Factors adversely influencing neurodevelopment.

Neurodevelopment has been studied extensively, especially in respect to abuse, anoxia, nutritional status and prematurity/low birth weight. However, less attention has been paid to innate and environmental factors, as well as to inflammatory conditions that may adversely affect neurodevelopment and learning in children. These include heavy metals, herbicides and polyvinyl chlorides (PVCs), mycotoxins, viral infections and Lyme disease-associated pathogens, as well as number of conditions such as chronic inflammatory response syndrome (CIRS) and Mast cell activation syndrome (MCAS). Early recognition of factors/conditions that could interfere with neurodevelopment is critical. Corrective actions, including the use of some unique natural flavonoids, could have lasting beneficial results.

A patient with intractable posthypoxic myoclonus (Lance-Adams syndrome) treated with sodium oxybate.

Posthypoxic myoclonus is a rare and devastating complication of near-fatal cardiopulmonary arrest. Despite treatment with available anti-myoclonic agents, some patients may recover cognitively but remain completely disabled by severe myoclonus. We report a 16-year-old patient with severe treatment-refractory posthypoxic myoclonus, which improved markedly with administration of the drug sodium oxybate.

[Gastric cancer and Helicobacter pylori: an interdisciplinary point of view]. / Cancro gastrico e Helicobacter pylori: un punto di vista interdisciplinare.

Gastric carcinogenesis involves a slow but continuous, stepwise evolution from superficial gastritis to glandular atrophy, metaplasia, dysplasia, and finally, to adenocarcinoma. In 1994, the International Agency for Research on Cancer defined Helicobacter pylori (H. pylori) as a group I carcinogen. Evidence supporting a causal association has been demonstrated by epidemiological data as well as by experimental animal models. The process of carcinogenesis, which may well extend over decades, provides an excellent opportunity for prevention or early detection of the events preceding development of the neoplasm. This is especially true because, at present, H. pylori can be readily treated. Despite this, the prognosis for gastric cancer is poor and, in most industrialised countries, the survival is only 10% after 5 years from diagnosis. The sole exception is Japan where this malignancy is often identified at an early stage when cure by radical surgery is more probable.

Treatment of chronic hepatitis D with thymus-derived polypeptide thymic humoral factor-gamma 2: a pilot study.

BACKGROUND: Thymic humoral factor-gamma 2 is a thymus-derived synthetic octapeptide, shown to be effective in chronic hepatitis B virus infection; as the latter is needed to support hepatitis D virus, thymic humoral factor-gamma 2 may have a therapeutic role in hepatitis D. AIM: To evaluate tolerability and efficacy of thymic humoral factor-gamma 2 in chronic hepatitis D. METHODS: Intramuscular thymic humoral factor-gamma 2, 40 microg, was given for 15 consecutive days and twice weekly for 22 additional weeks to adult patients with chronic hepatitis D virus hepatitis. RESULTS: A total of 11 patients (male/female 9/2, mean age 45.9 years] completed the treatment period, 10 the 6-month follow-up. At baseline, hepatitis D virus-RNA was positive in 8/11 (73%) patients. During treatment, hepatitis D virus-RNA became undetectable in 3/8 (37%), decreased in 1/8 (13%), remained unchanged in 4/8 (50%) and persisted undetectable in 3 patients, negative at baseline. During follow-up hepatitis D-viraemia relapsed in all patients but 2, one already negative at baseline. No changes in hepatitis B virus markers occurred. Mean serum alanine aminotransferase levels did not change significantly None of the patients reached normal serum alanine aminotransferase levels. CONCLUSION: At the doses given, thymic humoral factor-gamma 2 has been of limited efficacy A possible role of thymic humoral factor-gamma 2 in the treatment of chronic hepatitis D requires further dose-finding studies and/or combination with other antivirals.

[New therapeutic options in the treatment of hepatocellular carcinoma]. / Attuali possibilità terapeutiche nel trattamento del carcinoma epatocellulare.

