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Background. Workplace violence (WPV) is a major healthcare problem with important consequences in healthcare areas and may impact negatively not only healthcare workers but also the quality and safety of patient care. Objectives: This an observational online web-based survey using Google® Modules, specifically aiming to investigate the phenomenon of WPV in Italian healthcare services. Methods. Data collection for this study lasted one month, with the questionnaire available from 1 May 2021 to 31 May 2021. Continuous variables were considered as either mean ± standard deviation (SD) or median and interquartile range (IQR) based on their distribution. Comparison between groups was assessed by unpaired t-test or Mann–Whitney U test according to variable distribution. Categorical variables were analyzed using the chi-squared test. Results. The study population consisted of 203 healthcare workers, represented by nurses (61.6%), medical doctors (16.8%), patient care assistants (4.9%), and others (16.7%). Female gender was associated with a 2.6 times higher risk for the presence of aggression (p = 0.034), and nurse as a job with about 4 times increased risk for the presence of aggression (p = 0.006). The risk for aggression increased by 5% for each year of work experience. Conclusions. WPV is still matter of concern in Italian healthcare services. A strong organizational effort is demanded from healthcare institutions in order prevent internal and external violence in healthcare settings.

Background Trans-sphenoidal endoscopic surgery has drawn huge benefits from advances in surgical visualization. The Ultra-HD "4K" endoscope has improved 4-fold image resolution compared with HD, but its actual advantages are unclear. Aim of the present study was to assess its usefulness in the early outcome of trans-sphenoidal surgery. Methods We analyzed a series of 199 trans-sphenoidal pituitary adenoma procedures performed by an experienced team using alternatively HD (n=102) or 4K (n=97) endoscopes. We evaluated extent of resection both subjectively, based on intraoperative surgeon's impression, and objectively based on post-operative MR scan. Results Baseline patients' characteristics were balanced. Objective near-total and total resection rates were comparable between 4K and HD groups (91.5% vs 86.3% and 64.9% vs 56.9%, respectively). 4K endoscope slightly improved resection rate in recurrent adenoma. At multivariate analysis, the only independent prognosticator of total resection was cavernous sinus invasion. Importantly, 4K endoscope enhanced the reliability of intraoperative judgement on extent of resection, significantly reducing unexpected residuals (12.8% vs 33.3% for HD). Operative features and clinical outcomes were similar. Conclusions The HD endoscope remains the standard-of-care for pituitary surgery. The 4K enhanced, "immersive" visualization significantly improved the reliability of surgeon's judgment on resection and might be useful in surgically difficult cases.

Background Chronic Venous Disease (CVD) has a high prevalence in the western world. Varicose veins (VVs) are the main signs of this disease that is characterized by important pathological vessel wall changes. The aim of this study is to correlate the main histopathological abnormalities with related clinical issues of CVD. Methods A cohort of patients with VVs scheduled for open surgical treatment namely stab avulsion of VVs was recruited. Subsequently, venous tissue from stab avulsion was collected in order to evaluate the following biomarkers: Vascular-Endothelial Growth Factor (VEGF), Protein Gene Product 9.5 (PGP 9.5), Fibronectin (FN), and Matrix Metalloproteinase-9 (MMP-9). The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) criteria were used to classify CVD. Results Fourteen tissue fragments were processed for histological and immunohistochemical studies. Of these, 43% were from CEAP C2 patients, 36% from CEAP C3 patients, and 21% from CEAP C4 patients. CEAP Class C2 had few to moderate structures positive to VEGF; occasional structures positive to Fibronectin, numerous structures positive to MMP9, few to moderate structures positive to PGP 9.5. CEAP Class C3 had moderate structures positive to VEGF; few to moderate structures positive to Fibronectin; many structures positive to MMP9; few to moderate structures positive to PGP 9.5. CEAP Class C4 had numerous structures positive to VEGF; numerous structures positive to Fibronectin; abundant structures positive to MMP-9; few structures positive to PGP 9.5. Conclusions In this study, positive VEGF, FN, and MMP-9 structures were found with increasing trends in relation to the disease staging. VEGF and FN are associated with a progressive increase from C2 to C4. The MMP-9 marker has an important positivity even at early stage of the disease, being higher in CEAP C4 patients. PGP 9.5 decreases in CEAP C4 patients and this is concordant to decreased vein wall innervation.

