Effects of a new mixture of essential amino acids (Aminotrofic(®)) in malnourished haemodialysis patients

The aim of this study was to verify the clinical efficacy of a diet associated with already commercially available oral amino acid functional cluster (AFC) compared to the administration of a diet associated with a nitrogen protein-based supplement (casein) in antagonizing malnutrition in patients with Chronic renal failure (CRF) undergoing haemodialysis. The secondary aim was to assess the changes in protein levels during the acute phase such as the expression of inflammatory cytokines. Twenty patients in haemodialysis aged between 18 and 85 of both genders (13 m, 7f) were recruited, randomized and divided into two groups and treated for 4 months respectively with: (1) oral AFC supplement (*)8 g/die: group A, and (2) oral supplementation of a protein nitrogenous mixture compared to AFC with a casein protein source) of 6.6 g: group P. During the initial assessment and thereafter on a monthly basis all patients underwent the following: Dietary recall 24 h; Anthropometric: Weight, height, BMI, expected dry weight, actual weight; Biochemical: Albumin, transferrin, Na, K, Cl, Ca, P, Mg, long-interval creatinine (Aminotrofic(®): Errekappa Euroterapici, Milano) pre-albumin, α1 acid glycoprotein, C reactive protein (CRP), protein nitrogen appearance (PNA); Instrumental: Handgrip strength evaluation, Calorimetry by means of Armband, Bio-impedance analysis (BIA), Spitzer Index (quality of life), Subjective Global Assessment Generated by the patient (PG SGA). Considering the nutritional parameters, no significant differences concerning dry weight emerged between the beginning (T0) and the end (T4) (weight A to T0: kg 64.41 ± 6.34; weight A to T4: kg 64.51 ± 7.05: P = NS; weight P to T0: kg 60.17 ± 11.94; weight P to T4: kg 59.86 ± 11.43: P = NS); biochemical parameters, significant differences were observed only for two parameters: pre-albumin (Pre-albumin A to T0 30.12 ± 7.23; Pre-albumin A to T4: 28.91 ± 5.8; Pre-albumin P to T0 22.51 ± 6.04; Pre-albumin P to T4: 26.10 ± 9.82), and Transferrin (Transferrin A to T0 171.77 ± 28.87 mg/dL, Transferrin A to T4: 181.44 ± 38.83 mg/dL: P < 0.005; Transferrin P to T0 160.29 ± 27.46 mg/dL, Transferrin P to T4: 146.57 ± 24.96 mg/dL: P < 0.005), but not in other parameters. From a nutritional perspective, after 4 months of treatment an increase in protein synthesis was noted in group A compared to group P which was proved by the significant increase of transferrin. This pilot study suggests the AFC oral supplementation may represent a valid alternative to intradialytic parenteral treatment and may also allow for an improvement in blood chemical values and nutritional status.

Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review

Tilted implants have been proposed as an alternative to traditional protocols in the rehabilitation of edentulous maxillae. The aim of this meta-analysis was to evaluate the outcomes of upright and tilted implants supporting full-arch fixed dentures for the immediate rehabilitation of edentulous maxillae, after at least 1 year of function. An electronic search of databases and a hand search of relevant journals in oral implantology were performed according to PRISMA guidelines through August, 2011. The literature search yielded 1,069 articles. Eleven articles were available for analysis. A total of 1,623 implants (778 tilted, 845 upright) were inserted into the maxillae of 324 patients. Seventeen tilted (2.19%) and 16 upright implants (1.89%) failed during the first year. No significant difference in failure rate was found between tilted and upright implants (p value = 0.52). Marginal bone level results were obtained from 6 studies. A non-significant mean difference between tilted and upright implants was found with regard to bone loss. Tilted implants demonstrated a favorable short-term prognosis in full-arch immediate loading rehabilitations of the maxillae. Randomized long-term trials are needed to better elucidate long-term success of tilted vs. upright-positioned implants.

Sinus floor elevation using osteotomes or piezoelectric surgery

The aim of this paper is to describe a technique for sinus floor augmentation with a 1-step crestal approach where the residual bone is ≤ 7.5mm. 36 implants were installed in 25 patients in the atrophic posterior maxilla immediately after sinus floor elevation. Sinus floor elevation was performed with a crestal approach using either osteotomes and burs or piezosurgery. Standardized intraoral radiographs were taken prior to surgery and 1 year after surgery. The mean residual bone height was 5.61 mm (range 3-7.5mm). The mean gain of sinus elevation was 6.78 mm (range 3.5-10mm) at 1 year after surgery. Two patients dropped out of the study. Of the 23 patients completing the study, one implant failed, whilst the remaining 33 implants were stable 12 months after surgery (cumulative survival rate 97%). A statistically significantly higher bone height was achieved with tapered implants compared with cylindrical implants (P<0.05). No statistically significant differences were found in bone level using osteotomes or piezosurgery. Piezosurgery was considered to provide less discomfort for the patient and greater convenience for the surgeon.

Ossification timing of sacral vertebrae by ultrasound in the mid-second trimester of pregnancy

OBJECTIVES

The aim of the study was to establish the ossification timing of sacral vertebrae by ultrasonography in the second trimester of pregnancy, for the diagnosis of caudal regression syndrome with isolated sacral agenesis.

METHODS

The study was carried out on 77 normal single pregnancies, at gestational ages ranging from 15 to 21 weeks, using high-resolution transabdominal echography. The sacral region was visualized in a coronal plane, when the fetus was in anterodorsal position. The level of ossification of sacral vertebrae (S1 to S5) at each gestational age was recorded. Each sacral region was examined three times by the same observer and the nucleus was considered as present when it was visualized at least two times out of three. Blind assessment was performed three times by a second observer, who was not present at the previous examination, for interobserver and intraobserver error analysis.

RESULTS

Interobserver and intraobserver error calculation demonstrated the reproducibility of the method. Concordance between the two observers as evaluated by Cohen Kappa index was 0.77 (C.I. 95%, 0.69-0.85).S1 ossification nuclei were visualized in all fetuses at 15 weeks and S2 nucleus was found in all fetuses within 17 weeks. S3 nucleus was detected in 45% of fetuses by the beginning of the 16th week. S4 was visualized in 55% of the cases at 18 weeks and progressively in a higher percentage of cases during the following weeks of gestation.

