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Objective. To provide a comprehensive overview of peripheral spondyloarthritis (pSpA), focusing specifically on its occurrence and management in patients with inflammatory bowel disease (IBD). Methods. An exhaustive literature search was conducted in PubMed, Embase, Cochrane Database of Systematic Reviews, and Google Scholar to identify relevant studies on pSpA in IBD patients. Titles, abstracts, and full-text articles were screened for relevance. Data on study design, patient characteristics, diagnostic criteria, main findings, and conclusions were extracted from selected articles. Study quality was assessed using appropriate checklists. Information was synthesized narratively to summarize current understanding. Results. pSpA is the most common extraintestinal manifestation in IBD, with a median prevalence of 16%. It worsens quality of life and requires collaboration between gastroenterologists and rheumatologists for optimal diagnosis and treatment. Several “red flags” guide appropriate specialist referral of IBD patients with suspected pSpA. Once the diagnosis is confirmed, the choice of therapy depends on IBD phenotype and patterns of articular/axial involvement. Anti-tumor necrosis factor (TNF) drugs are first-line biologics, with interleukin (IL)-12/23 and IL-23 inhibitors as alternatives for anti-TNF failure. Small molecules like apremilast and Janus kinase inhibitors also have utility. Recommended treatment algorithms exist, but more randomized controlled trials are needed. Conclusions. Early identification of pSpA is crucial in IBD patients to enable timely intervention, prevent structural damage, and minimize disability. A multidisciplinary, holistic approach addressing musculoskeletal and extra-musculoskeletal manifestations is key to optimal patient outcomes.

This cross-sectional online study was designed by the study group on Capillaroscopy and Microcirculation in Rheumatic Diseases (CAP) of the Italian Society of Rheumatology (SIR) to provide an overview of the management of nailfold capillaroscopy in Italian rheumatology centers. Therefore, SIR distributed the survey to its members in July 2021, and each center’s physician with the most expertise in capillaroscopy completed the questionnaire. The survey was completed by 102 centers, with at least one representative from each Italian region. Ninety-three centers perform capillaroscopy, and 52 (56) conduct more than 200 investigations annually. Seventy-eight (84%) of respondents have more than five years of experience with the technique, and 75 centers (80.6%) have received certification from specific national or international training courses. In 85 centers, a videocapillaroscope with 200x magnification is employed (91.4%). The average waiting period for the examination is 2.4 months, and less than 3 months in 64 of the locations (68.8%). The study demonstrates that capillaroscopy is an integral part of both the diagnostic phase of Raynaud’s phenomenon and the monitoring of autoimmune connective tissue diseases (CTDs). However, the reporting methods and timing of patient followup are heterogeneous.

Impaired diffusing capacity of the lung for carbon monoxide (DLCO) was frequently observed in systemic sclerosis (SSc) patients, generally related to the presence of interstitial lung disease (ILD) and/or pulmonary arterial hypertension (PAH). However, in clinical practice abnormally low DLCO values may be found also in the absence of these SSc complications. The objective was to investigate the prospective clinical relevance of isolated DLCO reduction at baseline in SSc patients. Ninety-seven SSc female patients (age at the diagnosis: 51.3±14.5 years; disease duration: 10.4±6.6 years; limited/diffuse skin subsets: 92/5), without any clinical, radiological (high resolution computed tomography), and echocardiographic manifestations of ILD or PAH at baseline, nor other lung or heart diseases able to affect DLCO, were recruited at our Rheumatology Centre. Patients with DLCO

A 57-year-old woman with a diagnosis of antisynthetase syndrome (ASSD) underwent a nailfold videocapillaroscopy (NVC) showing a scleroderma pattern. Alterations in capillary morphology have been reported in adults with inflammatory myositis (IM) but only recently have the differences in NVC findings between these two diseases been established. ASSD is currently classified as a subset of IM, for which reason only a few studies in literature evaluate its specific hallmarks, showing nonspecific features of NVC in patients with polymyositis and dermatomyositis (DM) and antisynthetase antibodies. To our knowledge, this is the first description of ASSD capillaroscopy features, and the first report of NVC in ASSD with evidence of scleroderma pattern. Further studies are needed to define clearly frequency, typical features, and possible correlation with clinical and serological data of NVC changes in ASSD, differences between microangiopathy in ASSD and systemic sclerosis or DM.

