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Background: Previous studies on oxaliplatin and fluoropyrimidines as adjuvant therapy in older patients with stage III colon cancer (CC) produced conflicting results. Patients and methods: We assessed the impact of age on time to tumour recurrence (TTR), disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) in 2360 patients with stage III CC (1667 aged

Objective In the paper laser scanning was used to evaluate, by indirect methods, the accuracy of computer-designed surgical guides in the oral implant supported rehabilitation of partially or completely edentulous patients. Materials and methods Five implant supported rehabilitations for a total of twenty-three implants were carried out by computer-designed surgical guides, performed with the master model developed by muco-compressive and muco-static impressions. For all cases the surgical virtual planning, starting from 3D models obtained by dental scan DICOM data, was performed. The implants were inserted on the pre-surgical casts in the position defined in the virtual planning. These positions were acquired by three-dimensional optical laser scanning and compared with the laser scans of the intraoral impressions taken post-operatively. Results The comparison between the post-surgical implant replica positions and the positions in the pre-operative cast, for the five patients, shows a maximum distance in the range 1.02–1.25 mm, an average distance in the range 0.21–0.41 mm and a standard deviation in the range 0.21–0.29 mm. Significance The results of this research demonstrate accurate transfer of implant replica position by virtual implant insertion into a pre-operative cast and a post-operative cast obtained from impressioning. In previous studies the evaluation of the implant positions have required a post-surgical CT scan. With the indirect methods by laser scanning technique, proposed in the paper, this extra radiation exposure of the patient can be eliminated.

Omega-3 polyunsaturated fatty acids such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have beneficial effects on the heart and vasculature. We tested the hypothesis that 6 weeks of dietary supplementation with DHA (2.0 g/day) and EPA (3.0 g/day) enhances exercise-induced increases in brachial artery diameter and blood flow during rhythmic exercise. In seven healthy subjects, blood pressure, heart rate and brachial artery diameter, blood flow, and conductance were assessed before and during the last 30 s of 90 s of rhythmic handgrip exercise (30% of maximal handgrip tension). Blood pressure (MAP), heart rate (HR), and brachial artery vascular conductance were also determined. This paradigm was also performed in six other healthy subjects who received 6 weeks of placebo (safflower oil). Placebo treatment had no effect on any variable. DHA and EPA supplementation enhanced contraction-induced increases in brachial artery diameter (0.28 ± 0.04 vs. 0.14 ± 0.03 mm), blood flow (367 ± 65 vs. 293 ± 55 ml min−1) and conductance (3.86 ± 0.71 vs. 2.89 ± 0.61 ml min−1 mmHg−1) (P < 0.05). MAP and HR were unchanged. Results indicate that treatment with DHA and EPA enhances brachial artery blood flow and conductance during exercise. These findings may have implications for individuals with cardiovascular disease and exercise intolerance (e.g., heart failure)

Study objective: To determine the effect of the addition of adenosine, as a standing-order medication, on the prehospital management of supraventricular tachycardia (SVT) in a large urban emergency medical services (EMS) system. Design: Prospective observational case series with historical controls. Setting: Large urban municipal EMS system staffed by paramedics and emergency medical technicians trained to operate automatic or semiautomatic defibrillators (EMT-Ds). Participants: We observed a consecutive sample of prehospital patients who presented with an initial ECG rhythm of SVT, as interpreted by the treating paramedics, between July 1 and December 31, 1993. We used patients from the same 6-month period in 1992 as our control group. Indications for treatment were chest pain, evidence of myocardial ischemia, or shock. Adenosine had been introduced as a first-line medication to be used under standing orders in cases of unstable SVT before a physician was contacted for medical control options. Results: We studied 239 cases and 228 controls. Acceptable call reports with pretreatment and posttreatment ECGs were available for 140 (59%) of the study cases and 104 (46%) of the controls. The two groups were similar in terms of age, sex, and initial vital signs. In the control group, 75 patients had indications for treatment, and 16 were treated (21%). In the study group, 127 had indications for treatment and 103 (81.1%) were treated (odds ratio, 15.83; 95% confidence interval, 7.38-34.4). Conclusion: The introduction of adenosine as a standing-order medication into an urban EMS system increased the proportion of patients who received advanced life support treatment. Paramedics were able to accurately diagnose and begin treatment of SVT with adenosine without direct medical supervision. [Lozano M Jr, McIntosh BA, Giordano LM: Effect of adenosine on the management of supraventricular tachycardia by urban paramedics. Ann Emerg Med December 1995;26:691-696.]

Thyroid goiter is called plunged when, starting from the cervical region, it grows in the anterior-superior mediastinum to a depth of more than 2 cm. The highest frequency (48.44%) is evident in the age range from 60 to 70. From February 2002 to August 2005, performed 133 (80.6%) near total thyroidectomies, 26 total thyroidectomies (15.7%), 4 lobectomies (2.4%) and 2 (1.2%) totalisations of recurrences for plunged goiter in the 7th Division of General Surgery of the Second University of Naples. The goiters were classified using Lamke and Ferrante's topographical classification, which distinguishes between prevascular and retrovascular cervico-mediastinal goiters depending on the position assumed by the part plunged in the mediastinum in relation to the vascular layer of the epiaortic trunks. Retrovascular goiters are further subdivided into: pre-tracheal, laterovisceral and retrovisceral goiters depending on the relation to the trachea, oesophagus and epiaortic trunks. Among the patients who underwent near total thyroidectomy, there were 3 cases of permanent hypocalcaemia, 7 (7.2%) of temporary hypocalcaemia and only 1 (0.6%) monolateral temporary recurrent nerve lesion. Among those who underwent total thyroidectomy there was 1 case (0.6%) of temporary hypocalcaemia, and 1 (0.6%) of permanent hypocalcaemia. Postoperatively we also observed 3 cases (1.8%) of haemorrhage and 3 (1.8%) transfers to intensive care for respiratory insufficiency; 1 of these patients died 25 days after the operation. Ligature of the inferior and superior thyroid artery near the thyroid capsule protects the vascularisation of the parathyroid glands as well as the recurrent nerve and its division branches.

Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease.From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation.The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences.The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.

Crohn's disease is an inflammatory chronic intestinal disease characterized of an high level of postoperative recurrence. Actually surgical treatment is not decisive; patients can undergo several operations during their lives, running the risk of coming up against the syndrome of short bowel. The main disease frequently appears in the segment ileo-caecal, while the site more often affected by the recurrence seems to be the stump close to the anastomosis. General, local and not specific factors should influence the recurrence level. Among the general factors, cigarette smoking would have a leading role in the recurrences onset. Giving up smoking and a treatment with 5-ASA (amino-salicylic acid) help to reduce the risk of Crohn's recurrences after surgery. During the treatment of this pathology the wide intestinal resections are not justified because the anastomotic recurrence after resection seems to be influenced not by the presence of remaining lesions but by the type of realized anastomosis. Although they disagree about the type of anastomosis to adopt, the authors agree identifying the anastomotic stenosis as the main factor which determines the recurrences. Stenosis, in fact, determining fecal stasis and, therefore, the increase of the pressure at the intestinal wall level, causes ischemia of this same wall. Ischemia puts up the risk of fistulas and anastomotic dehiscence. The mechanical or manual ileo-colic side-to-side anastomosis, assuring a wide lumen, drops to the minimum the risk of stenosis compared with the end-to-end and end-to-side configurations. And then, the side-to-side ileo-colic anastomosis avoiding the intestinal compartmentation between ileo and colon, guarantees less reflow in the small bowel of bacteria and colic metabolite. In this way the inflammatory process which brings to the fresh outbreak of the disease on the mucosa of the near anastomotic head faints. In the light of this thesis, most of the authors, including the writer, agree about making the side-to-side anastomoses in the intestinal resections for the Crohn's disease.

BACKGROUND: Among subjects with endometriosis and deep dyspareunia (DD), those with endometriosis of the uterosacral ligament (USLE) have the most severe impairment of sexual function. This study examines the effect of laparoscopic excision of endometriosis on DD and quality of sex life. METHODS: This observational cohort prospective study included 68 women with endometriosis suffering DD (intensity of pain > 6 on a 10-cm visual analogue scale). Patients underwent laparoscopic full excision of endometriosis. Following surgery, they were asked to use nonhormonal contraception devices. Before surgery, at 6- and at 12-month follow-up, patients answered a self-administered questionnaire based on the Sexual Satisfaction Subscale of the Derogatis Sexual Functioning Inventory. RESULTS: At 6- and 12-month follow-up, women with and without USLE had significant improvement in DD. Subjects with USLE reported increased variety in sex life, increased frequency of intercourse, more satisfying orgasms with sex, relaxing more easily during sex and being more relaxed and fulfilled after sex. Similar improvements were observed among women without USLE; however, for some variables statistical significance was not reached. CONCLUSIONS: Surgical excision of endometriosis improves not only DD but also the quality of sex life.

Introduction This study aimed to investigate the desired menstrual frequency of subject s without menstruation-related symptoms. Materials and Methods The study included 270 women of reproductive age. Women with menstrual headache, dysmenorrhea, hypermenorrhea and/or premenstrual syndrome were excluded. The study subjects completed a standardized questionnaire. Results Of the women, 75.6% declared that menstrual periods interfere with their sexual life, 28.8% preferred not having their menstrual period when at work and 48.4% reported that menstrual periods interfere with practicing sports. Given the choice, 28.5% of the women would desire amenorrhea and 27.8% would prefer a reduction in the frequency of menstrual periods. Of the 152 women desiring to reduce menstrual frequency, 73.0% declared that they would accept to use a drug to reduce menstrual frequency. Conclusions Over 50% of women without menstruation-related symptoms would like to lessen the frequency of menstrual periods and about 50% of them would desire amenorrhea.

Background Considerable suffering is experienced by carers of patients with dementia. Most existing studies do not consider the coexistence of subjective and objective aspects that cause, interacting to each other, this suffering. Objectives In this study we: (1) define the high-risk group of caregivers on the bases of the scores obtained on the four scales evaluating burden, distress, depression and anxiety (BDDA) taken into account simultaneously and (2) evaluate risk factors related to the high level of BDDA. Subjects and methods 419 elderly outpatients with dementia and their caregivers were enrolled. Patients were evaluated for their cognitive, neuropsychological and functional impairment and for comorbidity. Caregivers were evaluated with four scales for the assessment of burden, distress related to neuropsychological disturbances, depression and anxiety. Cluster analysis was used to identify the group with the High level of BDDA (HBDDA). Results By multiple logistic analysis, disability, specific behavioural disturbances of the patients as well as caregiver's age, type of relationship and living in the south of Italy were observed to be a major risk factor for HBDDA. Conclusion The targeted use of scales specifically assessing BDDA of the caregiver and the identification of particular patient and caregiver characteristics are able to allow a precise and early definition of caregivers at high risk of burden and distress. This might be helpful in planning the correct social/clinical/rehabilitative approach. Copyright © 2005 John Wiley & Sons, Ltd.

Docetaxel is one of the most active drugs in second-line therapy for non-small-cell-lung-carcinoma (NSCLC). The aim of this multicenter study was to evaluate the safety and efficacy of weekly low-dose docetaxel. Forty-two patients with advanced NSCLC pretreated with cisplatinum-based chemotherapy were enrolled. Docetaxel was administered at a dose of 25 mg/m(2) weekly for 12 consecutive weeks. A total of 386 doses were given with a median number of 10 doses per patient (range: 3-12). Treatment showed low incidence of hematologic toxicity and modest non-hematologic toxicity. An episode of grade 4 thrombocytopenia was reported but no episodes of grade 3 or 4 neutropenia. Most frequent non-hematologic toxicities were asthenia and alopecia. Response rate was 10.5% and median survival time (MST) was 12.8 weeks. Weekly treatment with 25 mg/m(2) docetaxel for 12 consecutive weeks appears to be a feasible and active regimen with mild toxicity in heavily pretreated NSCLC patients.

