The Ventricular System Enlarges Abnormally in the Seventies, Earlier in Men, and First in the Frontal Horn: A Study Based on More Than 3,000 Scans

Objectives: To detect on computed tomography (CT) brain scans the trajectories of normal and abnormal ventricular enlargement during aging.

Methods: For each 1-year age cohort, we assessed in 3,193 axial CT scans the Evans’ index (EI) in the anterior frontal horns and the parieto-occipital (POR) and temporal ratio (TR) in the posterior and inferior horns. Cut-off values for abnormal enlargement were based on previous clinical studies.

Results: The mean age associated with normal linear measures was 71 years. Values for all three measures increased with age, showing a linear relationship below—but not above—each cut-off value. The mean age of participants with abnormal enlargement on CT progressed from 79 years for EI to 83 years for POR to 87 years for TR. These results suggested that ventricular dilatation progresses in an age–location relationship. First comes enlargement of the frontal horns (13.8% of scans), followed by the parieto-occipital horns (15.1% of scans) and then temporal horn enlargement (6.8% of scans). Scans from men displayed abnormal values earlier than scans from women (on average 6 years). Risk increased 5.1% annually for abnormal EI, 9.0% for abnormal POR, and 11% for abnormal TR (all p < 0.001). The most frequent agreement between categories (normal–abnormal) for values of neuroimaging measures was identified for POR–TR.

Conclusion: The results of this large radiological study suggest that the ventricular system enlarges progressively during aging, and in a subset of patients follows an abnormal consecutive geometric dilatation, influenced by age and sex.

Therapeutic efficacy of chlorhexidine-based mouthwashes and its adverse events: Performance-related evaluation of mouthwashes added with Anti-Discoloration System and cetylpyridinium chloride

OBJECTIVES

To compare 3 mouthwashes: 0.20% chlorhexidine (CHX) with Anti-Discoloration System (ADS), 0.20% CHX and 0.12% CHX with 0.05% cetylpyridinium chloride (CPC), in terms of reduction of plaque and gingival bleeding and side effects.

METHODS

Mild gingivitis patients were randomly divided into three Groups: they underwent professional oral hygiene and received instructions: oral rinse with 10 mL for 1', twice a day, 30' after tooth brushing, for 14 days. Primary outcomes were plaque and gingival bleeding, assessed with Plaque Control Record and Gingival Bleeding Index. Feedback questionnaire and spectrophotometer evaluated secondary outcomes: adverse events. Timing of the study was T0 (baseline), T1 (professional oral hygiene) and T2 (14th day after mouthwash use).

RESULTS

Sixty-six patients were recruited, two patients dropped out, and 64 patients completed the study. PCR T1-T2 mean variation was 30.67 (SD = 15.22; 95% CI 23.55 to 37.80; P = 0.000), 19.93 (SD = 11.03; 95% CI 14.90 to 24.95; P = 0.000) and 16.24 (SD = 15.35; 95% CI 9.60 to 22.88; P = 0.000) respectively in Groups 0.2% CHX + ADS, 0.2% CHX and 0.12% CHX + CPC. GBI mean variation (T0-T2) was -9.82 (SD = 9.27; 95% CI -5.48 to 14.16; P = 0.000), -19.31 (SD = 11.33; 95% CI -14.15 to -24.47; P = 0.000) and -21.13 (SD = 12.56; 95% CI -15.70 to -26.56; P = 0.000) respectively in Groups 0.2% CHX + ADS, 0.2% CHX and 0.12% CHX + CPC. Statistical significance was found in lower efficacy of 0.2% CHX + ADS Group. Patients tolerated 0.12% CHX + CPC mouthwash better in bleeding perception (95.5%; P = 0.046), burning sensation (13.6%; P = 0.006), and mouthwash taste (100%; P = 0.000). Results on staining were no statistically significant (P = 0.106).

CONCLUSIONS

Addition of CPC allows reduction of CHX percentage in mouthwash formulation while keeping equal efficacy and less side effects. ADS addition decreases CHX efficacy in reducing plaque and bleeding, while resulting more tolerated than CHX.

Catalogue of the primary types of marine molluscan taxa described by Tommaso Allery Di Maria, Marquis of Monterosato, deposited in the Museo Civico di Zoologia, Roma

We have compiled a complete list of new marine molluscan taxa introduced by Tommaso Allery Di Maria, Marquis of Monterosato (1841-1927). The dates of publication of every single work have been checked against available evidence, and an updated bibliography is also presented. Finally, the type material of all marine taxa expected to be in the collection Monterosato (presently preserved in the Museo Civico di Zoologia in Rome) has been searched in the main collection, and all retrieved specimens have been catalogued. A large majority of the material has been found, representative specimens of each taxon have been illustrated, and remarks on nomenclature and taxonomy have been provided yielding 42 new synonymies, 46 nominal taxa rediscovered, and 6 new combinations.

Fluctuations of Estimated Glomerular Filtration Rate Outside Kidney Disease Improving Global Outcomes Diagnostic Criteria for Acute Kidney Injury in End-Stage Liver Disease Outpatients and Outcome Postliver Transplantation

BACKGROUND

Renal dysfunction in end-stage liver disease (ESLD) results from systemic conditions that affect both liver and kidney with activation of vasoconstrictor systems. In this setting, estimated glomerular filtration rate (eGFR) may undergo variations often outside Kidney Disease Improving Global Outcomes criteria for acute kidney injury (AKI) diagnosis, whose meaning is not clear. The aim of this study was to evaluate eGFR variations in ESLD outpatients listed for liver transplant (liver Tx) and the association with post-Tx outcome.

METHODS

Fifty-one patients with ESLD were retrospectively evaluated from listing to transplant (L-Tx time), intraoperatively (Tx time), and up to 5 years post-Tx time. Variations between the highest and the lowest eGFR occurring in more than 48 hours, not satisfying Kidney Disease Improving Global Outcomes guideline, were considered as fluctuations (eGFR-F). Fluctuations of eGFR greater than 50% were defined as eGFR drops (DeGFR). Early graft dysfunction, AKI within 7 days, chronic kidney disease, and short- and long-term patient survivals were considered as outcomes.

RESULTS

All patients presented eGFR-F, whereas DeGFR were observed in 18 (35.3%) of 51 (DeGFR+ group). These patients presented higher levels of Model for End-stage Liver Disease score, pre-Tx bilirubin and significantly greater incidence of post-Tx AKI stages 2 to 3 compared with patients without drops (DeGFR-). DeGFR was the only independent predictive factor of the occurrence of post-Tx AKI. The occurrence of AKI post-Tx was associated with the development of chronic kidney disease at 3 months and 5 years post-Tx.

CONCLUSIONS

Drops of eGFR are more frequently observed in patients with a worse degree of ESLD and are associated with a worse post-Tx kidney outcome.

Near-infrared imaging: an in vivo, non-invasive diagnostic tool in neurofibromatosis type 1

PURPOSE

Only a few reports in the literature have investigated the presence of ocular abnormalities in neurofibromatosis type 1 (NF-1) patients. The aim of this study was to evaluate the prevalence of ocular abnormalities in a large population of NF1 patients, focusing on the choroidal changes.

METHODS

This study was conducted on 160 consecutive patients with NF1 and 106 sex- and age-matched healthy subjects (control). Each patient underwent a complete ophthalmological examination inclusive of best-corrected visual acuity, intraocular pressure measurement, slit-lamp biomicroscopy, indirect fundus biomicroscopy, and near-infrared reflectance (NIR) retinography by using the spectral domain OCT. Moreover, all patients underwent complete dermatological exam and 1.5-Tesla MRI scan of the brain to assess the presence of optic nerve gliomas.

