The efficacy of real versus sham external Trigeminal Nerve Stimulation (eTNS) in youth with Attention-Deficit/Hyperactivity Disorder (ADHD) over 4 weeks: a protocol for a multi-centre, double-blind, randomized, parallel-group, phase IIb study (ATTENS)

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD), if severe, is usually treated with stimulant or non-stimulant medication. However, users prefer non-drug treatments due to side effects. Alternative non-medication treatments have so far only shown modest effects. External trigeminal nerve stimulation (eTNS) is a minimal risk, non-invasive neuromodulation device, targeting the trigeminal system. It was approved for ADHD in 2019 by the USA Food and Drug administration (FDA) based on a small proof of concept randomised controlled trial (RCT) in 62 children with ADHD showing improvement of ADHD symptoms after 4 weeks of nightly real versus sham eTNS with minimal side effects. We present here the protocol of a larger confirmatory phase IIb study testing efficacy, longer-term persistency of effects and underlying mechanisms of action.

METHODS

A confirmatory, sham-controlled, double-blind, parallel-arm, multi-centre phase IIb RCT of 4 weeks of eTNS in 150 youth with ADHD, recruited in London, Portsmouth, and Southampton, UK. Youth with ADHD will be randomized to either real or sham eTNS, applied nightly for 4 weeks. Primary outcome is the change in the investigator-administered parent rated ADHD rating scale. Secondary outcomes are other clinical and cognitive measures, objective hyperactivity and pupillometry measures, side effects, and maintenance of effects over 6 months. The mechanisms of action will be tested in a subgroup of 56 participants using magnetic resonance imaging (MRI) before and after the 4-week treatment.

DISCUSSION

This multi-centre phase IIb RCT will confirm whether eTNS is effective in a larger age range of children and adolescents with ADHD, whether it improves cognition and other clinical measures, whether efficacy persists at 6 months and it will test underlying brain mechanisms. The results will establish whether eTNS is effective and safe as a novel non-pharmacological treatment for ADHD.

TRIAL REGISTRATION

ISRCTN82129325 on 02/08/2021, https://doi.org/10.1186/ISRCTN82129325 .

World addiction medicine reports: formation of the International Society of Addiction Medicine Global Expert Network (ISAM-GEN) and its global surveys

Addiction medicine is a dynamic field that encompasses clinical practice and research in the context of societal, economic, and cultural factors at the local, national, regional, and global levels. This field has evolved profoundly during the past decades in terms of scopes and activities with the contribution of addiction medicine scientists and professionals globally. The dynamic nature of drug addiction at the global level has resulted in a crucial need for developing an international collaborative network of addiction societies, treatment programs and experts to monitor emerging national, regional, and global concerns. This protocol paper presents methodological details of running longitudinal surveys at national, regional, and global levels through the Global Expert Network of the International Society of Addiction Medicine (ISAM-GEN). The initial formation of the network with a recruitment phase and a round of snowball sampling provided 354 experts from 78 countries across the globe. In addition, 43 national/regional addiction societies/associations are also included in the database. The surveys will be developed by global experts in addiction medicine on treatment services, service coverage, co-occurring disorders, treatment standards and barriers, emerging addictions and/or dynamic changes in treatment needs worldwide. Survey participants in categories of (1) addiction societies/associations, (2) addiction treatment programs, (3) addiction experts/clinicians and (4) related stakeholders will respond to these global longitudinal surveys. The results will be analyzed and cross-examined with available data and peer-reviewed for publication.

Clinical and cognitive effects of external trigeminal nerve stimulation (eTNS) in neurological and psychiatric disorders: a systematic review and meta-analysis

This pre-registered (CRD42022322038) systematic review and meta-analysis investigated clinical and cognitive outcomes of external trigeminal nerve stimulation (eTNS) in neurological and psychiatric disorders. PubMed, OVID, Web of Science, Chinese National Knowledge Infrastructure, Wanfang, and VIP database for Chinese technical periodicals were searched (until 16/03/2022) to identify trials investigating cognitive and clinical outcomes of eTNS in neurological or psychiatric disorders. The Cochrane Risk of Bias 2.0 tool assessed randomized controlled trials (RCTs), while the Risk of Bias of Non-Randomized Studies (ROBINS-I) assessed single-arm trials. Fifty-five peer-reviewed articles based on 48 (27 RCTs; 21 single-arm) trials were included, of which 12 trials were meta-analyzed (N participants = 1048; of which ~3% ADHD, ~3% Epilepsy, ~94% Migraine; age range: 10-49 years). The meta-analyses showed that migraine pain intensity (K trials = 4, N = 485; SMD = 1.03, 95% CI[0.84-1.23]) and quality of life (K = 2, N = 304; SMD = 1.88, 95% CI[1.22-2.53]) significantly improved with eTNS combined with anti-migraine medication. Dimensional measures of depression improved with eTNS across 3 different disorders (K = 3, N = 111; SMD = 0.45, 95% CI[0.01-0.88]). eTNS was well-tolerated, with a good adverse event profile across disorders. eTNS is potentially clinically relevant in other disorders, but well-blinded, adequately powered RCTs must replicate findings and support optimal dosage guidance.

The prospective association between the use of E-cigarettes and other psychoactive substances in young people: A systematic review and meta-analysis

The use of electronic cigarettes by young people has increased exponentially in the past decade due to various health and social influences. E-cigarettes, particularly those containing nicotine, can cause health complications and addiction, which may result in a subsequent initiation of psychoactive substance use. This systematic review and meta- analysis evaluated the prospective association between e-cigarette use and subsequent use of psychoactive substances in young people aged 10-24 years. Pooling of data from the identified longitudinal studies showed that ever e-cigarette users have an increased likelihood for subsequent cannabis, alcohol, and unprescribed Ritalin/Adderall use compared to never e-cigarette users. The findings indicate a need for interventions to reduce e-cigarette use in adolescents and young adults.

Early-onset smoking theory of compulsivity development: a neurocognitive model for the development of compulsive tobacco smoking

According to the literature, individuals who start tobacco smoking during adolescence are at greater risk of developing severe tobacco addiction and heavier smoking behavior in comparison with individuals who uptake tobacco smoking during subsequent developmental stages. As suggested by animal models, this may be related to the unique neuroadaptive and neurotoxic effects of nicotine on adolescents' fronto-striatal brain regions modulating cognitive control and impulsivity. Previous research has proposed that these neuroadaptive and neurotoxic effects may cause a heightened reward-oriented impulsive behavior that may foster smoking relapses during quit attempts. However, developments in the field of addiction neuroscience have proposed drug addiction to represent a type of compulsive behavior characterized by the persistent use of a particular drug despite evident adverse consequences. One brain region that has received increased attention in recent years and that has been proposed to play a central role in modulating such compulsive drug-seeking and using behavior is the insular cortex. Lesion studies have shown that structural damages in the insular cortex may disrupt smoking behavior, while neuroimaging studies reported lower gray matter volume in the anterior insular cortex of chronic smokers compared with non-smokers, in addition to correlations between gray matter volume in the anterior insular cortex and measures of compulsive cigarette smoking. Based on the findings of our recent study reporting on early-onset smokers (mean age at regular smoking initiation = 13.2 years) displaying lower gray matter and white matter volume in the anterior insular cortex compared to late-onset smokers (mean age at regular smoking initiation = 18.0 years), we propose that the anterior insular cortex may play a central role in mediating the association between smoking uptake during adolescence and smoking heaviness/tobacco addiction during adulthood.

