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Introduction: Fatigue is one of the commonest findings in multiple sclerosis (MS) although it has scarcely been investigated as an independent symptom., Objective: To evaluate the effect of fatigue in a population based series of patients with MS and to analyze its relation to other clinical variables., Methods: A descriptive, transverse study based on a geographically defined population. Fatigue was measured using the Krupp scale in 48 patients with definite clinical MS. We analyzed the relation between the degree of fatigue and sex, age of onset, age at the time of the study, type of evolution, index of progression of disability, duration of illness and degree of impairment according to the Expanded Disability Status Scale (EDSS) and neurological functional systems., Results: 64.6% of the patients had a significant degree of fatigue. Of these, 90% considered fatigue to be one of the three most disabling symptoms of their illness. There was no difference between men and women in their perception of fatigue. The patients with progressive illness, of greater age and those with higher EDSS scores had more fatigue. This aspect was not affected by age of onset, duration of illness nor index of progression., Conclusions: Fatigue should be evaluated as an independent symptom of MS. Evaluation using specific scales may contribute to better understanding of the physiopathology and investigation of more effective treatment.

Introduction: Apart from impairment there is hardly any other assessment of the repercussions of multiple sclerosis (MS) in population studies., Objective: To analyze the functional state of en epidemiological series of patients in the Valladolid health district., Material and Methods: A descriptive transversal study of a geographically defined population base. During a period of three months and complementing a prevalence study, were assessed, by means of the Minimal Record of Disability, impairment, disability and handicap in a series of 51 patients (33 women and 18 men) with clinically defined MS, who lived in the area on 1 March 1997., Results: There was a primarily progressive evolution in 21.6% of the patients, and secondarily progressive in 11.8%. Average follow-up time was 9.1 years (range 1-41) and average age of onset 27.8 years (range 14.7-51.0). The distribution of scores on the Expanded Disability Status Scale was bimodal (average and interquartile range: 3.0 (1.5-5.0). 80.4% of the patients continued to be ambulatory. 21.5% had frequent urinary incontinence or required a long-term urinary catheter. Less than 20% needed help with day to day activities. 78% of the patients complained of some degree of fatigue, and 51% had difficulties with social relationships. 59.4% of the patients had full-time jobs and 70.6% had no financial problems., Conclusions: The study shows that the functional state of persons with MS is better than was thought, and that assessment of the consequences of this illness should include disability and handicap profiles.

Pneumoperitoneum as a complication of barotrauma is a rare condition due to mechanical ventilation. The diagnostic dilemma often leads to perform an exploratory laparotomy, with the suspect of perforation of a hollow viscus, that makes worse the prognosis of these patients. We describe three patients who developed pneumoperitoneum, secondary to barotrauma. In the last one the use of laparoscopy allowed us to avoid an useless laparotomy.

A retrospective study was carried out in the Ferrara Local Health District, Italy, for the period 1981-1993 (average resident population: 177,235 inhabitants) to establish whether people exposed to exogenous gangliosides had a higher risk of Guillain-Barré syndrome. The incidence of Guillain-Barré syndrome of 1.9/100,000 population/year [95% confidence interval (CI): 1.3-2.5] reported in Ferrara Local Health District in the same period was used as a reference for comparison. The data bank of Ferrara Local Health District made it possible, first to estimate the number of individuals exposed to gangliosides in the resident population of Ferrara Local Health District (3.7%), the number of ganglioside prescriptions and the number of cases of Guillain-Barré syndrome who had treatment with gangliosides (nine patients, 20.9%), and, secondly, to verify the sequence of events between the ganglioside injection and the onset of the disease. Seven of the nine patients (77.8%) received gangliosides as treatment for peripheral neuropathy (Guillain-Barré syndrome onset before gangliosides were prescribed). For the other two patients (22.2%) a possible appropriate temporal sequence between ganglioside injection and onset of Guillain-Barré syndrome was found. Based on two possible ganglioside-related cases, the risk of Guillain-Barré syndrome was higher in the exposed (0.53/100,000 population/month following ganglioside injection; 95% CI: 0.06-1.91) compared with the unexposed population, but the difference was not significant. When only individuals prescribed with mixed gangliosides were considered (both possible ganglioside-related Guillain-Barré syndrome cases received mixed gangliosides), the risk of Guillain-Barré syndrome was higher (0.64/100,000 population/month following ganglioside injection; 95% CI: 0.08-2.31) but the difference from the risk in unexposed individuals was not statistically significant. The relative risk for the exposure to mixed gangliosides was borderline (relative risk = 4.3; 95% CI: 1.0-17.8). The wide 95% confidence intervals were a consequence of sample size limitations. Considering also that the exposed and unexposed groups differed in age (those exposed were older than those unexposed and the age-specific incidence of Guillain-Barré syndrome in the study population increased with increasing age), the present findings question either a strong increased risk of Guillain-Barré syndrome in people exposed to exogenous gangliosides or an immunogenic role of these agents in humans. However, because of the limited sample size, the results are not conclusive.

