The clinical use of statistical permutation test methodology: a tool for identifying predictive variables of outcome.

OBJECTIVES: To identify the predictive variables affecting the outcome after radical surgery for bladder cancer by a newer statistical methodology, i.e. nonparametric combination (NPC). METHODS: A multicenter study enrolled 1,312 patients who had undergone radical cystectomy for bladder cancer in 11 Italian oncological centers from January 1982 to December 2002. A statistical analysis of their medical history and diagnostic, pathological and postoperative variables was performed using a NPC test. The patients were included in a comprehensive database with medical history and clinical and pathological data. Five-year survival was used as the dependent variable, and p values were corrected for multiplicity using a closed testing procedure. The newer nonparametric approach was used to evaluate the prognostic importance of the variables. All of the analyses were performed using routines developed in MATLAB© and the significance level was set at α = 0.05. RESULTS: A significant prognostic predictive value (p < 0.01) for tumor clinical staging, hydronephrosis, tumor pathological staging, grading, presence of concomitant carcinoma in situ, regional lymph node involvement, corpora cavernosa invasion, microvascular invasion, lymphatic invasion and prostatic stroma involvement was found. CONCLUSIONS: The NPC test could handle any type of variable (categorical and quantitative) and take into account the multivariate relation among variables. This newer methodology offers a significant contribution in biomedical studies with several endpoints and is recommended in presence of non-normal data and missing values, as well as solving high-dimensional data and problems relating to small sample sizes.

Enigmatic question of early reactive arthritis disclosed after researches of mycoplasmas, Chlamydia trachomatis and enteropathogens following the holistic vision of human being.

An HLA-B27 genetic profile patient is fully investigated by molecular analyses after an anamnestic assessment of multi-site ecosystems, following the holistic vision of human being.VDRL and Widal-Wright (WWR) resulted positive, showing at Wright’s reaction a title of 1:40. Of all the enzymatic activities measured, only the ALP enzymatic pool activities showed a low increasing value of 297 U/L. Of all later acute phase proteins, Only C3 c protein value (127 mg/dL) and fibrinogen (376 mg/dL) were altered. Cultural and molecular oropharyngeal ecosystem investigation resulted significantly positive to Mycoplasmas(Mhand Uu) and Chlamydia trachomatis(Ct) together with a spread of saprophytic flora. From an accurate anamnesis, several and severe uro-genital clinical symptomatology emerged from birth until the beginning of rheumatologic symptomatologies that were confirmed by oldest Mh, Uu and Ctsilent chronic infections between these ecosystems. The molecular HPV research was negative, while the Thin prep pap-test was indicative of vaginosis and cellular reactive changes associated with inflammation. Parasitological research resulted positive for presence of 5-7 newly-formed G. lambliacysts for microscopic field, while digestibility test was positive for presence of several free fatty acid crystals. The remarkable presence of indigested meat fibre and several mucous dense filaments were observed. The pH value was 6.5, while blood faecal test was positive. The values observed were: ferritin 12 microg/L (10-120), total iron-binding capacity (TIBC) 310 &mgr;g/dL (300+-20), unsaturated iron-binding capacity (UIBC) 286 microg/dL (200-220) and iron seric level 24 microg/dL (60-130). Faecal research highlighted a very scarce presence of E. coli, resulting in 102 UFC/g of stool. Of all enteroinvasive pathogens, researched by molecular analyses, only Yersinia spp. was positive. After several specific cycles of antibiotic and antinflammatory therapies, the patient improved its general health condition considerably and showed almost complete regression of aching inguinal lymph node inflammation. In a picture of a worsening inflammatory process, produced by pathogens like Mycoplasmas, chronic silent or low grade inflammation atypical agents, in young HLA-B27 positive patient, VDRL test resulted positive. This value represents the first non-specific unique spy to reveal the precocious immunological signal in order to register the beginning of early innate immune system decay, keeping in mind that mycoplasmal and chlamydial infections are the triggering of cancer in patients genetically susceptible.

