Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group.

BACKGROUND: In Italy, antiretroviral combination therapy was adopted in mid-1995 and protease inhibitors in mid-1996. OBJECTIVE: To conduct a prospective, population-based, observational study to evaluate the effect of these therapies on the survival of persons with AIDS (PWA). METHODS: PWA living in the Tuscany region diagnosed between 1985 and 31 March 1997 (National AIDS Registry) were studied. Information on antiretroviral drugs, prophylactic treatment, CD4 cell count, and AIDS-defining illnesses was collected for PWA still alive at 1 January 1996 and those diagnosed thereafter (analysis cut-off date, 30 November 1997). Kaplan-Meier curves were calculated by year of diagnosis. A Cox model was then used to estimate the adjusted (by sex, age, HIV exposure category, CD4 cell count, type and number of AIDS-defining illnesses) relative hazard (RH) of death by year of diagnosis and calendar date (considered as a time-dependent variable). Similar analyses were repeated for PWA diagnosed after 1989, having been stratified by disease-specific AIDS condition. A final analysis was performed for PWA still alive at 1 January 1996 or diagnosed thereafter for estimating the effect of single, double and triple combination therapy (time-dependent variables), having adjusted for the above variables and for prophylactic treatment. RESULTS: A total of 1683 (79.5%) out of 2118 PWA died before 1 December 1997. Use of more potent combination therapies, including protease inhibitors, greatly increased during 1997. Median survival was 2.9, 12.3, 13.4, 11.4 and 17.6 months for diagnoses before 1987, in 1987-1990, 1991-1993, 1994 and 1995, respectively; an estimated 62% of those diagnosed in 1996-1997 had survived 15 months after diagnosis. The Cox model showed a trend of decrease of RH for calendar time starting in the first half of 1996, compared with 1994. When stratifying by specific AIDS-defining disease there was no statistically significant evidence that the improved overall survival was due to increased survival only for certain diseases. The final multivariate analysis for the 771 PWA still alive at 1 January 1996 or diagnosed thereafter estimated significant RH < 1.0 for double and triple therapy (RH, 0.61 and 0.36, respectively) compared with no therapy. CONCLUSIONS: A significant reduction in risk of death after AIDS was observed from the second half of 1996, apparently due to the widespread use of antiretroviral combination therapies.

Photocoagulation of cerebral arteriovenous malformations and arterial aneurysms with the neodymium: yttrium-aluminum-garnet or argon laser: preliminary results in twelve patients.

Six arteriovenous malformations (AVMs) and five arterial aneurysms (AAs) were treated with either argon or neodymium:yttrium-aluminum-garnet laser irradiation; one AVM was treated with both. All AVMs were occluded completely, leaving adjacent tissue untouched and preserving the regional vascularization. Photocoagulation produced varying effects on AAs: in one case an intraoperative rupture was sealed, in two cases the volume of an ectasia was reduced when the bleeding and thinner areas were coagulated, and in one case a saccular aneurysm was progressively and completely obliterated while the patency of the parent artery was preserved. These preliminary results are satisfactory; more experience will indicate how and when these new techniques can replace traditional ones or be used in combination with them.