Adolescent mobile phone addiction during the COVID-19 pandemic predicts subsequent suicide risk: a two-wave longitudinal study

Both the rate of mobile phone addiction and suicidality among adolescents have increased during the pandemic lockdown. However, the relationship between mobile phone addiction and suicide risk and the underlying psychological mechanisms remains unknown. This study examined the associations between mobile phone addiction in adolescents during the first month of lockdown and the suicide risk in the subsequent five months. A two-wave short-term longitudinal web-based survey was conducted on 1609 senior high school students (mean age = 16.53 years, SD = 0.97 years; 63.5% female). At Time 1 (T1), the severity of mobile phone addiction and basic demographic information was collected from Feb 24 to 28, 2020 in Sichuan Province, China (at the pandemic’s peak). Five months later, between July 11 and July 23 (Time 2, T2), mobile phone addiction, daytime sleepiness, depression, and suicidality were measured within the past five months. The regression analysis revealed that mobile phone addiction during quarantine directly predicted suicidality within the next five months, even after controlling for the effect of depression and daytime sleepiness. Meanwhile, mobile phone addiction at T1 also indirectly predicted suicidality at T2, with depression and daytime sleepiness mediating this association. Programs targeting improvement of daytime sleepiness and depressive symptoms may be particularly effective in reducing suicide risk among adolescents with mobile phone addiction.

Chronic tobacco smoking, impaired reward-based decision-making, and role of insular cortex: A comparison between early-onset smokers and late-onset smokers

INTRODUCTION

The literature suggests that tobacco smoking may have a neurotoxic effect on the developing adolescent brain. Particularly, it may impair the decision-making process of early-onset smokers (<16 years), by rendering them more prone to impulsive and risky choices toward rewards, and therefore more prone to smoking relapses, in comparison to late-onset smokers (≥16 years). However, no study has ever investigated reward-based decision-making and structural brain differences between early-onset smokers and late-onset smokers.

METHODS

Computerized measures of reward-based decision-making [Cambridge Gambling Task (CGT); 5-trials adjusting delay discounting task (ADT-5)] were administered to 11 early-onset smokers (mean age at regular smoking initiation = 13.2 years), 17 late-onset smokers (mean age at regular smoking initiation = 18.0 years), and 24 non-smoker controls. Voxel-based morphometry (VBM) was utilized to investigate the gray matter (GM) and white matter (WM) volume differences in fronto-cortical and striatal brain regions between early-onset smokers, late-onset smokers, and non-smokers.

RESULTS

Early-onset smokers displayed a riskier decision-making behavior in comparison to non-smokers as assessed by the CGT (p < 0.01, Cohen's f = 0.48). However, no significant differences (p > 0.05) in reward-based decision-making were detected between early-onset smokers and late-onset smokers. VBM results revealed early-onset smokers to present lower GM volume in the bilateral anterior insular cortex (AI) in comparison to late-onset smokers and lower WM volume in the right AI in comparison to late-onset smokers.

CONCLUSION

Impairments in reward-based decision-making may not be affected by tobacco smoking initiation during early adolescence. Instead, lower GM and WM volume in the AI of early-onset smokers may underline a vulnerability to develop compulsive tobacco seeking and smoking behavior during adulthood.

Relationship Between Cardiovascular Disease Pathology and Fatal Opioid and Other Sedative Overdose: A Post-Mortem Investigation and Pilot Study

Introduction: In 2019, Scotland reported the highest number of drug deaths amongst EU countries. Of the 1,264 drug deaths reported in 2019, 94% were related to polysedative use. Studies have proposed a relationship between opioid use and cardiovascular disease. Furthermore, the concomitant use of sedatives and opioids has been associated with lethal cardiopulmonary events. However, evidence is still limited for the relationship between polysedative use and cardiovascular diseases. Thus, the present study aimed to investigate the association between polysedative use and the underlying cardiovascular pathologies in drug deaths.

Methods: This study consisted of a post-mortem investigation of 436 drug deaths. Data extracted from post-mortem reports included socio-demographic characteristics (e.g., gender, age), cardiovascular pathologies (e.g., atherosclerosis, atheroma, and inflammation), in addition to the presence of opioids (e.g. methadone, heroin) and other substances (e.g., alcohol, benzodiazepine) in the blood of the deceased. Stepwise multiple regression models were employed to identify which substances predicted cardiovascular pathologies.

Results: The presence of opioids, benzodiazepines, and alcohol in the blood of the deceased predicted overall cardiovascular disease (CVD) severity [R2 = 0.33, F (5, 430) = 39.64, p < 0.0001; adjusted R2 = 0.32, f2 = 0.49]. Positive Beta coefficients may indicate an exacerbation of CVD (B = 0.48 95% CI = 0.25, 0.70) due to the presence of opioids in the blood of the deceased. Negative associations may instead indicate a relative protective effect of alcohol (B = −0.2, 95% CI = −0.41, −0.00) and benzodiazepines (B = −0.29, 95% CI = −0.48, −0.09) on CVD.

Conclusion: These findings may inform national clinical guidelines on the need to monitor individuals who abuse opioids for presence of cardiovascular disease risk factors pathologies and provide timely interventions to reduce mortality in the population.

Neuroanatomical Correlates of Impulsive Choices and Risky Decision Making in Young Chronic Tobacco Smokers: A Voxel-Based Morphometry Study

Introduction: Impairments in the multifaceted neuropsychological construct of cognitive impulsivity are a main feature of chronic tobacco smokers. According to the literature, these cognitive impairments are relevant for the initiation and maintenance of the smoking behavior. However, the neuroanatomical correlates of cognitive impulsivity in chronic smokers remain under-investigated. Methods: A sample of 28 chronic smokers (mean age = 28 years) not affected by polysubstance dependence and 24 matched non-smoker controls was recruited. Voxel Based Morphometry (VBM) was employed to assess Gray Matter (GM) volume differences between smokers and non-smokers. The relationships between GM volume and behavioral manifestations of impulsive choices (5 trial adjusting delay discounting task, ADT-5) and risky decision making (Cambridge Gambling Task, CGT) were also investigated. Results: VBM results revealed GM volume reductions in cortical and striatal brain regions of chronic smokers compared to non-smokers. Additionally, smokers showed heightened impulsive choices (p < 0.01, Cohen's f = 0.50) and a riskier decision- making process (p < 0.01, Cohen's f = 0.40) compared to non-smokers. GM volume reductions in the left Anterior Cingulate Cortex (ACC) correlated with impaired impulsive and risky choices, while GM volume reductions in the left Ventrolateral Prefrontal Cortex (VLPFC) and Caudate correlated with heightened impulsive choices. Reduced GM volume in the left VLPFC correlated with younger age at smoking initiation (mean = 16 years). Conclusion: Smokers displayed significant GM volume reductions and related cognitive impulsivity impairments compared to non-smoker individuals. Longitudinal studies would be required to assess whether these impairments underline neurocognitive endophenotypes or if they are a consequence of tobacco exposure on the adolescent brain.

