The evolutionary origin of human hyper-cooperation.

Proactive, that is, unsolicited, prosociality is a key component of our hyper-cooperation, which in turn has enabled the emergence of various uniquely human traits, including complex cognition, morality and cumulative culture and technology. However, the evolutionary foundation of the human prosocial sentiment remains poorly understood, largely because primate data from numerous, often incommensurable testing paradigms do not provide an adequate basis for formal tests of the various functional hypotheses. We therefore present the results of standardized prosociality experiments in 24 groups of 15 primate species, including humans. Extensive allomaternal care is by far the best predictor of interspecific variation in proactive prosociality. Proactive prosocial motivations therefore systematically arise whenever selection favours the evolution of cooperative breeding. Because the human data fit this general primate pattern, the adoption of cooperative breeding by our hominin ancestors also provides the most parsimonious explanation for the origin of human hyper-cooperation.

Current trends in periprosthetic hip fractures: a review of the literature and an analysis of three clinical cases.

It is the purpose of this study to review current trends and guidelines in the treatment of periprosthetic hip fractures, and to report three cases of patients operated on and treated by different types of instrumentation: Modified Mennen plate by De Puy, Dall-Miles trochanteric grip, Zimmer cable-ready plate.

The combination of computerized cardiotocography and amniotic fluid index for the prediction of neonatal acidemia at birth: a modified biophysical profile.

OBJECTIVE: To study the combination of computerized cardiotocography (cCTG) and the amniotic fluid index (AFI) in the prediction of neonatal acidemia at birth. METHODS: A total of 89 singleton third-trimester high-risk pregnancies delivered by Cesarean section, with an AFI evaluated within 24 h from birth, and an antepartum cCTG performed within 6 h from delivery, were studied. The score was the sum of values for AFI (oligo/anhydramnios = 1, normal = 0) and cCTG (Dawes-Redman criteria, not met = 1, met = 0). The endpoint was to predict an abnormal neonatal outcome as defined by an umbilical artery pH of < or = 7.2. RESULTS: Fifteen neonates had an umbilical artery pH of < 7.2. The combination of cCTG + AFI score was able to predict pH values (< or = 7.20) with an OR = 2.83 (p < 0.02). The diagnostic accuracy of the combination of cCTG + AFI was as follows: sensitivity 80%, specificity 58%, positive predictive value 28%, negative predictive value 83%. COMMENT: We suggest that the cCTG + AFI score may be of value in the prediction of neonatal acidemia and help in the management of third-trimester high-risk pregnancies.

Effect of antenatal betamethasone therapy on maternal-fetal Doppler velocimetry.

BACKGROUND: The effect of antenatal betamethasone on fetal parameters includes a transient reduction of FHR variation and of fetal body movements. An effect on maternal-fetal blood flow has also been shown, with non-univocal results. AIMS: To evaluate the effect of antenatal betamethasone in third trimester singleton high-risk pregnancies by Doppler technology. SUBJECTS AND METHODS: Thirty-six pregnant women who received a full course of betamethasone (12 mg i.m. two times, 24 h apart) were studied. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI), the middle cerebral artery (MCA PI) and of resistance index of uterine arteries (Ut RI) before treatment, and 48 and 96 h after second dose of betamethasone. RESULTS: No significant variation was noted in UA PI through betamethasone therapy. MCA PI decreased significantly 48 h from the last injection of betamethasone (P=0.002), and returned to basal values at 96 h. No difference was found for the other Doppler parameters examined. When serial Doppler studies were analyzed according to the gestational age, in the group <32 weeks' gestation, MCA PI decreased significantly after 48 h (P<0.006) and returned to pre-treatment values after 96 h from the last betamethasone dose. Conversely, no difference was found in Doppler serial measurements in any of the analyzed districts in the subgroup > or =32 weeks. CONCLUSION: Betamethasone treatment is associated with a significant, although transient, reduction of MCA PI, especially at gestational ages <32 weeks'.