RESULTS

Choroidal abnormalities were detected in 97% of patients, with a positive predictive value of 100% and a negative predictive value of 96.4%. Interestingly, a small number of patients (4/160; 2.5%) showed Lisch nodules without choroidal abnormalities, whereas a larger number of patents (22/160; 13.75%) presented choroidal lesions in absence of Lisch nodules. None of the patients showed the absence of both choroidal lesions and Lisch nodules. The number of choroidal lesions increased with age (r = 0.364, p = 0.0001) and with the severity of pathology (r = 0.23, p = 0.003). Any statistically significant correlation between choroidal lesions, visual acuity, and intraocular pressure was observed.

CONCLUSIONS

NIR imaging represents an in vivo, non-invasive, sensitive and reproducible exam to detect choroidal nodules in NF-1 patients, suggesting that choroidal changes may represent an additional diagnostic criteria for NF1.

In normal aging ventricular system never attains pathological values of Evans' index

Ventricular enlargement in normal aging frequently forces the radiological diagnosis of hydrocephalus, but the reliability of Evans' index as a radiological marker of abnormal ventricular enlargement (values > 0.30) during aging is not assessed. Here we analyze ventricular size during aging and the reliability of Evans' index as a radiological marker of abnormal ventricular enlargement. We calculated Evans' index in the axial Computed Tomography scans of 1221 consecutive individuals (aged 45-101 years) from an emergency department. Stratified analysis of one-year cohorts showed that the mean Evans' index value per class was invariably < 0.30. Roughly one out five Computed Tomography scans was associated with Evans' index values > 0.30 and Evans' index values increased with age. The risk of having an Evans' index value > 0.30 increased by 7.8% per year of age (p < 0.001) and males were at 83.9% greater risk than females (p < 0.001). Overall, this study shows that normal aging enlarges the ventricular system, but never causes abnormal ventricular enlargement. Evans' index values > 0.30 should reflect an underlying neurological condition in every individual.

High prevalence of abdominal aortic calcification in patients with primary hyperparathyroidism as evaluated by Kauppila score

OBJECTIVE

The prevalence of abdominal aortic calcification (AAC) in primary hyperparathyroidism (PHPT) is unknown. We assessed both prevalence and severity of AAC in PHPT postmenopausal women.

METHODS

In this study 70 PHPT postmenopausal women and 70 age- and sex-matched controls were enrolled. Each participant underwent biochemical evaluation, lateral spine radiograph, bone mineral density (BMD) measurement (lumbar, femoral, radial sites), and kidney ultrasound. Lateral lumbar films were analyzed in the region of L1-L4 vertebrae and the Kauppila score (a semi-quantitative grading system) was used to assess the severity of AAC.

RESULTS

There were no differences regarding demographic and cardiovascular risk factors in the two groups. PHPT patients had higher prevalence of kidney stones (30% vs 7%, P=0.0008) and lower radial BMD values (0.558±0.071 vs 0.588±0.082 g/cm(2), P<0.05) compared with controls. PHPT patients showed higher prevalence of AAC (31 vs 18, P=0.03), with more severe calcifications (Kauppila score 7.35±6.1 vs 5.05±3.5, P=0.007). PHPT patients with AAC were older and had been suffering from the disease for a longer period compared with those without ACC. Moreover, PHPT patients with severe AAC had mean higher serum parathyroid hormone levels compared with patients with moderate or mild calcifications. In PHPT patients with AAC, multiple regression analysis, adjusted for age and years since diagnosis, showed that only parathyroid hormone significantly correlated with Kauppila score.

CONCLUSION

We found a higher prevalence and severity of AAC in PHPT related to parathyroid hormone effect.

The multitasking role of macrophages in Stanford type A acute aortic dissection

OBJECTIVES

The aim of the study was to determine whether the release by macrophages of matrix metalloproteinase (MMP)-12 and vascular endothelial growth factor (VEGF) - leading to inflammation, matrix degradation and neoangiogenesis - represents an effective pathway that underlies aortic wall remodeling in Stanford type A acute aortic dissection (AAD).

METHODS

Twenty-one consecutive patients with no genetic predisposition, with Stanford type A AAD were selected. In each patient, the levels of serum VEGF, MMP-12, serum interleukin (IL)-6, IL-8 and monocyte chemoattractant protein (MCP)-1 were evaluated using enzyme-linked immunosorbent assay. Ascending aortic specimens were collected for immunohistochemical identification of any presence of inflammatory infiltrate, VEGF and CD31 expression.

RESULTS

A significant increase in serum VEGF (p = 0.044), MMP-12 (p = 0.007), IL-6 (p = 0.0001), IL-8 (p = 0.0001) and MCP-1 (p = 0.0001) levels was observed in the AAD group compared to the control group. Furthermore, all AAD samples were positive for VEGF in the tunica media and showed vessel growth and immune-inflammatory infiltrate. A large number of cases (62.79%) showed inflammation at the edge of the dissection and approximately half (51.42%) showed neovessels growing at the edge of the dissection.

CONCLUSIONS

The results suggest that VEGF-mediated angiogenesis and matrix degradation play a role in AAD. Finally, we believe that MMP-12 should be considered a marker of AAD.

The effect of parathyroidectomy on chronic constipation in patients affected by primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is usually associated with chronic constipation; however, its prevalence is not defined by standardized criteria. The aim of the study was to evaluate both the prevalence of chronic constipation, defined by the standardized Rome diagnostic criteria III (Rome III) in PHPT, and the effect of parathyroidectomy (PTx). Fifty postmenopausal PHPT patients and 50 sex- and age-matched controls were studied. Each patient underwent mineral metabolism biochemical evaluation and completed a questionnaire and a 2-week diary card about bowel habits. PHPT patients were reevaluated after 6 months. According to Rome III, 40 % of PHPT patients had chronic constipation compared with 12 % of controls (p = 0.0002). The only difference between constipated PHPT patients (group A, n = 20) and those without constipation (group B, n = 30) was higher mean PTH values (79.9 ± 18.7 ng/l vs. 65.4 ± 26.0 ng/l; p = 0.03), which predicted the presence of constipation (p = 0.004, OR 1.059, CI 1.011-1.059). Forty percent of PHPT patients had undergone PTx. In group A, constipation was resolved in 80 % of patients after PTx compared to none of the same group who had not undergone PTx (p = 0.0007). In group B, 17.6 % of patients who had not undergone PTx became, after 6 months, constipated. According to Rome III, a higher prevalence of chronic constipation in PHPT patients was observed compared with controls. PTH levels predicted constipation. A significant reduction of chronic constipation was reported following successful surgery.

"Trabecular Bone Score" (TBS): an indirect measure of bone micro-architecture in postmenopausal patients with primary hyperparathyroidism

BACKGROUND

Patients with primary hyperparathyroidism (PHPT) generally show reduced bone mineral density (BMD) at cortical sites with relatively preserved trabecular bone. However, the increased fracture risk at all skeletal sites suggests that areal BMD probably is not effective in capturing all the determinants of bone strength. "Trabecular Bone Score" (TBS) has been recently proposed as an indirect measure of bone micro-architecture. Our study was aimed to investigate TBS in patients with PHPT.

METHODS

Seventy-three Caucasian postmenopausal women with PHPT and 74 age-matched healthy women (C) were studied. In all participants BMD at lumbar spine (LS) and at femoral sites (Neck-FN and total hip-TH) was measured by DXA and, in 67 patients and 34 C, also at the distal 1/3 of the radius (R). TBS was measured in the region of LS-BMD. Spine X ray was assessed in all patients.

