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Background Several studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality. Methods Subjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders. Results After adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities. Conclusions Despite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.

Summary Background Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin with high rates of local recurrence. It is debated whether Mohs micrographic surgery (MMS) involves lower recurrence rates than wide local excision (WLE). Recent preliminary reports indicate more consistently favorable cure rates with MMS. We report comparative observational data on 41 patients who underwent MMS and 38 who underwent WLE. Their data were then pooled with those available in the medical literature to obtain more precise estimates of recurrence rates with MMS and WLE. Methods The records of 79 patients with DFSP who underwent WLE (n = 38) or MMS (n = 41) in 1990–2005 were reviewed retrospectively. The primary endpoint was tumor recurrence rate. The PubMed database was searched for DFSP case series treated with WLE or MMS, and the recurrence proportions reported for the two separate procedures were pooled. Results Five of the 38 WLE patients (follow-up = 4.8 years) had recurrences (13.2%, 95% CI 4.4–28.1%) as opposed to none (95% CI 0–8.6%) of the 41 MMS patients (follow-up = 5.4 years). Pooling of these data with those from the literature yielded 6/463 recurrences for MMS (1.3%, 95% CI 0.5–2.8%) and 288/1394 recurrences for WLE (20.7%, 95% CI 18.6–22.9%). The relative risk of recurrence for WLE vs. MMS patients was 15.9 (95% CI 7.2–35.5). Conclusions Significantly lower recurrence rates were recorded in our patients subjected to MMS compared with those treated with WLE. The pooled data also indicated a clear advantage of MMS. There is inconclusive evidence for any advantage of MMS in non-primary cases, while MMS was most effective in treating head and neck tumors. These data may be useful to guide clinicians in the choice of the more appropriate surgical treatment for DFSP patients.

Despite their benign nature, keloids may constitute a severe aesthetic and, in some cases, functional problem with important repercussions on patients' quality of life. There is no consensus on keloid treatment and no wholly satisfactory therapy has yet emerged.To assess the efficacy of cryotherapy in the treatment of keloids.135 patients with 166 keloids received cryosurgical treatment between 1990 and 2004. Freeze times and number of sessions varied. Scar volume was measured before and after treatment. Median follow-up was 48.6 months (range 12.4-72.6 months).Of the 166 lesions treated, 79.5% responded very well with a volume reduction of the initial mass of greater than 80% after a median of 3 treatments (range: 1-9). A good result was obtained in 14.5% of lesions, while results were unsatisfactory in 6% of cases. The main adverse effects reported were atrophic depressed scars and residual hypopigmentation (75% of cases). No recurrences arose during the follow-up period (12-72 months).To date, cryotherapy appears to be the most effective, safe, economic, and easy-to-perform monotherapy to treat keloid lesions and hypertrophic scars.

Melasma is a common disorder of hyperpigmentation involving sun exposed face and neck areas. Three clinical patterns of melasma are recognized: the centrofacial, the malar, and the mandibular ones. Several factors have been implicated in the pathogenesis of this disorder including pregnancy, oral contraceptive therapy, sun exposure, genetic factors, cosmetics, and race. This condition is most frequently observed in women and affects all racial groups; however, it is commonly found in darker-complexioned individuals (skin types IV through VI) and in Asian women who live and work under strong sunlight exposure for long periods. Melasma is very difficult to treat and often resistant to therapy. Treatment of melasma includes various hypopigmenting agents, chemical peeling, and laser surgery with unsatisfactory results. We report 3 cases of facial melasma successfully treated with a Q-switched Alexandrite laser.

