The controversial management of giant congenital melanocytic nevi. When would it be better "to wait and see"?

AIM: A giant congenital nevus is a melanocytic nevus present at birth with wide extent on the skin surface. The management of this nevus remains controversial and needs to be personalized for each patient. METHODS: A retrospective multicenter study was carried out in the Dermatological Departments of Brescia, Padua, and Pavia, Italy. The inclusion criterion was the diagnosis of a giant congenital melanocytic nevus on the basis of clinical observation. RESULTS: Nine patients with giant congenital nevus are reported. None developed melanoma, whereas giant congenital nevi have been slowly fading in pigmentation. CONCLUSION: Having regard to the doubts on treatment that persist in the literature, we should consider that decisional management of giant congenital melanocytic nevi can be really complex, because of the size and depth of lesions. Indeed, the ablative surgery or other treatments might cause significant troubles and complete excision of deeper layers of the lesion is almost impossible to achieve. Moreover, the treatment does not reduce the risk of melanoma and might lead to a greater difficulty in clinical and dermoscopic observation due to the scarring occurrence after therapy. In our retrospective study, the pigmentation of giant congenital melanocytic nevi slowly faded on its own and until now none developed melanoma. Therefore, we suggest a close regular follow-up which should be focused on the exclusion of possible complications. Perhaps, it would be better "to wait and see" since other procedures do not decrease the risk of melanoma, but rather might lead the patient to underestimate it.

Improvement of left visuo-spatial hemineglect by left-sided transcutaneous electrical stimulation.

The effects of transcutaneous electrical stimulation on left visuo-spatial hemineglect, assessed by a visuo-motor exploratory task (letter cancellation), were investigated in patients with right hemisphere lesions. In Experiment 1 left neck stimulation temporarily improved the deficit in 13 out of 14 patients (93%), while stimulation of the right neck had no positive effects, worsening exploratory performance in nine patients (64%). Experiment 2 showed that left neck stimulation temporarily improved neglect also when head movements were prevented by a chin-rest. In Experiment 3, stimulation of both the left hand and left neck had comparable positive effects on visuo-spatial hemineglect. These results are interpreted in terms of: (1) non-specific activation of the right hemisphere, contralateral to the stimulation side; (2) specific directional effects of left somatosensory stimulation on the egocentric co-ordinates of extra-personal space, which in neglect patients are distorted towards the side of the brain lesion.

Adverse clinical events in dependent long-term nursing home residents.

OBJECTIVE: To assess the occurrence, type, and burden of adverse clinical events (ACE) among residents of chronic facilities. An ACE is any acute or subacute change in health status suggesting acute or subacute illness. DESIGN: Survey with face-to-face functional assessment and 3-month retrospective chart review. STUDY POPULATION: One hundred six continuing-care residents with a minimum length of stay of 4 months at an Italian chronic care facility. MEASUREMENTS: Functional assessment and chart review-based classification of ACE burden on care management according to a clinical-functional Severity Rating Scale. MAIN RESULTS: Functional dependence, dementia and concurrent clinical problems were common. Two hundred seventy-three ACEs were detected. Eighty-nine percent of residents experienced at least one ACE. Only 21% of ACEs could be managed by simple medical intervention and monitoring within 1 day; in 23% there was need for more complex care management; 7% of the latter ACEs resulted in residual (new) functional impairment. Cardiovascular and gastrointestinal systems were most commonly involved in ACEs. Neurological ACEs were the most frequent category leading to new functional impairment (22%). ACE occurrence/burden was higher in male residents (P < 0.01) and strongly associated with the number of concurrent medical problems (P < 0.001). Neither cognitive nor functional dependence levels were related to ACE occurrence. CONCLUSIONS: This description of the burden on care management resulting from acute and subacute changes in clinical and functional status of chronic patients emphasizes the continuing and unpredictable nature of medical attention required in a nursing home or chronic care facility. ACEs occur far more frequently among the elderly than is generally recognized. Thus a high level of medical and nursing skill is necessary in chronic care facilities.