Jugulodigastric lymph node inflammation derived from chronic atypical oropharyngeal phlogosis recurring annually after flu virus vaccination: a holistic vision of a clinical case solved after chlamydicidal antibiotic therapy.

In this report, we evaluated the case history of a patient with longstanding chronic pharyngitis who had periodic clinical manifestation for three years after a flu vaccine administration, and after various treatments tried to resolve the chronic pharyngitis with unsuccessful antibiotic and anti-inflammatory therapies. The patient occasionally presented a slight ocular inflammation, while dysuria occurred after sexual activity. The search for common pathogens by use of pharyngeal swabs resulted only in Corynebacterium ulcerans growth. After this first result, we focused our investigations on ocular and uro-genital infections of Chlamydiaceae (Ct and Cp) and Mycoplasmataceae (Mh and Uu) families. We examined the patient?s pharynx using molecular and culture techniques from three different sites. Although several infectious agents, including viruses and bacteria, causing chronic pharyngitis are reported in the literature, these ocular and uro-genital pathogens are seldomly routinely investigated in the same patient in ORL. Furthermore, while episodes of chronic pharyngitis is one of the most common clinical manifestation in ENT patients, these atypical pharyngitis represent ever-increasing infections which must always be considered and researched by suitable instruments such as PCR. Only from the collection of detailed medical history and careful observations of clinical manifestation, indicative of an oral chronic pathologic phenomenon of low intensity initiated several years previously, starting with sudden outbreak and relapse like a bout of flu, we suggest to study these atypical infecting agents frequently localized in the urogenital human area, awhich would allow to highlight and to recognize these clinical cases that manifest themselves as chronic inflammation of jugulodigastric lymph nodes, remaining still unrecognized and rarely associated to chlamydial infection, confused with the response to flu vaccination. After several specific cycles of antibiotic therapy, the patient's health improved considerably and showed almost complete regression of jugulodigastric lymph node inflammation.

Can latent synergism of intestinal pathogens be responsible for inflammaging process causing Reiter's syndrome in a young patient HLA-B27 infected by atypical pathogens? A holistic view and clinical biochemical reinterpretation.

A case of a genetically HLA-B27 patient fully investigated by molecular analyses, following a holistic vision and an anamnestic assessment of multi-site ecosystems is repeated. VDRL, Lupus anti-coagulant (LAC) and Widal-Wright (WWR), resulted positive. The antibodies (IgG/IgA anti-Ct) against chronic Chlamydia trachomatis inflammation were positive. In the context of all the enzymatic activities in reference range, the AMS and the ALP enzymatic activities showed an increasing trend and a time course augment depending respectively. Cultures, parasitological, digestibility tests and molecular analyses were then performed to investigate the different human ecosystems. Parasitological research and digestibility test were performed, resulting a latent chronic bowel inflammation, including certain enteroinvasive pathogens, such as, Salmonella, Shigella, Yersinia and Campylobacter (Enteric Pathogens Group, EPG) and Escherichia Coli pathogens (Escherichia Coli Pathogens Group, ECPG). The Salmonella typhi-DNA resulted positive, while 90% of the total microbic charge (TMC) was represented by C. freundi in culture analyses. Interpreting the VDRL positive test as early triggering of autoimmune disease, a few acute phase proteins as a pauci-symptomatic chronic phlogistic process, the amylase and alkaline phosphatase alterations as tissue markers of early intestinal inflammation, the Widal's reaction positivity together with the precocious clinical and faecal manifestations, this study suggests the prime triggering role of these atypical pathogens to cause a chronic low grade autoimmune response against the tissue/organ susceptible target, causing inflammaging phenomenon in young patient with chronic latent infection by Salmonella typhi, leading to Reiter's syndrome, in HLA-B27 positive patient.