BACKGROUND Early surgical intervention is still the most successful therapy for patients with melanoma. The results obtained with medical therapies are still quite disappointing, with better results observed in soft tissue and lymph node metastasis. There currently is no standardized adjuvant therapy for primary melanoma. On the basis of the activity demonstrated in vitro against melanoma cell lines and the results obtained in many clinical trials in patients with advanced melanoma, the authors chose to study the use of recombinant interferon-α (IFN-α) as adjuvant therapy for patients with Stage I and Stage II melanoma. METHODS A randomized multicenter trial based on the use of recombinant IFN-α-2b for 3 years at the dose of 3 MU given intramuscularly 3 times a week for a period of 6 months with a 1-month interval between cycles was conducted in Stage I and Stage II melanoma patients (using the American Joint Committee on Cancer classification). The efficacy of this treatment was evaluated calculating the incidence of recurrence after 3 and 5 years. RESULTS Results were collected at the end of the treatment period and after 5 years of follow-up for a smaller number of patients. Statistical evaluation showed a significant difference between treated patients and untreated controls with regard to progression of the disease. In particular, IfN-α appears to be more effective in patients with worse prognosis lesions. CONCLUSIONS IFN-α appears to be effective as adjuvant therapy for high risk melanoma patients and the risk/benefit ratio appears to be very favorable. The authors' next goal is to separate those patients who might benefit from adjuvant therapy from those who are cured after the surgical intervention only. Cancer 1997; 79:2354-60. © 1997 American Cancer Society.

Hyperhidrosis is an invalidating condition, and one that is difficult to treat. It is characterized by an excessive and uncontrolled production of sweat by the sweat glands, often causing psychological, social, and occupational problems for the patient. Hyperhidrosis can be distinguished in two forms: idiopathic (of unknown etiology), or secondary, due to an alteration of the endocrine system (ex: hyperthyroidism, neuropathy, neoplasia etc.) It is found in about 0.3-0.5% of the population and can be localized (axillary, palmar, plantar, facial) or diffused. The subcutaneous injection of type A botulinum toxin, until now used only for the treatment of blepharospasm or hemifacial spasm, has shown to be a useful treatment for localized hyperhidrosis. The objective of the authors is to evaluate the therapeutic efficacy, safety, and management of botulinum toxin treatment in patients affected with axillary or palmar hyperhidrosis resistant to conventional therapies.

The objective of this study was to estimate resource consumption and direct healthcare costs of patients with a first hospitalization for acute coronary syndrome (ACS) in 2008 in the Piedmont Region, Italy. Subjects hospitalized with a first episode of ACS in 2008 were selected from the regional hospital discharge database. All hospitalizations, drug prescriptions, and outpatient episodes of care in the 12 months following discharge were considered to estimate resource consumption and direct healthcare costs from the Piedmont Regional Health Service perspective. The analysis was carried out separately for ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA) populations. In the accrual period, 7765 subjects (1.75‰ of the total population) were hospitalized for ACS (64.2% men). The average age was 66.5 for men and 75.4 for women. The average in-hospital mortality was 6.5% (n = 508). The total ACS population was classified as: STEMI 45.2%, NSTEMI 29.4%, and UA 25.4%. The average yearly costs per patient alive at the end of follow-up (n = 6851) were 14,160.8OV0556; (18,678.7 USD): 83.9% for inpatient admissions [11,881.2OV0556; (15,671.8 USD)], 9.3% for drugs [1311.6OV0556; (1730.1 USD)], 5.0% for diagnostic and therapeutic procedures and outpatient visits [708.2OV0556; (934.1 USD)], and 1.8% for 1-day hospital stays [259.8OV0556; (342.7 USD)]. The average yearly direct healthcare costs by ACS event were 14,984.5OV0556; (19,765.2 USD) for STEMI, 14,554.1OV0556; (19,197.4 USD) for NSTEMI, and 12,481.5OV0556; (16,463.6 USD) for UA. In each subpopulation, costs were significantly higher for men than for women. ACS imposes a significant burden in terms of morbidity and mortality and generates major public health service costs.

