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Objectives: The etiopathogenesis of acute unilateral peripheral vestibulopathy (APV) still remains a matter of debate; ischemic changes in the circulation of the labyrinth may play a role. We consequently looked for possible hemostasis alterations in a group of patients with APV of an unknown nature., Methods: We evaluated blood parameters known to be involved in circulation disorders, including total and HDL cholesterol, triglycerides, apolipoprotein A and B, lipoprotein(a), homocysteine, folate, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, antithrombin III, protein C, protein S, activated protein C resistance, and anticardiolipin IgG and IgM antibodies. A series of 23 patients affected with APV were consecutively referred to our department, in the acute phase, before treatment, and in the follow-up phase after 4 to 6 weeks of pharmacologic washout. The aforementioned blood parameters were also measured in a series of 15 patients with Menière's disease., Results: The patients with APV in the acute phase compared with the patients with Menière's disease in the acute phase exhibited increased plasma levels of fibrinogen (mean, 338.3 +/- 135.9 SD vs 271.3 +/- 69.8 SD mg/dL, P = 0.05), increased plasma levels of D-dimer (mean, 320 +/- 207.8 SD vs 226.7 +/- 138.7 SD NG/mL), enhanced plasma levels of lipoprotein(a) (41.4 +/- 38.6 SD vs 16 +/- 18.2 SD mg/dL, F = 5.67, P = 0.02), high leukocyte count (9.1 +/- 2.7 SD vs 6.5 +/- 1.3 SD x 10(3)/microL; F = 8.42, P < 0.006), and low serum folate concentration (5.3 +/- 1.8 SD vs 7.1 +/- 2.7 NG/mg; F = 4.34, P = 0.04). During follow-up the prothrombin time was prolonged (F = 4.34, P = 0.04) and leukocyte count decreased (F = 7.39, P < 0.019) in the APV patients, whereas fibrinogen, D-dimer, lipoprotein(a), and folate were unchanged., Conclusion: Our results provide evidence suggesting an involvement of the hemostatic system in APV.

Objective: The aim of this study was to assess the clinical benefit of salvage surgical cytoreduction in patients with late recurrent ovarian cancer., Methods: Thirty patients with recurrent ovarian cancer who underwent salvage surgical cytoreduction were retrospectively reviewed. All had been initially treated by primary surgery and platinum-based chemotherapy and had a period of clinical remission of at least 6 months. Median time to recurrence was 17.5 months (range, 6-76 months)., Results: A macroscopically complete salvage cytoreduction was obtained in 17 (56.7%) patients, whereas 8 patients were left with macroscopic residual disease <2 cm and 5 patients with a larger residuum. Logistic regression showed that the probability of achieving a complete cytoreduction was significantly related to the residual disease after initial surgery (<2 cm versus >2 cm, P = 0.0027, odds ratio = 36.000, 95% confidence interval = 3. 473-373.176), but not to FIGO stage, tumor grade, histologic type, patient age at recurrence, and time to recurrence. In the whole series median survival following salvage surgery was 21 months. Survival was significantly longer in patients who were completely cytoreduced compared to those who were not (median: 37 months versus 19 months, P = 0.04). Moreover, survival was significantly related to time to recurrence (>17.5 months versus <17.5 months, median: 25 months versus 15 months, P = 0.039), number of recurrence sites (single versus multiple, median: 40 months versus 19 months, P = 0. 009), and residual disease after initial surgery (<2 cm versus >2 cm, median: 37 months versus 19 months, P = 0.01), but not to patient age, recurrence site with the largest size, FIGO stage, tumor grade, and histologic type., Conclusions: The present data seem to show that complete salvage surgical cytoreduction significantly improves further survival of ovarian cancer patients who recur at least 6 months after the completion of primary therapy., (Copyright 2000 Academic Press.)

Background: Patients with focal segmental glomerulosclerosis (FSGS) develop nephrotic syndrome and terminal renal failure in most cases. FSGS reappears in 15-50% of transplanted kidneys and frequently causes the graft loss. Sera from patients with FSGS of native or transplanted kidneys contain some proteinuric or permeability factors (PF) which can be removed by means of plasma exchange (PE) or protein A Immunoadsorption (IA)., Methods: We suggest a therapeutic protocol, for patients with biopsy proven FSGS of native or transplanted kidneys, resistant to steroid and immunosuppressive therapy, based on the association of PE or IA to conventional drug therapy. Daily proteinuria, renal function, serum albumin and circulating level of proteinuric factors (permeability test) will be monitored at regular time intervals during the apheresis cycle, which will be intensive at the beginning (8-10 sessions in 4 weeks) and very gradually discontinued. Results. We will consider satisfactory remission the reduction of proteinuria below 1 g/day, improvement of renal function, normalization of serum albumin level (> 3.5 g/dl). Partial remission will be considered: proteinuria below 3 g/day, stable renal function, serum albumin level between 3 and 3.5 g/dl. Permeability test, if positive at baseline examination, should be negative after apheresis., Conclusions: The primary endpoint of our protocol is: lasting remission (satisfactory or partial) after the apheresis suspension. Secondary endpoints are: maintained remission with continuing apheresis sessions, correlation between permeability activity and disease activity, identification of responders and non responders patients on the basis of positive permeability test.

