Identification of high risk patients with endometrial carcinoma. Prognostic assessment of endometrial cancer.

OBJECTIVES: To verify the importance of DNA ploidy on clinical outcome in endometrial carcinoma and to investigate whether the prognostic information obtained by this variable is independent from other clinical-pathologic features. MATERIALS AND METHODS: Univariate and multivariate analysis of clinical and pathologic prognostic factors obtained from 203 consecutive cases of endometrial cancer, that had been surgically treated in our hospital, were performed. RESULTS: Significant prognostic factors according to the Kaplan-Meier method were age at the time of diagnosis, grade of differentiation, peritoneal cytology, node involvement, vascular invasion, myometrial infiltration and ploidy. At multivariate analysis only DNA ploidy resulted to be an independent variable. CONCLUSIONS: In our analysis DNA content is the only parameter which preserved prognostic significance in multivariate analysis.

The role of central fat distribution in coronary artery disease in obesity: comparison of nondiabetic obese, diabetic obese, and normal weight subjects.

OBJECTIVE: To investigate the degree of coronary artery disease (CAD) in relation to obesity and fat distribution in obese patients with normal glucose tolerance, in comparison with CAD of diabetic obese patients and of normal weight subjects with CAD. DESIGN: Patients listed for coronary angiography with different body mass index (BMI) with or without diabetes: study of the correlation between severity of coronary damage and fat distribution. SUBJECTS: 92 patients subdivided into: 30 normal glucose tolerant obese (BMI 31.7+/-0.5, aged 53+/-1.7 y), 28 type 2 diabetic obese (BMI 30.7+/-0. 3, aged 57+/-1.2 y), and 34 normal weight patients (BMI 23.1+/-0.3, aged 54+/-1.7 y). MEASUREMENTS: CAD assessed by angiography and evaluated according to the method of Gensini. Fat mass and fat distribution assessed by bioelectrical impedance and anthropometry. Clinical, biochemical and hormonal variables, as well as smoking habits and alcohol intake. RESULTS: The angiographic coronary scores were similar in nondiabetic obese and in diabetic obese patients, and were significantly higher than those of normal weight subjects. In the entire population coronary score correlated with indices of abdominal fat distribution. In the stepwise analysis of each group separately, waist hip ratio (WHR) correlated with coronary score only in normal weight nondiabetic patients. CAD was inversely associated with BMI only in nondiabetic obese patients. CONCLUSION: CAD of obese patients: 1) is similar to that of diabetic obese patients; 2) is more severe than that of normal weight individuals; and 3) is inversely correlated with BMI. CAD appears to be associated with WHR, not with BMI, only in nondiabetic patients with normal body weight. On the contrary, CAD of diabetic obese patients is unrelated to BMI and parameters of fat distribution, but is associated with smoking habits.

Snoring & sleep apnea: a population study in Italian women.

The aim of this cross-sectional study was to evaluate the prevalence of sleep-disordered breathing by means of a validated portable instrument (MESAM IV) and to investigate the relationship between snoring and sleep apnea in a sample of Italian middle-aged female population. We randomly chose 750 subjects aged 40 to 65 years and 365 agreed to participate to the study. In this group, 19.7% of subjects were every-night snorers according to the questionnaire; when recorded, 54.2% snored for more than 10% of the night, and 7.1% for more than 50% of the night. Sleep apnea was also common: 10.7% of subjects had a respiratory disturbances per hour (RDI) between 5 and 9, 7.7% an RDI between 10 and 19, and 2.2% had an RDI > or =20. Snoring percentage and RDI were significantly correlated. However, 50% of subjects who snored for more than half the night had no evidence of sleep apnea. Snoring amount >50% resulted influenced by body mass index, while RDI>10 was influenced by neck diameter. We concluded that in middle-aged women, both snoring and sleep apnea are very common. A high percentage of snoring is not essential for the occurrence of sleep apnea, nor it necessarily indicates the presence of sleep apnea.

Nerve stimulator and multiple injection technique for upper and lower limb blockade: failure rate, patient acceptance, and neurologic complications. Study Group on Regional Anesthesia.