The early surgical reexploration to check the viability of intestinal loops in patients operated on for acute mesenteric ischaemia (the so called "second-look"), has contributed in improving the prognosis of this disease. However, since there are no certain predictive criteria for the progression of ischaemia, and not all patients are reoperated for a "second-look", some patients will undergo an unnecessary surgical and anaesthesiological procedure (negative second-look), and others, for which a surgical "second-look" might be beneficial, will not be operated on. In order to find a method which allows an effective early exploration of all patients operated for acute intestinal ischaemia, we performed a "laparoscopic second-look" on the last two patients we have operated on. They were admitted in our institution (Dipartimento di Scienze Chirurgiche e Trapianti d'organo--Divisione Chirurgia d'urgenza--Ospedale "S. Michele"--Cagliari) and had an intestinal resection for acute mesenteric ischaemia. Both had an early laparoscopic second-look under local anaesthesia, and the pneumoperitoneum was obtained with nitrous oxide insufflated through the drainage tube positioned during the surgical procedure. The exam showed normally healing anastomosis and viable intestinal loops. The consistent reduction of anaesthesiological and surgical trauma makes the "laparoscopic second-look" a routine substitute of the "surgical second-look" in all patients operated for acute mesenteric ischaemia.

A community-based cross-sectional study was carried out in Ferrara, Northern Italy, to verify the frequency of gingival overgrowth in chronic phenytoin (PHT) users and the risk factors associated with its development. All subjects taking phenytoin were identified using the computerized list of drug prescriptions available in the study area. Most of the subjects were interviewed and underwent an oral examination to evaluate their periodontal condition. The prevalence of gingival enlargement in chronic PHT users was about 40%. In our study, sex, age age at onset of therapy, treatment duration, and oral hygiene were not significantly associated with the risk of developing gingival overgrowth. A direct relationship with daily dose was found to be an independent risk factor. Younger age and poorer oral hygiene seemed to predispose to the severest level of gingival involvement. These results support data from experimental studies by suggesting that drug-induced gingival overgrowth is a dose-dependent side effect whose severity could be affected by local factors.

We performed a community-based study among children and adolescents with idiopathic and cryptogenic epilepsy and onset of the seizures between 0 and 19 years of age on the prognosis of being seizure-free. The study population was recruited during a descriptive investigation in the Local Health Service of Copparo (USL 34), Ferrara, Northern Italy. We included 111 patients (61 males and 50 females). The average length of follow-up was 18.8 years (ranging from 7 to 24 years). The cumulative probability of being in remission was 81.2% at 15 years after onset and the estimated percentage of patients in remission without therapy was 56% for the same time period. At 15 years after the onset of epilepsy, approximately 20% of patients continued to have seizures; nearly 25% continued to take antiepileptic drugs but had been free of seizures for at least 5 years; nearly 56% had been without seizures and free of medication for at least 5 years. Seizure type, gender, age at onset of the illness, epileptic abnormalities on EEG, family history of convulsive disorders, number and frequency of seizures prior to the start of treatment were found not to be helpful as prognostic factors. This community study, carried out on patients without the well known factors that adversely affect prognosis, confirms that the prospect of seizure control and for withdrawal of therapy is (generally) good.

The appearance of involuntary movements in the clinical course of reflex sympathetic dystrophy (DSR) constitutes a rare clinical entity. In this context, the most frequent changes in movements are muscle spasms and focal dystonia, although postural tremor, muscle weakness and rhythmic myoclonus have also been described. The disorder is more frequent in young women and in the lower limbs. It may have a focal, segmental, multifocal, hemicorporal or symmetrical distribution. It is almost always secondary to local trauma. The pathogenesis and most effective treatment are unknown. We present the case of a 62 year old woman with muscle spasms of both legs and feet as a complication of spontaneously appearing DSR. The electromyogram showed continuous non-rhythmic discharges with morphologically normal motor unit potentials in both anterior tibial muscles. The clinical course and symptomatic improvement following treatment with benzodiazepine seems to suggest that the disorder is of central origin.

