[Prevalence of aneurysm of the interatrial septum in the general population and in patients with a recent episode of cryptogenetic ischemic stroke: a tissue harmonic imaging transthoracic echocardiography study in 5.631 patients]. / Prevalenza di aneurisma del setto interatriale nella popolazione generale e in pazienti con recente stroke criptogenetico: studio ecocardiografico transtoracico con seconda armonica tessutale in 5.631 pazienti.

Cerebral ischemia is among the principal causes of mortality and morbidity in industrialized countries being responsible of 10-12% of all deaths and of an elevated number of permanent disability. The cardio-embolic forms may be responsible of the 30-35% of cerebrovascular acute syndrome, nevertheless in a significant percentage of cases, especially among young people, cerebral ischemic episodes are not induced by these cardio-embolic forms: these cases are defined as cryptogenetic stroke/TIA. In these patients cardiac abnormalities represented by an aneurysm of the interatrial septum (ASA) and by a patent foramen ovale (PFO) have been frequently observed. The purpose of our prospective, study was to evaluate, through transthoracic echocardiography and tissue harmonic imaging (ETT-THI), the prevalence of ASA in the general population (group A) and the prevalence of ASA-FOP in a subgroup of patients with recent episode of cryptogenetic ischemic stroke/TIA (group B). We studied in a prospective manner from January 1 2003 to October 31t 2004 n. 5.631 patients. The presence of ASA was found in 3.2% of patients of group A, while in patients of group B we identified an ASA in 32% and a POF in 42% of the cases. Using a ETT-THI, our study shows in a wide range of a non selected population a prevalence of ASA greater than in previous studies. Such high prevalence in the general population of patients submitted to echocardiography and the higher frequency in subjects with recent cryptogenetic stroke, suggests to search carefully these abnormalities at the level of the interatrial septum using the harmonic imaging method.

[Thrombolytic therapy during cardiopulmonary resuscitation for acute massive pulmonary embolism. A case report]. / Terapia trombolitica durante rianimazione cardiopolmonare per embolia polmonare acuta massiva. Descrizione di un caso clinico.

Massive pulmonary embolism associated with cardiac arrest has an extremely high mortality in spite of cardiopulmonary resuscitation maneuvers. An early diagnosis of pulmonary embolism as cause of cardiac arrest and a rapid specific therapy able to obtain a restoration of pulmonary flow can improve the prognosis. The authors report a case of cardiac arrest for massive pulmonary embolism promptly diagnosed by echocardiography and treated by thrombolytic therapy with an initial favourable outcome.

[The usefulness of the association of clinical probability, rapid plasma measurement of D-dimer, compression echography of the lower limbs and echocardiography in the diagnosis of acute pulmonary embolism]. / Utilità dell'associazione di probabilità clinica, dosaggio rapido plasmatico del D-dimero, ecografia compressiva degli arti inferiori ed ecocardiografia nella diagnosi di embolia polmonare acuta.

BACKGROUND: The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism. METHODS: One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE. RESULTS: One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval--CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-100%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity. CONCLUSIONS: The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.

[A health education program for the prevention of heart diseases carried out in a population in Calabria]. / Un programma di educazione sanitaria per la prevenzione delle cardiopatie realizzato in un ambito di popolazione della Calabria.

BACKGROUND: To evaluate the behaviour and knowledge of students on cardiovascular risk factors and to programme a campaign for the prevention of cardiovascular diseases. METHODS: All students attending the last year of the secondary school of this province answered a questionnaire. An educational campaign followed the analysis of the questionnaire. RESULTS: The analysis of 3675 questionnaires shows that almost all students were between 18 and 20; 16% of males (m) and 7.4% of females (f) were overweight; 1.5% and 0.4% respectively were obese; 88.8% of m and 44% of were doing physical activity; 32.4% of m and 26.8% of f were cigarette smokers. Knowledge about cardiovascular risk factors were poor. Development of the prevention campaign. In the school districts four seminars were organized to discuss about cardiovascular prevention with science teachers of the province, using audiovisual materials. The same teachers devote 4-6 hours to the same matters during school lessons. In the next months conferences destined to the population of the province will be organized. CONCLUSIONS: This program allows to promote health education in the whole population, through the students, with a low cost.

[The prevalence and clinical characteristics of heart failure in a population sample of Calabria]. / Prevalenza e caratteristiche cliniche dell'insufficienza cardiaca in un campione di popolazione della Calabria.

