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Background: Paracetamol is recommended as first-line treatment for pain control in osteoarthritis because it has fewer side effects than do other therapeutic options, including nonsteroidal anti-inflammatory drugs (NSAIDs). Prescribing proton pump inhibitors (PPIs) as gastric bleeding prophylaxis in chronic NSAID users is also common, although not recommended. In Italy, paracetamol is not reimbursed by the National Health System. The aim of this trial was to test whether the availability to osteoarthritis patients of free paracetamol would decrease their use of NSAIDs and, as a secondary objective, whether opioid and PPI consumption would also decrease., Methods: Eight general practitioners (GPs) (59 patients) were randomized to usual care and 8 (58 patients) to the experimental arm, where prescribed paracetamol was directly distributed for free by the local hospital. After 6 months, paracetamol was also available for free in the control arm. The main outcome was the pre/post difference in average NSAID and PPI consumption. Differences between experimental and control arms in pre/post differences are reported, as registered by the drug prescription information system., Results: Average NSAID consumption decreased non-significantly, from 6.79 to 2.16 defined daily dose (DDD) in the experimental arm and from 3.19 to 2.97 DDD in the control group (p = 0.067). No changes were observed for PPIs (from 11.27 to 14.65 DDD and from 9.74 to 12.58 DDD in experimental and control arms, respectively, p = 0.788) or opioids (from 1.61 to 1.14 DDD and from 1.41 to 1.56 DDD in experimental and control arms, respectively, p = 0.419). When the intervention was extended to the control arm, no decrease in NSAID consumption was observed (from 2.46 to 2.43 DDD, p = 0.521)., Conclusions: Removing small economic barriers had small or no effect on the appropriateness of opioid or PPI prescribing to patients with osteoarthritis; a reduction in NSAID consumption cannot be ruled out., Trial Registration Number: NCT02691754 (Approved February 24, 2016).

Background: The aim of this study was to demonstrate the efficacy of a management model to reduce hospitalizations in patients recently admitted for acute decompensated heart failure., Methods: The management model was based on a close integration between hospital and territory health services. Clinical evaluation, ECG, echocardiographic findings, total body bioimpedance and brain natriuretic peptide serum levels were used to assess clinical stability of patients at discharge and during follow-up. A dedicated nurse (care manager) was involved in patient empowerment, telephone follow-up, check of adherence to therapy and clinical conditions, and management of scheduled evaluations. All hospitalizations occurring prior to or after enrolment in the municipalities involved in the study were considered, as well as the hospitalizations occurring among enrolled patients., Results: A total of 301 patients were enrolled, 226 of them from the Centers of the Puglia Region, Italy. An overall reduction of 6% in total hospitalizations with DRG 127 was observed; the reduction was most evident in the two centers with the smaller reference population (-16% and -26%, respectively). In the group of patients enrolled, an overall reduction in hospital admissions was observed after comparing the period before and after enrolment. A significant increase in the prescription rate of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, beta-blockers and aldosterone antagonists was also observed. Finally, an overall reduction in the costs for patient management was demonstrated. Similar results were obtained in the two additional Centers of the Basilicata and Lazio Regions., Conclusions: An integrated management between hospital and territory allows optimization of the management of heart failure patients, with improvement of therapy and reduction in hospitalizations and management costs.

Objectives: The aim of our study was to assess the possible role of a prognostic index based on ambulatory blood pressure monitoring in a large cohort of patients with recent myocardial infarction., Methods: The study population included 1335 consecutive patients admitted for ST elevation myocardial infarction and discharged alive from 48 Italian hospitals participating in the multicentric IMPRESSIVE (Infarto Miocardico, Pressione arteriosa e frequenza cardiaca. Studio Italiano di Valutazione Epidemiologica) study. Ambulatory blood pressure monitoring was performed 3 weeks after discharge, with a clinical follow-up of 12 months. End-points included cardiac death and new admission for heart failure. A prognostic index was obtained from the ambulatory blood pressure monitoring variables according to the formula: (220-age)-mean 24 h heart rate (m24hHR)+mean 24 h diastolic blood pressure (m24hDBP)., Results: Among many potential predictors only left-ventricular ejection fraction, creatinine levels, Killip class and the prognostic index were independently associated with events during the follow-up. In particular, higher values of the prognostic index were associated with a lower incidence of events, with an odds ratio of 0.958 (95% confidence intervals 0.943-0.974) and a 4% reduction in risk for each point of the prognostic index. Overall incidence of cardiac events was 6-fold higher in patients within the lowest quartile of the prognostic index (< or =148) compared with the other three quartiles (12 vs. 2, 1.4 and 2% respectively in the other three quartiles; P<0.0001)., Conclusions: A simple prognostic index based on ambulatory blood pressure monitoring and age may be a useful tool in predicting cardiac death and heart failure in patients with recent myocardial infarction.