Hepatocellular carcinoma (HCC) is the fourth cause of death for cancer, the first in northern Africa and is the eighth tumor for incidence in the world. Risk factors are: liver cirrhosis, HBV, HCV and natural toxins (i.e. aflatoxin). A screening program is feasible and based on serum alpha-fetoprotein dosage and periodic liver ultrasonography. Instrumental diagnosis is based on ultrasonography associated with angiography or spiral TC associated with systemic portography. The best therapy of HCC is based on a multimodal approach: surgery when feasible, associated with or in alternative to intratumoral ethanol injection (PEI), transcatheter arterial chemoembolization (TACE), chemotherapy and radiotherapy. These different therapeutical approaches are related to the liver extent of the disease and liver functioning. Poor results obtained with chemotherapy led to research different therapeutical approaches as hormonal substances, immune modulators or genetic modulators. Most patients present with advanced disease, and their survival rate decreases with the increase of liver cirrhosis concomitant with HCC. Better results should be obtained with the use of different therapeutical approaches as angiogenetic inhibitors, today only for experimental use at present.

Combined regional and systemic chemotherapy by a mini-invasive approach for the treatment of colorectal liver metastases.

From February 1996 to December 1998, 95 patients affected with colorectal liver metastases underwent the positioning of an intraarterial hepatic catheter by a transcutaneous subclavian access, under local anesthesia. All patients were evaluated for catheter implantation complications. Moreover, 61 patients of 95 treated at our center were retrospectively evaluated for results of chemotherapy performed with two different schedules of hepatic artery infusion (HAI) combined with systemic chemotherapy (SC). Eleven patients (group A) were treated with combined SC (5-fluorouracil continuous infusion) and HAI (floxuridine). A subsequent 50 patients underwent HAI (floxuridine, 4 cycles) followed, if a response or stable disease were observed, by combined SC and HAI (group B). Three cases of aneurysm of subclavian artery occurred, which were treated by the positioning of a radiologic arterial stent and the reimplantation of the catheter by a femoral access. Thrombosis of the hepatic artery was registered in four cases. We observed 10.5% occurrence of dislocation of the catheter, which was always moved again in the hepatic artery. In group A, with 45% clinical objective response rate and 10% stable disease rate, median survival time and median time to extrahepatic progression were 9 and 6 months, respectively. In group B, we observed 44% clinical objective responses and 26% stable disease after HAI. Patients without disease progression and therefore submitted to sequential SC and HAI had a median survival time of 21 months and a median time to extrahepatic progression of 16 months. The development of the mini-invasive technique of implantation of an arterial port can avoid laparotomy for HAI. Percutaneous implantation of an arterial port has a low rate of technical complications. HAI followed by combined systemic and regional chemotherapy has good results in terms of survival and time to extrahepatic progression.

Divided vertical banded gastroplasty either for correction or as a first-choice operation.

BACKGROUND: Staple-line disruption may occur after vertical banded gastroplasty (VBG). METHODS: Since May 1996, the authors have performed the gastric restrictive procedure divided VBG, as described by MacLean, as a first-choice operation and not only as correction for staple-line breakdown. Divided VBG was done in 111 patients, 32 as correction after staple-line disruption and 79 as a first choice, 29 of them by hand-assisted laparoscopy with the dexterity pneumosleeve. RESULTS: Weight loss and nutritional status have been very satisfactory. Operating time for the standardized operation has been no longer than 60 minutes. CONCLUSION: Divided VBG, especially if done by hand-assisted laparoscopy using the dexterity pneumosleeve, is a valid restrictive procedure.

Anesthesia with sevoflurane in bariatric surgery.

BACKGROUND: Sevoflurane is a good halogen agent for bariatric surgery anesthesia because of its physical and chemical characteristics and its repartition coefficient (blood/gas = 0.65). METHOD: From November 1997 to April 1998, 98 bariatric surgery procedures with sevoflurane anesthesia were done: 17 lipectomies, 71 vertical gastroplasties, and 10 biliopancreatic diversions in 71 women and 27 men, average age 30.3+/-8.3 years, with body mass index 43.9+/-5.7. The average operating time was 50+/-15 minutes for vertical gastroplasty, 160+/-20 minutes for biliopancreatic diversion, and 80+/-12 minutes for lipectomy. The technique of anesthesia was as follows: preanesthesia with atropine sulfate 0.01 mg/kg (dosage refers to ideal weight), ranitidine 50 mg, fentanyl 0.1 mg, ketorolac 60 mg; induction with propofol 0.5-1 mg/kg, succinylcholine 1 mg/kg; orotracheal intubation; maintenance with O2-N2O 50%, sevoflurane 1% to 1.5%, actracurium 0.5 mg/kg (dosage refers to ideal weight); awakening and decurarization with atropine sulfate 1 mg and prostigmine 2 mg. RESULTS: This method permitted correct control of the anesthesia, a quick awakening with a low incidence of nausea and vomiting, a prompt regain of physical and psychological functioning, an early discharge from the hospital, and a larger turnover of patients with lower costs. CONCLUSION: Sevoflurane balanced anesthesia seems to be the best anesthesiologic method for bariatric surgery.