Severity of negative mood and anxiety symptoms occurring during acute abstinence from tobacco: A systematic review and meta-analysis

This review was conducted with the following goals: To quantify the severity of mood and anxiety symptoms emerging during acute abstinence from tobacco (1). To explore sex differences related to the experience of specific symptoms (2). To investigate the early time course of symptoms (3). A meta-analysis was performed from 28 studies assessing mood and anxiety symptoms during the earliest phases of tobacco abstinence (up to 24 hrs post-quit) conducted from 1999 to 2019. Results revealed a significant (p < 0.0001) increase in 'anxiety', 'anger/irritability', 'depressed mood /sadness', and composite negative affect ('NA') in the 24 hours following smoking cessation. The largest effect size was detected for 'anxiety' (0.63). A qualitative analysis was performed to investigate sex differences and the time course of the specific symptoms. Results indicated that female smokers may experience worse mood symptoms compared to male smokers and that these symptoms may emerge within 3 hrs post-quit. Smoking cessation programs should implement sex-tailored interventions in order to improve their effectiveness, while future research should focus on alternative methods of nicotine administration.

Patient centred consultation, satisfaction and young patients: A cross-country analysis

OBJECTIVES

The aim of this study was to investigate the link between perceived dimensions of patient centred care and the satisfaction of adolescents and young adults within the UK, USA, Australian, Italian, and Chinese healthcare systems.

METHODS

One thousand and thirty-four participants (212 from China,206 from Australia,208 from UK, 202 from USA, and 206 from Italy) answered a self-report questionnaire assessing the perceived dimensions of patient centred care. Factor analysis (PFA) was conducted on the data to identify relevant dimensions. One-way ANOVAs were run to identify differences between country samples related to perceived dimensions of patient centredness, and a multi-level multiple regression model was computed to assess the link between satisfaction and dimensions of patient centred care.

RESULTS

Countries' mean scores on 'Satisfaction with Care' (PF1) and on 'Psychosocial Context' (PF2) were statistically significant by inspecting the ANOVAs (p < .05). Satisfaction with care was predicted by PF2 and clinical utilization.

CONCLUSION

An online survey collected meaningful data on perceptions of healthcare received by respondents from five countries. This initial international study highlights important associations worthy of closer investigation.

PRACTICE IMPLICATIONS

Healthcare providers should assess comprehensively the psychosocial context of young patients during consultations.

Bioethics and the Italian National Bioethics Committee: historical highlights

Though the term "bioethics" was coined in 1970-1, it was immediately after World War II that there emerged the idea that the voluntary consent of human beings was absolutely mandatory for medical interventions to be ethically acceptable. The 1964 Declaration of Helsinki asserted that only an explicit consent could morally and ethically justify research on human beings. In the 1978 "Encyclopedia of Bioethics", the US author Warren T. Reich defined bioethics as the systematic study of human behaviour in the fields of health care and life sciences, and carefully differentiated the epistemological profile of bioethics from that of traditional medical ethics deriving from the Hippocratic Oath. An institutional milestone in the Italian evolution of bioethical knowledge and competence was the foundation of the Italian National Bioethics Committee (NBC), established in 1990. The NBC, which answers to the Council of Ministers, provides methodological support to the Italian Government in the field of bioethical issues, elaborating legislative acts and also furnishing information and consultation for other bodies and associations and for the general public. The activity of the NBC is clearly discernible in its free and user-friendly website. Today, the Internet is often the first repository where individuals and patients look for bioethical information. Given that the quality of this information is extremely variable and not infrequently unreliable, initiatives such as that of the above mentioned NBC website are particularly useful and precious both for health care operators and the entire community.

[Medical terminology and lay users. A quali-quantitative survey of a group of young motivated graduates]

AIMS

Medical terms occupy growing spaces in dictionaries and the media daily propose a great number of medical words. Nevertheless scientific data regarding the actual degree of comprehension of medical terminology on the part of lay users are scanty. Aim of this study was the evaluation, in a group of young motivated graduates, of the degree of understanding of a set of medical terms normally adopted by physicians in specialistic language, and also used when speaking with patients.

PARTICIPANTS AND METHODS

Nine medical terms used by physicians in daily practice were selected (“aphasia”, “edema”, “erythema”, “fibrillation”, “fibroma”, “jaundice”, “paraplegia”, “polypus”, “sclerosis”) and they were administered in paper form to eighteen young graduates, non-health operators who were asked to furnish one definition for each of the terms. A subsequent structured oral discussion integrated the recorded written findings.

RESULTS

Erythema and fibrillation were the most well-known and understood terms. Among the selected medical terms, the more difficult ones to understand were sclerosis and jaundice. Interesting features emerged from the characterization of the site attributed to some of the investigated terms, in particular edema was mainly perceived as the pulmonary one, fibroma was more often interpreted as a benign tumor localized in the uterus and polypus was more frequently associated with its collocation in the nose.

CONCLUSIONS

The participants involved in this quali-quantitative survey demonstrated a general good knowledge and comprehension of the medical terms proposed. Some limits in knowledge documented in this group, however, indicate that the use of medical terminology needs more clarification within the doctor-patient context. Such clarification appears even more mandatory in subjects with low scholastic-education levels.

Protective effects of regular physical activity on human vascular system

Regular physical activity exerts a comprehensive beneficial effect on the human vascular system. The benefits provided by physical activity are both direct and indirect. Direct protective actions of aerobic exercise are identifiable on vascular structures and functions, since regular physical activity guarantees the integrity of the endothelial function, promotes the decrease of oxidative stress and prompts the development of new muscular capillaries. Moreover, moderate aerobic effort has positive effects on fibrinolysis, blood viscosity and vascular tone. Indirect benefits include the pleiotropic actions of physical activity on cardiovascular risk factors, in particular hypercholesterolemia, hypertension, diabetes mellitus and obesity. In a primary and secondary prevention perspective, moderate physical activity reduces in a significant way the risk of appearance of ischemic heart disease and the mortality of already established ischemic heart disease. In conclusion, health operators ought to remind their patients to "Stay physically active" in order to "Stay really fit and healthy".