CONCLUSION

The data obtained showed that the sequence of development of sacral region ossification was related to gestational age. This observation allows clinicians to accurately exclude isolated sacral agenesis at 16 to 17 weeks of gestation, when the S1-S2 ossification nuclei are visualized. This opportunity may be of particular value in the offspring of diabetic mothers.

Analysis of the distribution and genetic variability of viral isolates in a cohort of HCV-positive hepatopathic patients

The genotyping of the hepatitis C virus (HCV) by viral nucleic acids sequencing allows accurate epidemiological evaluation of a cohort of patients suffering from HCV-related chronic hepatopathy. The identification of viral isolates, which can be generally associated with hepatic damage or, vice versa, which are more responsive to pharmacological treatment, might enhance clinical interest on the nature of the infecting genotypes. We, therefore, draw attention to those viral genotypes that are characterised by significantly high or altered viremic and enzymatic levels.

Influence of age, sex, and growth variables on phalangeal quantitative ultrasound measures: a study in healthy children and adolescents

Skeletal status by phalangeal quantitative osteosonography (DBM Sonic BP-IGEA) was examined in 1227 healthy children (641 boys and 586 girls) aged 3-16 years. Aims of the study were to evaluate some physical parameters pertaining to the ultrasound transmission crossing the phalanx in a school-age population and to relate these values to age, sex, and growth variables. A correlation was found between AD-SoS (amplitude-dependent speed of sound) and BTT (bone transmission time) and, age, height, weight, and pubertal stage, respectively. No correlation existed between FWA (fast wave amplitude) and SDy (dynamics of the ultrasound signal) and age, height, weight, pubertal stage, and BMI, respectively. AD-SoS increased in boys until 7-8 years of age. Thereafter a plateau was reached up to age 12-13 years, when a rapid increase was observed corresponding to pubertal growth rate acceleration. In girls, AD-SoS increased with age up to 10-11 years with a steeper increase at the time of puberty starting about 2 years earlier than in boys. BTT presented a similar trend. Mean AD-SoS values increased from Tanner pubertal stages 1 to 2 and from stage 3 to 4 in both sexes. Significantly higher mean AD-SoS values in stages 2, 3, and 4 were observed in girls as compared to boys. Mean BTT values increased significantly from stage 1 to 5 in girls and from 1 to 4 in boys. QUS technology showed the ability to assess bone changes in the growing bone.

Outpatient treatment of hemorrhoids with a combined technique: results in 7850 cases

A combination of sclerotherapy, rubber band ligation and infrared coagulation was performed in 7850 patients seen an outpatient clinic over a period of 9 years. The most common symptom was bleeding followed by prolapse, pain and itching. Results were considered satisfactory in 7100 patients (90.5%); 750 (9.5%) required a formal hemorrhoidectomy. Complications were mild to moderate pain in 1777 cases (22.6%), severe pain in 157 cases (2.2%), mild hemorrhage in 199 (2.5%) and hemorrhage requiring transfusion in 10 cases (0.1%). In conclusion, non-surgical outpatient treatment has a great impact on patient's perception of the disease and results in considerable savings for the healthcare system.

162 HIV-1 infected pregnant women and vertical transmission. Results of a prospective study

BACKGROUND

Aim of this paper is to describe the changes over a 16-year period of the characteristics and management of HIV infected pregnant women.

METHODS

Prospective study: analysis of data obtained from 162 women and 176 infants. Factors evaluated included: maternal socio-demographic level, immunological and virological parameters, antiretroviral therapy, mode of delivery, pregnancy outcome and babies follow-up.

RESULTS

The proportion of women with heterosexual acquisition of infection has increased significantly from 13.5% in 1985-1989 to 47.1% in 1996-2001 (p<0.0005, Fisher's exact test), while the proportion acquiring HIV through injecting drugs has declined. Mean CD4 cell count at delivery was 535 x 106/l (+/-522.3 x 106/l). In 1990, 50% of mothers received antiretroviral therapy, rising significantly to 87.5% in 2000. The elective cesarean section was introduced in 1998 and its rate has increased to 75% in 2000. The vertical transmission rate changed from 9.5% in 1985-1989 to 14.3% in 1996-2000 (this difference was not statistically significant, Fisher's exact test).

CONCLUSIONS

Social characteristics of the HIV-infected women have changed since the mid-1980s: in recent times women are having children at increasingly older ages and are more likely to know that they are HIV infected when they become pregnant. Antiretroviral therapy, elective caesarean delivery and avoidance of breastfeeding can reduce transmission of HIV, but the vertical transmission rate was unaffected by their use in our study and it remains high in comparison with rates reported from other studies.

Spine length measurement in the first trimester of pregnancy

OBJECTIVES

The aim of the study was to evaluate spine length as an indicator of skeletal growth in the first trimester of pregnancy and to provide a nomogram of spine length at the end of the first trimester of pregnancy.

METHODS

The study was carried out on 420 single pregnancies, at gestational ages ranging from 11 to 14 weeks, using high-resolution transabdominal echography. Biparietal diameter and crown-rump length (CRL) were measured to date the pregnancy. Using the same scanning plane used to measure CRL, the whole spine length in antero-dorsal position can be visualized as a double hyperechoic line from 10 weeks of gestation onwards. Spine length was measured three times by one observer and the mean of the three measurements was considered as definitive. Forty fetuses had multiple measurements for interobserver and intraobserver error analysis.

RESULTS

Linear relationship between spine length, and gestational age, biparietal diameter and CRL were demonstrated. Spine length (millimetres) as a function of gestational age (days) was expressed by the regression equation: spine length = 1.09 x (gestational age in days) -60.56, with a determination coefficient of R(2) = 0.744. Spine length ranged from 21.5 mm at 11 weeks to 41.9 mm at 14 weeks.

CONCLUSION

The data obtained showed that spine length increased progressively from the end of the first trimester to the beginning of the second. A high correlation between spine length, gestational age, biparietal diameter, and CRL was observed. Spine length measurement could therefore be considered a good indicator of fetal growth.

