[Hospital care for acute stroke at the Palestrina hospital: comparison of cost and quality of care with an "hospital at home" care model]. / Analisi dei ricoveri ospedalieri per patologia cerebrovascolare nell'Ospedale di Palestrina (RM): confronto dei costi e della qualità assistenziale con un modello di Ospedalizzazione Domiciliare.

INTRODUCTION: In the Lazio Region (Central Italy) the Emergency Care network has been recently re-arranged in order to improve the effectiveness of care. The aim of this paper is to assess the impact of stroke patient care on both cost and organization of the hospital of Palestrina (Lazio Region). METHODOLOGY: An analysis of cost and path of care of all stroke patients (239) with stroke attending the hospital in 2010 has been carried out. RESULTS: The care was more expensive than the one offered to the stroke patients attending the "Hospital at Home" service managed by the San Giovanni Battista Hospital in Turin; moreover the care was incomplete because of the lack of rehabilitation services in the hospital catchment area. CONCLUSION: The care model offered to stroke patient hit by stroke in Palestrina needs to be deeply revised.

Glomerular filtration rate is associated with trabecular bone score in patients with type 2 diabetes mellitus.

AIMS: The present study aimed to evaluate the trabecular and cortical bone components using Trabecular Bone Score (TBS) and its association with estimated-Glomerular Filtration Rate (e-GFR) in T2DM patients. METHODS: An assessment both of bone mineral density (BMD) and vertebral bone microarchitecture was performed in all patients using TBS iNsight® software version 3.0.2.0. Furthermore, the total population was divided into two groups based on the value of the eGFR (eGFR < o > at 60 ml/min/1.73 m2). RESULTS: TBS value was lower in patients with low e-GFR than that in patients with higher e-GFR (1.246 ± 0.125 vs 1.337 ± 0.115, respectively, p = 0.013 adjusted by gender and age) while there was no difference in total BMD value between two groups. In the multivariate model taking into account several possible confounders, such as age, gender, duration of diabetes, BMI, LDL cholesterol, serum calcium and HbA1c, the correlation between e-GFR and TBS remained significant (p: 0.046). CONCLUSIONS: In individuals with T2DM and reduced kidney function, TBS provides information independent of BMD, age and gender. TBS may be a useful additional tool to predict fracture risk in this unique population.

The representation of brightness in primary visual cortex.

Although neurons in primary visual cortex are sensitive to the spatial distribution and intensity of light, their responses have not been thought to correlate with the perception of brightness. Indeed, primary visual cortex is often described as an initial processing stage that sends information to higher cortical areas where perception of brightness, color, and form occurs. However, a significant percentage of neurons in primary visual cortex were shown to respond in a manner correlated with perceived brightness, rather than responding strictly to the light level in the receptive fields of the cells. This finding suggests that even at the first stage of visual cortical processing, spatial integration of information yields perceptual qualities that are only indirectly related to the pattern of illumination of the retina.

Autonomic dysfunction and neuropeptide Y in fibromyalgia.

OBJECTIVES: Fibromyalgia (FM) is a syndrome associated with widespread pain and various other signs and symptoms. Several of these multisystem features could be explained on the basis of autonomic nervous system (ANS) dysfunction. METHODS: The aim of the present study was to evaluate ANS dysfunction in FM based on time-domain heart rate variability (HRV) analysis and serum neuropeptide Y (NPY) levels in 51 patients with FM, 25 patients with systemic sclerosis (SSc), and 15 healthy controls (NHS). RESULTS: Compared with the SSc and NHS groups, the FM group had significantly higher NPY levels, and in the FM subgroup subjected to HRV analysis (25/51 patients, 49%), certain HRV indices were significantly reduced. In this subgroup, NPY was significantly correlated with the SDANN index and the NN50, but neither NPY or HRV parameters showed any significant correlation with clinical aspects of the FM. CONCLUSION: These findings suggest that autonomic dysfunction and NPY are crucial elements in the pathophysiology of FM. Additional studies are necessary to define the complex roles played by NPY and ANS in modulating pain and immunological functions of different diseases.