[Effects of betamethasone administration on maternal-fetal Doppler velocimetry]. / Effetti della somministrazione del betametasone sulla velocimetria Doppler materno fetale.

BACKGROUND: The effect of antenatal betamethasone on fetal parameters includes a transient reduction of fetal heart rate variation and of fetal body movements. An effect on maternal-fetal blood flow has also been shown, with non-univocal results. AIMS: To evaluate the effect of antenatal betamethasone in third trimester singleton high-risk pregnancies by Doppler technology. SUBJECTS AND METHODS: Thirty-six pregnant women who received a full course of betamethasone (12 mg i.m. two times, 24 hrs apart) were studied. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI), the middle cerebral artery (MCA PI) and of resistance index of uterine arteries (Ut RI) before treatment, and 48 and 96 hrs after second dose of betamethasone. RESULTS: No significant variation was noted in UA PI through betamethasone therapy. MCA PI decreased significantly 48 hours from the last injection of betamethasone (p = 0.004), and returned to basal values at 96 hours. No difference was found for the other Doppler parameters examined. When serial Doppler studies were analyzed according to the gestational age, in the group < 32 wks' gestation, MCA PI decreased significantly after 48 hours (p < 0.006) and returned to pre-treatment values after 96 hours from the last betamethasone dose. Conversely, no difference was found in Doppler serial measurements in any of the analyzed districts in the subgroup > or = 32 wks' gestation. CONCLUSION: Betamethasone treatment is associated with an increase in end diastolic flow of the middle cerebral artery, as reflected by a significant, although transient, reduction of MCA PI, especially at gestational ages < 32 weeks.

[Combination of the computerized analysis of fetal heart rate and amniotic fluid index in the prediction of neonatal acidemia: a modified biophysical profile]. / Combinazione dell'analisi computerizzata della frequenza cardiaca fetale (cCTG) e dell'indice del liquido amniotico nella predizione di acidemia neonatale: un profilo biofisico modificato.

OBJECTIVE: To study the use of a modification of the classical biophysical profile by the combination of computerized analysis of fetal heart rate (cCTG) and the amniotic fluid index (AFI) in the prediction of neonatal acidemia at birth. METHODS: We considered 89 singleton third trimester high risk pregnancies delivered by cesarean section, with an AFI evaluated within 24 hrs from birth, and an antepartum cCTG performed within 6 hrs from delivery. We assigned values for AFI (oligo/anhydramnios = 1, normal = 0) and cCTG (Dawes-Redman criteria, not satisfied = 1, satisfied = 0). The endpoint was to predict an abnormal neonatal outcome as defined by an umbilical artery (UA) pH < or = 7.2. RESULTS: Fifteen neonates presented an UA pH < or = 7.2. By performing a logistic regression, we found that cCTG + AFI score (abnormal value 1-2) was able to significantly predict a pH value (< or = 7.20) with an Odds Ratio = 2.83 (p < 0.02). The diagnostic accuracy of the combination of cCTG + AFI was as follows: sensitivity: 80%, specificity: 58%. COMMENT: We suggest that the combination of cCTG + AFI included in the simple score we propose, may be of value in the prediction of neonatal acidemia and help in the management of third trimester high risk pregnancies.

[Pulsatility index of the umbilical artery and fetal movements/hour in the prediction of neonatal acidemia in high risk pregnancy]. / Pulsatility index dell'arteria ombelicale e movimenti fetali/ora nella predizione dell'acidemia neonatale in gravidanze ad alto rischio.

