Effects of non-invasive ventilation on renal and endothelial function in patients with respiratory failure.

OBJECTIVE: Non-invasive positive pressure ventilation (NIV) is now an indispensable safeguard in the management of many pathologies. However, sometimes the positive end-expiratory pressure (PEEP) showed harmful effects on renal function, although effects on renal hemodynamic are unclear. We aimed at evaluating the effects of NIV on renal and endothelial function, in patients with chronic or acute respiratory failure. PATIENTS AND METHODS: We performed a longitudinal, prospective, interventional study. We enrolled 17 hospitalized and non-hospitalized patients (11 males) with indication to NIV and stable hemodynamic parameters. Patients were treated with NIV and followed up at T0, at T1 (at the end of the NIV cycle) and at T2 (fifteen days after). RESULTS: 17 patients (11 males) with a mean age of 71.94 ± 14.89 years were enrolled. A significant increase in flow mediated dilation (FMD) was found (p = 0.004). We showed a significant improvement, after NIV, in the values of pH (p = 0.0002), pCO2 (p = 0.0001), pO2 (p = 0.04), lactates (p = 0.04), sO2 (p = 0.02) and in the P/F Ratio (p = 0.004). We also showed a significant reduction of serum glucose (p = 0.01) and a significant increase of serum chlorine (p = 0.047), while we did not report a significant increase of creatinine (p = 0.297) or a significant change in diuresis. CONCLUSIONS: In our study NIV has no significant effects on renal function in patients with respiratory failure. Probably these patients required low PEEP values, which were less harmful to lung parenchyma and not effective on systemic hemodynamic. Furthermore, NIV has improved endothelial function in the short term, likely by reducing oxidative stress, as improvements of the gas-analysis parameters showed. Therefore, NIV could help to reduce cardiovascular risk of patients improving endothelial function.

Radiofrequency ablation of functioning and non-functioning thyroid nodules: a single institution 12-month survey.

PURPOSE: Radiofrequency (RF) treatment has played an increasing role in the management of benign thyroid nodules in recent years. The aim of this retrospective study was to evaluate the efficacy of RF treatment on volume reduction in functioning and non-functioning thyroid nodules. PATIENTS AND METHODS: We reviewed the medical records of patients who had thyroid nodule RF ablation at our department between August 2017 and May 2018. Patients underwent a periodical follow-up with ultrasound examinations and thyroid function tests at 1, 3, 6 and 12 months from RF. Complications were assessed using the reporting standards of Interventional societies. RESULTS: 43 patients were submitted to thyroid nodule RF ablation treatment. Patients were subdivided into two groups, those with functioning (17 patients) or non-functioning nodules. At baseline (i.e. pre-RF treatment), the two groups of patients were superimposable for gender, age, BMI, nodule volume and maximum nodule diameter. The volume reduction of all 43 nodules was 69.1 ± 17.3% (range 26.0-94.5%) with no difference between functioning and non-functioning lesions (72.9 ± 18.1% vs 66.7 ± 16.7%, p = 0.254). A total energy delivered per nodule was 16.5 ± 6.8 kJ, with no difference between functioning and non-functioning lesions (14.5 ± 7.2 kJ vs. 18.2 ± 6.3 kJ, p = 0.083, respectively). No major complications were observed. CONCLUSIONS: Radiofrequency ablation is a clinically effective and safe outpatient treatment in patients with benign nodules. In particular, we showed that a single treatment is effective in restoring euthyroidism in patients with autonomously functioning thyroid nodules.

Is bupropion useful in the treatment of post-stroke thalamic apathy? A case report and considerations.

Post-stroke apathy is considered to be one of the clinical consequences of lesions affecting the structures of the prefrontal cortex, basal ganglia, thalamus and limbic system. However, there is no current consensus on the treatment of post-stroke apathy, which mainly depends on the underlying etiology and comorbidities. A 62-year-old man, affected by hemorrhagic stroke in the left thalamus, presented with mood depression, anhedonia, hyporexia and marked apathy. The patient underwent clinical evaluation before and after receiving two different pharmacological therapies: escitalopram and bupropion. Only after treatment with the latter drug did the patient show changes: high motivation and willingness to pursue activities, greater interest in the external environment and social life activities, and an overall reduction of apathy. On the basis of our observations in this case, we hypothesize that the thalamic lesion resulted in disconnection of the fronto-striatal-thalamic circuits, and that loss of the dopaminergic striatal innervation caused the patient's apathetic state. The resolution of the apathetic disorder may be attributable to the action of the dopaminergic drug bupropion on the mesocortical pathway.