Objectives: We tested the accuracy of the UA-705 blood pressure semi-automatic monitor., Methods: Device evaluation was performed according to the modified British Hypertension Society protocol released in 1993. Eighty-five patients with characteristics outlined in the British Hypertension Society protocol were recruited among those attending our out-patient clinic. Sequential readings were taken for the main validation test. Outcome was classified according to the British Hypertension Society criteria, which are based on four zones of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more., Results: The mean blood pressure difference (+ or -1 SD) between device and observers was 0.4 mmHg (SD 7.7) for systolic blood pressure and 0.3 mmHg (SD 8.2) for diastolic blood pressure. Overall, 96% (observer 1) and 95% (observer 2) of readings between device and observers differed by 15 mmHg or less for both systolic and diastolic blood pressure. The device achieved a grade A for both systolic and diastolic blood pressure., Conclusions: This study shows that the A&D UA-705 device satisfies the British Hypertension Society standard for accuracy by achieving a grade A for both systolic and diastolic blood pressure.

We investigated the occurrence of the plant Uncoupling Protein (UCP) in mitochondria isolated from both fresh (f-JAM) and aged-dehydrated (a-d-JAM) slices of Jerusalem artichoke tubers (Helianthus tuberosus L.). The presence of UCP was shown by immunological analysis and its function was investigated by measuring the decrease of the mitochondrial membrane potential due to linoleic acid (LA) and its inhibition by purine nucleotides under conditions in which the adenine nucleotide translocator (ANT) was inhibited by atractyloside (Atr). f-JAM and a-d-JAM had the same protein content, but differed from one another with respect to purine nucleotide inhibition, substrate specificity, and sensitivity to ROS. Hydrogen peroxide and superoxide anion, generated in situ by xanthine plus xanthine oxidase, caused a significant increase in the UCP function in a-d-JAM, but not in f-JAM. This occurred in a manner sensitive to ATP, but not to Atr, thus showing that ANT has no role in the process. The dependence of the rate of membrane potential decrease on increasing LA concentrations, either in the absence or the presence of ROS, showed a sigmoidal saturation both in f-JAM and a-d-JAM. However, addition of ROS in a-d-JAM resulted in about 40% increase of the Vmax value, with no change in the K0.5 (about 20 microM), whereas in f-JAM no effect on either the Vmax or K0.5 (about 28 microM) was found. Furthermore, a decreased ROS production as a result of LA addition was found in both f-JAM and a-d-JAM, the effect being more marked in a-d-JAM.

Background: Type 2 diabetes is the most frequent form of diabetes in the adult population and is associated with an increasing risk of cardiovascular diseases. The objective of this study was to describe the prevalence and the state of control in an Italian population sample examined within the Osservatorio Epidemiologico Cardiovascolare study., Methods: The sample of this study consisted in 8972 subjects, men and women aged 35-74 years. A fasting capillary blood glucose > or = 126 mg/dl or being on antidiabetic treatment were the criteria used to define diabetes, while a fasting capillary blood glucose < 140 mg/dl was considered to represent effective treatment (controlled diabetes) in treated patients., Results: Diabetes was present in 8.4% of men and 6% in women. The prevalence of glucose intolerance was 8.2% in men and 4.3% in women. Only 50.7% of diabetic men and 56.5% of diabetic women knew about their disease; among these people, 21% was on treatment with oral antidiabetics and/or insulin. Such a therapy was effective in 39.5% of the treated cases., Conclusions: The prevalence of diabetes as well as glucose intolerance was greater in men and in the regions of the Center and South of Italy. The state of control of diabetes cannot be considered satisfactory; women and older age groups, when prevention strategies are less important, appear to be under better care.

