Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state.

Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.

Homocysteine-lowering treatment in coronary heart disease.

Homocysteine (Hcy) is a sulphur-containing amino acid product of methionine's metabolism. Hyperhomocysteinemia (HHcy) is considered an independent risk factor for cardiovascular (CV) disease, at least in high-risk patients. In fact, evidence indicates that although mild HHcy may be regarded as a minor risk factor for CHD in low-risk patients, it can play a role in triggering new events in patients with known CHD, also by interacting with the "classical" CV risk factors. This is of much interest because HHcy represents a correctable risk factor, inasmuch vitamin supplementation as has been shown to effectively lower total homocysteine plasma levels (tHcy). While case-control and cross-sectional studies have consistently demonstrated an association of HHcy with CV disease, prospective studies have given conflicting results. Moreover, the effect of the homocysteine-lowering treatment in preventing CV events is still under debate. Thus, it remains unclear which patients should be screened for HHcy and which ones should be treated to lower tHcy. In this paper we shall report and discuss knowledge on the potential role of HHcy in the development of CHD and on the benefits due to tHcy-lowering treatment with vitamins.

Comparison of in vitro drug-sensitivity of human granulocyte-macrophage progenitors from two different origins: umbilical cord blood and bone marrow.

Predictive in vitro hematotoxicity assays using human cells will provide estimation of tolerable level and aid considerably the development of agents with greater therapeutic activity and less toxicity. Human hematopoietic cells can be derived from three sources: human bone marrow by sternal or femoral aspiration, mobilized peripheral blood, or umbilical cord blood samples collected from placentas after deliveries. Because of the difficulties to have a continuous supply of bone marrow cells from normal human donors and the related ethical problems, we performed a study to compare the sensitivity of human bone marrow cells (h-BMC) and human cord blood cells (h-CBC) to chemicals in order to confirm if h-CBC can readily replace bone marrow cells in checking the sensitivity of GM-CFU progenitors to drugs as preliminarily reported in literature. Our results showed that the prediction of IC50 values in human model is quite similar by using h-BMC or h-CBC. On the contrary, the type of medium influenced in a significant way the ICs determination of some drugs.

Effects of caffeine on glucose tolerance: a placebo-controlled study.

OBJECTIVE: The investigation was performed to study the effects of 200 mg oral caffeine on glucose tolerance. DESIGN: Single-blind Latin square with active treatment (caffeine) and placebo. SETTING: The University of Padova, Department of Internal Medicine. SUBJECTS: 30 nonsmoking healthy subjects aged 26-32 years who abstained not only from coffee but also from tea, chocolate and cola for 4 weeks and who had given their informed consent. INTERVENTIONS: A 75 g oral glucose tolerance test (OGTT) was performed after giving caffeine or placebo (highly decaffeinated coffee). RESULTS: The glycaemic curve was normal in all subjects and was similar in the two groups until the second hour; in subjects taking caffeine a shift towards the right was detected at the 2nd, 3rd and 4th hours in comparison to those taking the placebo. Blood insulin levels were comparable after caffeine and after placebo along the entire OGTT. CONCLUSIONS: The data suggest that caffeine intake induces a rise in blood glucose levels that is insulin independent.

Autocrine-paracrine role of endothelin-1 in the regulation of aldosterone synthase expression and intracellular Ca2+ in human adrenocortical carcinoma NCI-H295 cells.