Lower P1NP serum levels: a predictive marker of bone loss after 1 year follow-up in premenopausal systemic lupus erythematosus patients.

SUMMARY: Predictors of bone mineral density (BMD) loss are additional tools in the management of osteoporosis in premenopausal women with systemic lupus erythematosus (SLE). This study provides original evidence that N-terminal propeptide of type 1 collagen (P1NP), the most specific bone formation marker, is a predictor of BMD loss in this group of women. INTRODUCTION: SLE is associated with a high risk of low bone mass/fractures but this risk is still controversial in premenopausal women. Our aim was to determine the 1 year incidence of BMD loss in premenopausal SLE women and the value of bone turnover markers as predictors of this complication. METHODS: This study enrolled a convenience sample of 63 premenopausal SLE patients. BMD was evaluated by dual X-ray absorptiometry at lumbar spine and hip at baseline and after 12 months. BMD changes above the least significant change were considered significant. Serum levels of P1NP and CTX (electrochemiluminescence), OPG, and RANKL (ELISA) were determined at baseline. RESULTS: Mean age was 31.1±6.8 years, and disease duration was 5.25±3.8 years. 36.5 % of patients presented BMD loss and 17.5 % BMD gain at lumbar spine and/or hip. Patients were divided in three groups: BMD loss (BL), no BMD change (NC), and BMD gain (BG). Patients with BL and NC received similar cumulative/mean/maximum glucocorticoid doses during the study, but patients with BG received lower doses (p<0.05). Baseline P1NP levels were different in the groups (BL: 36.95±23.37 vs. NC: 54.63±30.82 vs. BG: 84.09±43.85 ng/mL; p=0.031 BL vs. NC, p<0.001 BL vs. BG, and p=0.039 NC vs. BG). There was no difference in CTX, OPG, or RANKL levels. After multivariate analysis, P1NP remained as an independent risk factor for BMD loss (p<0.03). CONCLUSIONS: This study provides original evidence that lower levels of P1NP, the most specific bone formation marker, are predictive of BMD loss over 12 months in premenopausal SLE patients.

Ultrasound and color-flow Doppler evaluation for the diagnosis of subclinical hyperthyroidism.

AIM: Clinical significance, population screening and management of subclinical hyperthyroidism (SHyper) are still debated. Although the diagnosis of subclinical hyperthyroidism is, by definition, purely a biochemical one a conventional gray-scale sonography and, more recently, color-flow Doppler sonography (CFDS) have proven to be useful in obtaining information about thyroid morphology and function in thyroid disease, such as SHyper. The objective of this study was to evaluate, using CFDS, the presence and significance of changes in intrathyroidal blood flow and velocity in patients affected by SHyper and, to evalutate the potential diagnostic role of CFDS in mild thyroid disease in absence of a significant alteration in the serum level of circulating thyroid hormones. METHODS: In this study, patients with SHyper (the case group) and euthyroid patients (the control group) were enrolled. All patients from the two groups who were affected by multinodular goiter as preoperative diagnosis, underwent total thyroidectomy. In both groups preoperative examination included a conventional grey-scale sonography, followed by CFDS. Quantitative flow evaluation was performed measuring the maximal peak systolic velocity (PSV) at the level of intrathyroid arteries and inferior thyroid artery. RESULTS: Patients with SHyper showed an increased thyroid vascularization both intranodular and peripheral and the mean PSV values were higher in case patients than in control subjects. CONCLUSION: We have shown that significant changes in thyroid vascularity and blood flow velocity are already present in patients with SHyper. CFDS is a suitable technique to identify SHyper.

Risk of non-Hodgkin's lymphoma and residential exposure to air pollution in an industrial area in northern Italy: a case-control study.

The aim of this study was to evaluate the risk of non-Hodgkin's lymphoma (NHL) in an adult population residing in an area in northern Italy exposed to industrial air pollution from a big power plant, a coke oven, 2 chemical factories, and some minor plants. The design was a population-based case-control study and information about residential history and the main risk factors for NHL was obtained interviewing 133 cases and 279 controls using a structured questionnaire. Three exposure categories (heavy, moderate, and slight) were defined on the basis of the location of the major facilities with respect to the subject residence. NHL risk was not associated either with location or duration of residence in the heavily polluted area. However, the unavoidable limitations of this study prevent us from drawing definitive conclusions.