[Swimming, physical activity and health: a historical perspective]

Swimming, which is the coordinated and harmonic movement of the human body inside a liquid medium by means of the combined action of the superior and inferior limbs, is a physical activity which is diffused throughout the whole world and it is practiced by healthy and non-healthy subjects. Swimming is one of the physical activities with less contraindications and, with limited exceptions, can be suggested to individuals of both sexes and of every age range, including the most advanced. Swimming requires energy both for the floating process and for the anterograde progression, with a different and variable osteo-arthro-muscular involvement according to the different styles. The energetic requirement is about four times that for running, with an overall efficiency inferior to 10%; the energetic cost of swimming in the female subject is approximately two thirds of that in the male subject. The moderate aerobic training typical of swimming is useful for diabetic and hypertensive individuals, for people with painful conditions of rachis, as also for obese and orthopaedic patients. Motor activity inside the water reduces the risk of muscular-tendinous lesions and, without loading the joints in excess, requires the harmonic activation of the whole human musculature. Swimming is an activity requiring multiple abilities, ranging from a sense of equilibrium to that of rhythm, from reaction speed to velocity, from joint mobility to resistance. The structured interest for swimming in the perspective of human health from the beginning of civilization, as described in this contribution, underlines the relevance attributed to this activity in the course of human history.

[The evolution of the Italian Code of Medical Deontology: a historical-epistemological perspective]

The Italian Code of Medical Deontology is a set of self-discipline rules prefixed by the medical profession, that are mandatory for the members of the medical registers, who must conform to these rules. The history of the Italian Code of Medical Deontology dates back to the beginning of the twentieth century. In 1903 it appeared in the form of a "Code of Ethics and Deontology" and was prepared by the Board of the Medical Register of Sassari (Sardinia). This Board inserted the principles inspiring the correct practice of the medical profession in an articulated and self-normative system, also foreseeing disciplinary measures. About ten years later, in 1912, the Medical Register of Turin (Piedmont) elaborated a Code which constituted the basis for a subsequent elaboration leading to a Unified Code of Medical Ethics (1924). After World War II the idea prevailed in Italy that the codes of medical deontology should undergo periodical review, updating and dissemination, and the new 1947 text (Turin) was for the first time amply diffused among Italian physicians. The next national code dates back to 1958, and twenty years later a revision was published. In the 1989 Code new topics appeared, including organ transplantation, artificial in vitro insemination and the role of police doctors; these and other issues were later developed in the 1995, 1998 and 2006 versions of the Code. The last available edition of the Italian Code of Medical Deontology is that of May 2014.

[Albrecht von Haller: an encyclopaedic cosmopolite in the history of Swiss medicine]

Albrecht von Haller was born in Bern on October 16, 1708 and studied medicine in Tubingen and Leiden. From the middles thirties on, and for seventeen years, he taught botany, anatomy and surgery at the University of Gottingen, where he founded the botanical garden, the institute of anatomy and the Royal Society of Science. His research included the study of Swiss flora, experimentation in human physiology and the investigation of vascular anatomy. One of his main scientific interests was how the human body functions, and he believed that it worked as an active organism characterized by its capacity for reaction to stimuli and impulses. In his work Icones anatomicae (1743-1756), von Haller minutely described the human arterial circulation. This scientist also investigated the properties of the nervous and muscular systems, in particular in terms of sensibility and irritability, and the development of embryos. Albrecht von Haller died in Bern on December 12, 1777.

[Special medical terminology in Italian and in French: the model for drug factsheets]

Drug factsheets (DF) provide an interesting model for the evaluation of medical-popular texts in Italian and other languages. In this research 50 DF in Italian and the 50 corresponding DF in French were studied, offering a reasoned analysis of the modalities of presentation of medical-scientific information in two neo-Latin languages and a systematic comparison of the technical features of use of Italian and French medical languages. Basic parameters identified for evaluation were the following: length of texts, length of sentences, clarity of information, hierarchy of information, readability of texts, modalities of involvement of the reader. These parameters were also examined through time, given that the DF evaluated covered the last three decades. The diachronic analysis and the comparative assessment proposed document the positive characteristics and limits of a diffused model of medical-popular communication.

Predictors of functional outcome in patients with chronic low back pain undergoing back school, individual physiotherapy or spinal manipulation

BACKGROUND

Recent studies on chronic low back pain (cLBP) rehabilitation suggest that predictors of treatment outcome may be differ according to the considered conservative treatment.

AIM

To identify predictors of response to back school (BS), individual physiotherapy (IP) or spinal manipulation (SM) for cLBP.

POPULATION

outpatients with cLBP.

SETTING

Outpatient rehabilitation department.

DESIGN

Retrospective analysis from a randomized trial.

METHODS

Two hundred and ten patients with cLBP were randomly assigned to either BS, IP or SM; the Roland Morris Disability Questionnaire (RM) was assessed before and after treatment: those who decreased their RM score <2.5 were considered non-responders. Baseline potential predictors of outcome included demographics, general and cLBP history, life satisfaction.

RESULTS

Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76-0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21-0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for BS and IP, but not for SM (same risk for all tertiles).

CONCLUSIONS

In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation.

CLINICAL REHABILITATION IMPACT

Our results suggest that, independent form other characteristics, patients with cLBP and low pain-related disability should first consider spinal manipulation as a conservative treatment.

[Medical English and legal English: similarities and differences between two specialist languages]

The comparative evaluation of specialist languages has a growing importance nowadays. The medical lexicon is characterized by a notable terminological richness both in Italian and in English, and the same is true for legal English, which has included, through time, a number of terms deriving from Latin and French. This scientific contribution highlights some features of medical-scientific English and legal English, pointing out certain similarities and the differences between the two. Furthermore, with reference to the differences, a selection of terms with the same orthographical form but with very different lexical meanings is here presented.

The heart: a symbol from ancient times to current biomedics

The heart is an essential and central organ in human beings. The heart is a muscular pump which contracts approximately a hundred thousand times a day for a life time, and in the last few decades it has been scientifically documented that it also produces hormones. The symbolic role of the heart has been established from time immemorial; more recently, and intriguingly, modern biomedical evidence has proved that historical knowledge and common language expressions referring to the heart are, in many cases, correct. In this perspective it is interesting to consider that already in the remote past the heart was "at the heart" of the attention of great western and eastern civilizations. From the brief panorama presented in this paper, connections between popular historical knowledge and current biomedical evidence emerge, proving the relevance of the symbolic role of the heart and of its perceived functions from pre-Christian to contemporary times, and documenting how the heart continues to remain strategically central, and epistemologically and linguistically crucial in the physical, psychological and social context of human life.

The birth and evolution of anaesthesia in the nineteenth century: historical and epistemological considerations

Nowadays, with regard to the outcome of mortality, anaesthesia is one of the safest medical procedures available. Its effectiveness has a current solid base of experimental and clinical evidence and numerous surgical interventions are performed daily with local or general anaesthesia. However, only just two hundred years ago the available ways of controlling pain, especially during surgery, were neither effective nor safe. The rise of a really effective anaesthesia may be traced to the eighteen hundreds, since in that period considerable progress was achieved with regard to anaesthetic interventions and procedures. In the early decades of the nineteenth century, the affirmation of anaesthetic techniques was slow and not immediate, but from the forties onwards the expansion and diffusion of efficacious anaesthesia was particularly swift. In the second half of the eighteen hundreds the introduction of multiple anaesthetic substances and the availability of enhanced apparatuses for gas administration led, both in Europe and in the USA, to the attribution of the full status of scientific branch of medicine to research and practice in anaesthesia. The birth and development of anaesthetic techniques and the evolution of anaesthesia as we know it today, provide, in the historical and epistemological fields, significant models for the complex and fruitful synergy of different sciences, medical sectors and specialties.