UNLABELLED: To evaluate the failure rate, patient acceptance, effective volumes of local anesthetic solution, and incidence of neurologic complications after peripheral nerve block performed using the multiple injection technique with a nerve stimulator, we prospectively studied 3996 patients undergoing combined sciatic-femoral nerve block (n = 2175), axillary blocks (n = 1650), and interscalene blocks (n = 171). The success rate and mean injected volumes of local anesthetic were: 93% with 22.6 +/- 4.5 mL in the axillary, 94% with 24.5 +/- 5.4 mL in the interscalene, and 93% with 28.1 +/- 4.4 mL in the sciatic-femoral nerve blocks. Patients receiving combined sciatic-femoral nerve block showed more discomfort during block placement and worse acceptance of the anesthetic procedure than patients receiving brachial plexus anesthesia. During the first month after surgery, 69 patients (1.7%) developed neurologic dysfunction on the operated limb. Complete recovery required 4-12 wk in all patients but one, who required 25 wk. The only variable showing significant association with the development of postoperative neurologic dysfunction was the tourniquet inflation pressure (<400 mm Hg compared with >400 mm Hg, odds ratio 2.9, 95% confidence intervals 1.6-5.4; P < 0.001). We conclude that using the multiple injections technique with a nerve stimulator results in a success rate of >90% with a volume of <30 mL of local anesthetic solution and an incidence of transient neurologic complication of <2%. IMPLICATIONS: Based on a prospective evaluation of 3996 consecutive peripheral nerve blocks, the multiple injection technique with nerve stimulator allows for up to 94% successful nerve block with <30 mL of local anesthetic solution. Although the data collection regarding neurologic dysfunction was limited, the withdrawal and redirection of the stimulating needle was not associated with an increased incidence of neurologic complications. Sedation/analgesia should be advocated during block placement to improve patient acceptance.

Lessons from in vitro perifusion of pancreatic islets isolated from 80 human pancreases.

We report the average insulin response to acute glucose measured by in vitro perifusion of pancreatic islets isolated from 80 consecutive human organs. Different perifusion parameters were considered [basal release, stimulation index (SI), time to peak, incremental area under the curve delta-AUC alpha)], and the correlation among them was determined. SI positively correlated with delta-AUC alpha (p < 0.001, r = 0.80) while negatively with time to peak (p < 0.05, r = -0.23). We also evaluated several variables of the isolation procedure that might affect responsiveness to glucose by human islets. Sex and age of pancreas donors, cold ischemia time, duration of the digestion, collagenase concentration, and lot characteristics (collagenase, trypsin, clostripain, and proteases activity), and final islet yield were considered. Multivariate regression analysis showed only an independent association between SI and the concentration of collagenase (p = 0.01).

Cell loss and proliferation in non-small cell lung carcinoma: correlation with histological subtype.

BACKGROUND: Cell kinetic data are important indicators of the aggressiveness of tumor and treatment response. The size of a neoplasm depends on the balance between cell proliferation and death. Thus, the analysis of the kinetics of cell proliferation and death may explain differences in the rates of tumour progression. METHODS: We studied apoptosis and proliferative indices in 95 cases of non-small cell lung carcinomas. The analysis was performed on paraffin-embedded tissue, by both MIB-1 immunocytochemical detection to establish the proliferation index and the in-situ end labelling method for the apoptosis index. The two indices were related. RESULTS: Our results showed a high proliferative index and cell loss rate in squamous cell carcinoma, and a low proliferative index and cell loss rate in adenocarcinoma, suggesting two different growth patterns. CONCLUSION: These findings could explain the different biological behaviour and treatment response of the tumours. The tendency of a cancer cell to undergo apoptosis may be especially important for the chemotherapy of malignant tumours with a low growth rate, which are typically resistant to cytostatic agents.

Dementing disorders in north Italy: prevalence study in Vescovato, Cremona Province.

We investigated the prevalence of dementia in 673 subjects over 59 years of age in Vescovato, a small town of North Italy, using a two-phase survey. During phase I all subjects were administered the Hodkinson abbreviated mental test and the subjects with a score < or = 7 underwent further examination to ascertain the diagnosis of dementia. The prevalence ratio of dementia of all types was 9.8% (7.6-12.0, 95% CI) above age 59. In our population Alzheimer's disease (AD) was the most frequent type of dementia (prevalence ratio = 5.2%), followed by vascular dementia (2.7%). Our study confirms that AD prevalence estimate rises exponentially with age.

Breast carcinoma detection with a combination of radiolabeled monoclonal antibodies. Promising results from immunohistochemistry studies.