Integration of surface information in primary visual cortex.

Ample evidence suggests that primary visual cortex is involved in the perception of form, and there is increasing evidence that it may also be important in the perception of surfaces. Perceptual qualities of surfaces, such as brightness, are based on extensive integration of information throughout the visual field. In primary visual cortex, we found that the responses of neurons to surfaces were also influenced by the intensity and organization of light in large portions of the visual field. Interactions with surrounding stimuli typically extended 10 to 20 degrees beyond a cell's receptive field the same spatial scale as perceptual interactions. Moreover, there were both facilitatory and inhibitory influences, just as there are additive and substractive perceptual interactions. Surprisingly, influences from outside the receptive field obtained with surface stimuli did not reliably correlate with influences recorded with gratings. These properties suggest that the underlying neuronal interactions may serve as the fundamental building blocks of surface perception.

Visual neuroscience: illuminating the dark corners.

Recent experiments suggest that our perception of lightness involves a sophisticated interpretation of illumination and shadow. This finding challenges common notions about hierarchical processing and the neural basis of perception.

Neural correlates of perceived brightness in the retina, lateral geniculate nucleus, and striate cortex.

Brightness changes can be induced in a static gray field by modulating the luminance of surrounding areas. We used this induction phenomenon to investigate the neural representation of perceived brightness. Extracellular recordings were made in striate cortex, the lateral geniculate nucleus (LGN), and the optic tract of anesthetized cats using stimuli that produced brightness induction. While a cell's receptive field (RF) was covered by uniform gray illumination, the luminance of rectangular flanking regions was modulated sinusoidally in time, inducing brightness changes in the RF. We looked for a correspondence between the modulation of a cell's response and stimulus conditions that did or did not produce perceptual changes in brightness. We found that the responses of retinal ganglion cell axons in the optic tract were never correlated with brightness. On the other hand, many neurons in striate cortex and a small fraction in the LGN responded in a phase-locked manner at the temporal frequency of the flank modulation, even though the flanks were 3-7 degrees beyond the edges of the RF. Only in striate cortex were cells found that had responses correlated with brightness under all stimulus conditions. These findings suggest that brightness information is explicitly represented in the responses of neurons in striate cortex as part of a neural representation of object surfaces.

Isolation and characterization of the Streptomyces cattleya temperate phage TG1.

A temperate actinophage, TG1, was isolated from soil by growth on Streptomyces cattleya and has been shown to be potentially useful for the cloning of DNA in this organism and other streptomycetes. It forms stable lysogens by integration at a unique site on the chromosome. The phage genome consists of 41 kb of double-stranded DNA with cohesive ends. It has unique sites for ClaI, NdeI, PstI, SmaI, and XbaI. The PstI site has been shown to be in a dispensable region of the phage genome. Deletions (2 kb in length) were obtained which retain this site and should be useful for the cloning of DNA.

Lipoprotein(a) serum levels in patients affected by chronic obstructive pulmonary disease.

A recent study has suggested that symptoms of chronic bronchitis predict the risk of coronary disease independently of the known major cardiovascular risk factors. High serum levels of lipoprotein(a) (Lp(a)) have also been considered as an independent risk factor for coronary heart disease. Therefore, the aim of the present study was to investigate the behaviour of Lp(a) in patients affected by chronic obstructive pulmonary disease (COPD). Serum levels of total-cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides, apolipoprotein (Apo) B-100, and Lp(a) were measured in 90 COPD patients and in 90 normal subjects matched for age, sex and smoking habit. COPD patients showed lower serum levels of Apo B-100 (P<0.0001) and Lp(a) (P<0.003) compared to controls. Conversely, TC, HDL-C, LDL-C and triglycerides were similar between patients and controls. No significant differences were found in Apo B-100 and Lp(a) levels of patients either undergoing different therapeutic regimens, or with different smoking habits. A significant correlation between Apo B-100 and Lp(a) (rho=0.433, P<0. 0001) was also observed. In conclusion, COPD patients do not show an atherogenetic lipid pattern and their increased risk of coronary disease could be attributable to different factors, such as the ongoing hypercoagulability state often associated with COPD.