Nineteenth century "Traube's pulse" and current "Cardiac alternans": significant features in the history of cardiology

Pulsus alternans is nowadays considered, in the third millennium, a clinical finding indicative of decreased myocardial contractility and an effective expression of ventricular dysfunction. In recent years, clinical scientific studies have evidenced the relevant connections between cardiac alternans and the risk of heart arrhythmias. Pulsus alternans was described in detail for the first time in its meaning as clinical sign of cardiac disease by Ludwig Traube in 1872. Traube had great competence in physical semeiotics and, besides being considered one of the founders of experimental pathology, this German internist accurately presented a situation characterised by a succession of higher and lower pulses. It is not by chance that one of the current synonyms of pulsus alternans is precisely Traube's pulse. The present clinical-historical approach has been selected not only for diachronic purposes, but also to illustrate, on epistemological grounds, the notable articulation and considerable complexity of an only apparently straightforward concept such as that of pulsus alternans. Its comprehension has undergone progress and its definition evolution, and the expression has included through time different physiologic, pathophysiologic and pathologic phenomena. Although now a century and a half old, the concept of pulsus alternans remains extremely modern and fascinating.

The development of cardiac rehabilitation: a historical critical approach

Cardiac rehabilitation is an interdisciplinary and multidimensional process aimed at preventing and containing cardiovascular mortality, morbidity and disability, and promoting health in subjects with cardiocirculatory pathologies. A body of scientific evidence is today available with regard to the benefits of cardiac rehabilitation in terms of the containment of the progression of atherosclerosis, the increase in physical work ability, the reduction in symptomatology, the improvement in psychological well being and social re-adaptation, and the lowering in hospitalization rates and in recurrent clinical cardiac events. Cardiac rehabilitation derives its origin from the application of physical activity to the therapy of ischemic heart disease, and in this paper the historical evolution of the concept of angina pectoris and myocardial infarction as also the major progress in therapeutic exercise are discussed. Cardiac rehabilitation has become through time a multi-faceted process implemented in hospitals, in outpatient clinics and at home in a variety of models. However, recent data indicate that, in the USA, no more than 20% of eligible patients per year enter cardiac rehabilitation programs, and in Europe no more than 30% participate in them. The historical perception of cardiac rehabilitation provides knowledge of the fact that, through a long and articulated process, this health intervention has achieved relevant medical and social results and it also generates the awareness of the further advantages to be obtained in future cardiovascular patients.

Reconstructing medical history: historiographical features, approaches and challenges

Medical historiography deals with the concepts, theories, and approaches adopted in the reconstruction and discussion of the history of medicine. The expression has changed through time and according to different scholars and contexts, and it largely depends on the general standpoint from which the medicine of the past is examined. From an Evidence Based History of Medicine perspective, an accurate and complete examination of all available sources must be carried out to draw a picture of the medical theme examined, and, to reach this aim, the issue of the reliability of sources is a preliminary point to take into account. Different historiographical models adopted in the twentieth century will be discussed in this paper. The current ample discussion on the characterising features, methods and challenges of medical historiography documents the wide extent of the debate on the ways available today for the reconstruction of medical history. It also testifies to the relevance, inter-disciplinarity and remarkable vitality of the topic in current academic, scientific and social contexts. Medical and health history is an essential part of current medicine, and the study of the development of medicine through time is an extremely formative experience, which should not be confined to historians and professionals, but which, in appropriate formats and in correct methodological terms, should have full right of citizenship in current health care initiatives.

The concept of risk in medicine: historical and epistemological reflections

The concept of risk in medicine varies according to different health settings and different times. At present, risk is considered, in the cardiovascular area, the probability of developing a clinical event through time computed on the basis of the quantification of the presence and of the interaction of different diseases and/or risk factors. The definition of risk factors in the biomedical field is here documented through time to show how recent clinical-epidemiological elements have been achieved. In the twentieth century many epistemological and methodological objectives have been attained with regard to the theoretical idea of risk and to the practical tools useful to modify it, and the example of the management of diabetes is furnished as documentation of this progress. Nonetheless, correct risk evaluation continues to remain a formidable challenge in the health scenario.

The preventive and therapeutic impact of antiplatelet agents: past and present

Already more than two thousands years ago the Greek physician Hippocrates (V-IV century B.C.) used the extracts of the willow bark to fight fever. At the end of the eighteen hundreds the German chemist Felix Hoffmann obtained acetylsalicylic acid in stable and pure form, and from then on Aspirin (where A is the abbreviation of acetyl and Spir stands for Spirsaure, the German name of salicylic acid) has had enormous diffusion. In 1953 Lawrence Craven reported that he had successfully prescribed aspirin to hundreds of adult male patients for the non-specific prophylaxis of coronary thrombosis. Aspirin is now one of the most well-known drugs in the world, and in the last decades a large body of scientific evidence has appeared with regard to the preventive and therapeutic effects of aspirin and those of other antiplatelet agents. In fact, antiplatelet agents constitute a cornerstone in current pharmacological treatment and prophylaxis. Among the most interesting recent and beneficial areas of impact of aspirin and of other antiplatelet drugs, there are those of stroke and of coronary artery disease, and today targeted pharmacological and non-pharmacological interventions should be carefully combined to deal, preventively and therapeutically, with the cardiovascular epidemic.

Doctor-patient communication: a historical overview

Doctor-patient communication is an issue that is attracting more and more attention within the international scientific community, stimulating an interest involving many different health contexts, from academic to medico-legal ones. In the academic setting, the insertion of health communication courses into the curriculum has been a recent renovation, given that in the past such training was not considered a necessary formative step. In the medico-legal scenario, among the main causes of legal action is an incorrect, incomplete or non-existent transmission of information. Doctor-patient communication is therefore an extremely up-to-date topic, the problematic of which may already be discerned in Western medicine in the so-called Hippocratic Oath. In this paper the historical roots and the evolution through time of doctor-patient communication are discussed, together with the description of the predominant models of communication of the past (the physician-centred and the disease-centred approaches) and of the present (the patient-centred and the person-centred paradigms). Nowadays complete, correct and comprehensible communication is a primary exigency for the physician, for the patient/person and for all the organizational levels of the sanitary system. Every physician and, more in general, every health operator, must therefore learn to communicate effectively in the course of his/her medical training, and must continually refine this capacity during his/her professional career.