The incidence of thyroid cancer, which accounts for 1-2% of all malignancies, constantly increasing. Its management requires an integrated approach, in which the surgeon plays a pivotal role, providing the basis for further treatment. At present, the extent of exeresis, the lymph-node dissection technique and the management of upper respiratory-digestive tract infiltration are still debatable issues. The authors report on their experience with 243 surgically treated thyroid malignancies over the period from January 1986 to December 1999. The operations performed were: total thyroidectomy 226 cases, lobo-isthmectomy 3 cases, total thyroidectomy + lung metastasectomy 1 case, total thyroidectomy + SE quadrantectomy 1 case, total thyroidectomy + monolateral modified neck dissection 30 cases, total thyroidectomy + bilateral modified neck dissection 17 cases, total thyroidectomy + radical neck dissection 1 case, total thyroidectomy + tracheal sleeve resection 5 cases. In 9 cases, extensive tracheal involvement (5.5 cm), age or neoplastic histology allowed only palliative treatment (endoscopic recanalization + tracheal endoprosthesis or tracheostomy. Nd-Yag laser endoscopic recanalization was performed in 2 patients as a preliminary stage in subsegmental radical treatment, and in 5 cases for palliation. Recurrent laryngeal nerve palsy occurred in 3 cases, long-term hoarseness in 2, and hypoparathyroidism in 4. The overall mean hospital stay was 4.8 days. Of 299 patients still alive, 215 are free of disease. Surgery is the treatment of choice, with the goal of completely removing the neoplasm, together with any anatomical structures involved in infiltration (muscles, respiratory-digestive tract, lymph nodes). Satisfactory palliation can be achieved by endoprosthesis deployment or tracheostomy in all cases where surgery is ruled out due to extent of disease, patient age or histological type.

Background: The clinical benefit of an intensive follow-up protocol in endometrial cancer patients is still uncertain., Materials and Methods: One hundred and thirty-three patients underwent initial abdominal surgery for clinical stage I endometrial cancer between January 1988 and December 1997 and were periodically followed-up until April 1999 or until death. After surgery, 89 patients received postoperative adjuvant treatment. Periodical surveillance included physical examination, vaginal smear and abdominal-pelvic ultrasound every 3-4 months for the first 2 years from surgery, every 6 months for the next 3 years and yearly thereafter. Chest X-ray was performed every 6 months for the first 2 years, every year for the next 3 years and with individually increasing intervals afterwards. An abdominal-pelvic CT scan was carried out yearly for 5 years., Results: Twenty-four patients (18.0%) developed recurrent disease after a median time of 17.5 months (range, 6-64 months). Five-year actuarial disease-free survival was 81.2% in the whole series, and in detail 94.2% in the subset of patients with FIGO stage Ia grade 1 or 2 endometrioid adenocarcinoma, or stage Ib grade 1 endometrioid adenocarcinoma (low-risk), compared to 76.0 (p = 0.0472) in the subset of patients with stage Ia grade 3 endometrioid adenocarcinoma, stage Ib grade 2 or 3 endometrioid adenocarcinoma, stage equal to or greater than Ic endometrioid adenocarcinoma any grade, and aggressive histologies (high-risk). The site of recurrent disease was local in 6 (25.0%) patients, distant in 17 (70.8%), and local plus distant in 1 (4.2%). Eleven (45.8%) recurrences were symptomatic and 13 (54.2%) were asymptomatic. The median survival after recurrence was 10 months. Survival was longer in patients who relapsed after 17.5 months from initial surgery when compared to those who relapsed earlier (p = 0.02). Conversely, survival after recurrence was not related to patient characteristics at diagnosis, such as FIGO stage, tumor grade, myometrial invasion, histologic type, and lymph node status. It is noteworthy that survival was similar in asymptomatic women, in whom the relapse was occasionally detected by follow-up examinations, and in symptomatic ones., Conclusion: An intensive surveillance protocol seems to have no significant impact on the outcome of patients with clinical stage I endometrial cancer. Simplified follow-up programs tailored for patient subsets with different recurrence risk are required.

Aim of this study was to analyze the staging of disease according to correlation between depth of stromal invasion, lymph vascular space involvement, nodal metastases and recurrence and mortality rates in uterine cervical carcinoma. Data of 16 different surveys from 1980 to 1996 inclusive were collected through a Medline research; papers were selected according to available information about depth of invasion, lymph vascular invasion, nodal metastases, recurrence and mortality rate. Results of these surveys were pooled with the following aims: 1 correlation between depth of invasion and nodal metastases occurrence; 2 evolution of prognostic value of lymph vascular invasion; 3 best management according to biology of disease. Depth of stromal invasion seems to be the most important prognostic factor in early cervical cancer, with a critical cut-off of 3 mm of depth. Lymph vascular invasion correlates both with nodal metastases and with prognosis, which strictly depends only on depth of invasion; as a consequence, lymph vascular invasion would not represent an independent prognostic factor. Finally radical treatment (i.e. more aggressive therapies) does not add any curative advantage when compared with conservative treatment, which must be currently considered standard in stage IA cervical cancer.

