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New magnetic resonance (MR) measures considered to be putative workers of demyelination and axonal loss were found to be more closely related to clinical disability than T2-weighted MR imaging (MRI) findings in patients with multiple sclerosis (MS). In this study, we evaluated the reproducibility of such measurements in order to assess their reliability for longitudinal studies in MS. The intra-observer coefficients of variation for repeated measurements did not significantly differ among the MR techniques studied [2.6% for T2-weighted MR, 4.38% for unenhanced T1-weighted MRI, 3.65% for magnetisation transfer imaging (MTI) and 2.28% for spinal cord cross-sectional area at C5]. Our findings suggest that non-conventional MR techniques may be reliable outcome measures for clinical trials in MS.

Fast fluid-attenuated inversion recovery (fast-FLAIR), fast spin echo (FSE), and turbo-gradient spin echo (TGSE), new pulse sequences for magnetic resonance imaging (MRI), are able to display multiple sclerosis (MS) lesions more conspicuously (fast-FLAIR) and with shorter imaging times (FSE, TGSE) than is conventional spin-echo MRI. In this study, we scanned 7 MS patients, using fast-FLAIR (18 axial brain slices), FSE (27 slices), and TGSE (9 slices) sequences in the same session, to compare the brain MRI lesion loads detected by these different sequences and the intraobserver reproducibility of these measurements. On the subset of slices (n = 9) covered by all three measurements, the mean lesion load was 7.577 mm3 on fast-FLAIR, 5.248 mm3 on FSE, and 3.080 mm3 on TGSE (p = 0.006) sequences. The mean intraobserver coefficients of variation were 2.92% for fast-FLAIR, 2.86% for FSE, and 4.31% for TGSE (not significant). These findings demonstrate that both fast-FLAIR and FSE sequences may be potentially useful for serial MRI studies for monitoring clinical trials, while TGSE might be useful for speeding diagnostic MRI in MS patients. Longitudinal, clinically correlated studies using these new MRI sequences are needed to confirm these preliminary data.

In previously thrombolysed patients, we analysed residual myocardial viability using the PET-FDG technique and correlated its presence and extent to the angiographic appearance of the infarct-related vessel and left ventricular function. Thirty-six patients who had undergone intravenous thromboloysis for acute myocardial infarction 4.8 +/- 7.2 months previously were studied. Coronary angiography, left ventriculography, and assessment of myocardial perfusion and metabolism were all performed within 1 week. All patients exhibited perfusion defects consistent with the clinically identified myocardial infarction site. Residual viability, as assessed by the PET-FDG technique, was present in 53% of cases. The infarct-related coronary artery was patent in 19 (53%) patients (TIMI grade 3, 79%); of the remaining 17 with occluded infarct-related arteries, 11 had collaterals to the infarct area. Significant FDG uptake was observed in 63% of patients with a patent infarct-related artery and in 41% of those with an occluded infarct-related artery. The same study protocol was adopted in a control group of 30 patients with myocardial infarction who did not receive thrombolysis. The number of infarct-related patent vessels was significantly lower in these patients (30 vs 53%) (TIMI grade 3, 56%), but the overall percentage of PET viability was again 53%. Qualitative analysis of the regional perfusion pattern showed that the magnitude and severity of the perfusion defect was similar in the two groups, regardless of the presence or absence of FDG uptake. Global left ventricular function was also similar in the two groups. However, regional wall motion was significantly better in the thrombolysed patients with a patent infarct-related artery than in those who had not received thrombolysis and whose culprit vessel was also patent. In conclusion, the results of our study support the notion that early recanalization of the infarct-related artery is critical for preserving left ventricular function. Although the number of patent infarct-related coronary arteries is greater and left ventricular function is better in successfully thrombolysed patients, the regional metabolic pattern does not apparently correlate with the patency of the infarct-related artery. This suggests that, in "chronic' myocardial infarction, residual tissue viability as assessed by fluorodeoxyglucose uptake does not necessarily correlate with coronary recanalization.