OBJECTIVE: The aim of this study was to correlate antepartum computerized cardiotocography (cCTG) and Doppler velocimetry parameters to umbilical blood gas analysis (UBGA) value and Apgar score 1-5 min as neonatal outcome endpoints. METHODS: Forty-eight third trimester single high risk pregnancies were considered for this study, with a cCTG performed within 24 hrs from delivery, a complete Doppler velocimetry study performed within 48 hrs from delivery and an UBGA evaluation at birth and before the first breath. RESULTS: When we analyzed the backward stepwise regression of each Doppler velocimetry and cCTG parameters versus UBGA parameters as dependent variables, we found that the linear combination of fetal heart rate (FHR) (p < 0.001), high variation episodes in min (HV) (p < 0.01) and low variation episodes in msec (LV) (p < 0.03) was able to predict pO2 values. When performing a logistic regression of data for every single parameter of FHR tracing and Doppler velocimetry against pH < 7.2 and Becf < -4 as endpoints, we found that only umbilical artery pulsatility index (UA PI) was able to predict umbilical artery pH (O.R.: 8.1 [1.07-61.8]) and only fetal movements (FM) from FHR tracing values was able to predict UA pH (O.R.: 0.94 [0.89-0.99]). Further analysis considers a cut-off for the prediction of UA pH < 7.2 at birth a value at > or = 1.35 for UA PI and at < or = 12 for FM/h. The combination of UA PI > 1.35 and FM/h < 12 did not improve the ability to predict acidemia at birth. CONCLUSION: The validity of our data from the clinical point of view suggests that in third trimester high risk pregnancies, an UA PI > or = 1.35 and/or FM/h < or = 12 (in a FHR tracing > or = 40 min) may represent a risk of 70% acidemia in neonates.

[Computerized analysis of antepartum fetal heart rate and maternal glycemic levels in pregnancy complicated with insulin-dependent diabetes]. / Analisi computerizzata della frequenza cardiaca fetale (cCTG) antepartum e valori glicemici materni in gravidanze affette da Diabete insulino dipendente.

We aimed to evaluate the effect of maternal glycemia on the parameters of CTG as assessed by a computerized fetal heart rate interpretation system (cCTG). We studied prospectively 22 single insuline dependent diabetic pregnancies (34-39 wks' gestation). A negative correlation was found between high variability epochs (HV) in msec, and maternal glycemia (r = -0.58, p < 0.01). HV epochs are known to be related with hypoxic episodes in the fetus. We suggest that the evaluation of maternal glycemia at the time of cCTG may increase the diagnostic accuracy of automated fetal heart rate interpretation.

[Fetal lung maturity and fetal flowmetry changes]. / Maturità polmonare fetale ed alterazioni flussimetriche fetali.

OBJECTIVE: To verify whether in high risk pregnancies, fetuses with altered Doppler flow velocimetry waveforms (FVW) are associated with both biochemical and/or biophysical changes in the amniotic fluid (AF) lung surfactant. MATERIALS AND METHODS: Hundred-eight high risk pregnancies were considered on the basis of a complete Doppler velocimetry study performed within 24 hrs before amniocentesis and delivery within 1 week from amniocentesis. From this group, 22 pregnancies were recruited as altered FVW cases on the basis of simultaneous alteration of Umbilical Artery Pulsatility Index (UA PI), and UA PI/MCA PI (Middle Cerebral Artery Pulsatility Index) ratio (UA/MCA); in all altered FVW group cases the Mean Uterine Artery Resistance Index (Ut RI) was also altered. Amniotic fluid samples obtained by ultrasound guided amniocentesis were analysed for FLM within 24 hours from collection. Pulmonary maturity was determined by planimetric lecithin/sphingomyelin ratio (L/S), phosphatidylglycerol (PG) and the lamellar bodies count (LBs). RESULTS: When FLM parameters were regressed versus FVW in the whole study group, we found a significant negative correlation between UA/MCA and L/S (r = -0.19, p < 0.05). No significant correlations were found between FVW indices and LBs. When we compared FLM parameters for gestational age subgroups (23-32 wks, > 33 wks), L/S values were significantly higher in patients with normal FVW indices in comparison to pathologic FVW pregnancies for gestational ages > 33 wks. This was reflected by a negativè correlation between FVW and FLM (UA/MCA vs. L/S r = -0.54, p < 0.02; UA/MCA vs. PG, r = -0.60, p < 0.01). COMMENT: Our data suggest that fetuses with an UA/MCA ratio > 95 degrees are not protected from neonatal RDS, as usually felt, but show a delay in FLM, particularly in pregnancies > 33 wks.

