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Background: ICU patients must be kept conscious, calm, and cooperative even during the critical phases of illness. Enteral administration of sedative drugs might avoid over sedation, and would be as adequate as intravenous administration in patients who are awake, with fewer side effects and lower costs. This study compares two sedation strategies, for early achievement and maintenance of the target light sedation. Methods: This was a multicenter, single-blind, randomized and controlled trial carried out in 12 Italian ICUs, involving patients with expected mechanical ventilation duration > 72 h at ICU admission and predicted mortality > 12% (Simplified Acute Physiology Score II > 32 points) during the first 24 h on ICU. Patients were randomly assigned to receive intravenous (midazolam, propofol) or enteral (hydroxyzine, lorazepam, and melatonin) sedation. The primary outcome was percentage of work shifts with the patient having an observed Richmond Agitation-Sedation Scale (RASS) = target RASS ±1. Secondary outcomes were feasibility, delirium-free and coma-free days, costs of drugs, length of ICU and hospital stay, and ICU, hospital, and one-year mortality. Results: There were 348 patients enrolled. There were no differences in the primary outcome: enteral 89.8% (74.1-100), intravenous 94.4% (78-100), p = 0.20. Enteral-treated patients had more protocol violations: n = 81 (46.6%) vs 7 (4.2%), p < 0.01; more self-extubations: n = 14 (8.1%) vs 4 (2.4%), p = 0.03; a lighter sedative target (RASS = 0): 93% (71-100) vs 83% (61-100), p < 0.01; and lower total drug costs: 2.39 (0.75-9.78) vs 4.15 (1.20-20.19) €/day with mechanical ventilation (p = 0.01). Conclusions: Although enteral sedation of critically ill patients is cheaper and permits a lighter sedation target, it is not superior to intravenous sedation for reaching the RASS target. Trial registration: ClinicalTrials.gov, NCT01360346. Registered on 25 March 2011.

The size and shape of the jaws are related to occlusion and masticatory muscle function. Consequently, teeth and muscles are considered the functional matrix for the two jaws. Existing studies did not focus on the relationship between maxillary and mandibular base but on just their absolute dimensions. As the relationship between the two is of interest to orthodontists, the aim of this study was to calculate the maxillary-mandibular ratio (m-m ratio) in individuals from Central Italy and to compare it to that of ancient skulls from the same geographic area.Forty individuals from Opi, a small, isolated mountain village in Central Italy, and 40 ancient skulls from the same region were the sample of this study. The lengths of the maxillary and mandibular base were assessed on lateral cephalograms, the m-m ratio was calculated, and the measurements between the groups were compared.Due to a significantly shorter maxillary base in the modern human sample, the m-m ratio was significantly lower in these subjects.This finding supports the hypothesis that growth of the skull is strongly modulated by the functional matrix, within which a morphologic unit develops.

The mechanical valve produced by Sorin is a modified tilting disc device. Between March 1979 and November 1985, 763 Sorin prostheses were implanted in 710 patients. The study has been restricted to 504 isolated mitral or aortic valves. There were 238 females and 266 males whose ages ranged from 2 to 71 years (mean 43.8). Follow-up is 99.23% and covers 1045 patient-years. No structural failure has been observed. In the aortic position, 282 Sorin prostheses were implanted with the large orifice orientated towards the right coronary sinus. Hospital mortality was 5% (14/282). Actuarial survival at 78 months was 94.68% +/- 1.6% with a linearized mortality rate of 1.7% patient-years. There were 11 late deaths (9 valve-related and 2 non valve-related). The linearized rate of occurrence of embolic events was 0.32 patient-years (2/268). Actuarial survival complication-free at 78 months was 90.88% +/- 2.83%. Preoperatively, 19.8% patients were in NYHA class II, 68.5% in III and 11.7% in IV; postoperatively, 79.3% patients were in NYHA class I, 19.5% in II and 1.2% in III. In the mitral position, 222 Sorin prostheses were implanted with the large orifice orientated anteriorly in 46 patients (group 1) and posteriorly-in 176 patients (group 2). Hospital mortality was 4.5% (10/222). Actuarial survival at 66 months was 93.25% +/- 2.1% with a linearized mortality rate of 2.8 patient-years. There were 12 late deaths (9 valve-related and 3 non valve-related). The 66-month actuarial freedom from embolic events was 95.8% +/- 1.89% with a linearized rate of occurrence of 1.44 patient-years.(ABSTRACT TRUNCATED AT 250 WORDS)

The mechanical valve produced by Sorin is a modified tilting disc device. Over about a 6-year period, 763 Sorin Prostheses were implanted in 710 patients. No structural failure has been observed. 282 prostheses were implanted in aortic position with the large orifice oriented towards the right coronary sinus. Hospital mortality was 5% (14/282). Actuarial survival at 78 months was 94.68% +/- 1.6%, with a linearized mortality rate of 1.7% pt-years. There were 11 late deaths (9 valve related and 2 non valve-related). The linearized rate of occurrence of embolic events was 0.32 pt-years (2/268). Actuarial survival complication free at 78 months was 90.88% +/- 2.83%. Preop. 19.8% patients were in class II N.Y.H.A, 68.5% in III, 11.7% in IV; postop. 79.3% patients were in class I, 19.5% in II, 1.2% in III. The durability and satisfactory complication-free survival rate indicate the Sorin prosthesis as a fully reliable device for aortic valve replacement.

