Behaviour disorder caused by Cushing's syndrome in an older person.

An 81-year-old woman was hospitalised for behavioural disorders that had been progressively emerging over a period of few weeks. The symptoms appeared to worsen over time. A diagnosis of vascular dementia, complicated by psychosis, was initially hypothesised. The inefficacy of the antipsychotic/benzodiazepine medications used, along with the presence of hypertension, hypokalaemia and metabolic alkalosis (resistant to pharmacological attempts of correction), as well as the hirsutism and the development of several infections, led us to consider Cushing's syndrome. Endocrinological analysis suggested ectopic adrenocorticotropic hormone (ACTH) secretion. Although endogenous Cushing's syndrome is rare in older people, it should always be considered among the differential diagnosis of behavioural disorders.

Early ficolin-1 is a sensitive prognostic marker for functional outcome in ischemic stroke.

BACKGROUND: Several lines of evidence support the involvement of the lectin pathway of complement (LP) in the pathogenesis of acute ischemic stroke. The aim of this multicenter observational study was to assess the prognostic value of different circulating LP initiators in acute stroke. METHODS: Plasma levels of the LP initiators ficolin-1, -2, and -3 and mannose-binding lectin (MBL) were measured in 80 stroke patients at 6 h only and in 85 patients at 48 h and later. Sixty-one age- and sex-matched healthy individuals served as controls. Stroke severity was measured on admission using the National Institutes of Health Stroke Scale (NIHSS). The outcome was measured at 90 days by the modified Rankin Scale (mRS). RESULTS: Ficolin-1 was decreased in patients compared with controls measured at 6 h (median 0.13 vs 0.33 µg/ml, respectively, p < 0.0001). At 48 h, ficolin-1 was significantly higher (0.45 µg/ml, p < 0.0001) compared to the 6 h samples and to controls. Likewise, ficolin-2 was decreased at 6 h (2.70 vs 4.40 µg/ml, p < 0.0001) but not at 48 h. Ficolin-3 was decreased both at 6 and 48 h (17.3 and 18.23 vs 21.5 µg/ml, p < 0.001 and <0.05, respectively). For MBL no difference was detected between patients and controls or within patients at the different time points. In multivariate analysis, early ficolin-1 was independently associated with unfavorable mRS outcome (adjusted odds ratio (OR): 2.21, confidence interval (CI) 95 % 1.11-4.39, p = 0.023). Early ficolin-1 improved the discriminating ability of an outcome model including NIHSS and age (area under the curve (AUC) 0.95, CI 95 % 0.90-0.99, p = 0.0001). CONCLUSIONS: The ficolins are consumed within 6 h after stroke implicating activation of the LP. Early ficolin-1 is selectively related to 3-month unfavorable outcome.

A spontaneous decrease of blood pressure occurs in acute ischemic stroke with favourable neurological course.

BACKGROUND: In the acute phase of ischemic stroke the relationship between blood pressure (BP) and clinical outcome remains not clear. The aim of our study was to evaluate the association of stroke severity and BP measurements in the acute phase of stroke, and whether early variation of neurological status affects BP profiles. METHODS: BP on admission was obtained with mercurial sphygmomanometer and 24h-ambulatory BP monitoring (ABPM) was performed on days 1(st) and 6(th). Enrolled patient were grouped according to the neurological deficit at onset (graded by the NIHSS) in group A, (NIHSS score ≤ 10, mild/moderate) and group B (NIHSS score > 10, moderate/severe) and according to the occurrence of early neurological improvement, defined as a NIHSS score reduction of at least 4 points at the 6(th) day in group C (improved) and in group D (not improved). RESULTS: A total of 57 patients were enrolled. On admission sphygmomanometric systolic BP values were higher in group A with respect to group B (158,5 mmHg ± 26,9 vs 147,7 mmHg ± 15,5 respectively; p = 0.6) whereas no difference was found in ABPM. On admission sphygmomanometric BP and ABPM were similar in group C and group D. At the 6(th) day ABPM, both systolic BP and diastolic BP values were significantly reduced in clinically improved patients (Δ systolic BP 1(st) to 6(th) day = 9,9±13,3 in group C vs 0,5±17,6 in group D, p < 0,05; Δ diastolic BP 1(st) to 6(th) day = 5,1± 8,4 mmHg in group C vs 1,3 ± 9,7 mmHg in group D, p = ns) whereas no change in the 24-h BP profile was observed in patients without early improvement. CONCLUSION: BP on admission in not related to the stroke severity and does not predict early neurological outcome and patients that show an early neurological improvement show also a reduction of the BP profile.