Background. Systemic sclerosis (SSc) is characterized by endothelial dysfunction and widespread microangiopathy. However, a macrovascular damage could be also associated. Aortic pulse wave velocity (aPWV) is known to be a reliable indicator of arterial stiffness and a useful prognostic predictor of cardiovascular events. Moreover, aPWV may be easily measured by non-invasive, user-friendly tool. Aim of our study was to evaluate aPWV alterations in a series of SSc patients. Methods. The aPWV was evaluated in 35 consecutive female SSc patients and 26 sex- and age-matched healthy controls. aPWV alterations were correlated with cardiopulmonary involvement. Results. A significant increase of aPWV was observed in SSc patients compared to controls (9.4±3.2 m/s vs 7.3±1 m/s; P=0.002). In particular, 14/35 (40%) SSc patients and only 1/26 (4%) controls (P=0.0009) showed increased aPWV (>9 m/s cut-off value). Moreover, echocardiography evaluation showed an increased prevalence of right atrial and ventricular dilatation (atrial volume: 23.6±6.2 mL vs 20.3±4.3 mL, P=0.026; ventricular diameter 19.5±4.9 mm vs 15.9±1.6 mm; P=0.001) associated to higher values of pulmonary arterial systolic pressure (PAPs) in SSc patients (31.5±10.4 mmHg vs 21.6±2.9 mmHg; P50 years old. Furthermore, altered aPWV was more frequently associated with limited cutaneous pattern, longer disease duration (≥5 years), and/or presence of anticentromere antibody (ACA). Conclusions. A significantly higher prevalence of abnormally increased aPWV was evidenced in SSc patients compared to healthy controls. The possibility of more pronounced and diffuse vascular damage in a particular SSc subset (ACA-positive subjects with limited cutaneous scleroderma and longer disease duration) might be raised.

Objective: To describe clinical and serological features of a large series of patients affected by primary Sjogren’s syndrome (pSS), assessing the evolution of the disease in a long-term follow-up study. Methods: Clinical and laboratory data of 250 patients with pSS attending our Unit for a mean follow-up period of 140 months were retrospectively collected and analysed. In all the cases the diagnosis was made according with the recent international criteria. Results: Glandular involvement was almost universally present, typically as the first manifestation of the disease and a slow progression of the salivary and lachrymal dysfunction was seen during the observation period. Extraglandular involvement was mild, quite rare and delayed. The respective percentages for muscle-skeletal disease, urogenital, haematological, skin, pulmonary, gastrointestinal, neurological and renal involvement were 60%, 40%, 24%, 20%, 11%, 7%, 8% and 3%. Only 6 patients developed a lymphoma. The serological pattern of the majority of patients remained constant throughout the follow-up period. Conclusions: pSS is often a benign condition. Since some patients may develop lymphoid malignancies, clinical follow- up is recommended.

Background: Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and visceral organs. The microangiopathy is early detectable in the course of the disease by nailfold videocapillaroscopy (NVC), a non-invasive technique with a high diagnostic value. Objective: Aim of our study was to evaluate the feasibility of a quantitative score and its correlation with the digital skin ulcers, which frequently complicate SSc microangiopathy. Methods: We retrospectively analysed the NVC of 65 SSc patients, performed by 200x videocapillaroscopy connected to image analyse software (Videocap; DS MediGroup, Milan, Italy). The analysis of NVC images included: total number of capillaries in the distal row (N), maximum diameter (D) and number of giant capillaries (M), M/N ratio and percentage of M, presence/absence of micro-haemorrhages and tortuosity. Results: 21/65 SSc patients experienced digital ulcers within three months after the NVC examination. The N, D, M/N, and percentage of M significantly correlated with the appearance of ischemic ulcers. A multiple regression analysis showed a statistically significant correlation for N, M/N and D, while sensitivity and specificity of these parameters were unsatisfactory. A capillaroscopic score, according to the formula D·M/N2, showed a high specificity and sensibility (93.2% and 85.7% respectively; area under ROC curve: 0.918) to predict the appearance of digital ulcers. Conclusions: This capillaroscopic score may represent a feasible and simple tool in SSc patients’ assessment. The routinely use of this parameter might permit to recognize and to preventively treat SSc patients at high risk to develop digital ulcers.