Two-hundred and fourteen patients with congestive heart failure were identified over a six-month period in the general practice of 29 GPs covering an adult population of 29,959 subjects residing in the region of Calabria, in southern Italy, with an overall prevalence of 7 per 1000. Males represented 52% of the cases and females 48%, with a median age of 75 years. On average, the condition was first diagnosed 41 months before the present examination. Patients generally had a high body mass index (28 kg/m2). Patients were classified as follows in the NYHA classification: 9.4% in class I, 45.3% in class II, 39.2% in class III, 6.1% in class IV. Hypertension, either alone or associated with ischemic heart disease (totally about 75% of cases), was the most common etiology, while COPD was the most commonly associated chronic condition. Clinical symptoms and signs were used to classify patients in a simplified version of the Boston score which was reported in 48% of cases as definite, 12% as possible, 6% as improbable and 34% as absent. A specific treatment was already ongoing in 97% of patients. The most commonly administered drugs were diuretics (83%), ACE-inhibitors (77%), and digitalis (67%). This three-drug combination (alone or with other drugs) covered 46% of patients. A comparison of four predefined typologies of treatment against the Boston score suggested that at least part of the outcome in classifying patients using this procedure was due to pathomorphosis of the syndrome induced by early pharmacological treatment.

Iron-mediated generation of the neurotoxin 6-hydroxydopamine quinone by reaction of fatty acid hydroperoxides with dopamine: a possible contributory mechanism for neuronal degeneration in Parkinson's disease.

Exposure of dopamine to an excess of linoleic acid 13-hydroperoxide (13-hydroperoxyoctadecadienoic acid) in the presence of ferrous ions in Tris buffer, pH 7.4, resulted in a relatively fast, oxygen-independent reaction exhibiting first-order kinetics with respect to both catecholamine and metal concentrations. Product analysis in the early stages revealed the presence of significant amounts of the quinone of the neurotoxin 6-hydroxydopamine, together with some aminochrome and ill-defined melanin-like material. Quinone formation required the presence of iron, either in the ferrous or ferric form, and was unaffected by peroxidase, catalase, and hydroxyl radical scavengers, e.g. mannitol, as well as biologically relevant antioxidants, like ascorbate and glutathione. Hydrogen peroxide proved as effective as linoleic acid hydroperoxide in inducing dopamine oxidation and conversion to 6-hydroxydopamine quinone. Metal chelators, including EDTA and bipyridyl, markedly suppressed quinone formation without, however, inhibiting dopamine oxidation. These and other results are consistent with a hydroxyl radical independent hydroxylation/oxidation mechanism basically different from the Fenton reaction, which involves direct interaction of the peroxide with a dopamine-Fe(III) chelate generated during the process.

Diffusible melanin-related metabolites are potent inhibitors of lipid peroxidation.

Although it has long been known that epidermal melanocytes produce and excrete a number of melanin-related metabolites, including 5.6-dihydroxyindole (DHI), 5,6-dihydroxyindole-2-carboxylic acid (DHICA), and 5-S-cysteinyldopa (CD), the possible functional significance of these compounds has been so far largely overlooked. We report now evidence that DHI, DHICA and CD exert potent inhibitory effects in different in vitro models of lipid peroxidation. The compounds, at 100 microM concentration, substantially decreased malondialdehyde (MDA) formation by lipid peroxidation in rat brain cortex homogenates. At 1.2 microM concentration, DHI proved as effective as alpha-tocopherol (alpha-T), one of the most potent endogenous antioxidants, in suppressing azo-induced peroxidation of linoleic acid in phosphate buffer (pH 7.4), containing 0.10 M SDS, whereas CD and DHICA at the same concentration were less active. DHI, CD and DHICA (all in the range 25 microM-0.5 mM) were also found to inhibit Fe (II)/EDTA-induced oxidation of 0.5 mM arachidonic acid at pH 7.4, as well as MDA formation by iron-promoted degradation of 0.5 mM 15-hydroperoxy-5,8,11, 13-eicosatetraenoic acid (15-HPETE). In both cases the inhibitory effects were much greater than those of ascorbic acid and glutathione. These results point to melanin precursors as a novel class of biological antioxidants which may contribute to defense mechanisms against oxidative injury in human skin.

5,6-Dihydroxyindole-2-carboxylic acid, a diffusible melanin precursor, is a potent stimulator of lipopolysaccharide-induced production of nitric oxide by J774 macrophages.

