Turgor loss point and vulnerability to xylem embolism predict species-specific risk of drought-induced decline of urban trees.

Increasing frequency and severity of drought events is posing risks to trees' health, including those planted in urban settlements. Drought-induced decline of urban trees negatively affects ecosystem services of urban green spaces and implies cost for maintenance and removal of plants. We aimed at identifying physiological traits that can explain and predict the species-specific vulnerability to climate change in urban habitats. We assessed the relationships between long-term risk of decline of different tree species in a medium-sized town and their key indicators of drought stress tolerance, i.e. turgor loss point (TLP) and vulnerability to xylem embolism (P50 ). Starting from 2012, the study area experienced several summer seasons with positive anomalies of temperature and negative anomalies of precipitation. This trend was coupled with increasing percentages of urban trees showing signs of crown die-back and mortality. The species-specific risk of decline was higher for species with less negative TLP and P50 values. The relationship between species-specific risk of climate change-induced decline of urban trees and key physiological indicators of drought tolerance confirms findings obtained in natural forests and highlights that TLP and P50 are useful indicators for species selection for tree plantation in towns, to mitigate negative impacts of climate change.

Risk Factors for Postoperative Urinary Retention After Endoscopic Hernia Repair: Age and Unilateral Operation make the Difference.

BACKGROUND: Postoperative urinary retention (POUR) is a common complication after inguinal hernia repair that may result in catheter-related infections or injuries, longer hospital stays, and thus, higher overall costs. Our aim was to assess the incidence of POUR after endoscopic total extraperitoneal (TEP) inguinal hernia repair and identify its risk factors. METHODS: We retrospectively analyzed all data that were included in a prospective Hernia Database for patients undergoing a TEP inguinal hernia repair at our institution between July 2012 and May 2018. POUR was defined as the inability to urinate spontaneously after surgery, thus requiring a bladder catheter. RESULTS: Data from 1570 patients were included. Sixty-five patients developed POUR, which was an incidence of 4.1%. In the univariate analysis, patients over 50 years of age (1.6% vs. 5.5%), patients with higher American Society of Anesthesiologists (ASA) score (ASA-1 2.7% vs. ASA-3 12.5%), previous prostate surgery (3.9% vs. 10.9%), unilateral operation (1.9% vs. 6.0%), and intraoperative drain placement (2.1% vs. 4.9%) developed POUR more often than younger patients. After multivariate adjustment, advanced age and unilateral surgery remained risk factors for POUR. CONCLUSION: Advanced age and unilateral inguinal hernia repair, possibly due to a lack of catheterization, were risk factors for POUR. Due to increasing outpatient inguinal hernia repairs worldwide, it is imperative to identify patients who are at risk of POUR to apply prophylactic measures and reduce readmission, and thus, reduce health-care costs.

Gastric leiomyoma in a sea bass Dicentrarchus labrax broodfish.

This report describes a spontaneously arising non-infiltrative neoplasm of gastric tunica muscularis in a broodstock sea bass Dicentrarchus labrax from an Italian aquaculture farm. Microscopically, the mass was circumscribed and non-encapsulated and was composed of spindle cells arranged in parallel interlacing bundles or, occasionally, a whirling pattern. Cells had a small quantity of eosinophilic cytoplasm with distinct cell borders. Neoplastic cells were immuno-reactive with smooth muscle actin, vimentin and desmin; S100 was negative. The mucosal epithelium was intact with no neoplastic involvement. A gastric leiomyoma was diagnosed based on the findings. More efforts should be made to study the possible etiology of leiomyoma affecting fish from aquaculture.

The epidemiology of life-threatening complications associated with reproductive process in public hospitals in Argentina.

