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Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty—an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Background: Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The “timing in acute care surgery” (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts. Methods: This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4–5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease. Results: Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority. Conclusion: The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a “safe” timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

Contains fulltext : 292357.pdf (Publisher’s version ) (Open Access) BACKGROUND: Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The "timing in acute care surgery" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts. METHODS: This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease. RESULTS: Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority. CONCLUSION: The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a "safe" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

OBJECTIVE: Information on the long-term safety of electronic cigarettes (e-cig) is still limited. We report the results after six years of follow-up of the first observational study assessing e-cig long-term effectiveness and safety. PATIENTS AND METHODS: Participants were adults who smoked ≥1 tobacco cigarette/day (tobacco smokers); or used any type of e-cig inhaling ≥50 puffs weekly (e-cig users); or used both (dual users). Participants were contacted directly or by phone and/or internet interviews. Hospital discharge abstract data and carbon monoxide level tests were also used. RESULTS: Data were available for 228 e-cig users (all ex-smokers), 469 tobacco smokers, 215 dual users. A possibly smoking-related disease (PSRD) was recorded in 90 subjects (9.9%); 11 deceased (1.2%). No differences were observed across groups in PSRD rates, with minor changes in self-reported health. Among e-cig users, 64.0% remained tobacco abstinent. Dual users and tobacco smokers did not significantly differ in the rate of cessation of tobacco (38.6% vs. 33.9%, respectively) and all products (23.7% vs. 26.4%). A comparable decrease in daily cigarettes was also observed. 39.5% of the sample switched at least once (tobacco smokers: 15.1%; dual users: 83.3%). CONCLUSIONS: After six years, no evidence of harm reduction was found among e-cig or dual users. The complete switch to e-cig might support tobacco quitters remain abstinent, but the use of e-cig in addition to tobacco did not improve smoking cessation or reduction.

OBJECTIVE: To provide an overall estimate of the direct, indirect and total costs of irritable bowel syndrome (IBS) for the adult population of the European countries with universal healthcare coverage.MATERIALS AND METHODS: We searched MedLine and Scopus databases (up to September 2018) to identify the European studies that evaluated the economic impact of IBS. Mean annual direct, indirect and total per-capita IBS costs were estimated using random-effect single-group meta-analyses of continuous data. All analyses were stratified by payer category (governments, insurance, societal), and the results were expressed as summary mean and 95% CI.RESULTS: A total of 24 studies were included in the meta-analyses. Only two studies evaluated IBS costs in Italy. The pooled summary of direct IBS per-capita cost, obtained from 23 European datasets (n=15,157), was (sic)1837/year (95% CI: 1480-2195), with large differences across payers (from (sic)1183 to (sic)3358, in countries with publicly-funded and insurance-based health systems, respectively). The mean indirect cost, extracted from 13 datasets (n=3978), was (sic)2314/year (95% CI: 1811-2817), again with wide differences across payers. Finally, the meta-analysis estimating the total annual cost, based upon 11 European datasets (n=2757), yielded a summary estimate of (sic)2889/year (95% CI: 2318-3460) per patient, ranging from (sic)1602 (insurance-based health systems) to (sic)3909 (studies adopting a societal perspective).CONCLUSIONS: Considering a conservative estimate of 2,736,700 Italian adults affected by the syndrome, the minimum costs due to IBS in Italy - likely underestimated - range from 6 to 8 billion euro per year. Given the substantial economic burden for patients, healthcare systems and society, IBS should be included among the priorities of the public health agenda.