Objective: to determine lifestyle changes, such as physical activity, nutrition, and sleep in an Argentinean university population, caused by confinement during the COVID-19 pandemic. Methods: Cross-sectional study via web survey. 1021 the Argentinean university population (women, n = 645 and men, n = 376) aged between 18–70 years old was participate. Survey was utilized to measure participant physical activity behavior, nutrition, and sleep April to May 2020. Results: the main findings revealed that 4.3% of the sample showed obesity; the highest proportion of the sample stayed more than 6 hours in a sedentary status; 21.74% reported bad sleep quality; a reduction in good feeding pattern; and an increase in subjects who do not perform physical activity. According to socio-demographic and anthropometric factors, being a student (OR 2.19, CI95% 1.18 - 4, p= .012), overweight (OR 1.71, CI95% 1.19 – 2.44, p= .003), obesity (OR 4.45, CI95% 2.27 – 8.7, p< .001), and have been confined more than 45 days was associated with bad feeding. Likewise, low physical activity levels were associated with obesity (OR 3.2 CI95% 1.66 – 6.18, p= .001), being female (OR 1.61, CI95% 1.14 –2.28, p= .006) and get married (OR 1.72, CI95% 1.14 – 2.61, p= .009). Moreover, being a student was associated with poor sleep quality (OR 43.6, CI95%5.4 – 350, p< .001). Conclusion: This study suggests that confinement decreased healthy living habits such as good nutrition and physical activity and affected the quality of sleep in young subjects. Resumen. Objetivo: determinar los cambios en el estilo de vida, como la actividad física, la nutrición y el sueño en una población universitaria argentina, causados por el confinamiento durante la pandemia de COVID-19. Métodos: Estudio transversal mediante encuesta por Internet. Participaron 1021 personas de la población universitaria argentina (mujeres, n = 645 y hombres, n = 376) de entre 18 y 70 años de edad. La encuesta fue utilizada para medir el comportamiento de la actividad física, la nutrición y el sueño de los participantes de abril a mayo de 2020.Resultados: los principales hallazgos mostraron que el 4,3% de la muestra presentaba obesidad; la mayor proporción de la muestra permaneció más de 6 horas en estado sedentario; el 21,74% informó sobre la mala calidad del sueño; una reducción de los hábitos correctos de alimentación; y un aumento de los participantes que no realizan actividad física. De acuerdo con factores socio-demográficos y antropométricos, ser estudiante (OR 2.19, CI95% 1.18 - 4, p= .012), el sobrepeso (OR 1.71, CI95% 1.19 - 2.44, p= .003), la obesidad (OR 4.45, CI95% 2.27 - 8.7, p< .001), y haber estado confinado más de 45 días se asoció con una mala alimentación. Asimismo, los bajos niveles de actividad física se asociaron con la obesidad (OR 3,2; IC95% 1,66 - 6,18, p= .001), ser mujer (OR 1,61; IC95% 1,14 -2,28, p= .006) y estar casado (OR 1,72; IC95% 1,14 - 2,61, p= .009). Además, ser estudiante se asoció con una mala calidad de sueño (OR 43,6, CI95% 5,4 - 350, p< .001). Conclusión: Este estudio sugiere que el confinamiento disminuyó los hábitos de vida saludables como la buena nutrición, la actividad física, y afectó la calidad del sueño en sujetos jóvenes.

Background: Giant intracranial meningiomas (GIMs) are extremely rare and are usually considered arduous to resect totally with poorer prognosis. The real mechanisms by which a meningioma can grow to be defined as "giant" are unknown, as well as the real biological , radiological profile and the different outcomes.Methods: We performed a retrospective review of a consecutive series of surgically-treated patients suffering from intracranial Meningioma. All the patients were assigned on the ground of the preoperative imaging to the Giant and Medium/Large Meningiomas. We investigated whether the presence large diameter on radiological diagnosis is indicative for different mortality rate, grading, characteristic and clinical/neurological outcome.Results: The study shows that surgically treated giant meningiomas have a higher risk of developing complications in the postoperative phase (Chi square= 11.121, dF=1, p=0.001). The direct proportional relationship between peritumoral brain edema (PBE) volume and tumor volume was present only in the medium/large group and was not present in the giant meningioma group. When comparing the degree of performance there is a statistically significant difference between localization and KPS immediately postoperatively (p=0.04) particularly for sphenopetroclival meningiomas (p=0.071), and partially with GIM of the olfactory groove with arterial encasement. The most frequently encountered complications include the occurrence of ischemia (p=0.049), infection (p=0.03), and the occurrence of postoperative seizures.Conclusions: We identified that the major surgical risk factor for GIMs is location, where the petro-clival region and, to a lesser extent the anterior basicranium offer a greater risk of neurovascular involvement and arterial encasement. On other hand, the risk correlated with PBE is poorer in GIM although there is a well-noted correlation between the Edema volume and outcome in meningiomas.

Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.

El proceso investigativo tuvo el objetivo de determinar la percepción que tienen los pacientes diagnosticados con ansiedad y depresión acerca de la efectividad de los tratamientos breves y focalizados recibidos en el departamento de psicología del Sanatorio San Gabriel, de la sede de la Ciudad Autónoma de Buenos Aires (Argentina), durante 2017 y 2018. El diseño empleado fue no experimental, descriptivo y con enfoque cuantitativo. La población estuvo constituida las historias clínicas de 19 pacientes de ese contexto de estudio. El 52,63% de los participantes consideró que existió una reinstauración de los síntomas originales, lo que prevaleció en el estudio, además de los que valoraron su rehabilitación como bien o muy bien y aquellos que consideraban requerir renovar las sesiones de terapia.

Background Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non IgE-mediated food allergy that generally affects children in the first year of life. Usually symptoms break out when formula milk or solid foods are introduced for the first time but they might also appear in exclusively breastfed infants, since the trigger elements, especially cow’s milk proteins, can be conveyed by maternal milk as well. FPIES in exclusively breastfed babies is a very rare clinical condition and only few cases have been reported in the medical literature. Case presentation We describe two cases of FPIES in exclusively breastfed babies. The first one is a two-month-old infant with a brief history of vomit and diarrhea that presented to the Emergency Department in septic-like conditions. The main laboratory finding was a significant increase in methemoglobin (13%). Clinically, we noted that, when breastfeeding was suspended, diarrhea drastically improved, and vice versa when maternal milk was reintroduced. An amino acid-based formula allowed a complete normalization of the symptoms. The second one is a three-month-old infant admitted for a 3 days history of persistent vomit and diarrhea. Blood tests showed a raised level of methemoglobin (7%). An esophagogastroduodenoscopy was performed and biopsies showed an eosinophilic infiltration of the duodenal mucosa. A maternal exclusion diet and an amino acid-based formula allowed a rapid regularization of the bowel function. Conclusions We searched all the cases of FPIES in exclusively breastfed babies reported in the medical literature, identifying eight patients, with an average age of 3 months (range 15 days – 6 months). The majority of the cases were initially diagnosed as gastroenteritis or sepsis, five cases were characterized by an acute on chronic scenario and cow’s milk was the most frequently involved food. Methemoglobin was never tested. An oral food challenge test was performed in two patients. FPIES in exclusively breastfed infants is a rare condition that, in the presence of compatible history and symptoms, should be considered also in exclusively breastfed babies. The evaluation of methemoglobin can simplify the diagnostic process.