OBJECTIVE: To analyse life-threatening obstetric complications that occurred in public hospitals in Argentina. DESIGN: Multicentre collaborative cross-sectional study. SETTING: Twenty-five hospitals included in the Perinatal Network of Buenos Aires Metropolitan Area. POPULATION: Women giving birth in participating hospitals during a 1-year period. METHODS: All cases of severe maternal morbidity (SMM) and maternal mortality (MM) during pregnancy (including miscarriage and induced abortion), labour and puerperium were included. Data were collected prospectively. MAIN OUTCOME MEASURES: Identification criteria, main causes and incidence of SMM; case-fatality rates, morbidity-mortality index and effective intervention's use rate. RESULTS: A total of 552 women with life-threatening conditions were identified: 518 with SMM, 34 with MM. Identification criteria for SMM were case-management (48.9%), organ dysfunction (15.2%) and mixed criteria (35.9%). Incidence of SMM was 0.8% (95% confidence interval [95% CI] 0.73-0.87%) and hospital maternal death ratio was 52.3 per 100 000 live births (95% CI 35.5-69.1). Main causes of MM were abortion complications and puerperal sepsis; main causes of SMM were postpartum haemorrhage and hypertension. Overall case-fatality rate was 6.2% (95% CI 4.4-8.6): the highest due to sepsis (14.8%) and abortion complications (13.3%). Morbidity-mortality index was 15:1 (95% CI 7.5-30.8). Use rate of known effective interventions to prevent or treat main causes of MM and SMM was 52.3% (95% CI 46.9-57.7). CONCLUSIONS: This study describes the importance of life-threatening obstetric complications that took place in public hospitals with comprehensive obstetric care and the low utilisation of known effective interventions that may decrease rates of SMM and MM. It also provides arguments that justify the need to develop a surveillance system for SMM.

Guanine-based purines modulate the effect of L-NAME on learning and memory in rats.

Guanosine has been reported to exert neuroprotective effects. We recently reported that, following intraperitoneal (i.p.) injection to rats, it resulted to be widely distributed. Its metabolic product guanine also rapidly increased in all the tissues, including brain, after i.p. injection of guanosine and consistently we found a significant enzymatic activity of a soluble purine nucleoside phosphorylase in the plasma of the treated animals. In this study the effect of per os administration of guanosine or guanine to rats submitted to passive avoidance task has been evaluated. Guanosine (4 and 8 mg/kg) administered pretraining impaired retention in the passive avoidance task and was unable to prevent the amnesic effect caused by 100 mg/kg N-omega-nitro-l-arginine methyl ester (L-NAME), an inhibitor of the nitric oxide synthase (NOS) known to reduce the capability of treated animals to acquire or retain informations in several learning tasks. On the contrary, guanine (4 and 8 mg/kg), which per se did not modify the latency to step-trough in the passive avoidance task, when administered pretraining 15 min before L-NAME prevented, in a dose dependent manner, the amnesic effect of the NOS inhibitor. Moreover the nucleobase was able to rescue the memory trace also when administered after training. Neither guanosine nor guanine had effects on locomotor activity. These results indicate that guanine can exert important biological activities which may be different from those mediated by its precursor guanosine, thus this evenience should be taken into account when the biological effects of guanosine are evaluated.

Guanine-based purines modulate the effect of L-NAME on learning and memory in rats.

Guanosine has been reported to exert neuroprotective effects. We recently reported that, following intraperitoneal (i.p.) injection to rats, it resulted to be widely distributed. Its metabolic product guanine also rapidly increased in all the tissues, including brain, after i.p. injection of guanosine and consistently we found a significant enzymatic activity of a soluble purine nucleoside phosphorylase in the plasma of the treated animals. In this study the effect of per os administration of guanosine or guanine to rats submitted to passive avoidance task has been evaluated. Guanosine (4 and 8 mg/kg) administered pretraining impaired retention in the passive avoidance task and was unable to prevent the amnesic effect caused by 100 mg/kg N-omega-nitro-l-arginine methyl ester (L-NAME), an inhibitor of the nitric oxide synthase (NOS) known to reduce the capability of treated animals to acquire or retain informations in several learning tasks. On the contrary, guanine (4 and 8 mg/kg), which per se did not modify the latency to step-trough in the passive avoidance task, when administered pretraining 15 min before L-NAME prevented, in a dose dependent manner, the amnesic effect of the NOS inihibitor. Moreover the nucleobase was able to rescue the memory trace also when administered after training. Neither guanosine nor guanine had effects on locomotor activity. These results indicate that guanine can exert important biological activities which may be different from those mediated by its precursor guanosine, thus this evenience should be taken into account when the biological effects of guanosine are evaluated.

Influence of motion on face recognition.