A ten-year experience with reoperations for failure of cardiac bioprostheses is reported. 362 patients were operated for valve replacement with 412 bioprostheses. There were 35 (9.64%) reoperations for valve failure. Mean time between operation and reoperation was of 64.4 months. Operative mortality was 14.28%: 3 patients died for cardiac and 2 for extra-cardiac causes. Long-term mortality after reoperation was 6.25%. Morphological examination of the explanted bioprostheses confirmed the cause of bioprosthetic valve failure, due to calcific degeneration in 88.88% of case, to post-endocarditic rupture in 5.55% and to prosthetic thrombosis in 2.77%. The importance of timing reoperation is stressed in order to reduce the operative mortality. The conditions suitable for implantation of bioprostheses are listed.

In this work a case of splenic Hodgkin's disease is reported. It was diagnosed only by a second exploratory laparotomy. There was no involvement of lymph nodes, other organs or systems. Hodgkin's disease was histologically associated with sarcoid-like granulomas and the significance of this association is discussed. In addition to splenectomy, this patient was treated with chemotherapy.

PURPOSE: To evaluate the desensitizing efficacy of 2% sodium fluoride solution (NaF), diode laser (DL), a DL and NaF association and a solution of hydroxyl-ethyl-methacrylate and glutaraldehyde (HEMA-G: Gluma desensitizer) in cervical dentin hypersensitivity (CDH). METHODS: 262 teeth of 24 subjects (16 females and eight males; age 21 to 64 years, mean 38 years), each having at least two CHD teeth for each quadrant, were included in this prospective, split mouth, clinical study. Teeth of each oral quadrant were randomized in four groups (SG) to study the effectiveness of NaF (SG-1), of DL (SG-2) NaF-DL combination (SG-3) and HEMA-G (SG-4). The subjects were asked to rate the sensitivity experienced during air stimulation by placing a mark on a visual analogue scale (VAS) before treatment (baseline), immediately after treatment, and after 1, and 6 months. RESULTS: The outcomes showed a significant reduction of discomfort compared to baseline values for teeth of SG-3 immediately post treatment (82.6%) (P < 0.001), after 1 month (69.5%) (P < 0.001) and after 6 months (60.8%) (P < 0.001), respectively, compared with the reduction scores of 51.6% (P < 0.001), 29.7% (P < 0.05) and 4.7% (P > 0.05), recorded for SG-1; 72.2%, (P < 0.001), 62.5% (P < 0.001), and 47.2% (P < 0.05), recorded for SG-2; 77.4% (P < 0.001), 56.1% (P < 0.001), and 27.3% (P < 0.05), recorded for SG-4.

From the MeOH extract of Sideritis trojana , a new iridoid glycoside, 10- O -( E )-feruloylmelittoside ( 1 ) was obtained in addition to four known iridoid glycosides [melittoside ( 2 ), 10- O -( E )- p -coumaroylmelittoside ( 3 ), stachysosides E ( 4 ) and G ( 5 )]. Moreover, five phenylethanoid glycosides [verbascoside ( 6 ), isoacteoside ( 7 ), lamalboside ( 8 ), leonoside A ( 9 ), isolavandulifolioside ( 10 ), three flavone glycosides (isoscutellarein 7- O -[6‴- O -acetyl- β -allopyranosyl-(1 → 2)]-β-glucopyranoside ( 11 ), 4′- O -methyisoscutellarein 7- O -[6‴- O -acetyl- β -allopyranosyl-(1 → 2)]-β-glucopyranoside ( 12 ), 3′-hydroxy-4′- O -methyisoscutellarein 7- O -[6‴- O -acetyl- β -allopyranosyl-(1 → 2)]-β-glucopyranoside ( 13 ) and a benzylalcohol derivative (di- O -methylcrenatin) were obtained and identified. The structures were elucidated on the basis of NMR and HRMS data. All compounds were tested for their antioxidant activity by in vitro TEAC assay and some of them exhibited moderate activity (0.97–1.44 mM) when compared with the reference compound (quercetin 1.86 mM). Glycosides 6 – 13 , the most active compounds in the TEAC assay, were also tested by flow cytometry to evaluate their ability to affect the levels of reactive oxygen species (ROS) in human prostate cancer cells (PC3).

