The role of the foam formulation in improving psoriasis treatment acceptability: a real-life experience and a literature review.

BACKGROUND: Topical therapies represent the first-line treatment for mild-to-moderate psoriasis. Among various topical options, the fixed-dose combination of calcipotriene (Cal) and betamethasone dipropionate (BD) foam (Enstilar®, LEO Pharma, Ballerup, Denmark) showed superior efficacy to Cal and BD monotherapy and ointment and gel formulations. In addition, the Cal/BD foam is the only topical treatment allowed for either reactive treatment of relapse or twice-weekly maintenance use. Since treatment acceptability is crucial to optimize adherence, this paper presents a case series from a multicenter experience using the Cal/BD foam, to further characterize the use of this therapeutic approach. In addition, a narrative review of studies evaluating the acceptability of the Cal/BD foam, even compared with other formulations, is provided. CASE SERIES: The case series involved adult patients with mild-to-moderate psoriasis treated with the Cal/BD foam from October 2021 to June 2022. A clinical and dermoscopic evaluation of plaques was provided for all patients. Data from the clinical practice report complete clinical resolution of plaques in most patients after 4 weeks of active treatment with the Cal/BD foam, and the dermoscopic clearance after a maximum of 8 weeks. Full adherence to treatment was also reported. Literature evidence suggests that the Cal/BD foam is easy to apply and presents high cosmetic acceptance, rapid onset of action, high efficacy, optimal safety, and a high patient preference. The high satisfaction obtained with Cal/BD foam suggests that this formulation is better accepted than others. CONCLUSIONS: The Cal/BD foam represents a valuable approach for managing mild-to-moderate psoriasis, both in short and long-term treatment.

Comparison of the use of life cycle assessment and ecological footprint methods for evaluating environmental performances in dairy production.

One popular methodology for assessing the environmental impact of livestock sector is Life Cycle Assessment (LCA), that quantifies the environmental impact of a product. Ecological Footprint (EF) performs an environmental sustainability assessment, by comparing the demand for natural capital by an economic activity with the offer of such capital within a certain territory. The aim of the study was the comparison between LCA and EF in assessing the environmental performances of milk production, assuming as case study three cattle farms with increasing levels of production intensity. Different metrics and functional units (FU) (i.e., fat and protein corrected milk, FPCM and hectare) were adopted for LCA analysis, considering some of the major impact categories. For greenhouse gases emissions, the Global Warming Potential (GWP) and the Global Temperature Potential (GTP) were considered. Both metrics were calculated assuming or not the distinction between biogenic and fossil methane. Adopting GWP as a metric, the results per kg of FPCM provided by the LCA highlighted a different trade off compared to the EF method: the farm with the highest productive intensity produced the least impactful milk in terms of GWP but had the most negative Ecological Balance (EB). The same occurred for the other impact categories. When GTP was adopted, or the hectare was considered as FU, the least intensive farm, characterized by greater feed self-sufficiency, became the one that produced the least impactful milk and had the least negative EB. The study highlighted the scientific significance of the integration between the two approaches for creating a comprehensive representation of the effects of human activities on the environment. The LCA method evaluates impacts intensity referred to a specific functional unit and its results are strongly influenced by productive efficiency; the EF method evaluates environmental sustainability of productions in relation to the territory that supports them.

Onychoscopy with red light for vascular pattern identification: a study of 33 patients.

BACKGROUND: Nail dermoscopy (onychoscopy) during physical examination assists in correct diagnosis. Often further magnifications are necessary for an effective differential diagnosis. With the addition of a red light to the dermoscope, important vascular features can be visualized. OBJECTIVE: To describe common features observed at onychoscopy with a new device that combines the regular white light with the red light illumination, demonstrating that it is useful for diagnosis of nail disorders. METHODS: We enrolled 33 consecutive patients referred to the Nail Diseases Dermatology Unit of the University of Modena and Reggio Emilia and to the Outpatient Consultation for Nail Disease of the Dermatology Unit of the University of Bologna. Patients were assessed with a standard hand-held dermoscope and at the red light dermoscope. Dermoscopic images were collected. RESULTS: The new prototype was used during daily clinical practice and allowed a more accurate visualization of some details that classic onychoscopy can miss. In particular, with the help of the red light it was possible to better visualize nail lesions that were characterized by some kind of colour change or vascular alterations. CONCLUSION: The new device of red light for vascular pattern onychoscopy can be a new investigation method to observe nail alterations, especially due to vascular pattern, even with low magnification, without the necessity to use higher resolutions.

