Search

The world of chronic non-communicable diseases is progressively growing epidemiologically, requiring a significant commitment of resources, continuity of care, and strong integration between healthcare professionals and care settings. The National Recovery and Resilience Plan, in the Ministerial Decree 77 of 23/5/2022, identifies Community Homes as the privileged location for providing integrated, multidisciplinary and multiprofessional interventions, involving specialists and nursing clinics, general practitioners and district structures, utilizing all the necessary technological equipment, including digital platforms for telemedicine. In this context, cardiology is facing a complicated challenge: cardiologists must take care of patients with cardiovascular diseases who have also complex comorbidities and are required to extend their knowledge beyond the specific, sometimes super-specialistic, cardiovascular field, to avoid fragmentation, redundancy, and potential conflicts in the diagnostic-therapeutic care pathways. The Territorial Specialist Department, recently created in the Azienda Sanitaria Universitaria Giuliano Isontina, aims to promote the so-called "value-based medicine", that is, an effective yet sustainable medicine in both economic and social terms, reconciling guidelines with the actual needs of the patient. The ultimate goal is to implement an initiative-based medicine program with systematic stratification of patients at greater risk/complexity for a more efficient, appropriate and sustainable clinical governance.

In 2017 the Italian Society of Nephrology operating in the Triveneto area investigated through a questionnaire, distributed to the various nephrological centers in the regions of Friuli Venezia Giulia, Trentino Alto Adige and Veneto, the differences concerning organizational models, choice of dialysis, creation and management of vascular access. The results emerging from the analysis of the collected data are presented., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Background: Recent observational studies show an increase of more complex and critically ill patients referred to Italian cardiac rehabilitation (CR) departments; the exact mechanisms underlying this phenomenon, however, have not been clearly identified. The aim of our study was to evaluate the epidemiological and clinical changes that occurred over the last decade in patients hospitalized in CR departments with high admittance rates., Methods: We have retrospectively evaluated all patients admitted between 2002 and 2009 to our division of CR (n = 3340, 1155 female, mean age 66.4 ± 11 years) after recent cardiac surgery. The study population was divided into two homogeneous groups: the four-year period 2002-2005, group A (n = 1614, 540 female, mean age 66.1 ± 10 years) and the four-year period 2006-2009, group B (n = 1726, 615 female, mean age 67.4 ± 11 years). Data were compared using specific indicators of clinical complexity., Results: Patients aged >75 years were more in group B compared to A (26.3 vs 19.8%, p<0.0001), as well as patients with recent complex surgical interventions, such as combined coronary artery bypass grafting and heart valve surgery (16.4 vs 10.2%, p<0.0001). An increased incidence of cardiovascular death (1.4 vs 0.6%, p=0.02), acute coronary syndrome (1.5 vs 0.7%, p=0.02) and persistent atrial fibrillation/flutter (13.5 vs 7.1%, p<0.0001) was observed in group B, as well as an increased prevalence of systolic heart failure (18.3 vs 9.0%, p<0.0001). Similarly, the incidence of acute respiratory failure episodes (1.0 vs 0.4%, p=0.05), the prevalence of patients admitted with a tracheostomy tube (2.6 vs 0.2%, p<0.0001) and the incidence of acute renal failure (1.1 vs 0.5%, p=0.05) were significantly increased in group B. Postoperative infections and surgical wound complications were 4-fold higher in group B (13.9 vs 3.1%, p<0.0001, and 12.8 vs 2.3%, p<0.0001, respectively). Compared to group A, patients of group B showed a significantly lower physical performance, as expressed by the Rivermead motility index (3.8 ± 1.1 vs 5.2 ± 0.8, p<0.001); moreover, the number of subjects able to perform an incremental training program was significantly lower in group B than group A (14.8 vs 60.6%, p<0.0001). Mean hospital stay was longer in group B than group A (25.4 ± 13 vs 22.1 ± 9 days, p<0.001)., Conclusions: Our study, by collecting data from a CR division in northern Italy with high admittance rates, demonstrates a dramatic increase in clinical complexity over the last few years. This points to the need for new expertise and major resources to be allocated to CR departments.