A Monte-Carlo based model of the AX-PET demonstrator and its experimental validation.

AX-PET is a novel PET detector based on axially oriented crystals and orthogonal wavelength shifter (WLS) strips, both individually read out by silicon photo-multipliers. Its design decouples sensitivity and spatial resolution, by reducing the parallax error due to the layered arrangement of the crystals. Additionally the granularity of AX-PET enhances the capability to track photons within the detector yielding a large fraction of inter-crystal scatter events. These events, if properly processed, can be included in the reconstruction stage further increasing the sensitivity. Its unique features require dedicated Monte-Carlo simulations, enabling the development of the device, interpreting data and allowing the development of reconstruction codes. At the same time the non-conventional design of AX-PET poses several challenges to the simulation and modeling tasks, mostly related to the light transport and distribution within the crystals and WLS strips, as well as the electronics readout. In this work we present a hybrid simulation tool based on an analytical model and a Monte-Carlo based description of the AX-PET demonstrator. It was extensively validated against experimental data, providing excellent agreement.

Molecular characterization of an Italian series of sporadic GISTs.

PURPOSE: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract. Most (80 %) contain activating mutations in the KIT receptor tyrosine kinase, roughly 10 % in platelet-derived growth factor receptor-alpha (PDGFRA). In a small subset, BRAF mutations are an alternative molecular pathway. GISTs respond well to imatinib, but low response is seen in patients with wild-type KIT or PDGFRA. Resistance has also been reported as a result of mutations in downstream effectors such as BRAF. METHODS: We provide here a molecular characterization of a series of primary GISTs from Italian patients. Of 121 GIST cases diagnosed between 2000 and 2012, 83 were evaluated by PCR amplification and direct sequencing for mutations in KIT exons 8, 9, 11, 13, and 17, PDGFRA exons 12, 14, and 18, and BRAF exon 15. Eighty-one GISTs also underwent K-RAS testing. RESULTS: Sixty-four GISTs were positive: 55 had mutations in KIT and 9 in PDGFRA; 16 patients were mutation negative. Three samples came from NF1 patients and were KIT- and PDGFRA negative. Overall, we identified six novel mutations in KIT (p.K550_M552delinsL, p.Q556_W557delinsG p.Q556_G575del, p.W557_V559delinsQ p.P573_R588dup, p.G592_K593dup) and one novel mutation in PDGFRA (p.D842_N848delinsVDV), thus contributing to widening the spectrum of known mutations in GIST tumors and confirming the most frequently altered regions underlying GIST development. CONCLUSIONS: Among the 64 KIT- and PDGFRA-positive sporadic patients in our series, no BRAF or KRAS mutations were identified, suggesting that co-occurrence of these mutations is likely to be rare in the northwestern Italian population and not a frequent cause of primary resistance to imatinib in KIT-positive GIST patients.

Juvenile onset systemic lupus erythematosus: a possible role for vitamin D in disease status and bone health.

PURPOSE: In juvenile onset systemic lupus erythematosus (JoSLE), evidence for the association between vitamin D status, lupus activity, and bone health is very limited and not conclusive. The aim of this study was, therefore, to assess in JoSLE patients the possible relevance of vitamin D deficiency in disease and bone parameters. METHODS: Fifty-seven JoSLE patients were initially compared to 37 age, race and body mass index (BMI) -matched healthy controls. The serum concentration of 25 hydroxyvitamin D (25OHD) was determined by radioimmunoassay. Patients with 25OHD deficiency (≤20 ng/mL) were compared to those with levels >20 ng/mL. Disease activity was evaluated by SLE Disease Activity Index (SLEDAI). Bone mineral density (BMD) and body composition (BC) were measured using dual-energy X-ray absorptiometry (DXA). RESULTS: 25OHD levels were similar in patients and controls (21.44 ± 7.91 vs 22.54 ± 8.25 ng/mL, p = 0.519), regardless of supplementation (65% of patients and none in controls). Thirty-one patients with 25OHD deficiency (≤20 ng/mL) were further compared to the 26 JoSLE patients with levels >20 ng/mL. These two groups were well-balanced regarding vitamin D confounding variables: age (p = 0.100), ethnicity (p = 1.000), BMI (p = 0.911), season (p = 0.502), frequency of vitamin D supplementation (p = 0.587), creatinine (p = 0.751), renal involvement (p = 0.597), fat mass (p = 0.764), lean mass (p = 0.549), previous/current use of glucocorticoids(GC) (p = 1.0), immunosuppressors (p = 0.765), and mean current daily dose of GC (p = 0.345). Patients with vitamin D deficiency had higher SLEDAI (3.35 ± 4.35 vs 1.00 ± 2.48, p = 0.018), lower C4 levels (12.79 ± 6.78 vs 18.38 ± 12.24 mg/dL, p = 0.038), lower spine BMD (0.798 ± 0.148 vs 0.880 ± 0.127 g/cm(2), p = 0.037) and whole body BMD (0.962 ± 0.109 vs 1.027 ± 0.098 g/cm(2), p = 0.024). CONCLUSION: JoSLE vitamin D deficiency, in spite of conventional vitamin D supplementation, affects bone and disease activity status independent of therapy and fat mass reinforcing the recommendation to achieve adequate levels.