The prevalence of anti-hepatitis C virus (HCV) positive test is higher among patients in dialysis and in kidney recipients than in general population. Hepatitis C virus infection is the main cause of chronic liver disease in renal transplant patients. Liver biopsy and virological analysis were performed to clarify the grade of liver damage in kidney recipients.Renal recipients patients with at least 5 yr under immunosuppression were submitted to clinical and laboratory analysis. Patients who tested anti-HCV positive were candidates to liver biopsy with no regard to transaminase levels.Forty-five patients tested anti-HCV positive and 42 anti-HCV negative. Twenty-six anti-HCV and RNA-HCV positive patients were submitted to liver biopsy. Seventy-three percentage of these patients presented chronic active hepatitis, from these only one patient presented cirrhosis. Only 29% of the anti-HCV positive group presented elevated alanine aminotransferase levels. Anti-HCV positive patients presented longer previous time on dialysis and less rejection episodes than the group anti-HCV negative (p0.05). All anti-HCV positive patients but one tested RNA-HCV positive by polymerase chain reaction (PCR).In this series the prevalence of anti-HCV positive is 51.7%. Most of the patients presented liver damage in histology caused by HCV. However, we found only mild or minimal fibrosis and inflammatory activity grade, despite 10 yr of HCV infection and 5 yr of immunosuppressive treatment. Only one patient presented cirrhosis (4%). Performing serial liver biopsies in a long-term follow-up is needed to clarify the impact of HCV infection in renal transplant patients.

Fecal incontinence is a disabling condition causing social isolation, whose real incidence is difficult to be exactly valued because patients are often reluctant to speak about it, even with their physician, or because they don't trust on surgical procedure. Aim of this study is report our experience in sphincteric reconstruction by direct sphincteric repair in patients suffering from post-traumatic fecal incontinence.Seven patients suffering from fecal incontinence due to traumatic lesions of anal sphincterial apparatus were surgically treated between 1981-2000; in the first patient cause was an injury due to impaling, in the second a previous obstetrical lesion and in the last five a previous fistulectomy. Direct sphincteric reconstruction after finding and isolation of two retracted terminals of sectioned sphincter was performed in all the patients. Sphincteric reconstruction has been always accompanied by total parenteral nutrition for about two weeks during the postoperative period. A protective colostomy was never performed.In five cases the results were excellent: patients had continence total recovery and postoperative manometry recorded basal and voluntary contraction pressures normalisation. In the two remaining cases there was only a modest improvement because of concomitant pudendal neuropathy. No operative wound infection was observed.We hope that more attention is paid to fecal incontinence either regarding instrumental semeiotics or medical or surgical therapy. In particular, direct sphincteroplasty can restore a satisfactory continence in a strong number of patients with anal sphincterial apparatus single traumatic lesions without pudendal neuropathy, relieving them from a heavily disabling condition.

Colonoscopic screening has been recommended in asymptomatic first-degree relatives of patients with colorectal cancer. In fact this population is believed to have an increased risk in developing colorectal neoplasia. The purpose of this study is to report the impact of colonoscopy in a series of completely asymptomatic first-degree relatives of patients operated on for colorectal cancer at our institution. A total of 480 individuals was requested to participate in a screening program based on faecal occult blood testing (FOBT) and colonoscopy in those with positive FOBT. Colonoscopy was also suggested to persons with negative FOBT. After the first 195 examined relatives, FOBT was abandoned because of continuously increasing acceptance of colonoscopy.Two hundred fifty four subjects (52.4%) accepted to participate at the screening program. After the first 195 examined relatives, FOBT was abandoned because of continuously increasing acceptance of colonoscopy. A total of 142 colonoscopies was performed. Colonoscopy was completed in 112 relatives (78.9%). Thirty-three subjects (23.2%) had a positive colonoscopy: one had invasive adenocarcinoma, one had large villous adenoma and 31 had 54 polyps. Twenty-three lesions (40.3%) were located proximal to the splenic flexure. Of the 54 polyps, 45 (83.3%) were less than 1 cm in size. These findings confirm the utility of colonoscopic screening in asymptomatic first-degree relatives of patients with colorectal cancer. However, its feasibility with the current endoscopic facilities remains an unsolved question.

We conducted a randomized trial to evaluate whether melphalan-prednisone (MPH-P) treatment administered just after diagnosis improves survival of stage I multiple myeloma (MM). Between January 1987 and March 1993, 145 consecutive previously untreated patients with stage I MM were randomized between treatment with MPH-P (administered for 4 days every 6 weeks) just after diagnosis and treatment only at disease progression. Survival was not influenced by MPH-P treatment either administered just after diagnosis or at disease progression (64 vs 71 months respectively). Comparing the first with the second group the odds ratio of death is 1.17 (95% confidence interval 0.57–2.42;P = 0.64). Disease progression occurred within a year in about 50% of patients who were initially untreated. Response rate was similar in both groups, but duration of response was shorter in patients who were treated at disease progression (48 vs 79 months, P = 0.044). Patients actually treated at disease progression (34/70) survived shorter than those who had neither disease progression nor treatment (56 vs > 92 months;P = 0.005). Starting MPH-P just after diagnosis does not improve survival and response rate in stage I MM, with respect to deferring therapy until disease progression. However, patients with stage I MM randomized to have treatment delayed and who actually progressed and were treated had shorter survival than those with stable disease and no treatment. Biologic or other disease features could identify these subgroups of patients. © 2000 Cancer Research Campaign