Pre-incubation of J774 murine macrophages with 5,6-dihydroxyindole-2-carboxylic acid (DHICA), a diffusible intermediate in the biosynthesis of eumelanins, leads to a marked increase in the levels of nitric oxide (NO) produced by lipopolysaccharide (LPS)-induced NO-synthase (iNOS). The effect varies with DHICA concentration being maximum at a concentration of 1 x 10(-6)M, and is suppressed by the NOS inhibitor NG-monomethyl-L-arginine (L-NMMA). No stimulation is observed when macrophages are exposed to DHICA after activation with LPS, indicating that the indole does not affect the catalytic activity of iNOS. These results point to a hitherto unrecognized role of DHICA as a chemical messenger mediating interaction between active melanocytes and macrophages in epidermal inflammatory and immune responses.

Iron- and peroxide-dependent conjugation of dopamine with cysteine: oxidative routes to the novel brain metabolite 5-S-cysteinyldopamine.

The mechanism of formation of 5-S-cysteinyldopamine (5-S-CDA), a putative index of oxidative stress in dopaminergic regions of the brain, was investigated by comparing the ability of a number of neurochemically relevant oxidising systems to promote the conjugation of dopamine with cysteine in vitro. Autoxidation of the catecholamine proceeds at relatively slow rate in the physiological pH range, and is little affected by 1 mM Fe(2+)-EDTA complex. In the presence of cysteine, however, the Fe(2+)-induced autoxidation is hastened, affording little amounts of 5-S-CDA. Formation of the adduct is completely suppressed by ascorbic acid. Hydrogen peroxide, in the presence of Fe(2+)-EDTA (Fenton-type oxidation) or peroxidase, promotes a relatively efficient conversion of dopamine to 5-S-CDA and the minor isomer 2-S-CDA. Noteworthy, 15-hydroperoxyeicosatetraenoic acid (arachidonic acid hydroperoxide, HPETE), in the presence of Fe(2+)-EDTA complex, can also mediate 5-S-CDA formation, whilst superoxide radicals are little effective. Overall, these results suggest that ferrous ions, hydrogen peroxide and lipoperoxides may play an important role in 5-S-CDA generation.

A new dopachrome-rearranging enzyme from the ejected ink of the cuttlefish Sepia officinalis.

A melanogenic enzyme catalysing the rearrangement of dopachrome has been identified in the ejected ink of the cuttlefish Sepia officinalis. This enzyme occurs as a heat-labile protein which co-migrates with tyrosinase under a variety of chromatographic and electrophoretic conditions. On SDS/PAGE it shows like a single band with an approx. molecular mass of 85 kDa. The enzyme possesses high substrate specificity, acting on L-dopachrome (Km = 1 mM at pH 6.8) and on L-alpha-methyl-dopachrome, but not on D-dopachrome, L-dopachrome methyl ester, dopaminochrome and adrenochrome. Significant inhibition of the catalytic activity was observed with tropolone and L-mimosine. H.p.1.c. analysis of the enzyme-catalysed rearrangement of L-dopachrome revealed the quantitative formation of the decarboxylated product, 5,6-dihydroxyindole. These results point to marked differences between melanogenesis in cephalopod pigment cells and in melanocytes, which may have important implications in relation to the use of sepiomelanin as a model for studies of mammalian melanins.

Inhibitory effect of melanin precursors on arachidonic acid peroxidation.

A possible role of melanin precursors in lipid peroxidation was investigated using the lipoxygenase catalysed oxygenation of arachidonic acid (AA) as a model system. Polarographical monitoring of oxygen consumption showed that, among the metabolites examined, 5,6-dihydroxyindole (DHI) was the most active in inhibiting AA oxygenation catalysed by 15-lipoxygenase. The inhibition was found to be concentration-dependent with an IC50 value of 15 microM. Similar effects were observed in the case of the 5-lipoxygenase promoted reaction. Periodical HPLC analysis of the oxidation mixture showed that, in the presence of DHI, the rate of substrate consumption is markedly reduced. The inhibitory potency was significantly increased either by preincubation of DHI with the enzyme or by increasing the time of residence of the indole in aerated buffer solutions prior to contact with the enzyme. Addition of catalase to the incubation mixture resulted in a partial removal of DHI inhibition. From these and other experiments, an inhibition mechanism is proposed which involves inactivation of the enzyme by reactive species, especially hydrogen peroxide, arising from DHI autoxidation.

[Diltiazem in paroxysmal supraventricular tachycardia: electrocardiographic findings at termination]. / Diltiazem nella tachicardia parossistica sopraventricolare: quadri elettrocardiografici alla interruzione.