Insulin decreases circulating vitamin E levels in humans.

Both hyperinsulinemia and free oxygen radicals have been implicated in the pathogenesis of atherosclerosis, but the relationship between insulin levels or insulin action and the oxidant/antioxidant balance has not been explored. We measured the effect of physiologic hyperinsulinemia on plasma concentrations of vitamin E, a major free radical scavenger molecule. Isoglycemic clamps (at an insulin infusion rate of 6 pmol . min-1 . kg-1) were performed in four groups of subjects: (1) 12 non-insulin-dependent diabetic (NIDDM) patients, (2) eight patients with essential hypertension, (3) 11 nondiabetic obese individuals, and (4) 12 healthy subjects. In 10 healthy volunteers, a time-control experiment was performed by replacing the insulin infusion with normal saline. Vitamin E and plasma lipid levels were determined at baseline and after 2 hours of insulin/saline infusion. Insulin sensitivity was reduced in diabetic, obese, and hypertensive groups in comparison to healthy controls, but fasting plasma vitamin E concentrations were similar in all groups. A consistent decrement in plasma vitamin E concentrations (averaging 12% of baseline, P < .0001) was observed in all subjects receiving insulin regardless of the level of insulin sensitivity, whereas no significant changes in plasma vitamin E were seen in subjects receiving saline infusion (P < .001 v insulin infusion groups). The insulin-induced decrement persisted in all study groups when plasma vitamin E concentrations were corrected for total serum cholesterol levels (-8.9% +/- 1.2% v -0.4 +/- 2.3% of saline controls, P = .0004) or serum low-density lipoprotein (LDL(-10.0% +/- 1.2% v -0.4% +/- 2.2%, P = .0002). We conclude that insulin infusion acutely depletes vitamin E in circulating lipids regardless of insulin resistance. This effect may represent a physiologic means of transferring vitamin E into cell membranes; alternatively, it might reflect a pro-oxidant action of insulin in vivo.

Unilateral neglect and space constancy during passive locomotion.

Space constancy was investigated in seven blindfolded left-neglect patients by driving them along routes involving one or two, left or right, 90 degrees turns. At the end of each route patients had to indicate its starting point while still blindfolded. On average, no considerable left/right differences were found in pointing accuracy. The entailments of this finding for the understanding of neglect phenomena are briefly discussed.

Ejection phase indexes with apexcardiography. Comparison with echocardiographic and angiographic parameters.

The reliability of a new noninvasive method for evaluating ejection fraction and the mean velocity of circumferential fiber shortening by apexcardiography and carotid pulse tracing has been evaluated. Three groups of subjects were considered. Group 1: 30 normal subjects (mean age 43 years); Group 2: 34 patients with aortic valve disease (mean age 51 years); Group 3: 76 patients with coronary artery disease (mean age 50 years). The mechano-cardiographic tracing points were acquired by an ultrasonic digitizing system and compared with the same indexes measured from the ventriculogram. In 53 patients M-mode echocardiographic evaluations also were performed. The correlations between the apexcardiographic derived ejection phase indexes and the angiographic measurements were highly significant in all subjects and in each group of patients. The correlations between the ejection phase indexes determined by echocardiography and the same angiographic data were also significant, but the r-values were somewhat lower than those found between the apexcardiographic and angiographic parameters in the same patients. Our results have assessed the reliability of this new method and demonstrated that this noninvasive technique can be applied not only in coronary disease but also in aortic valve disease and in normal subjects. It can be concluded that the apexcardiographic evaluation of cardiac performance appears applicable to patients in whom a means of assessing and sequentially following ventricular function is indicated.

Modulation of neglect hemianesthesia by transcutaneous electrical stimulation.