The role played by endothelin (ET-1) and its receptor subtypes A and B (ET(A) and ET(B)) in the functional regulation of human NCI-H295 adrenocortical carcinoma cells has been investigated. Reverse transcription-PCR with primers specific for prepro-ET-1, human ET-1 converting enzyme-1, ET(A), and ET(B) complementary DNAs consistently demonstrated the expression of all genes in NCI-H295 cells. The presence of mature ET-1 and both its receptor subtypes was confirmed by immunocytochemistry and autoradiography, respectively. Aldosterone synthase (AS) messenger RNA was also detected in NCI-H295 cells, and AS gene expression was enhanced by both ET-1 and the specific ET(B) agonist IRL-1620; this effect was not inhibited by either the ET(A) antagonist BQ-123 or the ET(B) antagonist BQ-788. A clear-cut increase in the intracellular Ca2+ concentration in NCI-H295 cells in response to ET(B), but not ET(A), activation was observed. In light of these findings, the following conclusions can be drawn: 1) NCI-H295 cells possess an active ET-1 biosynthetic pathway and are provided with ET(A) and ET(B) receptors; 2) ET-1 regulates in an autocrine/paracrine fashion the secretion of aldosterone by NCI-H295 cells by enhancing both AS transcription and raising the intracellular Ca2+ concentration; and 3) the former effect of ET-1 probably involves the activation of both receptor subtypes, whereas calcium response is exclusively mediated by the ET(B) receptor.

Hemodynamics following real and hypnosis-simulated phlebotomy.

Forearm arterial flow was measured in 22 healthy first-time blood donors during a 300-ml. blood letting and during the subsequent recovery. Blood pressure (BP) was also taken simultaneously and forearm peripheral resistance calculated. Following a transient BP and flow increase due to tachycardia related to needle insertion, both systolic BP and flow progressively and significantly decreased, while resistance increased. In a further 22 sex- and aged-matched highly hypnotizable subjects, blood donation was simulated by means of verbal hypnotic suggestions. The BP, flow and resistance curves were similar to those obtained with the real blood letting, without any between-subject difference or group/time interaction. Mere hypnosis without suggestion of phlebotomy and the simple bed resting did not produce any effect. These results indicate that the hemodynamic changes observed during and after a blood loss are partly due to mental involvement rather than merely to the hydraulic effects of the removal of blood.

Blood pressure and atherogenic lipoprotein profiles of fish-diet and vegetarian villagers in Tanzania: the Lugalawa study.

BACKGROUND: There is evidence that populations with a high intake of fish, and specifically fish oils, are at reduced risk of cardiovascular disease. To explore the effect of fish intake, we compared two groups of Bantu villagers in Tanzania; one group live on the shores of Lake Nyasa and their diet includes large amounts of freshwater fish; the other group live in the nearby hills and have a vegetarian diet. METHODS: We carried out a cross-sectional study of 622 fish-consuming villagers and 686 vegetarian villagers. 618 (99.4%) and 645 (94.0%), respectively, agreed to take part. Anthropometric and self-reported medical history data were collected by one local physician and a medical assistant, who also measured blood pressure and took blood samples for measurement of plasma lipids. A dietary questionnaire was administered to 25 families (about 15% of the study population) in each village. FINDINGS: After adjustment for age, sex, and alcohol intake the fish-consuming group had lower mean blood pressure than the vegetarian group (123/72 vs 133/76 mm Hg, p < 0.001). The frequencies of definite and borderline hypertension (by WHO criteria) were lower in the fish-consuming than in the vegetarian group (2.8 vs 16.4%; 9.7 vs 22.3%, respectively). Plasma concentrations of total cholesterol (mean 3.53 [SD 1.04] vs 4.10 [1.04] mmol/L), triglycerides (0.92 [0.64] vs 1.31 [0.64] mmol/L), and lipoprotein(a) (201 [213] vs 321 [212] mg/L), were all lower (p < 0.0001) in the fish-consuming group than in the vegetarian group. The proportions of n-3 polyunsaturated fatty acids in plasma lipids were higher (p < 0.0001) in the fish-consuming group than in the vegetarian group (eicosapentaenoic acid 2.3 [1.3] vs 0.7 [0.2]%; docosapentaenoic acid 1.1 [0.4] vs 0.6 [0.3]%; docosahexaenoic acid 5.7 [1.6] vs 1.5 [1.1]%). INTERPRETATION: In these villagers, consumption of freshwater fish (300-600 g daily) was associated with raised plasma concentrations of n-3 polyunsaturated fatty acids, lower blood pressure, and lower plasma lipid concentrations.

Antiatherogenic action of nitrendipine in hypercholesterolemic rabbits: changes in aortic macrophage accumulation and smooth muscle cell phenotype.