The effects of diltiazem hydrochloride (0.3 mg/kg i.v. over 2 min.) was studied by continuous electrocardiographic monitoring in 60 patients. Conversion to sinus rhythm was achieved in 55 patients (91%). Electrocardiographic findings were: undisturbed sinus rhythm in 20 patients; A-V junctional rhythm in 4 patients; complex ventricular arrhythmias (ventricular tachycardia or complex VPCs) in 19 patients. Patients with complex ventricular arrhythmias were matched against patients with normal sinus rhythm, with respect to the following parameters: age, sex, heart disease, tachycardia duration, tachycardia cycle length, sinus cycle length, pre- and post-infusion blood pressure. No differences between the two groups of patients were found. Ventricular arrhythmias occurring at the termination of supraventricular tachycardia are difficult to explain. Nevertheless, these arrhythmias are not associated with organic heart disease. They could be the expression of triggered activity.

Photodynamic degradation of vitamin E induced by psoralens.

Psoralens and other furocoumarins currently used in PUVA photochemotherapy are shown to have, to a variable extent, the ability to hasten the rate of ultraviolet-induced photooxidation of alpha-tocopherol (alpha-T) in ethanol or ethanol-phosphate buffer (pH 6.8). The sensitizing effect varies significantly with the substrate concentration and the nature of the furocoumarin used, and is dependent on the presence of oxygen. Scavengers of singlet oxygen, e.g., sodium azide, markedly inhibit the psoralen-sensitized photooxidation of alpha-T, whereas superoxide dismutase exerts an opposite, accelerating effect on the reaction rate. Catalase has no significant influence on the kinetics of alpha-T decay. Analysis of the products formed by psoralen-sensitized photooxidation of alpha-T in ethanol-phosphate buffer showed the presence of alpha-tocopherolquinone, its 2,3-epoxide and two related compounds containing the 7-oxaspiro[4.5]dec-1-ene-3,6-dione ring system. The nature of these products, coupled with the results of the kinetic experiments, suggest that psoralens induce a type II, oxygen-dependent photodegradation of alpha-T primarily mediated by singlet oxygen.

Synthesis and cytotoxic properties of new N-substituted 4-aminophenol derivatives with a potential as antimelanoma agents.

New tyrosinase-targeted compounds based on structural variants of the prototype unit 4-aminophenol have been synthesized and screened for their potential as antitumour agents against malignant melanoma. Cytotoxicity assays showed that N-4-hydroxyphenylglycine (NHPG) and its alpha-methyl derivatives methylphenylglycine and dimethylphenylglycine exhibit significant antiproliferative effects on pigmented human melanoma cell lines (HBL), with inhibitory concentrations at 50% (IC50) around 80 micrograms/ml. A marked increase in cytotoxicity was observed with morpholine-containing 4-aminophenols, e.g. N-(2-morpholinoethyl)-4-aminophenol, which showed an IC50 of 20 micrograms/ml of HBL cells. Much more pronounced was the effect of the diacetoxy-derivative, DiAcMoAc, which showed an IC50 of 15 micrograms/ml on HBL cells and as low as 2 micrograms/ml on tyrosinase-containing, non-pigmented human melanoma cells (LND1), with a toxicity response of the same order of magnitude as that of melphalan. These results open interesting perspectives in the design of new targeted pro-drugs against malignant melanoma.

Comparative action of dopachrome tautomerase and metal ions on the rearrangement of dopachrome.

A vis-a-vis comparison between the effects of dopachrome tautomerase (DCT) and metal ions, e.g., cupric ions, on the kinetics and mode of rearrangement of dopachrome has been carried out under appropriate analytical conditions. The enzyme-promoted reaction is highly stereospecific for L-dopachrome, is unaffected by metal chelators and has an optimal pH around 6.8. By contrast, the kinetics of dopachrome rearrangement catalysed by cupric ions are not dependent on the stereochemistry of the substrate, are affected by EDTA and are not influenced by the pH of the medium in the range between 5-7.5. Both cupric ions and DCT catalyse the rearrangement of dopachrome to give 5,6-dihydroxyindole-2-carboxylic acid (DICA) rather than 5,6-dihydroxyindole (DI). However, at comparable activity, the ratio of formation DICA/DI is significantly higher in the enzyme-catalysed than in the metal-catalysed reaction. These results provide an improved background to look into the mode of action of DCT and metal ions, enabling a clear cut differentiation between the effects of the two factors when both are present in biological extracts.

Mechanism of inhibition of melanogenesis by hydroquinone.