The increased prevalence of obesity worldwide has grown the body contouring market, as patients demand more solutions. One of the most popular body contouring methods is liposuction. Pioneered in Europe in the early 1980’s as a simple fat aspirating technique, liposuction has quickly expanded its breadth to incorporate a variety of energy sources and modus operandi. Many types of energies have been combined with standard liposuction techniques in an attempt to improve and optimize treatment outcomes. The current chapter is dedicated to the authors’ experience with the most recent addition to the liposuction family, RadioFrequency Assisted Liposuction (RFAL). RFAL delivers RF energy for a thermal effect to the adipose tissue, skin and sub-dermal matrix in a minimally invasive manner. Enhancing the standard lipoplasty experience with a safe and consistent thermal influence provides the following key benefits:  Blood vessel coagulation to reduce patient downtime through less bleeding and bruising.  Tissue tightening to expand the range of patients to now include individuals who are obese and/or have compromised skin conditions (lax skin).  Increased patient comfort and safety will increase consumer acceptance.  Reduced procedure time and ease of treatment will increase physician acceptance.

The role of platelet-rich plasma in enhancing fat graft take is attracting the scientific community. There is, however, a lack of clinical studies on the matter. The aim of this article is to report the authors' experience in breast fat grafting with and without platelet-rich plasma and to investigate the state of the art on adipose tissue platelet-rich plasma enrichment.The authors retrospectively reviewed 42 women who underwent breast fat grafting between September of 2007 and September of 2009. Seventeen of these patients (40 percent) were grafted with fat (according to Coleman) enriched with platelet-rich plasma at 10 percent (group A), and 25 patients (60 percent) received only fat grafts according to Coleman (group B). All patients underwent preoperative breast ultrasound and mammography and were regularly followed up with breast ultrasound 3 months later and then at 6-month intervals. The reconstructive and aesthetic outcomes were evaluated using the following parameters: (1) clinical outcomes according to the surgeons and the patient, (2) the rate of liponecrosis at breast ultrasound, and (3) the need of further fat grafting to achieve the planned result.The clinical outcomes, the rate of liponecrosis at breast ultrasound, and the need for further fat grafting reveal that fat grafting plus platelet-rich plasma at 10 percent is not superior to Coleman fat grafting alone.In the authors' retrospective analysis, no effect of platelet-rich plasma was seen in enhancing fat graft take when compared with the Coleman fat graft. Further research and prospective clinical studies are needed to understand the role of platelet-rich plasma, if any, in fat grafting.

To provide a basis for the development of approaches to treat elastin-degrading diseases, the aim of this study was to investigate the degradation of the natural substrate tropoelastin by the elastinolytic matrix metalloproteinases MMP-7, MMP-9, and MMP-12 and to compare the cleavage site specificities of the enzymes using complementary MS techniques and molecular modeling. Furthermore, the ability of the three proteases to release bioactive peptides was studied. Tropoelastin was readily degraded by all three MMPs. Eighty-nine cleavage sites in tropoelastin were identified for MMP-12, whereas MMP-7 and MMP-9 were found to cleave at only 58 and 63 sites, respectively. Cleavages occurred predominantly in the N-terminal and C-terminal regions of tropoelastin. With respect to the cleavage site specificities, the study revealed that all three MMPs similarly tolerate hydrophobic and/or aliphatic amino acids, including Pro, Gly, Ile, and Val, at P(1)'. MMP-7 shows a strong preference for Leu at P(1)', which is also well accepted by MMP-9 and MMP-12. Of all three MMPs, MMP-12 best tolerates bulky charged and aromatic amino acids at P(1)'. All three MMPs showed a clear preference for Pro at P(3) that could be structurally explained by molecular modeling. Analysis of the generated peptides revealed that all three MMPs show a similar ability to release bioactive sequences, with MMP-12 producing the highest number of these peptides. Furthermore, the generated peptides YTTGKLPYGYGPGG, YGARPGVGVGGIP, and PGFGAVPGA, containing GxxPG motifs that have not yet been proven to be bioactive, were identified as new matrikines upon biological activity testing.