OBJECTIVE: More than a decade after e-cigarette (e-cig) market launch, limited information are available on their safety after 24 months of use. In 2013, we started the first observational study assessing e-cig long-term effectiveness and safety, directly comparing tobacco smokers and e-cig users. Here we report the results after four years of follow-up. PATIENTS AND METHODS: Adults (30-75 years) were included if: smokers of =1 tobacco cigarette/day (tobacco smokers); users of any type of e-cig inhaling =50 puffs weekly (e-cig users); users of both tobacco and e-cig (dual users). Data were collected by phone and/or internet, and carbon monoxide levels tested in 50% of those declaring tobacco abstinence. Main outcomes were: possibly smoking-related diseases (PSRD; validated through hospital discharge data or visit in 62.6% of the sample); 4-year tobacco abstinence; number of tobacco cigarettes/day. RESULTS: Data were available for 228 e-cig users (all ex-smokers), 471 tobacco smokers, 216 dual users. A PSRD was observed in 73 subjects (8.0%). No differences emerged across groups in PSRD rates, with negligible variations in self-reported health. Of e-cig users, 63.6% remained tobacco abstinent; dual users and tobacco smokers showed non-significantly different rates of tobacco (33.8% vs. 26.8%) and all-product (20.2% vs. 19.4%) cessation, and a similar decrease in cigarettes/day. Almost 40% of the sample switched at least once (tobacco smokers: 17.2%; dual users: 81.9%). CONCLUSIONS: After four years, a scarce, non-significant harm reduction was observed among e-cig or dual users. Given the long-lasting health effects of tobacco smoking, the benefits of e-cig use may start being detectable at the next follow-up (six years). The complete switch to e-cig may help tobacco quitters remain abstinent, but e-cig use in addition to tobacco did not increase the likelihood of smoking cessation or reduction.

Diets rich in vegetables and fruit have been associated with reduced risk of gastric cancer, and there is suggestive evidence that citrus fruits have a protective role. Our study aimed at evaluating and quantifying the association between citrus fruit intake and gastric cancer risk. We conducted a one-stage pooled analysis including 6,340 cases and 14,490 controls from 15 case–control studies from the stomach cancer pooling (StoP) project consortium. Odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) of gastric cancer across study-specific tertiles of citrus fruit intake (grams/week) were estimated by generalized linear mixed effect models, with logistic link function and random intercept for each study. The models were adjusted for sex, age, and the main recognized risk factors for gastric cancer. Compared to the first third of the distribution, the adjusted pooled OR (95% CI) for the highest third was 0.80 (0.73–0.87). The favourable effect of citrus fruits increased progressively until three servings/week and leveled off thereafter. The magnitude of the association was similar between cancer sub-sites and histotypes. The analysis by geographic area showed no association in studies from the Americas. Our data confirm an inverse association between citrus fruits and gastric cancer and provide precise estimates of the magnitude of the association. However, the null association found in studies from America and in some previous cohort studies prevent to draw definite conclusions on a protective effect of citrus fruit consumption. © 2018 UICC

Aim: To further quantify the association between physical activity (PA) after breast cancer diagnosis and all-cause mortality, breast cancer mortality and/or breast cancer recurrence. Methods and results: PubMed was searched until November 2017 for observational studies investigating any type of PA in association with total mortality, breast cancer mortality and/or breast cancer recurrence among women with breast cancer diagnosis. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using random-effects models for highest versus lowest categories of PA. Ten studies were included in the meta-analysis. During an average follow-up ranging from 3.5 to 12.7 years there were 23,041 breast cancer survivors, 2,522 deaths from all causes, 841 deaths from breast cancer and 1,398 recurrences/remissions. Compared to women in the lowest recreational PA level (lowest quintile/quartile), women in the highest level had a lower risk of all-cause mortality (HR = 0.58, 95% CIs: 0.45–0.75; 8 studies), of death from breast cancer (HR = 0.60, 95% CIs 0.36–0.99; 5 studies) and a lower, albeit non-significant, risk of recurrence (HR = 0.79, 95% CIs 0.60–1.05; 5 studies). There was evidence of heterogeneity between the studies evaluating recreational PA and total mortality (Ι2 = 52.4%) and even higher for breast cancer mortality (Ι2 = 77.7%) or recurrence (Ι2 = 66.4%). Conclusion: Highest recreational PA after breast cancer diagnosis was associated with lower all-cause and breast cancer mortality. This finding probably reflects the favorable impact of PA on cardiovascular mortality, and a possible favorable role on breast cancer survival, though reverse causation cannot be excluded. © 2019 Elsevier Ltd