Alexithymia and body weight in obese patients

The authors evaluated severely obese patients to determine whether being far different in body shape from the accepted standard may cause obese people to develop alexithymic personality traits. They evaluated the food- and weight-related attitudes in obesity surgery patients and in long-term follow-up of those who had previously had biliopancreatic diversion (BPD) for obesity. One quarter of the obese patients had alexithymic characteristics without any modification following stable weight loss, a rate of alexithymia similar to that observed in the nonclinical population. Furthermore, the frequency of alexithymia and the patients' scores on the Toronto Alexithymia Scale were similar in obese and post-BPD individuals. The authors concluded that being obese by itself does not influence the presence of alexithymic personality traits. However, they suggest that the improvement in food-related and weight-related attitudes following stable weight loss may be different in alexithymic and in nonalexithymic obese patients.

Role of viral isolate in the etiopathogenetic determinism of HCV infection: diagnostic and epidemiological evaluation

HCV genotyping by nucleic acid sequencing emphasizes the difficulties involved in carrying out a more precise determination of the infectant viral population, probably due in part to the finding of still unknown isolates. Signs of heterogeneity in the genotype composition of the viral quasi-species and its evolutionary dynamism over time, together with the role played by some, more potentially aggressive, isolates in causing hepatic damage, encourage a more in-depth study of such topics.

Metabolic syndrome in severely obese patients

BACKGROUND

The authors assessed the prevalence of diabetes, hypertension, dyslipidemia and metabolic syndrome in patients with a high degree of obesity.

METHODS

A retrospective investigation was planned in a cohort of obese patients with a wide range of body mass index (BMI) referred to a large University Hospital for weight loss.

RESULTS

An increase in prevalence of diabetes and hypertension with increase in the degree of obesity was observed, while the prevalence of dyslipidemia and metabolic syndrome appeared to be independent of the BMI values.

CONCLUSION

In severely obese patients a still unknown factor which affects differently glucose and lipid metabolism cannot be excluded.

Failure of preoperative resting energy expenditure in predicting weight loss after gastroplasty

OBJECTIVE

To evaluate the predictive efficacy of preoperative resting energy expenditure (REE) on weight loss after vertical banded gastroplasty (VBG). When subjected to a gastric restriction procedure of similar extent, the patients with higher energy expenditure should experience a greater negative energy balance than those with lower-energy expenditure, and thus, lose more weight, thereby making REE a reliable predictor of weight loss after VBG.

RESEARCH METHODS AND PROCEDURES

This was a prospective investigation after VBG, taking into account the relationship between preoperative REE values and the results at 1-year follow-up in terms of weight loss and success of the procedure. The correlations were evaluated by multiple and logistic regression analysis.

RESULTS

The weight loss and the outcome at 1 year after VBG seemed to be completely independent of preoperative energy expenditure.

DISCUSSION

These findings suggest that, despite gastric restriction, patients may voluntarily adjust their energy intake, and that the weight outcome after VBG is influenced more by behavioral and cognitive variables than by biological or surgical factors.

Prognostic indicators of local recurrence in patients operated for rectal cancer

BACKGROUND/AIMS

To identify subgroups of patients at high risk of local relapse after curative surgery for rectal cancer.

METHODOLOGY

Thirty-five variables of 216 patients observed from January 1987 to December 1995 were retrospectively analyzed according to univariate and multivariate methods. Median follow-up was 38 months.

RESULTS

High and moderate grade (P = 0.0001), Size > or = 5 cm (P = 0.013), lymph nodes involvement (P = 0.002) and patients with locally advanced rectal cancer underwent extensive surgery and postoperative radiation significantly increased local relapse; whereas surgical procedure and experience of surgeons had no influence.

CONCLUSIONS

The above-mentioned prognostic factors of rectal cancer that show a risk of local relapse 2- to 3.5-times higher than comparative conditions could be useful in identifying subgroups of patients at high risk for local recurrence. These patients should undergo a careful selection according to risk factors of relapse in order to increase local control of disease performing "optimal" primary surgery, effective postoperative radiation and tailored follow-up.

Epilepsy associated with infantile hemiparesis: predictors of long-term evolution

To study the evolution of epilepsy associated with infantile hemiparesis (IH) in relation to age and identification of factors predictive of pharmacoresistance. Thirty-four children with epilepsy and associated IH were followed for a period of 13 years and 3 months (range 5-19 years). All the patients underwent clinical evaluation and EEG, CT and/or MRI. Disease course was evaluated from the time of diagnosis of epilepsy to end of follow-up by differentiating the cases with severe pharmacoresistance from those with favourable outcome. Several possible prognostic factors were identified predicting evolution toward intractable epilepsy. Univariate statistical analysis by calculating odds ratio (OR) with 95% confidence interval (CI) and multivariate analysis by logistic regression were performed. Eleven cases presented severe epilepsy evolving toward pharmacoresistance; duration of epilepsy was always longer than 8 years. Twenty-three cases (seven with severe epilepsy and 16 with mild epilepsy) evolved toward remission; in these patients epilepsy duration was shorter (2-7 years) and a complete remission was obtained within 12 years of age. Significant prognostic factors associated with pharmacoresistance included: non-vascular causes, cortical lesions, mixed and frequent seizures during the first two years of epilepsy. Our results show that surgical treatment could be considered in cases with unfavourable prognostis factors.