Effect of intravenous tirofiban and aspirin in reducing short-term and long-term neurologic deficit in patients with ischemic stroke: a double-blind randomized trial.

BACKGROUND: Thrombolysis with rt-PA is the only approved pharmacological therapy for acute ischemic stroke presently administrable in a 3-hour window (very recently extended to 4.5 h). After this time, the choice is limited to endovascular treatment and antiplatelet drugs, mainly aspirin (ASA), the efficacy of which in the acute phase of stroke has poorly been evaluated. We compared the efficacy of tirofiban, a GP-IIb/IIIa inhibitor, and ASA, with both drugs being administered within 6 h. METHODS: 150 patients were randomly assigned to treatment with tirofiban or ASA, both given for 3 days in a double-blind regimen. Major inclusion criteria were stroke onset within 6 h and a baseline National Institute of Health Stroke Scale (NIHSS) score of 5-25. Outcome variables were the proportion of patients with a NIHSS score reduction of > or =4 points after 72 h, and the proportion of patients with an mRS score of 0-1 at 3 months. RESULTS: The trial, originally planned to enroll 300 patients, was halted after enrollment of 150 patients at interim analysis due to the lack of a trend difference between the 2 treatment groups. Neurological improvement at 72 h was observed in 56% of the patients in each group. At the 3-month follow-up, minimal or absent disability was seen in 45% of the patients in the tirofiban group and 53% in the ASA group; these differences were not statistically significant. Three-month mortality was the same in both groups (10.6%); the rates of symptomatic intracranial hemorrhage were 1% (tirofiban) and 4% (ASA). CONCLUSION: In spite of the fact that the null hypothesis was not supported by our data, we found results supporting the safety (and potential efficacy) of ASA and tirofiban when used in the first hours of acute ischemic stroke. However, this needs to be confirmed by further studies.

Ulnar nerve entrapment neuropathy at the elbow: decisional algorithm and surgical considerations.

INTRODUCTION: We propose our surgical experience and the decisional algorithm we use to select the surgical procedure for the ulnar nerve entrapment at the elbow according to defined parameters. MATERIALS AND METHODS: Between 2005 and 2007, 44 patients were operated according to our algorithm that is based both on clinical parameters, classified through the McGowan scale, and on biological ones (the nervous morphology and the amount of scar around the medial epicondyle). Patients were treated through "modified" in situ simple decompression, subcutaneous and sub muscular transpositions. RESULTS: After an average follow-up of 13.4 months, function improved by one grade in 70% of patients, two grades in 16% and there was no change in 14%. Moreover 84.8% of patients operated through the modified in situ decompression technique reported an excellent outcome. CONCLUSION: We suggest an algorithm for uniformly treat the patients with cubital tunnel syndrome through a clinical and biological point of view. The modified in situ decompression is a safe and effective treatment for the majority of these patients reducing the risk of redo surgery.