Background: It has been 15 years since sirolimus, an mTOR inhibitor, received Food and Drug Administration approval to prevent acute rejection in kidney transplantation, and 8 years since its analog everolimus acquired the same status. Since then, these drugs have become more and more utilized and their immunosuppressive and antiproliferative properties have been tested in a great variety of clinical conditions, often achieving excellent results. Despite such positive evidence, the on-label indications for these rapalogs are still very restrictive, especially in children. Aims: The aims of this study were to describe our center’s experience with sirolimus and everolimus in managing rare pediatric conditions for which mTOR inhibitors have been reported as a therapeutic option, although without conclusive approval from regulatory agencies, and to evaluate safety and tolerability of the treatment at the prescribed doses. Methods: All the subjects who received off-label sirolimus or everolimus at the Pediatric Department of the IRCCS Burlo Garofolo in the last 13 years were included. For each disease found in our case series, we reviewed the current scientific literature. Results: Off-label treatment with rapalogs was prescribed in 16 children (11 males, 5 females, median age of 9.5 years, range 1–16 years). Seven had immunologic disorders: four autoimmune lymphoproliferative syndrome (ALPS), one multicentric Castleman disease (mCD), one activated PI3K delta kinase syndrome (APDS), and one immunodysregulation with polyendocrinopathy enteropathy X-linked (IPEX). Eight had proliferative disorders or vascular anomalies: one cystic lymphangioma, two Bannayan–Riley–Ruvalcaba syndrome (BRRS), one blue rubber bleb nevus syndrome (BRBNS), two tuberous sclerosis complex (TSC), and one low-flow mixed arterial and venous malformation. One case had congenital hyperinsulinism (CHI). The average dosage administered was 1 mg/m2 for sirolimus and 7 mg/m2 for everolimus. We experienced a good measurable clinical improvement in 14 patients. Nobody experienced serious adverse events (SAEs). The therapy was interrupted in two cases, for lack of efficacy and poor tolerance in one case and for occurrence of bacterial pneumonia in the other one. A review of the literature identified 101 published reports that met our inclusion criteria. Conclusions: Although use of mTOR inhibitors has been considered to be complicated, our experience shows that, using low dosages, it is possible to obtain relevant clinical improvements, with a good profile of safety and tolerability.

Objectives: Restrictive measures adopted during the COVID-19 pandemic, in order to limit contagion, have had a severe impact on mental health. The burden of lockdown has been particularly heavy on patients with chronic neurologic diseases such as People with Epilepsy (PwE). Our survey aims to describe the struggles and needs of Drug-Resistant (DR) PwE with implanted Vagal Nerve Stimulator (VNS) during the first wave of the COVID-19 lockdown in order to find strategies that help patients cope with present or future periods of restriction.Methods: We collected answers from 30 respondents who underwent an online survey including socio-demographic and clinical information and COVID-19-related information. Depression, anxiety symptoms, and sleep quality were investigated in patients through BDI II, GAD-7, and the PSQI scale.Results: In all, 46% of our sample reported an increase in the number of seizures; the entire sample complained of epilepsy-related issues (medication availability, VSN adjustments, anxiety, sleep disturbance); one out of three participants reported major epilepsy issues felt urgent; 30% had to postpone scheduled examination. Significantly higher scores for depression and anxiety scales were found in patients who perceived seizure frequency worsening and reported major epilepsy-related issues.Conclusion: Preliminary findings showed that the first lockdown influenced the clinical and psychological status of PwE and was related to seizures worsening. The lack of medical assistance and control on VNS therapy left patients to cope with the situation without a chance to contact a specialist. We discuss how a wider implementation of telemedicine programs could facilitate remote assistance of PwE with a VNS implant.

Background: Low back pain (LBP) is one of the most frequent diseases for which patients seek advice in a community pharmacy. The study aimed to evaluate the feasibility of the administration by community pharmacists of questionnaires to assess the LBP intensity and disability degree in patients entering community pharmacies and the attitudes they have toward pain management by pharmacological and non-pharmacological strategies. Methods: An explorative, cross-sectional, observational, and quantitative study was performed. Twelve Italian community pharmacists were asked to submit a questionnaire on LBP to patients visiting their pharmacies. The questionnaire included a pain intensity scale, and two validated tools: the Roland and Morris Disability Questionnaire (RMDQ) and the Start Back Screening Tool (SBST) to determine the degree and risk of patient disability, respectively. Results: 872 patients filled out the questionnaires in 6 months. No statistical differences between genders (p &gt, 0.30) were recorded for pain intensity (Female: median score 6, IQR 4&ndash, 7, Male: median scores 5, IQR 4&ndash, p &gt, 0.30) and disability associated with LBP (RMDQ high-disability level: Females, 14.7%, Males, 15.0%, 0.90). Most of the patients (69%) reported a low degree of disability, but the risk of disability was medium and high in 36% and 18% of them, respectively (p &lt, 0.05). About 14% of patients declare to never seek for physician&rsquo, s advice despite their medium-high degree of disability. Conclusion: The study demonstrated the feasibility of validated tools for assessing the degree and risk of disability in LBP patients administrable in community pharmacies. Moreover, the community pharmacy resulted in an important care portal for patients suffering from moderate LBP and for intercepting patients who suffered from severe LBP but had never reported their problem to their physician.