Purpose: To evaluate the frequency of peripheral vitreoretinal adhesions in the region of the vitreous base by ultrasound examination in relation to axial length of the eye and the age of the patient. Patient gender and the presence of visual symptoms also were considered., Methods: A total of 228 consecutive patients (445 eyes) underwent biometry, ultrasound examination, and biomicroscopic fundus examination. Their medical history also was taken. The patients were divided into three groups according to axial length of the eye (< 24 mm, 24-26.5 mm, and > 26.5 mm) and into three age groups (20-40 years, 41-60 years, and > 60 years)., Results: No correlations was found between peripheral vitreoretinal adhesions and gender or between peripheral vitreoretinal adhesions and axial length of the eye. A significant correlation was found between peripheral vitreoretinal adhesions and age (P < 0.001). The proportion of adhesions increased with age (P < 0.001). The association between adhesions and presence of symptoms also was significant (P < 0.001). Multivariate analysis showed that only the presence of symptoms independently correlated with adhesions (relative risk, 1.71, 95%; confidence interval, 1.19, 2.46)., Conclusion: Our study shows that peripheral vitreoretinal adhesions, detected by ultrasound, were always associated with the presence of symptoms.

This study was undertaken to assess the sensitivity of hydroxylysylpyridinoline (HP), lysylpyridinoline (LP), galactosylhydroxylysine (GHyl) and glucosylgalactosylhydroxylysine (GGHyl) to monitor bone response to estrogen deficiency and replacement by comparing their excretory patterns in ovariectomized aged (11-14 months old) rats. The ovariectomized (OVX) rats were randomized into two groups: (1) OVX plus vehicle; (2) OVX plus 17 beta-estradiol (17-beta E, 10 micrograms/kg, s.c., 4 days/week). Treatment with 17-beta E started immediately after OVX and continued for 60 days. The collagen catabolites were measured in urine for 1 month before OVX and thereafter for 60 days. In temporal coincidence with urine collection, bone area and bone mineral density (BMD) of lumbar vertebrae, femoral diaphysis and distal metaphysis were measured by dual-energy X-ray absorptiometry. In the untreated rats, BMD of the femoral metaphysis and lumbar vertebrae decreased significantly and the urinary excretion of LP, HP, GHyl and GGHyl increased with different patterns. In the treated rats, 17-beta E replacement prevented the increment in LP excretion, partially prevented the increase in HP excretion, but had no effect on the excretion of GHyl and GGHyl. In conclusion pyridinolines and glycosides have different sensitivities to the bone response to OVX. Glycoside excretion after OVX also reflects metabolic processes not strictly related to bone loss and, in contrast with LP, is not sensitive to estrogen replacement.

Objective: To investigate the relationship between lactation and bone mineral density (BMD) of the lumbar spine in a cohort of 540 healthy, postmenopausal women., Study Design: Women were selected who experienced long-term lactation (n = 155, median 18 months) or short-term lactation (n = 168, median 3 months) or who were parous, nonlactating subjects (n = 217). The groups were homogeneous in age and differed in body mass index, parity and age at menopause. Vertebral BMD was measured by x-ray absorptiometry., Results: No statistically significant difference in BMD was found between groups or after adjusting for body mass index, number of live births and age at menopause. Even when the 86 women with the longest lactation history (median 22 months) were matched with 112 parous women with the same parity who did not lactate, we could not find any significant difference., Conclusion: Long-term lactation did not significantly affect postmenopausal vertebral BMD in a cohort of healthy women.