[Fetal lung maturity in biamniotic twin pregnancy]. / Maturità polmonare fetale nelle gravidanze gemellari biamniotiche.

OBJECTIVE: To assess the need to perform amniocentesis for the evaluation of fetal lung maturity (FLM) in both amniotic sacs of twin pregnancies. STUDY DESIGN: A retrospective study. We considered 33 twin biamniotic pregnancies, delivering within 1 week from amniocentesis. FLM testing was performed by planimetric lecithin/sphingomyelin ratio (L/S), and lamellar bodies count (LB) according to our methodology. RESULTS: A strong correlation was found between L/S (p < 0.001, r = 0.59) and LB (p < 0.001, r = 0.69) values between smaller and larger twins. No significant regression was found between differences of L/S and LB among both amniotic sacs against gestational age. When stratifying FLM values < 34 and > 34 wks' gestation, again no difference was found in mean difference of L/S and LB before and after 34 wks. CONCLUSIONS: FLM should not be assessed in both amniotic sacs at any gestational age independent of weight and/or sex of the conceptus.

Rheumatoid arthritis: follow-up and response to treatment.

OBJECTIVE: To assess the role of diagnostic imaging techniques in the identification and follow-up of the anatomical damage induced by the chronic inflammatory process of rheumatoid arthritis (RA) not only to study the natural history of the disease but also and especially to assess the long-term response to disease-modifying anti-rheumatic drugs (DMARD). MATERIALS AND METHODS: The relative literature data were reviewed and compared with our personal experience with different imaging modalities such as conventional radiography (CR), ultrasound (US) and magnetic resonance imaging (MRI). RESULTS: Several radiologic techniques have been used over the years to study articular damage in RA: they describe and quantify the articular damage (semi-quantitative analysis) based on a series of parameters and elementary anatomical lesions which are given a rising score. For its sensitivity in detecting early disease signs and the possibility to express anatomical damage progression quantitatively, Sharp's index is considered the best tool for evaluating RA patients. The close correlation between clinical parameters and the radiologic scores obtained regardless of the method applied led to a new concept of anatomical damage related to the 'radiologic progression of the disease' which is a more precise measure of RA severity than the single isolated radiograph. The progression of radiologic damage in rheumatoid arthritis is expressed as the number or proportion of new eroded joints/year: independent of the index adopted and the terms used to express progression, severe radiologic damage occurs in the early disease stage, involving approximately 2% of the joints within about 1 year, and 13% within 2 years, with an estimated average annual progression of 1.3%. Radiologic techniques evaluate the anatomical damage in the course of RA only with reference to the osseous component of the joint and therefore apply to a disease stage that is largely irreversible. MRI and US detect the soft-tissue damage occurring in the earlier phases and are more likely to respond to early treatment. The former technique appears to be useful to detect soft-tissue damage like synovial pannus, intra- and periarticular and peritendinous effusion, capsuloligamentous articular and tendon changes. Its high sensitivity for minimal bone erosions and chondromalacia has been demonstrated. US allows to demonstrate a wide range of soft-tissue changes of the hand and wrist. Joint-cavity widening, loss of cartilage definition, bone erosions, widening of flexor tendon sheath and tendon structure are also well depicted on ultrasound images. CONCLUSIONS: CR is the central tool in the diagnosis, staging and follow-up of RA patients and in general in the assessment of treatment efficacy; MRI and US are complementary tools.

Dynamic MRI of the breast.