Varicose veins (VVs) and varicose ulceration (VU) are usually considered non-life-threatening conditions, but in some cases they can lead to major complications such as fatal bleeding. The aim of this systematic review is to evidence the most updated information on bleeding from VV and VU. As evidence acquisition, we planned to include all the studies dealing with "Haemorrhage/Bleeding" and "VVs/VU". We excluded all the studies, which did not properly fit our research question, and with insufficient data. As evidence synthesis, of the 172 records found, after removing of duplicates, and after records excluded in title and abstract, 85 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 68 articles because of the following reasons: (1) not responding properly to our research questions; (2) insufficient data; the final set included 17 articles. From literature searching, we identify the following main issues to be discussed in the review: epidemiology and predisposing factors, pathophysiology and forensic aspects, first aid. It has been estimated that deaths for bleeding due to peripheral venous problems account up to 0.01% of autopsy cases. From a pathological point of view, venous bleeding may arise from either acute or chronic perforation of an enlarged vein segment through the weakened skin. From a forensic point of view, in cases of fatal haemorrhage the death scene can even simulate non-natural events, due to crime or suicide. In most cases, incorrect first aid led to fatal complications. Further investigation on epidemiology and prevention measures are needed.

The use of ecological tests to assess executive functions (EFs) in patients with anorexia nervosa (AN) has not examined extensively. The objective of this study was to analyze and compare the performance of patients with AN and healthy controls (HCs) on standard versus ecologically valid tests on EFs. Sixty-two females aged between 16 and 42 who were diagnosed with AN and 70 matched HCs completed 2 neuropsychological test batteries: standard tests (WCST, TMT, Stroop, ToL, fluency test) and the Behavioral Assessment of Dysexecutive Syndrome (BADS). On the standard tests, patients with AN produced more perseverative response and were slower than HCs in the TMT; in contrast, they scored as well as HCs on tasks that assessed categorization, interference in color naming, planning and semantic fluency. Conversely, there were differences in the ecological tests with patients with AN systematically slower in the resolution of complex tasks. Results demonstrated the power of ecological tests in capturing selective impairments in multifaceted and unstructured tests. Patients with AN experienced systematic deceleration in the resolution of ecological tasks. Also, the increased time needed to solve the tasks, was not reflected in overall improvement in performance. This evidence is further discussed with respect to central coherence.

A 14-year-old boy was admitted for a painful swelling of the middle third of his right clavicle lasting 3 days. He denied any trauma and/or fever. Physical examination showed a soft swelling, without calor or hyperemia of the skin. Pain was exacerbated by bone percussion and by right arm abduction movements. Bone X-ray was normal, but an ultrasound showed enlargement with hypoechoic soft tissue and enhancement of the vascular signal with Doppler technique (figure 1). The blood tests were normal, with no elevation of erythrocyte sedimentation rate (ESR) and C reactive protein (CRP). Figure 1 Ultrasound of the right sternoclavicular joint showing an enlargement of the articular capsule filled of hypoechoic inflammatory tissue collected between the two bone heads (red arrows). Which of the following do you think is the diagnosis in this patient? 1. Infective osteomyelitis 2. Chronic recurrent multifocal osteomyelitis (CRMO) 3. Tietze syndrome (TS) 4. Primary chest wall tumour Which is the next diagnostic step to confirm the clinical hypothesis? 1. Bone biopsy 2. CT scan 3. MRI 4. Bone …

Background Stiff-limb syndrome is part of stiff person spectrum, presenting with fluctuating gait disorders attributed to leg stiffness, spasms, and posturing. It could also manifest with anxiety and specific phobias such as pseudoagoraphobia. We aimed to describe the importance of specific gait phobia as a diagnostic clue to anti-glutamic acid decarboxylase stiff-limb syndrome. Cases We reported on 2 cases of stiff-limb syndrome sharing a similar diagnostic path and phenomenology. Both were featured by pseudoagoraphobia, which has documented to typically cover organic conditions, and a remarkable diagnostic delay attributed to misdiagnoses. Presence of pseudoagoraphobia should not point to the diagnosis of a functional disorder-although a negative instrumental workup is documented. Conclusions Both cases are emblematic of the high misdiagnosis rate affecting stiff person syndrome patients. A proper diagnostic process, including the identification of a pseudoagoraphobia, should help in reaching a diagnosis and providing an early and effective treatment.

Background: Chronic nonspecific low back pain (CNSLBP) is the leading cause of long-term pain and disability. There is evidence suggesting a relationship between CNSLBP in adult women and altered hip kinematics and gluteus medius (GM) muscle function. However, this association has been less studied in young women. Objective: To assess the association between lower limb and pelvis kinematics in the frontal plane, and GM strength and electromyographic activity in young women with CNSLBP compared with an age-matched control group of asymptomatic women. Methods: In this cross-sectional study, 32 young women with CNSLBP ([Formula: see text] months of pain; Oswestry index range: 21–40%) and 20 healthy age-matched women were included. The frontal plane projection angle (FPPA) and contralateral pelvis drop (CPD) at the endpoint of the single-leg squat (SLS) test were measured through photogrammetry. Mean GM muscle activity during the SLS and peak isometric GM strength was measured using surface electromyography (sEMG) and hand-held dynamometry, respectively. Results: The Hotelling’s trace showed no significant differences between groups when the variables were considered as a composite ([Formula: see text]; [Formula: see text]). Also, the univariate results showed no individual differences between groups considering each variable separately. Conclusions: The results showed no association between CNSLBP, hip and pelvis kinematics, and GM strength and activity in young women.

Post-operative pulmonary complications (POPC) occur frequently, especially in patients with pre-existing pulmonary disease and have a significant effect on post-surgical morbidity and mortality. By understanding the patient's existing pulmonary diseases that have a significant effect on post-operative morbidities a combination of information has to be gathered from a thorough history and physical exam as well as selected laboratory and diagnostic tests. Evidence based scores can then be employed to predict the risk of significant POPC. Numbers and testing alone, however, such as diagnosis of chronic obstructive pulmonary disease based on spirometry, may not provide as clear a picture as of the true risk of POPC that is determined by a combination of estimations of the patient's functional status, (b) measured by the patient's estimates of activity and (c) confirmed by the patient's ability to perform simple tasks such as the 6-minute walk test. This information can then be used to rationalize perioperative interventions and improve the safety of the perioperative experience.