Quality of life in 244 recipients of allogeneic bone marrow transplantation

The number of long-term survivors after allogeneic bone marrow transplantation (BMT) has been increasing over the past years, and quality of life (QOL) has become an important end-point. We studied 244 patients undergoing an allogeneic BMT to identify factors and events influencing psychosocial outcome. Patients enrolled received the Psychosocial Adjustment to Illness Scale (PAIS) questionnaire assessing psychological and social adjustment to chronic illness or its sequelae. Eighty-two per cent of patients had a haematological disease. The median age was 28 years at BMT, and the median follow-up was 61 months. The median overall PAIS score for all patients was 56 (range 22-76): 25% (n = 61) of patients were considered to have a good QOL (</= 25 percentile score); 44% (n = 108) of patients had an intermediate QOL (26-75 percentile score) and 31% (n = 75) had a poor QOL (> 75 percentile score). Factors associated with a poor QOL in multivariate analysis were: patients' age at BMT (> 25 years, P < 0.01); presence of long-term sequelae (P < 0.01); chronic graft-versus-host disease (GVHD) (P < 0.05); and a short interval from BMT (< 5 years; P < 0.05). The QOL improved with time: 12% of patients reported a good QOL within 5 years compared with 38% after this time point and, conversely, 38% reported a poor QOL within 5 years compared with 24% after this time point (P < 0. 0001). Older patients had significantly poorer QOL compared with younger patients (< or = 25 years; P = 0.01). Females had significantly poorer scores when compared with males in the sexual (P < 0.0001) and psychological domains (P = 0.001). The data suggest that (i) one-third of patients undergoing allogeneic BMT report a poor QOL; (ii) factors associated with poor QOL are older age, presence of long-term sequelae, chronic GVHD and short follow-up; (iii) QOL is superior in long-term survivors; and (iv) BMT affects different aspects of life in males and females. A longitudinal study is ongoing to prove the effect of time on quality of life.

Inadequate diagnosis and therapy of arterial hypertension as causes of left ventricular hypertrophy in uremic dialysis patients

BACKGROUND

Left ventricular hypertrophy (LVH) is highly prevalent in the dialyzed population, possibly because of inadequate diagnosis and therapy of arterial hypertension. The purpose of this study was to ascertain the adequacy of our approach in correctly identifying and treating arterial hypertension in our dialysis center.

METHODS

Fifty-five dialyzed uremics were studied by continuous ambulatory blood pressure (BP) monitoring, which started before a single hemodialysis (HD) session, continued for 24 hours after HD ended, and was repeated for 15 minutes before the beginning of the next HD. Clinical pre-HD and post-HD routine BP measurements taken the month preceding BP monitoring were retrieved, and echocardiography was performed.

RESULTS

LVH was present in 46 out of 55 patients, and clinical pre-HD arterial hypertension was present in 36 out of 55. There were discrepancies between clinical and monitored BPs, mostly concerning diastolic pre-HD BP since BP readings were lower than monitored BP records (P < 0.0002). Although both clinical and monitored BPs bore strong direct correlations with the left ventricular mass (LVM), the closest correlations were those for monitored BP. Four groups of patients were identified by BP monitoring: group A (N = 14), with persistently normal BP, and group D (N = 13), with persistently supranormal BP levels. There were also two other groups (group B, N = 19; and group C, N = 9), whose BP values were high before HD, normalized after HD, and then increased again either soon after HD (group C) or later on following HD (group B). Monthly averaged clinical pre-HD mean BP values differed significantly among the four groups [91 +/- 10 (SD) mm Hg in group A, 101 +/- 7 in group B, 106 +/- 6 in group C, and 106 +/- 7 in group D; P < 0.0001, analysis of variance], as did their corresponding LVMs [132 +/- 27 g/m2 body surface area (BSA), 156 +/- 26, 201 +/- 51, and 200 +/- 36; P < 0.0001]. There were also differences in dialytic age, which was significantly longer in group A patients (109 +/- 54 months), who also tended to have higher, although not significantly higher, Kt/V(urea) values. No differences, however, were detected among the groups as far as type, dosages, and number of antihypertensive drugs given to each individual patient.

CONCLUSIONS

The high prevalence of LVH in the dialysis population might be the result of inadequate diagnosis and therapy of arterial hypertension. Arterial hypertension, in fact, was insufficiently treated in our dialysis center, since patients with varying degrees of severity of both arterial hypertension and LVH were kept on antihypertensive therapy of similar strength. Undertreatment may have resulted from not having recognized and/or from having underestimated the severity of arterial hypertension since some clinical BPs were measured incorrectly. Reluctance to use more aggressive antihypertensive therapy might also result from the deceptive feeling of "normalized" BP that one has following volume unloading with dialysis. This causes both the BP to run out of control between dialyses and LVH to worsen.

Inadequate diagnosis and therapy of arterial hypertension as causes of left ventricular hypertrophy in uremic dialysis patients

BACKGROUND

Left ventricular hypertrophy (LVH) is highly prevalent in the dialyzed population, possibly because of inadequate diagnosis and therapy of arterial hypertension. The purpose of this study was to ascertain the adequacy of our approach in correctly identifying and treating arterial hypertension in our dialysis center.

METHODS

Fifty-five dialyzed uremics were studied by continuous ambulatory blood pressure (BP) monitoring, which started before a single hemodialysis (HD) session, continued for 24 hours after HD ended, and was repeated for 15 minutes before the beginning of the next HD. Clinical pre-HD and post-HD routine BP measurements taken the month preceding BP monitoring were retrieved, and echocardiography was performed.

RESULTS

LVH was present in 46 out of 55 patients, and clinical pre-HD arterial hypertension was present in 36 out of 55. There were discrepancies between clinical and monitored BPs, mostly concerning diastolic pre-HD BP since BP readings were lower than monitored BP records (P < 0.0002). Although both clinical and monitored BPs bore strong direct correlations with the left ventricular mass (LVM), the closest correlations were those for monitored BP. Four groups of patients were identified by BP monitoring: group A (N = 14), with persistently normal BP, and group D (N = 13), with persistently supranormal BP levels. There were also two other groups (group B, N = 19; and group C, N = 9), whose BP values were high before HD, normalized after HD, and then increased again either soon after HD (group C) or later on following HD (group B). Monthly averaged clinical pre-HD mean BP values differed significantly among the four groups [91 +/- 10 (SD) mm Hg in group A, 101 +/- 7 in group B, 106 +/- 6 in group C, and 106 +/- 7 in group D; P < 0.0001, analysis of variance], as did their corresponding LVMs [132 +/- 27 g/m2 body surface area (BSA), 156 +/- 26, 201 +/- 51, and 200 +/- 36; P < 0.0001]. There were also differences in dialytic age, which was significantly longer in group A patients (109 +/- 54 months), who also tended to have higher, although not significantly higher, Kt/V(urea) values. No differences, however, were detected among the groups as far as type, dosages, and number of antihypertensive drugs given to each individual patient.