Intimal accumulation of macrophages and changes in the phenotype and growth properties of vascular smooth muscle cells (SMCs) represent key events in the development of atherosclerotic lesions. Here we report on the in vivo effect exerted by nitrendipine on aortic tissue of cholesterol-fed rabbits. We have focused especially on the myosin heavy chain (MyHC) pattern expressed by aortic SMC, taken as a marker of cell differentiation. Using monoclonal antibodies specific to the different forms of MyHC, three differentiation steps were determined: adult, postnatal, and fetal. Nitrendipine administered in conjunction with a cholesterol-enriched diet reduced the development of atherosclerotic lesions (atherosclerosis index: 0.21 vs. 0.32 in untreated animals, p< 0.005), despite persistently high serum cholesterol levels. Compared to untreated controls, nitrendipine-treated animals displayed a decreased number of postnatal-type SMCs in the media underlying the plaque (prevalence index: 0.07 vs. 0.26, p < 0.0001 and a lower aortic cholesterol content (free cholesterol: 3.3 vs. 11.5 ng/mg, p< 0.0001; esterified cholesterol: 7.2 vs. 40.5 ng/mg, p< 0.0001). Moreover, nitrendipine treatment decreased the intimal accumulation of macrophages and fetal-type SMCs. It is conceivable that calcium antagonists may exert their antiatherogenic effect, at least in part, through cellular changes unrelated to the classical risk factors.

[The relationship between overweight, life style and casual and 24-hour pressures in a population of male subjects with mild hypertension. The results of the HARVEST study]. / Relazione tra sovrappeso, abitudini di vita e pressione casuale e delle 24 ore in una popolazione di soggetti di sesso maschile con ipertensione lieve. Risultati dello studio HARVEST.

AIM OF THE STUDY: To evaluate the relationship of coffee use, smoking, physical inactivity, alcohol intake and overweight with casual and ambulatory blood pressure in a large population of borderline to mild hypertensive subjects. METHODS: Six hundred and thirty men with a mean (+/- SE) age of 33 +/- 0.4 years (range = 18-45 years) and a mean office blood pressure of 146 +/- 0.4/94 +/- 0.2 mm Hg, participating in the multicentre HARVEST study, were divided into three categories according to: coffee consumption (0 cups, 1-3 cups, > 3 cups/day), number of cigarettes smoked per day (0, 1-10, 11-20), degree of physical activity (no activity, regular training, competitive activity), alcohol intake (no alcohol, < 50 g, > or = 50 g/day) and body mass index (tertiles). All patients underwent non invasive ambulatory blood pressure monitoring with either the A&D TM-2420 model 7 or the Spacelabs 90207 monitor. Moreover, 24-hour urine collection was made for epinephrine and norepinephrine assessment (n = 611). RESULTS: Twenty-four-hour systolic blood pressure was higher in the coffee drinkers than the nondrinkers (+2.6 mm Hg in the moderate drinkers). Instead, 24-hour diastolic blood pressure was mainly influenced by overweight (3.2 mm Hg difference between the low and high BMI tertiles) and physical inactivity (3.2 mm Hg difference between the sedentary men and the athletes). Generally, the association of the above factors was stronger with ambulatory than with office blood pressure, whereas alcohol intake was only related to office diastolic blood pressure. However, in a multivariate regression analysis alcohol use did not show an independent effect on either office or ambulatory blood pressure. Smoking showed a different effect on office and ambulatory blood pressure. In fact, office blood pressure was higher in the nonsmokers, while 24-hour blood pressure was higher in the smokers. Smoking, coffee and physical inactivity were associated with sympathetic overactivity, as documented by increased urinary catecholamines output. CONCLUSIONS: The results of the present study indicate that overweight and behavioural factors affect 24-hour blood pressure to a larger extent than office blood pressure does. This is likely to be due to their effect on the sympathetic nervous system activity, which would enhance the blood pressure response to daily life stressors.

Gene expression, localization, and characterization of endothelin A and B receptors in the human adrenal cortex.