The effects of transcutaneous electrical stimulation on deficits of tactile perception contralateral to a hemispheric lesion were investigated in 10 right brain-damaged patients and in four left brain-damaged patients. The somatosensory deficit recovered, transiently and in part, after stimulation of the side of the neck contralateral to the side of the lesion, in all 10 patients with lesions in the right hemisphere, both with (six cases) and without (four cases) left visuo-spatial hemineglect, and in one left brain-damaged patient with right hemineglect. In three left brain-damaged patients without hemineglect, the treatment had no detectable effects. In one right brain-damaged patient, the stimulation of the side of the neck ipsilateral to the side of the lesion temporarily worsened the somatosensory deficit. These effects of transcutaneous electrical stimulation are similar to those of vestibular stimulation. The suggestion is made that these treatments modulate, through afferent sensory pathways, higher-order spatial representations of the body, which are pathologically distorted toward the side of the lesion. The modulatory effect is direction-specific: the defective internal representation of the contralesional side may be either partly restored, improving the disorder of tactile perception, or further impoverished, worsening the deficit. The possible neural basis of this modulation is discussed.

Effects of anabolic steroids, testosterone, and HGH on blood lipids and echocardiographic parameters in body builders.

To evaluate the metabolic or cardiovascular effects induced by self-administration of human growth hormone (HGH) alone or combined with testosterone and anabolic steroids, we conducted a study with 15 male body builders. Of these, 8 (control group) did not take any hormonal substances; 6 (experimental group) self-administered testosterone, anabolic steroids, and HGH for 6 weeks in various dosages; 1 subject self-administered only HGH for an equal period of time. At the end of the period of treatment with the hormonal combination, the experimental group continued for 2 additional weeks with anabolic steroids and testosterone only. All maintained the same, unaltered type and intensity of training, and constant diet. Before the beginning of treatment with hormonal substances, after 6 weeks, and at the end of treatment (for a total of 8 weeks), they were tested for total and HDL-cholesterol (t-chol and HDL-chol), apolipoproteins A-1 and B (apo A-1 and B), and triglycerides (tg). Before the start and after 6 weeks, an echocardiographic examination was performed to assess left ventricular dimensions and function in all 15 body builders. The most interesting result is a significant decrease of HDL-chol and apo A-1 derived from self-administration of anabolic steroids and HGH together.

[Exercise-induced R wave changes in normals and coronary patients. Computer analysis of CB5 lead (author's transl)]. / Comportamento dell'onda R durante sforzo in soggetti normali e coronaropatici. Analisi automatica della derivazione CB5.

Changes in R-wave amplitude (delta R) during treadmill test were studied in 84 coronary artery disease (CAD) patients and in 150 normal subjects. The evaluation of ECG recordings (CB5 lead) was carried out by a computer program. At maximal exercise, R-wave decreased by 2.1 +/- 2.8 mm in normal subjects, while in CAD patients mean delta R was significantly lower (0.4 +/- 1.7 mm). When the evaluation of delta R was performed at comparable heart rate and work load values, no significant differences were observed between normals and CAD patients. Using as criterion for a positive test an ischemic ST segment depression greater than or equal to 1.0 mm, the diagnostic sensitivity was 66.7%, while the specificity was 94.0%. When an increase or no change in R-wave was taken as evidence of an abnormal response, sensitivity and specificity values were 57.1% and 65.3% respectively. After a critical review of different parameters able to affect delta R, the difficult physiopathological evaluation and the poor diagnostic reliability of delta R were emphasized. The different heart rate and work load values attained by normals and CAD patients proved to be a further confounding factor in delta R comparison between the two groups.

Non-invasive evaluation of left ventricular function through systolic time intervals following oral administration of SB 7505 in man.