In hemodialysis patients, C-reactive protein (CRP), an acute-phase reactant, is a sensitive and independent marker of malnutrition, anemia, and amyloidosis. The aim of the present studies was to evaluate CRP and interleukin 6 levels in plasma samples from long-term hemodialysis patients on different extracorporeal modalities associated with or without backfiltration. Two hundred and forty-seven patients were recruited in eight hospital-based centers. All patients had been on their dialytic modality for at least 6 months. At enrollment, 46 hemodialysis patients out of 247 (18.6%) had clinical evidence of pathologies known to be associated with high CRP values. The 201 remaining patients were defined as clinically stable and were on conventional hemodialysis (34%), hemodiafiltration with infusion volumes <10 liters/session (10%), hemodiafiltration with infusion volumes <20 liters/session (32%), and double-chamber hemodiafiltration with infusion volumes <10 liters/session (22%). Analysis of CRP values in the clinically stable patients showed that an unexpectedly high proportion (47%) of the patients had CRP values higher than 5 mg/l (taken as the upper limit in normal human subjects). The values of CRP and interleukin 6 were significantly higher in hemodiafiltration with infusion volumes <10 liters/session than in hemodiafiltration with infusion volumes >20 liters/session, in hemodialysis and in double-chamber hemodiafiltration. The same pattern occurred after 6 months of follow-up in 171 out of 201 clinically stable patients. Hemodialytic conditions that expose to the risk of backfiltration such as low exchange volume hemodiafiltration may induce a chronic inflammatory state as reflected by increased plasma values of both CRP and interleukin 6, thus suggesting the need for hemodialytic strategies that reduce (hemodialysis with low-permeability membranes or hemodiafiltration with infusion volumes >20 liters) or eliminate (double-chamber hemodiafiltration) backfiltration of bacteria-derived contaminants., (Copyright 2000 S. Karger AG, Basel)

A time series study was carried out to assess the relationship between the air pollutants measured by the air quality monitoring network and daily mortality in Turin, Italy. We used TSP, SO2, NO2, O3, and CO concentrations measured from 1-1-1991 to 31-12-1996 at three stations of the city network, chosen to represent different, typical circumstances of exposure to air pollution in the town. The analysis was performed by robust Poisson regression model including loss smoothing functions to allow for long-time trend, seasons, temperature and relative humidity. Dummy variables for the days of the week and holidays were also included. The relative risk of death for a unit increase in the pollutant concentration either during the same day (lag 0) in the previous ones (lag up to 5) was computed. The unit increase was 50 micrograms/m3 for TSP, SO2, NO2, O3, and 2 mg/m3 for CO. The average daily number of deaths for natural causes was 21. The relative risks for total mortality were 1.04 for TSP (lag 1), 1.10 for SO2 (lag 2), 1.06 for NO2 (lag 1), 1.01 for O3 (lag 0), 1.03 for CO (lag 1). The relative risks were 1.05 for TSP (lag 0), 1.12 for SO2 (lag 2), 1.07 for NO2 (lag 1), 1.03 for O3 (lag 0), 1.03 for CO (lag 1) for cardiovascular mortality, and 1.08 for TSP (lag 2), 1.20 for SO2 (lag 2), 1.12 for NO2 (lag 2), 1.03 for O3 (lag 2), 1.05 for CO (lag 2) for respiratory mortality.

This multicenter retrospective study is based on 192 patients with advanced ovarian cancer in pathological complete response at second-look surgery. Ninety-four (48.9%) patients developed recurrent disease after a median time of 18 months (range, 4-89 months) from surgical reassessment. The recurrence involved the pelvis in 45 (47.9%) cases, the abdomen in 42 (44.7%), the retroperitoneal lymph nodes in 13 (13.8%), and distant sites in 20 (21.2%). On the whole series, 5- and 7-year disease-free survival rates after negative second-look were 47.4 and 44.5%, respectively. By log-rank test the disease-free survival rate was related to FIGO stage (P = 0.008), tumor grade (P = 0.0021), size of residual disease after initial surgery (P = 0.0038), and type of second-look (laparoscopy vs laparotomy, P = 0.0061), but not to histological type and first-line chemotherapy. Cox proportional hazard model showed that tumor grade, size of residual disease, and type of second-look were independent prognostic variables for disease-free survival. The risk ratio of relapse was 2.386 (95% CI, 1.140-4.990) for grade 2 and 3.118 (95% CI, 1.515-6.416) for grade 3 compared to grade 1 disease. For patients with residual disease 1-2 cm and > 2 cm the risk ratio was, respectively, 1.877 (95% CI, 1.117-3.156) and 2.156 (95% CI, 1.324-3.511) compared to patients with residual disease < 1 cm. The risk ratio was 1.826 (95% CI, 1.121-2.973) for patients who were submitted to a laparoscopic second-look compared to those who underwent a laparotomic reassessment. Poorly differentiated grade and large residual disease after initial surgery are the strongest prognostic variables for recurrence after a negative second-look.

