impact Profile (SIP).

RESULTS

In PD, WBRS correlated linearly with SIP global score, whereas a significant linear relationship between measures of disease severity and SIP score was limited to the least severely diseased stroke (FMS score>160) and the most severely diseased CHD (TWC <700 Kg x m) patients.

CONCLUSIONS

In some disease, the relationship between clinical measures of disease severity and HRQL is nonlinear. Thus, depending on initial severity, similar changes in disease severity may have different impacts on HRQL. These findings may help in identifying patients most likely to improve their SIP score substantially, after even small changes in disease severity. However, studies examining the metric properties of SIP across the whole score range are needed to verify whether such improvement really translates into a better HRQL.

Resting metabolic rate, fat-free mass and catecholamine excretion during weight loss in female obese patients

The reduction in resting metabolic rate (RMR) during weight loss exceeds that accounted for by changes in body composition by 15%, suggesting that factors other than fat-free mass (FFM) explain the metabolic adaptation during food restriction in obesity. Our study aimed to establish if changes in the sympathoadrenal system activity, as inferred from an integrated measure such as 24 h urinary excretion of catecholamines, may play a role in the RMR adaptation observed during dietary restriction in obese patients. Ninety-three obese female subjects consumed a low-energy diet (LED) (2930 kJ/d (700 kcal/d)) for a 3-week period. At the beginning and at the end of the study, 24 h urinary excretion of catecholamines, FFM and RMR were measured. The LED induced a significant reduction in body weight (-3.3 (SEM 0.4) kg; P < 0.01), FFM (-1.9 (SEM 0.7) kg; P < 0.01) and in the fat mass (-1.2 (SEM 0.5) kg; P < 0.01). Noradrenalin excretion (24 h) decreased during the LED from 264 (SEM 26) during a weight-maintenance period to 171 (SEM 19) nmol/24 h after consumption of the LED for 3 weeks (P < 0.001); mean 24 h adrenalin excretion did not change during the LED (22 (SEM 3) during the weight-maintenance period v. 21 (SEM 3) nmol/24 h after consumption of the LED for 3 weeks; NS). The LED induced a significant decrease in RMR (7300 (SEM 218) v. 6831 (SEM 138) kJ/24 h; P < 0.001). The only independent variable that significantly explained variations in RMR both before and after consumption of the LED for 3 weeks, was FFM (r2 0.79 and r2 0.80 respectively). Urinary noradrenalin excretion explained a further 4% of the variability in RMR, but only before the diet, so that a role of sympathoadrenal system on RMR seems to be present in obese patients in basal conditions but not at the end of the LED.

[Risk factors and prevention of infections of hip and knee prostheses]

Prevention of deep periprosthetic infection requires appreciation of the contributing factors to this phenomenon. The concept of an interdependent relationship between the bacteria, wound and host is most useful when considering the prevention of infections. Establishment of infection depends on the number and virulence of the bacteria, the host's ability to eliminate those bacteria and the status of the wound. Multiple variables contribute to the deposition and proliferation of bacteria into the wound environment which enhance the infectious process, such as the presence of a prosthetic implant or medical conditions and medications which impair the patient's defense. Prevention must address optimization of the wound environment, minimizing the number of bacteria into the wound and augmenting the host defenses. Administration of prophylactic antimicrobials prior to skin incision reduces the incidence of wound infections. The optimal antimicrobial agent should have excellent in vitro activity against staphylococci and streptococci, a long serum half-life, good tissue penetration, be non-toxic and inexpensive.

Effect of tourniquet use on activation of coagulation in total knee replacement

Total knee replacement often is performed with tourniquet application. The advantages of a dry field, including fixation, are well known, but it still is debatable if tourniquet application increases deep vein thrombosis. Measurement of coagulation markers is a well accepted method of studying thrombogenesis activation intraoperatively and postoperatively. Twenty patients undergoing total knee replacement with subarachnoid anesthesia were assigned randomly to two groups: either with tourniquet application (Group I) or without tourniquet application (Group II). There were no differences between patients in the two groups in terms of age, gender, diagnosis (all had osteoarthritis), operative time, and total (intraoperative and postoperative) blood loss. Markers for thrombin generation and fibrinolysis were measured. Blood samples were drawn at four times: baseline before the operation; after bone cuts; after cement fixation (Group II) or 2 minutes after tourniquet deflation (Group I); and 1 hour after surgery. Markers of thrombin generation and fibrinolysis showed a significant increase from baseline in all the patients. In Group II these markers started to increase during surgery, whereas in Group I the increase occurred at the end of the procedure when the tourniquet was deflated. The total amount of thrombin generation was significantly higher in Group II (without tourniquet), whereas fibrinolysis was significantly greater in Group I. Total knee replacement is accompanied by a hypercoagulative state with or without the use of a tourniquet, but it seems to be higher when the tourniquet is not used. In addition, tourniquet application may increase fibrinolysis.

Identification of a putative regulatory subunit of a calcium-activated potassium channel in the dup(3q) syndrome region and a related sequence on 22q11.2

Duplication of a segment of the long arm of human chromosome 3 (3q26.3-q27) results in a syndrome characterized by multiple congenital abnormalities and neurological anomalies in some patients. We have identified a novel gene (KCNMB3) that maps to this region. KCNMB3 has significant sequence similarity to the regulatory subunit of the large-conductance calcium-activated potassium channel. Due to the significance of potassium channels in neuronal functions, the overexpression of this gene may play a role in the abnormal neurological functions seen in some of these patients. A related sequence corresponding to the second and third exons of this gene resides in the pericentromeric region of 22q11, where a number of other unprocessed pseudogenes are known to map.

Safety, tolerability and immunogenicity of a Haemophilus influenzae type b vaccine containing aluminum phosphate adjuvant administered at 2, 3 and 4 months of age

The primary aim of this study was to assess the tolerability and immunogenicity of a new Haemophilus influenzae type b (Hib)/AlPO4 (CHIRON, SpA) vaccine, in two-month-old healthy infants. Twenty-three subjects were enrolled and administered the new Hib vaccine containing AlPO4 adjuvant at two, three and four months of age concomitantly with diphtheria-pertussis-tetanus (DPT) and hepatitis B vaccines according to the local program. Children were observed for 30 minutes after each immunization for any immediate local and systemic reactions. An active surveillance for side effects was performed on the 2nd and 7th days following each immunization by telephone. Families also filled out diaries for the first seven days. From the 2nd day to the next immunization only data about adverse events necessitating a physician's visit or about serious adverse events were collected. Blood samples were obtained before the first immunization and one month after the third dose for evaluation of anti-polyribosylribitol phosphate (PRP) antibody response. Local reactions at the Hib site were mild and less frequent compared to those observed at the DPT site. Systemic reactions noted after the three immunizations were fever in 70 percent, irritability in 48 percent, persistent crying in 26 percent, change in eating habits in 22 percent, diarrhea in 17 percent, sleepiness in 17 percent, vomiting in 9 percent, and unusual crying in 4 percent of the cases. There was no serious adverse event. One hundred percent and 95 percent of children achieved an anti-PRP antibody response over 0.15 microg/ml and 1.0 microg/ml, respectively. The geometric mean titer was 15 microg/ml and the geometric mean ratio 84. It was concluded that the new (Hib)/AlPO4 vaccine is safe and well tolerated, and induced a good PRP antibody response in healthy two-month-old infants.