A genetic mendelian autosomal recessive condition of deficiency of lecithin- cholesterol acyltransferase (LCAT) can produce two different diseases: one highly interesting nephrologic picture of complete enzymatic deficiency (lecithin:cholesterol acyltransferase deficiency; OMIM ID #245900; FLD), characterized by the association of dyslipidemia, corneal opacities, anemia and progressive nephropathy; and a partial form (fish eye disease; OMIM ID #136120; FED) with dyslipidemia and progressive corneal opacities only. The diagnosis of FLD falls first of all under the competence of nephrologists, because end-stage renal disease appears to be its most severe outcome. The diagnostic suspicion is based on clinical signs (corneal opacities, more severe anemia than expected for the degree of chronic renal failure, progressive proteinuric nephropathy) combined with histology obtained by kidney biopsy (glomerulopathy evolving toward sclerosis with distinctive lipid deposition). However, the final diagnosis, starting with a finding of extremely low levels of HDL-cholesterol, requires collaboration with lipidology Centers that can perform sophisticated investigations unavailable in common laboratories. To be heterozygous for a mutation of the LCAT gene is one of the monogenic conditions underlying primary hypoalphalipoproteinemia (OMIM ID #604091). This disease, which is characterized by levels of HDL-cholesterol below the 5th percentile of those of the examined population (<28 mg/dL for Italians), has heritability estimates between 40% and 60% and is considered to be a predisposing condition for coronary artery disease. Nevertheless, some monogenic forms, and especially those associated with LCAT deficiency, seem to break the rule, confirming once more the value of a proper diagnosis before drawing prognostic conclusions from a laboratory marker. As in many other rare illnesses, trying to discover all the existing cases will contribute to allow studies broad enough to pave the way for further therapies, in this case also fostering the production by industries of the lacking enzyme by genetic engineering. Epidemiological studies, although done on selected populations such as hypoalphalipoproteinemia patients on dialysis and with the effective genetic tools of today, have been disappointing in elucidating the disease. Spreading the clinical knowledge of the disease and its diagnostic course among nephrologists seems to be the best choice, and this is the aim of our work.

Scope: Patients with tracheostomy tube after major cardiac surgery undergoing Cardiac Rehabilitation Program often present swallowing disorders that need a specific evaluation. This study aimed at validating the usefulness of a swallowing screen protocol in order to obtain an early assessment of dysphagia and to prevent aspiration, malnutrition and dehydration risks., Materials and Methods: The protocol has been applied to 38 consecutive patients with tracheostomy tube after cardiac surgery between September 2007 and December 2009. The average age of patients was 73 +/- 6 years; the average value of left ventricular ejection fraction was 41 +/- 4%. The protocol included a water swallowing test and a specific swallowing test with blue dye. During tests, the presence of signs of swallowing dysfunction was evaluated and oxygen saturation levels were monitored., Results: Out of 38 patients, 2 did not show any swallowing deficits; 18 showed deficits in the water swallowing test even though they presented a preserved swallowing function during specific swallowing test. All these 20 patients (53%), before discharge, restarted an oral feeding and obtained an adequate body mass index and effective coughing, so they were soon decannulated. Twelve patients (31%) showed deficits during the water swallowing test, confirmed by the specific swallowing test with blue dye: the tracheostomy tube was not removed and a specific program of swallowing rehabilitation was performed. Before discharge all patients restarted an oral feeding, recovered an effective coughing and were decannulated. Six patients (16%), because of persistent dysphagia, underwent percutaneous endoscopic gastrostomy. None of these 38 patients developed ab ingestis pneumonia, dehydration or malnutrition., Conclusions: An early assessment of swallowing in patients with tracheostomy tube after cardiac surgery allows the selection of patients with higher aspiration risk, preventing possible severe complications.

Hematopoietic stem cell transplantation, autologous or allogeneic, is a well established hematology procedure. There can be a number of renal complications in this setting, which may occur in every phase but all strongly influence prognosis. Among the late complications, there is the well-known possibility of progressive chronic renal failure, appearing together with hypertension and modest alterations of the urinary sediment, and characterized by pathological findings of thrombotic microangiopathy, often without the corresponding clinical aspects. This clinical picture must be distinguished from other forms of clinically more severe thrombotic microangiopathy, such as those occurring in the early post-transplant period, and from other causes of renal disease in the hematopoietic stem cell transplantation setting. Total body irradiation, chemotherapeutic drugs, calcineurin inhibitors and opportunistic infections have all been considered as causal factors. The nosological classification is still poorly defined, as are the real prognosis and the best treatment. Kidney biopsy is a necessary tool to make a correct diagnosis, assess the frequency of the condition, make a prognostic judgment, and set up rational treatment.