We investigated whether and how mitochondria from durum wheat (Triticum durum Desf.) and potato (Solanum tuberosum), isolated from etiolated shoots and a cell suspension culture, respectively, oxidize externally added NADH via the mitochondrial shuttles; in particular, we compared the shuttles and the external NADH dehydrogenase (NADH DHExt) with respect to their capacity to oxidize external NADH. We found that external NADH and NADPH can be oxidized via two separate DHExt, whereas under conditions in which the activities of NAD(P)H DHExt are largely prevented, NADH (but not NADPH) is oxidized in the presence of external malate (MAL) and MAL dehydrogenase, in a manner sensitive to several non-penetrant compounds according to the occurrence of the MAL/oxaloacetate (OAA) shuttle. In durum wheat mitochondria and potato cell mitochondria, the rate of NADH oxidation was limited by the rate of a novel carrier, the MAL/OAA antiporter, which is different from other carriers thought to transport OAA across the mitochondrial membrane. No NAD(P)H oxidation occurred arising from the MAL/Aspartate and the alpha-glycerophosphate/dihydroxyacetonphosphate shuttles. We determined the kinetic parameters of the enzymes and the antiporter involved in NADH oxidation, and, on the basis of a kinetic analysis, we showed that, at low physiological NADH concentrations, oxidation via the MAL/OAA shuttle occurred with a higher efficiency than that due to the NADH DHExt (about 100- and 10-fold at 1 microm NADH in durum wheat mitochondria and in potato cell mitochondria, respectively). The NADH DHExt contribution to NADH oxidation increased with increasing NADH concentration.

To evaluate the prognostic impact of left ventricular (LV) mass exceeding individual needs to compensate hemodynamic load, the percentage of excess of echocardiographic LV mass in relation to individual ideal value predicted by gender, stroke work, and height (in meter(2.7)) from a reference population was assessed in 1019 white hypertensives (627 women [24% obese] and 392 men [17% obese, P<0.02 versus women]) without prevalent cardiovascular disease or type 1 diabetes, from the Italian multicenter, prospective study MAVI. Low LV mass (<73% of predicted) was found in 36 patients (3.5%), 661 had appropriate LV mass, and 322 (37%) had inappropriate LV mass. During follow-up (35+/-11 months), 52 fatal or nonfatal primary cardiovascular events occurred. Age, systolic blood pressure, and LV mass as a percentage of the predicted value were significant predictors of cardiovascular events (all P<0.01), independently of gender, glycemia, antihypertensive treatments, and body mass index, even in subgroups with or without LV hypertrophy. Survival analysis showed that cardiovascular risk increased stepwise from the lowest to the highest quintile of LV mass as a percentage of predicted value (P<0.01). The excess LV mass showed incremental prognostic value compared with assessment of traditional LV mass (P<0.01). Thus, inappropriate LV mass predicts a risk of cardiovascular events, independently of risk factors, and remains a significant predictor of risk either in the presence or in the absence of traditionally defined LV hypertrophy.