CONCLUSIONS

The high prevalence of LVH in the dialysis population might be the result of inadequate diagnosis and therapy of arterial hypertension. Arterial hypertension, in fact, was insufficiently treated in our dialysis center, since patients with varying degrees of severity of both arterial hypertension and LVH were kept on antihypertensive therapy of similar strength. Undertreatment may have resulted from not having recognized and/or from having underestimated the severity of arterial hypertension since some clinical BPs were measured incorrectly. Reluctance to use more aggressive antihypertensive therapy might also result from the deceptive feeling of "normalized" BP that one has following volume unloading with dialysis. This causes both the BP to run out of control between dialyses and LVH to worsen.

Weight loss after dieting with behavioral modification for obesity: the predicting efficiency of some psychometric data

The aim of the study was to identify the predicting efficiency of some psychometric data on weight loss after behavior modification in moderately obese patients. A group of patients on a weight loss program with a moderately hypoenergetic diet plus behavior modification therapy for 24 weeks completed the Eating Inventory (EI), the Eating Disorder Inventory (EDI), the Body Shape Questionnaire (BSQ) and the Body Attitude Questionnaire (BAQ). Correlations between the pre-diet and post-treatment scores were evaluated by stepwise regression analysis. The weight loss percentage was positively correlated with the EDI Bulimia scale and the BAQ Feeling Fat, and negatively with the EDI Body Dissatisfaction and Interpersonal Distrust scores. These findings indicate the true effectiveness of the behavior modification technique employed to extinguish bulimic behaviors. Furthermore, it can be suggested that realistic attitudes towards own fatness with a strong motivation and a good relationship with the therapist guarantee a greater weight loss.

Interpretation and diagnostic implications of an immunoblotting (INNOLIA) test for HCV serology

The association analysis of antibodies versus HCV, carried out with INNOLIA test, prevented a clear determination of the existence of specific serological patterns. In this respect, it may be of interest to monitor the immune response to the non-structural genomic regions (NS3, NS4, NS5). The INNOLIA kit is reliable, but susceptible to improvement in terms of specificity, sensitivity and biological standardization.

Autografting with Ph-negative progenitors in patients at diagnosis of chronic myeloid leukemia induces a prolonged prevalence of Ph-negative hemopoiesis

OBJECTIVE

In many patients with chronic myeloid leukemia (CML), a residual population of primitive normal (Ph-negative) progenitors persists despite the marked expansion of the leukemic (Ph-positive) clone. These cells may be found in the blood of patients studied soon after diagnosis or during the period of endogenous hematopoietic recovery that follows myeloreductive therapy. Based on those observations, we have developed a clinical protocol that allows collection of Ph-negative peripheral blood progenitor cells (PBPC) with transplantable hematopoietic regenerative potential. The aim of this study is to examine changes that occur in the percentage of Ph-negative- and Ph-positive-committed progenitor cells and to determine the relationship between changes and clinical outcome.

MATERIALS AND METHODS

We followed 15 patients with CML, mobilized and autografted soon after diagnosis with 85%-100% Ph-negative PBPC for a median time of 28 months (range 18-50) after transplant. At 6 months, 1 year, 2 years, and last follow-up, cytogenetic analyses were performed on fresh bone marrow cells and on colony-forming cells (CFC).

RESULTS

Autologous transplantation induces a reduction in the proportion of Ph-positive CFC, from 70%-100% to 0%-25% in the majority of patients (78%). After autografting, 8 of 15 patients achieved a long-lasting cytogenetic remission (median, 24 months; range, 21-43) with a Ph-positivity ranging between 0% and 20% at the level of mature mononuclear cells and colony-forming cells (CFC). In some patients, the majority of CFC remained Ph-negative, whereas the majority of the mature cells were Ph-positive. Other patients (5/15) developed cytogenetic relapse (100% Ph-positive), although they were in hematological remission. We found that detection of Ph-positive long-term-culture initiating cells (LTC-IC) in the marrow at diagnosis was the only factor significantly associated with recurrence of the disease (p < 0.01); on the other hand, the number of Ph-negative LTC-IC infused showed a significant correlation with a better outcome (p < 0.03).

CONCLUSION

We have shown that a prolonged period of complete or almost complete Ph-negative hemopoiesis can be achieved in patients with CML who undergo autografting with Ph-negative progenitors. Longer follow-up study will be needed to assess whether these changes are associated with improved survival.

[Tic disorders in children and adolescents. Clinical and genetic features, comorbidity]

Tic disorders in children and adolescents. Clinical and genetic features, comorbidity.

BACKGROUND

Aim of the study is to evaluate the clinical and genetic characteristics of tic disorders, in view of individuating similarities or differences relevant to the prognosis among different nosological groups.

METHODS

A retrospective study of 79 children and adolescents (average age 9.3 yrs) was performed. The cases were diagnosed according to DSM-IV as: transitory tics (TT) 13 cases; chronic tics (CT) 50 cases; Tourette disease (TD) 16 cases. They were compared to a control group of 18 school age children without any neurological or psychiatric disturbance. The study included: semi-structured interviews focused on natural history of the disturbances, familiarity, presence of perinatal pathology, comorbidity; neurological examination, EEG, psychodiagnostic tests and investigation.

RESULTS

Mean age of onset and type of first symptoms are the same in the three groups. Compared to the control group there is a significant increase in: familiarity for tics disturbances in TD; presence of perinatal pathological factors in the three groups of patients; comorbidity for obsessive-compulsive disorder (OCD) in CT and TD, comorbidity with ADHD in CT group. Three clinical cases are reported to exemplify the mixed features in the families and the different responsivity to the pharmacological treatment.

Body image and body weight in obese patients

OBJECTIVE

To evaluate the influence of body weight on body image.

METHODS

The study was carried out in severely obese patients and in postobese subjects, having attained and maintaining a normal or nearly normal weight following biliopancreatic diversion; body image was assessed by self-report questionnaires.

RESULTS

The obese patients' scores were different from those of postobese subjects. In postobese individuals with adult-onset obesity, body image was very similar to that of controls, whilst in those with early-onset obesity it was abnormal.

DISCUSSION

In the adult-onset obese patients, since the weight normalization causes a sharp improvement of body image, its alterations could be accounted for by a body shape far different from that socially acceptable. In the early-onset obese patients, being the postoperative findings similar to those of the obese patients and different from those of never-obese controls, the body image disparagement might reflect inner feelings, independent of body weight.