Previous studies have reported that Mediterranean diet is inversely related to the risk of several neoplasms; however, limited epidemiological data are available for bladder cancer. Thus, we examined the association between Mediterranean diet and this neoplasm in an Italian multicentric case-control study consisting of 690 bladder cancer cases and 665 controls. We assessed the adherence to the Mediterranean diet via a Mediterranean Diet Score (MDS), which represents the major characteristics of the Mediterranean diet and ranges from 0 to 9 (from minimal to maximal adherence, respectively). We derived odds ratios (ORs) of bladder cancer according to the MDS score from multiple logistic regression models, allowing for major confounding factors. The ORs of bladder cancer were 0.72 (95% confidence interval, CI, 0.54–0.98) for MDS of 4–5 and 0.66 (95% CI, 0.47–0.93) for MDS of 6–9 (p for trend = 0.02) compared to MDS = 0–3. Results were similar in strata of sex, age, and education, while the risk appeared somewhat lower in never-smokers and patients with pT1–pT4 bladder carcinomas. Among individual components of the MDS, we observed inverse associations for greater consumption of legumes, vegetables, and fish. In our study, which was carried out on an Italian population, the higher adherence to the Mediterranean diet was related to a lower risk of bladder cancer. © 2018 by the authors. Licensee MDPI, Basel, Switzerland.

Nell’ottica di implementazione di un modello di Chronic Care Model per la presa in carico dei pazienti con patologie croniche, l’Azienda Usl di Ravenna ha dato il via, nel marzo del 2010, nell’ambito dei Progetti CCM 2009 , al progetto “Comprehensive community and home-based health care model (CCHBHC) per soggetti con fragilità sociosanitaria e pazienti affetti da BPCO e scompenso cardiaco. Implementazione delle migliori evidenze scientifiche disponibili in una realtà aziendale e valutazione degli strumenti più efficaci per l’applicazione del modello a livello locale”. Il Progetto è stato realizzato dall’Azienda USL di Ravenna in collaborazione con il Dipartimento di Medicina e Sanità Pubblica dell’Alma Mater Studiorum Università di Bologna e si è concluso nel marzo 2013. Obiettivo generale del Progetto era implementare in tre NCP dei Distretti dell’AUSL di Ravenna, uno per ciascun Distretto, un modello “comprensivo” di presa in carico di pazienti affetti da BPCO e con fragilità sociosanitaria. Per il raggiungimento dell’obiettivo, la prima fase del Progetto prevedeva l’individuazione dei soggetti affetti da BPCO e la creazione di un registro di patologia, quindi la stratificazione dei soggetti inseriti nel registro per rischio di fragilità. Successivamente è stata dedicata molta attenzione alla formazione integrata dei professionisti coinvolti nella gestione territoriale dei pazienti con BPCO, in primo luogo MMG e Infermieri professionali, preliminare alla definizione ed organizzazione dei percorsi clinico-assistenziali. Individuazione dei casi e creazione del registro BPCO. Nell’ambito dell’Azienda USL di Ravenna, con il Progetto CCM 2009, è stato fatto un primo passo verso questo obiettivo, in particolare per la presa in carico e la gestione dei soggetti affetti da BPCO. Il paziente con BPCO è un paziente “fragile” innanzitutto per la presenza della patologia; allo stato di malattia si possono poi aggiungere altre problematiche, sia cliniche (comorbidità, ecc.) sia sociali. Di qui l’importanza di agevolare la costruzione e implementazione di percorsi clinico-assistenziali integrati che siano sempre più in grado di tenere conto della “complessità” e della “fragilità” di questi pazienti. Dal punto di vista organizzativo questo si può tradurre con l’implementazione di modelli assistenziali che prevedano ad esempio la presa in carico e il follow-up dei pazienti presso ambulatori territoriali dedicati alla patologia cronica, superando però la logica del “disease management”, in cui operano professionisti adeguatamente formati per la gestione di tutte le fasi della malattia, compresa l’autocura (self-management e patient education), la prevenzione terziaria e il coinvolgimento della famiglia e di tutta la comunità.