Ulnar nerve entrapment neuropathy at the elbow: decisional algorithm and surgicalconsiderations

Introduction. We propose our surgical experienceand the decisional algorithm we use to select the surgicalprocedure for the ulnar nerve entrapment at theelbow according to defined parameters.Materials and methods. Between 2005 and 2007, 44patients were operated according to our algorithm thatis based both on clinical parameters, classified throughthe McGowan scale, and on biological ones (the nervousmorphology and the amount of scar around the medialepicondyle). Patients were treated through "modified"in situ simple decompression, subcutaneous and submuscular transpositions.Results. After an average follow-up of 13.4 months,function improved by one grade in 70% of patients,two grades in 16% and there was no change in 14%.Moreover 84,8% of patients operated through themodified in situ decompression technique reported anexcellent outcome.Conclusion. We suggest an algorithm for uniformlytreat the patients with cubital tunnel syndrome througha clinical and biological point of view. The modified insitu decompression is a safe and effective treatment forthe majority of these patients reducing the risk of redosurgery (AU)

Introducción. Proponemos nuestra experiencia quirúrgicay el método decisivo que utilizamos para elegirla técnica quirúrgica en el atrapamiento del nervioulnar en el codo según parámetros concretos.Materiales y técnicas. Entre el 2005 y el 2007, 44pacientes han sido sometidos a cirugía según nuestroalgoritmo basado en unos parámetros clínicos, clasificadosa través de la escala de McGrowan, y otros biológicos( morfología del nervio y cantidad de cicatriz entorno al epicóndilo medial). Los pacientes fueron tratadosmediante la decompresión simple "modificada" insitu, la transposición subcutánea y submuscular.Resultados. Después de un control durante 13.4meses, el 70% recuperó la función en un grado, el 16%en dos grados y no hubo cambios en el 14%.Además, el 84,8% de los pacientes operadosmediante la técnica de decompresión modificada in situpresentó excelentes resultados.Conclusión. Proponemos un algoritmo para trataruniformemente pacientes con síndrome del túnelcubital a través de puntos de vista clínicos y biológicos.La decompresión modificada in situ es un tratamientoseguro y eficaz en la mayor parte de pacientes reduciendoel riesgo de reintervención (AU)

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region.

The partial labyrinthectomy petrous apicectomy (PLPA) approach is a transpetrous route that provides the advantages of the labyrinthine removal but with hearing preservation. Using seven temporal bone tissue blocks and three formaldehyde-fixed cadaveric heads we have made a morphometric and comparative study on this approach that summarizes the invasiveness, the optimal surgical exposure, the anatomic complexity of the skull base approaches and, on the other hand, the spirit of preservation that is the constant aim of modern neurosurgery. The morphometric analysis is designed to make the bony phase of the PLPA approach safer and to define the relationship between petrous landmarks. The comparative study is made between the PLPA and other neurosurgical routes enhancing the potentiality of the PLPA approach that permits a wider angle of incidence towards the brainstem than with the retrosigmoid routes.

Factors influencing delay in presentation for acute stroke in an emergency department in Milan, Italy.

BACKGROUND AND AIMS: Early treatment is critical for successful intervention in acute stroke. The aim of this study was to describe delays in presentation to hospital and in the emergency department (ED) management of patients with acute stroke and to identify factors influencing these delays in an Italian urban hospital. METHODS: The present series includes all patients presenting with acute stroke, in whom arrival delay was ascertainable. To describe delays into the ED, the triage-visit delay, visit-computed tomography (CT) delay and visit-CT report delay were registered. Type of stroke, severity of stroke assessed using the modified National Institute of Health Stroke Scale (mNIHSS) scale, level of consciousness, history of previous stroke or previous hospital admission, use of the emergency medical service (EMS), onset of stroke during day or night and admission during working or non-working day were registered for every patient. Univariate and multivariate analysis were performed to evaluate factors influencing early arrival. RESULTS: Over a one-year period 537 patients with acute stroke were evaluated; 375 patients in whom arrival delay was ascertainable were included in the study. Median arrival delay was 5.4 h (interquartile range (IQR) 2.7-11.6); 104 patients (28%) arrived within 3 h and 198 (53%) within 6 h. Triage-visit delay was 0.3 h (IQR 0.2-0.7), visit-CT scan delay was 1.2 h (IQR 0.8-1.9), visit-CT report delay was 2.7 h (IQR 1.7-4.5). Triage-visit delay and visit-CT delay were shorter for patients presenting within 3 h. The type of stroke was ischaemic in 240 (64%), haemorrhagic in 61 (16%) and transient ischaemic attack in 74 (20%). The median basal mNIHSS score was 5 (IQR 3-10); 64 patients (17%) had an altered level of consciousness, 103 (27%) had had a previous stroke, 223 (59%) had had a previous hospital admittance. In this series 214 patients (57%) arrived with the EMS, 323 (86%) presented with symptoms during the day, 261 (70%) were admitted during working days. Univariate analysis showed a significantly shorter arrival delay in patients calling the EMS (median 4.2 vs 7.2 h; p<0.001) and in patients with a higher basal mNIHSS score (Spearman rho = -0.204; p<0.001) or altered level of consciousness (normal 5.8 h, not alert but arousable 3.8, not alert but arousable with strong stimulation 2.5, totally unresponsive 6.0; p = 0.005). Multivariate analysis showed that use of the EMS and higher basal mNIHSS score were independent variables associated with a shorter arrival delay. CONCLUSION: A substantial proportion of patients does not arrive at the ED in a suitable time for reperfusion therapy. Patients using the EMS have a shorter arrival delay. Approximately half of the patients with stroke are sufficiently aware of the urgency of this clinical condition to activate the emergency telephone system.