Feature-specific effects of selective visual attention.

Four experiments were conducted to quantify the effect of performing a foveal discrimination task on sensitivity for a peripheral grating. The observer's primary task was to discriminate either the spatial frequency or orientation of successive foveal Gabor patches. On a third of the trials they also performed a secondary task to detect the presence of a near-threshold grating in the periphery. We find that sensitivity for detection of the peripheral grating depends on the similarity of the spatial frequencies and orientations between the foveal and peripheral stimuli. Importantly, sensitivity is also affected by which feature is being discriminated in the central task. Because the detectability of the peripheral grating is different when different features of the central stimuli are discriminated, we suggest that the effects on sensitivity are due to feature-specific attention and not simply to passive interactions between filters with similar tuning properties.

Brightness perception and filling-in.

Three experiments were performed in which a stimulus with homogeneous color and luminance was masked by a second stimulus containing contours. In the first experiment the target was a large white disk and the mask was a white circle concentric with the disk but of smaller radius. We found that the mask had a large (up to 2 log unit) suppressive effect on the brightness of the target, but only inside the radius of the mask. With monoptic presentation of target and mask, the greatest suppression was observed with an SOA of 50-100 msec. With dichoptic presentation the strongest suppression was obtained with simultaneous stimuli. The second experiment demonstrated that the latest time at which masking was effective was correlated with the distance between the edge of the target stimulus and the contour in the mask. One possible explanation of the results from these two experiments is that the masking contour is interfering with the propagation of a brightness signal from the target's border. In the third experiment gaps were introduced into the masking circle. Surprisingly, even with rather large gaps there was significant suppression of brightness in the center of the target. We have encountered difficulties attempting to account for these findings with known physiological mechanisms such as lateral inhibition. A qualitative explanation of the results that looks promising is a two-component process involving brightness filling-in and smoothing to satisfy fixed boundary conditions at contours.

Orientation discrimination as a function of stimulus eccentricity and size: nasal/temporal retinal asymmetry.

Orientation discrimination threshold is a monotonically increasing function of retinal eccentricity. Increasing stimulus length extends the range of eccentricities over which fine orientation discriminations can be made. Orientation discrimination thresholds at all eccentricities are determined by the size of the cortical image of the stimulus. Thresholds obtained using either nasal or temporal hemiretina are similar up to the blind spot, beyond which the temporal retina yields increasingly higher thresholds. The results are consistent with a recent theoretical study which predicts that orientation discrimination threshold is determined by the number of cortical cells activated by the discrimination target.

Temporal limits of brightness induction and mechanisms of brightness perception.

The luminance of a squarewave grating was modulated in a manner such that every other stripe temporally varied between bright and dark and the intervening stripes had constant luminance. This produces brightness induction in the constant stripes, roughly in antiphase to the luminance modulation. We used this stimulus as a probe to explore the temporal properties of brightness induction and the mechanisms determining perceived brightness. Over a range of spatial frequencies we measured: (1) the highest temporal frequency at which brightness induction occurs; (2) the magnitude of induced brightness; and (3) the temporal phase of the induced brightness modulation. We find that brightness induction ceases with luminance modulation above a cutoff temporal frequency that depends on spatial frequency. The magnitude of induced brightness modulation is greatest at low spatial frequencies and low temporal frequencies. Induced brightness lags behind the luminance modulation and this phase lag increases as spatial frequency decreases. All of these findings can be understood as consequences of an induction process that takes longer to complete as the induction region increases in size.

Filling-in percepts produced by luminance modulation.