OBJECTIVE: To describe the rationale, the technical requirements and the examination technique of dynamic magnetic resonance studies of the breast and to assess the role of this method in the clinical diagnostic protocol. MATERIAL AND METHODS: We reviewed the relative literature and compared the results with our personal experience. RESULTS: The earliest reports on the possibility of differentiating carcinoma from benign tissue with magnetic resonance imaging came from Germany, where in 1986 Heywang and coworkers used T1-weighted spin-echo sequences before and after i.v. Gd-DTPA administration with an imaging time of approximately 5 mins and 5 mm slice thickness. With advances in magnetic resonance technology, Heywang Koebrunner adopted a static three-dimensional fast low-angle shot technique permitting < 3 mins' imaging time and providing high resolution with thin slices. This approach may detect even the carcinoma which occasionally does not enhance in the typical rapid, intense way. A review of 400 biopsy-proved lesions showed that all carcinomas enhanced strongly, all but 5% rapidly and 85% focally. Over 70% of benign masses exhibited no major contrast uptake, although some benign tumors and proliferative dysplasias enhanced strongly. At present, Heywang-Koebrunner use rapid three-dimensional gradient-echo sequences (TR/TE 14/7, FA 25 degrees; at 1.0 T) which have the advantages of three-dimensional imaging and permit dynamic studies (< 1 min/sequence). The same sequence is used at our institution. The dynamic technique is advocated by Kaiser who in 1989 reported preliminary sensistivity and specificity values over 95%. The time/signal intensity curves revealed the rapid and strong enhancement of malignancies, the gradual and strong enhancement of the only fibroadenoma studied, and the gradual and mild contrast uptake of benign dysplasia. In 1992, in nearly 1000 dynamic examinations, Kaiser and Reiser reported 98.3% sensitivity, 97.0% specificity, 82.1% predictive value and 97.2% accuracy. The combination of rapid acquisition with techniques that preserve high spatial resolution may improve specificity by allowing the study of lesion morphology as well as of enhancement patterns. A whole-breast imaging technique has been reported which permits acquisition times < 15 s by partial sampling of the central k-space region superimposed on high-resolution three-dimensional images. CONCLUSIONS: Dynamic magnetic resonance imaging of the breast is currently an important step of the clinical protocol of breast diseases, but there is no established study protocol yet.

A longitudinal study of pulmonary involvement in primary Sjögren's syndrome: relationship between alveolitis and subsequent lung changes on high-resolution computed tomography.

Eighteen non-smoking women suffering from primary Sjögren's syndrome (pSS) with previously documented alveolitis were re-examined, clinically and by pulmonary function tests (PFT), bronchoalveolar lavage (BAL), chest X-ray and high-resolution computed tomography (HRCT) after a 2 yr follow-up period. Longitudinal evaluation revealed unchanged PFT. The final BAL study showed a normal differential count in six of 14 patients with initial lymphocyte alveolitis, and a persistent alveolar lymphocytosis in the remaining eight patients, associated with an increased percentage of neutrophils in one of them. In four patients with initial mixed alveolitis, the BAL cell profile was unchanged 2 yr later. Five of 18 patients (28%) had abnormal HRCT, represented by isolated septal/subpleural lines in three patients, ground-glass opacities with irregular pleural margins in one patient, and ground-glass opacities associated with septal/subpleural lines in another. All these patients had abnormal BAL results with an increased proportion of both neutrophils and lymphocytes. The presence of alveolar neutrophils was associated with a significantly (P=0.005) greater mean rate of reduction of carbon monoxide diffusing capacity (DLCO) -- more than four times the normal rate of loss of DLCO. Chest X-ray, repeated at the end of the 2 yr follow-up period, showed parenchymal abnormalities in only one patient who had evidence of fibrosis on HRCT. This study provides evidence that lung involvement is not an uncommon extraglandular manifestation of pSS and that a BAL neutrophilia may play an important role in the pathogenesis of pulmonary disease in this autoimmune disorder.

[Therapy of refractory rheumatoid arthritis. Cyclosporin and methotrexate combination]. / Terapia dell'artrite reumatoide refrattaria. Associazione ciclosporina e metotrexato.