The association of cigarette smoking with the development of occlusive vascular disease is firmly established. Unfavourable changes in a series of variables held independent risk factors for the development of vascular lesions (HDL-cholesterol, haematocrit, white blood cell count, fibrinogen and plasminogen activator inhibitor-1 (PAI-1)) are thought to be directly influenced by cigarette smoking. However, the role played by the genotype in the effect of smoking on the above parameters has not been investigated. To control the genotype, we studied the relationship between cigarette smoking and a series of cardiovascular risk factors in 27 monozygotic twin pairs (7 male and 20 female pairs, mean age +/- SD: 47.4 +/- 12.9 yrs) with a life-long discordance for smoking. Smoking twins had a life-long dose of smoking (Brickman index) of 287.3 +/- 241.5. Body mass index, blood pressure, haematocrit, haemoglobin and red blood cell counts, total cholesterol levels and the acute phase reactants alpha 1-acid glycoprotein and C-reactive protein were similar in smokers and non-smokers. Triglyceride was higher by 12.6% (9.5-35%, 95% confidence interval, p = 0.02) and HDL-cholesterol lower by 7.5% (0.2-15%, p = 0.04) in the smoking co-twins, who also had 8.4% (-0.2-17%, p = 0.06) higher white blood cell counts and 4.1% (1.2-7%, p < 0.01) larger mean platelet volume. There was no significant difference in clottable fibrinogen (by two methods) or in the activity of plasminogen activator inhibitor-1 between the two groups, nor was the within-pair difference in these parameters related to the smoking dose. Echo-doppler examination of the carotid arteries of 24 twin pairs showed mostly minor atherosclerotic lesions in 46% and 42% of the smoking and non-smoking co-twins. After adjustment for age, systolic blood pressure and platelet count and volume were the only variables significantly associated to the presence of vascular lesions. Cigarette smoking is associated with an atherogenic lipid profile and with changes in platelets and white cells potentially reflecting endothelial cell damage. When controlling the genotype, fibrinogen and PAI-1 activity levels did not seem directly influenced by cigarette smoking.

Objective: To evaluate the prevalence of moderate hyperhomocysteinemia and inherited thrombophilia disorders (congenital defects of the natural anticoagulant or fibrinolytic mechanisms) in patients with early-onset venous or arterial thromboembolic disease., Design: Cross-sectional 2-year evaluation of consecutive unrelated patients with a history of venous or arterial occlusive disease occurring before the age of 45 years or at unusual sites, in the absence of local predisposing factors., Setting: Thrombosis research unit of a community hospital., Patients: 107 patients with venous thromboembolism (mean age at event, 32.9 +/- 11.9 years) and 50 patients with arterial occlusive disease (mean age at event, 31.1 +/- 10 years) who did not have acquired coagulation defects, overt cancer, or acquired conditions affecting methionine metabolism., Measurements: Total plasma homocysteine (fasting levels), antithrombin III, protein C, protein S, activated protein C resistance, plasminogen, and heparin cofactor II were measured at least 3 months after the event. In 87 patients, total plasma homocysteine levels were also measured 8 hours after an oral methionine load was administered (L-methionine, 0.1 g/kg body weight). Ninety-fifth percentiles of the distribution of these variables were established in 60 apparently healthy persons; sex-specific ranges were used for protein S and total plasma homocysteine. Relatives of patients with laboratory abnormalities were studied to confirm inheritance of the defects., Results: Moderate hyperhomocysteinemia was detected in 13.1% (95% CI, 7.6% to 21.3%) and in 19.2% (CI, 9.0% to 31.9%) of patients with venous or arterial occlusive disease. The prevalence of hyperhomocysteinemia was almost twice as high when based on homocysteine measurements done after oral methionine load as when based on fasting levels. The remaining defects were detected only in patients with venous occlusive disease (activated protein C resistance in 11.2% of patients, protein S or C deficiency in 6.6%, and plasminogen deficiency in 0.9%), with an overall prevalence of 18.7% (CI, 12.1% to 27.6%). Inheritance of hyperhomocysteinemia and of the other defects was confirmed in 26 of the 30 families studied. Event-free survival analysis showed that the relative risk for occlusive disease in patients with moderate hyperhomocysteinemia and other defects was 1.70 times (CI, 1.19 to 2.42; P < 0.01) greater than in patients without defects. After adjustment for the presence of predisposing factors (for example, use of contraceptive drugs, pregnancy, surgery, prolonged bedrest, smoking, mild hypertension or dyslipidemia) and a family history of thrombosis, the age at first event of patients with moderate hyperhomocysteinemia was similar to that of patients with the other defects (26.4 +/- 11.2 years compared with 25.2 +/- 10.6 years), and the 43 patients with defects were significantly younger at first event than the 114 patients without defects (25.5 +/- 11.1 years compared with 31.0 +/- 12.3; P < 0.005). Patients with mild hyperhomocysteinemia had a higher rate of recurrence than those without defects (52% compared with 25%; P = 0.01); among the 56 patients who had their first event more than 1 year before observation, the recurrence rate was higher (80% [CI, 51% to 95%]) in patients with defects than in patients without defects (41% [CI, 26% to 57%] P = 0.01)., Conclusions: Moderate hyperhomocysteinemia may have pathogenic significance in premature venous and arterial occlusive disease and should be included among the (inherited) disorders of venous and arterial thrombophilia.