Prostaglandin E1 for treatment of erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED), the inability to achieve or maintain an erection sufficient for satisfactory sexual activity, is one of the most common sexual dysfunctions in men. ED may have a dramatic impact on the quality of life of many men and their partners. OBJECTIVES: The aim of this systematic review was to evaluate and summarise the effectiveness and safety of PGE1 in the treatment of erectile dysfunction. SEARCH STRATEGY: We searched the Cochrane MS Group Trials Register (June 2003), the Cochrane Central Register of Controlled Trials (issue 2, 2003), MEDLINE (January 1966 - June 2003), EMBASE (January 1988 - June 2003) and reference lists of articles. We also undertook handsearching and contacting trialists and pharmaceutical companies. SELECTION CRITERIA: All unconfounded, double blind, randomised controlled trials comparing PGE1 and placebo treatment in participants with ED of different aetiology were considered. Primary outcomes were: (a) patient and partner satisfaction measured by means of a self-assessment; (b) quality of life and (c) safety assessment. Both parallel group and cross-over design trials were considered for inclusion. DATA COLLECTION AND ANALYSIS: All the reviewers independently selected articles for inclusion, assessed the trials' quality and extracted the data. Study authors were contacted for additional information. MAIN RESULTS: Four trials involving 1.873 people, heterogeneous with respect to aetiology of ED, were included. Study design was two cross-over and two parallel group trials. Only the latter provided adequate data for meta-analyses. PGE1 was effective during follow-up in the "at least one successful intercourse" outcome (Peto Odds Ratio, OR 7.22, 95% CI. 5.68-9.18) and "number of successful intercourse/number of PGE1 administrations" (Peto Odds Ratio, OR 6.46, 95% CI. 5.95-7.01). One cross-over study reported "at least one successful intercourse" in 63.6% of participants with at least one dose of PGE1 (P < 0.01 for each active dose versus placebo). In the other cross-over study, only one of three treatment groups conducted a self-evaluation (55.5%: "good" or "excellent" response). Adverse effects were most frequent in the treated groups and occurred more often and intensely as doses increased. Penile pain (Peto OR 7.39, 95% CI. 5.40-10.12) and minor urethral trauma (Peto OR 3.79, 95% CI. 1.88-7.65) were predominant. REVIEWERS' CONCLUSIONS: PGE1 was beneficial for many participants with ED of different aetiology. Adverse effects were proportional to dosage, albeit never serious. The use of PGE1 in ED could have been better interpreted if its effectiveness were compared by aetiology and with different forms of administrations, a longer follow-up were considered and more emphasis given to patient/partner relationships and quality of life.

Effect of in vivo He-Ne laser irradiation on biogenic amine levels in rat brain.

In order to elucidate the metabolic modifications induced in rat brain by low power He-Ne laser irradiation in vivo, the variations in the biogenic amine levels in cortex, striatum and hippocampus were studied. Noradrenaline (NA), dopamine (DA) and serotonin (5-HT) were evaluated by HPLC-EC on irradiated rats, untreated rats (controls) and rats which had undergone restraint stress (stressed). The results obtained on groups of four to eight rats assayed individually showed that irradiation caused a strong increase in 5-HT in striatum and hippocampus, a small but significant decrease in NA in cortex, and DA levels were not significantly affected. Restraint stress per se led to a considerable decrease in 5-HT and DA in striatum and hippocampus, but did not significantly alter the NA levels.

Sudden presentation of intracranial meningioma after elective general anesthesia.

A case of "silent" intracranial meningioma unmasked by narcosis is described. The diagnosis was made because of the patient's failure to wake up after elective general anesthesia for orthopaedic surgery. Factors leading to this complication and its management are discussed. Early computed tomography scan and antiedema therapy are strongly suggested for these patients.

Relationship between intracranial hypertension and ultrasonic patterns of the common carotid artery and the internal jugular vein.

The Doppler technique has only been used in neurological practice to evidence local vessel pathology such as occlusion or stenosis. Both common carotid artery and internal jugular vein flows can change not only because of pathological processes of the vessels but also because of impedance of their distribution territory. In this report we analyze the relationship between flow velocity, one of the parameters of blood flow, and intracranial impedance variations which occur in cerebral concussion, tumors and acute vascular cerebral pathology. During our observations we noticed that the diastolic wave of the velocity curve of the common carotid artery is a very important signal of the flow variations in the internal carotid artery and, in turn, of variations in cerebral flow. We studied the behaviour of the common carotid artery velocity curve in our patients both during clinical disease development and during the action of mannitol in the acute phases of the disease. We found that the ultrasonic patterns during antiedema action were similar to the ones obtained during the recovery period. We were able to note some differences and some similarities of the curve morphology in relation to generalized or focal causes of cerebral edema. This may be very important considering that at present no non-invasive and therefore repeatable technique is available for monitoring cerebral blood flow in intracranial hypertension.

Dietetic treatment with hypercaloric and hyperprotein intake in patients following severe brain injury.