Several studies in the literature investigated the association between temporomandibular disorders (TMD) and otogenous symptoms, like vertigo, tinnitus, otalgia and muffling, although the question of the existence of a cause-effect relationship is still controversial. Epidemiological findings showed that the prevalence of ear symptomatology in the general population is variable from 10% to 31%, and increases up to 85% in TMD patients. Based on these data, many attempts have been performed to describe the physiopathological interactions between aural symptoms and TMD, as a strict anatomical link exists between the structures of the ear and those of the stomatognathic system. Unfortunately, methodological weaknesses of most studies are evident so that the comparison of results is often difficult. Considering these premises, the present study critically reviewed the literature on this debated issue, discussing the main etiopathogenetic hypotheses, the features of ear symptomatology in TMD patients and its relationship with TMD treatment in order to present current suggestions about the relationship between aural and TMD symptoms. Suggestions for future researches have been also presented, since a full understanding of this plausible interaction will be an important factor in diagnosis making and treatment planning for both pathologies.

Primary leiomyosarcoma of venous origin is a rare but frequently lethal disease. Clinical symptoms can be different, often not much evident or absolutely absent. Preoperative diagnosis is difficult also with modern imaging and only pathological examination can identify this malignant tumor. Successful therapy requires early surgery but the long-term survival is poor. A case of leiomyosarcoma arising from veins has been presented.

The Lichtenstein inguinal hernioplasty in the original version or with small variations currently allows good results both from the surgical point of view and in terms of reduction of the sanitary expenses. "Tension free" repair and diffusion of local anesthesia allow a drastic reduction of the hospital stay, a early time of the working activity and the diffusion of the admission to the Day Hospital. The authors introduce the own casuistic that comprise 1116 inguinal hernioplasty in 1,034 patients and on the base of two studies, a retrospective one and another prospective, they conclude that a greater attention in the behavior of the intervention and a more accurate preparation of the patients represent fundamental moments to obtain even more satisfactory results.

Micrometastases, (metastases smaller than 2 mm), had benn subject of several studies. In literature is documented a prognostic worsening due to their presence. Research of micrometastases in sentinel lymph node is of great interest and can allow a clinical application with profitable cost efficacy ratio. The Authors discuss about clinical, prognostical and therapeutical implicationes in case of micrometastases into sentinel lympho nodes.

The term temporomandibular disorders (TMD) is used to indicate a heterogeneous group of painful conditions involving masticatory apparatus and its related structures whose complicated etiology involves a number of diagnostic and taxonomical matters. The prevalence of TDM has remarkably increased in the last years, such that, at present, these clinical conditions represent the most frequent cause of orofacial pain in the general population: in particular, among these disorders, pathologies affecting masticatory muscles have a considerable clinical and epidemiological relevance. Due to the high prevalence of masticatory myofascial pain, as well as the taxonomical issue that emerges from literature data, the wide range of treatment modalities proposed for this condition seems to be justifiable. Among the various therapeutic solutions employed in the management of masticatory myofascial pain, it is interesting to focus on the efficacy of the different kinds of physical therapy. In fact, due to the difficulties related with the attempt to isolate a sole etiological factor, at the beginning should be carried out reversible and noninvasive interventions: in these terms, the use of physical therapy seems to be reasonable. The aim of the present paper is to provide a critical review of the literature about the use of physical therapy approaches in relieving pain symptoms that often accompany masticatory muscles disorders. This study seems to suggest that the employ of physical therapy could be useful in the treatment of myogenous TDM, even though further studies are needed to assess the efficacy of this tool.

Aim: The aim of this investigation was to suggest criteria in order to evaluate magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ). Such criteria have been discussed on the basis of our experience at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa., Methods: The study sample was constituted by 135 patients. All subjects underwent bilateral MRI of the TMJs to evaluate disc structure and position, bony structure abnormalities, joint effusion localization and entity., Results: MRI allowed depiction of the articular disc in 98.9% of the TMJs, showing a normal disc structure in 91.1% of the cases and abnormal in 7.7%. The disc-condyle relationship was normal in 46.6% TMJs, while a disc displacement with reduction was revealed in 35.5% cases, a disc displacement without reduction in 16.7% and a posterior disc displacement in 1.5% joints. In the coronal images, the disc was positioned lateral to the condyle in 8.9% of the TMJs and medial in 6.7%. Osseous abnormalities have been found in 177 joints (65.5%), with cases of bony flattening (condyle and/or tuberculum), erosions, subchondral cysts, osteophytosis and sclerosis. T2 sequences showed effusion in 26.7% of the TMJs., Conclusions: These findings suggest that standardized methodology application and well-defined criteria can facilitate MR imaging observations and interpretation as well as the diagnosis of intra-articular pathologies.