The Stanford Health Assessment Questionnaire developed by Singh et al. to measure functional status in children with chronic arthritis (CHAQ) was translated into Italian (I-CHAQ), with minor modifications to obtain cross-cultural equivalence. This version was evaluated in a series of 96 patients with juvenile rheumatoid arthritis (JRA), both males and females ranging in age from 3 to 19 years (mean age 9.9 years). All three onset subtypes and all four classes of disability were represented in the sample. The questionnaire was filled in by the parents if the children were less than 8 years of age (23 cases), and by the children themselves in all other cases; a health professional was always present to provide assistance. As expected, JRA patients with a systemic or polyarticular disease onset had higher scores than those with a pauciarticular onset, and there were statistically significant differences in disability index values between patients from different Steinbrocker functional classes. The instrument showed good reproducibility in a test-retest over a two-week period, a high correlation between the child and parent scores, excellent internal reliability, and good convergent and discriminant validity.

Between 1989 and 1993, 62 patients underwent Whipple pancreatoduodenectomy and 75 pylorus-preserving pancreatoduodenectomy (PPPD); 35 patients in the first group and 37 in the second had pancreatic adenocarcinoma while 17 and 21 patients respectively had periampullary adenocarcinoma. The aim of this retrospective study was the comparison of operative outcome, nutritional recovery and survival of patients who underwent these two operations. No significant differences were found between the two groups in operative mortality or morbidity, duration of gastric aspiration and time to start of solid meals. Patients who underwent PPPD had a better nutritional recovery: the increase of both body-weight and serum albumin level at 6 months after discharge was significantly higher for those who had preservation of the whole stomach (P < 0.001 and P < 0.05 respectively). No significant difference in survival was found between the two procedures when patients with pancreatic or periampullary adenocarcinoma were analysed separately.

This study evaluated the arousal pattern and sleep fragmentation in the sleep microstructure of heavy snorers and obstructive sleep apnoea (OSA) patients. Fifteen snorers [Group A, (A + H I) 10 30) were studied retrospectively analysing the number, duration and type of arousals according to scoring rules concerning definition (including delta bursts) and length (from 2 to 60 s) of phasic arousal events. The number of arousals per hour of sleep related to respiratory events was higher in Groups B and C, whilst in Group A there was a number of arousals not related to apnoea or hypopnoea. Daytime sleepiness, present in all three groups and measured by a subjective evaluation, correlated with both the number and EEG type of arousal, but not with the duration. Statistical analysis indicated that arousal index related to apnoea or hypopnoea was the best variable for determining the sleepiness risk in OSA and snorers. Sleep microstructure analysis seems a good scoring method for the detection of sleep fragmentation and arousals in relation to abnormal respiratory events.

To provide complete prevalence data on diabetes mellitus in Italy (diagnosed and undiagnosed), a population survey was performed in the Health District of Cremona, a representative area of the Po river (north Italy). The survey is characterised by particular attention being paid to methodology, non-responders being investigated for possible selection biases affecting diagnosed and undiagnosed diabetes prevalence estimations. Out of a population aged 44 years or older from three municipalities, a random sample of 3097 subjects was selected to undergo an oral glucose tolerance test. In addition, past medical history, clinical and laboratory data were collected. A total of 1797 subjects participated (58%), and information on known diabetes status was obtained for 2618 persons (85%), also including 826 interviewed non-participating subjects. Overall rates were age-standardised according to the 1991 Italian census. Overall prevalence and 95% confidence interval of diagnosed diabetes was 8.5% (6.9-10.1) in males and 7.9% (6.7-9.3) in females over the age of 44 years; previously undiagnosed diabetes was 2.5% (1.4-3.6) in males and 3.4% (2.1-4.7) in females; glucose intolerance was 7.7% (5.7-9-7) in males and 8.9% (7.0-10.8) in females. Total diabetes prevalence above age 44 years, developed-world age, and sex standardised, was 10.7%. This study provides the first reliable prevalence estimation of impaired glucose tolerance, diagnosed and undiagnosed diabetes in Italy, according to World Health Organization criteria, and one of the few figures for Southern Europe. The role of body mass index on both prevalence of diabetes and cluster of cardiovascular risk factors is considered, with implications for prevention.