Analysis of the "endocannabinoidome" in peripheral tissues of obese Zucker rats.

The endocannabinoid system (ECS) represents one of the major determinants of metabolic disorders. We investigated potential changes in the endogenous levels of anandamide (AEA), 2-arachidonoylglycerol (2-AG), N-oleoylethanolamine (OEA) and N-palmitoylethanolamine (PEA) in some peripheral organs and tissues of obese Zucker(fa/fa) and lean Zucker(fa/+) rats by qPCR, liquid chromatography mass spectrometry, western blot and enzymatic activity assays. At 10-12 weeks of age AEA levels were significantly lower in BAT, small intestine and heart and higher in soleus of Zucker(fa/fa) rats. In this tissue, also the expression of CB1 receptors was higher. By contrast in Zucker(fa/fa) rats, 2-AG levels were changed (and lower) solely in the small and large intestine. Finally, in Zucker(fa/fa), PEA levels were unchanged, whereas OEA was slightly lower in BAT, and higher in the large intestine. Interestingly, these differences were accompanied by differential alterations of the genes regulating ECS tone. In conclusion, the levels of endocannabinoids are altered during obesity in a way partly correlating with changes of the genes related to their metabolism and activity.

Perspectives on endocrine disruptor effects on metabolic sensors.

Endocrine disrupting (EDs) chemicals can increase or block the metabolism of endogenous peptidergic or steroid hormones by activating or antagonizing nuclear receptors in the hypothalamus, besides adipose tissue, liver and gonads. Toxicological and epidemiological studies have suggested the involvement of different EDs in an increasing number of metabolic disorders such as obesity and diabetes. The aim of this review is to summarize the literature from experimental animal studies demonstrating the impairment of body weight raised by the deregulation of peptidergic signals as well as by the activation of key metabolic molecular targets. Regarding the modification of gene transcription levels induced by EDs, new data on DEHP effect on food intake and lipid metabolism in the experimental model zebrafish (Danio rerio) have also been included in this review providing evidences about the dangerousness of DEHP low doses.

Salbutamol increases SMN mRNA and protein levels in spinal muscular atrophy cells.

Spinal muscular atrophy (SMA) is an inherited neuromuscular disorder caused by homozygous absence of the survival motor neuron gene (SMN1). All patients have at least one, usually two to four copies of the related SMN2 gene which, however, produce insufficient levels of functional SMN protein due to the exclusion of exon 7 in the majority of SMN2 transcripts. Here, we show that salbutamol, a beta2-adrenoceptor agonist, determines a rapid and significant increase in SMN2-full length mRNA and SMN protein in SMA fibroblasts, predominantly by promoting exon 7 inclusion in SMN2 transcripts. These data, together with previous clinical findings, provide a strong rationale to investigate further the clinical efficacy of salbutamol in SMA patients.

Instrument-, age- and site-dependent variations of dermoscopic patterns of congenital melanocytic naevi: a multicentre study.