The role of HCV RNA levels and host factors in the severity of liver injury was studied. Enrolled were 298 consecutive liver biopsy-proven chronic hepatitis (CH) C patients (179 men; median age: 52 years, range 19-68; CH, 198; cirrhosis, 100) and 18 chronic hepatitis C with normal ALT. HCV genotypes were: 1a, 4.3%; 1b, 53%; 2a/c, 28%; 3a, 7%; 4, 1.3%, and mixed 6.4%. Serum HCV RNA levels were similar for all genotypes (median: 2.8 x 10(6) eq/ml; range0.2-69). In patients with chronic hepatitis without cirrhosis, the serum HCV RNA levels reflected the grade of liver necroinflammatory activity (R = 0.45; P0.001) and the stage of fibrosis (R = 0.51; P0.001), regardless of age, gender, HCV genotype, hepatic steatosis, and hepatic iron overload. Patients with high serum HCV RNA levels (or =3 x 10(6) eq/ml) had higher ALT values (P0.002) than those with lower HCV RNA levels. Patients with normal ALT showed low HCV RNA levels (median: 0.82 x 10(6) eq/ml) and histological features of minimal or mild chronic hepatitis. Cirrhotic patients showed significantly lower levels of viremia than those with chronic hepatitis with a similar HAI. The data of a subgroup of 62 patients with an established time of infection showed that for a similar duration of disease, patients with serum HCV RNA levelsor =3 x 10(6) eq/ml had a significantly higher fibrosis score than those with lower levels. HAI and fibrosis score were significantly higher in patients with HCV RNA levelsor =3 x 10(6) eq/ml and grade 3-4 steatosis than those with lower HCV RNA levels and steatosis grades. The data indicate that the liver damage is correlated with the HCV RNA levels and that a high viral load acts together with steatosis in accelerating the progression of liver injury.

In metastatic breast cancer (MBC) doubling the epirubicin (EPI) dose intensity (DI) within the FEC (5-fluorouracil, EPI, cyclophosphamide) regimen could increase the response rate (RR) and ameliorate the quality of life (QoL) over standard FEC. From May, 1995, 74 consecutive patients with MBC were randomly treated with 6 courses of two FEC regimens containing 60 (60FEC) or 120 (120FEC, supported by primary G-CSF) mg/m2 of EPI. Drugs were administered every 21 days. The QoL was assessed over and after treatment by the EORTC QLQ-C30 (VER 2.0) and QLQ-BR23 questionnaires, compiled by the patient, and the Spitzer's QL-index, compiled by the physician. The study was prematurely closed in May, 1997, due to RR and QoL data of 4th interim analysis. The delivered EPI DI was 20.0 and 37.9 mg/m2/week in 60- and in 120FEC, respectively. Among the two regimens, there was no statistically significant difference in RR or in improvement of baseline overall QoL. With respect to 60FEC patients, the 120FEC patients had longer time to progression (19.2 vs 13.1 mos, p=0.04). Over baseline, the 120- but not the 60FEC patients had significantly greater pain decrease and lower deterioration of body image. In MBC, both 60- and 120FEC regimens furnished the same RR and improvement in overall baseline QoL. With respect to 60FEC patients, the 120FEC patients experienced longer time to progression. Over baseline, pain decrease and preservation of body image were also greater in these patients.

The possible dermatological and proctologic causes, of Pruritus Ani that often, due to its persistence and for its consequent lesions of scratching, becomes a real disease, are analysed. Particular attention is given to therapeutical treatment, describing which hygienic-dietetic rules must be followed and which treatments can be utilised, if the cause of the symptom is known and if it is possible to remove it or not. Moreover, personal experience on 312 patients examined in twelve years is reported.

Personal experience on transanal excision of rectal adenomas without affecting sphincteric function is reported.From 1985 to 1997, 27 patients suffering from rectal adenomatous polyps underwent surgery; the sites of lesions were within 3 to 10 cm from anal orifice in the whole series; the age of patients ranged from 30 to 81 years. Two different procedures were employed: the Parks' technique and the electroresection by traction flap technique according to Faivre.Any postsurgical complication such as hemorrhage, stenosis or incontinentia occurred; surgical mortality was absent. Histological examination disclosed severe dysplasia as well as in situ carcinoma in 6 patients (22.2%) and malignant polyps in 9 patients (33.3%). Only in a case a palliative excision was performed since the poor general conditions of this patient did not permit a more extended treatment; a local relapse of the tumour associated with liver metastases led the patient to death 22 months after surgery. Three patients were lost to follow-up and 2 patients died because of other causes, 6 and 8 years after surgical excision, respectively.The conclusions are is drawn that either Park's and Faivre's procedures are useful and safe for the surgical treatment of rectal villous polyps extended up to 8-12 cm from anal orifice, in spite of the presence of malignant foci within their mass. These surgical procedures are simple and relatively poor traumatic; for this reason they are more suitable than other transabdominal or abdomino-perineal approaches for older patients and other at risk-patients. It is underlined that the treated patients require a long-term follow-up aimed at the early diagnosis of possible relapses of adenomatosis.

Technological evolution allowed to record high fidelity traces that--when analysed by complex mathematical systems--may provide extremely detailed and new information about all the factors involved in the determinism of pulse wave. Suprasystolic waves, i.e. those recorded immediately before systolic pressure, may be regarded as similar to aortic pressure waves evaluated during cardiac catheterization. Suprasystolic dP/dt max was calculated from the profile of pulse wave recorded by the DynaPulse, an automatic portable non-invasive oscillometric method to simultaneously measure BP and analyse arterial waveforms, in 10 normal healthy subjects (age 37 +/- 5) and 5 subjects with ischaemic dilatative cardiomyopathy (age 41 +/- 7) whose ejection fraction--invasively assessed--was40%. The 24 h dP/dt max curves were analysed by parametric and non parametric tests. We found a significant difference (p0.001) in the average 24-h dP/dt max between healthy subjects (471 +/- 36.7 mmHg/sec) and patients with impaired cardiac function (271 +/- 54.2 mmHg/sec). The average daytime and nighttime dP/dt max values showed significantly higher values in normal subject in comparison to patients with heart failure (daytime 7.23 h: 529 +/- 74 mmHg/s versus 227 +/- 64 mmHg/s, p0.001; nighttime: 572 +/- 82 mmHg/s versus 202 +/- 67 mmHg/s, p0.001). We also found a difference in the occurrence of acrophases, at similar blood pressure value, i.e. the highest dP/dt values occurred during the night in normal subject, the opposite in ischaemic patients. Furthermore, the dP/dt max correlates only with systolic blood pressure.