In the last few years, due to the implementation of European and Italian laws, public agencies are in urgent need of objective criteria and methodologies for the correct location of air quality monitoring networks. This paper describes MoNet, a decision support system oriented to network designers, to help them in the choice of the number and the location of instruments in an assigned area. The package includes a model base consisting of a set of pollution diffusion simulation models and two optimization algorithms for network location and allows the user to integrate his or her own subjective knowledge of the problem with the results of the simulations performed by means of objective techniques. The package has been applied to revise the air quality network located in an industrial and urban area of Northern Italy. The results of the simulations performed by using different diffusion models, location algorithms and problem constraints are shown and discussed in the concluding section.

The period 1981-1993, 124 patients underwent resection for pancreatic cancer; they represented 30.8% of all patients observed in that period. Surgical procedures were a pancreatoduodenectomy (PD) in 100 cases, a total pancreatectomy (TP) in 3 cases and a distal pancreatectomy in 21 cases. PD was performed by the injection of Neoprene into the residual pancreatic stump, rather than of pancreatojejunal anastomosis; in 37 cases a pylorus-preserving PD was performed. Adjuvant treatments were given in addition to resection in 75 patients: 47 underwent intraoperative radiation therapy, following a PD in 41 cases, a TP in 1 case and a distal pancreatectomy in 5 cases. Overall operative mortality was 2.4%, overall morbidity 26.6%. In the 103 patients undergoing PD or TP mortality was 2.9% and morbidity 29.1%. Postoperative diabetes occurred in 12.8% of patients undergoing PD with Neoprene injection. Overall median survival was 16 months. Survival was significantly related to UICC staging distribution, to the radical nature of the operation or to adjuvant treatments. No relationship was found between survival and the type of resection (PD versus distal pancreatectomy) or the pylorus preservation. Pancreatic resection, whenever technically possible, represents the treatment of choice of localised pancreatic cancer, in association with adjuvant treatments.

A working group of ten rheumatology institutes (UNIREUM) was formed in Italy to promote multicenter therapeutic studies on rheumatoid arthritis. The Functional Disability Index (FDI) of the Health Assessment Questionnaire (HAQ) was chosen as a measure of disability. This paper reports the results of a multicenter study to validate an Italian translation of the instrument and to assess its reliability and validity. Two questions were modified to achieve cross-cultural equivalence. Back-translation into English showed agreement with the American instrument. Reproducibility was high: the test-retest correlation coefficient was 0.989 and ranged from 0.81 to 0.99 for the centers taken separately. Validity was confirmed by a correlation coefficient of 0.95 between the patient self-attributed and the physician-attributed FDI scores. We conclude that our Italian version of the HAQ FDI is a reliable and valid self-administered instrument.

The aim of the present study, which is part of a larger population survey, is to provide an Italian estimate of the total prevalence of diabetes taking into account the fraction of known diabetes among the non-responders. The study consists of a population survey. Out of the population aged over 40 ys. of two municipalities, Casalbuttano and Vescovato, in the Health District of Cremona, a random sample of 2,229 subjects was selected to undergo an OGTT. In addition, a series of anamnestic, clinical, and laboratory data were collected for each individual. Overall response rate was 63%. Prevalence of known diabetes was 7.8% (6.5%-9.1%, 95% CI), (F = 7.9%, M = 7.6%). The comparison between responders and the telephone-interviewed non-responders showed an unpredictable and age- and sex-dependently varying frequency of known diabetes, even if the overall differences were not statistically significant. This suggests that, to avoid biases, many efforts should be spent to collect information about diabetes also for non-responders. Prevalence of unknown diabetes was 3.2% (2.2%-4.2%, 95% CI), (F = 4.0%, M = 1.8%) and total diabetes was 10.9% (9.3%-12.5%, 95% CI) (F = 11.9%, M = 9.4%). In contrast to other countries, the relationship between unknown and known diabetes was less than 1 to 2, and the proportion of unknown diabetes was almost negligible below the age of 70. A positive family history and a lower level of triglycerides were associated with awareness of the disease (p = 0.0005 and p = 0.006, respectively), thus suggesting different behaviour towards one's own health between known and unknown diabetic subjects.