Cardiac surgery in patients with preexisting bleeding disorders can be a challenge. Cardiopulmonary bypass can lead to bleeding disorders, above all in patients with coagulopathy. We report the case of a 42-year-old woman, with type I von Willebrand disease, who underwent off-pump coronary artery bypass grafting. Beating heart surgery associated with an adequate replacement of von Willebrand factor and factor VIII levels were chosen to prevent bleeding disorders. Her postoperative course was uneventful and she was discharged home after 5 postoperative days.

Manufactured environmental toxins (METs) are a global problem, causing or contributing to health maladies across socioeconomic classes. This article is intended to educate pediatric nurse practitioners (PNPs) about select METs and their effects on the health of children. Infants and children are especially vulnerable to the effects of METs because of their physiological and developmental characteristics. Moreover, PNPs are obligated to be informed about METs and share their knowledge with families via anticipatory guidance so that caregivers can make informed decisions. PNPs should advocate for proper regulation of METs and prevention of their harmful effects.

Continuous spinal anaesthesia combines the advantages of single-dose spinal anaesthesia, rapid onset and a high degree of success, with those of a continuous technique. The introduction of micro-catheters invigorated interest in the technique and allowed its expansion to additional populations and surgical procedures. However, multiple cases of cauda equina syndrome associated with micro-catheters and (primarily) hyperbaric lidocaine solution led to withdrawal of micro-catheters from the US market, casting doubt over the safety of continuous spinal anaesthesia as a whole. A decade after these events it is possible to look back at the experience with continuous spinal anaesthesia for operative anaesthesia and postoperative analgesia and to compare it with the available alternatives. From this perspective, continuous spinal anaesthesia remains a useful and safe technique. Future research should focus on the comparison of continuous spinal anaesthesia with the combined spinal/epidural technique and the use of newer spinal agents.

Vestibular neuritis (VN) is a common neuro-otologic syndrome characterized by acute prolonged vertigo lasting several days, nausea, vomiting. Vestibular-evoked myogenic potentials (VEMPs) are becoming the better diagnostic tool in this pathology. VEMPs can be recorded from tonically contracted neck muscles by acoustic and galvanic stimulation or forehead tap (cervical VEMPs, c-VEMPs) or from extraocular muscles, using the same stimuli. (ocular VEMPs, o-VEMPs). The aim of our study was to assess the reliability of c-VEMPs and o-VEMPs in the diagnosis of VN. We examined 16 patients, 6 F, 10 M, mean age 50.1 with vestibular neuritis (VN). c-VEMPs were recorded from electrodes placed over the SCM, with reference placed over the clavicle. o-VEMPs were recorded from the same electrodes placed beneath the eye and reference 2 cm below. For both c-VEMPs and o-VEMPs we used acoustic stimuli. In 10 patients (62.5%), only o-VEMPs were absent or abnormal in the affected side; in one patient (6.2%) only c-VEMPs were abnormal; in 5 patients (31.2%) both c-VEMPs and o-VEMPs were absent or abnormal. c-VEMPs and o-VEMPs are reliable tests in the diagnosis of VN. Our results confirm o-VEMPs to be the most impaired test in this disease.

between adiposity and brain structure has not yet been fully elucidated. We aimed to evaluate the association of body fat composition with cortical thickness in cognitively normal subjects. Methods: In total, 1,777 (887 men and 890 women) cognitively normal subjects, aged 45 years or older, were enrolled from Health Promotion Center in Korea. Normal cognition was determined by the results of an interview conducted by a qualified neurologist and scores on the Mini-Mental Status Exam that were above the 16th percentile for age-, gender-, and education-matched norms. Medical records including 3D magnetic resonance imaging, body fat percentage, waist-hip ratio (WHR), and other factors were reviewed. The WHR was categorized into six groups based on gender-specific percentile, and surface-based morphometric analysis was used to estimate cortical thickness. Multiple linear regressions and generalized additive models were used to investigate the linear and non-linear relationship of fat percentage and WHR with cortical thickness. Results: In men, the percentage of fat was positively associated with cortical thickness and the highest WHR group showed significant cortical thinning; in imaging analysis, cortical thinning was observed in the bilateral paracentral lobule, posterior cingulate gyrus, and left medial frontal areas. The WHR showed an inverted U-shaped association with total cortical thickness and frontal lobe thickness in men. Among women, there was no significant association of body fat percentage andWHRwith cortical thickness.Conclusions:Our finding suggests that in men, body fat percentagemight have a beneficial effect, while abdominal fat might have a harmful effect on cortical thickness.

Objective: The purpose of this study was to investigate the effectiveness of atrial and brain natriuretic peptides (ANP and BNP, respectively) as indicators of recovery of left ventricular (LV) function after coronary surgery. Methods: We measured the concentrations of these peptides in 31 patients with poor LV function (ejection fraction, EF , 35%) undergoing coronary artery bypass, and evaluated their correlation with the echocardiographic indexes of LV function. Results: Pre-operatively, the plasma levels of both ANP and BNP were markedly higher in coronary patients than in normal control subjects, and strongly correlated with both EF (BNP: ra 20:8; P , 0:001; ANP: ra 20:6; P , 0:001U and wall motion score index (WMSI). At post-operative follow up, plasma levels of both natriuretic peptides were markedly reduced compared with pre-operative values in 21 patients. In addition, the post-operative‐pre-operative differences of BNP (DBNP) and ANP (DANP) plasma levels strongly correlated with the differences of both EFOra 20:7; P , 0:0001 vs. DBNP; ra 20:6; Pa 0:0003 vs. DANP) and WMSI Ora 0:6; Pa 0:002 vs. DBNP; ra 0:6; Pa 0:04 vs. DANP). Finally, by logistic regression analysis, BNP appeared a significant predictor of LVEF recovery after surgery. Conclusion: Plasma levels of ANP and BNP might be used in routine clinical practice as a support to echocardiography in detecting recovery of the LV function after coronary surgery. q 2001 Elsevier Science B.V. All rights reserved.