BACKGROUND: Recently, we identified and described dermoscopic aspects, present with a higher frequency in congenital melanocytic lesions with respect to acquired naevi. We also classified small- and medium-sized congenital naevi (CN) into nine subtypes according to their macroscopic and dermoscopic aspects. OBJECTIVES: Because the recognition of dermoscopic features may be instrument dependent, in this study, we wanted to check whether dermoscopic patterns specific for CN can be identified in digital images acquired by means of different instruments. We also wanted to check the validity of our previously proposed classification and assess possible age- and site-dependent variations of dermoscopic patterns and naevus subtypes. PATIENTS/METHODS: Images corresponding to 384 small- or medium-sized CN were collected in eight different centres employing four different instruments. Lesion images were evaluated and checked for the presence of specific dermoscopic criteria, classified, and compared with a database of 350 acquired naevi. RESULTS: Specific and unspecific dermoscopic features were identifiable in images acquired by means of all four instrument types. The mean number of identified features per lesion did not vary according to the instrument employed for the acquisition of the images; however, it was lower for lesions recorded employing low magnifications. The previously proposed classification was easily applied to the whole image database. The variegated naevus type was identified as a highly specific clinical/dermoscopic pattern. Dermoscopic features varied according to age and location. The globular type prevailed in subjects under 11 years of age and on the trunk, whereas the majority of reticular lesions were located on the limbs. CONCLUSIONS: Because definite clinical and histological criteria for the diagnosis of the congenital nature of naevi are lacking, the use of dermoscopy can be of great help in identifying those lesions where the presence of specific dermoscopic features makes the diagnosis of CN more likely. Moreover, dermoscopy can be useful both for the classification of lesions already identified as congenital according to definite clinical and anamnestic data and for a possible correlation of naevus phenotype and dermoscopic patterns to the risk of developing a malignant melanoma in prospective studies.

PROPAT: a study to improve the quality and reduce the cost of diabetes care.

OBJECTIVE: In PROPAT we implemented an integrated approach to diabetes care designed to improve the quality and reduce the cost of care. STUDY DESIGN AND METHODS: PROPAT was a case-control study matching patients by age and gender (diabetes:control ratio 1:2) within IOMA, a public employment-based health maintenance organization (HMO) of the Province of Buenos Aires, Argentina. Costs were evaluated using prevalence data from an HMO perspective. We currently report clinical and biochemical data and costs from the first 297 patients enrolled who completed 1 year in PROPAT, and compare them with those derived from control patients. RESULTS: All recommended practices recorded as care provided at baseline increased significantly 1 year after implementing PROPAT, with a parallel significant improvement in several clinical and biochemical parameters, and markedly lower total annual per capita costs. CONCLUSIONS: These results demonstrate that the implementation of a comprehensive diabetes care program can simultaneously improve quality while reducing costs.

Hospitalization and re-hospitalization of people with and without diabetes in La Plata, Argentina: comparison of their clinical characteristics and costs.

OBJECTIVE: To examine the prevalence, characteristics, and costs of hospitalization and re-hospitalization of diabetic and non-diabetic patients in La Plata, Argentina, and to compare the data with those of developed countries. RESEARCH DESIGN AND METHODS: We studied all in-hospital registries of diabetic patients enrolled in a health maintenance organization of the Province of Buenos Aires (IOMA, November 1996). For each diabetic patient (127 persons), the characteristics of two other hospitalized non-diabetic patients matched by age and gender were simultaneously recorded. RESULTS: Of the 2200 recorded hospitalizations, 5.8% were for diabetic patients, accounting for 10.5% of the hospitalization cost. Cardiovascular diseases were the major cause of hospitalization in both groups. The per capita hospitalization cost of diabetic patients was significantly higher: 1628.5+/-1754.0 US dollars versus 833+/-842 US dollars; P=0.00002. Percent re-hospitalizations were five and a half times higher in diabetic patients (P=0.0001), and significantly associated with history of severe episodes of acute (odds ratio: 3.61; 95% CI: 1.11-11.70; P=0.03) and chronic (odds ratio: 4.26; 95% CI: 1.60-11.29; P=0.004) complications. CONCLUSIONS: The combination of higher and longer hospitalization rates and frequent re-hospitalizations resulted in increased costs for our diabetic population. Implementation of care programs based on education (for physicians and patients) could effectively decrease current and future costs of the disease.

Hemodynamic effects of chest closure in adult patients undergoing cardiac surgery.