Coronoid hyperplasia is a rare condition which is macroscopically characterized by an increase in the dimensions of the coronoid process resulting from an abnormal bony elongation of histologically normal bone. Unilateral cases are more frequent than bilateral ones and can recognize a number of etiological factors, such as exostoses, osteochondroma, traumatic events, inflammatory reactions, neoplasia and manifestations secondary to other pathologies. Etiopathogenesis of bilateral forms has not yet been clarified: in the literature hints to both developmental and endocrine abnormalities are present, and a familiar pattern of inheritance has been evidenced. The poor specificity of signs and symptoms associated with coronoid hyperplasia, which are similar to those of other more frequent forms of temporomandibular disorders, present some problems of differential diagnosis. An accurate assessment must be based on a clinical and anamnestical approach aiming at the identification of pathognomonic clinical symptoms. Considering its limits (such as the possible presence of artefacts and image distortions), orthopantomography has a poor diagnostic usefulness. In this case, magnetic resonance (MR) allowed to evaluate disk-condyle relationship, but it could be also useful to evaluate post-operative complications. In the case of coronoid hyperplasia, the computed tomography (CT) is fundamental for a correct differential diagnosis. CT also allows surgical planning due to its accuracy to detect coronoid process volume and morphology. The present case report is an example of the need for a correct differential diagnosis between the different types of temporomandibular disorders, and it also lends support to the importance of requesting modern imaging techniques during the diagnostic process of the rare or complex cases.

Aim: Many theories have been proposed as to the relationship between fibromyalgia (FM) and temporomandibular disorders (TMD). The aim of this study was to investigate the clinical features of the involvement of the stomatognathic system in patients with fibromyalgia, and to compare signs and symptoms of masticatory dysfunction between TMD and FM patients., Methods: The study sample consisted of 30 subjects with fibromyalgia recruited at the Rheumatology Disease Department, University of Pisa, Italy, and of 30 with temporomandibular disorders at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa, Italy. Masticatory dysfunction has been compared between the 2 groups by means of a clinical assessment conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Patients of the TMD group underwent a rheumatologic examination to investigate for the presence of previously undiagnosed fibromyalgia., Results: As regards specific clinical variables and RDC/TMD diagnoses, differences between the 2 groups appear to be not relevant, with the exception of the values of mouth opening, both voluntary and passive, and the presence of trigger points. FM patients showed a decrease in both maximum voluntary and passive mouth opening which was about 2 mm worse than that recorded in TMD patients. FM patients also showed a significantly higher number of trigger points, even though muscle palpation evoked tenderness in the same number of sites in the 2 groups., Conclusions: This study showed that most patients with fibromyalgia (86.7%) report signs and symptoms localized at the stomatognathic system; by contrast, only a minority of patients with temporomandibular disorders (10%) are actually affected by fibromyalgia.

Aim: Considering the hypothesis that some temporomandibular joint (TMJ) tissues could be a potential target for sexual hormones, the aim of the study was to evaluate estrogen (17-beta-estradiol) and progesterone serum levels in a young adult population affected by articular forms of temporomandibular disorders (TMD) versus a control group of healthy subjects., Methods: A total of 35 patients with Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I Group II diagnosis of disk displacement and/or Group III diagnosis of arthralgia, osteoarthritis or osteoarthrosis, were recruited at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa, Italy, along with a sex- and age-matched group of 24 healthy controls. In all patients, 17-beta-estradiol, progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) serum levels were determined using a radioimmunoassay. A T-test was performed to compare mean 17-beta-estradiol and progesterone serum levels in the TMD groups with mean serum levels of their respective control groups. Significance was set at p<0.05., Results: Significant differences between patients affected by TMJ disorders and healthy controls were found for serum concentration of 17-beta-estradiol, both in males (p<001) and in the luteal phase of the menstrual cycle in females (p<0.05). No difference was found for progesterone serum levels in the different experimental samples., Conclusions: The results of this study suggest that high serum estrogens levels might be implicated in the physiopathology of temporomandibular joint disorders, since subjects with these pathologies showed significantly higher serum levels with respect to a group of healthy controls.