Objective: Diabetes mellitus is a well-known risk factor in patients undergoing coronary artery bypass grafting. Myocardial and pulmonary injury often occurs after cardiopulmonary bypass (CPB), mediated in part by neutrophil activation and adhesion to endothelial cells. The objectives of the present study are to compare the degree of neutrophil activation and neutrophil-endothelial cells adhesive interactions in diabetic patients after CPB. Methods: Nitro-blu tetrazolium scores, CD11b expression and neutrophil-endothelial cells adhesion were assessed in blood samples from 15 diabetic and 15 control patients who had undergone elective coronary bypass grafting. Blood samples were obtained at baseline, 30 min after beginning CPB, at the end of CPB and 60 min postoperatively. At the same sampling points as above, blood glucose levels were also checked in all patients. Results: Diabetes was associated with a significant basal increase in neutrophil CD11b expression and adhesion to endothelial cells as well as with an increased superoxide anion production. The increased adhesion of diabetic neutrophils persisted by the end of the CPB to 60 min postoperatively independently of the blood glucose levels. Antibodies directed against CD11b and CD18 significantly reduced the degree of neutrophil adhesion observed 60 min postoperatively. Conclusions: These results indicate that diabetes mellitus is associated with an increased neutrophil-endothelial cell adhesion probably mediated by the CD11b/CD18 molecule; this, in turn, might be responsible for the increased risk of postoperative complications observed in diabetic patients undergoing coronary artery bypass grafting. © 1998 Elsevier Science B.V. All rights reserved

1. In this article some of the most important and tolerated drugs in the elderly are reviewed. 2. Tricyclic antidepressants have to be used carefully because of their important side effects. Nortriptyline and desipramine appear to be the best tolerated tricyclics in old people. 3. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose. 4. MAO inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy and the last generation drugs (reversible MAO inhibitors), such as moclobemide, seem to be very successful. 5. Lithium is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients due to its side effects. 6. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide, or drug-resistant forms.

We treated a patient with a 30-year history of ethanol and benzodiazepine abuse who, on emerging from general anesthesia, was combative and confused. Our working diagnosis was acute ethanol withdrawal, and the patient received intravenous (i.v.) propofol, and midazolam. Initially small doses (10 to 20 mg) of propofol, combined with a midazolam infusion (50 mg/hr), produced sedation. Later, however, the patient became increasingly combative, confused, hypertensive, and tachycardic despite an i.v. propofol infusion at doses up to 1,000 micrograms/kg/min (total propofol dose: 1,755 mg). Immediate sedation was produced by thiopental bolus (500 mg) and i.v. infusion (200 mg/hr). The implication of the patient's initial appropriate response to propofol, followed by the lack of effect when much higher doses were employed, is discussed. While tachyphylaxis has been reported after long-term propofol use, we believe this to be the first case of acute tachyphylaxis.

Pericardiectomy for post-irradiative constrictive pericarditis achieves poor results because of the extensive damage to the heart and pericardium caused by ionizing radiation. The extracellular structural protein, collagen, is responsible for the functional integrity of the myocardium and allows reversible interdigitation and the transmission of force between contracting myocytes. Collagen concentration and composition were examined in the cardiac tissue of three patients undergoing pericardiectomy and post-irradiative pericarditis. Normal heart tissue was taken at autopsy from patients without cardiac disease and acted as controls. Total collagen concentration (mean(s.e.m.)) was significantly increased in the ventricular tissue of patients with post-irradiative pericarditis compared with that of the controls (119.8(16.6) versus 50.4(5.2) mg/g dry weight, P

The pharmacologic use of phosphocreatine (Pcr) in cardiology and cardiac surgery, along with other so-called metabolic drugs, to prevent the ultrastructural and clinical effects of ischemia on the myocardium has been the aim of many studies during recent years. To evaluate the protective action of Pcr in a series of surgical vascular patients with an associated heart disease, the authors have included in this study 62 patients undergoing vascular operations and have randomly divided them into a Pcr-treated group and a control group. The cardiac index (L x min-1 x m-2), the use of inotropic drugs (number of patients), the EKG alterations (ST ≥ 2 mm, arrhythmias) with a Holter registration, and the measurement of ejection fraction by 2D-Echo Doppler analysis were examined. A statistically significant improvement in the central hemodynamics during the immediate postoperative course was observed in the Pcr group, preserving a good left ventricular function and preventing severe arrhythmias. The results revealed that the use of Pcr induced a more efficacious protection of the myocardium with an improved functional recovery, a positive inotropic effect, and an antiarrhythmic action. Nevertheless there is need for further studies to demonstrate the real benefit of using Pcr for myocardial protection in vascular surgery.