OBJECTIVE: To evaluate hemodynamic effects of sternal retractor removal and sternal closure after cardiopulmonary bypass and to correlate these changes with preoperative and intraoperative variables. DESIGN: Prospective. SETTING: University hospital. PARTICIPANTS: Fifty adults undergoing cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Arterial, pulmonary artery, and transesophageal echocardiography measurements were obtained immediately before and 1 minute after removal of the sternal retractor and immediately before and 1 minute after sternal closure. Retractor removal caused a significant decrease in cardiac index by 5.6% (p < 0.01), stroke volume index by 4.0% (p < 0.05), and mean pulmonary artery pressure by 4.8% (p < 0.001). Sternal closure caused a significant decrease in cardiac index by 7.7%, stroke volume index by 10.2%, and left ventricular end-diastolic area by 9.2% (p < 0.001) There were significant increases in pulmonary capillary wedge pressure and systemic vascular resistance by 9.1% and 10.8% (p < 0.01). There was no significant change in the ejection fraction area. The magnitude of decrease in stroke volume index with sternal closure correlated positively with end-diastolic area immediately before the closure. CONCLUSION: Chest closure is associated with significant hemodynamic changes and a change in the ventricular transmural pressure-volume relationship. Patients with lower preload immediately before closure are more vulnerable to a decrease in cardiac index. Based on the results of this study, volume appears to be the appropriate preventive and treatment option to limit the impact of chest closure.

Skin barrier, hydration, and pH of the skin of infants under 2 years of age.

The goal of this study was to instrumentally evaluate the skin of healthy infants and to compare it to adult skin. A total of 70 infants, 45 girls and 25 boys, ages 8-24 months, and 30 healthy women were studied by means of transepidermal water loss (TEWL), capacitance, and pH measurements at two different skin sites, the volar forearm and the buttocks. No significant differences in TEWL were found between infants and adults, either on the buttocks or on the volar forearm. On the contrary, capacitance values were higher in infants. Their skin also appeared less acid than that of adults, with high statistical significance. No TEWL, capacitance, or pH variations were observed in infants according to sex and age. On the basis of the above data, the skin of infants 8-24 months of age shows functional signs of immaturity. This may lead to an increased permeability and a reduced capacity for defense against chemical and microbial aggression.

Intestinal permeability correlates with severity of injury in trauma patients.

BACKGROUND: Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied. METHODS: The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded. RESULTS: The IP of healthy volunteers (L/M, 0.025 +/- 0.008) was within the normal range (L/M < or = 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 +/- 0.172) and on the fourth hospital day (L/M, 0.346 +/- 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R2 = 0.87, p < 0.001; TRISS: r = 0.93, R2 = 0.87, p < 0.001; ISS: r = 0.84, R2 = 0.70, p < 0.001; RTS: r = 0.68, R2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R2 = 0.26, p = 0.04). Patients with markedly increased IP (L/M > or = 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%; p = 0.03) and subsequent infectious complications (58 vs. 13%; p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R2 = 0.76, p < 0.001). CONCLUSION: These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.

Well differentiated "lipoma-like" liposarcoma of the sigmoid mesocolon and multiple lipomatosis of the rectosigmoid colon. Report of a case.

Liposarcoma is the second most common soft tissue sarcoma in adults. These neoplasms take their origin from primitive mesenchymal cells and are rarely encountered in fat rich areas, such as subcutaneous tissue and/or the subserosa of the intestinal tract which, on the contrary, are the two most common sites of lipomas. The two major locations of liposarcomas are the extremities and the retroperitoneum followed with much less frequency by the inguinal region. Other sites are uncommon, particularly the mesentery (9 cases to date in the literature) and, even more so, the mesocolon (only 3 cases of primary sarcoma of the mesocolon reported to date). This paper reports on the case of a well differentiated "lipoma-like" liposarcoma of the sigmoid mesocolon, associated with multiple lipomatosis of the recto-sigmoid colon in a 75 year-old female patient. Surgical treatment consisted of a trans-anal extra-peritoneal anterior resection by CEEA 28 stapler under endoscopic vision. The patient has been followed up for the last 2 years and is still disease-free and well. The peculiarity of the case consists in the contemporaneous presence in close contiguity of two different rare neoplasms whose association is not yet known.