Long-term birth cohort studies are essential to understanding the life course and childhood predictors of allergy and the complex interplay between genes and the environment (including lifestyle and socioeconomic determinants). Over 100 cohorts focusing on asthma and allergy have been initiated in the world over the past 30 years. Since 2004, several research initiatives funded under the EU Framework Program for Research and Technological Development FP6-FP7 have attempted to identify, compare, and evaluate pooling data from existing European birth cohorts (GA2LEN: Global Allergy and European Network, FP6; ENRIECO: Environmental Health Risks in European Birth Cohorts, FP7; CHICOS: Developing a Child Cohort Research Strategy for Europe, FP7; MeDALL: Mechanisms of the Development of ALLergy, FP7). However, there is a general lack of knowledge about these initiatives and their potentials. The aim of this paper is to review current and past EU-funded projects in order to make a summary of their goals and achievements and to suggest future research needs of these European birth cohort networks. © 2012 S. Karger AG, Basel.

Un crescente numero di ricerche mostra che la qualità delle cure erogate aumenta quando i pazienti sono ben informati e giocano un ruolo attivo nella gestione del proprio percorso di salute. L’interesse alla partecipazione del paziente al processo decisionale sul trattamento di cura si è spostato ben oltre il consenso informato per includere più ampi principi di alfabetizzazione sanitaria (Health Literacy), autonomia e controllo del percorso assistenziale: un processo decisionale condiviso (Shared Decision Making) è visto come un meccanismo per ridurre l’asimmetria informativa tra paziente e medico, aumentare la consapevolezza della persona, il suo senso di autonomia e/o di controllo sulle decisioni di trattamento che lo riguarda. A partire da queste considerazioni, l’Azienda Usl di Ravenna, in collaborazione con il Dipartimento di medicina e sanità pubblica dell’Università di Bologna, l’Istituto di ricerca e cura a carattere scientifico (Irccs) di Meldola e l’Agenzia Nazionale per i Servizi Sanitari Regionali, ha avviato il progetto di ricerca “O.P.T.I.On” (Opportunità Per Il Trattamento In Oncologia) che si pone l’obiettivo di analizzare la comunicazione medico-paziente in ambito oncologico, il grado di supporto dato al paziente nel definire e decidere il tipo di trattamento da seguire, con uno speciale focus sull’opportunità di ricevere un secondo parere e, infine, la soddisfazione del paziente sul percorso di cura intrapreso.

Obiettivi. La fiducia negli altri ha una grande rilevanza nella vita economica, politica e sociale di un paese: infatti, laddove la fiducia reciproca è elevata, la società funziona meglio, è più produttiva, più cooperativa, più coesa, meno diffusi sono i comportamenti opportunistici e più ridotto è il livello della corruzione. Alla luce dei dati più recenti, ci proponiamo di indagare la fiducia come componente fondamentale della cura, che si costruisce nel tempo attraverso i contatti ripetuti tra il cittadino e i servizi sanitari. Metodi. Sono stati analizzati i principali studi nazionali-internazionali che dal 2003 ad oggi hanno posto al centro il tema della fiducia dei cittadini nelle istituzioni sociali, sanitarie e in maniera più dettagliata si sono interrogati sulla fiducia dopo un’esperienza di cura. Risultati. La proporzione di italiani che ha fiducia nei confronti delle istituzioni sociali (54%) risulta essere una delle più basse tra i paesi dell’area OECD, mostrando una forbice di disuguaglianza tra centro Nord e Sud dell’Italia (41,3% vs 26,3%). Risulta, invece, largamente apprezzata la professionalità e la competenza di medici e infermieri per il 64,2% degli intervistati. Aumenta inoltre la percentuale degli italiani soddisfatti del Servizio Sanitario Nazionale se si chiede di esprimersi sulla base dell’esperienza diretta e non secondo una generica opinione. Conclusioni. La fiducia è un valore che richiede alle istituzioni di vigilare sull’equilibrio fragile tra delega e valutazione, in particolare valorizzando le buone pratiche e la comunicazione trasparente dei dati, indagando l’esperienza dei pazienti e creando una partnership tra tutti gli attori coinvolti. Ulteriori approfondimenti sono necessari per comprendere quali siano i più efficaci metodi di costruzione di partnership all’interno delle organizzazioni sanitarie.

