[The network of health promoting companies (WHP) in the province of Bergamo]. / La rete WHP delle aziende che promuovono la salute nella provincia di Bergamo.

OBJECTIVES: To create, by 2012, a network of Promoting Health companies in the Province of Bergamo, with at least 10% of companies with over 90 employees (about 10,000 workers) adherent, and attending up to 15% by 2015. METHODS: The work was carried out by building partnerships and collaboration with Confindustria Bergamo and the main healthcare and Union stakeholders in the province, selecting good practices and experimenting feasibility and effectiveness in two mid-sized companies, before extending the proposal A system of accreditation was defined. Member companies should implement a at least 18 good practices in three years. The areas of good practices are: nutrition, tobacco, physical activity, road safety, alcohol and substance and wellbeing. The results are surprising in terms of network and adhesion. Currently 46 companies are involved (over 9,200 employees). CONCLUSIONS: The model seems to work well and in our opinion is extensible on a larger scale.

An economic evaluation of Clostridium difficile infection management in an Italian hospital environment.

BACKGROUND AND OBJECTIVES: Clostridium difficile infection (CDI) accounts for the majority of nosocomial cases of diarrhea, and with recent upsurge of multidrug-resistant strains, morbidity and mortality have increased. Data on clinical impact of CDI come mostly from Anglo-Saxon countries, while in Italy only two studies address the issue and no economic data exist on costs of CDI in the in hospital setting. A retrospective cross-sectional study with pharmacoeconomic analysis was performed on the CDI series of the Policlinico Gemelli of Rome, a major 1400 bed Hospital. PATIENTS AND METHODS: The clinical charts of 133 patients in a 26 month period were reviewed. All costs of the involved resources were calculated and statistical analysis was carried out with means and standard deviations, and categorical variables as number and percentages. RESULTS: The results show the significant sanitary costs of CDI in an Italian hospital setting. The cost analysis of the various elements (exams, imaging studies, therapies, etc.) shows that none independently influences the high cost burden of CDI, but that it is the simple length of hospital stay that represents the most important factor. CONCLUSIONS: Prevention of CDI is the most cost-effective approach. The major break-through in cost reduction of CDI would be a therapeutical intervention or procedure that shortens hospital length of stay.

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Iron, zinc and aluminium ferritin content of hemodialysis hyperferritinemic patients: comparison with other hyperferritinemic clinical conditions and normoferritinemic blood donors.

The present study describes the specific content of ferritin iron, zinc and aluminium in four different groups: 1) hemodialysis hyperferritinemic patients; 2) septic patients; 3) iron overloaded patients with hematologic diseases; and 4) blood donors. In all four groups high levels of aluminium and zinc were found in addition to those of iron. However, the sum of the ferritin ions of the control group is significantly higher than that of the other three groups. Furthermore, while ferritin of hemodialysis patients has the same molecular ratio of metal ions as control group (high Al content vs. Fe and Zn), a lower Al/Fe ratio is found both in septic and hematological patients. The results of the present paper might help to explain the high percentage of hyperferritinemia found in hemodialysis patients also in presence of low transferrin saturation and in absence of inflammatory markers. Moreover, the high content of ions other than iron in the ferritin core leads us to believe that ferritin is not only an iron storage protein but rather a regulator of redox active ions.

[Malnutrition in patients on chronic hemodialysis: prevalence, pathogenesis, and treatment]. / La malnutrizione nel paziente in emodialisi cronica: prevalenza, patogenesi, terapia.

Malnutrition is common in patients on hemodialysis and is a strong predicor of morbidity and mortality. Much progress has been made in recent years in identifying the causes and pathogenesis of malnutrition in hemodialysis patients as well as in recognizing the link between malnutrition and morbidity and mortality. Nevertheless, there is no consensus concerning its management. Conventional interventions such as nutritional counseling, oral nutritional supplements and intradialytic parenteral nutrition and novel preventive and therapeutic strategies such as appetite stimulants, growth hormone, androgenic anabolic steroids, and antiinflammatory drugs have been tested with contradictory and inconclusive results. Malnutrition still remains an important challenge for the nephrologist in the third millennium.

Ferritin iron content in haemodialysis patients: comparison with septic and hemochromatosis patients.