Rokitamycin is a semisynthetic macrolide with a lactonic ring with 16 atoms, showing anti-bacterial action at concentrations near to MIC. A controlled clinical study is carried out, in parallel groups, whose aim was to assess the therapeutic action and safety of two dosage schemes of rokitamycin, in the short term treatment (5 days) of acute infective processes of odontostomatological origin.Twenty patients (14 males, 6 females) were recruited for the trial, suffering from alveolitis, abscess, phlegmon, sialadenitis and suppurating cysts. The patients were divided in a randomized fashion into two groups: 10 patients were treated orally with 800 mg/day and 10 with 1200 mg/day. Rokitamycin was supplied in 400 mg tablets.The 5 days of treatment with rokitamycin determined the complete resolution of the infective process, with eradication of the germs originally isolated, all belonging to the Streptococcus genus. Clinical efficacy was evident by the third day of treatment, with a prompt improvement of symptoms (functional limitation, pain, tumefaction) and the return of body temperature to within normal limits, in a totally superimposable fashion between the two groups. Safety was excellent with both doses, with no side effects observed.The results of the study show that treatment with rokitamycin in the short term, at the usual dosage of 800 mg/day, is a valid therapeutic scheme in infective processes in odontostomatology.

The bcl-2 gene product has been shown to regulate apoptotic cell death, and its dysregulation has been shown to induce several abnormalities in the immune system. No data exist regarding bcl-2 expression in autoimmune diseases, such as human insulin-dependent diabetes mellitus (IDDM). We investigated bcl-2 protein expression by testing T lymphocytes from 15 newly-diagnosed (3 weeks) IDDM patients in comparison to 10 age-matched control subjects. The expression of bcl-2 on CD3+ lymphocyte subsets was investigated after membrane permeabilization by two- or three-colour immunofluorescence. When the percentage and mean fluorescence intensity (MFI) of bcl-2+/CD3+ cells from normal individuals and patients were compared, we found that bcl-2 expression within the CD3+ and CD4+ CD45R0+ T-cell populations was reduced significantly in IDDM patients (46.8 +/- 15.4 vs 79.6 +/- 11.7; 25.7 +/- 3.8 vs 47.15 +/- 5.7, respectively; p0.001). To establish whether low bcl-2 expression in T cells from newly-diagnosed patients reflects their susceptibility to death by an apoptotic process, we also evaluated DNA staining with propidium iodide in CD3+ lymphocyte suspension after a (24-72 h) culture period (spontaneous apoptosis). We found that IDDM patients have higher levels of spontaneous apoptosis (mean +/- SEM: 24 h = 4.6 +/- 0.8; 48 h = 9.9 +/- 1; 72 h = 12.8 +/- 1.1) than control subjects (24 h = 1.8 +/- 0.4; 48 h = 4.6 +/- 0.4; 72 h = 5.7 +/- 0.3; p0.02-0.001). Our study suggests that recent onset IDDM is characterised by reduced bcl-2 expression, which in turn may be associated with the increased spontaneous apoptosis we observed.

The simple determination of transaortic pressure gradient does not accurately assess the severity of an aortic valve stenosis. Thus, estimating the aortic valve area (AVA) is vital for clinical decision-making. Cardiac catheterization has been considered the "gold-standard" for the quantification of the stenotic valve area, but this technique may underestimate the actual valve area when aortic regurgitation is associated. Doppler transthoracic echocardiography (TTE) with the continuity equation method is usually employed for AVA estimation. Recently, in pure aortic stenosis, transesophageal echocardiography (TEE) has provided AVA values well-correlated to hemodynamic invasive results.In this study, we correlated AVA values by TTE and multiplane TEE in 18 patients with combined aortic valve stenosis and regurgitation.The mean values of AVA by TEE and TTE were 0.74 +/- 0.12 and 0.68 +/- 0.55 cm2, respectively (p = NS). TEE-derived AVA correlated well to TTE-derived AVA (r = 0.816; p0.0001). Critical aortic stenosis was predicted by TEE with 100% sensitivity and specificity. Total time of examination was significantly longer for TTE (p0.00001).In conclusion, direct planimetry by multiplane TEE is a reliable method for AVA determination in aortic stenoinsufficiency. For this purpose, when the technical quality of TTE study is poor or when the patient is critically ill and does not tolerate a longer lasting TTE, multiplane TEE should be considered.

People with low self-esteem (LSE) seem to focus on self-protection; rather than trying to achieve gains for their self-esteem, they try to avoid losses. This research examined, in a social comparison context, the hypothesis that LSEs seek self-enhancement when they have an opportunity that is "safe," that is, carrying little risk of humiliation. Experiments 1 and 2 indicated that LSEs sought the most social comparisons after receiving success feedback, whereas high-self-esteem Ss (HSEs) sought the most comparisons after failure. Further results suggested that LSEs who succeeded were seizing a safe means of self-enhancement and that HSEs who failed were seeking to compensate for the failure. Also supporting this interpretation for LSEs was Experiment 3, in which LSEs who succeeded sought the most comparisons when such comparisons promised to be favorable. All three studies illustrate the value of a new measure of social comparison selection.