Physiological analysis of 8-ISO-PGF2 alpha: a homeostatic agent in superficial bladder cancer.

Recent studies underscore the importance of oxygen supply in bladder cancer. Tumour growth stimulates the production of vasoactive factors to increase oxygen delivery to tissues by vasodilatation. Any vasoconstrictor mediator could impair this vasodilatation reducing the oxygen supply. 8-Iso-PGF2 alpha is a potent vasoconstrictor agent. The aim of this work is to determine 8-Iso-PGF2 alpha release in healthy bladder mucosa and in superficial bladder cancer in order to investigate a pathophysiological vasoconstrictor answer of the superficial bladder cancer. The study was conducted on a sample of 12 patients; for every subject studied 8-Iso-PGF2 alpha release was assayed in healthy bladder mucosa and in superficial bladder tumour. 8-Iso-PGF2 alpha release was significantly reduced (p less than 0.001) in superficial bladder cancer compared with healthy bladder mucosa. The inhibition of the production of a powerful vasoconstrictor such as 8-Iso-PGF2 alpha in the vascular homeostatic mechanism of bladder cancer can represent a response of the tumor tending to contrast an antagonist effect of vasodilatation and the necessary to support the oxygen supply.

Pampiniform plexus and oxidative stress during chronic hypoxia and hyperoxia.

The aim of the present study is to investigate oxidative stress produced by experimental hypoxia and hyperoxia in young and old pampiniform plexus rats, in order to evaluate the oxidative role of oxygen. Oxidative stress causing molecular and cellular dysfunction increases in hypertension and can therefore be considered a state of oxidative stress. This consideration makes us reflect on the responsibility of oxidative stress in the veins of the pampiniform plexus, notoriously under high hydrostatic pressure. After experimental hypoxia and hyperoxia we studied the 8-iso-PGF2alpha release (a specific index of cellular oxidative stress) in young and old left pampiniform plexus rats. The basal 8-iso-PGF2alpha release showed a statistically significant difference P=0.0067 between young and old rats PP. After hypoxia and hyperoxia, the release was higher in young rats as compared to normoxia, respectively P=0.0001 and P=0.0002. After hypoxia the release was not modified in old rats P=0.544 while after hyperoxia the release was increased in old rats as compared to control P less than 0.0001. The results show how chronic hypoxia and hyperoxia represent two important causes of oxidative stress and lipid peroxidation in pampiniform plexus rats. In young rats an increase of oxidative stress suggests that pampiniform plexus is sensitive to variations of oxygen supply. In old rats the pampiniform plexus is liable to a reduction of oxygen-sensing mechanisms and it is possible that the missing oxidative answer to the hypoxia in old rats is attributable in all likelihood to adaptation to a hypoxic condition typical of aging.

The role of hypoxia in erectile dysfunction mechanisms.

Chronic hypoxia is related to many pathological conditions: aging, heart and respiratory failure, sleep apneas, smoke, chronic obstructive pulmonary disease (COPD), diabetes, hypertension and arteriosclerosis, all characterized by reductions of sleep-related erections (SREs) and by erectile dysfunction (ED). Sleep-related erections occur naturally during rapid eye movement (REM) sleep in sexually potent men. Hypoxia is also a physiological condition at altitude. The level of inspired oxygen decreases progressively with the increase of altitude; for this reason, this study was performed to evaluate the relationship of SREs with hypoxic environment. SREs have been recorded by an erectometer (RigiScan) on three mountain climbers (mean age: 32.5) during a 26-day stay at an altitude ranging from 2000 to 5600 m above sea level. Twenty-four records have been made at progressively increasing altitudes. A data analysis was carried out on a statistical mean of the three values of each variable and an analysis of variance (ANOVA) and Newman-Keuls test were carried out for multiple comparison among groups. At altitudes over 4450 m, we found lack of rigidity at 80-100% and 60-79%. Mean % of rigidity and rigidity time of 80-100% (tip and base) decreased progressively with altitude. No significant reductions were shown in rigidity time at 0-19% and at 20-39% (tip and base), of total number, of total and mean duration of SREs. Pathological rigidometric records at high altitude in sexually potent men at sea level clarify the primary role of hypoxia in physiopathological ED pathway.

