Multiple suicidal gunshot wounds. Case reports and mini-review of literature.

Background: To determine the manner of death (MOD) and, there-fore, to classify the event as natural, suicidal, homicidal, or accidental is an essential and routine task in forensic medicine. The evaluation of MOD presents numerous difficulties due to unusual anamnestic and circumstantial data, in addition to autopsy findings and postmortem findings. Materials and Methods: A mini review of the literature on the topic was performed. Here we report two cases of uncommon self-inflicted multiple GWs (SMGWs) to the head and thorax, suspected of killing. The presence of more than one gunshot wound is suggestive of homi-cide, especially when they involve the head. A review of the literature on the topic was performed on PubMed's database, showing, although considered infrequent, cases documenting SMGWs are not rare. Conclusion: In the cases reported, the initial suspicion of involvement of third persons was excluded through the examination of the death scene, post-mortem (CT and autopsy) findings and clinical-circumstantial data. The analysis derived from the review of the related literature allowed us to highlight the presence of common findings which should be considered in the evaluation of such cases.

Gastric Antral Vascular Ectasia (GAVE) a case report, review of the literature and update of techniques.

INTRODUCTION AND IMPORTANCE: Gastric Antral Vascular Ectasia is a rare disorder that causes up to 4 % of severe acute gastrointestinal bleeding. It affects elderly females with iron deficiency anemia due to chronic blood loss as a common presenting sign. CASE PRESENTATION: We report the case of a 70-year-old man admitted to the Urgency Department for severe asthenia associated with abdominal pain and severe anemia. An urgent upper endoscopic examination showed antral hyperemic streaks and vascular ectasias extending from the pyloric ring to the gastric body as well as signs of recent bleeding. Histological results demonstrated the pathognomonic features of GAVE. CLINICAL DISCUSSION: The first line treatment is considered argon plasma coagulation (APC), given its wider availability, safety, efficacy and cost-effectiveness. In current literature, other therapies and different types of endoscopic treatments have been proposed, such as EBL, RFA and Yag: laser. To date, there is no specific recommendation that privileges one method over another in the treatment of GAVE, although APC has proven effective and even better in terms of complications and costs than the other techniques. CONCLUSION: In our experience, endoscopic coagulation with APC probes is a relatively easy-to-use technique with low cost, minimal invasiveness and provides immediate results. On the other hand, a standardized algorithm is also required concerning to the different subtypes to give the best treatment in every case.

What is the role of contrast-enhanced ultrasound in the evaluation of the endoleak of aortic endoprostheses? A comparison between CEUS and CT on a widespread scale.

OBJECTIVE: To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) in comparison to CT angiography (CTA) to identify and classify endoleaks following abdominal aortic aneurism repair with endoprosthesis. MATERIALS AND METHODS: A retrospective analysis of 181 patients treated with EVAR, from September 2009 to September 2014, was performed. Patients were evaluated with CEUS, CTA and angiography in the cases requiring treatment. Sac diameter, sac integrity, identification and classification of endoleaks were taken into consideration. Sensitivity, specificity, accuracy and negative predictive values were considered for each modality of endoleak identification. RESULTS: Forty-two endoleaks (23.2%; type II: 39 cases, type III: 3 cases) were documented. Sensitivity and specificity of CEUS and CT were, respectively, 97.6 and 90.5, 100 and 100%. In two cases, CEUS was able to better classify endoleaks compared to CT. CONCLUSIONS: CEUS accuracy to identify endoleaks following EVAR is similar to CT. CEUS should be considered as an effective modality for the long-term surveillance of EVAR because of its capability to correctly classify endoleaks with no ionizing radiation exposure.

Cranberry supplementation in the prevention of non-severe lower urinary tract infections: a pilot study.

OBJECTIVE: Cranberry extracts have been tested as a nutritional supplementation in the prevention of recurrent lower-urinary tract infections (R-UTIs), with mixed results. This pilot, registry study evaluates the prophylactic effects of oral supplementation with a new well-standardized cranberry extract in patients with R-UTI, over a 2-month follow-up. PATIENTS AND METHODS: All subjects were suggested to take one capsule containing a cranberry extract (Anthocran™) for 60 days and were also given lifestyle advice. Clinical outcomes were compared between patients on cranberry extracts and those who don't take this supplementation. RESULTS: In total, 22 subjects completed the study in each of the two groups. In the cranberry group, the reduction in the frequency of UTI episodes during the study period compared with the two months before the inclusion was 73.3% (p < 0.05). This figure was 15.4% in the control group (p < 0.05; p = 0.012 vs cranberry group). Seven (31.8%) subjects in the cranberry group were symptom-free; no patient was symptom-free in the control group (p < 0.05). The mean duration of UTI episodes was 2.5 ± 1.3 days in the cranberry group, compared with 3.6 ± 1.7 days in subjects not on cranberry (p < 0.05). Three subjects (13.6%) in the cranberry group and 8 (36.3%) in the control group required medical consultation for UTI symptoms (p < 0.05). Urine evaluation was completely negative in 20/22 subjects in the Cranberry group (90.9%) and in 11 control subjects (50.0%; p < 0.005). No adverse events were observed. CONCLUSIONS: These preliminary results, obtained in a field-practice setting, indicates the effectiveness and safety of a well-standardized cranberry extract in the prevention of R-UTI.