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas. A quantitative anatomic comparison with other approaches to the same region

La laberintectomía parcial con apicectomía petrosa (PLPA) es una vía de abordaje que proporciona las ventajas de la extirpación parcial del laberinto preservando la audición. Trabajando sobre 7 piezas anatómicas de hueso temporal y 3 cabezas de cadáver fijadas con formaldehido, hemos realizado un estudio morfométrico y comparativo de este abordaje interesándonos los aspectos de la invasividad del abordaje, óptima exposición quirúrgica obtenida, complejidad anatómica de la entrada a la base craneal, y por otra parte, la actitud conservadora de la moderna neurocirugía. El análisis morfométrico tiene como objetivo hacer la fase ósea de la PLPA más segura al definir la relación entre los puntos de referencia petrosos. El estudio comparativo entre la PLPA y otros abordajes neuroquirúrgicos exalta la posibilidades de la PLPA ya que proporciona un ángulo de incidencia hacia el tronco cerebral más amplio que el que proporcionan las vías retrosigmoideas

The partial labyrinthectomy petrous apicectomy (PLPA) approach is a transpetrous route that provides the advantages of the labyrinthine removal but with hearing preservation. Using seven temporal bone tissue blocks and three formaldehyde-fixed cadaveric heads we have made a morphometric and comparative study on this approach that summarizes the invasiveness, the optimal surgical exposure, the anatomic complexity of the skull base approaches and, on the other hand, the spirit of preservation that is the constant aim of modern neuro surgery. The morphometric analysis is designed to make the bony phase of the PLPA approach safer and to define the relationship between petrous landmarks. The comparative study is made between the PLPA and other neurosurgical routes enhancing the potentiality of the PLPA approach that permits a wider angle of incidence towards the brainstem than with the retro sigmoid routes

Spinal dural arterio-venous fistula with multiple points of shunt.

A 45-year-old man presented with a history of dysaesthesiae, sensory impairment of the legs and sphincter disturbances. Selective angiography showed a mid-thoracic dural arterio-venous fistula with five shunt points. The venous plexuses were demonstrated by injections at T5 on the right side and T6 on the left, but the venous pattern on the two sides did not overlap. Angiography did not unquestionably point to any single location of a fistula, as would normally be expected. During surgery five dorsal locations of shunt were identified. We have not found any publication describing a spinal dural arterio-venous fistula with multiple venous drainage channels at the same level.

Minor stroke and major vascular occlusion. A case report.