Priapism caused by 'Tribulus terrestris'.

A 36-year-old Caucasian man was diagnosed with a 72-h-lasting priapism that occurred after the assumption of a Herbal supplement based on Tribulus terrestris, which is becoming increasingly popular for the treatment of sexual dysfunction. The patient underwent a cavernoglandular shunt (Ebbehoj shunt) in order to obtain complete detumescence, from which derived negative post-episode outcomes on sexual function. All patients consuming non-FDA-approved alternative supplements such as Tribulus terrestris should be warned about the possible serious side effects.

Glutathione peroxidase and glutathione reductase activities in cancerous and non-cancerous human kidney tissues.

Selenium-dependent (Se-GSH-Px), selenium-independent (non-Se-GSH-Px) glutathione peroxidase and glutathione reductase (GSSG-Rx) activities have been determined in cancerous and non-cancerous human adult kidney. Large inter-individual variation in the activities of all enzymes tested were found in both tumour and non-tumour specimens. In general a significant decrease in the activities of the three enzymes was found in tumours. When a comparison was made between cancerous and non-cancerous tissues of the same individual, Se-GSH-Px activity was found to be lower in tumour in 17 cases out of 29, and the non-Se-GSH-Px activity in 20. In 20 cases out of 29 GSSG-Rx was found to be lower in tumour. It was concluded that changes in the factors involved in the anti-oxidative protection actually occur in human kidney tumour.

Glyoxalase activities in tumor and non-tumor human urogenital tissues.

Glyoxalase I and glyoxalase II activities have been measured in human tumor and non-tumor samples of 15 kidneys, 15 bladders, 4 testes, 2 adrenals as well as in 4 samples of prostatic adenomas. In all tissues examined glyoxalase I and glyoxalase II activity values varied widely from one patient to another. No significant difference in glyoxalase I activity between the tumor and non-tumor samples was found. When comparison was made between normal and neoplastic tissues of the same patients, glyoxalase I activity was found to be lower in tumor tissues of 10 out of 15 kidneys, and 2 out of 8 bladders and 1 out of 3 testes. A significant (P < 0.004) decrease of glyoxalase II activity was found only in tumor kidney. The possibility of using the present data to predict the relative sensitivity of human tumor tissues to glyoxalase-related chemotherapy is discussed.

Lack of prognostic value of immunohistochemical determination of epidermal growth-factor receptors in human prostate-cancer.

We have investigated whether the expression of Epidermal Growth Factor Receptors (EGF-Rc) evaluated by immunohistochemical technique, may influence the prognosis of patients with prostate cancer. EGF-Rc were positive in 20/76 (26.3%) of tumors. There was no correlation between EGF-Rc and other prognostic factors such as tumor size, Gleason score, metastases at diagnosis, DNA content and S-Phase fraction (SPF). In patients with locally advanced tumors EGF-Rc expression was significantly correlated with the presence of metastases at diagnosis (p=0.038). Both disease-free survival (DFS) and overall survival (OS) did not differ between patients with receptor-positive and receptor-negative tumors. It is concluded that the immunohistochemical localization of EGF-Rc is of limited prognostic value in prostate cancer.

Simple renal cysts in hypertensive patients: relation between cyst growing and anti-hypertensive therapy.