Background: The use of osteotome for vertical bone augmentation and localized sinus elevation with minimal surgical trauma represents a suitable procedure to increase the vertical dimension of available bone for implant placement. Purpose: The aim of this study was to report clinical and radiographic results of localized management of sinus floor (LMSF) in fresh molar sockets at 13-year follow-up. Materials and Methods: Fifty-three patients, needing one or two maxillary molar extraction, were enrolled in this study. LMFS procedure was performed and 68 implants were positioned. A presurgical distance from the alveolar crest to the floor of the maxillary sinus and the amount of new radiopacity between the sinus floor and alveolar crest were measured from the mesial and distal surfaces of each dental implant surface. Results: After a mean follow-up period of 9.76 ± 5.27 years (ranged from 4 to 17 years) a survival rate of 100% was reported. Mean bone height at temporary prosthesis placement was 7.99 ± 1.16 mm. They were stable over time, reporting a mean value of 8.01 ± 1.46 mm at 13-year follow-up. Conclusions: The results of this study demonstrated that LMSF procedure in fresh molar sockets allowed to expand the dimensions of resorbed posterior maxillary alveolar bone both vertically and horizontally with a success rate of 100% of implant osseointegration over time.

OBJECTIVES: Patients with temporomandibular disorders (TMDs) often report increased pain in response to changes in weather conditions. Nevertheless, scientific evidence supporting this relationship is scarce. The aim of this study was to assess a potential relationship between pain intensity and meteorological factors, through a newly developed, portable device, in patients affected by chronic masticatory muscle pain. METHODS: Seven female subjects were diagnosed with myofascial pain of the masticatory muscles, according to RDC/TMD criteria, were recruited, and participated in the study. Each patient was provided with a portable data logger that recorded and stored weather variables (atmospheric pressure, air humidity, temperature) every 15 min. Patients were asked to record the level of perceived pain on an electronic visual analogue scale (VAS) every hour. The relationship between meteorological variables and pain scores was investigated using separate generalized least squares regression models with a correlation structure estimated via autoregressive integrated moving average models. RESULTS: Individual VAS trajectories in the study period were different. The effect of meteorological factors on VAS scores was statistically significant in five subjects, with at least one main effect and/or one two-way interaction between meteorological variables being significant. CONCLUSIONS: The analyses suggest the existence of different interindividual responses to climatic changes. However, the identified putative role of meteorological variables and of their two-way interactions suggests that further investigations on larger samples may be useful to assess the research question under examination.

Background & Aims Hepatocellular carcinoma (HCC) has a very poor prognosis and any effort to identify additional risk factors, besides those already established, would be important for the prevention of the disease. Data on the role of diet on HCC risk are still controversial. Methods We have evaluated the association of adherence to the Mediterranean diet with HCC risk, as well as the interaction of this dietary pattern with chronic hepatitis infection, by combining two case-control studies undertaken in Italy and Greece, including overall 518 cases of HCC and 772 controls. Adherence to the traditional Mediterranean diet was assessed through the Mediterranean diet score (MDS), which ranges between 0 (lowest adherence) and 9 (highest adherence). Odds ratios (OR) for HCC were obtained through multiple logistic regression models, controlling for potentially confounding factors, including chronic infection with hepatitis B/C viruses. Results Compared to MDS of 0-3, the ORs for HCC were 0.66 (95% confidence interval (CI), 0.41-1.04) for MDS equal to 4 and 0.51 (95% CI, 0.34-0.75) for MDS ≥5, with a significant trend (p

Previous evidence indicates that pioglitazone may improve dyslipidemia in patients with Type 2 diabetes mellitus (T2DM).The primary objective of this study was to evaluate the effect of either pioglitazone or placebo with metformin on levels of serum HDL cholesterol (HDL-C) in patients with T2DM. A secondary objective evaluated changes in metabolic syndrome (MS)-specific parameters.This multicenter, double-blind, randomized study was performed in patients with T2DM treated with metformin and hemoglobin A1c (HbA1c) levels between 6-8%, central obesity and reduced HDL-C. MS was evaluated from global changes in parameter values and expressed as a single factorial score following multivariate analysis of each parameter. 213 patients (110 in the pioglitazone group and 103 in the placebo group) were available for intention-to-treat analysis.Pioglitazone-treated patients showed a significant increase in HDL-C compared to placebo group (6.3 mg/dl vs 3.0 mg/dl; p0.01) in addition to a greater reduction in the extent of MS (-13.2 vs -4.9; p=0.0055). Upon study completion, patients treated with pioglitazone had lower levels of HbA1c (6.41±0.65 vs 6.96±0.74%; p0.001) and homeostasis model assessment-insulin resistance (HOMA-IR) (2.88±1.95 vs 4.68±3.63; p=0.013) and a reduction of the atherogenic LDL subfraction (pattern B) (-5.7%).The beneficial effects observed in pioglitazone-treated patients in the present study, (i.e. the increase in HDL-C and the reduction of insulin resistance and atherogenic LDL subfractions), support findings from the PROactive trial, where pioglitazone showed pleiotropic effects and reduced death, fatal myocardial infarction (MI) and non-fatal MI in T2DM patients with MS. Furthermore, medication used in this study showed good tolerability.