Background: Previous descriptive surveys on multiple sclerosis (MS) in the province of Ferrara, northern Italy, carried out by our own epidemiological research group, pointed out that this area was not at low-medium risk for MS., Objective: To verify the morbidity estimates and update the temporal trend of MS., Design and Methods: We used a complete enumeration approach by reviewing all the possible sources of case collection available in Ferrara for 1965 through 1993. We included all patients with definite and probable MS according to the criteria of Poser et al., Results: The mean annual incidence rate was 2.3 per 100,000 population (95% confidence interval, 2.0-2.6 per 100,000), 3.0 per 100,000 for women and 1.5 per 100,000 for men. On December 31, 1993, 249 patients (170 women and 79 men) suffering from definite or probable MS were living in the province of Ferrara, giving a crude prevalence rate per 100,000 population of 69.4 (95% confidence interval, 61.2-78.7), 90.8 for women and 46.0 for men., Conclusion: The data confirm that in Ferrara, MS occurs more frequently than previously suggested by the latitude-related epidemiological model, supporting the view that northern Italy is a high-risk area for the disease. While the prevalence rate is much higher than in our previous studies, probably owing to the increasing survival of the patients because of improving supportive care, the incidence rates, similar in magnitude to those observed in high-risk areas of northern and central Europe, have remained relatively stable over time.

We present a case of horseshoe kidney. He was operated because of nephrolithiasis, and was found to have a tumour-like mass in the isthmic localization 2 years after the operation. The tumour-like mass was proven to be an isthmus hypertrophy after detailed research.

It is generally agreed upon that the attacks of migraine with aura are indicative of abnormal cerebral perfusion, while the permanence of such perfusion abnormalities during the pain-free intervals of migraine remains debated. This study was aimed at assessing: 1) the presence of cerebral perfusion abnormalities also during the interictal phase and 2) the role of SPET with 99mTc HM-PAO to diagnose migraine. Twenty-eight patients (22 women and 6 men), diagnosed as having migraine with aura according to the International Headache Society (Headache Classification Committee criteria), were submitted to SPET studies, within 10 days of the last attack. 99mTc HM-PAO was used as perfusion tracer and a single head rotating gamma camera equipped with a high-resolution collimator was used for data acquisition. The qualitative analysis of SPET images showed slight hypoperfusion areas in 22 of 28 patients (79%). In 12 of 22 patients (55%) a regional correlation was observed between hypoperfusion areas and the neurologic symptoms of aura. The results of the present study are in agreement with the current physiopathologic interpretation of migraine with aura, confirming the instability of cerebral perfusion control, even with instrumental evidence of perfusion abnormalities in the interictal period. Moreover, SPET with 99mTc Hm-PAO seems to be a useful tool in the diagnostic assessment of migraine.

In a retrospective case-control study of multiple sclerosis (MS), set up with the aim of verifying the role of environmental factors in pathogenesis, we included a section on dietary habits. We compared the frequency and pattern of food consumption by cases and controls. We found an association between. MS and high consumption of bread and "pasta", butter and lard, legume soup, horse flesh, coffee and tea in the period from infancy to adolescence. A different pattern of consumption of eggs, wine and mineral water between cases and controls was found during adulthood. Our results support, at least partially, the data already reported in the international literature on an association between certain dietary factors and MS. Some foods consumed at certain "critical" ages could play a causal role in the onset of MS.

The frequency of multiple sclerosis (MS) in Italy and in other areas of the world seems to have increased over time, suggesting that some environmental factors operate in its etiology. We performed a retrospective, community-based case-control study on MS in order to verify the etiologic role of selected environmental factors. We found an association between MS and higher educational level, employment in public administration, past history of allergies, and infection at an early age with measles, rubella and whooping cough. Our data seem to confirm that exogenous factors play a role in the etiology of MS although some confounding variables could have accounted for the associations.