The study investigates relationship between simple renal cyst enlargement studied by ultrasonography and anti-hypertensive treatment. To this purpose we enrolled 42 patients with newly diagnosed hypertension affected by simple renal cysts. Fourteen were randomly assigned to treatment with ACE-Inhibitors (group 1), twelve to diuretics (group 2) and sixteen to Ca-Antagonists (group 3). Patient performed a basal ultrasonography to evaluate basal cyst dimension before starting anti-hypertensive treatment. Following 12 months of the anti-hypertensive regimen, a new echograph was performed to evaluate changes in cyst size. A control group consisting of 15 patients with normal blood pressure and simple renal cysts was enrolled (group 0). An enlargement of cysts was detected in all patients. However, the enlargement observed in patients treated by Ca-Antagonists was significantly greater than that observed in the other groups (p<0.05). Our study supports the hypothesis that Ca-Antagonists may favor cyst enlargement by enhancing cyclic AMP production. In fact, cAMP and cAMP agonists stimulate fluid secretion by lining cells of the cyst wall, inducing cyst enlargement.

[Stage P-1 primary neoplasia of the bladder. Critical evaluation of results obtained with the use of adriamycin and mitomycin C in the prevention of recurrences]. / Neoplasie primitive della vescica allo stadio P1. Valutazione critica dei risultati ottenuti con l'impiego dell'adriamicina e della mitomicina C nella profilassi delle recidive.

However adequately treated, surface carcinomas of the bladder recur sooner or later with infiltration found in about 10% of cases. Any development that may offer therapeutic progress and reduce the incidence of recurrences is therefore of primary importance. Two homogeneous groups of patients were selected for the present study: 35 were given Adriamycin and 25 Mitomycin C. In evaluating results, the incidence of recurrences in relation to the primary neoplasia and the existence of single or multiple tumors was analysed. It is concluded that Mitomycin C in association with either T.U.R. or T.V.R. is a particularly useful and indubitably effective form of topical chemotherapy in cases of single or multiple primary neoplasias.

[Etiology of bladder cancer]. / Eziologia del carcinoma vescicale.

Multiple agents have been suggested as urinary bladder carcinogens. Of these, certain aromatic amines and some tryptophan metabolites (Anthranilic acid, 3 hydroxy Anthranilic acid) have been proved to be carcinogenic. Others are suggested but are not conclusively proved as carcinogenic agents. Various animal species have been used as experimental models for the study of induction of cancer of the bladder and substantial progress has been made in the search for etiologic factors and pathogenesis of bladder tumors. A carcinogenic model of cancer bladder induction is proposed. However, knowledge of the tumorigenesis of cancer of the bladder is still limited and fragmentary. It appears, however, that Tryptophan dysmetabolism play a major role in this field and future experimental and epidemiologic studies should take this fact into consideration.

[Determination of the composition of renal calculi by x-ray spectrometry]. / Determinazione della composizione dei calcoli renali mediante l'impiego delle tecniche spettrometriche ai raggi X.

X-ray spectrophotometry shows undoubtful advantages versus conventional chemical methods employed in the analysis of kidney stones. In fact, it is possible to detect little crystals that are very important in the genesis and treatment of urinary calculosis.

[Levels of monokines in peripheral monocytes in patients with superficial tumors of the bladder treated with BCG. Results after 1- and 3-year follow-up]. / Livelli di monochine nei monociti periferici nei pazienti affetti da tumore superficiale della vescica trattati con BCG. Risultati ad uno e a tre anni di follow-up.

BCG has been shown in prospective randomized clinical trials to provide superior therapeutic results when composed to transurethral resection alone, or to adjuvant therapy with Thiotepa or Adriamicin. Even if the mechanism by which BCG mediate antitumor activity are not clearly established, an association between the immunological response and antitumoral activity is known IL-1 and TNF alfa are the monokines that have multiple biological effects, including linfocyte proliferation, production of fever, augmentation of cytotoxicity and production of cytokines. The goal of this study is show the response from LPS induced and not peripheral monocytes of superficial bladder cancer patients BCG treated and not, i.e. the levels of TNF alfa, IL-1 and not IL-6.