The purpose of the work described in this article was to analyze the psychometric properties of a new Italian instrument for the assessment of irritability in adult patients with epilepsy (I-Epi). Five hundred four patients from nine secondary and tertiary Italian centers for the care of epilepsy were recruited and interviewed. Each patient was evaluated on a series of demographic and clinical variables recorded before administration of the I-Epi and the AQ (Aggression Questionnaire), used for external validity. The final results supported the reliability and validity of the I-Epi as a measure of irritability in the adult epilepsy population. The psychometric characteristics of the I-Epi seemed fairly good. We believe that adoption of this new instrument could be very useful in both clinical and research management of patients with epilepsy.

Objective: As intake of flavonoids has been associated with reduced risk of coronary heart disease but data on the relation with specific classes of flavonoids are scarce, we assessed the relation between dietary intake of specific classes of flavonoids and the risk of acute myocardial infarction (AMI) in an Italian population. Design: Case-control study. Dietary information was collected by interviewers on a questionnaire tested for validity and reproducibility. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were obtained by multiple logistic regression models including terms for energy and alcohol intake, as well as sociodemographic factors, tobacco and other major recognised risk factors for AMI. Setting: Milan, Italy, between 1995 and 2003. Subjects: Cases were 760 patients, below age 79 years, with a first episode of non-fatal AMI, and controls were 682 patients admitted to hospital for acute conditions unrelated to diet. Results: A reduced risk of AMI was found for increasing intake of anthocyanidins (OR=0.45, 95% CI 0.26-0.78 for the highest vs. the lowest quintile, P-trend=0.003) and flavonols (OR=0.65, 95% CI 0.41-1.02, P-trend=0.02). A tendency towards reduced risks, although not significant, was observed for flavan-3-ols (OR=0.73, 95% CI 0.48-1.10) and total flavonoids (OR=0.74, 95% CI 0.49-1.14). No meaningful heterogeneity was found between the sexes. No association emerged for other flavonoids, including isoflavones, flavanones and flavones. Conclusions: High intake of anthocyanidins reduced the risk of AMI even after allowance for alcohol, fruit and vegetables, supporting a real inverse association between this class of flavonoids and AMI risk.

Two sets of Co-cemented tungsten carbide (WC ¡VCo ) cutting inserts were sintered using WC powders having different average sized particles (1 and 6 m m ). Fine grained WC ¡VCo inserts contained 5.8 wt.%Co and were doped by 0.2 wt.%VC and 0.2 wt.%TaC, which acted as grain growth inhibitors in the liquid-phase sintering. Coarse grained substrates contained 6 wt.%Co and no dopants. Prior to deposition, the inserts were etched using Murakami eagent and then with an acid solution of hydrogen peroxide. The substrates were coated by 31 ¡V33-ƒÝm diamond films using hot filament chemical vapor deposition (HFCVD ) in an atmosphere of 1.5%methane in hydrogen for 14 h, at a substrate temperature of 950 ¢XC. Upon cooling from CVD temperature, only films deposited onto coarse grained inserts were adherent, while films grown on fine grained substrates underwent spontaneous delamination. This fact was due to the presence of a layer of graphitic carbon at the interface between the diamond film and fine grained substrates only. The formation of this sp2-carbon layer correlated well with the observed huge segregation of grain growth inhibitors at the interface between diamond and fine grained substrates.