The influence of motion information and temporal associations on recognition of non-familiar faces was investigated using two groups which performed a face recognition task. One group was presented with regular temporal sequences of face views designed to produce the impression of motion of the face rotating in depth, the other group with random sequences of the same views. In one condition, participants viewed the sequences of the views in rapid succession with a negligible interstimulus interval (ISI). This condition was characterized by three different presentation times. In another condition, participants were presented a sequence with a 1-sec. ISI among the views. That regular sequences of views with a negligible ISI and a shorter presentation time were hypothesized to give rise to better recognition, related to a stronger impression of face rotation. Analysis of data from 45 participants showed a shorter presentation time was associated with significantly better accuracy on the recognition task; however, differences between performances associated with regular and random sequences were not significant.

Impulsiveness and time perception in alcohol dependent patients in alcoholic rehabilitation treatment.

INTRODUCTION: To analyze the relationship between alcoholism, impulsiveness, anxiety and depression. Further, we wish to investigate the relationship between these variables and both the period of alcohol abuse and the length of hospitalization. METHODS: The investigation was carried out on a group of alcoholics in residential treatment (N=60) and on a control group (N=60); within the group of alcoholics in treatment, we attempted to investigate possible differences in performance between "pure alcoholics" (N=48) and polyabusers (N=12). A questionnaire assessing anxiety (BAI) and one assessing depression (BDI-II) were administered Since many psychological studies agree that impulsiveness is of multidimensional nature, for its assessment a questionnaire (BIS-11) and two computer-based tests (TCIP and Time Paradigm) were used. RESULTS: Alcoholics in treatment seem to be more impulsive than controls in two of the three test used; further, the period of alcohol abuse influences impulsiveness considered as a personality dimension. Significant differences between "pure alcoholics" and polyabusers were obtained only in two of the three tests used. Patients hospitalized for alcohol detoxification do not seem particularly anxious or depressed, and there seems to be no relationship between the duration of alcohol abuse or the length of hospitalization and the psychological distress. CONCLUSIONS: These results clearly show the existence of a relationship between alcoholism and impulsiveness considered as a dimension of personality; however, they do not explain whether it is personality that is a consequence or antecedent of the problematic use of substances.

Sediment characteristics and macrofauna distribution along a human-modified inlet in the Gulf of Oristano (Sardinia, Italy).

We studied the spatial variability and within-year temporal changes in hydrological features, grain size composition and chemical characteristics of sediments, as well as macrofaunal assemblages, along a heavily modified inlet in the Gulf of Oristano (western Sardinia, Italy). The inlet connects the Cabras lagoon to the gulf through a series of convoluted creeks and man-made structures, including a dam and fish barriers built in the last three decades. Sediments were muddy and mainly composed of the "non-sortable" fraction (i.e., <8 microm particle size) in all four areas investigated: Lagoon, Creeks, Channel and Seaward. Along the inlet, however, the ratio between the <8 microm and the 8-64 microm fractions was highest in Creeks and Channel, between the fish barriers and the dam, suggesting impaired hydrodynamics. Consistently, steep gradients in water salinity, temperature and dissolved oxygen concentrations were found in proximity to the fish barriers. The whole inlet was characterized by a major organic enrichment of sediments, with up to an annual mean of 33.6% of organic matter and 11.7% of total organic carbon in Seaward due to the presence of seagrass leaf litter. Acid-volatile sulphide and chromium-reduced sulphur concentrations were highest throughout the year in Seaward and Lagoon, respectively, with a peak in summer. Consistently, the whole inlet supported low structured macrofaunal assemblages dominated by few opportunist species, with a relatively lower diversity in Lagoon throughout the year and the highest abundances in Seaward in summer. We infer that the presence of artificial structures along the inlet, such as fish barriers and the dam, impair the lagoon-gulf hydrodynamics, sediment exchange and animal recruitment and colonization. We suggest that the removal of these structures would favour water renewal in the Cabras lagoon, but would also increase the outflow of organic C-bonding fine particles into the gulf with serious consequences for Posidonia oceanica and Cymodocea nodosa seagrass meadows. We conclude that all possible consequences of such initiatives should be carefully considered before any action is taken.

Review article: the treatment of fatty liver disease associated with the metabolic syndrome.