We report that when the luminance of a homogeneous spot of light is gradually increased or decreased, there are conditions in which the brightness of the spot is spatially nonuniform. When the spot luminance is increased, brightness changes in the spot's center lag behind changes at the edge and brightness appears to sweep inward. Conversely, if the luminance of the spot is decreased, there is a relative lag in the darkening toward the center of the spot and darkness seems to spread inward. In Experiment 1 we found that with both increasing and decreasing luminance sweeps, the strength of the brightness filling effects was strongest with luminance sweep durations of 0.25-0.5 sec. In Experiment 2, the sweep duration was held constant at 0.5 sec; the filling effect was seen when the dwell time spent at each luminance step was less than about 100 msec, but nonuniformities were not observed at longer dwell times. In Experiment 3, a spot of light was positioned to surround the optic disk in one eye. Surprisingly, when the spot was luminance modulated from bright to dark, darkness appeared to sweep from the edge to the center of the modulated disk, even though most of the disk's interior was imaged on a portion of the retina devoid of photoreceptors. These findings are consistent with the hypothesis that a neural filling-in mechanism in visual cortex plays a key role in brightness perception.

A physiological correlate of the Pulfrich effect in cortical neurons of the cat.

When a swinging pendulum is viewed with a light-attenuating filter before one eye, the pendulum bob is perceived to move in an elliptical path in depth. It is believed that the filter causes this illusion, the Pulfrich effect, by delaying processing of the image in the filtered eye relative to that of the unfiltered eye. We sought a physiological correlate of this effect by studying binocular integration in cortical neurons of cats while they viewed moving stimuli. Special attention was focused on single unit disparity tuning because it is widely believed that depth perception is related to the responses of disparity selective neurons in visual cortex. We found that placing a filter before one of the cat's eyes produced a temporal delay in the cortical response. The temporal delay was always associated with a shift in the neuron's spatial disparity tuning. The observed temporal delays and disparity shifts are comparable with the magnitude of the Pulfrich effect in humans.

Cortical processing of hyperacuity tasks.

Spatial discrimination thresholds were determined by having subjects make comparisons between stimuli presented successively at the same or at different locations in the visual field. Two tasks were employed, discrimination of line orientation and discrimination of the distance between two parallel lines (spatial interval discrimination). We find that discrimination thresholds based on the comparison of features in spatially-separated stimuli are comparable to those based on the comparison of features in two stimuli presented successively at the same location. This holds even when the stimuli are presented in nonhomologous positions in the visual field or are presented in a manner such that they activate cells in opposite cortical hemispheres in the early visual areas. This shows that discriminability is not determined solely by differences in the firing rates of striate or pre-striate neurons. Rather, it appears that the attributes of visual stimuli are precisely coded and available for comparison at higher levels of visual processing. Implications of this finding for models of hyperacuity are discussed.

Subjective contours, tilt aftereffects, and visual cortical organization.

The tilt aftereffect (TAE) was used to study interactions between real and subjective contours. Subjects adapted to either real or illusory lines and were then shown test stimuli containing real or illusory lines. In our first experiment, we found that there is a marked asymmetry in the interactions between real and subjective stimuli. Adaptation to real lines produces comparable TAEs with real and subjective test lines. With either type of test stimulus the maximum effect occurs with a 10-20 deg difference between the orientations of the adaptation and test stimuli. Also, there is a strong TAE when the adaptation and test stimuli contain only subjective lines. However, there is a significantly weaker TAE when the adaptation stimulus is subjective and the test stimulus is real. In a second experiment we find that interocular transfer of tilt aftereffects is greater when the test stimulus is subjective than when it is real. These results are consistent with physiological reports that a subset of orientation selective cells in visual cortex is responsive to subjective contours and that these cells are more binocular, on average, than those responsive only to real contours. Our findings also suggest that the perception of subjective contours is based on the activation of neurons with properties, such as orientation selectivity, which are characteristic of early visual cortical areas.

Signal-averaged electrocardiography and echocardiography in the evaluation of myocardial involvement in progressive systemic sclerosis.