[Peripheral anesthesia techniques in surgery of the arm]. / Tecniche di anestesia periferica nella chirurgia dell'arto superiore.

BACKGROUND: This report deals with the techniques of peripheral anaesthesia used by the Authors for surgical treatment of lesions of the upper extremity. METHODS: Plexus brachial block anaesthesia using a supraclavicular approach was performed for arm, forearm and hand surgery, axillary block anaesthesia for forearm and hand surgery, while block anaesthesia was employed for wrist and hand injuries. Local anaesthetics as Bupivacaine 0.5% and Mepivacaine 2% without Epinephrine were used. RESULTS: In 95% of the cases the results were satisfactory, in 5% (not cooperating and young patients, long operations, incomplete block anaesthesia) it was necessary to perform a general anaesthesia. CONCLUSIONS: Surgeons and patients well accepted these techniques of anaesthesia because of: less bleeding during the operation, easy surgical performance, high percentage of success in reimplantations, absence of side effects due to narcosis, better recovery of psycho-physical conditions and long lasting postoperative analgesia.

Effect of patient characteristics on hospital costs for cirrhosis: implications for the disease-related group (DRG) reimbursement system.

The Prospective Payment System uses Diagnosis-Related Groups (DRG) as a reimbursement system. DRG 202 is a disease-related group including liver cirrhosis as a whole. Patients referring to the inpatient unit complain of variable severity and complications of cirrhosis, possibly implying different expenditure of resources. Aim of the investigation was to identify factors affecting cost variability in patients with cirrhosis. A total of 73 consecutive, DRG 202-assigned, cirrhotic patients classified according to demographic and clinical variables were evaluated for length and costs of hospitalization calculated on a full-cost basis. Mean length of hospitalization was 10.2 +/- 7 days. Mean cost of hospitalization was Lit. 4.348.000 +/- 2.718.000. Medical, nursing, diagnostic, drug and general charges accounted for 13%, 29%, 37%, 5% and 16% of the cost, respectively. Child-Pugh score significantly correlated with drug consumption (p < 0.005), length (p < 0.01) and costs (p < 0.001) of hospitalization, but not with cost per day. Age, sex, admission status, referral reason, associated diseases and liver transplant susceptibility did not correlate with duration and costs of hospitalization. Disease severity significantly modifies costs of hospital admission in cirrhotic patients mostly on account of longer hospital stay. Surrogate indexes of disease severity, derived from ISTAT/DRG records, cannot identify patients consuming larger resources. In liver cirrhosis, the DRG system could be improved by introducing parameters, such as Child-Pugh score, directly taking into account disease severity.

[Cerebral venous thrombosis. Report of a clinical case]. / Trombosi venosa cerebrale. Descrizione di un caso clinico.

A typical case of CVT is reported in which a certain diagnosis was reached only through NMR. Etiopathogenesis, clinical pictures and therapy are shortly discussed. Anticoagulant therapy at both short and long term is a preventive measure recommended for patients with thrombophilia.

A polygraphic study of systolic time intervals and their correlations with heart rate and workload during supine ergometry in one hundred normal subjects.

The present study was designed to investigate systolic time intervals (STI) in 100 normal subjects undergoing continuous-maximal supine cycle ergometry and to search for possible linear correlations between STI (dependent variables) and heart rate, diastolic blood pressure, systolic blood pressure, age, sex, weight, and height (independent variables), by stepwise regression analysis. The only significant correlation discovered in the study was between the contractility index (isometric contraction time-ICT) and the total work produced by each participant. Exercise tolerance was limited primarily by shortening of the ICT interval, all subjects discontinuing the test when ICT reached 13.7 +/- 7 ms.