L'importanza relativa delle idee che formano la teoria keynesiana è stata a lungo oggetto di controversie per quanto riguarda la possibilità di individuare un nucleo di concetti fondamentali che sono logicamente separabili dagli altri. Uno dei punti discussi è il ruolo della teoria degli investimenti e della preferenza per la liquidità rispetto al principio della domanda effettiva :questi aspetti costituiscono un tutto le cui parti si sostengono a vicenda , o sono in qualche modo "autonomi " , analiticamente separabili e quindi sostituibili ? JEL: E12

Aim: Using the statistic method of sequential allocation, we realized a prospective double-blind study in order to establish the minimum local anesthetic concentration (MLAC) of large intrathecal volume of levobupivacaine, during the first stage labour analgesia in spontaneous and induced laboring women., Methods: Seventy-five nulliparous, at term, with cervical dilatation <5 cm parturients requesting combined spinal/epidural analgesia, were enrolled. The starting concentration was chosen according to recent literature. Total volume of study solution was 10 ml and efficacy was assessed with a visual analogue pain scale at the height of the uterine contraction., Results: We established that MLAC of levobupivacaine, in 10 ml intrathecal volume, during the first stage of spontaneous and induced labour was 0.0134% and 0.0195%, respectively. No complications occurred during the study and the only side effect was shivering, which is common even in other anesthetic techniques. We produced a very selective sensitive block. Neither sympathetic nor motor block occurred., Conclusions: Low intrathecally concentration of local anesthetic allows the anesthetist to reduce the total amount of drug and improves not only the differential blockade between motor and sensitive but also between sympathetic and sensitive fibers.

Purpose: We report on the importance of the integration of data obtained from digital coronary angiography and stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography in evaluating the hemodynamic significance of coronary arteriovenous fistulae., Material and Methods: Coronary fistulae were detected with coronary angiography in 9 patients. All patients underwent clinical examination, transthoracic echocardiography, stress electrocardiogram and stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography., Results: Stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography and stress electrocardiogram showed stress-induced myocardial ischemia in 2 patients. The first patient with familial predisposition and risk factors for ischemic heart disease presented a mesocardic heart murmur on clinical examination. At stress ECG (125 Watt, 153 b/m' max frequency 93%, arterial pressure 230 mmHg, max frequency pressure product 35,200) ischemic alterations were recorded at the first minute of the second stage of the Bruce protocol. Coronary angiography detected a circumflex artery fistula in the coronary sinus. Stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography for the evaluation of stress/rest perfusion detected a reversible perfusion defect of the proximal portion of the posterolateral and lateral walls, thus confirming the hemodynamic importance of the flow through the fistula during stress cycloergometric testing. In the second patient familial predisposition to ischemic heart disease and previous inferior wall myocardial infarction and non-significant stress ECG, coronary angiography identified a subocclusive stenosis of the right coronary artery and an anomaly between the anterior interventricular artery and the left pulmonary artery. The presence of the contrast medium in the left pulmonary artery identified a flow from the left ventricle to the left pulmonary artery. Good angiographic results were obtained after percutaneous coronary angiography of the right coronary artery stenosis. Due to the onset of angina stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography was performed to evaluate stress/rest perfusion (75 Watt, 125 b/m', 88% max frequency, arterial pressure 200 mmHg, double max product 25,000 with ST depression of 1.5 mm in V1-V4) and identified an irreversible perfusion defect due to infarction and a reversible perfusion defect of the anterior wall and apex due to ischemia caused by the anomalous flow through the coronary fistula. The correspondence between the site of the coronary artery where the fistula originates, identified by coronary angiography, and the reversible perfusion defects, identified by stress/rest 99mTc sestamibi myocardial perfusion single photon emission tomography, indicates that the anomalous flow through the fistula may cause myocardial ischemia. The irreversible perfusion defects of the inferior wall are the result of right coronary artery subocclusive stenosis., Conclusions: Coronary fistulae cause myocardial ischemia only in a small number of patients. Data obtained from single photon emission tomography in evaluating stress/rest myocardial perfusion, correlated with data from coronary angiography, have shown that changes in patients with terminal coronary anomalies may be due to different coronary diseases: ischemia to anomalous flow through the fistula and myocardial infarction to subocclusive right coronary artery stenosis. Stress/rest 99mTc sestamibi single photon emission tomography for the evaluation of myocardial perfusion is a reliable means of assessing the functional importance of the terminal coronary anomalies detected by coronary angiography. Evaluation of the hemodynamic importance of the coronary fistulae is indispensable in programming corrective surgery.

