How to compare doses of different antipsychotics: a systematic review of methods.

BACKGROUND: The ability to calculate equivalent dosage is important when comparing or switching between doses of different antipsychotics in the treatment of schizophrenia. It is also necessary when designing antipsychotic comparator trials which control for dosage. METHOD: A systematic review to identify and critically evaluate the methods available for the estimation of antipsychotic dose equivalence was conducted. Electronic searches were carried out using Medline and PubMed and additional information was requested from pharmaceutical companies. The identified methods were evaluated against specific criteria regarding scientific rigour, quality of source data underpinning the method, clinical applicability and utility. RESULTS: Eleven articles were identified that described methodologies for antipsychotic dose equivalence. Seven of these referred to calculated methods, including chlorpromazine equivalence, maximum dose and daily-defined dose, and relied on an evidence base from both fixed and flexible dosing data. The remaining four described consensus methods which were based on the knowledge and experience of experts. Chlorpromazine was used as the standard comparator drug in the majority of the calculated equivalence studies, whereas risperidone was used for most consensus methods. CONCLUSIONS: Comparison of methods for calculating antipsychotic dose equivalence suggests that different methods yield different equivalencies and the evidence is not sufficiently robust for any of these to be considered as a gold standard method. Thus, choice of method may introduce bias, either an over or underestimate of equivalent dosage, when designing head-to-head, antipsychotic, fixed-dose trials. Consequently, clinical trial reports should routinely include justification of the choice of method for calculating dose equivalence.

[Serologic investigation on the prevalence of Leptospira spp infection in occupationally exposed subjects]. / Indagine sierologica sulla prevalenza di infezione da Leptospira spp in soggetti occupazionalmente esposti.

BACKGROUND: Leptospirosis is a worldwide zoonotic infection with a high in tropical regions. OBJECTIVE: The aim of the present survey was to verify the occurrence of diffusion of leptospirosis infections in Eastern Sicily, in some groups (6 veterinarians, 34 farmers and 28 abattoir workers), who were considered at high occupational risk. METHODS: Serologic investigation were performed using the immunological method (Martin Petit test); the Leptospira serovars considered were: ictero-haemorrhagiae (Bianchi 1); canicola (Alarik); pomona (Mezzano 1); grippo-typhosa (Moskva V); bratislava (Riccio 2); sejroe (Topino 1); hardjo (Hardjoprajitno); saxkoebing (Mus 24). RESULTS: Contagion was observed in 16 subjects out of 68 (23.5%), and the anti-leptospira antibodies detected were canicola, hardjo, sejroe grippo-typhosa e ictero-haemorrhagiae. CONCLUSIONS: The authors stress the importance carrying out periodic health surveillance in subjects working in wet and contaminated environments or who are continuously in contact with animals receptive to infections. The present study also confirms the need to adopt preventive measures such as vaccines, and control programs for activities at high risk.

The discovery of nephrouroameba: was it real or not?

In 1938 Procaccini showed scientific interest in a new kind of ameba, and called it "nephrouroameba" from which the disease "nephrouroamebiasis" is derived. He wrote a paper titled "La Nefrouroamoebiasi" thus describing its history, the biopathogenetic evolutionary cycle of the protozoon, its therapeutic, epidemiological, anatomo-biological, diagnostic, cultural, biological and morphological features. Between 1934 and 1939, Procaccini had the opportunity to follow many patients belonging to a group of Italian soldiers serving in the Eastern Italian Army in Ethiopia. At that time he was responsible for the biopathological laboratory. After a short preclinical stage of fatigue, patients suffering from nephrouroamebiasis showed a nephrotic syndrome with gross hematuria. The symptoms ceased within a few days but residual microhematuria, albuminuria and urine casts persisted for many months. After microscopic observation, he reproduced some protozoons and classified them as a kind of ameba. Critical analysis of his report leads to the morphological identification of Trichomonas, thus excluding his classification as nephrouroamebas.

A novel approach to calculation of mean mitral valve gradient by Doppler echocardiography.