Angiotensin-converting enzyme gene polymorphism and reversibility of uremic left ventricular hypertrophy following long-term antihypertensive therapy

BACKGROUND

Prolonged antihypertensive therapy might be less effective in reversing the left ventricular hypertrophy (LVH) in uremics bearing the deleted (DD) allele of the angiotensin converting enzyme (ACE) gene than in patients with the inserted (II) allele or in those heterozygous (ID) for the gene.

METHODS

Thirteen DD and 17 II + ID hemodialyzed uremics were followed-up with yearly echocardiography and 24-hour blood pressure (BP) monitoring over five years while on an antihypertensive therapy that included ACE inhibitors as first line drugs.

RESULTS

In the II + ID group there were significant decreases of the left ventricular mass index (LVMi) and of both systolic and diastolic BPs. These changes were less pronounced in the DD group, but the difference was not statistically significant given the wide overlap between the two groups. Further analysis of the data revealed that the only factor associated to a decreased LVMi was the decrease of the systolic BP irrespective of the ACE gene genotype of each individual patient.

CONCLUSIONS

The ACE-gene genotype does not necessarily predict the extent to which LVMi will be lowered by ACE-inhibitors therapy. The LVH of hypertensive uremics is amenable by long-term antihypertensive therapy provided that it results in significantly decreased systolic blood pressure.

Influence of dietary habits on thyroid status of a nomadic people, the Bororo shepherds, roaming a central African region affected by severe iodine deficiency

OBJECTIVE

In contrast with the endemic goiter reported in several African countries, the nomadic Bororos of the Central African Republic have an unexpectedly low prevalence of goiter. This study was conducted to elucidate this puzzling observation.

DESIGN

Thyroid function and iodine and thiocyanate intakes were evaluated in Bororos and inhabitants of the same area and compared with an Italian population.

RESULTS

Urinary iodine concentrations indicated moderate iodine deficiency in the rural people and the Bororos. In the latter, no individual with clinical hypothyroidism was observed. Compared with the reference population, the Bororos had slightly lower thyroxine (T4) and free thyroxine (FT4), slightly increased tri-iodothyronine (T3) and T3/T4 ratio, slightly higher TSH, normal serum thyroglobulin, a prevalence of goiter of 17.1% and a higher urinary thiocyanate. The rural people showed striking differences: lower T4 and FT4, increased T3/T4 ratio, markedly increased TSH and thyroglobulin, a prevalence of goiter of 76.9% and a high urinary thiocyanate, indicating frequent consumption of cassava. A dietary survey indicated that the Bororos ingest large amounts of milk and related products but infrequently eat cassava.

CONCLUSION

A minute difference in iodine deficiency between two populations induces totally different patterns of goiter and thyroid function. The reason for such a contrast probably involves differences in diet.

Long-term outcome of children and adolescents with anorexia nervosa: study of comorbidity

Eighty-seven children and adolescents with anorexia nervosa, admitted to the Gaslini Department of Child Neurology and Psychiatry between 1976 and 1990, were followed up after a mean of 9.6 years. Outcome measures included the Morgan Russell Outcome Schedule as modified by Jeammet. Outcome was good in 43 (53%) cases, intermediate in 27 (34%) cases, and negative in 11 (14%) cases. No deaths occurred. Based on the Jeammet assessment schedule, the most significant items predicting outcome were insight; sexual, familial, and social relationships; and mental state. Gender of patients and early disease onset did not seem to be predictive measures. Poor outcome was associated with a severe initial clinical picture and length of in-patient treatment. In regard to comorbidity, mood and personality disorders seemed to be negative prognostic indicators, whereas anxiety disorders did not show prognostic value.

alpha 1-Antitrypsin (AAT) deficiency and ANCA-positive systemic vasculitis: genetic and clinical implications

A high incidence of alpha 1-antitrypsin (AAT) deficiency has been reported in patients with C-ANCA systemic vasculitis in association with antibodies against proteinase-3 (PR3). To clarify the role of AAT deficiency in the acute vasculitic process as well as in progression of the disease, we studied 84 patients with either C-ANCA or P-ANCA vasculitis with special reference to: (a) the AAT gene, (b) the phenotypic (Pi) variants and (c) the serum levels during both acute illness and remission. The PiZ gene was found in six patients (8% vs. 1.5% controls) irrespective of the type of autoantibodies (C-ANCA vs. P-ANCA). All PiZ patients displayed the ability to raise their AAT serum levels up to the normal range during acute illness. In contrast, 24 patients with the PiM phenotype presented low AAT serum levels during acute illness. In all these patients, the AAT levels returned to normal values during the remission. Low AAT levels were associated with low levels of C-reactive protein (PCR) (P < 0.001), with a less severe renal involvement or a minor risk of death, and, in one tested patient, with a novel point mutation (TCGA-->TCAA) at the enhancer-promoter region of the AAT gene. Low AAT serum levels did not correlate with either type/titre of autoantibody or distribution/severity of the vasculitis process. In the case-control study, high AAT levels emerged as a major determinant of progression towards end-stage renal failure [odds ratio 3 (95% CI 1.1-8.4)]. These results indicate: (a) a high incidence of the PiZ gene of AAT in systemic vasculitis irrespective of the type of autoantibodies; (b) a novel form of AAT deficiency associated with the normal PiM phenotype becoming manifest only during acute illness; (c) dysregulation of the acute-phase response affecting selectively AAT or both AAT and PCR; (d) correlation between low plasma levels of AAT and less severe renal involvement or risk of death.

[The use of n-3 fatty acids in chronic juvenile arthritis]

Juvenile Chronic Arthritis (JCA) is a chronic disease still lacking of a complete therapeutic solution. Therapy traditionally used consists of non steroidal anti-inflammatory drugs and in some selected cases of gold salt and immuno-suppressive agents. Recently it has been described the possibility of a dietary supplementation of n-3 fatty acids in addition to conventional pharmacotherapy. The aim of our study is to demonstrate the real efficacy of this dietary supplementation on JCA symptoms. The group of 16 patients treated, compared to a control group of 16 patients, has shown a significative decrease of CRP.