Background and Objectives: The cytological pattern of bacterial vaginosis (BV) in the Papanicolaou smear has a controversial history (coccoid vs. Gardnerella type) that has not allowed an efficient use of cervical/vaginal cytology in the diagnosis of this condition. Our study is an attempt to clarify this topic., Goals: To evaluate the accuracy of cervical/vaginal cytology in the diagnosis of BV., Study Design: 1,896 separate examinations were performed on 1,471 women attending our sexually transmitted diseases center between 1990 and 1993. Amsel's composite clinical criteria were used as a gold standard. The Pap smear was prepared on two slides with the addition of a vaginal specimen., Results: In the 166 cases of BV, sensitivity is 88.7%, and specificity is 98.8%. Positive predictive value is 89.8, and negative predictive value is 98.7. Kendall's correlation coefficient is 0.88 (p < 0.001)., Conclusions: Our findings support the validity of the vaginal Pap smear in diagnosing BV and suggest the screening of such a disease.

The Authors report their experience in the surgical management of three adults affected by intussusception. The different symptoms and different diagnostic approach, compared to those of childhood, induced the Authors to some evaluations on pathophysiology of intussusception in adults. On the basis of the different pathogenesis some differential criteria between the two forms are stressed, finally suggesting a systematic surgical approach in adults.

Intussusception in childhood, especially the idiopathic type, is herein considered. The Authors evaluate some etiopathological aspects on the basis of their experience in 34 patients, and affirm the need of an early and correct diagnosis. They also consider therapeutical management and surgical approach, evaluating local and general conditions of the patient as well as time passed since the onset of symptoms. Finally the importance of an accurate diagnostical examination during the quiescent period and some details of the surgical technique are stressed.

The operative management of patients with hyperparathyroidism is controversial. High rates of persistent hypercalcemia and postoperative hypoparathyroidism are seen in multiple hyperplasia and bilateral neck exploration. Patients undergoing unilateral neck exploration with removal of a single parathyroid adenoma have a rapid clearance of PTH which declines within hours after surgery. There is a sensitive immunometric assay (IRMA) for the intact molecule which demonstrates a decline in 15 minutes during surgery. Intraoperative measurement of PTH may be complementary to surgical skill and histopathologic information and may modulate extension of neck exploration.

The Authors review biliary peritonitis. After some evaluations on etiopathogenesis, biliary peritonitis without perforation in childhood is discussed. The rarity of this form is considered as well as etiopathological hypothesis, difficulties of diagnosis and surgical management. Two cases of primary biliary peritonitis without perforation observed and operated in two children are reported.

The Authors carried on a retrospective study of risks factors in oncologic surgery based on a univariate analysis. The study includes 337 patients hospitalized for neoplastic pathology from January 1991 to June 1995. In agreement with Literature the most important risks factors were represented by associated pathologies, TNM staging and ASA classification. The opportunity of a correct preoperative evaluation of risks factors is recommended to assure the best conditions for the surgical patient and to rescue to surgery patients otherwise considered not surgically manageable.

The objective of this retrospective multicenter study was to assess the rates, times, and sites of recurrences of 126 patients with uterine leiomyosarcomas. Surgery was the initial therapy for all patients. Median follow-up of survivors was 50 months (range, 3-168 months). Of the 90 patients with stage I-II disease, 26 received postoperative irradiation and/or chemotherapy. Thirty-five (38.9%) patients developed recurrent disease after a median time of 16 months (range, 2-102 months). Recurrence was pelvic in 5 (14.3%) patients, distant in 23 (65.7%), and pelvic plus distant in 7 (20.0%). The overall recurrence rate was similar in patients who received adjuvant treatment and in those who did not. None of the 15 patients who underwent pelvic irradiation developed local recurrences, but 5 of them failed in distant sites. Of the 16 patients with stage III leiomyosarcomas, 2 died of intercurrent disease within 1 month from surgery and 11 received postoperative irradiation and/or chemotherapy. Thirteen patients developed recurrent tumor after a median time of 8 months (range, 1-21 months). Recurrence was pelvic in 3, distant in 4, and pelvic plus distant in 6 patients. Of the 20 patients with stage IV leiomyosarcomas, after surgery 6 were clinically free of disease (group A) and 14 had clinically evaluable residual disease (group B). With regard to group A, 3 patients received postoperative irradiation and/or chemotherapy. Five patients developed recurrent disease after a median time of 11 months (range, 8-16 months). Recurrence was distant in 3 patients and pelvic plus distant in 2. With regard to group B, 11 patients underwent postoperative chemotherapy. Eleven patients died after a median time of 6 months (range, 1-15 months), and 3 are still alive with clinical evidence of disease after 4, 5, and 8 months, respectively, from surgery. Cox model showed that stage (P = 0.0001), mitotic count (P = 0.0002), and age (P = 0.0048) were independent prognostic variables for disease-free survival. In conclusion, uterine leiomyosarcomas have an aggressive clinical behavior, with a propensity to recur both locally and moreover at distant sites. Tumor stage is the strongest prognostic variable. Only patients with early-stage disease have a chance of surviving, whereas the treatment of patients with advanced or recurrent disease is palliative.