Sixty four patients, following severe acute brain injury were fed according to a strict dietetic therapy at the Intensive Care Unit at the Institute of Neurological Surgery, University of Turin. We used mixtures composed of simple nutritional elements consisting of carbohydrate as glucose polymers from 7 to 15 units, free aminoacids and MCT oil, integrated with natural elements. The solutions were administered via a nasogastric tube with the maximum caloric intake of 6.000 Kcal and 186 grams proteins/24 hr. After recording a series of hematochemical and clinical parameters we obtained the following results: 1) the average blood sugar level was always found to be pathological among the 11 patients who eventually died during their hospitalization, while 30% of the discharged patients had normal blood sugar values; 2) kidney function was significantly more affected among eventually deceased patients than among discharged ones; 3) the hospitalization time had a negative influence on the hepatic functions. Total serum albumins and proteins cease their decline respectively at average values of 2 and 5.5% gr, cholesterol maintains a constant level between 180 and 200% gr, calcium between 8 and 9 mg% and phosphorous around 3 mg%. Alkaline phosphatase in all patients rose significantly to pathological values only after a week of hospitalization. All other tests presented an irregular course. The survival period of our group of patients was significantly longer than that of control group. Within our group the survival rate was better among patients who received, within 10 days from cerebral damages, a hypercaloric and hyperprotein diet of more than 5.000 Kcal and 120 grams of proteins in 24 h, as compared to those whom the same diet was administered more gradually or following a longer period of time after having sustained cerebral damage.

The effects of new technologies on the surgical management of brainstem tumors.

Nuclear magnetic resonance, real-time and A-scan ultrasonography, and computerized CO2 lasers were recently introduced for diagnosis and surgical treatment of brainstem tumors. These new technologies offer many advantages: safe but aggressive surgery on the brainstem, the possibility of performing a correct histologic diagnosis, and an exact indication for radiotherapy. Eleven tumors were operated on in our series: seven were intrinsic and four protruded out from the axis. Patients with high-grade malignant tumors died from 5 to 12 months after treatment, whereas those with pilocytic astrocytoma are still alive and leading useful lives.

[Controlled hypotension with nitroglycerin in neurosurgery (author's transl)]. / L'hypotension controlée avec la nitroglycérine en neurochirurgie.

Controlled hypotension with nitroglycerin has been used n 30 neurosurgical procedures for aneurysms clipping, artero-veinous malformations, cerebral vascularised tumours and in some cases in the course of serial carotido-cerebral angiography. Farmacodynamic aspects of this drug and its effects on intracranial pressure are compared with sodium nitroprusside. Controlled hypotension was induced with prepared solution of nitroglycerin via an infusion pump in order to achieve a mean arterial blood pressure from 70 to 40 torr. All patients during hypotension were monitored by continuous blood pressure, pulse rate and intracranial pressure records. First results of our clinical evaluation indicate that this drug produce a rapid fall in blood pressure without harmful effect and does not significantly modify intracranial pressure. Its potential benefit in spasm of intracranial arteries associated with subarachnoid bleeding is investigated.

[The "quality" system in health care]. / Il sistema "qualità" nell'assistenza sanitaria.

The evolution of the quality assistance care management, is contributing to create a new strategy toward the single operations responsibility. This program is based on efficiency improvements, based on a synthesis of scientific evidences translated with specifications and criteria, that represents the application of the progress of clinic methodology and of the scientific information in the clinics. The evaluation of new criteria, like the guidelines and evidence based medicine, are our goal of this work, because can be a continuous improvements of the healthy and care programs at all the levels of applications.

[Hospices from the DPCM 20/1/2000 perspective: requirements to ensure a better quality of "residual life"]. / Gli hospices nell'ottica del DPCM 20/1/2000: requisiti per garantire una migliore qualità "di vita residua".

INTRODUCTION: In this paper, the authors analyse the increasing number of oncological patients, above all the terminal ones. The aim of hospice is to guarantee a high quality residual life. Hospice must not be regarded as a place of sweet death; on the contrary it's a hospital where palliative cares take place. It is, then, an alternative to home in the most critical phases of illness. CONSIDERATIONS: Despite a lasting interest in the matter, a law setting up a standard has been lacked until DPCM of 20/1/2000 that established structural, technological and managerial requirements for the centres of palliative cares. New hospices must be built in sunny places, in close contact with nature and easily reachable both by private and public means of transport. The law provides for three areas: a residential area, an evaluation and therapy area and a general area of support.