Cerebellar infarction in a patient with cerebral vein thrombosis and patent foramen ovale: brain-to-brain embolism?

Although the association between PFO and cryptogenic stroke is well shown in young adults, the causality is still unclear. The pathogenetic mechanism of ischemic stroke related to PFO is not entirely understood. Indeed, besides the well-known paradoxical embolism, formations of thrombi in situ, especially in the presence of ASA, a higher incidence of atrial fibrillation have been often observed. Cerebral sinus venous thrombosis may be due to local inflammation or to acquired or genetic thrombophilia including hyperhomocysteinemia. We report a case of a young man presenting with a cerebellar infarction probably secondary to a paradoxical brain-to-brain embolism, in which the only detectable embolic source was a cerebral vein thrombosis.

Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients' life. Results of an Italian mortality follow-back survey.

BACKGROUND: This study estimates prevalence, management, and relief of pain during the last 3 months of life of a representative sample of dying cancer patients in Italy. PATIENTS AND METHODS: This is a mortality follow-back survey (the Italian Survey of the Dying of Cancer). Caregivers were interviewed, after the patient's death, about pain experienced by the patients in all settings of care. RESULTS: According to caregivers' reports, 82.3% [95% confidence interval (CI) 79.9% to 84.4%] patients experienced pain, and 61.0% (95% CI 57.9% to 64.0%) very distressing pain. The younger population experienced a higher prevalence of pain in respect to older patients (P < 0.01). Patients with tumors of the central nervous system experienced the lowest prevalence (51.9%). According to caregivers' reports, only 59.5% (95% CI 3.7% to 65.0%) received analgesic treatment with opioids for moderate to severe pain. Not surprisingly, pain was 'only partially relieved' or 'not relieved at all' in 54% of the patients with very distressing pain. CONCLUSIONS: Although potentially slightly biased, the results from this survey regarding undermedication and poor treatment results for cancer related pain are unequivocal. The research agenda should focus on testing the effectiveness of interventions to improve the quality of pain assessment and management.

Putting endotoxin to work for us: monophosphoryl lipid A as a safe and effective vaccine adjuvant.

The development of non-infectious subunit vaccines greatly increases the safety of prophylactic immunization, but also reinforces the need for a new generation of immunostimulatory adjuvants. Because adverse effects are a paramount concern in prophylactic immunization, few new adjuvants have received approval for use anywhere in the developed world. The vaccine adjuvant monophosphoryl lipid A is a detoxified form of the endotoxin lipopolysaccharide, and is among the first of a new generation of Toll-like receptor agonists likely to be used as vaccine adjuvants on a mass scale in human populations. Much remains to be learned about this compound's mechanism of action, but recent developments have made clear that it is unlikely to be simply a weak version of lipopolysaccharide. Instead, monophosphoryl lipid A's structure seems to have fortuitously retained several functions needed for stimulation of adaptive immune responses, while shedding those associated with pro-inflammatory side effects.

Population-based incidence and mortality cancer trends (1986-1997) from the network of Italian cancer registries.