In this study, by means of computerized static posturography, we evaluated the postural changes after acupuncture treatment in a group of 15 patients with balance disorders caused by cervical torsion due to Whiplash Injury (WI). The acupuncture treatment consisted of 3 sessions (one weekly session for 3 weeks) during which the acupuncture points Bladder 10 (Bl.10) and Gall Bladder 20 (G.B.20). VB were stimulated by means of piercing with needles, and manipulating the needles for 20 seconds. Each patient underwent posturographic evaluations before and just after each session of acupuncture. The posturographic tests were performed with open eyes (OE), closed eyes (CE) and closed eyes with retroflexed head (CER). As a control group, we used 17 patients complaining of the same symptoms as the study group due to WI, but treated with drugs (FANS and myorelaxing) and physiotherapy only. The patients of the control group also underwent posturographic tests once a week for three weeks. We observed a significant difference between the two groups regarding the reduction of the CER Length of the statokinesigram just before each session of acupuncture and reduction of the frequency oscillations (FFT) of the patients on the sagittal plane in the study group, in CER, whereas in the control group we observed a progressive increase in these values. The high percentage of positive results in our WI patients leads us to advocate the therapeutic efficacy of acupuncture for balance disorders due to cervical pathology, where it can be associated with or be a valid alternative to pharmacological treatment.

The Authors report their experience in the management of surgical hyperthyroidism, evaluating the different clinical pictures and the possibility of non surgical treatment. Advantages and disadvantages of both hemithyroidectomy and total thyroidectomy, are also described. The Authors conclude affirming their preference for techniques such as total hemithyroidectomy or thyroidectomy in some types of hyperthyroidism.

The operative treatment of thyroid pathology has to be distinguished for benign and malignant pathology. The major complications associated with thyroid surgery are injury to the recurrent laryngeal nerve and hypoparathyroidism. Postoperative hypoparathyroidism is rarely the result of inadvertent removal of all parathyroid glands but, non commonly, is due to disruption of their blood supply. Postoperative hypoparathyroidism results in patients with symptomatic hypocalcemia, transitory and permanent hypoparathyroidism. Subtotal thyroidectomy is used for the treatment of benign thyroid pathology while tumors are treated by total thyroidectomy with neck dissection.

The Authors reviewed their series of 28 consecutive elderly patients operated on for gastric cancer in the Division of General and Oncological Surgery--Department of Surgery and Surgical Emergencies of the University of Perugia from January 1993 to December 1994. Thirteen subtotal gastrectomies associated with resection of the nearby organs in 5 cases, six total gastrectomies, two gastrojejunal bypass, and seven atypical resections of the middle third of the stomach were performed. The Authors focus their attention on this atypical technique pointing out the advantages compared to other procedures as well as criteria for patients selection. Gastric resection of the middle third seems a worthwhile procedure for well selected elderly patients, resulting in a good quality of life with low morbidity and mortality.

The Authors after a review of the embriology, physiology and pathophysiology of diaphragm, report three cases of congenital or acquired diaphragmatical hernias. They discuss advantages and disadvantages of different surgical techniques on the basis of their technical experience as well as results obtained.

Background: Aging and diabetes mellitus have been recognized as strong predictors of heart failure in patients with acute myocardial infarction. The aim of this study was to assess, by echocardiography, the influence of aging and non-insulin-dependent diabetes mellitus on the changes of left ventricular parietal kinesis in patients with acute myocardial infarction over the 6 months after hospitalization., Methods: The study population consisted of 82 patients (42 male, 40 female) aged 70 years, consecutively admitted to coronary care unit with acute myocardial infarction from January 1991 to May 1993. They were divided into two groups: group 1 comprised 36 patients with non-insulin-dependent diabetes mellitus, aged 78.8 +/- 6.02 years, 17 men and 19 women; group 2 comprised 46 patients without diabetes aged 78.7 +/- 6.9 years, 25 men and 21 women. Echocardiography was performed at admission to the unit (T0), at discharge (T1), and after 6 months of follow-up (T2). The echocardiographic wall motion score index was calculated by considering the number of akinetic and dyskinetic left ventricular wall segments. Fatal and non-fatal incidents of heart failure were also considered and a multivariate analysis was applied to identify the clinical and instrumental parameters that were independent predictors of wall motion score index changes and heart failure events., Results: At T1 the two groups were comparable in localization of acute myocardial infarction, previous myocardial infarction, creatinine kinase serum peak, ECG score and wall motion score index. A statistically significant reduction in akinesia (P < 0.001) was observed in group 2 at T1 and T2, but was not seen in group 1. At T2 the difference in wall motion score index between the groups became significant (P < 0.05). The occurrence of heart failure was significantly higher in group 1 than in group 2 either during hospitalization (P < 0.03) or during follow-up (P < 0.004). The multivariate analysis identified non-insulin-dependent diabetes mellitus as an independent predictor of lacking recovery in LV kinesis (P < 0.01) and of heart failure development (P < 0.001)., Conclusion: In elderly patients with non-insulin-dependent diabetes mellitus lack of recovery in wall motion score index after acute myocardial infarction seems to be an important factor, with a higher heart failure prevalence adversely affecting the in-hospital and long-term outcome. Non-insulin-dependent diabetes mellitus appears to be an important factor related to this unfavorable outcome.