RESULTS

Mean TBS values were significantly reduced in PHPT (1.19 ± 0.10) compared to C (1.24 ± 0.09, p<0.01). Patients and controls did not differ for age, years since menopause (YSM), BMI, 25(OH)D serum levels, creatinine clearance, LS-BMD and FN-BMD. On the contrary, mean BMD values at both TH and R were significantly lower in PHPT patients compared to controls (p<0.01 and p<0.0001, respectively). In PHPT with vertebral fractures (VF+, n=29) TBS was significantly lower than in those without fracture (VF-, n=44)(1.14 ± 0.10 vs. 1.22 ± 0.10, respectively; p<0.01), whose TBS values did not differ from C. Mean TBS values in patients with (n=18) and without (n=55) non-vertebral fractures did not significantly differ (1.16 ± 0.09 vs. 1.20 ± 0.11). The presence of vertebral fractures was independently associated with the reduction of TBS (OR=0.003, 95% CI=0-0.534, p=0.028) and with YSM (OR=1.076, 95% CI=1.017-1.139, p=0.011), but not with age, the reduction of LS-BMD and the increase of BMI. The combination of YSM > 10 years plus TBS < 1.2 was associated with a significant risk of VF (OR=11.73, 95% CI 2.43-66.55, p<0.001). A TBS value <1.2 showed a better performance in individuating VF (sensibility 79.3%, specificity 61.4%, positive predictive value 57.5%, and negative predictive value 81.8%) in respect to YSM > 10 years.

CONCLUSIONS

TBS seems to indirectly reflect an alteration of bone micro-architecture in postmenopausal women with PHPT.

Visual evoked potential importance in the complex mechanism of amblyopia

To compare the visual evoked potential (VEP) responses of amblyopic eyes with VEP responses of sound eyes in amblyopic children. A study of 65 amblyopic children with pattern-reversal VEPs elicited by checkerboard stimuli with large, medium and small checks. The children were classified into three groups: Group A, 22 children with anisometropic amblyopia; Group B, 16 children with exotropic strabismic amblyopia; and Group C, 27 children with esotropic strabismic amblyopia. Visual acuity (VA) was significantly worse in the amblyopic eye as compared to the sound eye. However, no statistically significant difference was found between the amblyopic and sound eye of amblyopic children in the three groups for VEP P1 amplitude and latencies for any check sizes. VEP is a very important tool in understanding the complex amblyopic mechanism. Although the sound eye has superior VA, the absence of differences in VEP P1 amplitudes and latencies demonstrate the functional abnormality of the eye considered ‘good’. More studies are necessary to explain why the sound eye in amblyopic children cannot be considered completely normal. Special attention should therefore be paid to amblyopic treatment, as patching can have a negative effect on the sound eye.

Cephalometric evaluation of the hyoid triangle before and after maxillary rapid expansion in patients with skeletal class II, mixed dentition, and infantile swallowing

BACKGROUND

Rocabado's hyoid triangle is the only cephalometric parameter that can assess the effects of orthodontic treatment on tongue posture.

AIM

To evaluate the restoration of tongue posture and function by conducting a cephalometric assessment of the hyoid triangle before and after rapid maxillary expansion.

METHODS

Sixty-four healthy patients aged 6-11 years with skeletal class II malocclusion, mixed dentition, and infantile swallowing took part in this study. They submitted to lateral cephalometric radiography before and after orthodontic maxillary rapid expansion, in order to assess the resulting changes in the proportions of the hyoid triangle (following Rocabado's parameters). The cephalometric findings were compared according to sex, age, and divergence using the chi-square McNemar test at the 5% significance level (p<0.05).

RESULTS

The orthodontic treatment resulted an improvement from skeletal class II malocclusion to class I, with elimination of infantile swallowing in 81.8% of male patients [95% confidence interval (CI)=61.5-92.7%], in 87.1% of patients aged 6-7 years (95% CI=71.1-94.9%).

CONCLUSIONS

This cephalometric analysis revealed that the hyoid triangle was modified by the orthodontic maxillary expansion, reconditioning of tongue posture and function particularly among male, aged 6-7 years old with skeletal class II malocclusion, mixed dentition, and infantile swallowing.

Maternal C-reactive protein at hospital admission is a simple predictor of funisitis in preterm premature rupture of membranes

AIM

To analyze the prognostic value of maternal serum C-reactive protein (CRP) in predicting funisitis in patients with preterm premature rupture of membranes (pPROM).

METHODS

66 patients (gestational age 24-33 weeks) hospitalized 1-12 h after pPROM were enrolled. White blood cell count (WBC), platelet count (PLT) and plasma concentration of CRP were assessed every 3 days. Histological evidence of chorioamnionitis and funisitis was obtained post-partum. Receiver operating characteristic (ROC) curves were employed to evaluate the role of maternal CRP in predicting funisitis.

RESULTS

Funisitis was found in 24 patients (36.3%); 42 patients (63.7%) without funisitis were considered as controls. PLT and WBC at admission and before delivery did not show significant differences and were not statistically different between the two groups. Patients with funisitis had significantly higher CRP levels both at admission to hospital and 24- 48 h before delivery. ROC curve analysis showed that CRP at admission (area under the curve: 0.671, p = 0.021) and before delivery (area under the curve: 0.737, p = 0.001) are predictive of funisitis.

CONCLUSIONS

High maternal serum CRP levels (>20,000 µg/l) in pPROM patients at admission to hospital may be an early marker which indicates, with a good diagnostic performance, the presence of funisitis.

Clinical and histological outcome predictors in renal limited pauci-immune crescentic glomerulonephritis: a single centre experience

Renal-limited vasculitis is a pauci-immune crescentic glomerulonephritis with no signs of systemic involvement, representing one of the most common causes of rapidly progressive glomerulonephritis. The study aims to examine clinical and histological features in twenty-four patients with RLV diagnosed by the Nephrology Department of Sapienza University of Rome, Italy, evaluating the role of these parameters in predicting renal survival. Patients details, clinical and histological features and outcomes were recorded at the time of renal biopsy and over a mean follow-up period of 36±6 months. In our study, serum creatinine at presentation was significantly higher in patients who had a poor outcome than in those who survived with independent renal function (6.3±2.47 mg/dl vs 2.84±2.01 mg/dl, P= 0.002). The presence of C3c was found in the area of glomerular fibrinoid necrosis and in small arteries and arterioles with fibrinoid necrosis in 17 patients (P= 0.018). In conclusion, serum creatinine at presentation and focal C3c depositions in areas of glomerular and arteriolar fibrinoid necrosis were the best determinants of poor renal outcome, maybe underlining the pathogenic role of alternative pathway activation of complement system but also demonstrating the focal distribution of necrotizing lesions.

Insulin-like growth factor-I (IGF-1), IGF-binding protein-3 (IGFBP-3) and mammographic features

INTRODUCTION

The IGF system has recently been shown to play an important role in the regulation of breast tumor cell proliferation. However, also breast density is currently considered as the strongest breast cancer risk factor. It is not yet clear whether these factors are interrelated and if and how they are influenced by menopausal status. The purpose of this study was to examine the possible effects of IGF-1 and IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density stratified by menopausal status.

PATIENTS AND METHODS

A group of 341 Italian women were interviewed to collect the following data: family history of breast cancer, reproductive and menstrual factors, breast biopsies, previous administration of hormonal contraceptive therapy, hormone replacement therapy (HRT) in menopause and lifestyle information. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels. IGF-1/ IGFBP-3 molar ratio was then calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). Student's t-test was employed to assess the association between breast density and plasma level of IGF-1, IGFBP-3 and molar ratio. To assess if this relationship was similar in subgroups of pre- and postmenopausal women, the study population was stratified by menopausal status and Student's t-test was performed. Finally, multivariate analysis was employed to evaluate if there were confounding factors that might influence the relationship between growth factors and breast density.