Pycnogenol® in postpartum symptomatic hemorrhoids.

AIM: The aim of this registry study was to evaluate the efficacy of Pycnogenol® (Horphag Research Ltd.), a standardized extract from the French maritime pine bark, to control signs/symptoms and prevent complications associated with hemorrhoids in the months after delivery in healthy women. METHODS: Women with hemorrhoids after their second pregnancy were included within the third month after pregnancy. Pycnogenol dosage was 150 mg/day for 6 months. Symptoms for 4th and 3rd degree hemorrhoids were evaluated. RESULTS: The registry groups were comparable. For 4th degree hemorrhoids, main symptoms were reduced after 6 months in all patients, but the group using Pycnogenol in addition to standard best management showed more improvement. In patients with 3rd degree hemorrhoids, symptoms were reduced in both management groups at 6 months; with Pycnogenol the reduction in symptoms scores was significantly better. At 6 months 18/24 subjects (75%) in the Pycnogenol group were symptom-free in comparison with 14/25 (56%) in controls. In the 4th degree hemorrhoid group, 7/10 patients (70%) in the Pycnogenol group were symptom-free at 6 months in comparison with 4/11 subjects (36%) in the best management group. No significant side effects were observed. CONCLUSION: Pycnogenol appears to positively affect hemorrhoid signs and symptoms in the months after pregnancy.

Lady Prelox® improves sexual function in generally healthy women of reproductive age.

AIM: This supplement study evaluates the Female Sexual Function Index (FSFI) of 100 healthy women (37 to 45 years) with moderate sexual dysfunction who underwent a management program of lifestyle, diet, exercise, and stress control. In association with the management program a group of these women also used the supplement Lady Prelox® in tablets (20 mg Pycnogenol® pine bark extract, 200 mg L-arginine, 200 mg L-citrulline and 50 mg Rosvita® rose hip extract) for eight weeks. METHODS: One group of women was supplemented with Lady Prelox® for 8 weeks. The nine-item FSFI questionnaire was used for evaluation of women's sexual function at inclusion (baseline), after four weeks, and after eight weeks of management and supplementation. Variation in oxidative stress was also evaluated by measuring plasma free radicals. RESULTS: Following supplementation with Lady Prelox® the mean total FSFI scores increased from 14.96±2.68 to 28.25±2.35 after four weeks and 33.91±2.7 after eight weeks. Treatment values were significantly higher than in controls (who used only the management plan) with baseline values of 17.92±2.32 and scores of 23.45±1.82 after four weeks and to 23.52±2.20 after eight weeks. Women in the Lady Prelox® group had an initial value of plasma free radicals (PFR) of 398±29 Carr units: this value decreased to 344:28 at 4 weeks (P<0.05) and 332:31 at 8 weeks (P<0.05). Lower changes were observed in controls with an initial value of 389±33, decreasing to 377±32 (P<0.05) at 4 weeks and to 365; 33 (P<0.05) at 8 weeks (value significantly higher in controls not using Lady Prelox®). The supplementation was well tolerated; no unwanted effects occurred and no women had to stop the supplementation. CONCLUSION: The study suggests that supplementation with Lady Prelox significantly improves sexual function across all domains evaluated by the FSFI in healthy women of late reproductive age. The improvement in FSFI is also associated with a significant decrease in oxidative stress.

Lady Prelox® improves sexual function in post-menopausal women.

AIM: The aim of this pilot, single-blinded study was to evaluate the efficacy of a proprietary, dietary supplement Lady Prelox® for supporting and improving sexual function in generally healthy, post-menopausal women. METHODS: The Lady Prelox® and placebo control groups were comparable at inclusion with regard to the total Female Sexual Function Index (FSFI) score, as well as for the six individual FSFI domains, with 40 women (50.1 ± 3.1 years) and 43 women (51.2 ± 2.3 years), respectively. RESULTS: At baseline the women in the verum group presented with a mean total FSFI score of 44.6 ± 24.1 which increased significantly already after four weeks treatment with Lady Prelox® to 70.9 ± 18.5 and further increased to 71.7 ± 23.9 after completion of the eight-week trial period. In the control group the mean total FSFI was 44.1 ± 22.8 at inclusion and non-significantly increased to 45 ± 21.4 after four weeks and 47.4 ± 21.8 after eight weeks, respectively. The treatment with Lady Prelox® was comparatively significantly more effective than placebo after both four and eight weeks of treatment (P<0.05). The individual six FSFI domains related to desire, arousal, lubrication, orgasm, satisfaction and pain did all respond favourably to treatment with Lady Prelox®; however, with only marginable higher scores in the placebo group. Four women in each group dropped out because of inabilities to attend scheduled check-ups. No adverse effects were reported. CONCLUSION: This study opens an interesting perspective for women experiencing moderate sexual function impairment and suggests a promising new treatment option. Further studies with larger numbers of women, including also premenopausal and perimenopausal women are warranted.