OBJECTIVES: Hemodialysis (HD) population commonly show high plasma ferritin levels with a poor diagnostic value. The objective of this study is to elucidate the meaning of HD hyperferritinemia through the analysis of its ferritin iron content (FIC). DESIGN AND METHODS: FIC (iron atoms/ferritin molecule) was measured by atomic emission spectrometry. Ferritin and FIC values were correlated with iron storage and inflammation markers and the results of HD patients compared to those of septic and hemochromatosis patients. RESULTS: 1) In the whole HD population, high ferritin levels were associated to low FIC values; 2) the correlation of ferritin with iron indices and inflammation markers in HD patients was intermediate in between that of septic and hemochromatosis patients; 3) the FIC level of HD patients was lower than that of the other two groups. CONCLUSIONS: The high ferritin levels of HD patients are not synonymous with either inflammation or of high levels of iron storage. Their high levels and the low FIC values might be due to the presence inside the ferritin core of oligoelements other than iron.

[The ATLS Courses in Italy. Twelve years experience]. / I Corsi ATLS (Advanced Trauma Life Support) in Italia. Dodici anni di attività.

ATLS Courses were introduced in the USA in 1980 and have been taught in Italy since 1994. Through theoretical lessons and practical sessions, their scope is to provide proper training for doctors with every kind of speciality who work in Emergency Departments, in order to prepare them to rapidly and effectively intervene on a patient who has suffered a serious trauma. Universities, in fact, do not prepare doctors adequately on this topic, while the application of the ATLS method in the first hours after trauma can effectively improve the prognosis of the patient. This study collects the data of the Italian experience in ATLS training, which has been carried out under the aegis of the Italian Chapter of the American College of Surgeons. The ATLS Courses have become widespread throughout our Country, which today is the fourth in the world for number of courses held every year.

Effect of botulinum toxin antral injection on gastric emptying and weight reduction in obese patients: a pilot study.

BACKGROUND: A potential approach to the treatment of morbid obesity is reduction of gastric emptying to achieve satiety. Botulinum toxin A (Btx-A) is a long-acting inhibitor of acetylcholine-mediated peristalsis, which is mainly responsible for gastric motility. AIM: To investigate whether botulinum toxin A, injected in the antrum of obese patients, delays gastric emptying. METHODS: In a double_blind study, 18 healthy obese subjects (body mass index >30) were randomized into three groups (BTX133, BTX200 and Saline); they received Btx-A133U, Btx-A200U, or saline under endoscopic control. Gastric emptying was tested by scintigraphy before and 10 days after treatment. Body weight variations and appetite sensation were recorded after 5 weeks. RESULTS: Fourteen patients completed the study. The botulinum toxin A-treated groups showed weight reduction, which was not statistically significant. The effects on gastric emptying were variable. Most of the botulinum toxin A treated patients reported a reduced appetite. CONCLUSION: This pilot clinical trial suggests potential activity of botulinum toxin A for the manipulation of appetite.

Botulinum toxin injected in the gastric wall reduces body weight and food intake in rats.

BACKGROUND: Botulinum toxin is a powerful, long-acting inhibitor of muscular contractions in both voluntary and smooth muscle. It acts by blocking the release of the neurotransmitter acetylcholine. In the stomach, propulsive contractions of the antrum are necessary for the gastric contents to pass into the duodenum. AIMS: To investigate whether intramuscular injections of botulinum toxin type A into the gastric antrum of rats would cause a reduction in food intake and hence body weight, by inhibition of gastric emptying. MATERIALS AND METHODS: This was a prospective, randomized, 3-way parallel group study in rats. The first group was anaesthetized, laparotomized and given 20 U of botulinum toxin type A by intramuscular injection into the gastric antrum (botulinum toxin type A group, n=14). The second group was anaesthetized, laparotomized and injected with saline (sham group, n=14) and the third group did not have any intervention (control group, n=5). Food intake was measured daily for 7 weeks and body weight was measured daily for 10 weeks. RESULTS: There was a significant difference in loss of body weight between the two treated groups (14.0 +/- 8.2% botulinum toxin type A group, 4.4 +/- 2.7% sham group; P < 0.001). Further, the time to reach the weight nadir was significantly longer in the botulinum toxin type A group (8.7 +/- 3.9 days) compared with the sham group (5.3 +/- 3.8 days; P < 0.04). There were no significant differences between the sham and control groups for any of the body weight parameters. The minimum dietary intake was significantly lower in the botulinum toxin type A group than in the sham group (37.8 +/- 21.8% of the basal value in the botulinum toxin type A group, vs. 65.5 +/- 32.0 in the sham group, P < 0.05). In addition, the time to reach the nadir was significantly prolonged (8.2 +/- 3.5 days, botulinum toxin type A group vs. 4.9 +/- 1.7 days, sham group, P < 0.001). CONCLUSIONS: The parallel reduction of body weight and food intake in botulinum toxin type A treated animals is consistent with a long lasting inhibition of the antral pump. This is probably due to slowed gastric emptying leading to early satiety. Patients with morbid obesity might benefit from endoscopic injections of botulinum toxin type A into the stomach wall.