The treatment of non-alcoholic fatty liver disease may be worthwhile to prevent progression to advanced liver failure, but no therapy is definitely evidence-based. Weight loss or lifestyle modifications remain the primary line of intervention, particularly in overweight or obese subjects. In adult non-alcoholic fatty liver disease, they are effective in the short-term, but require a multidisciplinary team approach that is rarely available in liver units. Insulin-sensitizing agents are probably the treatment of choice. They definitely reduce the insulin resistance that promotes steatosis. Several uncontrolled and controlled studies have documented an improvement in liver biochemistry and in histology, but the long-term results remain unsettled. This is an area where significant advances are expected in the next few years.

WHO and ATPIII proposals for the definition of the metabolic syndrome in patients with Type 2 diabetes.

AIMS: Different criteria have been proposed by the World Health Organization (WHO) and by the Third Report of the National Cholesterol Education Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII) for the diagnosis of the metabolic syndrome. Its identification is of particular importance for coronary risk assessment. METHODS: The prevalence of the metabolic syndrome was determined according to the two different proposals in 1569 consecutive subjects with Type 2 diabetes. RESULTS: By the WHO proposal, 81% of cases (95% confidence interval, 79-83) were labelled as metabolic syndrome. Microalbuminuria had the highest specificity (99%) and visceral obesity the highest sensitivity (93%). Seventy-eight per cent of patients (95% CI, 76-80) fulfilled the ATPIII criteria for metabolic syndrome, low HDL-cholesterol having the highest specificity (95%), elevated blood pressure having the highest sensitivity. According to both proposals, 1113 patients were positive; 183 were concordantly negative, indicative of a fairly good agreement (k statistics, 0.464). Subjects only positive for the WHO proposal were more frequently males, had a lower BMI and a higher arterial pressure. Only subjects identified by the ATPIII proposal had a significantly higher prevalence of previously detected coronary heart disease. CONCLUSIONS: Minimum criteria for the metabolic syndrome are met in most patients with Type 2 diabetes. Correct identification of the syndrome is important for an integrated approach to reduce the high costs and the associated disabilities. The ATPIII proposal more clearly identifies the burden of coronary heart disease associated with the metabolic syndrome.

Ten years' experience of retrograde balloon dilatation of pelvi-ureteric junction obstruction.

OBJECTIVE: To analyse the long-term success of retrograde balloon dilatation (RBD) of pelvi-ureteric junction obstruction (PUJO). PATIENTS AND METHODS: The records of 58 adult patients (mean age 48 years, range 18-94) who had RBD between 1990 and 2001 were reviewed retrospectively. All symptomatic patients were included and assessed by dynamic renography. Success was judged as a symptomatic and/or functional improvement. Recurrence of symptoms was recorded and any evidence of deterioration of function despite improved symptoms. Complications were also recorded. RESULTS: In all, 44 (76%) patients were asymptomatic after RBD. There was no relationship between symptomatic change and renographic improvement; some patients who were rendered pain-free had either no improvement or even deterioration in their split renal function. Conversely, some patients who had a demonstrable improvement in their renal function continued to be symptomatic. However, a long-term follow-up (mean 6.1 years) of nine patients who were symptomatically improved showed good maintenance of split renal function. CONCLUSION: RBD is an effective treatment for PUJO and its success is maintained in the long term.

Cognitive behavioural therapy for obesity: one-year follow-up in a clinical setting.

Cognitive behavioural therapy (CBT) is the most comprehensive means of medically treating obesity, but only few data have so far been published concerning its long-term effectiveness. We here report our experience of 1068 consecutive patients (868 females) treated with CBT at a university-based obesity centre. The patients were enrolled into three different programmes: a 14-week LEARN programme (672 patients), a 16-week MOB programme for the morbidly obese (259 patients), or a 20-week BINGE programme for subjects affected by binge eating (137 patients). Eighty-five percent of the subjects completed the weekly programmes. The percentage of patients attending the scheduled control visits during the 1-year follow-up gradually decreased, being very low in the BINGE group (10%). The percentage weight loss was an average of 6% during the weekly courses, being higher in the MOB programme; by the end of the weekly sessions, it exceeded 10% of initial body weight in 22% of cases and increased to 36% during the follow-up. The cumulative probability of follow-up was higher among the patients undergoing the MOB and LEARN programmes than among the BINGE patients (p < 0.0001), and decreased with the increasing severity of obesity. Female gender and a weight loss of > 10% i.b.w. increased compliance to follow-up. The study further demonstrates the difficulty of achieving compliance to chronic management of obesity and the critical role of binge eating disorder in the medium-term treatment of obesity. Strategies are needed to improve adherence to a follow-up protocol.