Intraoperative esophageal manometry: our experience.

In order to improve the results of functional surgical procedures on the esophagus, the authors, after a number of experimental studies, proposed the use of intraoperative esophageal manometry (IEM). The technique was performed for the first time in 1972. IEM has been employed in the course of Heller's cardiamyotomies and Nissen-Rossetti (N-R) fundoplications, respectively, to document the ablation of the lower esophageal sphincter (LES) high-pressure zone (HPZ) and to calibrate the pressure of the fundal wrap between values ranging from 20 to 40 mmHg ('hypercalibrated Nissen'). This hypercalibration resulted from the retrospective evaluation of a former series when, at the beginning of our experience, we used to calibrate the fundoplication to pressure values similar to those of a normal sphincter ('normocalibrated Nissen': 10-20 mmHg). This experience, in fact, was followed by a high rate of gastroesophageal reflux (GER) recurrence (28.5%) in the first 12 months after surgery. Since 1985 to date, IEM has been employed in the course of 309 functional surgical procedures on the esophagus. This paper, however, reports on 281 patients: 144 with achalasia treated with Heller's myotomy + Nissen-Rossetti fundoplication and 137 with gastroesophageal reflux disease (GER-D) submitted to Nissen-Rossetti fundoplication. Our data suggest that IEM can be a useful tool in the field of functional surgery of the esophagus, and its routine use seems to be able to improve the postoperative results. In this series, in fact, IEM was able to detect the persistence of an HPZ in 15.2% of apparently complete myotomies, all performed with the aid of intraoperative endoscopy. As regards the manometric calibration of the n-HPZ, our results seem to confirm the validity of the technique, yet some findings still remain unexplained: i.e. two patients with a hypotonic n-HPZ and GER recurrence and two with an n-HPZ, exceeding 20 mmHg with postoperative persistent dysphagia. Finally, we would like to emphasize that the concept of a 'hypercalibrated Nissen' contrasts with the 'floppy Nissen' of Donahue and DeMeester; our wrap is also loose around the esophagus and does not impair the esophagogastric transit.

Mediastinoscopy for the evaluation and treatment of projectile injuries.

This case report describes the first use of mediastinoscopy for the evaluation of a projectile injury and concomitant removal of the projectile. The described treatment made it possible to avoid the significant morbidity associated with mediansternotomy or thoracotomy. Complications secondary to retained mediastinal foreign bodies including infection, migration, and perforation were also avoided.

Correlative transmission and scanning electron microscopy study of microglia activated by interferon-gamma and tumor necrosis factor-alpha in vitro.

Microglia, in response to cytokines, demonstrate a number of enhanced biochemical and functional properties which reflect a state of activation. In this study, we evaluated the ultrastructural alterations of murine microglia that were associated with activation by interferon-gamma (IFN-gamma) plus tumor necrosis factor-alpha (TNF-alpha). Microglial cell culture treated with these cytokines generated significant amounts of the free radical nitric oxide (NO), a biochemical marker of activation. Correlative transmission (TEM) and scanning (SEM) electron microscopic analyses of these cytokine-activated microglia demonstrated two prominent features: proliferation of cell processes and increased formation of membrane bound dense bodies typical of lysosomes. Since activated microglia have been implicated in the pathogenesis of a number of neurodegenerative diseases, application of the ultrastructural findings in the in vitro study may prove useful in determining the state of activation of microglia in brain specimens from patients with these neurological disorders.

Decortication for chronic postpneumonic empyema.