RESULTS

The analysis of the relationship between mammographic density and plasma level of IGF-1, IGFBP-3 and IGF-1/ IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group (IGF-1: 109.6 versus 96.6 ng/ml; p= 0.001 and molar ratio 29.4 versus 25.5 ng/ml; p= 0.001) whereas IGFBP-3 showed similar values in both groups (DB and NDB). Analysis of plasma level of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio compared to breast density after stratification of the study population by menopausal status (premenopausal and postmenopausal) showed that there was no association between the plasma of growth factors and breast density, neither in premenopausal nor in postmenopausal patients. Multivariate analysis showed that only nulliparity, premenopausal status and body mass index (BMI) are determinants of breast density.

CONCLUSIONS

Our study provides a strong evidence of a crude association between breast density and plasma levels of IGF-1 and molar ratio. On the basis of our results, it is reasonable to assume that the role of IGF-1 and molar ratio in the pathogenesis of breast cancer might be mediated through mammographic density. IGF-1 and molar ratio might thus increase the risk of cancer by increasing mammographic density.

Open debridement and radiocapitellar replacement in primary and post-traumatic arthritis of the elbow: a multicenter study

BACKGROUND

Postmortem and clinical studies have shown an early and prevalent involvement of the radiohumeral joint in primary and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) prosthesis has recently been developed for the treatment of lateral elbow arthritis. However, few data have been published on LRE results.

MATERIALS AND METHODS

A prospective multicenter study was designed to assess LRE preliminary results. There were 20 patients (average age, 55 years). Preoperative diagnosis were primary osteoarthritis in 11 and post-traumatic osteoarthritis in 9. All patients underwent open debridement and LRE prosthesis. Patients were evaluated preoperatively and postoperatively with the Mayo Elbow Performance Score (MEPS), modified American Shoulder Elbow Surgeons (m-ASES) elbow assessment, and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH). Mean follow-up was 22.6 months.

RESULTS

At the last follow-up, the mean improvement of MEPS and m-ASES was 35 (P = .001) and 34 (P = .001) respectively; the average Quick DASH decreased by 29 (P = .001). Average range of motion was improved by 35° (P = .001). MEPI results were excellent in 12 patients, good in 2, and fair and poor in 3 each. Mild overstuffing was observed in 5 patients, and an implant malpositioning in 3. The implant survival rate was 100%.

CONCLUSION

LRE showed promising results in this prospective investigation. Most patients had an uneventful postoperative course and have shown a painless elbow joint, with satisfactory functional recovery at short-term follow-up. Further studies with longer follow-up are warranted.

Comparative study of seminal parameters between samples collected in 1992 and samples collected in 2010

OBJECTIVE

The aim of this study was to conduct a comparative study of semen quality in two large populations; one evaluated in 1992 and another in 2010, in order to evaluate any possible decline in male fertility due, at least in part, to environmental factors.

MATERIAL AND METHODS

A total of 701 subjects in 1992 (TOTAL group 1992) and a total of 626 subjects in 2010 (TOTAL group 2010) were enrolled in our Andrology Unit. Each group was subdivided into 3 subgroups: Subfertile, Pathology and Control. Standard semen analysis was performed using the Superimposed Image Analysis System, according to WHO guidelines 1987 (for TOTAL group 1992) and WHO guidelines 1999 (for TOTAL group 2010).

RESULTS

The mean values of sperm number (concentration/ml as well as the total ejaculate) and progressive motility were significantly higher in TOTAL group 2010 than TOTAL group 1992. Atypical forms in TOTAL group 1992 semen samples were significantly lower than TOTAL group 2010. The mean age of TOTAL Group 2010 was significantly higher compared with TOTAL Group 1992. In particular, the mean age gap was more evident in Subfertile subjects.

CONCLUSIONS

In conclusion, environmental factors have not determined a significant decline in seminal parameters in the past 18 years.

Possible effects of insulin-like growth factor-I, IGF-binding protein-3 and IGF-1/IGFBP-3 molar ratio on mammographic density: a cross-sectional study

The purpose of this study was to examine the possible effects of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density and assess whether this relationship was similar in subgroups of pre- and postmenopausal women. A group of 341 Italian women of childbearing age or naturally postmenopausal who had performed mammographic examination at the section of radiology of our department a maximum three months prior to recruitment were enrolled. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels and IGF-1/IGFBP-3 molar ratio was calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). To assess the association between mammographic density and IGF-1, IGFBP-3 and Molar ratio Student's t-test was employed before and after stratified by menopausal status. The analysis of the relationship between mammographic density and plasma levels of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group whereas IGFBP-3 showed similar values in both groups (DB and NDB). After stratification of the study population by menopausal status, no association was found. Our study provides strong evidence of a crude association between breast density, and plasma levels of IGF-1 and molar ratio. IGF-1 and molar ratio might increase mammographic density and thus the risk of developing breast cancer.

Complex fracture-dislocations of the proximal ulna and radius in adults: a comprehensive classification

BACKGROUND

Complex fracture-dislocations of the proximal ulna and radius include multiple anatomic lesions, the management of which is known to be demanding. Although several classifications have been proposed, none appear to be exhaustive, and most of them have neither therapeutic nor prognostic value. The purpose of this study was to design a comprehensive classification that may provide a guide for the operative management of these injuries.

MATERIALS AND METHODS

The classification is aimed at identifying definite anatomic lesions, called the "main lesions," the presence of which can affect the prognosis and require peculiar treatments. The main lesions include (1) ulnar fracture (including its location with respect to the insertion of collateral ligaments and coronoid fracture), (2) radiohumeral dislocation, (3) proximal radioulnar dislocation, (4) radial fracture, (5) distal radioulnar joint and interosseous membrane lesion, and (6) humeral-ulnar dislocation. Intraobserver and interobserver reliability was assessed in 25 complex fracture-dislocations. Standard radiographs and computed tomography scans were analyzed by 3 independent observers.

RESULTS

The main lesions were labeled by an alphanumeric system. Numbers 1 through 6 identified the type of ulnar fracture, and letters A through E indicated the dislocated joint or presence of a radial fracture. The direction of dislocation and the type of radial fracture were identified by Roman numerals, from I to III, placed after the letter. A κ value of 0.873 or greater resulted from intraobserver and interobserver evaluation.

CONCLUSION

We created a comprehensive classification of complex fracture-dislocations of the elbow. The classification appeared to be reproducible and may represent a useful tool for the management of such difficult injuries.

Acute renal failure in liver transplant recipients: role of pretransplantation renal function and 1-year follow-up

Chronic renal failure and acute renal failure (CRF and ARF) are common complications after orthotopic liver transplantation (OLT) that adversely affect patient survival. Many factors influence the development of ARF in the OLT setting. In a previous study we reported an association between ARF and the development of CRF at 1 month after OLT. The aims of our study were to evaluate the influence of ARF on short-, middle-, and long-term renal function after OLT and its influence on 1-year survival of patients and grafts. Fourty-four patients who underwent deceased donor OLT between August 2008 and August 2010 were evaluated pretransplantation, in the perioperative period, and at 1, 6, and 12 months posttransplantation. ARF was associated with CRF at 1 month post-OLT, whereas no association was observed at 6 and 12 months post-OLT. The development of CRF at 6 months post-OLT was associated with pre-OLT renal dysfunction and 1 month post-OLT CRF. Four patients died in the ARF group, whereas 3 patients died in the group without ARF. We confirmed ARF to be a predictive event for short-term renal dysfunction. The majority of patients recovered renal function after the first month. Although many pre-, peri-, and post-OLT factors may contribute to the development of posttransplantation CRF, pre-OLT CRF seemed to be the most important risk factor.