Twenty eight elderly patients scheduled for urologic surgery were randomly assigned to receive in a double blind fashion subarachnoid hyperbaric bupivacaine 15 mg with the addition of 50 micrograms (group A, n = 7), 25 micrograms (group B, n = 7), 12.5 micrograms (group C, n = 7), of fentanyl or 1 ml of saline (group D, n = 7) for a total volume of 4 ml. The pattern of breathing and the ventilatory response to CO2 were studied before 90, 150, 480 minutes after the subarachnoid injection. In group A mild pruritus and sedation occurred in 5 patients, nausea, vomiting and periodic breathing occurred in 2 patients. In group B mild pruritus and sedation were observed in 4 patients, nausea, vomiting in 2 patients. No significant changes in VE, Vt/Ti and Ti/Ttot were observed between the groups. Patients receiving 50 micrograms of fentanyl showed a slope VE/PET CO2 significantly below baseline values at 90 and 150 minutes (p less than 0.05). In this group the baseline values were restored after 480 minutes. No side effects were observed in group C and D. 25 micrograms fo fentanyl is the only dose with a significant analgesic effect without any respiratory depression.

The authors review a total of 132 cases of acute neoplastic obstruction of the large gut seen in their clinical material over the last twenty years. In the light of the results obtained they discuss the indications and limitations of the various surgical strategies adopted (radical surgery, derivative surgery, and palliative resection); they conclude that radical procedures are best for the majority of cases.

Authors experience in the Dixon's operation regarding the surgical treatment of cancer of the rectum and recto-sigmoid junction is reviewed. It consists in 224 cases of malignant lesions which were treated by Miles operation (106 cases--47%), Dixon's operation (49 cases--21%), palliation anterior resection (16 cases--7%), other operations (53 cases--24%). After a brief discussion on anatomo-pathological conditions and tecniques, the Authors consider their results: operatory mortality 4%; complications: total anastomosis dehiscence 1 case, partial anastomosis dehiscence 14%; local repetitions 10%; hepatic metastasis within 5 ys 40%; survival at 5 ys 46%. Functional results were always very good. The Authors conclude that, even considering the large rate (56%) of wide-spread cancers treated, Dixon's operation, at least in their experience, doesn't seem to satisfy those needs of radically requested by a correct surgical therapy, which only Miles' operation guarantees.

The authors offer a critical review of eight cases of hemorrhagic colorectitis and Crohn's disease (regional ileitis) managed with medical treatments, and eleven like cases treated surgically, during the last ten years. After a discussion of the resources and limitations of medical therapy, the authors describe the various surgical strategies adopted in their cases; they define the possibility of obtaining final cures in Crohn's disease with extended ileocolectomy; and concerning ulcerative forms, they point out the greater efficacy of surgical procedures involving sacrifice of the rectum compared to those in which the terminal segment of the gut is used immediately or later for restoring continuity of the intestinal canal.