Hydroquinone (HQ) is one of the most effective inhibitors of melanogenesis in vitro and in vivo, and is widely used for the treatment of melanosis and other hyperpigmentary disorders. In an attempt to get some insight into the molecular mechanism of the depigmenting action, which is still very poorly understood, we have investigated the effect of HQ on the tyrosinase catalysed conversion of tyrosine to melanin. Incubation of 0.5 mM tyrosine with 0.07 U/ml tyrosinase in phosphate buffer at pH 6.8 in the presence of 0.5 mM HQ led to no detectable melanin formation, due to the preferential oxidation of HQ with respect to tyrosine (HPLC evidence). Kinetic investigations showed that HQ is a poorer substrate of tyrosinase than tyrosine; yet, it may be effectively oxidised in the presence of tyrosine owing to the generation of catalytic amounts of dopa acting as cofactor of tyrosinase. Product analysis of HQ oxidation with tyrosinase in the presence of dopa showed the predominant formation in the early stages of hydroxybenzoquinone (HBQ), arising from enzymic hydroxylation and subsequent oxidation of HQ, along with lower amounts of benzoquinone (BQ). These results suggest that the depigmenting activity of HQ may partly be related to the ability of the compound to act as an alternate substrate of tyrosinase, thereby competing for tyrosine oxidation in active melanocytes.

Selective uptake of 2-thiouracil into melanin-producing systems depends on chemical binding to enzymically generated dopaquinone.

2-Thiouracil (TU), an antithyroid drug, is receiving growing interest as a specific tumor marker for malignant melanoma, owing to its capability of being selectively accumulated into active melanin-producing tissues. However, up until now, the molecular mechanism of TU uptake by growing melanin has remained largely unknown. In an attempt to fill this gap, we have investigated the effect of TU on the tyrosinase catalyzed oxidation of tyrosine. At a concentration of 0.5 mM, TU was found to totally inhibit melanin formation by tyrosinase catalyzed oxidation of 0.25 mM tyrosine in phosphate buffer at pH 6.8. Polarographical monitoring of oxygen consumption under conditions of complete suppression of melanogenesis revealed a significant tyrosinase activity, with TU acting as a modest non-competitive inhibitor of the enzyme (Ki = 0.6 mM). HPLC and TLC analysis of the tyrosine-tyrosinase reaction in the presence of excess TU showed that the substrate is progressively consumed and a major hitherto unknown product (lambda max = 284 nm), positive to ninhydrin and ferric chloride, is concomitantly formed. This was isolated by repeated gel filtration chromatography of the reaction mixture on Sephadex G-10 and was formulated as the TU-dopa adduct 3,4-dihydroxy-6-(4'-hydroxypyrimidinyl-2'-thio)phenylalanine by spectral analysis. These results suggest that selective TU incorporation in pigmented melanomas and other melanin-producing systems is due to the covalent binding to dopaquinone, produced by tyrosinase catalyzed oxidation of tyrosine.

Activation of mammalian tyrosinase by ferrous ions.

Kinetic experiments are reported showing that mammalian tyrosinase from B16 mouse melanoma is significantly activated by catalytic amounts of ferrous ions. Monitoring of tyrosine oxidation by both dopachrome formation and oxygen consumption showed that ferrous ions at micromolar concentrations induce a marked enzymatic activity with 0.01 U/ml of highly purified tyrosinase, whereas no detectable reaction occurs in the absence of metal over a sufficiently prolonged period of time. The extent of the activating effect, which is specific for the reduced form of iron, is proportional to the concentration of the added metal with a typical saturation profile, no further effect being observed beyond a threshold value. Changing the buffer system from phosphate to hepes or tris results in a marked decrease of the Fe2(+)-induced activation. Scavengers of active oxygen species, such as superoxide dismutase, catalase, formate and mannitol have no detectable effect on the tyrosinase activity. These results are accounted for in terms of an activation mechanism involving reduction of the cupric ions at the active site of the resting enzyme.

A new look at the rearrangement of adrenochrome under biomimetic conditions.

At physiological pH values, the rearrangement of adrenochrome leads, besides adrenolutin, to a major dimeric compound consisting of an adrenolutin moiety covalently linked to the angular 9-position of adrenochrome. When the reaction is carried out in air, the initially generated adrenolutin undergoes autoxidation to give 5,6-dihydroxy-1-methyl-isatin (DHMIs), which is smoothly oxidized to the 4,4'-dimer. Under an oxygen-depleted atmosphere, formation of these latter compounds is prevented, and the rearrangement of adrenochrome leads mainly to the adrenochrome dimer (about 50% yield) along with adrenolutin and 5,6-dihydroxy-1-methylindole (DHMI) in about 10% yield each. The product distribution is markedly dependent on the concentration of the aminochrome undergoing rearrangement, the nature of the buffer system used, and the pH of the medium. Heavy metal ions of common occurrence in biological systems, such as Cu2+, Zn2+, Co2+, significantly direct the reaction course towards the formation of adrenolutin, while Fe2+ and other cations with low redox potentials induce the almost exclusive formation of DHMI.