The objective of this study was to analyse incidence and mortality cancer trends in the Italian Network of Cancer Registries (about 8,000,000 inhabitants) during the period 1986-1997. Included were 525,645 newly diagnosed cancers and 269,902 cancer deaths (subjects > 14 years). Joinpoints (points in time where trend significantly changes from linearity) were found and estimated annual percentage changes (EAPC) used to summarize tendencies. Overall cancer incidence increased in both sexes and cancer mortality significantly decreased (since 1991 among men). Lung cancer showed significantly decreasing incidence (EAPC = -1.4%) and mortality (EAPC = -1.6%) among men and increasing trends among women. In women, breast cancer incidence significantly increased (EAPC= +1.7%) and mortality decreased since 1989 (EAPC= -2.0%). Stomach cancer incidence and mortality decreased in both sexes. Prostate incidence sharply increased since 1991 and mortality decreased. Colon cancer incidence increased and rectum mortality decreased significantly in both sexes. Significant increases in incidence were also found for kidney (up to 1991 among men), urinary bladder, skin epithelioma, melanoma, liver (up to 1993 among men), pancreas, mesothelioma, Kaposi's sarcoma (up to 1995 among men), testis, thyroid, non-Hodgkin's lymphomas and multiple myeloma. Mortality significantly decreased for cancers of the oral cavity and pharynx, oesophagus, liver (women), larynx (men), bone, cervix (since 1990), central nervous system, urinary bladder, thyroid, Hodgkin's lymphomas and leukaemias (men). Non-Hodgkin's lymphoma mortality increased in both sexes. In conclusion, most of the changes seen can be explained as the effect of changes in smoking habits and of the extension of secondary prevention activities. The Italian health care system will also have to cope with growing cancer diagnostic and therapeutic needs due to population ageing.

[Severe hypercalcemia due to acute primary hyperparathyroidism: role if parathyroidectomy]. / Ipercalcemia grave da iperparatiroidismo primitivo acuto: ruolo della paratiroidectomia.

Grave hypercalcemia may complicate primary hyperparathyroidism. This clinical condition is potentially life-threatening, if it is untreated. The emergency therapy consist in rehydratation, stimulation of diuresis and somministration of biphosphonates. A urgent surgery is required if conservative therapy is not successful. The Authors herein present a consecutive series of 6 cases with acute hypercalcemic crisis due primary hyperparathyroidism, successful treated with urgent parathyroidectomy after conservative treatment.

[Hypoparathyroidism following total thyroidectomy: prognostic value of intraoperative parathyroid hormone assay]. / Ipoparatiroidismo dopo tiroidectomia totale: utilità prognostica del dosaggio intraoperatorio del paratormone.

Transient and definitive hypoparathyroidism represent a frequent complication after thyroid surgery. Recently some authors proposed the use of intraoperative parathyroid hormone assay for the rapid detection of this complication. In this paper the authors describe the data obtained from 42 total thyroidectomies with intraoperative measurements of parathyroid hormone. When parathormone decrement was over 75% during thyroidectomy, the hypocalcemic symptomatology was found in all cases during postoperative observation. The authors emphasize intraoperative PTH dosage for immediate identification of patients at risk for postoperative hypoparathyroidism. In this cases parathyroid autotransplantation is suggested to prevent postoperative hypoparathyroidism.

[Acute appendicitis associated to "serrated" adenoma: a case report]. / Appendicite acuta associata ad adenoma "serrato": descrizione di un caso clinico.

The authors describe a case of acute appendicitis associated "serrated" adenoma (SA). to the histological finding of a SA is a colorectal pre-cancerous lesion which presents the morphological and architectural characteristics of hyperplasic polyps, combined with aspects of adenomatous dysplasia. SA can eventually evolve into a malignant cancer, similarly to classic adenomatous polyps. Clinical and pathological aspects of this lesion are hereby analysed, with respect to recent Literature data.

[Mesenteric fibromatosis: a case report]. / Fibromatosi mesenterica: a proposito di un caso.

Authors report a case of mesenteric fibromatosis, not associated to familial adenomatous polyposis or Gardner's syndrome. It is generally considered benign lesion without metastases, though local recurrences are very frequent. No symptoms are usually referred until compression of the surrounding organs, due to the mass growing, takes place. Surgical therapy is considered treatment of choice.

[Tardive cecal metastasis from ovarian cancer: a case report]. / Metastasi colica tardiva da carcinoma ovarico. A proposito di un caso clinico.

Intestinal insolvement is a frequent sequela of metastatic ovarian cancer may be syncronous or following ovaric resection, after several years of disease free condition. The authors herein describe a clinical report of a case of cecal metastatic neoplasm due to ovarian cancer treated with surgical resection 24 years before.