A double blind comparison between morphine and buprenorphine was performed in 20 patients using a new demand and continuous infusion analgesic system to provide analgesia after cesarean section. The patients were randomized in two equal groups to receive either morphine 1 mg/h or buprenorphine 0.03 mg/h. The PCA system was set to deliver bolus of either morphine 1 mg or buprenorphine 0.03 mg, with a lockout interval of 10 and 15 min respectively. A loading dose of morphine 5 mg or buprenorphine 0.15 mg was given if necessary. The quality of analgesia, assessed by a visual analogue and a subjective scale was good with both drugs. No difference in side effects between the groups was observed. The mean potency ratio between buprenorphine and morphine was 32:1. Patients receiving buprenorphine showed a more prolonged analgesia and a significant improvement of sedation score.

A reduced coronary flow reserve has been reported in patients with ischemia-like symptoms and normal coronary arteries. In 13 such subjects both coronary vasomotion and flow reserve were studied. The luminal area of the proximal and distal third of the left anterior descending and left circumflex artery were determined by biplane quantitative coronary arteriography using a computer-assisted system. Subjects were studied at rest, during submaximal supine bicycle exercise (4.0 min, 116 W) and 5 min after sublingual administration of 1.6 mg nitroglycerin. Heart rate, mean pulmonary and aortic pressure as well as the percent change of both proximal and distal luminal area were determined. In 10 of the 13 subjects, coronary sinus blood flow was measured by coronary sinus thermodilution technique at rest and after dipyridamole infusion (0.5 mg/Kg in 15 min) 10 +/- 5 days after quantitative coronary arteriography. Coronary flow ratio (dipyridamole/rest) and coronary resistance ratio (rest/dipyridamole) were determined in these subjects. Subjects were divided into 2 groups according to the behaviour of the coronary vessels during exercise (vasodilation = Group 1, vasoconstriction = Group 2). Coronary vasodilation of the proximal (luminal area + 26%; p less than 0.001) and distal (+ 45%; p less than 0.001) artery was observed in 7 subjects (Group 1) during exercise and after sublingual nitroglycerin (+46%; p less than 0.001 and +99%; p less than 0.001, respectively). In Group 2 (n = 6), however, there was coronary vasoconstriction of the distal vessel segments (-24%; p less than 0.001) during exercise, whereas the proximal coronary artery showed vasodilation (+ 26%; p less than 0.001) during exercise. Following sublingual nitroglycerin, both vessel segments elicited vasodilation (distal coronary + 44%; p less than 0.001, proximal coronary artery +47%; p less than 0.001). Coronary flow ratio amounted to 2.5 in Group 1 and to 1.2 in Group 2 (p less than 0.05) and coronary resistance ratio to 2.7 in Group 1 and to 1.2 in Group 2 (p less than 0.05), respectively. Thus, among subjects with ischemia-like symptoms and normal coronary arteries there is a subgroup of patients (Group 2) with an abnormal dilator response of the distal coronary arteries to the physiologic dilator stimulus of exercise and a reduced dilator capacity of the resistance vessels after dipyridamole (= abnormal coronary vasodilator syndrome). The nature of this exercise-induced distal coronary vasoconstriction is not clear but might be due to an abnormal neurohumoral tone which may cause or contribute to the blunted vascular response during exercise.

Since Burnet expounded the theory of immune surveillance, various cells have been indicated as the "effectors" of the body immunological defence against tumours. Until recently, the ability to lyse tumour target cells was assigned to macrophages and the so-called thymus-dependent lymphocytes, known as killer T cells. The discovery of natural killer cells in mice recently has widened the number of effectors and the field of research in this sector. An examination is made of the features and main properties of these cell groups, and some questions are posed concerning their ability to cooperate in anti-neoplastic immunological defence.