Compelling evidence indicates that the endothelium-derived potent vasoconstrictor endothelin-1 (ET-1) stimulates aldosterone secretion by interacting with specific receptors. Although two different ET-1 receptors have been identified and cloned, the receptor subtype involved in mediating aldosterone secretion is still unknown. Accordingly, we wished to investigate whether the genes of ET-1 and of its receptors A and B are expressed in the normal human adrenal cortex. We designed specific primers for ET-1 and the ETA and ETB receptors genes and developed a reverse transcription polymerase chain reaction (RT-PCR) with chemiluminescent quantitation of the cDNA. In addition, we carried out 125I ET-1 displacement studies with cold ET-1, ET-3 and the specific ETA and ETB ligands BQ123 and sarafotoxin 6C. Localization of each receptor subtype was also investigated by autoradiography. Binding experiments were first individually analyzed by Scatchard and Hofstee plot and then coanalyzed by the nonlinear iterative curve fitting program Ligand. Histologically normal adrenal cortex tissue, obtained from kidney cancer patients (n = 7), and an aldosterone-producing adenoma (APA), which is histogenetically derived from the zona glomerulosa (ZG) cells, were studied. Results showed that the ET-1, ETA and ETB mRNA can be detected by RT-PCR in all adrenal cortices as well as in the APA. The best fitting of the 125I ET-1 displacement binding data was consistently provided by a two-site model both in the normal adrenal cortex (F = 22.1, P < 0.0001) and in the APA (F = 18.4, P < 0.0001). In the former the density (Bmax) of the ETA and ETB subtype was 2.6 +/- 0.5 pmol/mg protein (m +/- SEM) and 1.19 +/- 0.6, respectively. The dissociation constant (Kd) of ET-1, ET-3, S6C, and BQ-123 for each receptor subtype resulted to be within the range reported for human tissue for the ETA and ETB receptors. In the APA tissue the Bmax tended to be lower (1.33 and 0.8 pmol/mg protein, for the ETA and ETB, respectively) but the Kd were similar. Autoradiographic studies confirmed the presence of both receptor subtypes on the ZG as well as on APA cells. Thus, the genes of ET-1 and both its receptor subtypes ETA and ETB are actively transcribed in the human adrenal cortex. Furthermore, both receptor subtypes are translated into proteins in ZG and APA cells.

Haemodynamic effects of coffee and purified caffeine in normal volunteers: a placebo-controlled clinical study.

In order to evaluate the effects of 'espresso' Italian coffee on resting flow, blood pressure, and peripheral resistance, 15 non-coffee drinking healthy volunteers received 2 cups of regular coffee, 200 mg purified caffeine or placebo in a latin square double-blind crossover protocol. Before and 30, 60, 90 and 120 min after ingestion, segmental resting flow and BP were measured and peripheral resistance was calculated. An echocardiogram was also performed before and 60 and 120 min after caffeine intake. Both regular coffee and caffeine produced a significant decrease in resting flow and a significant increase in resistance; both systolic and diastolic BP also increased, although not significantly. No variation was observed in heart rate and in cardiac contractility. Placebo (highly decaffeinated coffee for regular coffee and china bitter extract for caffeine) did not produce any haemodynamic effect. In five other healthy volunteers used to drinking more than 5 cups of coffee a day, coffee administration had no effect. These data demonstrate that the caffeine contained in espresso Italian coffee is a vasoconstrictor agent whose effects however are completely blunted in usual coffee drinkers as a consequence of adaptation.

Haemodynamic effects of coffee and caffeine in normal volunteers: a placebo-controlled clinical study.

The acute haemodynamic effects of Italian coffee and 200 mg purified caffeine were investigated in 15 healthy non-coffee-drinkers compared to individuals who consumed placebo (highly decaffeinated coffee for regular coffee, and china bitter extract for caffeine). Before coffee and caffeine consumption and 30, 60, 90 and 120 min afterwards, rest flow and blood pressure were measured, and peripheral resistance in the arm was calculated; an echocardiogram was also performed before and 60 and 120 min after caffeine consumption. Both coffee and caffeine significantly decreased rest flow, and increased peripheral resistance. Systolic blood pressure increased by 10% and diastolic pressure increased by 5% for at least 2 h. No variation in heart rate or cardiac contractility was found. No effects were observed after placebo treatment. It is concluded that Italian coffee and caffeine increase blood pressure via vasoconstriction.