The Doppler-derived mean mitral valve gradient (DeltaP(M)) based on the simplified Bernoulli equation requires computerized integration of the Doppler signal and evaluation by a technician with the use of special equipment. We have noted empirically that the DeltaP(M) can be derived by the equation DeltaP(M) = (P(P) - P(T)) / 3 + P(T). Peak (P(P)) and trough (P(T)) pressures are derived from the simplified Bernoulli equation (P = 4V(2)). This equation can be used by the experienced observer to calculate the mean mitral valve gradient without specialized equipment. The purpose of this study is to validate the above empirically derived equation in patients with mitral stenosis. We retrospectively reviewed 41 consecutive studies done at our institution from October 1, 1997, through September 30, 1998, in which mean mitral valve gradient was assessed. Each study was reviewed and the DeltaP(M), P(P), and P(T) were measured for 3 beats by using the software package on an HP Sonos 2500. DeltaP(M) was also calculated with our formula. A linear regression model was used to compare the results of the measured versus the calculated DeltaP(M). The following sub-categories were also evaluated: transthoracic studies (TTE), transesophageal studies (TEE), native valve gradients (NV), prosthetic valve gradients (PV), sinus rhythm (SR), and atrial fibrillation (AF). The results of the regression analysis of the entire population of mean versus calculated DeltaP(M) are n = 41, r = 0.99, P <.001, and standard error of the estimate (SEE) = 0.67. The regression results for the subgroups are as follows: TTE: n = 30, r = 0.99, P <.001, SEE = 0.51; TEE: n = 11, r = 0.99, P <.001, SEE = 59; NV: n = 26, r = 0.99, P <.001, SEE = 0.59; PV: n = 15, r = 0.98, P <.001, SEE = 0.84; SR: n = 23, r = 0.99, P <.001, SEE = 0.58; and AF: n = 18, r = 0.98, P <.001, SEE = 0.82. In conclusion, the simple formula that we have derived is an accurate method for calculation of mean mitral valve gradient, and it is accurate over multiple subgroups. Furthermore, the formula allows visual verification of mean mitral gradient without specialized software.

[Occupational activity with risk of leptospirosis. Prevention and health surveillance]. / Rassegna delle attività lavorative a rischio d'infezione da leptospire. Prevenzione e sorveglianza sanitaria.

The analysis of the epidemiological studies carried out in Italy give us the idea for a very precise survey of the occupational leptospirosis. We have identified the occupational hazards and the precautionary measures. In Italy the first epidemiological data about human leptospirosis goes back to 1917. During following decades were highlighted several occupational forms of leptospirosis, specifically seasonal epidemics among rice-workers. Epidemiological studies carried out in Italy from 1950 to 1990 showed that leptospirosis was again widespread although precautionary measures and there was a probable spread of the "minor leptospirosis" at the same time of common cases of "major leptospirosis". The latest data issued by Ministry of the Health related years '94-'97 confirm the persistence of leptospirosis, for the most part in the north. However there is a problem of underestimate because many times human leptospirosis show itself with minor clinical forms. In the working environment is essential the function of the Medico Competente. He must avail himself of the precautionary measures for the biological risk specified in D.lgs 626/94.

Epidemiological trend of human leptospirosis in Italy between 1994 and 1996.

In the three-year period 1994 1996, 222 reports on human cases of leptospirosis were received by the Italian Ministry of Health. The average annual number of reports was 29.2% lower than in the preceding eight years. In all cases but two the infections were thought to have been acquired in Italy. As in previous years, the majority of cases was observed in the northern regions of the country (83.8%), mostly in males (88.9%). Cases occurred in all age groups, but were more common in the working-age population (15-64 years). There was no common-source outbreaks. The typical leptospiral seasonal course, with a peak in August, was observed. During 1994, leptospirosis was the reported cause of death in 19 patients. Mortality was higher among males than females. The overall fatality rate was 22.6%. During the study period, a total of 126 cases of leptospirosis were confirmed by the National Centre for Leptospirosis or one of the 12 Regional Leptospira Laboratories. Of the 103 patients for whom information on place of residence, contact with animals, occupational and recreational activities was available, 98 (95.1%) were people who live in rural areas or devote themselves to occupational or recreational activities at risk. The likely source of infection and the mode of exposure were known for 55 patients. Forty-five patients (81.8%) were likely infected by contaminating water (43 cases) or soil (2 cases), ten (18.2%) by direct contact with animals or animal urine. Both running (51.2%) and stagnant water (27.9%) have been reported as a source of infection. Rodents were implicated in 50.0% of the 10 cases involving animals. In comparison with the preceding eight-year period, the risk of contracting leptospirosis was found to have increased for recreational activities (from 34.7 to 38.2%) and decreased for occupational activities (from 45.8 to 32.7%). A large number of infections, however, was ascribed to accidental events (25.5%). As in the previous period, besides fever, the involvement of the liver was the most frequent clinical manifestation (70.8%). Influenza-like symptoms were the only signs of illness in 15.1% of cases. Infections by 9 different serogroups were detected. The most frequent antibodies were those against serovars icterohaemorrhagiae, poi, copenhageni and brattislava. The presence of co-agglutinins against serovars belonging to different serogroups prevented the identification of the presumptive infecting serogroup in 19.8% of subjects.

[Apropos of 1 case of anisakiasis contracted in Sicily]. / A propos d'un cas d'anisakiase contractée en sicile.