A mortality study on Multiple Sclerosis (MS) was carried out in the province of Ferrara, Northern Italy, over the years from 1968 to 1989 (mean population 382,379 inhabitants) to outline the temporal trend of the disease in the residing population that can be regarded as a representative sample of the caucasians of Northern Italy. Given the difficulties in performing retrospective incidence studies over long time periods, the mortality rate was used as an indirect indicator of MS occurrence. Through a review of mortality tabulations with 340-345 ICD code and an intensive survey of all the MS cases, with successive check of the deceased ones at the general register offices of the study area communes, 56 MS patients who had lived and died in the province of Ferrara in the period 1968-1989 were selected with an average crude death rate of 0.67 per 100,000 per year (95% confidence interval: 0.51-0.87), 0.55 per 100,000 if adjusted to the Italian population. The death rate was stable over the considered time period with only a slight but insignificant increase in the last years of the survey. No differences were found among the rates from the 5 Local Health Units (USLs) in which the study territory is subdivided. The highest age-specific death rates were in the fifth and sixth decade of life and the average duration was 21.17 +/- 11.05 years. The results are consistent with a relatively stable MS risk in the population of the province of Ferrara and a homogeneous occurrence of the disease in the study territory.

The epidemiological approach has undoubtedly contributed to our knowledge of Multiple Sclerosis (MS) by providing some etiological hypotheses in spite of the fact that a definitive basis for the conclusive resolution of its enigma is still lacking. Epidemiological studies have indicated that MS has an uneven geographical distribution and a changing incidence over time at least in several areas of the world: this suggests an etiological role of both genetic and environmental factors. The racial difference in disease risk, the results of familial and twin studies as well as the association between MS and some HLA markers, support the great importance of genetic factors. On the other hand, the evidence of temporal trends and the data from migrant studies seem to underline the etiological contribution of environmental factors. In the light of these results much of the present views have emerged interpreting the disease as caused by multiple factors acting at a susceptible age in genetically predisposed subjects.

This study was performed in order to verify the prevalence of retinal periphlebitis and other ocular changes in a well-defined population of multiple sclerosis (MS) patients, and to correlate the presence of these features with some clinical variables which characterize the disease. 110 MS-affected subjects were submitted to a standard ophthalmologic examination including a biomicroscopical evaluation of the fundus oculi. The prevalence of retinal sheathing in MS patients was found to be nearly 36%. It is significantly higher in patients evaluated in an active phase of the disease than in those examined in a stationary phase.

Diaphragmatic injuries due to blunt trauma are steadily related to a high mortality. Their diagnosis may be difficult, due to the lack of specific symptoms and, more frequently to the high incidence of coexisting lesions which can mask the clinical appearance. This work presents the main aspects of ten cases admitted to the Emergency Surgery Division of Cagliari (USL 21), during the last seven years, with a review of the literature.

Thirty-nine patients with clinically definite multiple sclerosis (MS) entered the study. Of 28 subjects with a relapsing-remitting course, 19 were classified in acute relapse, 9 in remission; 11 patients had a progressive course without remissions. Furthermore, 6 subjects with inflammatory neurological disease (IND), and 10 with non-inflammatory and non-neoplastic neurological disease (NIND) were investigated. We simultaneously studied cerebrospinal fluid (CSF) and peripheral blood (PB) T-, B- and NK-cell subsets, as defined by following monoclonal antibodies: anti-CD3, -CD4, -CD8, -CD19, -CD16, -HLA-DR and -IL-2-R. We found a significant increase of CD4+ T-cells compared with controls in CSF, with respect to PB, of MS patients, particularly in acute relapse. An increase of HLA-DR+ cell percentages in the CSF than in the PB in all MS groups, especially in attacks of MS but also in remission, was also observed, with a positive correlation between CD4+ T-cell and DR+ cell percentages both in the CSF as well as in the PB of relapsing MS patients. These findings, together with the increase of IL-2-R+ cells in the PB, particularly in relapsing MS, give further support for the presence of a systemic T-cell activation in MS.

We investigated an alleged association between ganglioside therapy and the risk of developing the Guillain-Barré syndrome (GBS) in a historical cohort study. Using official medical records of the Local Health Unit No. 31 of Ferrara Province, northern Italy, we linked data on sales of gangliosides with information regarding hospital admissions and discharge diagnoses between January 1, 1988, and May 31, 1990. The number of incidence cases of GBS observed within 30 days of gangliosides administration in a cohort of 13,373 treated subjects (0.0 cases) was not significantly different from that expected in the general population (0.014). Our study suggests that patients receiving gangliosides are not at increased risk of developing GBS. However, because of sample size limitations, these findings should be confirmed in a larger cohort study.