Association between drinking water disinfection and somatic parameters at birth

We conducted an epidemiological study in Liguria, Italy, on the association between somatic parameters at birth and drinking water disinfection with chlorine dioxide and/or sodium hypochlorite. Over 2 years (1988-1989), 676 births at two public hospitals, one in Genoa (548 cases) and another in Chiavari (128 cases) were examined and data regarding both mother and child were obtained from hospital records. Results indicate a higher frequency of small body length (< or = 49.5 cm) and small cranial circumference (< or = 35 cm) in infants born to mothers who drank water treated with chlorine compounds. In particular, the statistical analysis (by simultaneous variance analysis and Scheffé test) indicated that there may be an association between infants with smaller body length and mothers who drank water treated with chlorine dioxide [adjusted odds radio (OR) = 2.0; 95% CI = 1.2-3.3] or sodium hypoclorite (adjusted OR = 2.3; 95% CI = 1.3-4.2) and between infants with smaller cranial circumference and mothers who drank water treated with chlorine dioxide (adjusted OR = 2.2; 95% CI = 1.4-3.9) or sodium hypochlorite (adjusted OR = 3.5; 95% CI = 2.1-8.5). The presence of neonatal jaundice is almost twice as likely (adjusted OR = 1.7; 95% CI = 1.1-3.1) in infants whose mothers drank water treated with chlorine dioxide.

Ovarian recovery after total body irradiation and allogeneic bone marrow transplantation: long-term follow up of 79 females

Seventy-nine females undergoing allogeneic BMT following conditioning with total body irradiation (TBI), were prospectively followed between March 1983 and March 1992 with regular gynaecological examinations, including plasma levels of luteinising hormone (LH), follicle stimulating hormone (FSH), 17-beta oestradiol (E2) and pelvic ultrasonography. The end-points of this study were the following: (1) early and late effects of TBI on ovarian function, (2) compliance and results of hormonal replacement therapy (HRT), and (3) predictive events for ovarian recovery. During the first year post-BMT most adult women complained of vasomotor and/or genitourinary tract symptoms. These were associated with decreased E2 and increased LH-FSH plasma levels and a deterioration in their sexual life (94% of sexually active women). Forty-nine adult females were selected to receive systemic hormonal replacement therapy (HRT), consisting of cyclic transdermal oestrogens plus medroxyprogesterone acetate (MPA) or cyclic oral therapy with low doses of conjugated oestrogens and MPA: these patients were selected on the basis of age (< 45 years), absence of medical contraindications or subjective refusal. Compliance and tolerability were overall good: most women (65%) never stopped HRT; this was discontinued in 14 patients for medical reasons and in 3 because of refusal. Forty-three females completed 6 months of HRT: vasomotor symptoms disappeared in 91% of 58 women who previously referred these symptoms. Improvement of genitourinary symptoms was seen both with local and systemic hormonal therapy. However sexual symptoms were reduced in 21 of 26 women (81%) given HRT compared with 8 of 19 (42%) women given local treatment (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Malignant tumors in the head of the pancreas and the periampullary region. Diagnostic and prognostic aspects

This paper analyzes the value of ultrasonography (US), computerized tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) to establish the location, nature and resectability of carcinomas of the pancreatic head and of the periampullary region. The prognostic importance of certain pathological factors in relation to survival was also evaluated. As regards the site of origin, 112 cases with carcinoma were classified as follows: 56 pancreatic, 32 ampullary, 10 common bile duct, and 14 undefined. Papillary tumors were more accurately defined by ERCP compared to CT+US (p = 0.033), whereas CT was less accurate than US+ERCP (p = 0.05). No significant differences were found in pancreatic and common bile duct tumors. Pathological confirmation was obtained with ERCP in 54 cases (46% pancreatic, 69% papillary and 50% common bile duct). In the remaining 58 patients (including 1 chronic pancreatitis) the diagnosis was confirmed with percutaneous or intraoperative biopsy. Tumor extent was better defined by US+CT. In 42 resected patients the final pathological examination revealed an error of preoperative staging in 79% pancreatic, 59% papillary, and 83% common bile duct tumors. Tumor size, nodal status, perivascular, capsular and portal vein infiltration proved to be significant prognostic factors for pancreatic tumors. Stepwise regression identified tumor size, capsular infiltration and perivascular invasion as the most important covariates for survival. Ulceration, papillary histotype, pancreas and Oddi muscle infiltration, grading, perineural, lymphatic and vascular involvement were found to be significant in papillary tumors. The Cox proportional hazard model showed that pancreatic, Oddi muscle, perineural infiltration, and histologic type respectively represent a relative risk of 5.93, 107.36, 21.31, 20.61. The limited number of cases of common bile duct primary did not allow us to carry out statistical analysis on these tumors.

Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature

This paper analysed the literature published in the last 15 years regarding the onset of pancreatic fistula after pancreaticoduodenectony carried out for tumours in the periampullary region, in the head of the pancreas and in the distal common bile duct. Out of 8370 pancreatic resections we were able to go by only 2684 cases, which showed the type of treatment used in the remaining stump, the rates of leakage and relative mortality. The data collected were analysed statistically using the Cochran test and or the chi 2, evaluating the possible significant difference relative to the various methods of reconstruction. The onset of pancreatic fistrula was found to be statistically more frequent after ligation of the stump than after pancreatico-jejunal anastomosis (p = 0.001). Comparing the pancreatico-jejunal end-to-side anastomosis, to pancreatico-jejunal end-to-end and wirsung-jejunal end-to-side anastomosis the first one had shown a significantly higher rate only for leakage (respectively p = 0.008 and p = 0.010). The occlusion of the wirsung duct with biological substances showed better results compared to ligation (p = 0.001) only as regards onset of the fistula, while the comparison between the occlusion and the three types of anastomosis did not show any statistically difference, except for the pancreatico-jejunal end-to-side anastomosis, in which it was significant only as regards leakage (p = 0.009). The statistical analysis between pancreatico-gastrostomy and pancreatico-jejunal anastomoses indicated that the first technique had a lower morbidity rate than pancreatico-jejunal end-to-side (p = 0.001), pancreatico-jejunal end-to-end (p = 0.010) and wirsung-jejunal end-to-side (p = 0.011). We analysed and compared the results obtained before and after 1975, in order to discover whether was an improvement in the prevnetion or in the treatment of such a complication and its consequences. Furthermore, we tried to establish whether the transanastomotic drainage, the site of the neoplasm, the texture of pancreatic parenchyma and the patient's age could in any way influence the onset and course of the fistula.