An improved method for the purification of myrosinase and its physicochemical characterization.

An improved high yielding procedure for the purification of myrosinase from Sinapis alba L. consisting of concanavalin A affinity chromatography followed by a chromatofocusing step is presented. The purified enzyme was homogeneous as judged by sodium dodecyl sulfate-gel electrophoresis and by analytical ultracentrifugation although the presence of at least three isoenzymes, with pI values from 5.05 to 5.15, was detected by isoelectric focusing. It was found that the enzyme has a molecular weight of 135.1 kg mol-1 and consists of two, possibly identical, subunits of molecular weight 71.7 kg mol-1. The structure of myrosinase was studied by circular dichroism. Contin analysis of the CD data indicates a mixed alpha-helix and beta-sheet conformation for the native protein a with approximately 19% alpha-helix and approximately 35% beta-sheet content. Denaturation with guanidinium chloride was found to be irreversible although the enzyme has excellent storage characteristics in aqueous solution.

[Hemodynamic effects of "expresso" Italian coffee and pure caffeine on healthy volunteers]. / Effetti emodinamici del caffè espresso all'italiana e della caffeina pura in volontari sani.

In 15 healthy non-coffee-drinker subjects and in 5 usual coffee-drinkers, the effects were studied of 2 cups of "espresso" italian coffee and of 200 mg purified caffeine on blood pressure, heart rate, forearm rest flow and peripheral resistance. In the 15 non-coffee-drinkers, left ventricular ejection fraction, fractional shortening, cardiac output and end-systolic stress were also evaluated by a 2D-guided M-mode echocardiogram before and 60 and 120 min after oral administration of 200 mg purified caffeine. In the non-coffee-drinker volunteers, diastolic and systolic blood pressure and peripheral resistance increased both after "espresso" coffee and after caffeine. In the usual drinkers no hemodynamic effect was seen. No variation of cardiac contractility was observed. We conclude that caffeine contained in the "espresso" coffee obtained with the high-pressure italian procedure is a strong vasoconstrictor agent, while it has no action on cardiac contractility.

Changes in ventricular creatine-kinase with progression and regression of cardiac hypertrophy in hypertensive rats.

We studied the distribution of four isoenzymes of creatine-kinase (MM, MB, BB and the mitochondrial) in 13 renovascular hypertensive rats and five age-matched controls. After 6 weeks of hypertension, seven rats were treated with captopril (2 mg/kg daily) for 4 weeks and the other six were left untreated for 4 weeks. After the rats were killed an adaptive increase in MB and BB was found at the expense of MM in the hypertensive rats compared with the controls. The captopril-treated rats displayed persistently higher levels of both MB and BB than the controls. Therefore, the regression in cardiac hypertrophy that is achieved by captopril is accompanied by persistence of the isoenzymic pattern that leads to better use of energy-rich phosphates.

Prevention of aortic hypertrophy in spontaneously hypertensive turkeys.

In spontaneously hypertensive turkeys, both high blood pressure and high catecholamine levels play a role in the development of vascular hypertrophy. We studied the effect of labetalol, an alpha- and beta-blocking drug, on the aortic media. Seventeen turkeys were given increasing doses of the drug (20-35 mg/kg daily) from the 2nd to the 35th week of age; 13 control birds were given a daily placebo. The actively treated turkeys showed significantly lower values of blood pressure and a lower heart rate compared with the controls throughout the study period. After the turkeys had been killed, seriate histological sections taken from the abdominal aorta near the bifurcation were used for a three-dimensional assessment of the aortic media by computerized morphometry. The volume of aortic media was significantly lower in the labetalol-treated birds than in the controls. This was also observed in the non-responder turkeys. This finding indirectly supports the view that catecholamines may play a major but independent role in the development of vascular hypertrophy.