Aim: The aim of this work was to evaluate the predictive value of clinical examination for magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) disk position abnormalities., Methods: Participants in this study were 51 consecutive patients with signs and symptoms of temporomandibular disorders (TMD). All 102 temporomandibular joints (TMJ) were evaluated to detect disk position abnormalities by means of a standardized clinical assessement according to Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and MRI performed by a blinded radiologist at the Section of Prosthetic Dentistry, University of Pisa, Italy. The accuracy of clinical assessment was evaluated with respect to MRI., Results: Clinical assessment showed a good predictive value (PV) for the diagnosis of normal disk position (86.2%) and an acceptable PV for the diagnosis of disk displacement with reduction (70.3%), while it seems less accurate in predicting MRI diagnosis of disk displacement without reduction. The overall agreement between clinical RDC/TMD examination and MRI for the evaluation of disk position was 77.3%., Conclusion: Clinical RDC/TMD examination proved to be accurate in detecting normal disk position and disk displacement with reduction but not reliable in predicting MRI diagnosis of disk displacement without reduction in the temporomandibular joint.

Aim: The aim of the present study was to evaluate the prevalence of the different Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I types of temporomandibular disorders (TMD) in a population of subjects seeking for TMD treatment at 2 University Departments in Italy and to compare it with data from similar studies in the literature, in order to assess the usefulness of the RDC/TMD classification system as a tool for epidemiological data gathering and multicenter and cross-cultural comparison., Methods: A total of 210 consecutive patients seeking for TMD treatment at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Italy, and 109 consecutive patients seeking treatment at the Section of Prosthetic Dentistry and Temporo-mandibular Disorders, University of Pavia, Italy, were assessed using RDC/TMD., Results: Only 181 of the patients referring to the University of Pisa and 104 of those referring to the University of Pavia satisfied the criteria for inclusion. Findings from the 2 study populations were very similar. Mean age of the patients was 40 years, with a female:male ratio of 3.5:1 (222 females, 77.9%; 63 males, 22.1%). The prevalence of RDC/TMD Axis I diagnoses was 50.2% (143/285) for Group I disorders (muscle disorders), 38.6% (110/285) for Group II disorders (disc displacement), and 50.2% (143/285) for Group III disorders (arthralgia, osteoarthritis, osteoarthrosis)., Conclusion: Results from the present investigation have confirmed the usefulness of the RDC/TMD classification system for research purposes and for data gathering in cross-cultural and multicenter comparisons.

Among the different pharmacological approaches that could be adopted in the treatment of myofascial pain of masticatory muscles, attention has to be paid to muscle relaxants drugs, since very few studies evaluated their efficacy, despite most authors suggest their use. The present paper is a critical review of the literature on the use of the most common drugs with muscle relaxant effects (benzodiazepines, tricyclic antidepressants) and of a muscle relaxant drug (tizanidine hydrochloride) in the treatment of such condition. From literature data it emerged that these drugs had phases of alternate enthusiasm, characterized by a not constant clinical use and a fair interest in research. Nevertheless, within all the limitations that have been discussed in this paper, the use of muscle relaxants in patients with myofascial pain of masticatory muscles seems to be justifiable, even though further research is needed to verify their usefulness in terms of risk-benefit ratio.

Aim: The aim of this investigation was to estimate the contribution of occlusion to differentiate bruxers from non-bruxers., Methods: Participants in the study were 160 patients consecutively selected among 20-30 year old patients attending the Section of Prosthetic Dentistry for conservative care. The presence of bruxism was clinically and anamnestically investigated. In each patient the following occlusal features were recorded: retruded contact position-intercuspal position slide length, vertical overlap, horizontal overlap, unilateral posterior crossbite, incisor dental midline discrepancy, mediotrusive interferences, laterotrusive interferences. A stepwise logistic regression model was used to identify the significant associations between occlusal features and bruxism., Results: Diagnosis of bruxism was made in 67/160 subjects (41.8%). Differences between sex were not significant (p=0.814). Among the 8 occlusal variables included in the logistic regression analysis, those remaining in the final model were laterotrusive interferences (OR 2.47) and anterior open-bite (OR 0.88). This model showed good specificity (87%) but an unacceptable sensitivity (26.9%) to predict bruxism (accuracy=61.6%). Therefore, multivariate analysis did not lead to an improvement in bruxism predictability with respect to univariate analysis, which revealed that the presence of bruxism was significantly associated with laterotrusive interferences alone (p=0.040), and not with unilateral cross-bite (p=0.208), anterior open-bite (p=0.202), deep-bite (p=0.572), large horizontal overlap (p=0.261), dental midline discrepancy (p=0.519), mediotrusive interferences (p=0.119), slide >or=2 mm (p=0.857)., Conclusion: According to our findings the contribution of occlusion to differentiate bruxers from non-bruxers is very poor. Infact, only laterotrusive interferences seem to be significantly associated with bruxism.