Psychiatric distress and health-related quality of life in obesity.

UNLABELLED: Health-related quality of life (HRQL) is poor in obese patients and not necessarily related to the severity of disease. In a large proportion of patients psychopathological distress is also present and its role on poor HRQL has never been quantified. METHODS: In 207 patients entering a University-based weight-reducing programme (38 males, 169 females), a package of self-administered questionnaires was submitted to measure HRQL (Short-Form 36) and psychopathological distress [general: Symptom Check-List 90 (SCL-90); depression: Beck Depression Inventory (BDI); binge eating: Binge Eating Scale (BES)]. Several clinical and anthropometric data were also recorded. RESULTS: HRQL, both in its physical and mental component, was significantly reduced in obesity when related to Italian population norms. SCL-90 identified psychopathological distress in 53 patients (26%), the BDI was indicative of depression in 89 cases (43%), whereas high scores of the BES were measured in 88 cases. Logistic regression analysis identified psichopathological distress as the major factor associated with poor HRQL. CONCLUSIONS: Psychiatric disturbances significantly contribute to poorly perceived health status. Only a comprehensive treatment including a specific approach to psychiatric symptoms may be effective in improving the perceived health status of obese patients seeking treatment.

The burden of obesity on everyday life: a role for osteoarticular and respiratory diseases.

The burden of obesity on patients' everyday life is high; obese subjects perceive a poor Health-Related Quality of Life (HRQL) in both physical and mental dimensions. We aimed to identify the areas of everyday life limited by health status and factors mainly responsible for perceived problems. The Nottingham Health Profile questionnaire (NHP) was used in 274 obese subjects seeking treatment at a university-based obesity center. Values were compared with normative Italian data, corrected for age and sex. Anthropometric and clinical data were also recorded, and correlated with health status. All domains of NHP were significantly impaired in obesity, the effect size ranging from 0.14 (Emotional Reactions; p = 0.02) to 0.99 (Physical Mobility; p < 0.0001), and varying in relation to gender, age and obesity class. Female subjects reported a higher-than-expected prevalence of problems in most areas of daily life [from 20% (Paid Employment) to 44% (Jobs around the home), compared with 14-26% in controls]. Males reported a high prevalence of problems in Sex life (31%), Holidays (37%) and Hobbies (49%), compared with 14, 14, and 16% in controls, respectively. Logistic regression analysis identified osteoarticular pain (knee and hip pain) and respiratory diseases as major factors predicting a poor HRQL in its physical dimensions, or perceived problems in everyday life. The relative importance of knee pain was higher than that of hip pain. Osteoarticular and respiratory diseases are major determinants of poor HRQL in obesity. Prevention strategies and treatment of somatic diseases are mandatory for a comprehensive approach to obesity.

Effects of cognitive-behavioural therapy on health-related quality of life in obese subjects with and without binge eating disorder.

OBJECTIVE: To measure the effects of cognitive-behavioural therapy on health-related quality of life (HRQL) in obese patients, in relation to binge eating disorder. DESIGN: Longitudinal, clinical intervention study consisting of structured sessions of cognitive-behavioural therapy, preceded by sessions chaired by a psychologist in subjects with binge eating. SUBJECTS: Two groups of obese patients (92 treated by cognitive-behavioural therapy (77 females); 76 untreated controls (67 female), selected from the waiting list (control group)). Of 92 treated patients, 46 had a binge eating disorder at psychometric testing and structured clinical interview. MEASUREMENTS: Health-related quality of life by means of Short-Form 36 questionnaire at baseline and after 3-5 months. RESULTS: Cognitive-behavioural treatment produced an average weight loss of 9.4+/-7.5 kg, corresponding to a BMI reduction of 3.48+/-2.70 kg/m(2). No changes were observed in the control group. All scales of HRQL improved in treated subjects (by 5-19%). In obese subjects with binge eating weight loss was lower in comparison to non-bingers (7.7+/-8.1 vs 11.1+/-6.6; P=0.034). However, the improvement in HRQL was on average larger, and significantly so for Role Limitation-Physical (P=0.006), Role Limitation-Emotional (P=0.002), Vitality (P=0.003), Mental Health (P=0.032) and Social Functioning (P=0.034). Bodily Pain was the sole scale whose changes paralleled changes in body weight. CONCLUSIONS: The positive effects of cognitive-behavioural therapy, mainly in subjects with binge eating, largely outweigh the effects on body weight, resulting in a significant change in self-perceived health status.