[Clinico-experimental study of low-mineral "Monteferrante" water: monitoring the recurrences in patients with calculi]. / Studio clinico-sperimentale su un'acqua oligominerale abruzzese "Monteferrante": osservazione sull'andamento delle recidive in pazienti litiasici.

This study presents the use and effects of a low mineral content water called "Monteferrante" on patients with urinary stone disease. We evaluated the blood and urine sample of twenty stone formers and ten healthy volunteers at three and six months after "Monferrante" water intake. Besides a benefic increasing of diuresis, the results show: an increase of: urinary magnesium (p < 0.001), urinary calcium (p < 0.01), uricosuria (p < 0.01), and reduction of: blood uric acid (p < 0.01), blood sodium (p < 0.05), azotemia (p < 0.05) and cholesteremia (p < 0.01). The "Monferrante" oligomineral water can be considered as an efficacy presidium in the prevention of stone disease.

[Role of MCP-1 chemokine in the response of monocytes of patients with superficial tumors of the bladder treated with BCG immunotherapy]. / Ruolo delle chemiochine MCP-1 nella risposta dei monociti di pazienti affetti da tumore superficiale della vescica sottoposti ad immunoterapia con BCG.

Mechanism by which intravesical BCG treatment mediates antitumor activity are currently poorly understood. We initiated studies to determine the sequence and the factors that produce the immunological events. During the inflammatory answer a lot of molecules are produced. Chemokines MCP-1 and RANTES induces the mast-cell recruitment, that begins the "immunological fall". In our study 5 patients with superficial bladder cancer treated with BCG present an improvement of this cytokines correlated with a tumor-free status.

[Betamethasone versus placebo in Peyronie's disease]. / Betametasone versus placebo nella malattia di la Peyronie.

The Peyronie's disease or Induratio Penis Plastica, represents one of the most controversial and uncertain points of the modern andrology, since its real etiology is still disputable. Consequently also the non-surgical therapy results as still confused and variable as shown in the considerable number of drugs utilized till now. Our study takes into consideration the injection therapy, by the use of the Betamethasone (corticosteroid), and it tries to explain, how it is possible, the real efficacy of drug versus placebo. The randomized study includes 30 patients. The valuation of the results has been effected in reference to three parameters: disappearance of pain, decrease of plaque volume and consistency of 50%, decrease subjective penile curvature. The data obtained show no significant differences between group A (treated with Betamethasone) and group B (treated with placebo). At twelve months of mean follow-up the pain at erection disappeared in 66.6% of the patients of group A, in 53.3% of the patients of group B. The curvature diminished in 20% of the patients of group A and in 26.6% of the patients of group B. A decrease in plaque volume and consistency was noted in 40% of the patients of group A and in 40% of the patients of group B. The data show that probably the clinical results of the therapy is to refer to a mechanical effect of injected volume and not to the drug action itself.

[Clinical efficacy of intravesical BCG treatment for superficial bladder neoplasms with respect to the iduced immune response]. / Efficacia clinica del trattamento intravescicale con BCG per neoplasie vescicali superficiali in rapporto alla risposta immunitaria indotta.

We evaluated the immune response after BCG treatment in superficial bladder cancer analyzing the modifications induced on lymphocytic sub-populations. In 21 patients with superficial bladder cancer we performed TURB and after 12 days began the induction cycle of 6 weeks with Pasteur BCG (75 mg/50 micromilligrams), followed by one instillation monthly for one year. Before treatment every patients underwent Mantoux intradermoreaction, blood-count and determination of peripheral blood lymphocytic subpopulations. Blood-count and lymphocytic subpopulations were repeated after 1 week, after 6 weeks, after 3 months and after 1 year. During cystoscopy after 3 months every patients underwent vesical biopsy. CD4+ and CD8+ are mainly interested among lymphocytic subpopulations at the beginning: BCG decreased CD4+ value in the patients with complete response and then it increased CD4+ and reversed the ratio between CD4+ and CD8+ on vesical mucosa.