Aim: The aim of this study was to assess the accuracy of ultrasonography (US) in the evaluation of temporomandibular joint (TMJ) effusion compared with magnetic resonance imaging (MRI) findings, assumed as the gold standard., Methods: The study group consisted of 44 patients with signs and symptoms of temporomandibular disorders (TMD). Each joint (N=88) was evaluated using US and magnetic resonance (MR) to detect the presence of effusion. The 2 examinations were carried out by 2 blinded operators within no more than 2 weeks from each other. During that period the patients did not receive any kind of treatment. Sensitivity, specificity, positive predictive values (PPV) and negative predective values (NPV) of US were calculated. The agreement between the 2 diagnostic techniques was then evaluated by Cohen's K test., Results: MRI depicted intra-articular effusion in 41 of the 88 TMJs (46.5%) while no effusion was detected in the remaining 47 joints (53.5%). Ultrasonographic imaging revealed effusion in 42/88 joints (47.8%), while the remaining 46 joints (52.2%) showed no effusion. US showed a sensitivity of 75.6% and a specificity of 76.5%. The PPV and NPV were 73.8% and 78.2% respectively. US vs MRI agreement for the diagnosis of TMJ effusion was fairly good (pct. agreement 76.1%; K=0.521)., Conclusion: US is a low-cost, easy-performing, non-invasive, rapidly-executing imaging technique whose possible employ in the study of the TMJ is very promising.

A broad consensus does exist among main authors on the importance of parafunctional habits in the etiopathogenesis of temporomandibular disorders (TMD). Mechanisms through which an intense parafunctional activity determined a pathological effect on the temporomandibular joints (TMJs) and their related structures have still not been definitively clarified; nevertheless, before investigating those mechanisms, it's useful to study predisposing, triggering and/or worsening factors of parafunctions themselves. At present the theory, once widely accepted, according to which occlusal interferences can trigger a muscular hyperactivity through the activation of periodontal receptors, has lost a lot of credit. Recently, the hypothesis that bruxism and other parafunctions have a central etiology has become more and more accepted. In such a context, the role of the psychic component assumes a strong relevance, particularly for its relation with the limbic system, which is the part of the central nervous system (CNS) that regulates emotions. Such a hypothesis is confirmed by clinical practice, but it doesn't explain why some patients have reported a worsening of parafunctional activities after occlusal adjustment. The aim of this study is to investigate this issue through a critical review of the literature, indicating how the 2 theories might be complementary for the development and worsening of a parafunctional habit. From this review, despite the number of clinical opinions, there emerges a lack of methodologically appropriate associative works and controlled clinical trials which consent to clarify the effective importance of psychic and/or occlusal factors in the etiopathogenesis of parafunctional habits.

Recent researches on temporomandibular disorders (TMD) have been focused on the interaction between physical and psychological factors. In this work, studies on the role of the latter have been critically reviewed and analysed. A number of works proved the existence of an association between TMD and anxiety, depression and stress, but none demonstrated causality of that relation. In consideration of that, debates are still open to discuss the possible predisposing, triggering and/or worsening role played by some psychic disorders in TMD subjects. Nevertheless, considering the usefulness of recent taxonomic proposals, it seems logical to adopt a broad therapeutic approach, directed both to the physical and psychic component of TMD symptoms. Besides, from this review it is underlined the need for controlled trials which, regardless of the causality of TMD-psychic disorders associations, definitively evaluate the efficacy of the various psychotherapy modalities proposed.

Sample size calculation is a fundamental step for the validity and the usefulness of results from a study. Nevertheless, as demonstrated by some papers in the literature, such calculation is often ignored. Despite the lack of papers on this topic, it is probable that this shortcoming also affects studies on temporomandibular disorders. Therefore, the aim of this paper was to provide some basic rules to calculate the sample size necessary for different types of studies, both longitudinal and transversal, on those pathologies. Some examples of the application of such rules for different types of studies have also been provided, in order to make a full comprehension easier. In fact, the systematic application of those rules is strongly requested for the effective usefulness of results. Furthermore, an analysis of the statistical power of past studies on temporomandibular disorders could be useful to evaluate if our epidemiological and clinical-therapeutic knowledge of temporomandibular disorders is effectively based upon studies conducted with the appropriate sample size.