The beta-oxidation of arachidonic acid and the synthesis of docosahexaenoic acid are selectively and consistently altered in skin fibroblasts from three Zellweger patients versus X-adrenoleukodystrophy, Alzheimer and control subjects.

The beta-oxidation of [3H] arachidonic acid (AA; 20:4 n-6) and the conversion of [1-14C]eicosapentaenoic acid (EPA, 20:5 n-3) to docosahexaenoic acid (DHA, 22:6 n-3) have been studied in skin fibroblasts from patients with inherited peroxisomal diseases, such as Zellweger (ZW) and X-linked adrenoleukodystrophy (X-ALD), from patients with Alzheimer's disease (AD), a non-inherited neuropathology, and from controls. EPA is not converted to DHA, while there is enhanced formation of the intermediate product 22:5 n-3 in ZW, when compared to X-ALD, AD and controls. We also confirmed that AA is not beta-oxidized to 4,7,10-hexadecatrienoic acid (16:3), a metabolite produced by peroxisomes, while being more effectively converted to the elongation product 22:4, in ZW, in comparison to X-ALD, AD and controls. The data demonstrate a defect in DHA synthesis and in AA beta-oxidation, and the occurrence of associated adaptative modifications in the metabolism of these long chain PUFA, in three Italian ZW patients.

Arachidonic acid synthesis and lipid metabolism in retinoic acid-differentiated neuroblastoma cells.

SK-N-BE cells were differentiated (D) to neurons with retinoic acid. Total n-6 polyunsaturated fatty acids (PUFA), especially arachidonic acid (AA), were increased in D versus ND cells. AA synthesis from linoleic acid (LA) and phospholipid (PL) synthesis from glycerol were initially elevated, whereas both processes were reduced approaching differentiation. At this stage, the incorporation of glycerol in triglycerides was enhanced. Formation of long chain PUFA and synthesis of acceptors (PL) for esterification, during RA-induced SK-N-BE differentiation, appear to be associated.

Hypocholesterolemia and risk of death in the critically ill surgical patient.

OBJECTIVE: To evaluate the additional information provided by the determination of cholesterolemia to the Acute Physiology and Chronic Health Evaluation (APACHE) II score. DESIGN: Retrospective evaluation of patients admitted to the intensive care unit (ICU). SETTING: ICUs in a university hospital. PATIENTS: 638 consecutive critically ill surgical patients. INTERVENTIONS: Surgical and medical therapy according to clinical status. MEASUREMENTS AND MAIN RESULTS: Two indices were devised: DELCUPOS and DELCUNEG (cubed absolute value of the difference between measure cholesterol and the value of 190 mg/dl when cholesterolemia was, respectively, over and under 190 mg). The first estimation of cholesterolemia was taken upon admission to the ICU. The APACHE II score was computed from teh worst values obtained during the first 24h of the ICU stay, including the pre-operative period for patients transferred from the operating theatre. Mortality (24.4%) over the whole time of hospitalization has been considered. A stepwise linear logistic regression on APACHE II, DELCUPOS, DELCUNEG, and on interactions among these three factors has been carried out. A U-shaped relationship between cholesterolemia and morality was demonstrated. The significance of DELCUPOS (p = 0.0021) and DELCUNEG (p = 0.0002), considered together with the APACHE II score, has demonstrated an additive information content with respect to the APACHE score for the prediction of mortality. CONCLUSION: Both hyper- and hypocholesterolemia have a highly significant relationship to mortality. Cholesterolemia improves the prognostic power of the APACHE II score. This result could be used to create a more powerful prognostic index.

Changes in arachidonic acid levels and formation and in lipid synthesis in the human neuroblastoma SK-N-BE during retinoic acid-induced differentiation.