Endothelin (ET), besides being a powerful vasoactive agent, acts as a mitogen in some cell types. ET-like immunoreactivity has been recently detected by immunocytochemistry in the vascular endothelium of human tooth germ and dental pulp, thus providing evidence for local ET production in these tissues. The effects of ET-1 on DNA synthesis in primary cultures of human dental pulp were now investigated. DNA synthesis was evaluated by flow cytometric assay and by 5-bromo,2′deoxyuridine incorporation as detected by immunocytochemistry. Cultured cells were morphologically similar to dental pulp cells and displayed vimentin immunoreactivity. Incubation of cultures with ET-1 resulted in a dose-dependent increase in the number of S-phase-traversing cells over control (unstimulated) cultures. Control skin fibroblasts were also responsive to ET. This finding raises the possibility that the multifunctional peptide ET-1 might subserve growth-promoting activity in the human tooth. It is tentatively suggested that such as an activity might be important during tooth development and in pulp inflammation and healing.

Indwelling venous catheters are invaluable for long-term chemotherapy, antibiotics, and hyperalimentation. However, their placement and chronic use can cause serious complications. This study was done to develop guidelines for minimizing complications of long-term vascular access. Complications associated with 355 lines placed in 297 patients were recorded prospectively at the George Washington University Hospital. Single or double lumen catheters were placed via the infraclavicular subclavian approach (126), external jugular cutdown (133), internal jugular cutdown (22), and cephalic vein cutdown (42). While catheters were malpositioned in 15 cases (5.2%), route of placement did not influence this adverse outcome. Pneumothorax occurred only in the subclavian approach (5.6%). Axillary vein thrombosis was significantly more prevalent in catheters placed via the subclavian vein (10.3%) compared with the external jugular (2.3%) P0.05 or cephalic (2.3%) vein. Line sepsis occurred in 28 instances; this was statistically associated with an abnormal white blood count and with the use of double-lumen catheters (double-lumen catheter sepsis = 18.4%, single lumen = 4.4%, P0.01). The morbidity of long-term venous catheters is affected significantly by the route of placement, the number of catheter lumens, and the pre-placement white blood count. As a result of our analysis, we recommend single-lumen catheter placement using the external jugular cutdown route whenever possible.

Seventeen consecutive patients with previously untreated poor prognosis Hodgkin's disease (clinical stage II and III with systemic symptoms, and stage IV) received 6 courses of aggressive chemotherapy, with (9 patients) and without (8 patients) the addition of recombinant human granulocyte-macrophage colony stimulating factor (rhGM-CSF). Chemotherapy (MOPP/ABV/CAD regimen) included full doses of nitrogen mustard, lomustine (CCNU), vindesine, melphalan, prednisone, epidoxorubicin, vincristine, procarbazine, vinblastine and bleomycin, and was administered between days 1 and 15 of each course. Course were planned for 28-day intervals. rhGM-CSF was given at a dose of 5 micrograms/kg/day subcutaneously from day 16 to 26 of each course. With cytopenia (i.e. white blood cell, WBC, count3.0 x 10(9)/L and/or platelet count100 x 10(9)/L) delaying courses was preferred to administering reduced drug dosages. Substantial delays (ranging from 7 to 28 days) in delivering cytostatics were necessary between 70% of courses. The cumulative mean number of days for which the courses had to be delayed before completing the 6 MOPP/ABV/CAD courses was 57. The percentage of planned doses of cytotoxic drugs (nitrogen mustard, melphalan, epidoxorubicin, procarbazine) actually administered was 92%. Causes of treatment delay were presented by leucopenia in 82% and by leuco-thrombocytopenia in 23% of the courses. The WBC nadir was constantly encountered at day 20-21 following completion of courses, and slightly worsened with subsequent courses. The decrease in platelet values was milder than that in WBC counts. There were no differences in any of the above parameters between patients treated with MOPP/ABV/CAD alone or followed by rhGM-CSF.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of two distinct and successive clinical pilot studies investigating feasibility of aggressive chemotherapy in large cell and unclassified non-Hodgkin's lymphomas are reported. In the first study (1986-87) the ProMACE-MOPP chemotherapy (P-M), a 2nd generation regimen, was administered to 10 patients, whereas in the second study (1987-88) the ProMACE-CytaBOM schedule (P-C), a 3rd generation regimen, was administered to 13 patients. The clinical and prognostic features of the two groups of patients were quite comparable, the only difference being the different follow-up times (median: 43 vs 26 months). The number of complete remissions, freedom from relapse and overall survival were slightly better in the P-M group, with-out a statistically significant difference, despite the longer follow-up time. Hematological toxicity was higher in the P-M study, while gastrointestinal (mucositis, hepatic transitory damage) and neurological toxicity (peripheral neuritis) were somewhat lower. In conclusion, the P-M regimen is worth considering for the treatment of high grade malignant lymphomas, although it was not recently designed and is not widely used at present.

Bromodeoxyuridine (BUDR) is a thymidine analog that is incorporated into the DNA of proliferating cells. Because the dose of BUDR that is needed to label cells is not toxic, cell labeling can be accomplished in vivo by infusing the substance into patients. A monoclonal antibody against BUDR is then used to identify BUDR-labeled cells. The same cell population can also be stained for DNA content with propidium iodide (PI). Using bivariate flow cytometry (FCM) for measurements, both the percentage of BUDR-labeled cells and their total DNA content can be evaluated. This technique allows one to obtain the labeling index (LI) and the DNA synthesis time (TS). The potential doubling time (Tpot) and the fractional turnover rate (FTR) can be mathematically derived. During a 15-month period, in vivo BUDR infusion to study cell kinetics was used in 112 consecutive patients with various types of malignant tumors: acute leukemia (50), gastric cancer (42), and brain gliomas (20). The procedure took 6 to 9 h to complete and there was no immediate toxicity from BUDR administration. Successful LI and TS determinations were obtained in 89 (80%) and in 80 (72%) of the 112 patients, respectively. Proliferative activity in 34 patients with acute nonlymphoblastic leukemias who were uniformly treated for remission induction and maintenance was measured from Tpot and FTR. It was greater in responsive than in nonresponsive patients, and in those who experienced remission for over 8 months than in those who had a shorter remission. Proliferative activity was also greater in patients with advanced gastric cancers than in those with more limited disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Following a brief review of the literature, the paper describes a case report of mandibular osteosarcoma and discusses the prognostic and therapeutic aspects.