Aim: Temporomandibular disorders (TMD) are a number of conditions which are frequently associated with depressive symptoms, but the possible existence of some form of manic-depressive illness in TMD patients has never been investigated. The aims of this work were to evaluate the reliability of a newly adopted spectrum model of psychopathology to detect depressive symptoms in TMD patients, and to produce pilot data on the presence of manic symptoms in TMD patients., Methods: Ninety-one consecutive TMD patients (72 females, 19 males; mean age 26.3) and 26 TMD-free subjects (21 females, 5 males; mean age 24) were administered a validated questionnaire to evaluate mood spectrum (MOODS-SR). Helkimo's Clinical Dysfunction Index (CDI) was calculated for all patients. One-way ANOVA and Bonferroni's post-hoc test for multiple comparisons were used to compare mean MOODS-SR scores of the groups identified as TMD-free (CDI=0), mild dysfunctionals (CDI=1), moderate or severe dysfunctionals (CDI= or >2)., Results: Total scores of domains evaluating depression were significantly higher in moderate or severe dysfunctionals than in both TMD-free (mean difference 8.87+/-3.5; p=0.017) and mild dysfunctionals (m.d. 9.41+/-2.62; p=0.001). As regards manic symptoms, differences between groups were not significant (F=1.299; p=0.277)., Conclusion: Our findings support the reliability of MOODS-SR to detect depressive symptoms associated with TMD. The hypothesis that depressive symptoms in TMD patients could be an expression of a more complex manic-depressive illness has to be rejected, since no differences between TMD patients and TMD-free subjects have been revealed for the presence of manic symptoms.

Temporomandibular disorders (TMD) comprise a heterogoneous group of pathologies or dysfunctions of the temporomandibular joints and their related neuromuscular systems. The multifactoral etiology of these disorders raises serious diagnostic and therapeutic problems. A modern approach demands close collaboration between a number of specialists in order to create the best possible treatment plan. The progressive nature of certain forms of TMD, combined with the major advantages deriving from early treatment, encourage the dental surgeon to carry out early interception of all those dental and/or skeletal anomalies which may determine the dysharmonic function and development of the facial mass, even though such anomalies may not represent the sole causes of the various forms of TMD. The general practitioner, and to an even greater extent the pediatrician, may therefore play a role of primary importance as those medical influences capable of early detection of TMD risk situations.

The aim of this work is giving, through a wide literature review, a detailed analysis of the histological and ultrastructural characteristics that distinguish masseter and temporal muscles from the other skeletal muscles. Furthermore we'll explain the functional meanings of these differences. We developed the following points: fibre type composition and relative frequency of the various fibre types, fibre size, myosin composition, capillarization and age-related changes. With standard staining method for the myofibrillar ATPase, besides the two main fibre types, I and II, in the masticatory muscles a moderate share of IM fibres with intermediate stainability, which usually don't appear in adult skeletal muscles, are shown. The relative frequency of the various fibre types is also peculiar, with a prevalence of type I fibres in almost every portion of the masseter and temporal muscles, which therefore are functionally slow muscles. Another unusual characteristic is also the mean diameter of type I fibres, that are commonly larger than type II fibres. This finding suggests that masticatory muscles are adapted to carry out specially prolonged and fatiguing tasks. The findings about contractile protein patterns and the changes in myosin heavy chain composition during ageing are also relevant. The deep differences between jaw-closing and limb and trunk muscles are reviewed on the basis of their special functional activities.

Systemic Lupus Erythematosus (SLE) is a pathology of unknown cause, characterized by tissue and cellular damage, secondary to production of autoantibodies and to deposition of immunocomplexes. Lupus nephritis is one of the most common complications of SLE. Our purpose is to propose a therapeutic protocol for patients suffering from Lupus nephritis. This consists of Plasmapheresis associated with pharmacological therapy so that dosage of immunosuppressors can be reduced and consequently also the side effects of the pharmacological therapy.

A case of amanita phalloides which presented a typical picture of phalloides intossication has been treated at our Centre. The patient was submitted to four treatments of plasmaexchange (Plasmafiltration), exchanging from 70 to 80% of the plasmatic volume and using substitutive liquids 4% albumine and frozen plasma, using as filter Plasmaflo Asahi OP-O5 (1) and Plasmapheresis equipment SIFRA mod. 914. Already after the first treatment there was an improvement of the general condition with a stabilization of the renal and hepatic parameters at the end of the cycle.