BACKGROUND: Thoracic empyema after pneumonia continues to be a source of morbidity and mortality. Despite the widespread use of antibiotics, more than 50 percent of empyemas are secondary to a primary pulmonary process. An empyema present for four to six weeks is considered chronic and can severely restrict the movement of the entire hemithorax. STUDY DESIGN: Twenty-five adult patients with chronic, postpneumonic empyema required decortication at the Bronx Municipal Hospital Center between 1988 and 1990. Only patients with chronic postpneumonic empyema were included. All patients failed conservative treatment with antibiotics and tube drainage. Decortication was required to control infection and release the pulmonary entrapment. RESULTS: Patients were often debilitated from alcoholism (52 percent), drug addiction (32 percent), and chronic disease. Ten patients (40 percent) required additional operative procedures to control infection: two pneumonectomies, three lobectomies, three wedge resections, and two debridements of pulmonary abscess were performed. Preoperative plain roentgenographs and computed tomographic scans diagnosed the empyema in all cases; however, they were frequently unable to predict the operative findings. There was one recurrence and one mortality (4 percent). The average postoperative period of hospitalization was 18 days (seven to 30 days). CONCLUSIONS: Decortication remains a highly effective treatment for chronic postpneumonic empyema and may identify underlying complications that could account for a patient's poor response to conservative treatment. Pulmonary abscess and parenchymal necrosis may not be detected during preoperative evaluation.

Priorities in general surgical training.

PURPOSE: We wished to determine which area of surgical resident training receives the highest priority--surgical technique, surgical judgment, or "book knowledge." We were also interested in how the programs addressed each area, particularly the teaching of surgical technique. METHODS: A questionnaire was distributed to the program directors and chief residents of all 289 general surgery residency programs in the United States. RESULTS: Answers were received from 144 chief residents (50%) and 152 program directors (53%). Programs to teach surgical judgment and technique were offered by 55 (36%) and 68 (45%) of general surgical residencies. Most program directors (83%) and chief residents (72%) considered surgical judgment the most important aspect of surgical training. Sixty-four percent of chief residents felt they were receiving adequate training in the technical aspects of surgery. Approximately half of the program directors felt that residents needed better training in the technical aspects of surgery. One hundred thirty programs (86%) had specific curricula for teaching "book knowledge." CONCLUSIONS: With the advent of minimal access surgery and the constant introduction of new instruments and procedures, new demands are constantly being placed on practicing surgeons. In order to prevent the further fragmentation of general surgery, a more structured approach to the early teaching of surgical skills should be considered.

Continuous normothermic retrograde cardioplegia for valve surgery.

We have studied warm heart surgery, deemed as continuous warm blood cardioplegia and normothermic cardiopulmonary bypass (CPB), as an alternative to the technique of intermittent cold cardioplegia for valvular surgery. Between August 1990 and January 1994, 137 consecutive patients underwent valve repair or replacement using normothermic CPB. Eighty-six of these patients received continuous normothermic retrograde blood cardioplegia via the coronary sinus (CNRC). Fifty-one patients received intermittent cold blood cardioplegia (ICBC). All procedures were performed by the same surgeon (RWMF). The two groups were matched for age, sex, NYHA class, preoperative ejection fraction, diagnosis, procedure and activated clotting time. Warm blood cardioplegia was delivered continuously via the coronary sinus after antegrade arrest (oxygenated blood 1:4 to 1:3, 37 degrees C, 250-300 ml/min, maintaining coronary sinus pressures of 40-60 mmHg. Perioperative myocardial infarction was significantly less prevalent (4.6 vs. 8.0%; p < 0.05) in the warm cardioplegia group. Cardiac output immediately after bypass was significantly higher than before bypass only in the CNRC group (4.1 +/- 0.8 to 5.2 +/- 0.9 L/min; p < 0.01). CNRC patients had significantly higher incidence of spontaneous resumption of sinus rhythm at cross-clamp removal (80 of 86, 93%) compared to the hypothermic patients (14 of 51, 27%, p < 0.001). The time from removal of the aortic cross-clamp to discontinuation of CPB (reperfusion time) was significantly shorter in the warm cardioplegia group (43 +/- 7.4 versus 75 +/- 10.2 min; p < 0.001.(ABSTRACT TRUNCATED AT 250 WORDS)