Skin laxity is a common cosmetic complaint of aging patients. Improvement in skin laxity can be difficult to achieve without invasive surgical lifting procedures. The radiofrequency (RF) system is based on an entirely different treatment principle than the photothermal reaction created by most dermatologic lasers. Unlike a laser, which uses light energy to generate heat in targeted chromophores, based on the theory of selective photothermolysis (Anderson and Parrish 1983), RF technology produces an electric current that generates heat through resistance in the dermis and subcutaneous tissue. Radiorefresce uses Surgitron Dual Frequency RF (Radiowave Technology, Ellman International), which develops a proprietary capacitive coupling method to transfer higher-energy fluences through the skin to a greater volume of dermal tissue than nonablative lasers, while protecting the epidermis (Hardaway and Ross 2002). The components of the device include (1) an RF generator producing a 4-MHz alternating-current RF signal, the energy level of which is set by the clinician, and (2) a handpiece for directing the RF energy to the skin. The neutral plate of the apparatus is placed approximately 15–20 cm from the patient. Spherical handpieces (5, 10, 15, and 20 mm in diameter) are used. The application of RF energy has been carried out in ambulatory settings, with no need for skin sterilization. The Surgitron 4.0 Dual Frequency RF has various operative modes. For ideal treatment, the manufacturer recommends a setting of 4.0 Mhz.

The sialidase activity of neuraminidase-1 (Neu-1) is responsible for ERK 1/2 pathway activation following binding of elastin peptide on the elastin receptor complex. In this work, we demonstrate that the receptor and lipid rafts colocalize at the plasma membrane. We also show that the disruption of these microdomains as well as their depletion in glycolipids blocks the receptor signaling. Following elastin peptide treatment, the cellular GM(3) level decreases while lactosylceramide (LacCer) content increases consistently with a GM(3)/LacCer conversion. The use of lactose or Neu-1 siRNA blocks this process suggesting that the elastin receptor complex is responsible for this lipid conversion. Flow cytometry analysis confirms this elastin peptide-driven LacCer generation. Further, the use of a monoclonal anti-GM(3) blocking antibody shows that GM(3) is required for signaling. In conclusion, our data strongly suggest that Neu-1-dependent GM(3)/LacCer conversion is the key event leading to signaling by the elastin receptor complex. As a consequence, we propose that LacCer is an early messenger for this receptor.

One limiting factor of hair transplantation is the amount of hair available in the patient donor scalp. Several techniques have been proposed as steel punches, multiblade knives, FUE (follicular unit extract) and single-strip harvesting. The authors introduce a modified surgical scalpel with a No. 10 blade to minimize side effects. This scalpel is folded at 120-degree angle and allows the incision to be parallel to the hair follicles and help the surgeon to avoid resection of the hair during dissection. The authors propose this modified scalpel as a new ideal instrument for removing the donor area in hair transplantation.

Methods for accessing information have evolved making thus possible the planning of a new generation of web applications. In the Piemonte region, tools for accessing demographic data and main health and epidemiologic indicators are available since several years. A new application named MADEsmart (from the Italian for "Engine for demographic and epidemiological analysis") provides various functions that allow the user to obtain information useful for creating health reports and health profiles at the subregional level.

Capsular contracture is the most common complication and the main cause of dissatisfaction after augmentation mammoplasty, for both the patient and the plastic surgeon. The formation of fibrous tissue around the prosthesis alters the form or the consistency of the implant, thus modifying the breast shape, its contour and its softness. The initial satisfaction with the achieved aesthetical result is then transformed into great dissatisfaction, due to the presence of a shapeless and undesired mass.The following study considered data collected between 1998 and 2007. Sixty-seven female patients (aged between 35 and 53 years) who suffered from mammary hypotrophy and had undergone submuscular augmentation mammoplasty were enrolled. All the implanted prostheses were round and texturized, with a volume of 250 cm3 to 450 cm3. The patients underwent pre-, intra- and postoperative antibiotic therapy in order to prevent clinical and subclinical infection of the implants.The follow-up ranged from a period of two to nine years. All patients were examined during the first antibiotic administration and again subsequently, after 1, 3, 6 and 12 months, to evaluate the results in terms of capsular contracture. Of all patients, 90% presented a degree I Baker's classification, the remaining 10% a degree II. Not one of the patients treated showed grade III or IV capsular contracture nor was there any need to remove the prosthesis during the examination period.It is clear that a main role in capsular contracture is played by the infectious process, with the activation of specific inflammatory cells. Interfering with the infectious process can prevent fibrotic reaction evolving into capsular contracture. Although the process causing capsular contracture is multifactorial, our study showed a favourable response can be achieved when using antibiotic therapy associated with the transaxillary approach.