This retrospective multicentric study assessed the prognostic value of the serum CA 125 assay and the common clinicopathological variables in 225 patients with advanced epithelial ovarian cancer. All of these patients had serum CA 125 > or = 35 U/ml before the first cycle of chemotherapy and had had serial antigen determinations during early chemotherapy. By univariate analysis pathological complete response rate was significantly related to stage, size of residual disease after first surgery, serum CA 125 before the first cycle and before the third cycle of chemotherapy, and serum CA 125 half-life. Multiple logistic regression showed that residual disease (P = 0.002), serum CA 125 half-life (P = 0.004), serum CA 125 before the third cycle (P = 0.004), and serum CA 125 before the first cycle (P = 0.03) retained a significant value in predicting second-look findings. By log-rank test survival was significantly related to stage, residual disease, tumor grade, serum CA 125 before the third cycle, and serum CA 125 half-life. Cox proportional hazard model showed that residual disease (P = 0.0001), serum CA 125 half-life (P = 0.007), and tumor grade (P = 0.01) retained a significant value in predicting survival. In conclusion, serum CA 125 half-life during early chemotherapy was an independent prognostic factor for both the achievement of a pathological complete response and the survival of patients with advanced epithelial ovarian cancer.

The Authors discuss about thoracic wall neoplasms examining in particular neurogenic tumors, their origin, most frequent locations, and biological behaviour. Two cases are reported and preoperative diagnosis as well as surgical techniques and results obtained are discussed.

The Authors report their experience in the management of 68 patients aged over 70 years affected by gastric cancer: 64 of them were operated. After some considerations on patients status, nutritional and immunological conditions, operative risk and cancer characteristics the Authors, on the basis of the results obtained, discuss about the opportunity of surgical therapy and relative adequate surgical techniques in the elderly.

The Authors report their experience with 738 children observed and operated for minor diseases in the period January 1989-June 1993. The children were hospitalized for day surgery or one day surgery. After some surgical, anaesthesiological, and postoperative pathophysiological considerations, and on the basis of their results (reduced local and general postoperative complications), the Authors confirm the benefit of this type of organization in terms of reduced nosocomial infections, reduced psychological traumas and increased socio-economic advantages.

The relation of ECG findings to presenting features and prognosis was evaluated in 125 consecutive patients with hypertrophic cardiomyopathy (HC). Seventy-nine men and 46 women (mean age, 34 +/- 7 years) were studied since 1970. Most ECG features were similar in patients with and without a left ventricular outflow tract gradient. Those with obstruction had a higher prevalence of left ventricular hypertrophy according to ECG voltage criteria (54% vs. 28%, p less than 0.01), whereas higher grade ventricular arrhythmias were more common in patients without an outflow gradient (20% vs. 7%, p less than 0.05). The prevalence of ECG abnormalities was also similar in younger (less than or equal to 14 years) and older patients (greater than 14 years), and only repolarization abnormalities were more frequently detected in the older age group (56% vs. 32%, p less than 0.025). Stratification of patients according to the clinical state revealed that those who had moderate to severe functional limitation had a higher prevalence of atrial fibrillation than asymptomatic or mildly symptomatic patients (24% vs. 1%, p less than 0.001). There were no significant differences in most hemodynamic variables among patients dichotomized according to any specific ECG abnormality. Only patients with atrial fibrillation had significantly higher right ventricular end-diastolic pressure (10 +/- 7 vs. 6 +/- 4 mmHg, p less than 0.01), lower systolic index (22 +/- 8 vs. 37 +/- 15 ml/m2; beat, p less than 0.02) and lower ejection fraction (53 +/- 8 vs. 64 +/- 10%, p less than 0.001) than those in sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood, plasma and serum viscosity and blood filtration were investigated in 43 unselected mixed cryoglobulinemia patients. A hyperviscosity syndrome was present in only one patient, and rapidly improved after plasma exchange and cyclophosphamide therapy. A clear-cut increase in blood viscosity was infrequently observed in mixed cryoglobulinemia, although significant differences were present in the plasma and serum viscosity of patients and controls. In contrast, blood filtration was severely impaired in a high percentage of cases (51 and 72% of the values recorded at 37 degrees and 25 degrees C, respectively), and was on the average significantly higher in patients than in controls. Indirect evidence suggests that blood viscosity is at least in part related to cryoglobulins. In 19 patients studied before and after cryoglobulin removal, serum viscosity significantly decreased when the serum was deprived of cryoglobulins. In addition, the cryocrit correlated with all the hemorheological parameters with the exception of blood filtration. The hemorheological findings were compared with multisystemic features of the disease, i.e. liver, renal, lung, neurologic, vascular and funduscopic alterations. The potential clinical relevance of the hemorheological parameters was stressed by the close correlation between blood filtration parameters and serum creatinine. Furthermore, by discriminant analysis, viscosity and blood filtration changes were the serological parameters most significantly associated with the presence of renal, liver and neurological involvement. Thus, hemorheological parameters are frequently abnormal in mixed cryoglobulinemia patients, and seem to play a significant clinical role; they should therefore be included in the work-up of these patients.