It is well known that hypertension is a highly prevalent condition in the population, carries a significant risk of adverse cardiovascular events and is therapeutically difficult to control. These factors render it "a major unsolved - but soluble - mass public health problem". One of the present-day aspects of the complexity of managing patients with high blood pressure (BP) derives from clinical and epidemiological data that have emerged over the past 10 years: the growing importance of the clinical significance of systolic and pulse BP. The pathophysiological basis of these data is based, on the one hand, on a better articulated definition of the components of BP, and on the other, on precise information concerning age-related modifications. The common definition of BP does not take into account pressure fluctuations occurring during the cardiac cycle; in fact, systolic and diastolic BP denote the extreme values of continuous variations in differential pressure. Diastolic BP reflects, to a greater extent, the trend of arterial resistances and mean BP (usually calculated as diastolic BP plus one third of the differential BP, and considered the "stable component" of the arterial sphygmogram) and has long been used as a diagnostic and therapeutic target. Systolic BP is more closely linked to variations in pulse BP (given from the difference between systolic and diastolic BP and considered the "dynamic component" of the arterial sphygmogram) and is produced by a group of factors including left ventricular ejection and the reflection of the sphygmic wave. As age increases, the walls of the aorta and the large elastic arteries progressively harden due to senile degenerative phenomena and the loss of elasticity as well as the progressive diffusion of atherosdclerotic lesions. This leads to the reduced capacity of the arterial wall to distend during the systole with a consequent increase in both systolic and pulse BP. These pathophysiological data have important clinical and prognostic implications and account for the possible diversity of significance to attribute to systolic, diastolic, mean and pulse BP, factors which, in their entirety, can represent an element, albeit partial, of resolvability of problems in managing hypertension. In fact, possibilities of diversification in the stratification of risk of the hypertensive patients may be considered on a pathophysiological basis, with the prospect of better aimed therapeutic interventions. On the whole, it appears that the clinical significance to attribute to pulse BP should be considered not as an alternative to that of systolic and diastolic BP, but rather in complementary terms, with age kept in careful consideration. In practice, by simplifying to a maximum the state of present knowledge, the values of systolic, diastolic, mean and pulse BP are all important in subjects under 60 years old. This indicates that the clinical significance to attribute to diastolic hypertension in young or middle-aged patients, which have been so accurately described by well-known meta-analyses, is not presently under discussion. What seems to change, with respect to the past, is the importance that should be attributed to the systolic and pulse BP in subjects of all ages and in particular to pulse BP in subjects over 60 years old: in these persons, the increase in pulse BP summarizes and integrates the adverse prognostic value of an elevated systolic BP and a low diastolic BP. It should be clearly understood that, in subjects over 60 years old, a high systolic BP and a low diastolic BP mean rigidity of the wall of the aorta and of the main elastic arteries; in these subjects, the isolated increase in diastolic BP, usually easily controllable by antihypertensive treatment, should not cause excessive clinical concern; instead, an increase in systolic BP - even if isolated - and, above all, an increase in pulse BP, should cause greater preoccupation, inasmuch as they are signs of consistent serious structural lesions. In other words, a 60-year-old subject with 150/90 mmHg would have a lesser risk of cardiovascular events, particularly cardiological events, than a contemporary with equal risk factors who has 150/50 mmHg. A large number of clinical studies suggest that an increase in pulse BP seems to predict cardiac ischemic events to a greater extent than the cerebrovascular events, which seem to be predicted to a greater extent by the mean BP. On the therapeutic level, the reference datum is represented by the unequivocal demonstration, furnished by wide scale interventional studies, that in hypertensive patients adequate pharmacological control of both the diastolic and systolic BP, particularly in the elderly, significantly reduces adverse consequences linked to the progression of atherosclerotic disease in the heart, brain and kidney. A degree of complexity is represented by the modest percent of patients in treatment who have BP values < 140/90 mmHg. Only a series of ad hoc studies will enable us to know when and if this negative situation can be resolved, even partially, by the clinical application of new knowledge in the pathophysiological field. From this point of view, it should be kept in mind that ACE-inhibitors, diuretics, dihydropyridinic calcium antagonists and vasopeptidase inhibitors seem to be more effective than beta-blockers in terms of preferential reduction of pulse BP. The contents of the reports that make up the Symposium constitute a valid base of knowledge and represent a concrete stimulus for research initiatives, which in the spirit of "operativeness" of the Area Prevenzione of the Italian Association of Hospital Cardiologists, follow the objective of bringing together scientific and managerial needs.