The paper describes a case of embryonal rhabdomyosarcoma of the maxillary antrum which, according to the Intergroup Rhabdomyosarcoma Study (IRS) protocol, was treated with a protocol which included cycles of chemotherapy and radiotherapy.

Takayasu's disease affects young females in the second and third decade of life. During the chronic phase, the aorta and its major arteries become stenotic, causing significant sequelae. Surgical treatment is possible with expectation of good results. The author advises treatment of stenotic arteries that are potentially dangerous or that adversely affect lifestyle with either percutaneous transluminal angioplasty or surgery. The author emphasizes the difference between surgical procedures for atherosclerosis versus a procedure for Takayasu's disease.

Thirteen high-risk patients underwent lower extremity revascularization anesthetized with a regional nerve block technique. The sciatic, femoral, and obturator nerves were infiltrated with 1% lidocaine and 0.25% bupivacaine. Eight femoropopliteal and five femorotibial bypasses were performed for limb salvage (11 patients), disabling claudication (one patient), and popliteal artery aneurysm (one patient). Analgesia was adequate with only one patient who needed supplemental nitrous oxide. One patient died on the sixth postoperative day of a myocardial infarction. Regional nerve block is an effective anesthetic technique that should be considered if general or spinal anesthesia is inappropriate. (J VASC SURG 1986;4:351-4.)

SummaryTwenty-three patients with rheumatoid arthritis and 9 patients with other forms of rheumatic diseases were treated for 20 days with 420 mg glucametacin per day, given as three 140 mg capsules. The treatment produced anti-inflammatory effects which were rated as good in about half the cases, with improvement of the majority of the clinical parameters studied. There were mild digestive side-effects. One patient with gallstones developed biliary colic, but the relationship of this to glucametacin treatment was not clear. The results obtained in the 32 patients treated with 140 mg glucametacin capsules were very similar to those which the same authors had observed in a very extensive case series of patients with rheumatic diseases treated with the same daily dose, but given as 70 mg capsules. It is suggested that the new preparation, which halves the number of capsules taken each day, is to be preferred to the smaller dose capsules.

Between 1969 and 1978 more than 1000 mandible fractures were treated by the otolaryngology services at the University of Minnesota and affiliated hospitals. Most were successfully treated but 17 patients had significant loss of mandibular bone resulting in a much more difficult management problem. The loss of bone was usually due either to the initial injury such as a gunshot wound or was secondary to the complications of non-union or osteomyelitis. Particulate cancellous marrow grafts within a Vitallium or titanium mesh crib (PCM crib graft) were used to reconstruct the mandibular defects. One patient had bilateral defects requiring 2 PCM crib grafts. Thus, 18 grafts spanning defects 2 to 12 cm were performed. Success was measured by a stable mandible with satisfactory occlusion and he ability to chew, swallow and articulate satisfactorally. Of 18 grafts, 15 met these requirements. Several factors important to successful mandibular reconstruction included adequate immobilization, intraoral soft tissue coverage, external skin cover and tension-free closure and optimal intraoral hygiene. The crib used to hold the particulate cancellous marrow in position during the healing phase has been removed in three otherwise successful cases because of intraoral mucosal tenting or dehiscence or to allow adequate fitting of dentures. In our experience, the use of autogenous cancellous bone and marrow in metallic mesh has been a successful means of restoring function and stability to mandibular defects.

• In a review of 350 patients with mandibular fractures between 1976 and 1978, eight cases of chronic mandibular osteomyelitis were found. Treatment in all cases consisted of intravenous antibiotics and debridement. In addition, in some cases a suction-irrigation system was used after debridement. From this study, the following can be stated: (1) Osteomyelitis following mandibular fractures is uncommon. (2) Once chronic osteomyelitis has developed, aggressive antibiotic and surgical treatment is needed. (3) The use of the suction-irrigation system after debridement is an effective adjunctive aid in treating osteomyelitis. Cosmesis is superior to that obtained with older techniques because wounds are closed primarily. ( Arch Otolaryngol 1982;108:30-33)

Purpose: The VICTOR-1 study demonstrated that the all-oral metronomic combination of vinorelbine and capecitabine is highly active and well tolerated in hormone receptor-positive/HER2-negative patients. The VICTOR-2 study was designed to confirm these results. Methods: Patients received mVNR 40 mg three times a week and mCAPE 500 mg three times a day, continuously. The primary endpoint was the clinical benefit rate (CBR); secondary endpoints were toxicity, objective response rate (ORR), and progression-free survival (PFS). Results: Eighty patients were evaluable for the primary efficacy analysis. Median age was 65.3 years; most patients had HR-positive tumors (65 %). The CBR was 45.7 % (95 % CI 28.8–63.4) and 51.1 % (95 % CI 35.8–66.3) in first- and ≥ second-line therapy, respectively. The ORR was 35.5 % in first-line (95 % CI 19.2–54.6) and 25.6 % in ≥second-line (95 % CI 13.5–41.2). The median duration of response was 11.3 and 6.4 months and PFS rates at 1 year were 24.3 and 22.2 %, respectively. In triple-negative breast cancer patients (N = 28, 35 %) a lower, but clinically relevant CBR (35.7, 95 % CI 18.6–55.9) was observed. The main toxicities per cycle were non-febrile neutropenia (1.1 %), hand-foot syndrome (1.0 %), nausea and vomiting (1.0 %), leucopenia (0.8 %), fatigue (0.7 %), and diarrhea (0.4 %). Conclusion: The VICTOR-2 study confirms the clinical activity of mVNR and mCAPE in HER2-negative breast cancer patients, suggesting that the easy schedule of administration, which requires monthly blood tests and limits patients’ dependence on hospitals, and the low cost of the drugs are valuable elements, even for countries with limited access to innovative or expensive drugs.