WHO and ADA criteria for the diagnosis of diabetes mellitus in relation to body mass index. Insulin sensitivity and secretion in resulting subcategories of glucose tolerance.

OBJECTIVE: To determine the influence of body mass index (BMI) on agreement between the American Diabetes Association (ADA) and the new World Health Organization diagnostic criteria for the diagnosis of diabetes mellitus and to investigate the metabolic profile of the resulting subcategories. DESIGN: Cross-sectional study SUBJECTS: A total of 3018 subjects with no previous history of diabetes and fasting glucose <7.8 mmol/l, with a wide range of BMIs. MEASUREMENTS: (1) Prevalence of impaired glucose regulation (IGR) and diabetes (DM) according to ADA and WHO diagnostic criteria; (2) basal and post-load insulin sensitivity and secretion, calculated on the basis of data derived from an oral glucose tolerance test (OGTT). RESULTS: The diagnosis according to the two classifications was concordant in 2490 subjects, discordant in 528 (452 were identified as impaired glucose tolerance (IGT) and 76 as DM only by means of OGTT). The disagreement increased with increasing BMI, being as high as 25.3% in subjects with BMI > or = 35 kg/m(2). Subjects with isolated fasting hyperglycaemia were mainly characterised by reduced insulin sensitivity and secretion in the basal state, but normal first-phase insulin secretion and moderately reduced insulin sensitivity after glucose challenge. Subjects with isolated 2 h hyperglycaemia were mainly characterised by normal basal insulin secretion and by a marked insulin resistance associated with a blunted first-phase insulin secretion after the glucose load. CONCLUSIONS: The disagreement between ADA and WHO classifications is particularly relevant in obesity, making OGTT mandatory in these subjects. Different pathogenic mechanisms are involved in isolated fasting or post-load hyperglycaemia, possibly related to a different site of insulin resistance (hepatic vs peripheral), and/or to a different disregulation of insulin secretion (basal vs post-load). A correct identification of the underlying mechanism(s) is the rationale for future studies to detect the effectiveness of different pharmacological or behavioural approaches.

Nonalcoholic fatty liver disease: a feature of the metabolic syndrome.

Insulin sensitivity (euglycemic clamp, insulin infusion rate: 40 mU. m(-2). min(-1)) was studied in 30 subjects with biopsy-proven nonalcoholic fatty liver disease (NAFLD), normal glucose tolerance, and a BMI <30 kg/m(2). Of those 30 subjects, 9 had pure fatty liver and 21 had evidence of steatohepatitis. In addition, 10 patients with type 2 diabetes under good metabolic control and 10 healthy subjects were studied. Most NAFLD patients had central fat accumulation, increased triglycerides and uric acid, and low HDL cholesterol, irrespective of BMI. Glucose disposal during the clamp was reduced by nearly 50% in NAFLD patients, as well as in patients with normal body weight, to an extent similar to that of the type 2 diabetic patients. Basal free fatty acids were increased, whereas insulin-mediated suppression of lipolysis was less effective (-69% in NAFLD vs. -84% in control subjects; P = 0.003). Postabsorptive hepatic glucose production (HGP), measured by [6,6-(2)H(2)]glucose, was normal. In response to insulin infusion, HGP decreased by only 63% of basal in NAFLD vs. 84% in control subjects (P = 0.002). Compared with type 2 diabetic patients, NAFLD patients were characterized by lower basal HGP, but with similarly reduced insulin-mediated suppression of HGP. There was laboratory evidence of iron overload in many NAFLD patients, but clinical, histological, and biochemical data (including insulin sensitivity) were not correlated with iron status. Four subjects were heterozygous for mutation His63Asp of the HFE gene of familiar hemochromatosis. We concluded that NAFLD, in the presence of normoglycemia and normal or moderately increased body weight, is characterized by clinical and laboratory data similar to those found in diabetes and obesity. NAFLD may be considered an additional feature of the metabolic syndrome, with specific hepatic insulin resistance.