Occlusion of middle cerebral artery (MCA) is generally associated to severe stroke and poor prognosis; however a few patients with mild to moderate presentation and long-term reversibility of neurological deficits have been reported. A 66-year-old male presented with left-side weakness and dysarthria (NIHSS score 7), which progressively resolved within a few days; ischaemic lesion of the anterior arm of the right internal capsule was found at brain CT obtained 72 h after presentation. Transcranial Colour Doppler showed absence of flow of the right MCA. Cerebral angiography showed occlusion of the right MCA that was retrogradely revascularised by leptomeningeal collaterals. Non-invasive intracranial vascular examinations could identify major intracranial artery lesions in patients who present with mild to moderate stroke symptoms. These patients could be identified and followed to clarify their best treatment and prognosis.

Vertebral arterio-venous fistula presenting with intracranial hemorrhage.

Vertebral arteriovenous fistulas are rare lesions consisting of an abnormal shunt between the extracranial vertebral artery and the neighboring veins. The authors present a case of post-surgical high-flow left vertebral arteriovenous fistula presenting with intracranial hemorrhage. The patient underwent endovascular balloon occlusion of the fistula: after endovascular treatment a reduction of the flow was evident but the patient presented neurological deterioration related the occurrence of intraventricular-subarachnoid hemorrhage. Intracranial hemorrhage is a potential manifestation of high-flow vertebral AVF and a possible complication of endovascular fistula balloon occlusion. Direct endovascular occlusion of the vertebral artery may be primarily considered in selected cases.

Surgical excision of clival tumors via the enlarged transcochlear approach. Indications and results.

BACKGROUND: The results of the surgical resection of 9 clival tumors using the enlarged transcochlear approach (ETCA) are evaluated. The literature is reviewed to compare the ETCA with other approaches to the clival and petroclival region; the surgical indications are discussed. METHODS: Between June 1996 and June 1997, 9 patients were operated on through the ETCA either alone or combined with other approaches. Only meningiomas and chordomas with a significant involvement of the clivus and huge extension into the posterior fossa were included into this study. RESULTS: Gross total tumor removal was achieved in 5 cases and in 4 cases a residual meningioma was left in place inside the cavernous sinus and treated by radiosurgery. No postoperative mortality or major neurological morbidity were recorded. The postoperative facial nerve function was good in 75% of cases. No tumor recurrence was recorded (mean follow-up = 45.9 months). CONCLUSIONS: The indications to the ETCA should be as strict as possible. The ETCA is an effective procedure in the treatment of large clivopetrous tumors. Tumor characteristics like consistency, vascularity, encasements of vertebro-basilar vessels, bone erosion and previous surgery are also indicative. The transient postoperative facial nerve palsy and deafness should be considered as major disadvantages related to this approach.

Chondrosarcoma of the thoracic spine: total en bloc sagittal resection. A case report.

Chondrosarcomas located in the spine are uncommon tumors and are challenging to manage. A case of a 65-year-old man with a T3-T4 spine chondrosarcoma is reported. The onset of symptoms consisted in progressive dorsal pain with sometimes a girdle-like radiation and, successively, in dysaesthesia and paresthesia from the lower limbs to the thoracic region. After preoperative oncologic and surgical planning the patient underwent a total en bloc resection of the mass. No postoperative adjunctive neurological deficits were recorded. An adjuvant radiation therapy with a dose of 5.500 centigrays (cGy) over four weeks was performed. At one year follow-up the patient is alive with no signs of recurrence on computed tomographic scans and magnetic resonance imaging. We discuss this case with particular emphasis on the preoperative planning, the surgical procedure and related prognosis.

Desmopressin stimulation test before and after pituitary surgery in patients with Cushing's disease.