Model for end-stage liver disease score versus simplified acute physiology score criteria in acute renal failure after liver transplantation

Hepatic function and renal failure are closely related among patients with end-stage liver disease (ESLD) due to splanchnic hemodynamic mechanisms that characterize advanced decompensated cirrhosis. Acute renal failure (ARF) is a frequent complication that occurs immediately post-orthotopic liver transplantation (OLT). The Model for End-stage Liver Disease (MELD) score describes the survival of patients with ESLD awaiting OLT related to the severity of liver disease. The Simplified Acute Physiology Score (SAPS II) is a mortality prediction model that scores the severity of illness among intensive care unit patients. In a previous study we observed an association between ARF post-OLT and a higher MELD score, but it was not clear whether this association depends on the grade of ESLD or on the critical condition of liver transplant patients. The aim of this study was to evaluate the association of ARF with MELD score and/or SAPS II criteria among liver transplant patients. We analyzed 46 patients with ESLD who underwent deceased donor OLT. All patients were evaluated at baseline and in the first 7 days post-OLT. According to the RIFLE classification, the incidence of the worst grade of ARF post-OLT was 19.2%. These patients showed significantly higher MELD scores, while there was no association with systemic parameters related to the critical patient's condition or with the mortality score as evaluated by SAPS II criteria. We confirmed the association between renal failure and hepatic function among liver transplant patients. A more severe degree of hepatic dysfunction before OLT was associated with a greater incidence of ARF that can adversely affect patient survival.

Tacrolimus trough levels and level-to-dose ratio in stable renal transplant patients converted to a once-daily regimen

Numerous evidence has been reported to support a safe 1:1 conversion from the twice-daily tacrolimus (Tac-T) to the once-daily tacrolimus regimen (Tac-O), but frequently there is a reduction in drug trough levels, which has been estimated by some authors to be about 20%. The relationship between Tac-O dosage and trough levels after conversion is not clear. The tacrolimus trough levels-to-dose ratio has been applied to better define the wide variability in doses and blood levels of tacrolimus. The aim of this study was to evaluate tacrolimus trough levels, tacrolimus daily dosage, and tacrolimus level-to-dose ratio during 1 year pre-postconversion follow-up in 31 stable kidney transplant patients who had received Tac-T therapy for over 6 months with stable renal function. They were converted to the same dosage of Tac-O. Patients before and after conversion were their own controls. The trough levels of tacrolimus showed a slight albeit significant reduction after conversion, remaining in the therapeutic range. Nineteen percent underwent an adjustment in total daily dosage after conversion versus 39% before conversion with no significant difference. No significant differences were detected in the total daily dose administered either by tacrolimus level-to-dose ratio before or after conversion. Kidney transplant recipients under Tac-O therapy were safely maintained using the same therapeutic monitoring as when receiving Tac-T.

Inflammation and immune response in acute aortic dissection

OBJECTIVE

The aim of our study was to evaluate the lymphocyte subpopulations and the cytokines in the peripheral blood of patients with type-A Stanford acute aortic dissection (AAD group) and to determine whether inflammatory cells are present at the site of aortic dissection.

METHODS

Thirty-five consecutive patients with type-A Stanford dissection were evaluated for haemochrome and lymphocyte subpopulations (CD3+, CD4+, CD8+, CD19+, CD4+CD25+, CD16+CD56+, CD4+CD28-, CD8+CD28-) by flow cytometry. C-reactive protein (CRP), tumour necrosis factor (TNF)-α, interleukin (IL)-2, IL-4, IL-6, IL-8, IL-10, interferon-gamma (IFN-γ), and monocyte chemoattractant protein (MCP)-1 were measured by ELISA. In addition, immunohistochemical staining with cell type-specific antibodies was performed to study the inflammatory cells detected inside the aortic wall.

RESULTS

In the AAD group, a significant increase in natural killer (NK) (P = 0.032), B cells (P = 0.022), and CD8+CD28- (P = 0.045) subpopulations was observed, whereas there was a significant decrease in total T lymphocytes (P = 0.004) and T helper fractions (P = 0.005). Moreover, a significant increase in CRP (P < 0.0001), IL-6 (P < 0.0001), IL-8 (P < 0.0001), IL-10 (P < 0.0001), TNF-α (P < 0.0001), and MCP-1 (P < 0.001) was observed; macrophages represented the main population detected inside the media.

CONCLUSIONS

Our results strongly support the hypothesis of a pivotal role of innate immunity in type-A Stanford AAD.

RIFLE criteria and hepatic function in the assessment of acute renal failure in liver transplantation

Renal dysfunction in cirrhotic patients is primary related to disturbances of circulatory function, triggered by portal hypertension with chronic intrarenal vasoconstriction and hypoperfusion. Pretransplant renal function is an important factor implicated in the development of acute renal failure (ARF) after liver transplantation (OLT), but other factors mostly related to liver function seem to influence the development of ARF. The Acute Dialysis Quality Initiative workgroup developed the RIFLE classification to define ARF. We sought to evaluate the incidence of ARF among patients undergoing OLT, to evaluate the association of ARF with pre-OLT renal and hepatic functions, and to evaluate the influence of ARF on chronic kidney disease (CKD) at 1 month post-OLT. Clinical, renal, hepatic function, and donor risk index data of 24 patients who underwent deceased donor OLT were collected before transplantation, in the perioperative period and in the first month post-OLT. ARF occurred in 37.5% of patients with 56% developing the R grade and 44% the I grade; no patient showed the F grade. An association was observed between ARF and a higher Model for End-Stage Liver Disease (MELD) score and between ARF and a reduced pre-OLT serum albumin. No association was noted between ARF and other pre-OLT parameters. In cirrhotic patients serum creatinine is a bias for renal function assessment and the Modification of Diet in Renal Disease formula overestimates GFR. Post-OLT CKD was present in 6.7% of patients without ARF and in 44.4% of patients with ARF. The R grade developed more frequently among patients with viral cirrhosis. The association of ARF with MELD and hypoalbuminemia may be the result of a close relationship between renal and hepatic functions among cirrhotic patients. Post-OLT CKD may be the result of unrecognized, preexisting CKD and/or the effects of not fully resolved acute damage to an injured kidney.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Gadofosveset-enhanced MR angiography of carotid arteries: does steady-state imaging improve accuracy of first-pass imaging? Comparison with selective digital subtraction angiography

PURPOSE

To evaluate the diagnostic accuracy of gadofosveset-enhanced magnetic resonance (MR) angiography in the assessment of carotid artery stenosis, with digital subtraction angiography (DSA) as the reference standard, and to determine the value of reading first-pass, steady-state, and "combined" (first-pass plus steady-state) MR angiograms.

MATERIALS AND METHODS

This study was approved by the local ethics committee, and all subjects gave written informed consent. MR angiography and DSA were performed in 84 patients (56 men, 28 women; age range, 61-76 years) with carotid artery stenosis at Doppler ultrasonography. Three readers reviewed the first-pass, steady-state, and combined MR data sets, and one independent observer evaluated the DSA images to assess stenosis degree, plaque morphology and ulceration, stenosis length, and tandem lesions. Interobserver agreement regarding MR angiographic findings was analyzed by using intraclass correlation and Cohen kappa coefficients. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated by using the McNemar test to determine possible significant differences (P < .05).