BACKGROUND: Recent studies have demonstrated that the use of radiolabeled monoclonal antibodies (MoAbs) directed against tumor-associated antigens could help in the recognition of primary tumors, their extent, and their metastases by external scintigraphy (used preoperatively) or by hand-held gamma-detecting probe (GDP) (used intraoperatively). METHODS: The authors evaluated carcinoembryonic antigen (CEA), c-erb B-2 protein, and TAG-72 expression in 100 cases of breast carcinoma using F023C5 (anti-CEA), B72.3, and anti-c-erb B-2 protein MoAbs that were previously investigated for their usefulness in radioimmunoguided surgery and external scintigraphy. The goal of this study was to examine the biodistribution of each antibody in primary, multifocal, and metastatic lesions to evaluate the suitability of their simultaneous use in GDP and external scintigraphy. RESULTS: Results showed immunoreactivity for c-erb B-2 protein in 39 of 99 cases, for B72.3 in 41 of 100 cases, and for CEA in 15 of 100 cases. Multifocal lesions demonstrated positivity for c-erb B-2 protein in 37.4% of cases (6 of 16), for B72.3 in 68.8% of cases (11 of 16), and for CEA in 6.2% of cases (1 of 16). In lymph node metastases, immunoreactivity was found for c-erb B-2 protein in 36.4% of cases (12 of 33), for B72.3 in 63.7% of cases (21 of 33), and for CEA in 24.3% of cases (8 of 33). When the authors considered the immunoreactivity of all three MoAbs, the percentage of positive cases they observed was 60% in primary tumors (60 cases), 78% in lymph node metastases, and 81.2% in multifocal lesions. CONCLUSIONS: These results suggest that in vivo tumor radioimmunodetection could be improved by the use of more antibodies directed against different tumor-associated antigens.

Factors predicting chronic hepatic encephalopathy after distal splenorenal shunt: a multivariate analysis of clinical and hemodynamic variables.

BACKGROUND: This study was aimed at evaluating several factors that promote chronic hepatic encephalopathy by multivariate analysis of data for patients with cirrhosis with good or moderate liver function submitted to distal splenorenal shunts. METHODS: The study group comprised 131 patients: 55 had alcoholic and 76 nonalcoholic cirrhosis. Seventy patients were in Child's class A and 61 in class B. Cerebral function was assessed by a complete neurologic examination. Angiography with venous phase was performed before and within 1 month after the shunt operation. In 84 cases the original Warren technique was used and in 20 cases a Britton's modified procedure was used. Twenty-seven patients had distal splenorenal shunts with a splenopancreatic disconnection. Statistical analysis was performed by two multivariate analyses based on stepwise selection. RESULTS: Thirty-nine patients died during a follow-up period of 51 +/- 32 months. Chronic encephalopathy occurred in 18 patients (14%). According to the multivariate analysis of the preoperative prognostic factors, only age (p = 0.0001) and albumin values (p = 0.0002) were independent predictive risk factors for chronic encephalopathy. In the multivariate analysis concerning the hemodynamic consequences of the selective shunts, independent risk factors promoting chronic encephalopathy were postoperative portal perfusion (p = 0.0001), postshunt portal pressure (p = 0.001), and surgical disconnection (p = 0.0064). CONCLUSIONS: Our study has shown that chronic encephalopathy after selective shunt surgery is promoted by both clinical and hemodynamic factors. A better selection of the candidates for shunt surgery and prevention of the development of portal malcirculation by accurate surgical disconnection should further decrease the risk of chronic encephalopathy.

Excimer laser photorefractive keratectomy for myopia: results in 1165 eyes. Italian Study Group.