The effects of cholinergic muscarinic receptor antagonist pirenzepine on the GHRH-induced GH release were studied in 10 adolescent females with anorexia nervosa at different stages of the disease, in 5 adolescent females with eating disorders and in 5 normal adolescents. The patients were characterized according to psychological (DSM III-R), endocrinological (GnRH test), nutritional (Somatomedin-C, T3), and clinical (% IBW, duration of the amenorrhoea) criteria. On two separate occasions, each subject received an i.v. bolus injection of GHRH 1-40 (1 microgram/kg) alone or preceded by pirenzepine (0.6 mg/kg i.v. 5 min before GHRH 1-40). GHRH 1-40 injection induced a significantly (P less than 0.05) higher GH increase in the patients with anorexia nervosa at the acute stage as compared with the controls. Pirenzepine did not abolish opportunely the exaggerated GH response to GHRH 1-40 in anorectic patients at the acute stage unlike the control, who showed the blockade of GHRH-induced GH release by the cholinergic muscarinic antagonist (P less than 0.05). The anorectic adolescents at the non acute stage and the adolescents with eating disorders showed varying reductions of GH response; however, pirenzepine produced a blunted suppression of GHRH-induced GH increase as compared to the controls, which was not statistically significant. Somatomedin-C values were significantly (P less than 0.05) lower in anorectic patients at the acute stage as compared with controls. The abnormal activity of cholinergic system in anorectic patients, as our data show, could induce the GH hypersecretion through an inhibitory influence on the somatostatinergic function. The reduced somatomedin-C levels, a specific malnutrition index in anorectic patients, produce a modified feed-back on the hypothalamic site (somatostatin) and/or directly on the pituitary, following the GH hypersecretion.

The relationship of left ventricular outflow tract gradient as well as of clinical, ECG and haemodynamic data to presenting features and prognosis was evaluated in 125 consecutive patients with hypertropic cardiomyopathy, 79 men and 46 women (mean age: 34 +/- 7 years) studied between January 1970 and December 1985. Most clinical, ECG and haemodynamic findings were similar in the 44 patients (35%) with a pressure gradient (greater than or equal to 30 mmHg) and in the 81 patients (65%) without. Those with obstruction had greater ECG voltage SV1 and RV5; however, higher grade ventricular arrhythmias were more common in patients without obstruction. During a mean follow-up period of 7.6 +/- 4.5 years (range 2-18 years), death from a cardiac cause occurred in 28 patients (21 died suddenly) and was significantly less common in patients with a pressure gradient than in those without (11% vs 28%, P = 0.039). Univariate analysis of survival curves showed that the most powerful predictors of a poor prognosis were ejection fraction P = 0.0001), mean pulmonary artery pressure (P = 0.0001), dyspnoea (P = 0.001), left ventricular end-diastolic pressure (P = 0.002), complex ventricular arrhythmias (P = 0.029) and severe mitral regurgitation (P = 0.037). Using multivariate analysis, a decreased ejection fraction (P = 0.006) and a raised mean pulmonary artery pressure (P = 0.022) were the only independent prognostic determinants. Thus, the presence of a left ventricular outflow tract gradient does not seem of adverse prognostic significance. Risk factor characterization in patients with hypertrophic cardiomyopathy may be improved by assessment of ventricular arrhythmias in the context of left ventricular function.

To evaluate long-term prognosis during medical treatment of hypertension associated with angina pectoris, a total of 1083 patients with angiographically-documented coronary artery disease were followed for a mean of 66 months. At the end of the study, follow-up was complete in 98% of all patients. Of the 1083 patients, 132 (12%) had hypertension and 951 (88%) were not hypertensive. During the follow-up period, there was a total of 15 deaths (11.3%) among the hypertensive population (vs. 61 or 6.4% in the nonhypertensives) as well as a higher incidence of nonfatal myocardial infarction (9.0% in the hypertensives vs. 3.7% in the nonhypertensives) (Figure 2). Six-year cumulative survival was 84% in the hypertensive patients as compared to 92% in the nonhypertensives. Among risk factors, historical data, clinical and catheterization findings, the only noninvasively-obtainable independent predictor of prognosis using multivariate analysis was hypertension (Table 3).

CA125 (reference value [RV] = 35 U/mL), CA50 (RV = 20 U/mL), CA72.4 (RV = 3.8 U/mL) and SCC (RV = 3.6 ng/mL) levels were retrospectively assayed in blood samples collected at diagnosis from 42 patients with endometrial carcinoma, 45 patients with cervical carcinoma and 68 patients with benign uterine pathology as controls. Among the patients with endometrial carcinoma. CA50 was the antigen with the highest sensitivity (SE) (34.4%) followed by CA125 (26.2%), CA72.4 (21.9%) and SCC (16.7%). The incidence of elevated serum CA125 and CA72.4 levels was significantly greater in advanced stages than in early ones (66.7% vs 19.4%, p = 0.032 for CA125; 66.7% vs 11.5%, p = 0.012 for CA72.4), while CA50 positivity was not significantly correlated with the extent of disease (50% in advanced stages vs 30.8% in early ones, p = 0.38). Among the patients with cervical carcinoma, CA125 and CA50 respectively showed a SE of 33.3% and of 42.9% for adenocarcinoma, while SCC had a SE of 33.3% and of 42.9% for squamous cell adenocarcinoma; in particular among the patients with squamous cell carcinoma, the incidence of elevated SCC levels was correlated with the extent of tumor (57.1% in advanced stages vs 12.5% in early ones, p = 0.013). In conclusion, CA50 and CA125 were the most sensitive tumor markers in both endometrial carcinoma and cervical adenocarcinoma, while SCC was the most reliable antigen for squamous cell carcinoma of the cervix. Because of the affinity of SCC, CA50 and CA125 for different histological types of cervical carcinoma, the combined evaluation of SCC with CA50 or CA125 showed an increased SE with respect to each marker alone.