Eight obese patients (4 male, 4 female; mean age = 35.9 years) before [mean body mass index (BMI) = 37.1] and after (mean BMI = 31.4) weight loss by means of a mixed hypocaloric diet were compared with 8 lean subjects (4 male, 4 female; mean age = 37.1 years, mean BMI = 22.3) in a study of their nocturnal sleep patterns and sleep-related growth hormone (GH) secretions. Although no sleep disorders (in particular, sleep apnea and hypersomnia) were observed, GH secretion was markedly altered in obese patients that showed no sleep-related GH peaks. After weight loss, the sleep architecture in obese subjects was unchanged. On the contrary, GH peak appeared to be only partially restored and delayed until after stage III-IV of non-REM sleep. Our study on obese subjects suggests that the altered nocturnal GH secretion, probably related to a hypothalamic dysfunction, may be the result of the obesity per se.

This study was undertaken to identify and validate possible existing sources of information to estimate the prevalence of known diabetes and the incidence of Type 1 (insulin-dependent) diabetes in Italy. The prevalence of known diabetes was estimated on the basis of data on drug sale, using specific defined daily doses as index of drug consumption. The estimation of the average daily dose used for calculations was carried out on a consecutive series of 911 diabetic subjects from two outpatient clinics. The incidence of Type 1 (insulin-dependent) diabetes was obtained by processing data routinely collected by the Regional Health Services, related to hospital discharge diagnosis records mentioning diabetes mellitus. The validation was carried out in 12 hospitals of the same Region. The estimated prevalence rate of known diabetes was 1.7%, including patients on dietary treatment. In the Lombardia Region in 1982-83 the estimated annual average incidence of Type 1 (insulin-dependent) diabetes, under the age of 35 was 4.6/100,000. This rate appears much lower then that observed in Northern Europe and the United States while it is similar to the French rate. This is in agreement with the findings of studies showing changes with latitude of the incidence rates of Type 1 (insulin-dependent) diabetes.

The authors describe a case of a self-caused giant lynphoedema of the hand. The authors underline the importance of hospitalization for the diagnosis, also to be able to exclude any form of organic pathology. They suggest the utility of a decompressive operation of the lynphatic circulation by a little fasciatomy at the root of the forearm, in order to avoid the application of a lace on the wound of the forearm root. Of great importance is furthermore to close the limb into a plastered apparatus for the same purpose.

The authors report on a rare case of Cutaneous Horn of the hand: the lesion is interesting, for the considerable dimensions it reaches and for its evolution. The treatment has had the character of a radical local resection.

The authors think that the compressive osteosynthesis, in the pseudarthrosis of the carpus scaphoid, represents an excellent system in the treatment of these lesions, and it has the advantage to guarantee a sure recovery from pseudoarthrosis in a very short while.

A multicenter population-based study was undertaken from 1983 to 1985 in 12 diabetes centers in Lombardy, in order to assess the prevalence of microalbuminuria and clinical proteinuria. Out of a total population of 17,704 diabetics, 1,155 were randomly selected within four strata of duration of disease and albumin excretion rate (AER) assessment was carried out in 541 unselected subjects. Albuminuria was evaluated from an overnight urine collection using a radioimmunoassay. The overall prevalence rates were 25.8% for microalbuminuria (30 less than or equal to AER less than 350 micrograms/min) and 3.0% for macroalbuminuria (AER less than or equal to 350 micrograms/min). In Type II diabetes the rate of microalbuminuria increases with duration of disease up to 10 years and then tends to level off. This could be due to the existence of two subgroups of diabetics with different life expectancy and different degree of risk of nephropathy. The Italian prevalence of microalbuminuria appears to be rather similar to that of other studies, while the prevalence of macroalbuminuria is quite low with respect to middle and northern Europe, indicating a rather slow rate of progression to clinical proteinuria. This could be explained on the basis of differing protein intakes. The cases with AER greater than or equal to 30 micrograms/min, greater than or equal to 70 micrograms/min, and greater than or equal to 350 micrograms/min have been compared with matched diabetic controls with AER less than or equal to 15 micrograms/min.(ABSTRACT TRUNCATED AT 250 WORDS)