BACKGROUND: We report the results of a prospective study conducted in Italy to evaluate the efficacy, safety, predictability, and complications of excimer laser photorefractive keratectomy for the correction of myopia. METHODS. Photorefractive keratectomy was performed on 1236 myopic sighted eyes in 16 centers, using the Summit Excimed 193 nm excimer laser. The attempted correction ranged from -0.80 to -25.00 diopters (mean, -7.83 +/- 3.88 D). The population was divided into three groups of attempted correction: between -0.80 and -6.00 D, between -6.10 and -9.90 D, and between -10.00 and -25.00 D. We report the data of 1165 eyes at 1 month, 970 eyes at 3 months, 752 at 6 months, and 330 at 12 months. At each visit, we evaluated (1) the refractive changes over time; (2) the difference between attempted and achieved correction; (3) uncorrected and best spectacle corrected visual acuity; and (4) haze. RESULTS: Twelve months after surgery, the spherical equivalent refractive error in 146 eyes with attempted correction of -0.80 to -6.00 D was -0.52 +/- 1.04 D; 104 eyes (71.2%) were within +/- 1.00 D of attempted correction. In 145 eyes with attempted correction of -6.10 to -9.90 D, the spherical equivalent refractive error was -1.66 +/- 1.88 D; 50 eyes (34.5%) were within +/- 1.00 D of attempted correction. The spherical equivalent refractive error in 39 eyes with attempted correction of -10.00 to -25.00 D was -1.86 +/- 3.47 D; 11 eyes (28.2%) were within +/- 1.00 D of attempted correction. Eight eyes (2.4%) lost two or more Snellen lines of best spectacle corrected visual acuity. None of the treatments caused severe postoperative complications, or scarring. CONCLUSIONS: Photorefractive keratectomy proved safe and effective, but highly predictable only in the correction of myopia up to -6.00 D.

Estimating the depth of myometrial involvement by endometrial carcinoma: efficacy of transvaginal sonography vs MR imaging.

OBJECTIVE: In this study we compare transvaginal sonography with MR imaging for use in detecting the depth of myometrial involvement by endometrial carcinoma. SUBJECTS AND METHODS: Forty-two consecutive patients with stage I endometrial carcinoma had transvaginal sonography and MR imaging at 0.5 T. All the patients had a hysterectomy within 1-10 days after the imaging studies. The results of histologic examination of the surgical specimen were considered the gold standard of the study. We compared transvaginal sonography and MR imaging for use in assessing myometrial invasion by endometrial carcinoma by means of the staging classification of the International Federation of Gynecology and Obstetrics: stage Ia (tumor limited to endometrium), stage Ib (invasion of less than half the myometrium), stage Ic (invasion of more than half the myometrium). The overdiagnoses and the underdiagnoses for both techniques were calculated. We also evaluated the sensitivity and specificity of the two techniques for assessing the presence of myometrial invasion (stage Ib + stage Ic) and the presence of deep myometrial invasion (stage Ic). The diagnostic indexes evaluated and the differences between them were analyzed by using McNemar's test and 95% confidence intervals. The staging diagnoses based on MR imaging and sonographic findings were compared with staging diagnoses based on histologic examination, and a score was assigned to each diagnosis: these scores were then evaluated with Wilcoxon's signed rank test for paired data. RESULTS: Histologic examination showed that six of the 42 patients had tumor confined to the endometrium (stage Ia), 14 had involvement of the inner half of the myometrium (stage Ib), and 22 had involvement of the outer half of the myometrium (stage Ic). The staging was concordant between the two imaging techniques in 32 cases (concordance, 76%). Among the 10 discordant cases, diagnosis was correct in six cases for MR and four cases for sonography. Overall staging based on sonography was correct with respect to histologic staging in 29 cases (69%; 95% confidence interval, 52-81%). Five tumors (12%) were underdiagnosed and eight (19%) were overdiagnosed. Staging based on MR findings was correct with respect to histologic staging in 31 cases (74%; 95% confidence interval, 58-85%). Five tumors (12%) were underdiagnosed, and six (14%) were overdiagnosed. CONCLUSION: In our experience, there is no difference in the staging diagnoses of transvaginal sonography and MR imaging. Also, concordance with histologic staging diagnoses and sensitivity and specificity indexes did not show statistical differences between the two techniques, although these last results have to be considered with caution because of the low power of the statistical tests.

Myometrial invasion by endometrial carcinoma: assessment with plain and gadolinium-enhanced MR imaging.

A prospective study was designed to determine the sensitivity and specificity of nonenhanced T2-weighted and contrast material-enhanced T1-weighted magnetic resonance (MR) imaging in assessing the depth of myometrial invasion in patients with proved endometrial cancer. In 56 consecutive patients with clinically determined early-stage disease, findings of the two MR imaging techniques were compared with results of histologic examination of surgical specimens. Myometrial invasion was classified as absent (stage IA), superficial (stage IB), or deep (stage IC). In the assessment of each tumor stage, the sensitivity and specificity of contrast-enhanced T1-weighted MR imaging were higher than those of non-enhanced T2-weighted MR imaging. In determining the degree of myometrial tumor invasion, the overall sensitivity of enhanced T1-weighted MR imaging was 87.5%, whereas that of nonenhanced T2-weighted MR imaging was 71.4% (P less than .05). The use of contrast material may improve the ability to assess, with MR imaging, the depth of myometrial invasion by endometrial cancer.