Lady Prelox® improves sexual function in post-menopausal women.

AIM:he aim of this pilot, single-blinded study was to evaluate the efficacy of a proprietary, dietary supplement Lady Prelox® for supporting and improving sexual function in generally healthy, post-menopausal women. METHODS: The Lady Prelox® and placebo control groups were comparable at inclusion with regard to the total Female Sexual Function Index (FSFI) score, as well as for the six individual FSFI domains, with 40 women (50.1±3.1 years) and 43 women (51.2±2.3 years), respectively. RESULTS:At baseline the women in the verum group presented with a mean total FSFI score of 44.6±24.1 which increased significantly already after four weeks treatment with Lady Prelox® to 70.9±18.5 and further increased to 71.7±23.9 after completion of the eight-week trial period. In the control group the mean total FSFI was 44.1±22.8 at inclusion and non-significantly increased to 45±21.4 after four weeks and 47.4±21.8 after eight weeks, respectively. The treatment with Lady Prelox® was comparatively significantly more effective than placebo after both four and eight weeks of treatment (P<0.05). The individual six FSFI domains related to desire, arousal, lubrication, orgasm, satisfaction and pain did all respond favourably to treatment with Lady Prelox®; however, with only marginable higher scores in the placebo group. Four women in each group dropped out because of inabilities to attend scheduled check-ups. No adverse effects were reported. CONCLUSION: This study opens an interesting perspective for women experiencing moderate sexual function impairment and suggests a promising new treatment option. Further studies with larger numbers of women, including also premenopausal and perimenopausal women are warranted.

Extreme endovascular revascularization for limb salvage in critical limb ischemia.

AIM: Distal bypass has been considered as a primary choice for the treatment of critical limb ischemia (CLI). When bypass failed with limb threatening ischemia, the amputation rate is high in patients with increased surgical risks and lack of conduit. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI even in patients with failed bypass graft. The aim of this study was to review our experience and results of extreme endovascular revascularization in patients with CLI following occluded lower limb bypass graft. METHODS: Retrospective review from January 2005 to June 2008 of patients with CLI following occluded bypass graft who underwent PTA was performed. All patients were studied by Duplex scanning and dual-energy computed tomographic angiography (DE-CTA) bone removal technique. Stents were used in cases of residual stenosis or dissection. Technical success was defined as a residual stenosis less than 30%. Demographics, comorbidities, functional status, details of the procedure information were recorded. Descriptive, logistic regression and life-table analyses performed. RESULTS: Thirty-six patients with occluded bypass grafts were treated. The mean age was 69 years (range 56-89), 44% were older than 80 years, 83% had diabetes mellitus, 88% of limbs treated had multiple lesions included Tasc C and D lesions. Technical success was achieved in 91%. Mean follow-up was 24 months. At follow-up, there were 19 PTA failures which were followed by subsequent procedures: redo PTA in 16 limbs, redo bypass in 2, amputation in 5. Cumulative primary patency was 60% (±0.08 SE) and 24% (±0.07 SE). Secondary patency was 96% (±0.03 SE) and 83% (±0.08 SE). Limb salvage was 84% (±0.06 SE) and 70% (±0.10 SE). Freedom from surgical revision was 78% (±0.07 SE) and 54% (±0.11 SE). Overall survival was 89% (±0.05 SE) and 58% (±0.11 SE) at 12 and 24 months, respectively. CONCLUSION: Endovascular revascularization of patients with CLI and occluded bypass graft is a safe and feasible procedure with reasonable technical and clinical success and limb salvage. PTA may be the only alternative to amputation in these patients with extensive comorbidities and limited life expectancy.

Supplementation with Pycnogenol® improves signs and symptoms of menopausal transition.