We observed that retinoic acid, which differentiates the human neuroblastoma SK-N-BE into mature neurons, induced an elevation in levels of polyunsaturated fatty acids, especially arachidonic acid (20:4 n-6). This effect was not induced by phorbol myristate acetate, another differentiating agent. We then explored the effects of retinoic acid on the formation of arachidonic acid and of docosahexaenoic acid from precursors and on the de novo lipid synthesis from acetate at various stages of differentiation, which was assessed by morphological (cell number and neurite outgrowth) and biochemical (protein content and thymidine incorporation) criteria. At 3 days of incubation with retinoic acid, in the n-6 series, total conversion of linoleic acid, especially to 20:3 n-6, was elevated, in association with preferential incorporation of acetate into phospholipids; in contrast, at 8 days, synthesis of 20-carbon polyunsaturated fatty acids declined, in association with enhanced incorporation in triglycerides. In the n-3 series, eicosapentaenoic acid was converted to docosahexaenoic acid in SK-N-BE, but the conversion was not affected by retinoic acid. During the early stage of neuronal differentiation, therefore, enhanced production of 20-carbon polyunsaturated fatty acids from their precursors occurred, and newly formed fatty acids were preferentially incorporated in phospholipids, possibly in association with membrane deposition. When differentiation was completed, arachidonic acid formation and incorporation of acetate in phospholipids and cholesterol declined with enhanced labeling of storage lipids.

Stiff-man syndrome: a rare disorder of the central nervous system.

Stiff-man syndrome is a rare disorder of the central nervous system characterized by painful involuntary stiffening of axial muscles accompanied by spasms. Symptomatology is often precipitated by tactile or emotional stimuli, volitional movements and startling noises. It is occasionally associated with epilepsy and endocrine disorders, including insulin-dependent diabetes mellitus. Certain diagnostic criteria are essential for the diagnosis of Stiff-man syndrome since the initial clinical manifestations are similar to those of other neuromuscular diseases. Research findings support the theory of central nervous system autoimmunity with resultant impairment of neuronal pathways as the probable pathogenesis of Stiff-man syndrome.

[Opaque enema as the first test: is it always the right choice?]. / Clisma opaco come primo esame: è sempre una scelta giusta?

Dual contrast barium enema is the first investigation which is performed in a patient with symptoms of colic pathology. According to the results the doctor will decide whether to continue with further tests. The authors have carried out a retrospective study of the consequences of this diagnostic iter in an attempt to establish whether barium enema can be used as grounds to identify patients requiring further tests, also taking into account the costs of this diagnostic procedure. The medical records were examined for all patients admitted to hospital with colic symptoms and subjected to barium enema and then total colonoscopy in our unit from January 1990 to April 1992. A total of 131 patients were included in the study, of which 71 were males and 60 females, with a mean age of 62.4 years (range 22-89). Patients with rectorrhagia (59) routinely underwent barium enema and, irrespective of radiological results, colonoscopy. Patients with other forms of colic symptoms (72), with the exception of rectorrhagia, only underwent colonoscopy if barium enema was positive. Radiological findings were divided into positive, negative and radiological images of uncertain interpretation, were controlled using colonoscopy. Colonoscopy was total in 115 cases (87.5%), partial due to the presence of insuperable stenoses in 10 cases (7.4%), and incomplete due to technical difficulties in 6 cases (5.1%). In 24 cases endoscopy showed false negative (18.3%), false positives in 20 cases (15.2%) and uncertain radiological findings in 15 cases (11.4%) with no pathological endoscopic finding. In one case (0.7%), barium enema failed to make the entire colon opaque.(ABSTRACT TRUNCATED AT 250 WORDS)

Thiopental efficacy in phenobarbital-resistant neonatal seizures.

The successful treatment with thiopental (10 mg/kg, i.v.) of 9 severely asphyxiated newborns, under artificial ventilation, with neonatal seizures resistant to phenobarbital, is reported in this pilot study. The clinical and electroencephalogram control of seizures was prompt and resolute. No adverse effect on cardiovascular function (heart rate, blood pressure) was observed. The terminal half-life of thiopental averaged 9 h, the total plasma clearance 0.20 l/h/kg, and the steady-state volume of distribution 3.6 l/h/kg. The kinetic profile of the drug compared to phenobarbital and phenytoin in newborns suggests that its action is quicker and shorter lasting. Thus, from these findings, thiopental may offer a useful and handy approach for the safe and effective treatment of phenobarbital-resistant neonatal seizures.