RESULTS

Interobserver agreement regarding all MR angiogram readings was substantial. For grading stenosis, sensitivity, specificity, PPV, and NPV were, respectively, 90%, 92%, 91%, and 91% for first-pass imaging; 95% each for steady-state imaging; and 96%, 99%, 99%, and 97% for combined imaging. For evaluation of plaque morphology, respective values were 84%, 86%, 88%, and 82% for first-pass imaging; 98%, 97%, 98%, and 97% for steady-state imaging; and 98%, 100%, 100%, and 97% for combined imaging. Differences between the first-pass, steady-state, and combined image readings for assessment of stenosis degree and plaque morphology were significant (P < .001).

CONCLUSION

Gadofosveset-enhanced MR angiography is a promising technique for imaging carotid artery stenosis. Steady-state image reading is superior to first-pass image reading, but the combined reading protocol is more accurate.

MicroRNA profiling in human medulloblastoma

Medulloblastoma is an aggressive brain malignancy with high incidence in childhood. Current treatment approaches have limited efficacy and severe side effects. Therefore, new risk-adapted therapeutic strategies based on molecular classification are required. MicroRNA expression analysis has emerged as a powerful tool to identify candidate molecules playing an important role in a large number of malignancies. However, no data are yet available on human primary medulloblastomas. A high throughput microRNA expression profiles was performed in human primary medulloblastoma specimens to investigate microRNA involvement in medulloblastoma carcinogenesis. We identified specific microRNA expression patterns which distinguish medulloblastoma differing in histotypes (anaplastic, classic and desmoplastic), in molecular features (ErbB2 or c-Myc overexpressing tumors) and in disease-risk stratification. MicroRNAs expression profile clearly differentiates medulloblastoma from either adult or fetal normal cerebellar tissues. Only a few microRNAs displayed upregulated expression, while most of them were downregulated in tumor samples, suggesting a tumor growth-inhibitory function. This property has been addressed for miR-9 and miR-125a, whose rescued expression promoted medulloblastoma cell growth arrest and apoptosis while targeting the proproliferative truncated TrkC isoform. In conclusion, misregulated microRNA expression profiles characterize human medulloblastomas, and may provide potential targets for novel therapeutic strategies.

Low absolute lymphocyte count is a poor prognostic factor in diffuse-large-B-cell-lymphoma

The prognostic value of absolute lymphocytic count (ALC), has been a recent matter of debate in non-Hodgkin-lymphoma (NHL). We assessed prospectively the value of ALC at diagnosis and also after the completion of immuno-chemotherapy in 101 diffuse-large-B-cell-lymphoma (DLBCL). Analysis of prognostic factors with respect to overall survival (OS), event free survival (EFS) and progression free survival (PFS) was done by two-tailed log-rank test. The ALC cut-off value was calculated as <0.84 x 10(9)/L at diagnosis: this was a strong negative prognostic factor for OS (p = 0.0004), EFS (p < 0.00001) and PFS (p < 0.00001) and in multivariate analysis was independent from the revised-international-prognostic-index (R-IPI). ALC after chemo-immunotherapy was not of prognostic value. As R-IPI and ALC < 0.84 x 10(9)/L, were the factors better discriminating poor prognosis, a new trichotomous score (ALC/R-IPI) was built up: (1) low risk: R-IPI = very good or good and ALC < 0.84 x 10(9)/L; (2) intermediate risk: patients with at least one risk factor (R-IPI = poor or ALC < 0.84 x 10(9)/L). (3) high risk: patients with both risk factors. This new prognostic score was highly significant in univariate analysis for OS (p = 0.0002), EFS (p < 0.00001) and PFS (p < 0.00001). In multivariate analysis ALC/R-IPI was the most predictive factor for OS (OR = 2.954; p = 0.002) and EFS (OR = 2.381; p < 0.00001) and the only predictive factor for PFS (OR = 4.018; p < 0.00001). Our data, show that ALC at diagnosis has a strong prognostic relevance and is independent from the R-IPI. The new score including both values proved the most powerful predictor at multivariate analysis.

Prostate cancer detection rate of transrectal ultrasonography, digital rectal examination, and prostate-specific antigen: results of a five-year study of 6- versus 12-core transperineal prostate biopsy

AIM

The purpose of the present comparative work was the processing and assessment of data collected in a five-year period of urological practice with more than 1.500 transperineal, ultrasound-guided, prostatic biopsies performed. Our aim was to identify advantages and limitations of 6 and 12-core protocols, by extending the evaluation not only to cancer detection rate but also to the other histological findings.

METHODS

A total of 1.151 patients were included in the study. Two subgroups were identified: 836 patients who had undergone a 6-core biopsy from 2001 to 2004, and 315 patients who had undergone a 12-core biopsy from 2005 to 2006.

RESULTS

Cancer detection rate was 291/836 (34.8%) in group 1 (6-core biopsy), and 148/315 (47%) in group 2 (12-core biopsy) (P<0.0001). The total number of histological diagnoses other than cancer was 162/836 in group 1 (19.4%) and 103/315 (32.7%) in group 2 (P<0.0001).

CONCLUSION

In prostate biopsy, a higher number of cores seems to definitely improve its diagnostic value by dramatically decreasing the number of negative findings. The 12-core technique is particularly effective in case of prostate-specific antigen (PSA) values ranging between 4.1 and 10 ng/mL combined with a free-to-total PSA ratio below 16%, in case of negative digital rectal examination and when serum prostate-specific antigen levels are lower than 4 ng/mL. On the other hand, in the case of abnormal digital rectal examination, especially when combined with high prostate-specific antigen levels and/or changes detected at transrectal ultrasound, the 6-core technique can be considered a reasonable strategy.

Response to anti-tumour necrosis factor alpha blockade is associated with reduction of carotid intima-media thickness in patients with active rheumatoid arthritis

OBJECTIVES

To determine whether tumour necrosis factor (TNF)-alpha blockers may reduce carotid intima-media thickness (cIMT) in patients with active rheumatoid arthritis (RA) steadily responsive to such therapy.

METHODS

From 287 consecutive RA patients attending our out-patient clinic and diagnosed on the basis of the American College of Rheumatology (ACR) criteria, 49 without traditional cardiovascular risk factors and meeting the requirements for TNF-alpha blockers therapy were selected. Among them, 39 actually started TNF-alpha blockers, but only 30, who reached at least a response on the ACR 20% improvement criteria at 14 weeks, maintained during the whole year of treatment, were finally considered (group A). The remaining 10/49, homogeneous for age, sex, traditional cardiovascular risk factors, socioeconomic status, disease activity and duration, who did not consent to TNF-alpha-blocker administration, were used as controls (group B). Disease activity score in 44 joints (DAS44), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were evaluated before starting the study, and 3, 6, 12 months thereafter; cIMT was measured by ultrasound before and 12 months thereafter only.

RESULTS

Patients in group A showed a very significant cIMT reduction (P < 0.0001 and P < 0.0001, on the right and left side, respectively), preceded by an early and lasting significant decrease in DAS44, ESR and CRP. Moreover, a significant correlation was found between cIMT and DAS44 (r = 0.435, P < 0.05).

CONCLUSIONS

These results demonstrate that TNF-alpha blockade is associated with cIMT reduction in RA patients steadily responsive to therapy, probably by lowering inflammation.

Computer-Assisted Evaluation of Nipple-Areola Complex Sensibility in Macromastia and following Superolateral Pedicle Reduction Mammaplasty: A Statistical Analysis

BACKGROUND

The authors performed a prospective study quantifying nipple-areola complex sensibility by computer-assisted neurosensory testing in breast hypertrophy before and after superolateral breast reduction.