Hypereosinophilic syndrome (HES) is characterized by an overproduction of eosinophils that leads to organ damage. Although most cases of HES frequently affect the lungs, heart, and gastrointestinal tract, there are a few reported cases of peripheral vascular involvement. We report a case of a patient with a history of colonic HES who presented with idiopathic occlusion of the brachial artery. A 28-year-old woman with a recent history of eosinophilic colitis presented with a several-week history of left hand pain, pallor, and paresthesias. Her hand was cool, without palpable pulses. Her eosinophilia count was 38%. An arteriogram documented a left brachial artery occlusion and diffuse left arm vasospasm. A brachial-to-brachial bypass was performed. Postoperatively, there was extensive vasospasm of her distal upper extremity arteries, which was treated with calcium-channel blockers and steroids. Her symptoms resolved and she has been asymptomatic for 9 months. The segment of occluded artery was found to contain many eosinophils on histologic examination. HES of the arterial system is an exceedingly rare cause of occlusion. Our patient presented with eosinophilia, arterial vasospasm with subsequent occlusion, and the presence of eosinophilic infiltration on the pathologic specimen. These data, combined with the patient's previous history, demonstrate that the patient's occlusion may have been secondary to HES.

• Between 1972 and 1987, a total of 159 cases of esophageal foreign body were treated at the University of Minnesota Affiliated Hospitals, Minneapolis. Although coins were the most frequent offending agent in the pediatric group, meat was the most common in the entire series (60%). Eighty percent of coins were impacted in the upper esophagus, while meat impaction occurred most frequently in the distal esophagus (42%). Rigid esophagoscopy was performed in 134 patients. The foreign body was removed during esophagoscopy in 122 cases, advanced into the stomach in two cases, and not found in ten cases. In addition to esophagoscopy, when meat obstruction was suspected, several pharmacologic agents were successful in relieving the obstruction, such as parenterally administered diazepam (Valium) (8/27) and glucagon (6/14). Spontaneous passage was noted in seven cases. No cases of esophageal carcinoma were discovered in this series. ( Arch Otolaryngol 1981;107:249-251)

A 20-year-old female with three laboratory ARA criteria pro SLE (LE cells, FANA, and positive Coombs test with hemolytic anemia), not under steroid therapy, developed polyarthritis, erythematous rash and acute pancreatitis simultaneously. The latter regressed with high doses of 6-methylprednisolone. Twenty-five months after remission of pancreatitis, no new clinical manifestations (of SLE) have appeared. In another 74 cases of SLE with an average follow-up of 3 years and 8 months there were no other cases of pancreatitis.

The importance of individualized treatment of patients with primary and secondary axillary-subclavian vein thrombosis is described with special emphasis on the use of thrombolytic therapy. Nine patients were treated with streptokinase or urokinase. Balloon dilation of the axillary or subclavian vein and first rib resection were also selectively used. Of the five patients with primary axillary-subclavian thrombosis, three did not have symptoms after the thrombus was lysed. Two had successful lysis of the thrombus but later suffered a rethrombosis, one of which most likely resulted from an untreated stenosis. All four of the patients with secondary thrombosis had successful thrombolysis. Patients with primary axillary-subclavian thrombosis are usually young and as many as 40% continue to have intermittent upper extremity edema or pain. For this reason we believe aggressive attempts to reestablish normal venous return through the axillary and subclavian veins are warranted. Patients with secondary axillary-subclavian thrombosis usually require prolonged venous catheterization for chemotherapy or total parenteral nutrition. Since patency of major upper extremity veins is extremely important in these patients with secondary thrombosis, we believe that vigorous attempts to restore these venous access routes are indicated and appropriate.

In a 24-week multicenter double-blind clinical trial, efficacy and safety of the novel nonsteroidal anti-inflammatory drug imidazole salicylate (750 mg t.i.d. per os) and ibuprofen (600 mg t.i.d. per os) were compared in 60 patients with classical or definite rheumatoid arthritis, randomly assigned to one of the two treatment groups. The patients improved significantly with both treatments in all the clinical parameters examined such as the duration of morning stiffness, grip strength of both hands, Ritchie's articular index and severity of joint pain. The systemic tolerability, assessed by hematological, liver and kidney function tests was excellent with both treatments. The incidence of side effects was overall fairly low with both drugs, and lower in the group treated with imidazole salicylate (23% vs. 33%).

The presence of false tendons (FT) was sought with M-mode and 2-D echocardiography in a consecutive series of 316 patients with a wide age range (13-73 yrs). FT were observed in 13 patients (4.1%), all of them in the left ventricular cavity. Their clinical significance is pointed out together with the possibility of diagnostic error with other pathological formations, particularly intracavitary thrombi.

A new nonsteroidal anti-inflammatory agent, 1-(p-chlorobenzyl)-5-methylindole-3-acetic acid monohydrate glucosamide (glucametacine, Teoremac¿), was used in the treatment of a total of 39 patients including 31 cases of rheumatoid arthritis, 3 of ankylosing spondylitis, 1 of psoriatic rheumatism, 1 of chronic chondrocalcinosis and 3 of arthrosis. Teoremac was given for 14 days at a dosage of 420 mg/day. The drug was shown to be more or less active in all the patients except 4. The improvement in the various clinical parameters of rheumatoid arthritis studied was statistically significant. The side effects recorded were headache, which was severe in only 1 case, and "minor" disturbances of the gastro-intestinal tract. A double blind crossover trial was carried out in 15 patients with rheumatoid arthritis to compare the action of Teoremac (420 mg/day for 14 days) with that of indometacin (100 mg/day for 14 days). Under the conditions of the trial, the clinical findings showed Teoremac to be slightly superior to indometacin, but the difference was not significant statistically.