[Thyroid hormone profiles in goitrous and non-goitrous subjects seen in an endemic goiter area of the Central African Republic]

In the present study T3, T4, TSH serum concentrations were measured in 166 subjects whose goiter grading was ascertained according to WHO classification; 39 of them had no goiter (grading 0), 127 were goitrous with a grading comprised between 1a and 4. The two samples were composed by Males and Females of various ages whose choice was strictly predetermined by random numbers. The median ages of 127 goitrous and 39 non goitrous subjects were respectively 23.5 years and 33.5 years; 30 Males and 5 Females were in the first group; 58 Males and 69 Females in the second. They lived in the Ouham region of Centro African Republic where some of the Authors ascertained a severe goiter endemia due to iodine deficiency and manioc consumption as staple food. All the values of T4 and TSH of the two group of subjects, were significantly different from the control values (p less than 0.01) excepting T3. Goitrous subjects had T4 value lower than non goitrous subjects (p less than 0.05). The subjects of each group were distributed in the four subsequent subgroups: A) with T3, T4, TSH in the normal range; B) with elevated TSH and T3 and T4 in normal range; C) with elevated TSH, subnormal T4, and T3 in normal range; D) with elevated TSH and subnormal T3 and T4. From fig. 1 it can be seen that the 79.5% of goitrous subjects had a supranormal TSH (subgroups B + C + D) and 40.7% of them had a subnormal T4 (subgroups C + D).(ABSTRACT TRUNCATED AT 250 WORDS)

[Hormone profile of hypothyroidism in an area of the Central African Republic with endemic goiter]

In the Ouham region of Centro African Republic, one of the present Authors (B.P.) described a severe goiter endemia due to marked iodine deficiency and high daily intake of manioc as staple food. In the present study serum TSH, T3 and T4 of 233 subjects were determined; 150 of them lived in rural villages (Group 1) and 83 lived in Bocaranga, chief town of the province (Group 2). The blood samples done contemporaneously to the epidemiological survey, were strictly randomized in the population examined. The subjects of each group were divided in 4 sub-groups: A) with TSH, T3 and T4 in normal range; B) with elevated TSH; C) with elevated TSH and sub-normal T4; D) with elevated TSH and sub-normal T3 and T4. An apparently euthyroid pattern of TSH, T3 and T4 was evident in only 60 subjects (19.3% from group 1; 37.35% from group 2); the remaining 173 (80.67% from group 1; 62.65% from group 2) were hypothyroid (subclinical in the sub-group B; mild in the sub-group C; overt in the sub-group D). The mean hormonal values of the apparently euthyroid subjects (sub-group A) in the villages and in the chief town, were significantly different (p less than 0.05) from the control values of our laboratory. More significant differences were clearly evident between the control values and the mean values of sub-groups B, C and D in each of the two groups (1 villages; 2 chief town).(ABSTRACT TRUNCATED AT 250 WORDS)

[The Guillain-Barré syndrome. The clinico-electrophysiological correlations]

The authors refer about clinico-electrophysiological correlations in children with Guillain-Barré syndrome (GBS). The dates confirm the diagnostic and prognostic value of electrodiagnostic studies in GBS, so that the authors suggest an electrodiagnostic protocol. According to the authors, independently of the extent of electrophysiological abnormalities, young age has a favourable influence on the restoration of conduction abnormalities and on the evolution of damage to peripheral neurones.

Hormonal and biochemical patterns in subjects from a new endemic goiter area in the Central African Republic

Hormonal serum patterns of 268 subjects, living in rural villages and in the chief town of the Ouham province (Bocaranga), were studied to accomplish a survey in this endemic goiter area of the Central African Republic (CAR). Circulating TSH, TT3, TT4, FT4, rT3 and TG were determined in an accurately randomized population sample. Urinary excretion of iodine and thiocyanate (SCN) was also measured. The comparison of the mean values of such parameters with control values showed statistically significant differences (P < or = 0.05 divided by 0.001) in all the parameters studied, excepting TT3. The urinary iodine excretion was lower than 35 micrograms/l in the chief town and of 25 micrograms/l in the rural villages. The thiocyanate excretion was constantly greater than 8 mg/l; the I/SCN ratio = 3.7 was clearly lower than in controls. In a sample of 41 subjects, whose hormonal patterns were in the physiological range, significant differences were found between their TT3, TT4, FT4, TSH and TG serum concentrations and the respective control values. The severe iodine deficiency and the high consumption of manioc as a staple food are the prominent etiopathogenic factors of the hyper endemic goiter in this region. The authors believe that extensive iodoprophylactic action is urgently needed.

[Double-blind controlled comparison of placebo and paracetamol in patients with G-6-PD deficiency]

In this study are reported 17 patients with G-6-PD deficiency. These subjects have been studied with double-blind trial between placebo and Paracetamol, looking for the possible hemolysis induced from drug in these children with G-6-PD deficiency. Hemolysis had been valued by various hematological parameters (Hb, erythrocyte count, reticulocytosis, bilirubinemia, haptoglobin, hemopexin, and survival of erythrocytes marked with Cr). The results (8 cases with placebo and 9 cases with paracetamol) demonstrate that paracetamol have not induced hemolysis in these G-6-PD deficient subjects.

[Pain in Guillain-Barré syndrome]

The clinical features of pain were analysed in 31 children with Guillain-Barré Syndrome. Pain may be considered characteristic of childhood GBS. Pain, various painful sensations and dysaesthesias must be emphasised in the early diagnosis of GBS. An attempt was made to identify the meanings of early pain (preceding or accompanying the onset of weakness), late pain, mild or severe sensory symptoms or signs and the role played by triggering or perpetuating factors. Only the application of a diagnosis-therapeutic protocol for childhood GBS, that pays particular attention to the problem, will suggest satisfactory answers to research.