Myometrial invasion by endometrial carcinoma: assessment by MR imaging.

In patients with early-stage endometrial cancer, preoperative knowledge of myometrial tumor extension has important prognostic and therapeutic implications. The purpose of this prospective study was to determine the sensitivity and specificity of MR imaging for assessing the depth of myometrial invasion in patients with endometrial cancer that clinically was thought to be confined to the uterine corpus. Sixty-five consecutive patients were included in the study. All patients had MR imaging before radical surgery. MR imaging findings were compared with microscopic pathologic findings in all cases. On MR images and at histologic analysis, myometrial invasion was classified as absent (tumor confined to the endometrium), superficial (less than 50% of myometrial thickness), or deep (50% or more of myometrial thickness). At histologic examination, tumor limited to the endometrium was proved in 14 cases, superficial myometrial invasion by tumor was present in 34 cases, and deep tumor invasion was demonstrated in 17 cases. In determining the presence of tumor confined to the endometrium, MR imaging had a sensitivity of 57% and a specificity of 96%. In the assessment of tumor with superficial myometrial invasion, MR imaging had a sensitivity and a specificity of 74%, whereas in assessing deep myometrial penetration, the sensitivity and specificity of MR were 88% and 85%, respectively. Errors in MR interpretation when determining myometrial tumor spread were more frequently overestimations rather than underestimations. Our results indicate that MR imaging is useful for the preoperative assessment of myometrial invasion in patients with proved endometrial cancer.

Incidence and prevalence rates of diabetes mellitus in Italy from routine data: a methodological assessment.

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.

Identification of the cohort of type 1 diabetes presenting in Lombardy in 1983-84: a validated assessment.

An incidence register for Type 1 diabetes was started in Lombardy in 1983-84 for people under 35 years of age. The main information source was the Regional Health Service record system, which provides anonymous reports on all patients discharged from public and private hospitals. Great care was taken to assure the quality of the data in the register. The clinical diagnosis was validated by examining the case notes. Completeness of the register was assessed using multiple independent sources of case ascertainment such as the list of the Youth Diabetics Association, the files of three hospital endocrinology centres, and the registry of conscripts rejected because of diabetes. The estimated age-adjusted (world standard) annual incidence rate was 6.04 per 100,000 in the group 0-18 years and 5.96 per 100,000 in the age group 0-14 years. Females had peak incidence at 11 years of age, males had peak incidence 2 years later. These results confirm the low occurrence of Type 1 diabetes in northern Italy. A seasonal variation in onset of Type 1 diabetes was seen.

Clinical and epidemiological aspects of Alzheimer's disease with presenile onset: a case control study.

Little is known regarding the pathogenetic factors for Alzheimer's disease (AD). We studied 63 AD patients in order to evaluate if there were clinical subtypes of AD and whether prior illnesses and life-styles were involved in the development of the disease. In our patients selected for onset of symptoms before age 65 we did not find any significant clinical heterogeneity. Furthermore, we found no data in the medical history that are predictive for the development of presenile AD but observed a significantly increased frequency of dementia in the families of AD patients in comparison to controls.

CT-guided pancreatic percutaneous fine-needle biopsy in differential diagnosis between pancreatic cancer and chronic pancreatitis.

Differential diagnosis between pancreatic cancer and chronic pancreatitis is still difficult to establish. In 63 patients with suspected pancreatic neoplasm we performed: serum CA 19-9 assessment, abdominal ultrasound. CT scan and CT-guided pancreatic percutaneous fine-needle biopsy. The conclusive diagnosis was pancreatic cancer in 40 patients and chronic pancreatitis in 23 patients. With regard to the differential diagnosis, sensitivity and specificity were respectively 80% and 78% for serum CA 19-9, 75% and 65% for abdominal US. 85% and 70% for CT scan. 00% and 87% for percutaneous fine-needle biopsy. We conclude that CT-guided percutaneous fine-needle biopsy is the most reliable method for differential diagnosis between pancreatic cancer and chronic pancreatitis.