To assess the myocardial involvement in progressive systemic sclerosis we evaluated the presence of late potentials by signal-averaged electrocardiography (signal-averaged ECG) and the left ventricular function by M-mode, two dimensional and Doppler echocardiography. Fifteen outpatients, 7 with diffuse progressive systemic sclerosis and 8 with CREST syndrome variant, without clinical or electrocardiographic evidence of cardiac disease were studied and compared with 18 normal subjects. Late potentials occurred in 5 out of 15 progressive systemic sclerosis patients (33%) with a significant difference versus controls (P < 0.05) and were present only in the patients with diffuse progressive systemic sclerosis (P < or = 0.001 vs. controls). All progressive systemic sclerosis patients showed a normal left ventricular systolic function. Abnormal left ventricular filling was found in 9 progressive systemic sclerosis patients (5 with diffuse progressive systemic sclerosis and 4 with CREST). A more severe impairment of the mean values of diastolic function indexes was found in diffuse progressive systemic sclerosis than in CREST. In all diffuse progressive systemic sclerosis patients at least one method showed altered results, whereas half the CREST patients showed no pathological findings with both techniques. These results confirm a lower myocardial involvement in the CREST syndrome than in diffuse progressive systemic sclerosis and consequently this is probably related to a better prognosis.

Prevalence and clinical features of skin diseases in chronic HCV infection. A prospective study in 96 patients.

BACKGROUND: Between extra-hepatic manifestations of hepatitis C virus (HCV) infection particular interest is focused on some dermatological diseases such as: leukocytoclastic vasculitis, oral lichen planus, pruritus-urticaria, psoriasis, etc. The aim of this study was to determine the prevalence of some dermatoses in our population of patients with HCV infection and describe the more characteristics clinical pictures. METHODS: Ninety-six patients (36 men and 60 women) aged from 35 to 74 years with HCV documented by 3rd generation ELISA and RIBA tests were prospectively examined for 3 years to determine the prevalence of some skin disorders, reported as associated with HCV infection. All patients were also studied for presence and quantification of HCV-RNA by polymerase chain reaction and genotyping when possible. Eighty-one underwent a liver biopsy. Routine laboratory tests and some immunological investigations (ANA, AMA, SMA, LKM, ANCA, ICC, crioglobulins) were performed using standard procedures and indirect immunofluorescence, nephelometric, RIA methods. RESULTS: Twelve of 96 patients (12.5%) presented skin disorders in progress of chronic virus C hepatitis: 5 cases of leukocytoclastic vasculitis (LCV) by mixed cryoglobulinemia, 1 case of pruritus, 2 cases of oral lichen planus (OLP), 2 cases of alopecia areata, 1 case of urticaria, 1 case of psoriasis. CONCLUSIONS: Our findings show a calculated prevalence of clinical dermatoses in HCV infected patients around 12.5%. These findings confirm however the importance of liver examination in presence of skin diseases not related to other pathogenetic mechanisms.

Erectile dysfunction after kidney transplantation: our 22 years of experience.

AIM: To evaluate the results of treatment of erectile dysfunction (ED) in kidney transplant recipients before and after the advent of sildenafil. MATERIALS AND METHODS: From 1981 through 2002, 971 male patients of mean age 53.4 years received a renal graft. Erectile dysfunction (ED) was investigated in all patients at the first urologic visit posttransplantation. Psycho-sexual support was offered to all patients. Before sildenafil use (1998), our diagnostic approach was complex. From 1998 we tested: serum levels of testosterone, prolactin, and glucose with penile duplex ultrasonography and NPT reserved for selected cases. RESULTS: From 1981 through 1998, 365 male kidney transplant recipients (45%) reported ED. Only 169 patients chose to be treated: 27 responded to psycho-sexual therapy; 3 received testosterone with benefit; 133 had a good results from intracavernosal injection of vasoactive drugs; and 6 received a penile prosthesis. Since 1998, 126 patients reported ED (78.3%). Only 78 chose treatment: 24 patients had a satisfactory response to sildenafil (65% with 50 mg and 35% with 100 mg). PGE1 alone or in combination with papaverine and phentolamine produced a good response in 37 patients; 17 patients did not respond to pharmacotherapy; and 5 received a tricomponent penile prosthesis without complications. The side effects of sildenafil and PGE1 therapy were similar to those reported in the literature. CONCLUSIONS: ED is an important problem in male renal transplant recipients. Cultural resistance to treatment is common. However, treatment with sildenafil citrate and intracavernosal self-injection of PGE1 are well accepted, and prosthetic devices may help in resistant cases.