An investigation on the effect of diisobutyric ester of N-methyl-dopamine (SB 7505) on systolic time intervals (STI), heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure(DAP), saluretic activity was carried out on 8 male volunteer in-patients who had normal renal, gastrointestinal, cardiac and hepatic functions and were free from other serious illness. SB 7505 was administered orally at three doses of 50, 100 and 150 mg. HR, SAP and DAP either showed no variations or marginal insignificant shifts. STI decreased evidencing a dose-related positive inotropic effect like digitalis, but shorter than digitalis. SB 7505 also showed diuretic action with all three doses investigated. The positive inotropic effect and diuretic activity point to the possible usefulness of SB 7505 in treating some heart and kidney diseases.

Noninvasive evaluation of the effects of oral ibopamine (SB 7505) on cardiac and renal function in patients with congestive heart failure.

We investigated the effect of oral ibopamine (SB 7505) on myocardial and renal function in eight patients suffering from congestive heart failure. Ibopamine was administered orally 50 mg twice a day for 7 days. Systolic time intervals PEP (preejection period) and EMS (electromechanical systole) decreased significantly after each administration of ibopamine. Maximum reduction of systolic time intervals was observed 4 h after ibopamine administration. Statistically significant shortening was still apparent at 8 h. Twenty-four hour urinary volume was greater than control values on each day of ibopamine administration. The average daily increase in urine output was 70.2%. Sodium and potassium excretion increased. Each patient showed symptomatic improvement during therapy. No side effects attributed to ibopamine therapy were observed, and clinical laboratory values were unchanged. Tachyphylaxis was not observed during the period of treatment. We conclude that oral administration of ibopamine improves cardiovascular performance and renal function in patients with congestive heart failure.

[Modification of left ventricular filling after acute administration of nifedipine in hypertensive patients. Doppler echocardiographic study]. / Modificazioni del riempimento ventricolare sinistro dopo somministrazione acuta di nifedipina in pazienti ipertesi. Studio eco-Doppler.

This study was undertaken to determine the acute effects of nifedipine on left ventricular filling, examined by Doppler echocardiography in patients with arterial hypertension and normal left ventricular systolic function. Twenty-seven patients with mild to moderate systemic hypertension, and 18 normotensive subjects were studied. Pulsed Doppler, M-mode and B-mode measurements were performed before and 30 min after sublingual nifedipine administration (10 mg). Peak E, peak A, area A, area E, ratio area A/area E, E deceleration and E acceleration time were measured. Before administering nifedipine, some of these diastolic filling parameters were significantly different in the hypertensive patients as compared with normal subjects. After nifedipine, in patients with arterial hypertension, peak E and area E increased significantly (p less than 0.01), while ratio peak A/E and ratio area A/area E showed a significant decrease (p less than 0.001). No significant changes were observed in normal subjects. The result of this study demonstrates that the acute administration of nifedipine modifies transmitral flow velocity pattern in hypertensive patients, suggesting that the left ventricular filling abnormalities are in part dynamic and reversible.

Comparative evaluation of exercise ST response in healthy males and females. A computer study.

In order to evaluate both quantitatively and qualitatively exercise ST response in females, we have studied 232 healthy subjects (age range 35-59 years): 82 women (mean age 45.8 years) and 150 men (mean age 46.1 years). All subjects had performed a maximal treadmill exercise in 1976 and were followed up for 6 years in order to exclude the presence of subclinical coronary artery disease. Exercise ST segment responses were evaluated in a single bipolar lead (CB5) and were classified as 'positive' by visual interpretation when a 1.0-mm or greater 'ischemic' ST depression occurred. A computer system was employed to evaluate exercise ST changes quantitatively. The following ST parameters were evaluated: ST depression at R + 80 ms point (ST2); mean ST depression (STmean), and ST time-voltage integral (STarea). Computer analysis of resting ECG has shown lower ST voltages in females than in males. ST2, STarea, and STmean changes from basal to maximal exercise values were not significantly different in men and women. A similar prevalence of 'positive' responses in males and females was also found by ECG visual interpretation. In conclusion, our data show that in healthy subjects exercise ST segment response is comparable in males and females and indirectly suggest that the lower predictive value of exercise ECG in women is likely to be related to different coronary artery disease prevalence.