Environmental effects on school age child psychomotricity

AIM

This study had the following aims: to verify whether children living in different environmental areas present a different development degree of the functional prerequisites of psychomotricity; to test whether a targeted psychomotricity education program could favourably modify the potential differences which may be observed; to investigate the relationship, if any, between the anthropometric differences and the functional prerequisites of psychomotricity.

METHODS

One hundred and sixty-five Italian children, 83 males and 82 females, 6-7 years old were enrolled in this study. Based on the provenance area, the children were subdivided into two groups: the urban one (N=85) and the rural one (N=80). Both groups underwent an initial psychomotor assessment including standardised psychomotor tests aimed at evidencing the general dynamic coordination ability and the static and dynamic balance capacity of every child.

RESULTS

The findings of this research point out that children living in an urban setting selectively showed a lower degree of balance development, if compared to children living in rural areas; a targeted psychomotor education program favourably modified the differences in the balance development between the two examined groups, up to their disappearance. In the urban group the body mass index had a trend towards a negative relationship with balance development.

CONCLUSION

Children grown up in an urban environment showed a delay in balance development, if compared to children of the same age grown up in rural areas. This study also clearly proves that such a delay may be regained by means of a targeted psychomotor education program.

Relationship between physical activity and cardiovascular disease. Selected historical highlights

The full awareness that physical exercise represents a form of prevention and therapy for cardiovascular diseases is rather recent, considering that the discovery of blood circulation dates back to the 17th century and that the definition of major cardiovascular risk factors is an acquisition of the 20th century. In this paper a historical review has been undertaken so as to evidence major selected highlights of cardiovascular knowledge applied to physical activity from antiquity to the present day. Despite of the fact that the role of physical activity for the sake of a good body equilibrium is an ancient concept, as documented by the recurrent term ''exercise'' in the works of Hippocrates, only about 70 years have passed from the time when, in the '30s, myocardial infarction patients were strictly advised to observe a period of bed rest of at least 6 weeks; less than a century has passed since the so-called ''chair therapy'' constituted the cornerstone of the therapy of the cardiovascular patient. In the '40s and the '50s a certain amount of attentive mobilization proved to be beneficial, given that it was associated with a remarkable reduction of thromboembolic risk. In the '70s an increasing amount of clinical literature documented that even healthy subjects, remaining in bed for a long period, showed relatively rapidly signs of de-conditioning. In 1973 Kavanagh et al. demonstrated that the patients included in cardiac rehabilitation showed an improvement in their physical work capacity, an increase in their global cardiovascular function and went back more quickly and safely to their work environment, as compared with cardiac patients not performing rehabilitative physical exercise. The studies performed in the '70s provided the bases of modern cardiovascular rehabilitation, a multidimensional and integrated approach, one of whose pillars is structured physical activity.

The concept of normality through history: a didactic review of features related to philosophy, statistics and medicine

Normality characterises in medicine any possible qualitative or quantitative situation whose absence implies an illness or a state of abnormality. The illness concept was first a philosophical one. But the use of mathematics in the study of biological events, which began with Galton (1822-1911) and with Pearson (1857-1936), changed the frame of reference. In the second part of the 19th century mathematics was used to study the distribution of some biological characteristics in the evolution of the species. Around 1900, statistics became the basis for the study of the diffusion of the illnesses. Half a century later statistics made possible the transition from the description of single cases to groups of cases. Even more important is the concept of "normality" in laboratory medicine. In this field the search for the "perfect norm" was, and possibly still is, under way. The widespread use of statistics in the laboratory has allowed the definition, in a certain sense, of a new normality. This is the reason why the term "reference value" has been introduced. However, even the introduction of this new term has merely shifted the problem, and not resolved it.

The concept of "context" in health care: historical perspective and current views

The concept of "Context" presents various aspects ranging from the emotive to the cognitive, from the structural and organisational to the methodological, from the social to the educational, and therefore merits consideration. Furthermore, the influence of the health context on clinical outcomes has recently had a rebound of attention in biomedical literature, given that the ability of clinicians to modify their professional practice is considered to be strongly influenced by the organisational and managerial milieu of their work. In the past attention was largely focussed on the ability of the environment to modify the health status of individuals and so to cause, or con-cause, diseases. There was instead a relative lack of interest in the influence of the health context on health operators, and, more importantly, in its effect on the relationship between patients and health operators and, in turn, of this latter relationship on clinical outcomes. This interest has recently been investigated and research has provided preliminary evidence that physicians adopting a friendly and reassuring approach are more effective than those who keep visits and counselling at a formal level. An awareness that many features of the concept of context in health care have been relatively little studied should address future research to clarifying scientifically the global role of context in health. The promising findings of the studies available, such as those here illustrated, point to the fact that valid research would be both feasible and effective.

Past and present of ''what will please the lord'': an updated history of the concept of placebo

In ecclesiastic tradition the term ''Placebo'' indicated the promise to please the Lord in medieval prayer. The expression ''Placebo Domino'' (''I shall please the Lord'') constituted the beginning of a famous passage of a V century A.D. translation of the Bible. It was in the second half of the XVIII century that the word Placebo became an integral part of the medical-pharmacological vocabulary, and in fact Quincy's Lexicon (1787) defined it as a remedy used more to please than to heal people. For centuries placebos have been considered precious deceptive therapies and, until 1945, they were generally considered to be morally useful management tools. At the end of World War II it was clear that a critical evaluation of the function of placebos was needed to shed some light on their real role. Following this methodological call, in the years following different studies on placebos were proposed, and in 1955 HK Beecher published in the JAMA a paper, ''The Powerful Placebo'', in which he concluded that it was evident that placebos had a high degree of therapeutic effectiveness. Recent evidence points to the fact that, on the contrary, placebos do not have major clinical effects and that the limits of their application should be fully acknowledged.

The historical evolution of the concept of apoptosis in rheumatic diseases

Even if the idea of apoptosis may probably be detected for the first time in a Hippocratic treatise, it was Rudolph Virchow, the founder of cellular pathology in the XIX century, who gave the first structured description of the processes underlying the term. In the course of the XX century a body of systematic observations on cell death was elaborated in an organic way. In 1908 Mechnikov won the Nobel Prize for his studies on phagocytosis, while in the '30s and '40s many studies on metamorphosis were carried out, and Fell and Canti identified cell death in chondrocytes in culture. At the end of the '40s Saunders began to observe cell death in chick limbs, and Hamburger and Levi Montalcini began their exploration of nerve growth factors. In mid '50s research on lysosomes began, and in the '60s Kerr defined shrinkage necrosis. The term apoptosis was definitely introduced by Kerr in 1972 to indicate a particular form of death in which cells commit suicide by dissolving themselves into membrane-bounded apoptotic bodies. In the '80s ced-3 was described and at the beginning of the '90s apoptosis genes were identified. In more recent times new instruments have allowed a wide range of cellular deaths to be described, including apoptosis as currently defined. Extremely interesting are its role and function in many different diseases; in particular in rheumatic ones recent evidence indicates that, far from being simple, brief and monomorphic, apoptosis is a complex, long-lasting, and pleiomorphic process.