METHODS

A superolateral pedicle breast reduction was performed on 30 macromastia patients. The mean age of the patients was 46 years. The cup sizes of the patients were as follows: D, 14 patients; E, 12 patients; and EE, four patients. Ptosis was 3 degrees in 12 and 4 degrees in 18; nipple elevation ranged from 4 to 18 cm; glandular resection ranged from 379 to 1850 g. Static and moving one- and two-point discrimination was tested preoperatively and 6 months postoperatively at the nipple-areola complex, evaluating the impact of breast hypertrophy (D versus E and EE cups), nipple elevation (<9 cm versus > or =9 cm), and glandular resection (<900 g versus > or =900 g).

RESULTS

Statistical analyses revealed preoperatively significant higher pressure thresholds in the nipple-areola complex of larger versus smaller hypertrophies and in the nipple of longer nipple-areola complex transposition breasts for static and moving one-point discrimination. Postoperatively, worsening of sensibility was more significant in the nipple-areola complex of smaller versus larger hypertrophies and of shorter versus longer nipple-areola complex transposition breasts for moving one-point discrimination.

CONCLUSIONS

This study confirms that macromastia patients present a reduced breast sensibility, which is not necessarily worsened by reduction mammaplasty. After reduction mammaplasty with the superolateral pedicle technique, nipple-areola complex sensibility might be slightly reduced, which is less detectable in large-breast hypertrophy because of lower preoperative levels of sensibility and less of a postoperative decrease.

Lumbar bone mineral density as the major factor determining increased prevalence of vertebral fractures in monoclonal gammopathy of undetermined significance

The possible relationships between biochemical measurements and both densitometric and radiographic indexes of skeletal fragility were evaluated in 65 postmenopausal women with monoclonal gammopathy of undetermined significance (MGUS). There was a significantly higher prevalence of vertebral fractures in the MGUS group compared with a control population (P < or = 0.001). The MGUS patients were then grouped according to the presence or absence of at least one mild vertebral fracture. Patients with fractures (Fx, n=34) were older (62.8 +/- 6.1 years), with long-standing disease (8.8 +/- 7.1 years) when compared with those without fractures (NFx, n=31; 59.7 +/- 5.0 years, P < or = 0.05 and 5.8 +/- 4.1 years, P < or = 0.05). The receptor activator of nuclear factor kappa-B ligand/osteoprotegerin ratio was higher in Fx compared with NFx (0.092 +/- 0.018 vs. 0.082 +/- 0.020; P < or = 0.05). Lumbar spine (0.811 +/- 0.14 vs. 0.956 +/- 0.12 g/cm2), femoral neck (0.660 +/- 0.09 vs. 0.747 +/- 0.10 g/cm2) and total bone mineral density (BMD) (0.788 +/- 0.11 vs. 0.884 +/- 0.11 g/cm2) were lower (all P < or = 0.001) in FxMGUS compared with Nfx patients. Receiver operating characteristic curves identified lumbar BMD as the variable that best predicted vertebral fractures (area under the curve 0.817; 95% confidence interval, 0.713-0.921). This study provides an indication for the measurement of BMD in MGUS patients, as a means of predicting vertebral fractures, especially in those that are asymptomatic. Patients with prevalent fractures should undergo pharmacological treatment to prevent further fractures.

Nerve growth factor and brain-derived neurotrophic factor levels in patients with rheumatoid arthritis treated with TNF-alpha blockers

Twenty consecutive rheumatoid arthritis (RA) patients (mean age 50.4 +/- 10.5 years; 17 females; mean disease duration 5.78 +/- 3.75 years) enrolled for tumor necrosis factor-alpha (TNF-alpha) blockers therapy (10 infliximab and 10 etanercept) were selected. Before starting therapy, 3 and 6 months thereafter all patients were evaluated for disease activity score (DAS), erythrocyte sedimentation rate (ESR), serum levels of C-reactive protein (CRP), interleukin-6 (IL-6), nerve growth factor (NGF), and brain-derived neurotrophic factor (BDNF). After 3 and 6 months a significant reduction in DAS, ESR, CRP, and IL-6 was observed, whereas no significant differences of NGF and BDNF serum levels were found. These preliminary results confirm that TNF-alpha blockers significantly improve disease activity and inflammation in RA; nevertheless further studies are needed to explain the mechanisms regulating NGF and BDNF release in RA patients treated with TNF-alpha blockers.

Cardiac calcifications: Fetuin-A and other risk factors in hemodialysis patients

Cardiac calcifications are a frequent finding in hemodialysis for chronic renal failure. Several factors may play a role in the intimal and medial calcification of coronary arteries such as age and some known atherogenetic factors. In addition, Fetuin-A has been proposed as a protective agent through solubilization of calcium phosphate salt. Fetuin-A is also a marker of inflammatory-nutritional state, and its changes could be an expression of this condition. The aim of this cross-sectional study is to evaluate the relative importance of risk factors of calcifications with special regard to Fetuin-A. The study was conducted with 132 hemodialysis patients. They were subjected to multislice computed tomography for evaluation of calcium deposits in the heart. In addition, the patients were sampled for evaluation of calcium-phosphate parameters, lipid profile, nutritional and inflammatory markers, and also Fetuin-A. There was a wide variability of the extent of calcium deposits expressed as Agatston score, with only 9.3% of patients without calcifications. Age, hemodialysis age, sex, calcium-phosphate parameters, and lipid profile were important risk factors, together with nutritional and inflammatory status of the patients. An inverse correlation between coronary calcium score and Fetuin-A emerged from a multiple regression analysis. However, there was no significant difference in serum Fetuin-A among different grades of calcium score. By dividing the patients in tertiles of serum Fetuin-A, an association between low levels of Fetuin-A and high calcification score was found. Fetuin-A as dependent variable was strictly linked to prealbumin serum levels. In addition, there was a clear link between cardiac calcification scores and inflammatory-nutritional markers. Serum calcium and treatment with calcitriol emerged as predictive variables of coronary score.Fetuin-A could be involved in the process of calcification both in the case of markedly low serum levels, due to decreased prevention of calcium phosphate precipitation, and also as a marker of inflammation, a well-known risk factor of atherogenesis. Treatment with intravenous calcitriol could marginally enhance cardiac calcifications, probably through its hypercalcemic effect.

Preconditioning effects of levosimendan in coronary artery bypass grafting—a pilot study

BACKGROUND

The calcium sensitizer levosimendan protects against myocardial ischaemia and reperfusion injury in animal models.

METHODS

The present pilot study investigated whether a short infusion before coronary artery bypass grafting (CABG) would protect the myocardium and improve postoperative haemodynamics. Twenty-four patients with stable angina undergoing elective CABG surgery were randomized to receive either placebo or levosimendan (24 microg kg(-1)) infused i.v. over a 10 min period just before placing the patient on cardiopulmonary bypass.

RESULTS

Perioperative haemodynamic variables, concentrations of cardiac troponin I over the 48 h postoperative period, and clinical outcomes were assessed. There were no adverse effects related to levosimendan. Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.05) and a higher cardiac index (P<0.05).

CONCLUSION

Patients receiving a short infusion of levosimendan before CABG showed evidence of less myocardial damage, suggestive of a preconditioning effect. Larger outcome studies are thus indicated to confirm benefit.

Colorectal polyps: detection with low-dose multi-detector row helical CT colonography versus two sequential colonoscopies

PURPOSE

To prospectively evaluate the diagnostic accuracy of low-radiation-dose computed tomographic (CT) colonography for detection of colorectal polyps by using two sequential colonoscopies, with the second colonoscopy as the reference standard.