Parotid sialography and labial salivary gland biopsy were performed in 84 patients with clinical features of primary or secondary Sjögren's syndrome (SS). Signs of focal sialoadenitis were found in 73/84 patients (87%), but only 37 (44%) scored 4 which is considered diagnostic for classic SS. In contrast 55/84 patients (66%) showed some sialographic abnormalities. In patients with both primary and secondary SS, hypergammaglobulinemia and anti-SSA antibodies appeared to be the serological variables more closely related to the entity of either sialographic or histologic abnormalities. In primary SS extraglandular manifestations and recurrent parotid swelling were significantly associated with parotid sialography and labial salivary gland biopsy changes, respectively. Our study indicates that currently both radiological and histological examination are necessary for the assessment of salivary gland involvement in SS.

We have developed a radioimmunoassay method (RIA) to measure urinary albumin excretion. We determined the albumin excretion rate (AER) (micrograms/min) of 122 healthy subjects and 145 diabetic patients (115 type I, 30 type II). The results indicate that the RIA is sensitive (0.39 +/- 0.08 mg/L), precise (CV 5-8%), and gives reliable results on previously frozen urine samples. The distribution of the AER values in healthy subjects and diabetic patients was not normal. It was normalized by log or square-root transformation of the data. Seventy-three percent of diabetic patients lay within the normal range (0.6-10.6 micrograms/min). Twenty percent could be considered "at risk" to develop overt diabetic nephropathy because their albuminuria exceeded a threshold level of 15 micrograms/min chosen previously as the cutoff value for microalbuminuria. We found no correlation between AER and glycated hemoglobin, and only a weak correlation between AER and diabetes duration in type I diabetic patients.

In this study we evaluated the relationships between plasma metformin levels, measured by reverse-phase high-performance liquid chromatography, and serum lipid levels in 20 metformin-treated, type II diabetic patients. Mean fasting plasma metformin concentration was 490 +/- 188 ng/ml. No correlation was found between daily dose of drug and lipid parameters. A significant correlation emerged between circulating metformin concentration and serum triglycerides (r = -0.574, p less than 0.01), HDL-cholesterol (r = 0.583, p less than 0.01) and HDL2-cholesterol (r = 0.670, p less than 0.05). Multiple linear regression analysis showed that the correlation between plasma metformin concentration and serum triglycerides still remained significant after correction for other clinical and metabolic parameters. Total cholesterol and HDL3-cholesterol were not correlated with metformin concentrations. These results demonstrate the clinical usefulness of measuring plasma metformin concentrations and indicate that some effects of metformin on lipid metabolism depend on the drug plasma levels.

Plasma lipid levels have been proposed as probable risk factors of diabetic retinopathy. To clarify this question, we evaluated the apolipoprotein levels in 68 type I diabetic patients (39 +/- SD 14 years; duration of diabetes 13 +/- SD 8.4 years). By the analysis of fluorescein angiography we have classified diabetic retinopathy as follows: absent retinopathy (AR, n = 23), minimal retinopathy (MR, n = 16), exudative retinopathy (ER, n = 15), proliferative retinopathy (PR, n = 14). For all patients we measured: total, LDL- and HDL-cholesterol (T-CH, LDL-CH, HDL-CH), apolipoproteins A and B (Apo A and B), fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1). The mean age of the patients with ER (47 +/- SD 14 years) was greater than those with MR (36 +/- SD 15 years) or AR (33 +/- SD 13 years) (p less than 0.05). Significant differences within groups were not found for relative body weight, daily insulin dose, FPG, HbA1% (analysis of variance, ANOVA). The groups differed between each other with regard to T-CH, LDL-CH and HDL-CH/LDL-CH ratio (T-cholesterol: AR 186 +/- SD 34, MR 191 +/- SD 32, ER 212 +/- SD 52, PR 215 +/- SD 41 mg/dl; LDL-cholesterol: AR 124 +/- SD 28, MR 122 +/- SD 18, ER 148 +/- SD 38, PR 145 +/- SD 33 mg/dl; HDL/LDL-cholesterol ratio: AR 0.38 +/- SD 0.1, MR 0.35 +/- SD 0.1, ER 0.30 +/- SD 0.1, PR 0.29 +/- SD 0.1). The total-CH levels increased and HDL-CH/LDL-CH ratio decreased along with the severity of the retinopathy.(ABSTRACT TRUNCATED AT 250 WORDS)