The association between Multiple Sclerosis (MS) and DR2 HLA antigen is well known in Caucasoids. In the past few years a significant correlation has been found between DQwl and MS in North-East Scotland and in several other countries. In previous HLA studies in Italian MS patients, a lack of any association or an increased frequency of DR2 have been observed; however, the results of most Italian surveys derive from heterogeneous sample of affected individuals. This study was carried out in a homogeneous population of patients living in and originating from the province of Ferrara, Northern-Italy. Among the prevalence cases, 116, indigenous, unrelated patients, were typed for HLA-A-B, -DR and DQ antigens. The comparisons with 185 healthy individuals, originating from the same area, revealed an increased prevalence of DR2 antigen in Ferrara MS patients. This antigen does not appear to be related to the clinical variables of the disease.

The few incidence estimates on Guillain-Barré syndrome (GBS) in Italy indicate rates lower than the values provided by other previous non-Italian population-based studies. The latter range from 0.6 to 1.9 cases per 100,000 population per year. To verify whether Italy may be considered a low-risk area for GBS we studied the incidence of the disease in Local Health Unit No. 31 (USL 31) of Ferrara, Northern Italy (mean population 180,701 inhabitants) for the years 1981-1987. The annual incidence rates were stable during this period with an average incidence of 1.26 cases per 100,000 population per year. No significant difference was found for urban or rural residence and there was no significant seasonal clustering. In 37.5% of the series an antecedent infection was recorded within 4 weeks before GBS onset. The survey seems to support the hypothesis of a homogeneous distribution of GBS in space and time and does not support the notion that GBS is less common in Italy than elsewhere.

This report describes 51 vascular patients with peripheral vascular disease treated intraoperatively by means of the autotransfusion apparatus with a minimum of 750 cc of reinfused blood. An early decrease of Hct, Hb, RBC, fibrinogen and Plt count was observed without any significant coagulation disorder.

Spatial-temporal dissemination of neurological signs is an essential criterion for establishing a definite diagnosis of Multiple Sclerosis (MS). Unfortunately, we often observe patients who present a history consistent with MS but without objectivity indicating the presence of at least two or more distinct lesions of Central Nervous System (CNS). In recent years, many Authors have emphasized the use of Multimodal Evoked Responses (MER), Cerebrospinal Fluid (CSF) analysis for the research of Oligoclonal Bands (OB), and Magnetic Resonance Imaging (MRI) as highly sensitive techniques for demonstrating the spreading of the lesions. This study, carried out to evaluate whether the combined use of these three methods would increase the diagnostic MS sensitivity, comprises 62 patients classified in Definite (n = 24). Probable (n = 18) and Possible (n = 20) MS according to the clinical criteria of McAlpine. All our cases fulfilled a complete ER evaluation (VER, SER, BAER), a paired CSF and serum Isoelectric focusing (IEF) and a cerebral MRI. Moreover, IgG Index was also estimated. CSF IEF was the most sensitive test in Definite (91.7%) and Possible (80.0%) MS, nearly followed by MRI (87.5% and 45.0% respectively). VER (87.5% and 60.0%) and SER (87.5% and 65.0%). On the contrary, MRI showed the higher sensitivity in Probable MS (94.4%). The course of the disease influenced only SER and VER in all diagnostic group, while the duration correlated positively with BAER and VER. Only VER and BAER, finally, supplied additional information about the not revealed clinically or by MRI CNS disorders. Thus, our data further emphasize the value of combining these laboratory tests for establishing an early and more accurate diagnosis of MS.

Incidence and prevalence investigations on childhood epilepsy, throughout the world, have suggested wide variations in the frequency of convulsive disorders. Also the few studies presently available from Italy mirror such a disagreement. However, these studies cannot be completely comparable owing to a marked methodological dishomogeneity in definition of epilepsy, classification of seizures, and ascertainment, collection, and selection of the cases. Therefore, to verify the true frequency of childhood epilepsy in our country, we performed an epidemiologic study of convulsive disorders in 0-14 age children of the U.S.L. 34 (Copparo, Northern Italy). The prevalence per 1.000 children on October 24, 1981 was 6.14 (6.4 if standardized to the Italian population). The average annual incidence for the period 1964 through 1980 was 95.1 per 100,000 (98.9 if standardized). These results, similar to those found in other Western countries, support the view that the frequency of childhood epilepsy in Italy as a whole is higher than that indicated by previously published Italian studies and furthermore suggest that epilepsy is evenly distributed in Europe and the United States. Antecedents which could be considered potential causes of seizures were found in 40.2% and 43.6% of the incidence and prevalence cases, respectively; for both groups, perinatal brain injuries were the most frequent event. These results point out the urgency of planning precautionary measures in Italy to improve prenatal and perinatal medical care.