This paper describes the use of multi-family group therapy with dually diagnosed adolescents. It includes a brief review of the concept of dual diagnosis, and describes the authors' experience in working with multi-family group therapy in a dual diagnosis day treatment program.

c-VEMPs and o-VEMPs are a new diagnostic tool to detect diseases of the inner ear and the vestibular pathways. The aim of our study was to assess the reliability of c-VEMPs and o-VEMPs in some otoneurological diseases. We examined 27 patients, 15 F, 12 M, mean age 42,5. 20 Meniere disease (MD), 3 Benign Paroxysmal Positional Vertigo (BPPV) and 4 vestibular neuritis (VN). c-VEMPs were recorded from electrodes placed over the SCM, with reference over the clavicle. o-VEMPs from the same electrodes placed beneath the eye and reference 2 cm below. For both c-VEMPs and o-VEMPs we used acoustic stimuli (tone burst, 117 dB SPL). MD: both c-VEMPs and o-VEMPs were normal in 13 patients (65%); c-VEMPs were abnormal in 1 patient (5%); o-VEMPs in 4 patients (20%) and both c-VEMPs and o-VEMPs in 2 patients (10%). BPPV: normal in 2 pts. (67%); o-VEMPs abnormal in 1 pt. (33%) VN: c-VEMPs abnormal in 1 pt; (25%), o-VEMPs in 1pt. (25%) both c-VEMPs and o-VEMPs in 2 pts. (50%). c-VEMPs and o-VEMPs seem to be reliable tests to improve the diagnosis of otoneurological diseases. We point out that in some subjects with MD the only abnormal test was o-VEMPs.

To evaluate the effect of coenzyme Q10 in reducing postoperative cardiac complications after ischemia and reperfusion, we randomly divided 40 patients undergoing elective coronary artery bypass into two groups: patients in group 1 received coenzyme Q10 (150 mg/day) for 7 days before operation, and those in group 2 were the control group. Concentrations of thiobarbituric acid-reactive substances (malondialdehyde), conjugated dienes, and cardiac isoenzymes of creatine kinase were measured in samples from both arterial and coronary sinus sites. Serial sampling was performed 5 minutes after heparin administration, at 10 and 30 minutes during cardiopulmonary bypass, 15 and 30 minutes after aortic cross-clamp removal, and 5 minutes after protamine administration. The concentrations of malondialdehyde, conjugated dienes, and creatine kinase in group 1 were significantly lower than those in group 2. The decrease in plasma malondialdehyde concentrations correlated positively with the decrease in creatine kinase levels in the coronary sinus. The treatment group showed a significantly lower incidence of ventricular arrhythmias during the recovery period than did the control group (p < 0.05). Although the percentage of patients requiring inotropic agents was not significantly different between the two groups, the mean dosage of dopamine required to maintain stable hemodynamics was significantly lower in patients of group 1 than in those of group 2 (p < 0.01). Our findings suggest that pretreatment with coenzyme Q10 may play a protective role during routine bypass grafting by attenuating the degree of peroxidative damage.

Vestibular-evoked myogenic potentials (VEMPs) have been recorded from tonically contracted neck muscles by acoustic and galvanic stimulation or forehead tap (cervical VEMPs, c-VEMPs). VEMPs can also be recorded from extraocular muscles, using the same stimuli. (ocular VEMPs, o-VEMPs). The aim of our study was to assess the feasibility and reproducibility of both c-VEMPs and o-VEMPs in healthy subjects. We examined 21 healthy subjects, 9 M, 12 F, mean age 40,8. c-VEMPs were recorded from electrodes placed over the SCM, with reference placed over the clavicle. o-VEMPs were recorded from the same electrodes placed beneath the eye and reference 2 cm below. For both c-VEMPs and o-VEMPs we used acoustic stimuli (tone burst, 117 dB SPL). We obtained reproducible c-VEMPs and o-VEMPs in all the subjects. Mean latency (ms): c-VEMPs (p13): 13.5 ± 0.8; o-VEMPs (n1): 10.2 ± 0.7. Mean amplitude (μV): c-VEMPs (p13-n23): 138 ± 51; o-VEMPs (onset-n1): 5.2 ± 2.8. Our study confirms that c-VEMPs and o-VEMPs are a reliable test with reproducibility and stability of its components. In association with BAEPs, c-VEMPs and o-VEMPs could help to better diagnose the peripheral and central diseases of the cocleo-vestibular pathways.

IntroductionSeveral neuropsychiatric pathologies have been recently linked to oxidative stress.ObjectivesIn this study, we investigated the relationship between depression, markers of oxidative stress and neurotransmission, as expressed by sensory cortex excitability.MethodsSerum levels of oxidative stress markers and somatosensory magnetic fields, evokedby external galvanic stimulation, were measured in 13 depressed patients and 13 controls.ResultsDepressives had higher levels of total and free copper than controls and lower levels oftransferrin. They also showed lower sensory cortex excitability, which correlated with copperlevels in controls, but not in patients. Transferrin correlated with sensory cortex excitability inboth patients and controls, although in opposite ways. Copper level results associated with thepatients’ clinical status.ConclusionsPro-oxidant agents appear to affect neuronal excitability and clinical state ofdepressed patients, as free copper excess alters their cortical glutamatergic neurotransmission.

International audience; Disentangling the demographic processes that determine the genetic structure of a given species is a fundamental question in conservation and management. In the present study, the population structure of the European eel was examined with a multidisciplinary approach combining the fields of molecular genetics and population dynamics modelling. First, we analyzed a total of 346 adult specimens of known age collected in three separate sample sites using a large panel of 22 EST-linked microsatellite loci. Second, we developed a European eel-specific model to unravel the demographic mechanisms that can produce the level of genetic differentiation estimated by molecular markers. This is the first study that reveals a pattern of genetic patchiness in maturing adults of the European eel. A highly significant genetic differentiation was observed among samples that did not follow an Isolation-by-Distance or Isolation-by-Time pattern. The observation of genetic patchiness in adults is likely to result from a limited parental contribution to each spawning event as suggested by our modelling approach. The value of genetic differentiation found is predicted by the model when reproduction occurs in a limited number of spawning events isolated from each other in time or space, with an average of 130-375 breeders in each spawning event. Unpredictability in spawning success may have important consequences for the life-history evolution of the European eel, including a bet-hedging strategy (distributing reproductive efforts over time) which could in turn guarantee successful reproduction of some adults.