Obesity and nutritional behavior within a historical perspective

Obesity is an ever increasing pathological condition in Western countries. Genetic, metabolic, social and cultural factors play different roles in the varying pictures of obesity, together with nutritional behavior. This research proposes to formulate a comparison through the literary sources of the classical world, so as to determine the modalities with which obesity and nutritional habits have been perceived in the past. In Greek and Roman art, obesity often assumed the characteristics of caricature and of satire, confirmed by the elaboration of the stereotype of the sponger. Obesity generated irony and sarcasm; meanwhile the figure of the tyrant too was modelled on the physical type of the obesus, in whom the vice both of alimentary and sexual excess was concentrated. The evaluation of obesity, in the course of the time, has seen alternate phases, that propose different physical models and elaborate different aesthetical canons, but always closely related to a strong social factor as a distinctive sign: opulence. Nowadays obesity is seen, on the contrary, as an ever increasing nutritional disorder, both in prevalence and in incidence, and, to the ideal of the fat subject, very recent years have progressively substituted a different aesthetic typology, also because hyperalimentation has been qualified as a concomitant cause for a number of degenerative disorders.

The evaluation of the results of clinical trials: surrogate end points and composite end points

The evaluation of the clinical outcome of patients enrolled in randomised controlled studies should always be accurate and objective. The methods used to assess and report patients' results must consequently be indicated a priori in the design of the clinical experimentation. Major (hard) individual end points currently constitute the gold standard in the definition of outcome measures, yet surrogate and composite end points are spreading diffusely as alternative/complementary outcome measures. Surrogate end points are minor outcome measures that are easier to record and are being adopted instead of major end points. They may be considered acceptable substitutes of hard end points when capable of predicting major events reliably, and when it may be demonstrated that the intervention on such surrogate end points consistently modifies the incidence of the event. In other cases they cannot represent predictive elements of major clinical outcomes. Composite (combined) primary end points may contribute to improve the statistical precision of a clinical trial; moreover, since clinical trials are particularly expensive, their identification permits more limited samples of patients to be enrolled. Their limits include the possibility that the direction in which the different outcome measures composing the combined end point are modified is not the same. Biomedical researchers are called upon to design studies adopting major (hard) end points, rather than solitary surrogate end points, in order to provide really useful information for the care of patients. The selection of composite end points requires notable methodological attention so as to retrieve the most reliable estimates on the efficacy and the effectiveness of treatments.

Tuberculosis: a long fight against it and its current resurgence

Unlike the discovery of penicillin in 1928 by A. Fleming, largely due to fortuitous circumstances, the isolation of streptomycin by S.A. Waksman was the result of a systematic research project carried out by a number of workers. In 1952, Waksman received the Nobel Prize in Medicine for having produced the first useful drug against tuberculosis. Before the tubercle bacillus was recognised as the causative agent of the disease, various sanatoria had been set up, as the only remedy for sufferers of tuberculosis. Between 1880 and 1930 sanatoria spread across Europe and North America, and they were partially effective against the ever worsening diffusion of tuberculosis: therefore in the United Kingdom a government-funded agency, the Medical Research Council (MRC), was created in 1913. In 1947 streptomycin was put on the market, opening a new era in the history of modern medicine. Indeed, the first published report of the results of an (individually) randomised clinical trial was the 1948 paper by Bradford Hill and co-workers of the MRC's trial on the use of streptomycin. Streptomycin still represents a first-line agent in the recommended therapy of tuberculosis, whose burden is far higher in low-income countries. The current aim of any global intervention against tuberculosis should be the elimination of the pathology itself, an effort that will need both financial investments in scientific research and the targeted use of the fruits of that research to develop new, effective, preventive and therapeutic tools, such a tool as streptomycin proved to be more than fifty years ago.

ACE DD genotype: an independent predisposition factor to venous thromboembolism

BACKGROUND

The renin angiotensin system affects haemostasis through different mechanisms; data on the possible role of angiotensin-converting enzyme I/D polymorphism in the pathogenesis of deep venous thrombosis are conflicting, and no information is available regarding the A1166C polymorphism of the angiotensin type 1 receptor gene. In order to investigate this issue, angiotensin-converting enzyme and AT1R polymorphisms were genotyped in 336 consecutive venous thromboembolism patients and 378 controls.

MATERIALS AND METHODS

Haemostasis-related risk factors have been evaluated by routine tests. Factor V Leiden, Factor II (G20210A), angiotensin-converting enzyme (I/D), and angiotensin type 1 receptor (A1166C) polymorphisms have been identified by molecular analysis.

RESULTS

We documented a significant association between angiotensin-converting enzyme DD genotype and venous thromboembolism (OR=2.19 95%CI 1.51-3.17 adjusted for acquired and haemostasis-related risk factors, P<0.0001); in patients with haemostasis-related risk factors, angiotensin-converting enzyme DD genotype modified the risk of venous thromboembolism in hyperhomocysteinaemic and Factor V Leiden patients and was associated with the risk of recurrent venous thromboembolism (OR=1.83 95%CI 1.06-3.17 P=0.03). In patients without haemostasis-related risk factors the angiotensin-converting enzyme DD genotype was still an independent predictor of venous thromboembolism (OR=3.29 95%CI 2.17-4.98 adjusted for acquired risk factors, P<0.0001). No significant association between the angiotensin type 1 receptor CC genotype and venous thromboembolism was found.

CONCLUSIONS

This study shows that angiotensin-converting enzyme DD genotype represents a susceptibility marker of thrombosis in subjects apparently without predisposing factors and traditional thrombophilic alterations, and increases the risk of venous thromboembolism in subjects in whom a thrombogenic condition occurs. Moreover, angiotensin-converting enzyme DD genotype may be considered a new predisposing factor to venous thromboembolism recurrence.

[Appropriateness in the health system: past, present and future]

Nowadays, a health procedure or a clinical pathway are considered appropriate when they appear adequate with respect to scientific knowledge, consistent with the patient's values, safe as to risk management, and convenient with regard to the allocation of resources. This has not always been the case during the course of history, as the different clinical-methodological approaches to the same pathology in different Schools and Universities indicate, even in the same country. A hundred years ago, the difference of approaches could be explained by the limited circulation of ideas, usually based upon weak evidence, if not the personal impressions, of individual physicians. Today, on the contrary, evidence based medicine can represent a useful element in rendering homogeneous different types of behaviour in the same situation, and one of its characterising features is the elaboration of the concept of appropriateness. Appropriateness is a parameter internal to the evolution of health professions, requiring reasoned and shared employment. It originates from the need of health operators to explain why so many different kinds of behaviour exist in the context of the same clinical question. All the issues related to the concepts of clinical judgement and clinical decision-making derive from this and today more and more attention is being dedicated to the idea of appropriateness. The search for appropriateness is a progressive and cyclic process, that may always be improved. At present, strenuous team work is needed to avoid the features of the health system that are more clearly inappropriate, and that emerge from very simple analyses. Doing this is in the interest of the citizens, of health professionals and of the health economy as well.