OBJECTIVE: The desmopressin test has been proposed as a useful tool for the differential diagnosis of Cushing's disease. The aim of our study was to investigate, in a large series of patients with Cushing's disease, the incidence of a positive ACTH and cortisol response to desmopressin. Moreover, we repeated the test soon after surgery to verify its usefulness in the assessment of early and late surgical results. PATIENTS AND METHODS: One hundred and seven consecutive patients with Cushing's disease, 89 female and 18 male patients, with a mean age of 37.2 +/- 1.3 years, were studied. All patients, except three, repeated the test 5-6 days after surgery. Desmopressin (10 microg) was injected i.v. and blood samples were drawn 15, 30, 45 and 60 minutes thereafter. Plasma ACTH and serum cortisol were measured in duplicate by commercially available immunoassays. A positive response to desmopressin was considered to be a plasma ACTH and serum cortisol increment of at least 30% and 20% above baseline, respectively. RESULTS: Mean basal plasma ACTH level was 17.3 +/- 1.7 pmol/l and rose to a peak level of 42.7 +/- 4.9 pmol/l at 15 minutes Mean basal serum cortisol level was 574 +/- 19 nmol/l and rose to a peak level of 814 +/- 28 nmol/l at 45 minutes. ACTH and cortisol incremental changes were inversely correlated with their respective basal levels. Ninety patients (84.1%) had an ACTH and 84 patients (78.5%) had a cortisol response to desmopressin. Several clinical and demographic characteristics were not significantly different among desmopressin responders and non responders, except that basal ACTH and cortisol levels were significantly higher in desmopressin non responders (27.2 +/- 8.3 pmol/l, 781 +/- 86 nmol/l) than in desmopressin responders (15.4 +/- 1.2 pmol/l, 535 +/- 14 nmol/l). Disappearance of the ACTH and cortisol response to desmopressin after surgery occurred in 50 of 87 (57%) ACTH responders and in 57 of 81 (70.4%) cortisol responders, respectively. However, concordance between the desmopressin test and surgical outcome was not complete. Indeed, 18 patients considered in remission still showed an ACTH increase after desmopressin and, on the contrary, four patients with disappearance of the ACTH response had persistence of hypercortisolism. During follow-up monitoring, three patients, who had persistence of the ACTH response to desmopressin, relapsed 24, 38 and 54 months after surgery. CONCLUSIONS: Desmopressin administration elicits a significant rise in ACTH and cortisol levels in the majority but not all patients with Cushing's disease. There is a good, but not complete, concordance between the response to the desmopressin test and the surgical outcome. Our preliminary data show that persistence of the ACTH response to desmopressin in the early postoperative period might be associated with a higher risk of late relapse.

Exposure of the petrous segment of the internal carotid artery through the extradural subtemporal middle cranial fossa approach: a systematic anatomical study.

The relationships between the horizontal segment of the internal carotid artery (ICA) and other petrous apex structures was studied in 14 anatomical specimens obtained from routine autopsies and on 10 magnetic resonance images obtained from healthy volunteers. The dissection was performed under an operating microscope using the middle fossa transpetrous approach. A pentagonshaped area of 67.91 mm(2) posterior to the trigeminal nerve and bordered by anatomical structures was identified inside the petrous apex. The results suggest a method for exposing the ICA when the artery is not visible after dural elevation.

Treatment of Helicobacter pylori and Chlamydia pneumoniae infections decreases fibrinogen plasma level in patients with ischemic heart disease.

BACKGROUND: Chronic Chlamydia pneumoniae and Helicobacter pylori infections could be a risk factor for ischemic heart disease (IHD), possibly by increasing fibrinogen levels. The aim of our study was to evaluate changes in fibrinogen level in patients with IHD and H pylori and/or C pneumoniae positivity randomly assigned to antibiotic treatment. METHODS AND RESULTS: Eighty-four patients with chronic IHD, H pylori and/or C pneumoniae antibodies, and normal acute-phase reactants were randomly assigned to treatment or no treatment. Treatment consisted of omeprazole, clarithromycin, and tinidazole in H pylori-positive patients and clarithromycin alone in C pneumoniae-positive patients. The effect of treatment and other baseline variables on fibrinogen levels, determined at 6 months, was evaluated by multivariate analysis. Treatment significantly reduced fibrinogen level at 6 months in the overall study population and in the groups of patients divided according to H pylori or C pneumoniae positivity. In the 43 treated patients, mean (+/-SD) basal fibrinogen was 3.65+/-0.58 g/L, and mean final fibrinogen was 3. 09+/-0.52 g/dL (P<0.001), whereas in the 41 untreated patients, mean basal and final fibrinogen levels were 3.45+/-0.70 and 3.61+/-0.71 g/L, respectively. The largest decrease was observed in patients with both infections. Fibrinogen changes were also significantly and negatively correlated with age. CONCLUSIONS: Our data suggest that a short, safe, and effective course of antibiotic therapy might be suggested as a means of interacting with an "emerging" risk factor.