The Web is an evolving system, which tries to adapt to the needs of users. The transition to Web2.0, and, currently, to Web3.0, are the expression of this trend: the goal is to focus on the leading role of the end user in Web browsing, which should be supported by adequate tools. In this paper, we propose Bor`e, an architectural paradigm for developing content-based web applications based on cooperative interaction, whose foundations are based on the principles of the model Web3.0. The proposed architecture is extremely innovative in three respects. The first one is the possibility of defining, organizing, storing, querying and displaying the information as customizable objects and relations: a notexpert user can create the Web that he/she may prefer. A second aspect is the realization of social networks (Social Cooperations), which spontaneously arise, through user resource sharing. Finally, there is the possibility of analyzing users' browsing activities, through learning tools that enable the user to enrich his/her Web browsing experience with new knowledge

Data concerning electrocardiographic (ECG) abnormalities in thalassemic cardiomyopathy are scanty. Current techniques to detect early findings of myocardial involvement in thalassemia (Magnetic Resonance, Stress Echo, Tissue Doppler Imaging) are not widely available. We sought to determine whether new ECG abnormalities emerge in thalassemia patients when heart failure due to cardiomyopathy occurs. ECG and Echo Doppler examinations of 28 consecutive adult thalassemia patients with heart failure observed at our hospital were compared with ECG and Echo Doppler examinations performed before the onset of heart dysfunction and with those of 60 age and sex-matched patients with thalassemia without evidence of cardiac involvement. All the patients with heart failure had new ECG abnormalities. New onset supraventricular arrhythmias, T wave inversion, low voltages, right QRS axis deviation and S1Q3 pattern developed respectively in 46%, 79%, 43%, 18% and 15% of thalassemic patients with heart failure. None of the patients without heart failure showed any ECG abnormality (P < 0.001). In conclusion this study suggests that new onset ECG abnormalities are always evident in patients with and always absent in patients without heart failure due to thalassemic cardiomyopathy.

A panel of leading Italian specialists in infectious diseases, obstetrics and gynaecology met in a national consensus workshop on women facing HIV to review critical aspects and discuss recommendations for selected key questions on four issues: (1) women and highly active antiretroviral therapy (HAART): access to care and adherence to therapy, side effects and drug-drug interaction; (2) HIV-infected pregnant women: prevention of mother to child transmission; (3) desire for children among women living with HIV: assisted reproduction; (4) sexually transmitted diseases and genital disturbances. The method of a nominal group meeting was used, and recommendations were graded for their strength and quality of evidence using a system based on the one adopted by the Infectious Diseases Society of America. Main conclusions are summarized and critically discussed, and some of the most recent data supporting recommendations are provided.

Diabetic ketoacidosis (DKA), a pathophysiologic, life-threatening process that results from uncontrolled diabetes mellitus-induced hyperglycemia, is seen frequently in the pediatric ICU. This article reviews the pathophysiology, management, goals of treatment, and nursing implications of the child who is diagnosed with DKA. Facets particular to the pediatric population are reviewed.

Current techniques for the production of transgenic domestic animals remain inefficient. Only recently, DNA transposons resulted in improved efficiencies for mouse and pig transgenesis. In this work, we evaluated Tn5 and Sleeping Beauty systems for transgenesis in bovine and ovine species. First, both transposon systems were assessed in vitro in bovine embryos employing transposons carrying fluorescent reporter genes. In vitro-produced bovine zygotes were microinjected with either 1) a complex of Tn5:egfp transposon (20 ng μL–1) (protein: transgene with mosaic ends recognised by Tn5, in Mg+2 free medium), or 2) two plasmids carrying Sleeping Beauty 100X (pSB100X, 5 ng μL–1) and pT2/Venus transposon (10 ng μL–1). In vitro results for Tn5 transgenesis in bovine showed that blastocysts, Day 4 egfp embryos and egfp blastocysts rates for the group injected with Tn5:egfp did not differ from the group injected with the egfp transposon alone (73/145, 50%; 86/145, 59%; and 65/145, 45% v. 65/129, 50%; 87/129, 67%; and 57/129, 44%, respectively). For SB transgenesis, blastocysts, D4 Venus embryos, and Venus blastocysts rates did not differ between co-injection of pSB100X and pT2/Venus or injection with pT2/Venus alone (46/99, 46.5%; 64/99, 64.6%; and 33/99, 33.3% v. 41/83, 49.4%; 52/83, 62.7%; and 26/83, 31.3%, respectively). However, Venus intensity in blastocysts was markedly higher for the group co-injected with pSB100X and pT2/Venus respective to pT2/Venus alone. Both systems were assessed in vivo for the production of transgenic lambs employing a functional transposon (hrFIX, recombinant human factor IX driven by a Beta-lactoglobulin promoter). Laparoscopic artificial insemination of donor sheep was performed, and presumptive zygotes were flushed from the oviducts. The microinjections were done identically as described for the bovine embryos. A total of 24 presumptive zygotes were recovered and injected with the Tn5:hrFIX complex. Then, 21 zygotes were transferred to 5 synchronized ewes; one pregnancy of siblings was obtained, and one animal was born. Genomic DNA from skin, placenta, and blood was genotyped by PCR, but the hrFIX gene could not be detected. For the SB approach, 64 presumptive zygotes were recovered from 4 superovulated ewes, microinjected with the SB plasmids, and 21 of them were transferred to 7 oestrous synchronized recipients. The remaining zygotes were cultured in vitro and blastocysts (n = 7) were vitrified. Currently, 3 donor ewes are pregnant, one with siblings (4 total fetuses). Deliveries are expected by the end of August of this year. Our results indicate that both Tn5 and SB systems are capable of resulting in the production of transgene expressing embryos, and the presence of the transposases does not affect embryo viability. However, phenotyping of blastocyst stages does not seem to be predictive for stable transgene integration. The in vivo results will help to better address the suitability of Tn5 and SB approaches for the production of transgenic sheep.