AIM: The aim of this study was to evaluate the efficacy of Pycnogenol® standardized pine bark extract for alleviation of signs and symptoms associated with menopausal transition. METHODS: Pycnogenol® was used by 38 women as daily supplement in a dosage of 100 mg over an eight week period and menopausal symptoms were evaluated by means of a scoring system, based on a total number of 33 common signs and symptoms. A parallel control group of 32 comparable women was also followed up for the same period. Pycnogenol® was well tolerated, no side effects were reported and the compliance was very good with 98.6% of tablets used as prescribed. A range of 33 menopausal symptoms were evaluated using a scoring system with values ranging from zero (absent) to maximum 4 (very serious). RESULTS: A subset of six most common symptoms comprising hot flushes, night sweats, mood swings, irregular periods, loss of libido and vaginal dryness showed a decrease from average 2.67/4 to 1.45/4 after 8 weeks supplementation with Pycnogenol®. The control group of women showed no change from initial average 2.72/4 to 2.73/4 after eight weeks. The improvement of symptoms was statistical significant compared to the control group. Further symptoms related to fatigue, sleeping disorders, concentration and memory problems, dizziness, depression and irritability all improved significantly with Pycnogenol® compared to baseline values but did not reach statistical significance compared to the control group of women. The sensation of pain related to headaches, breast pain, the feeling of "electric shocks", tingling extremities, burning tongue and itchy skin all improved significantly after intake of Pycnogenol® for eight weeks compared to baseline. Specifically the sensation of "electric shocks" and digestive problems improved significantly with Pycnogenol® as compared to women in the control group. The presence of elevated oxidative stress in women was investigated measuring capillary blood plasma free radicals. Oxidative stress was significantly lowered after four weeks (P<0.05) and eight weeks (P<0.022) in the Pycnogenol® group while no significant changes were observed in the control group at any time. CONCLUSION: Pycnogenol® significantly contributed to reduce signs and symptoms associated with menopausal transitions in women investigated in this study. Furthermore, Pycnogenol® improved the quality of life of most women and these benefits may be at least in part attributed to decreased oxidative stress levels.

Contrast-enhanced ultrasonography (voiding urosonography) of vesicoureteral reflux: state of the art.

Three methods are currently used to identify vesicoureteral reflux (VUR) in children, namely, radiographic voiding cystourethrography, radionuclide voiding cystography and, more recently, echo-enhanced voiding urosonography (VUS). Recent advances in tissue-harmonic and contrast-specific imaging techniques, together with the development of second-generation contrast agents, have improved the potential of ultrasonography both in the diagnosis and grading of VUR in children. Today, VUS is able to accurately assess the grade of reflux and the state of the urethra, previously considered fundamental limitations to the extensive use of this technique. The aim of our paper is to review the role of ultrasonography in the diagnosis of VUR, from the initial experiences up to the recent use of second-generation microbubbles combined with contrast-specific low-mechanical-index software. We discuss the advantages and limits of VUS with respect to radiographic and radionuclide imaging in the light of an analysis of the most recent literature, and we described the new VUS study technique using second-generation contrast media. Growing requests by paediatric nephrologists and surgeons require that even general radiologists become familiar with this technique.

[Caroli's disease: literature review and characteristics of a clinical case]. / La malattia di Caroli: revisione della letteratura e particolarità di un caso clinico.

The Author's report the case of the simple form of Caroli's disease, a rare malformation, and review literature pointing out the difficulty of an early diagnosis, because disease can be silent for a long time too and it is identified for complication. Today, imaging, endoscopy and interventionist radiology are the most valid tools for a correct diagnosis and treatment, above all in a case of emergency, when other therapeutic solutions are not possible.

[Endoscopic treatment of a gastric phytobezoar using electrohydraulic lithotripsy: a case report]. / Trattamento endoscopico di un fitobezoario gastrico mediante litotrissia elettroidraulica intracorporea (LEI): descrizione di un caso.

The Authors report a case of spontaneous large gastric phytobezoar in an unoperated stomach and describe this pathology especially with regards to pathogenesis, diagnosis and endoscopic treatment.

[Giant fibrovascular polyp of the esophagus]. / Su di un caso di polipo fibrovascolare gigante dell'esofago.

Fibrovascular polyps of the oesophagus are rare tumor-like lesions characterized by development of the peduncolated intraluminal masses that can reach gigantic size and may have spectacular clinical presentation including regurgitation of a fleshy mass into the mouth and can lead to sudden death for occlusion of the larynx. Starting from a case observed and successfully treated by transoral resection we review the clinical radiographic and pathological findings of benign oesophageal tumor that requires surgical removal because of the progressive nature of the symptoms and the small, just known, risk of sudden death. The approach depends on the pedicule site.

Influence of attenuation models in seismic hazard evaluation for the north-eastern Sicily area

From the influence already revealed by attenuation models on the values of expected intensity for north-Eastern Sicity, the necessity arises to quantify the 'weigt' of these models and of their respective coefficients on the projection of intensity. A first evaluation is presented in this paper using the Sponheuer, Blake and Grandori models. A comparison of the expected intensity maps allows a first critical estimate, showing the greater adaptability of the Grandori model to describe the attenuation of intensity for the investigated area (AU)