Surgical management of thyrotropin-secreting pituitary adenomas.

The reported cases of hyperthyroidism due to a TSH-secreting pituitary adenoma have steadily increased in previous years; however, information about the results and long term outcome after pituitary surgery is scanty. Twenty-four patients with a TSH-secreting adenoma underwent pituitary surgery at our department in the last 15 years. Hypersecretion of other pituitary hormones was diagnosed in 7 patients. Three patients were euthyroid at the time of surgery because of previous ablative thyroid therapies. The success rate of surgery strictly depends on the criteria used. Normalization of elevated FT3 and FT4 levels occurred in 17 of the 21 patients with preoperative hyperthyroidism: however, only those with early postoperative undetectable TSH level (12 cases) had no recurrence of disease during follow-up and no residual tumor tissue on postoperative MRI, whereas recurrence of hyperthyroidism occurred in 3 of the 5 patients without postoperative TSH inhibition. All 3 euthyroid patients had a subtotal removal of the tumor, as judged by postoperative MRI. Surgical removal is the therapy of choice of TSH-secreting adenomas, whereas radiotherapy and medical treatment with somatostatin analogues are usually reserved to patients with incomplete tumor removal. A thorough postoperative evaluation is necessary to discriminate between complete and partial remission of disease.

Portal hypertension and iron depletion in patients with genetic hemochromatosis.

Clinically, portal hypertension has been considered to be less common and less severe in patients with cirrhosis resulting from iron overload in homozygotes for genetic hemochromatosis than in patients with cirrhosis of other causes. To characterize the prevalence and progression of portal hypertension in genetic hemochromatosis (GH), 120 cirrhosis and iron-overloaded patients were compared with a control group of 120 patients with postnecrotic cirrhosis (PNC) who were matched for gender, age, Child's class, and alcohol abuse. Gastroesophageal endoscopy and abdominal ultrasonography were performed at diagnosis and repeated every 12 months and every 6 months, respectively, to evaluate the presence and severity of varices, the caliber of the portal vein and its collaterals, and splenic size. At diagnosis a similar frequency of varices was observed in patients with GH (25%) and in PNC (24%), as well as of portal vein abnormalities and spleen enlargement. During the follow-up period, all but two of the patients with GH were treated by phlebotomy and depleted of excess iron. After a mean of 6 +/- 4.3 (SD) years of observations (range, 2 to 10 years), varices were improved or completely reversed in 26% of patients with cirrhosis and GH but in only 5% of those with PNC (P < .01). Bleeding from varices was observed in only one patient with GH but in five patients with PNC. Of 22 patients with GH in whom portal hypertension was unmodified or worsened, 16 had coexistent hepatic viral infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of DNA ploidy and ERB-B2 oncogene expression in the prognosis of endometrial carcinoma.

Seventy-three patients with endometrial carcinoma have been retrospectively evaluated in this paper. Stage, grade, depth of myometrial invasion, flow cytometric DNA ploidy and ERB-B2 oncogene expression by immunohistochemical method have been analyzed on paraffin embedded tissue. Results showed the existence of a significant correlation between stage and grade of neoplasia and between DNA ploidy and course of disease; it has been observed that patients with aneuploid tumor tend to have a shorter time before relapse of disease. No significant correlation between depth of myometrial invasion and survival was found. Besides, it has been shown that tumours with ERB-B2 oncogene hyperexpression seem to have a more aggressive evolution.