Rheumatoid arthritis (RA) is a chronic multisystemic disease affecting mainly the joints and characterised by a poor prognosis. In a four month open study we evaluated the efficacy and tolerability of a combination therapy in 14 patients with active and refractory RA (non responsive to MTX or CsA monotherapy). After three pulses of methyl-prednisolone (125 mg/die i.v. for 3 days), at day the 4 patients received methotrexate (MTX 15/mg/week p.os) and cyclosporine (CsA 3 mg/kg/day p.os). At the end of treatment period, patients had a statistically significant improvement in the tender-joint count (Ritchie Index) in the swollen-joint count and in the pain as recorded on a 100-mm visual-analogue scale. Following the criteria of the American College of Rheumatology for response to treatment in RA, 6 patients (60%) met these criteria, whereas 2 had a worsening. We could not detect any clear difference in serological parameters (ESR, CRP and Hb levels) between the beginning and the end of the therapy. A significant difference in the score of edema/joint effusion was documented at the RM analysis. Side-effects were not substantially increased as compared to MTX or CsA in single therapy. Combination therapy with CsA and MTX seems to be a safe and effective treatment for patients with active and refractory RA.

[Virtual bronchoscopy: the correlation between endoscopic simulation and bronchoscopic findings]. / Broncoscopia virtuale: correlazione tra simulazione endoscopica e reperti broncoscopici.

PURPOSE: We carried out a preliminary clinical validation of 3D spiral CT virtual endoscopic reconstructions of the tracheobronchial tree, by comparing virtual bronchoscopic images with actual endoscopic findings. MATERIALS AND METHODS: Twenty-two patients with tracheobronchial disease suspected at preliminary clinical, cytopathological and plain chest film findings were submitted to spiral CT of the chest and bronchoscopy. CT was repeated after endobronchial therapy in 2 cases. Virtual endoscopic shaded-surface-display views of the tracheobronchial tree were reconstructed from reformatted CT data with an Advantage Navigator software. Virtual bronchoscopic images were preliminarily evaluated with a semi-quantitative quality score (excellent/good/fair/poor). The depiction of consecutive airway branches was then considered. Virtual bronchoscopies were finally submitted to double-blind comparison with actual endoscopies. RESULTS: Virtual image quality was considered excellent in 8 cases, good in 14 and fair in 2. Virtual exploration was stopped at the lobar bronchi in one case only; the origin of segmental bronchi was depicted in 23 cases and that of some subsegmental branches in 2 cases. Agreement between actual and virtual bronchoscopic findings was good in all cases but 3 where it was nevertheless considered satisfactory. The yield of clinically useful information differed in 8/24 cases: virtual reconstructions provided more information than bronchoscopy in 5 cases and vice versa in 3. Virtual reconstructions are limited in that the procedure is long and difficult and needing a strictly standardized threshold value not to alter virtual findings. Moreover, the reconstructed surface lacks transparency, there is the partial volume effect and the branches < or = 4 pixels phi and/or meandering ones are difficult to explore. CONCLUSIONS: Our preliminary data are encouraging. Segmental bronchi were depicted in nearly all cases, except for the branches involved by disease. Obstructing lesions could be bypassed in some cases, making an indication for endoscopic laser therapy. Future didactic perspectives and applications to minimally invasive or virtual reality-assisted therapy seem promising, even though actual clinical applications require further studies.

[Magnetic resonance versus traditional breast imaging in solid nodular diseases of the breast]. / Risonanza magnetica versus imaging senologico tradizionale nelle malattie nodulari solide della mammella.

We report and compare the results obtained with conventional imaging (mammography and US) and MRI in the study of 46 solid nodular breast lesions verified with histologic, cytologic and/or instrumental follow-up examinations for 12-34 months. The variables we compared were relative to the identification, nature and size of the lesions. MRI, which was performed on the basis of previous mammographic and US findings, detected all the lesions but never modified the diagnosis of conventional imaging methods. Questionable MR diagnoses were fewer than mammographic and US ones (2 versus 11), but its role in correcting the questionable diagnoses of conventional imaging methods was controversial. Particularly, of 11 such cases on mammographic and US images, MRI made 8 correct diagnoses but exhibited 2 false positives and 1 false negative for carcinoma. Such MR mistakes are likely to be related to the non-use of contrast medium. As for size, US was more accurate than mammography and MRI; yet, very few misdiagnoses were make on the whole.