MATERIALS AND METHODS

The study was local ethics committee approved, and all patients gave written informed consent. Colonographic images were acquired by using a low-dose multi-detector row CT protocol (effective milliampere-second setting, 10 mAs). Three observers interpreted the CT colonographic data separately and independently by using a two-dimensional technique. Initial conventional colonoscopy was performed by an endoscopist unaware of the CT colonographic findings. Second colonoscopy performed within 2 weeks by a colonoscopist aware of both the CT colonographic and the initial colonoscopic findings served as the reference standard. The sensitivities of CT colonography and initial colonoscopy were calculated on a per-polyp and a per-patient basis. Specificities and positive and negative predictive values also were calculated on a per-patient basis.

RESULTS

Eighty-eight patients underwent CT colonography and initial conventional colonoscopy on the same day. Per-polyp sensitivities were 62% and 83% for CT colonography and initial colonoscopy, respectively. Sensitivities for detection of polyps 6 mm in diameter or larger were 86% and 84% for CT colonography and initial colonoscopy, respectively. Initial colonoscopy failed to depict 16 polyps, six of which were correctly detected with CT colonography. For identification of patients with polyps 6 mm in diameter or larger, CT colonography and initial colonoscopy, respectively, had sensitivities of 84% and 90%, specificities of 82% and 100%, positive predictive values of 70% and 100%, and negative predictive values of 91% and 95%.

CONCLUSION

Low-dose CT colonography compares favorably with colonoscopy for detection of colorectal polyps 6 mm in diameter or larger, with markedly decreased performance for detection of polyps 5 mm in diameter or smaller.

Tenascin C and epidermal growth factor receptor as markers of circulating tumoral cells in bladder and colon cancer

Tenascin C has been recently suggested as a tumor marker, however, its levels in serum has been evaluated only in patients with head and neck cancer and melanoma. In this study, we investigated Tenascin C expression in blood samples from colorectal and bladder cancer patients, compared to that of epidermal growth factor receptor (EGFR), a known circulating tumor marker in these cancer types. RT-PCR specific for Tenascin C and EGFR was performed on RNAs extracted from blood samples of 60 patients affected by colon or bladder cancer. We then investigated the statistical association between Tenascin C, EGFR expression and disease-free survival using the Kaplan-Meier method. Furthermore, in order to select which variable between EGFR and Tenascin C was the most predictive for recurrence, a Cox model for proportional risk was applied. Among all patients analysed, a significantly higher disease-free time was found in the group negative for both EGFR and Tenascin C expression; EGFR expression was significantly correlated to disease progression in stages III and IV, whereas in all patients with stage I and II disease Tenascin C correlated better with prognosis. Negative expression of both EGFR and Tenascin C identifies a group of patients with poor tendency to disease recurrence and longer relapse-free time. While Tenascin C expression seems to influence prognosis in patients with low-stage disease, EGFR appears a marker of worse prognosis in patients with high-staged tumors.

25-hydroxyvitamin D levels and bone histomorphometry in hemodialysis renal osteodystrophy

BACKGROUND

The importance of 25-hydroxyvitamin D (25-OHD) serum levels in hemodialysis chronic renal failure has not been so far histologically evaluated. Information still lacking relate to the effect of 25-OHD deficiency on serum parathyroid hormone (PTH) levels and on bone and its relationship with calcitriol levels.

METHODS

This retrospective study has been performed on a cohort of 104 patients on hemodialysis from more than 12 months, subjected to transiliac bone biopsy for histologic, histomorphometric, and histodynamic evaluation. The patients, 61 males and 43 females, mean age 52.9 +/- 11.7 years, hemodialysis length 97.4 +/- 61.4 months, were treated with standard hemodialysis and did not receive any vitamin D supplementation. Treatment with calcitriol was not underway at the time of the biopsy. Transiliac bone biopsies were performed after double tetracycline labels. In addition, serum intact PTH (iPTH), alkaline phosphatase, and 25-OHD were measured. Calcitriol serum levels was also measured in a subset of patients (N= 53). The patients were divided according to serum 25-OHD levels in three groups: (1) 0 to 15 (15 patients), (2) 15 to 30 (38 patients), and (3) >30 ng/mL (51 patients).

RESULTS

There was no significant difference in average age, hemodialysis age, serum PTH [490 +/- 494, 670 +/- 627, and 489 +/- 436 pg/mL, respectively (mean +/- SD)], alkaline phosphatase, and calcitriol between the three groups. The parameters double-labeled surface, trabecular mineralizing surface, and bone formation rate were significantly lower in group 1 than in the other groups (P < 0.03, < 0.03, and < 0.02, respectively). Osteoblast surface and adjusted apposition rate were borderline significantly lower in group 1 (P < 0.06 and < 0.10). There was no statistical difference in the biochemical and bone parameters between groups 2 and 3. A positive significant correlation was found between several bone static and dynamic parameters and 25-OHD levels in the range 0 to 30 ng/mL, showing a vitamin D dependence of bone turnover at these serum levels. However, actual evidence of an effect on bone of 25-OHD deficiency was found at serum levels below 20 ng/mL. With increasing 25-OHD levels beyond 40 ng/mL, a downslope of parameters of bone turnover was also observed.

CONCLUSION

Since PTH serum levels are equally elevated in low and high 25-OHD patients, while calcitriol levels are constantly low, an effect of 25-OHD deficiency (group 1) on bone, consisting of a mineralization and bone formation defect, can be hypothesized. The effect of vitamin D deficiency or bone turnover is found below 20 ng/mL. The optimal level of 25-OHD appears to be in the order of 20 to 40 ng/mL. Levels of the D metabolite higher than 40 ng/mL are accompanied by a reduction of bone turnover.

Vitamin D status as the major factor determining the circulating levels of parathyroid hormone: a study in normal subjects

We investigated the relative contribution of the major factors regulating calcium homeostasis in determining the circulating levels of PTH. We studied 137 males and 125 females who were healthy volunteers. Circulating PTH levels were determined by three different immunoradiometric assays (IRMA). The first one (PTH Sorin, PTH S) utilizes two affinity-purified polyclonal antibodies directed against the 1-34 and 39-84 sequence of the hormone. The two other IRMA share polyclonal anti-PTH (39-84) antibodies. The first assay (PTH Whole, PTH W) utilizes a second polyclonal antibody, directed against the 1-4 amino acid sequence. The second assay (PTH Total, PTH T) utilizes a second antibody specific for the 7-34 region. Concentrations of PTH fragments lacking the initial amino acid sequence (PTH N-truncated, PTH N-t) were determined by the difference of values between PTH T and PTH W. Vitamin D was the main explicative variable almost in every multiple linear regression model, both considering the group as a whole (PTH S: R2 = 0.238, P < 0.0001; PTH W: R2 = 0.08, P < 0.001; PTH T: R2 = 0.145, P < 0.0001; PTH N-t: R2 = 0.081, P < 0.009) and when considering men and women separately. In subjects with vitamin D insufficiency (n = 53) [25(OH)D < 30 nmol/l], mean serum levels of parathyroid hormone were significantly higher (P < 0.001) than those in subjects of similar age with normal vitamin status (n = 209) with all the assays employed. This study demonstrates the central role of 25(OH)D in regulating PTH secretion in physiological conditions.

[Predictive variables of lymphatic metastasis in breast carcinoma with a diameter below 2 cm]

The axillary lymph node status of patients with newly diagnosed breast cancer remains the most important prognostic information available at the moment. However, only a minority of patients presents with such node metastases at diagnoses. We reviewed our database and studied 500 consecutive patients with early breast cancer, and found that age inferior to 50 years, high grade, diameter superior to 1 cm, elevated Ki-67, and expression of oncogene p-53 are all factors associated with lymph node metastases.