The authors describe a case of anisakiasis in Sicily. The diagnosis was based on the knowledge that a contaminated fish, Lepidopus caudatus, had probably been absorbed, as well as on clinical intestinal symptoms, intestinal lesions observed by endoscopy and O.G.D.S, duodenal infiltration by eosinophilic polymorphonuclear, positive ELISA anisakis serology and successful treatment by albendazole.

Evaluation of hemolysis in patients with prosthetic heart valves.

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.

[Francesco Redi and the birth of experimental parasitology]. / Francesco Redi et la naissance de la parasitologie expérimentale.

Francesco Redi (1626-1697) born in Arezzo (Tuscany, Italy), an encyclopedic mind simultaneously naturalist, physician and poet is the founder of scientific and experimental parasitology by his works published in 1668 and 1684. In the first he showed the impossibility of spontaneous generation of insects (flies) and in the second are described over hundred species of parasites (helminths, mites, insects) from vertebrates and invertebrates with excellent illustrations. He has also recommended various antiparasitic remedies and specified their pharmacological action. It is besides under his influence that two of his disciples: Bonomo and Cestoni will rediscover and redescribe in 1687 the itch-mite (Sarcoptes scabiei var. hominis).

Mycotic aneurysm of the descending thoracic aorta: the role of transesophageal echocardiography.

Mycotic aneurysms of the aorta are prone to rupture. Thus rapid and accurate diagnosis is essential so that surgical repair can be undertaken. We report a case of mycotic aortic aneurysm caused by mitral valve endocarditis. The aneurysm situated at the junction of the thoracoabdominal aorta was readily detected by transesophageal echocardiography. Computed tomography and aortography were complementary to transesophageal echocardiography in establishing the diagnosis. The patient underwent successful repair and acute inflammation of the aneurysm was present at histologic examination.

Role of echocardiography in perioperative management of patients undergoing open heart surgery.

TEE has assumed a pivotal role in the perioperative management of patients undergoing open-heart surgery. The information obtained influences important therapeutic decisions in thoracic aortic surgery, valvular surgery, and coronary artery bypass surgery. TEE also assists in determining the reason for failure to wean from cardiopulmonary bypass and allows rapid detection of the etiology of hypotension in the patient after surgery. Advances in technology have resulted in three-dimensional images of cardiac structures, and this will further enhance the usefulness of echocardiography for the surgeon. TEE should no longer be regarded as an imaging tool available only in academic centers, but should be routinely used by qualified operators in centers performing open-heart surgery.

Cardiac sarcoidosis masquerading as a metastatic tumor: the role of transthoracic and transesophageal echocardiography.

We present an unusual case of biopsy-proven myocardial sarcoidosis in which the transthoracic and transesophageal echocardiographic findings suggested metastatic tumor involvement of the myocardium and pericardium. The pathologic, clinical, and echocardiographic features of cardiac sarcoidosis are reviewed, with emphasis on the role of echocardiography.

The utility of transesophageal echocardiography in the management of renal cell carcinoma with intracardiac extension.

The accurate assessment of the distal extent of vena caval invasion of renal cell carcinoma into the hepatic veins, inferior vena cava, and right atrium is critical before surgical resection. We present two cases of renal carcinoma with vena caval extension in which preoperative transesophageal echocardiography accurately assessed tumor extent and guided surgical therapy. The role of transesophageal echocardiography in comparison to other diagnostic modalities is discussed.

Long-term follow-up of mitral paraprosthetic regurgitation by transesophageal echocardiography.

Paravalvular regurgitation (PVR) is an uncommon complication of mitral valve replacement (MVR). Although severe PVR is almost always repaired immediately when recognized during surgery, there are little data available on the management of patients with mild and moderate PVR. This study includes eight patients with mild (n = 6) and moderate (n = 2) PVR identified by transesophageal echocardiography at the time of MVR who were treated conservatively. Clinical and echocardiographic follow-up was obtained at a mean of 16.3 months. Two of six patients with mild PVR at the time of MVR and two of two patients with moderate PVR at the time of MVR deteriorated clinically and echocardiographically over time. We suggest that moderate PVR should be corrected at the time of valve-replacement surgery, if this can be performed without high operative risk. Mild PVR should probably also be repaired, if this can be performed at low risk, because some will progress. Patients left with mild PVR after surgery, or patients in whom PVR is recognized only after surgery, should be followed up carefully with serial clinical and echocardiographic examinations.

[Parasitological research conducted between 1982 and 1991 in a sample of Zinvie (Benin) residents]. / Recherche parasitologique conduite entre 1982 et 1991 chez un échantillon de sujets résidents a Zinvie (Bénin).

The authors point out the frequency of intestinal parasitism in Zinvie (Benin). Out of 18,512 samples, 9,554 (51.60%) were found positive. The main parasites found were: Ankylostoma duodenale, Ascaris lumbricoides, Amoeba, Giardia lamblia. The authors underline the polyparaitism 16.75%.