Glioblastoma multiforme, which represents 80% of malignant gliomas, is characterized by aggressiveness and high recurrence rates. Despite therapeutic advances, patients with glioblastoma multiforme show a poor survival, and identification of novel markers and molecular targets for therapy is needed. A role for BAG3, a member of the BAG family of HSC/HSP70 co-chaperones, in promoting tumor cell growth in vivo has recently been described. We analyzed BAG3 levels by IHC in specimens from patients affected by brain tumors and we found that BAG3, although negative in normal brain tissues, was highly expressed in astrocytic tumors and increasingly expressed in more aggressive types of cancer; it was particularly high in glioblastomas. Down-regulating BAG3 both in vitro and in vivo in a rat glioblastoma model resulted in increased sensitivity to apoptosis, suggesting that BAG3 is a potential target for novel therapies. Finally, we determined that the underlying molecular mechanism requires the formation of a complex of BAG3, HSP70, and BAX that prevents BAX translocation to mitochondria, thus protecting tumor cells from apoptosis. Our data identify BAG3 as a potential marker of glial brain tumor sensitivity to therapy and thus also an attractive candidate for new molecular therapies.

Acute intermittent postoperative block of mechanical prostheses is a rare and life-threatening complication; its incidence and treatment are not well defined. Between January 1975 and June 1991, 2839 mechanical prostheses were implanted using the same technique: mattress suture for mitral valve replacement and simple suture for aortic valve replacement. Prosthetic block occurred in eight patients: four following mitral valve replacement and four after aortic valve replacement. The blocked prosthesis was always a tilting disc valve (five Sorin, two Björk-Shiley and one Medtronic). The event occurred over a time interval of 6-48 h (mean(s.d.) 17.3 (15.6)h). All patients having mitral valve replacement needed emergency prosthetic replacement. In aortic valve replacement, reoperation was necessary in two patients; the disc block disappeared in the others. All patients are alive with a follow-up ranging between 3 and 168 (mean 32.5) months. No structural failure was found in explanted prostheses leading to a diagnosis of extrinsic block. The overall incidence of this complication was 0.28% (eight of 2839); 0.24% (four of 1645) for mitral valve replacement and 0.33% (four of 1194) for aortic valve replacement respectively (n.s.). It was exclusively related to tilting disc valves (0.44%; eight of 1830) versus ball and bileaflets valve (0 of 1009). In mitral valve replacement reoperation on patients is mandatory; in aortic valve replacement patients the left ventricular pressure itself can overcome the prosthetic block. Attention should be paid to valve excision and suture techniques as tilting disc prostheses are more vulnerable to extrinsic block. Furthermore, their use is contraindicated in redo operations and mitral valve replacement with total or partial preservation of mitral apparatus.

In order to evaluate the influence of the profile of mitral prostheses on the outflow tract of the left ventricle, 99 patients underwent M-Mode echocardiography before and after surgery. In 67 cases high profile mitral prostheses had been implanted (48 mechanical and 19 biological); in 32 cases low profile mitral prostheses had been implanted (22 mechanical, 10 biological). Echocardiography showed that the implantation of high profile mitral prostheses did not induce changes of left ventricular diastolic and systolic dimensions ( EDDLV and ESDLV ) while induced significant reduction of left ventricular outflow tract (LVOT) dimension and LVOT/ EDDLV index with subsequent changes in transaortic flow. On the other hand, low profile prostheses did not induce significant changes of left ventricular dimensions, LVOT and LVOT/ EDDLV index. Finally, low profile biological mitral valve prostheses ( Liotta type) induced a significant increase of post-operative dimension of LVOT and LVOT/ EDDLV index. Authors conclude: that the implantation of high profile mitral prostheses changes LVOT dimension and transaortic flow and, that M-Mode echocardiography is a reliable technique to point out these changes.

The surgical treatment of 6 patients affected by right cardiac tumors is reported. Three of them showed a right atrial myxoma, 1 metastases from an occult embryonal carcinoma and 1 a leiomyosarcoma of the pulmonary artery. While clinical diagnosis was not reliable, the echocardiographic examination was able to assess the site of the tumor, supplying useful information for the anatomy and surgery in 5 cases out of 6; in one case, the diagnosis was reached intraoperatively. All the patients survived the surgical treatment: while those with atrial myxoma recovered completely, the others with malignant tumors died from metastases 5 to 10 months postoperatively. The importance of early diagnosis is stressed together with the role of surgery, which permits the recovery of cases with benign tumors and a longer survival of cases with malignant tumors.

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.

A clinical and hemodynamic study of a case of polysplenia, with typical left bilateral symmetry, anomalies of systemic venous drainage and defect of the endocardial cushions. A brief revision of the literature is given and the embriological and clinical concept of the left bilateral symmetry is discussed.