Background: Thromboembolic complications after electrical cardioversion (CV) of atrial fibrillation (AF) have been attributed to the dislodgment of preexistent left atrial thrombus during the resumption of atrial contraction. Transesophageal echocardiography (TEE) has been used to identify patients without thrombus, who potentially could undergo CV without anticoagulation. However, embolic events after CV in patients without evidence of thrombus on TEE have recently been reported., Aim of the Study: To evaluate if absence of thrombi or prethrombotic conditions such as spontaneous echo contrast or left atrial appendage disfunction can justify electrical CV without anticoagulant therapy., Methods: Seventy-four patients with AF and candidates for CV underwent monoplane TEE. Patients were cardioverted without anticoagulation in case of: 1) absence of thrombus and/or spontaneous echocardiographic contrast and 2) good visualization of left atrial appendage, with a well defined peak blood flow velocity greater than 20 cm/sec. In all other cases, patients underwent anticoagulant therapy which started 3 weeks before CV and continued for 4 weeks afterwards., Results: Forty-six patients, without thrombus or "prethrombotic" conditions, did not receive anticoagulation, while 28 followed traditional therapy with warfarin. Four patients with a thrombus in the left atrial appendage were identified: 1 died of cerebral embolism 3 days after the beginning of anticoagulation, in another one CV was definitely deferred because of the persistence of thrombus after 1 month of warfarin therapy. One patient, with left atrial appendage disfunction, died suddenly after 5 days of anticoagulation. Two patients reverted spontaneously in sinus rhythm. Two patients refused electrical CV. The remaining 67 patients underwent electrical CV which was successful in 56 of them. Cerebral embolism occurred 24 hours after CV in one patient who did not receive anticoagulation. Repeat TEE soon after embolism showed absence of thrombus or spontaneous echo contrast, but the presence of low flow velocity in the left atrial appendage., Conclusions: In patients in AF candidates for CV, exclusion of thrombi or prethrombotic conditions by TEE does not exclude the risk of thromboembolic events and the need for anticoagulant therapy. Left atrial appendage function can be stunned or impaired immediately after CV, favouring a thrombogenic milieu and subsequent embolic events. Therapeutic anticoagulation at the time of as well as after cardioversion is actually recommended.

The coronoid-maxillary space defines the distal maxillary rims, and it is usually tightened during mouth opening. It has been reported that its adequate filling or its overfilling is helpful in prosthesis retention. There are two types of individual anatomical variations, that can affect the size of this space. In fact, the coronoid process can be vertical or lateral. In the first case, the coronoid-maxillary space is reduced in oral opening, therefore the prosthesis edge must be thin. In the latter case, the space increases or does not vary during mouth opening, therefore the prosthesis must be thicker in order to obtain its adequate retention.

The feasibility, safety and prognostic importance of high-dose (0.84 mg/kg over 10 minutes) dipyridamole 2D echocardiography test (DET) were evaluated in 78 asymptomatic patients 10 to 14 days after uncomplicated acute myocardial infarction and the results were compared with those of exercise stress test (EST). Criteria of positivity were: for DET a new or worsening asynergy; for EST, ST segment depression greater than or equal to 1 mm (patients were in complete pharmacological wash-out). Patients were followed-up for 9 to 22 months (mean 14 +/- 5) or until one of the following end-points occurred: death, infarction or severe angina. DET was positive in 13/17 patients and EST in 5/17 patients with poor clinical outcome (sensitivity 76% vs 29%; p less than 0.005); for hard events only (death or infarction) sensitivity was respectively 64% vs 9%; (p less than 0.05). Both tests had the same specificity (92%). Cumulative event-free survival curves as a function of DET and EST results were both statistically different (p less than 0.001 and p less than 0.05 respectively). Cumulative survival curves obtained by the combination of DET and EST results showed: 1) an uneventful course in patients with both tests or only DET negative; 2) and a poor clinical outcome in patients with both test or only DET positive (p less than 0.001) DET correctly predicted clinical outcome in 12/16 patients in whom there was disagreement between the two tests. We conclude that DET is more sensitive than EST for identifying patients at increased risk for coronary events and more accurate for predicting clinical outcome after uncomplicated acute myocardial infarction.

The Authors have tried to underline the characteristics and limits of T-Scan so as to provide an aid for the reliable usage of the instrument and avoid possible erroneous interpretations of the given data.