Influence of the heart rate on mean circumferential shortening velocity: echocardiographic study of 183 normal subjects.

Echocardiography was used to explore the influence of independent variables (age, body surface area and heart rate) on the mean circumferential shortening velocity (MVCF) in 183 healthy subjects. Multiple stepwise regression analysis shows that heart rate is the only variable of the three just mentioned that influences MVCF. A regression equation is evolved and proposed as an index of MVCF correction for varying heart rates.

[Polygraphic study of left ventricular function in severe hepatitis cirrhosis]. / Studio poligrafico della funzione ventricolare sinistra nella cirrosi epatica severa.

Systolic time intervals have been investigated in 26 subjects with severe liver cirrhosis. The patients were subdivided as follows: 15 with alcoholic cirrhosis; 11 with post-necrotic cirrhosis. Systolic time intervals were recorded and measured according to the Weissler's method. The left ventricular ejection time was significantly shortened due to the low systemic vascular resistance, while the pre-ejection period was unchanged, denoting preserved myocardial contractility. The isometric contraction time was also significantly shortened, thus confirming a good myocardial response to increased pre-load due to hyperdynamic state. The cardiac performance as assessed by systolic time intervals, is unchanged in hepatic cirrhosis.

Platelet count and platelet function in patients with angina pectoris (before and after a cycloergometric exercise test).

Platelet count and platelet function (circulating platelet aggregates, retention by glass beads and aggregation) were studied under basal conditions and after a cycloergometric exercise test in 10 subjects with stable angina pectoris and 10 normal subjects. There were no baseline differences between patients and controls in any of the tests of platelet function, nor did the values change after the exercise test. There was, however, a significant increase in the number of circulating platelets after the test in angina patients. Possible reasons for this phenomenon are discussed, with emphasis on the role of catecholamine hypersecretion induced by the physical exercise.

Evaluation of systolic time intervals in patients with angina pectoris.

We have explored the systolic time intervals of 52 patients with angina pectoris at the time of their hospitalization in our wards. Our results are in close agreement with published data, essentially indicating prolongation of the preejection time and shortening of the ejection time. These alterations of systolic times can be interpreted pathophysiologically as as expressing reduced myocardial contractility. The long PEP-short LVET polygraph picture, occurring in the course of chronic ischemic heart disease, reveals the deficit of myocardial contractility at a stage of the disease at which clinical evidence of left ventricular failure is usually not yet detectable.

A polygraph study of ischemic heart disease: behavior of systolic times in acute myocardial infarction.

The authors investigated systolic time intervals in 28 cases of acute myocardial infarction (AMI). Polygraph recordings were made on the first day of illness and repeated at two, three, five, and seven hospital days. The patients were divided into two groups: one with a contributory history of ischemic and/or hypertensive heart disease (Group PH for "positive history") and one without such history (Group NH for "negative history"). The influence of numerous variables on systolic times were explored in both groups, and the emerging data were processed by multiple stepwise regression analysis. The results show that the left ventricular ejection time (LVET) is invariably shortened in AMI, whereas the pre-ejection indices (PEP and ICT) afford definite differentiation of patients of Group PH (with lengthened PEP and ICT values) from those of Group NH (shortened PEP and ICT). The authors emphasize the importance of obtaining polygraph recordings very early in the course of AMI and of taking into account the patient's history in view of a correct assessment of pre-ejection times.

[Methodological survey of erythrocyte filtration time]. / Rilievi metodologici sul tempo di filtrazione eritrocitaria.

We measured the whole blood filtration time of 30 healthy subjects. The influence of hematocrit, fibrinogen, leucocyte and platelet count on filtration time was also evaluated. Multiple regression analysis did not demonstrate any effect of the above-mentioned parameters when they were separately considered. We have subsequently taken from the entire population a group of 14 subjects in which were simultaneously found values of hematocrit greater than or equal to 41%, fibrinogen greater than or equal to 210 mg/100 ml and platelet count greater than or equal to 250,000/mm3. The filtration time was significantly higher in this group (69 +/- 4 sec) than in the remaining 16 normal subjects (56 +/- 4 sec), p less than 0.05. These data suggest that the simultaneous variation of several parameters could modify the whole blood filtration time, while these parameters have no effect when taken separately.