The Harderian gland of the lizard Podarcis sicula sicula (Raf) contains connective tissue type mast cells whose numbers vary during the year showing two peaks, one in spring the other in winter. No sex differences are found throughout the year. Thermal and photoperiodic manipulations indicate that only temperature influences mast cell number (MCN) both in winter and in summer but not in spring. In animals exposed to high temperatures in February (but not in May) MCN declined, while exposure to low temperature in July had the opposite effect. Estradiol treatment of the February and April lizards increased MCN, an effect counteracted by the synthetic antiestrogen tamoxifen; in July lizards, this did not occur. In animals exposed to a high temperature in February, estradiol had no effect, as in animals exposed to low temperatures in July. These data suggest that in spring MCN seems to be more responsive to hormonal stimuli rather than external cues (temperature), while in summer MCN is more sensitive to temperature than to hormonal stimuli (estradiol). Both humoral and external factors are concluded to influence mast cell numbers in the Harderian gland of the lizard P. sicula sicula.

Early surgical intervention is still the most successful therapy for patients with melanoma. The results obtained with medical therapies are still quite disappointing, with better results observed in soft tissue and lymph node metastasis. There currently is no standardized adjuvant therapy for primary melanoma. On the basis of the activity demonstrated in vitro against melanoma cell lines and the results obtained in many clinical trials in patients with advanced melanoma, the authors chose to study the use of recombinant interferon-alpha (IFN-alpha) as adjuvant therapy for patients with Stage I and Stage II melanoma.A randomized multicenter trial based on the use of recombinant IFN-alpha-2b for 3 years at the dose of 3 MU given intramuscularly 3 times a week for a period of 6 months with a 1-month interval between cycles was conducted in Stage I and Stage II melanoma patients (using the American Joint Committee on Cancer classification). The efficacy of this treatment was evaluated calculating the incidence of recurrence after 3 and 5 years.Results were collected at the end of the treatment period and after 5 years of follow-up for a smaller number of patients. Statistical evaluation showed a significant difference between treated patients and untreated controls with regard to progression of the disease. In particular, IFN-alpha appears to be more effective in patients with worse prognosis lesions.IFN-alpha appears to be effective as adjuvant therapy for high risk melanoma patients and the risk/benefit ratio appears to be very favorable. The authors' next goal is to separate those patients who might benefit from adjuvant therapy from those who are cured after the surgical intervention only.

Peripheral blood stem cells (PBSC) are used increasingly for autotransplantation in the treatment of acute leukemia, lymphoma, multiple myeloma, solid tumors such as ovarian and breast carcinoma. They are collected by leukaphereses during rapid hematopoietic recovery, following cytotoxic chemotherapy with or without administration of hematopoietic growth factors. We studied the clonogenic and cytokine-mediated expansion potential of CD34+ cells from mobilized PBSC. Low density mononuclear cells were processed using the CEPRATE LC CD34 KIT (CellPro). CD34+ purified cells, were cultured in suspension with 6 combined hematopoietic growth factors (IL1beta, IL3, IL6 at 100 U/ml and G-CSF, GM-CSF and stem cell factor at 10 ng/ml of each) for up to four weeks. Every week, cells were counted and CFU-GM assay was performed in a methylcellulose based medium. We have analysed the percentage of cells bearing CD34, CD33, CD38, HLA-DR, CD45RA, CD45RO antigens. Our results showed, that CD34+ cells were obtained with a purity of 92 +/- 2.3% and a yield of 71 +/- 10.7%. The majority co-expressed CD33 (57.76 +/- 34.16%) and CD38 (62.2 +/- 34%) antigens. These culture conditions, are necessary to obtain a fold increase of nucleated cells (377 fold at week 4), of CFU-GM progenitors (41.2 fold at week 3) and of CD34+ cell absolute number (10 fold at week 1) with an important differentiation of progenitors in particular myeloid progenitors.