Relationship between the calibre of carotid arteries and the configuration of the circle of Willis in healthy older persons

AIM

Recent papers have pointed out that the severity of brain damage that follows carotid occlusion is largely influenced by the state of integrity and functionality of the circle of Willis. In spite of this, duplex scanning investigation of carotid arteries has traditionally been focused on the assessment of the degree of the stenosis, while other features, such as the calibre of carotid arteries and their possible asymmetry, have often been neglected. The aim of the present paper was to verify, in a cohort of older persons, whether, based on the calibre of internal carotid arteries and their possible asymmetry, abnormalities of the circle of Willis can be predicted. Such information could be used to identify high risk patients in whom the status of the circle of Willis should be investigated by MR angiography.

METHODS

We studied 118 healthy older persons with both duplex scanning investigation of carotid arteries and MR angiography of the circle of Willis.

RESULTS

We found that the finding of abnormal internal carotid artery calibres was always associated with abnormalities of the precommunicating segments either of the anterior or of the posterior cerebral arteries. Abnormalities of communicating arteries did not affect the calibre of internal carotid arteries, but abnormalities of anterior communicating arteries could always be detected by contralateral common carotid artery compression manoeuvres.

CONCLUSION

In conclusion our findings show that, in healthy older persons, duplex scanning investigation of carotid arteries may provide useful information about the integrity and functionality of the circle of Willis. Future studies should confirm our findings in patients with atherosclerotic lesions of internal carotid arteries.

Collateral circulation in internal carotid artery occlusion. A study by duplex scan and magnetic resonance angiography

BACKGROUND

Clinical effects of internal carotid artery (ICA) occlusion may range from the absolute absence of symptoms to lethal hemispheric stroke. In this paper symptoms of patients with ICA occlusion have been related to the development of collateral circulation, different types of developed collateral circulation have been assessed, and the degree of sensitivity and specificity of duplex scan has been appraised.

METHODS

Forty-eight patients with ICA occlusion or subocclusion, 24 males and 24 females, aged between 50 and 83 years (67.7+/-7.15), underwent duplex scan and magnetic resonance (MR) angiography. Nineteen patients were completely asymptomatic, 20 patients showed permanent neurological symptoms and 9 patients had shown transient symptoms.

RESULTS

Twelve patients (25%) did not show any collateral circulation, 29 patients (60%) showed collateral circulation through homolateral external carotid artery branches and 7 patients (15%) showed collateral circulation through other circuits. Of the 20 patients with permanent symptoms only 8 showed collateral circulation. On the contrary, all the 19 asymptomatic patients and the 9 patients with transient symptoms showed collateral circulation. Eventually, duplex scan showed 78% sensitivity, 100%, specificity and 83% diagnostic accuracy.

CONCLUSIONS

Our data show: 1) a clear-cut prevalence of collateral circulation through homolateral external carotid artery branches with respect to other possible collateral circulation; 2) an inverse relationship between the development of collateral circulation and the appearance of permanent symptoms; 3) a good diagnostic accuracy of duplex scan in revealing collateral circulation in the case of ICA occlusion.

The circle of Willis in healthy older persons

BACKGROUND

The current indication for carotid surgery is based upon the percentage of stenosis of the internal carotid artery. This approach shows many limitations, one of which is to presume the anatomical completeness of the circle of Willis in all patients who are evaluated. On the contrary, there is increasing evidence of a great natural variability in the configuration of the circle of Willis.

METHODS

The aim of the present paper was to investigate, by magnetic resonance angiography, the variability of the circle of Willis in a cohort of 118 healthy older persons.

RESULTS

The circle of Willis showed an entirely complete configuration in 47% of the subjects, a complete configuration of its anterior part in 90% of the subjects, and a complete configuration of its posterior part in 48.5% of the subjects.

CONCLUSIONS

These findings confirm the great variability of the circle of Willis even in healthy older persons and suggest that, in indicating carotid surgery, the configuration of the circle of Willis should also be taken into account.

[Diabetic nephropathy. A historical, clinical and diagnostic framework]

Diabetic nephropathy is the major chronic complication of diabetes mellitus for mortality and morbidity. It is a condition of renal damage appearing in the course of diabetes mellitus, with a clinical expression characterized by urinary signs and arterial hypertension. This condition is functionally distinguished by a progressive decrease of the glomerular filtration rate, and in the Western world it is currently the major determinant of end stage renal disease. In the last twenty years the incidence of renal failure in the course of diabetes mellitus has grown continuously, particularly in type 2 diabetic patients. The majority of patients with diabetic nephropathy reach end-stage renal failure within ten years from the first evidence of proteinuria, and, in the United States, about 30% of the chronically dyalitic patients have diabetic nephropathy. The identification and the control of the renal disease over time are based on the measurement of proteinuria. Although the most useful and reliable dosage methods for proteinuria are still debated, it appears clear today that a spot measurement of albuminuria is not a reliable indication for the diagnosis of diabetic renal disease. The measurement of albuminuria as well as of creatinuria several times a year in the diabetic subject is therefore recommended, considering also that the test needs repetition both when positive and negative. Despite of the relevant results achieved in the last few years by clinical research both in the diagnostic and in the therapeutic fields, the role of prophylactic measures still remains essential in diabetics at higher risk of nephropathy.

Is the percentage of stenosis of the internal carotid artery a reliable measure of the risk of ischemic stroke? A morphometric study by duplex ultrasound of aortic arch branches in 500 normal adults

BACKGROUND

The percentage of stenosis has been considered for the last 20 years, and still continues to be, the main criterion of choice between a surgical and a medical treatment of the atherosclerotic lesions of the aortic arch branches, particularly as regards the internal carotid artery. On the other side, it has been demonstrated that the risk of adverse acute cerebrovascular events, besides being related to the characteristics of the plaque, such as softness, subintimal haemorrhage or surface ulcer, is strictly related to the actual residual lumen of the internal carotid artery. The pre-eminent role of the percentage of stenosis in the choice of the treatment, hence, presumes a narrow range of variation of the original calibre of the vessel, yet to be proven.

METHODS

Five-hundred normal adults underwent the measurement of the internal calibre of the aortic arch branches by duplex ultrasound in order to find out their actual range of variation.

RESULTS

The range of variation of the internal calibre of the aortic arch branches, expressed as the ratio between the maximum and the minimum value found for each vessel, was very wide in all cases (from 180% for the right common carotid artery to 340% for the right vertebral artery). With reference to the internal carotid arteries, the range of variation was 219% for the right internal carotid artery and 241% for the left internal carotid arteries.

CONCLUSIONS

Due to the wide range of variation of the original calibre of the aortic arch branches, the percentage of stenosis alone cannot be considered an accurate measure of the severity of the stenosis, and hence a reliable criterion of choice of the treatment.