The authors report on the incidence, clinical picture, etiology, pathogenesis and treatment of congenital pollex flexus, and communicate the results of surgery on 52 thumbs. The permanent flexion anomaly in the interphalangeal joint and a hard, palpable knot in the long flexor tendon of the thumb over the metacarpophalangeal joint are typical for the deformity. Although these changes are sometimes observed immediately post partum, delayed diagnosis and treatment are more common. The hypothesis that it is a hereditary, endogenous condition is supported by observations in twins, relatively frequent bilateral occurrence and a high familial incidence. Constriction of the synovial sheath over the basal joint of the thumb is a key pathogenetic factor, although little is known about its causes; anatomical factors, influences affecting the growth of the sesamoid bones, and mechanical causes have been postulated. A more plausible hypothesis was first advanced by Jeannin. Like Hueston and Wilson 100 years later, he compared the tendon to a thick thread which had to be passed through a narrow eye of a needle: as a result, the "thread" would be frayed and compressed. The knot in the tendon is held to be a secondary phenomenon. The pathologicoanatomical picture varies. Lymphocyte and monocyte infiltration, and metaplasias to fiber cartilage have been detected in specimens excised from the tendon and the synovial sheath. However, pathologic changes have not been found in all cases. In the first year of life conservative therapy may be attempted, with temporary splinting of the thumb following manual correction of the flexion anomaly in the interphalangeal joint.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical, electrocardiographic and echocardiographic data were collected in a group of 228 patients with autosomal dominant polycystic kidney disease (PKD) and in another group of 146 unaffected members (NPKD) both comprised in a five-generation kindred followed for 10 years, in order to determine the profile and prevalence of cardiovascular derangement of the genetic disease. A family of 181 members was used as a control. The prevalence of left ventricular hypertrophy in the three groups was 24, 14 and 6% respectively (p less than 0.01); after 10 years it increased up to 35, 26 and 13% respectively (p less than 0.05). The evidence of mitral-valve prolapse was more frequent in PKD and in NPKD group (25 and 20% respectively) than in control subjects (2%) (p less than 0.0001). Mitral incompetence was found in 30, 18 and 8% of those groups respectively (p less than 0.002). The large difference in mitral involvement did not change over time. Tricuspid valve prolapse was detected in 5, 4 and 1% of the three groups, respectively (p less than 0.05). A small increase in frequency was found after 10 years only in polycystic kidney disease patients. Regurgitant aortic lesions were present in higher prevalence in PKD (19%) and NPKD (17%) members than in controls (5%) (p less than 0.001). After 10 years they were 23, 20 and 8%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Papilloma is a rare primary heart tumour; only 75 cases have been reported and most were casual findings at autopsy. We describe another case of this tumour in a 9 years girl. The neoformation had produced a picture of angina pectoris, followed by death due to an occluded left coronary orifice. To our knowledge, this is the first report of this type of tumour with electrocardiographic documentation.

Urinary levels of free adrenaline, noradrenaline and 11-hydroxycorticosteroid were measured in 30 surgeons while they operated, to test the hypothesis that sympathetic and adrenocortical systems are overactivated by occupational environment of surgery procedures. They were divided in two groups according to a crossover design in which the surgeons had taken alternatively an oral dose of 40 mg oxprenolol and placebo. During operations with placebo urinary free adrenaline, noradrenaline and 11-hydroxycorticosteroid rose significantly compared with the control values obtained during ward-round performed by the same surgeons. The increase of adrenaline, noradrenaline and 11-hydroxycorticosteroid was abolished by 40 mg of oxprenolol which contained their urinary concentration to the control values. These data support the concept that operating stress of surgeons influences the adrenosympathetic and adrenocortical systems and they indicate a possible role of beta-blocking drugs in minimizing the adverse reactions of a such hormonal overactivity.

The role of the sympathoadrenomedullary and adrenocortical systems has been assessed by measuring serially the urinary excretion of free adrenaline, noradrenaline and 11-hydroxycorticosteroids in 32 healthy men under two conditions of job stress: piece-work and assembly line. The urinary levels of two catecholamines and 11-hydroxycorticosteroids rose significantly in piece work and assembly line workers, compared with the values observed respectively during salaried and "ordinary" work. Identical results were obtained in the same workers after six months of stressor exposure to piece-work and assembly line conditions. The results support the assumption that long-term exposure of conditions of work stress significant effects on the function under study, this being in the same direction and of the same order of magnitude as that described during short-term exposure in other types of every-day stress and distress. The methodological and clinical implication of these results are discussed.

In a prospective study blood pressure was recorded for 20 years in 132 white patients with congenital blindness and in 138 white control schoolchildren. The subjects for both groups were consecutively enrolled without any selection parameters. During the study period a similar proportion of blind patients and controls reported identical consumption of tobacco (above the age of 14 years) and of oral contraceptives (above 21 years) among women. Mean 24-h urinary sodium excretion, collected randomly in both groups, did not differ between the blind patients and the controls. During the 20-year period systolic and diastolic blood pressure rose with age in the control group as expected and much less in blind patients; after 14-17 years the difference was statistically significant. The mean slope of the regression line (beta coefficient) for systolic blood pressure versus age was 1.143 in the blind patients and 1.794 in the controls (P less than 0.001), and for diastolic blood pressure 0.908 in the patients and 1.353 in the school children (P less than 0.001). The mean weight and body mass index increased more in the blind patients than in the controls (difference 5.9 and 2.8 kg, respectively). The results support the hypothesis that low visual and cognitive stress levels determine a lower level of cardiovascular reactivity with ageing.