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The red palm weevil Rhynchophorus ferrugineus is an invasive pest from southeastern Asia and Melanesia that has spread widely across the Middle East and the Mediterranean Basin over the last 30 years. Its endophagous larvae cause huge amounts of damage to several palm tree species from the Arecaceae family. Many of these palms are economically important for agricultural and ornamental purposes. Therefore, a lot of attention has recently been focused on studying this species with the aim of identifying sustainable and effective eradication strategies. Sterile insect techniques are biological control strategies that are currently being investigated for their potential to eradicate this pest in selected invasion areas. Mating system features (e.g., polyandry and related features) can affect the success and suitability of these approaches. The main goal of this research was to assess the performance of a previously developed microsatellite panel in terms of the paternity assignment of progeny from laboratory mating experiments. Using a simulation approach, we evaluated the reliability of the microsatellite markers in the paternity tests both in complex laboratory experiment scenarios and on the progeny of wild-caught gravid females to help future studies on the RPW mating system. As a case study of the simulation results, we performed two double-mating experiments, genotyped the progeny and estimated the P 2 values to compare to the expected progeny genotypes according to the crossing scheme of each experiment. The results of our simulations on laboratory experiments showed that it was possible to carry out paternity assignments for all progeny with reliable statistical confidence using our 13 microsatellites set. On the contrary the low genetic variability measured in red palm weevil populations in invaded areas made the resolution power of our loci too low to carry out paternity analyses on natural populations. Results of laboratory crossing were completely congruent with the expectations from the Mendelian laws.

The treatment of municipal wastewater produces clean water and sewage sludge (MSS), the management of which has become a serious problem in Europe. The typical destination of MSS is to spread it on land, but the presence of heavy metals and pollutants raises environmental and health concerns. Bioconversion mediated by larvae of black soldier fly (BSFL) Hermetia illucens (Diptera, Stratiomyidae: Hermetiinae) may be a strategy for managing MSS. The process adds value by generating larvae which contain proteins and lipids that are suitable for feed and/or for industrial or energy applications, and a residue as soil conditioner. MSS from the treatment plant of Ladispoli (Rome province) was mixed with an artificial fly diet at 50% and 75% (fresh weight basis) to feed BSFL. Larval performance, substrate reduction, and the concentrations of 12 metals in the initial and residual substrates and in larval bodies at the end of the experiments were assessed. Larval survival (> 96%) was not affected. Larval weight, larval development, larval protein and lipid content, and waste reduction increased in proportion the increase of the co-substrate (fly diet). The concentration of most of the 12 elements in the residue was reduced and, in the cases of Cu and Zn, the quantities dropped under the Italian national maximum permissible content for fertilizers. The content of metals in mature larvae did not exceed the maximum allowed concentration in raw material for feed for the European Directive. This study contributes to highlight the potential of BSF for MSS recovery and its valorization. The proportion of fly diet in the mixture influenced the process, and the one with the highest co-substrate percentage performed best. Future research using other wastes or by-products as co-substrate of MSS should be explored to determine their suitability., (© 2022. The Author(s).)

Background: Acute pancreatitis (AP) caused by gallstones has an increased rate of incidence in young women in the 2 years postpartum. Middle-aged women with longer periods of breastfeeding have less hospitalization for gallbladder disease., Aim: To investigate whether breastfeeding or other variables may be associated with AP., Methods: We conducted a population-based case-control study among all Sicilian women of childbearing age, and we identified all women who delivered (2013-2016) and had AP within 2 years postpartum. We reviewed their medical records, and for each case we matched four women of the same age (± 5 years), without AP. Univariate and multivariate logistic regression was used to estimate the odds ratios (OR) with their confidence intervals (CI) to assess associations between AP and clinical determinants., Results: In the 74 women with AP and 298 controls at univariate analysis, > 6 months oral contraception history (p < 0.01; OR 3.30; 95% CI 1.33-8.16), previous biliary disease (p < 0.001; OR 5.90; 95% CI 1.98-17.57) and smoking (p = 0.035; OR 2.04; 95% CI 1.04-4.0) were predictors of AP; amenorrhea ≥ 3 months (p < 0.001; OR 0.34; 95% CI 0.19-0.59) and breastfeeding ≥ 3 months (p < 0.001; OR 0.07; 95% CI 0.03-0.14) were protective. At multivariate analysis, previous biliary disease (p = 0.011; OR 5.49; 95% CI 1.48-20.38) and breastfeeding ≥ 3 months (p < 0.001; OR 0.06; CI 95% 0.03-0.14) were associated with AP., Conclusions: Women who breastfeed for at least 3 months and do not have a history of biliary disorders have reduced risk of developing AP in the 2 years after delivery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To compare in a randomised, open-label, non-inferiority clinical study, the efficacy and tolerability of Serenoa repens (SeR) + selenium (Se) + lycopene (Ly) (SeR-Se-Ly) therapy vs tadalafil 5 mg in men with lower urinary tract symptoms (LUTS)., Patients and Methods: From May 2015 to January 2017, 427 patients were enrolled in 21 different centres (International Standard Randomised Controlled Trial Number Register [ISRCTN] 73316039). Inclusion criteria included: age between 50 and 80 years, International Prostate Symptom Score (IPSS) ≥12, maximum urinary flow rate (Q max ) ≤ 15 mL/s, and post-void residual (PVR) <100 mL. Patients were randomised into two groups in a 2:1 ratio: Group A (SeR-Se-Ly, 1 tablet daily for 6 months) and Group B (tadalafil 5 mg, 1 tablet daily for 6 months). The primary endpoint of the study was the non-inferior variation in the IPSS and Q max in Group A vs Group B after 6 months of treatment., Results: In all, 404 patients completed the full protocol. When comparing both therapies, Group A was statistically not inferior to Group B considering the median change in IPSS (-3.0 vs -3.0; P < 0.01), IPSS quality of life (-2.0 vs -2.0; P < 0.05), and Q max (2.0 vs 2.0 mL/s; P < 0.01). We found statistically significant differences in the increase of at least 3 points in Q max (38.2% vs 28.1%; P = 0.04) and of at least 30% of Q max (39.2% vs 27.3%; P < 0.01) in Group A compared to Group B. The percentage of patients with an increase of at least 3 points in the IPSS and a decrease of at least 25% of the IPSS was not statistically different between the two groups. For adverse events, four patients in Group A (1.44%) and 10 in Group B (7.81%) (P < 0.05) reported side-effects., Conclusion: We have shown that treatment with SeR-Se-Ly was not inferior to tadalafil 5 mg for improving IPSS and Q max in men with LUTS., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

The Red Palm Weevil (RPW) Rhynchophorus ferrugineus (Olivier 1790) is an invasive pest from southeastern Asia and Melanesia that in the last 30 years has spread widely in the Middle East and Mediterranean Basin. Its stem-boring larvae cause great damage to several palm species of the Arecaceae family, many of which are economically important for agricultural and ornamental purposes. Therefore, great attention has recently been focused in studying this species to identify sustainable and effective eradication strategies, such as sterile insect technique (SIT). The rapid spread of RPW is associated with its high reproductive success. To evaluate the suitability of a SIT strategy, particular physiological and behavioral aspects of RPW reproduction, such as the presence of polyandry and post-copulatory sperm selection mechanisms, were investigated. To determine paternity of progeny from multiply mated females, double-crossing experiments were carried out confining individual females with either a wild-type male or a γ-irradiated male (Co-60). Fecundity and fertility of females were scored to evaluate post-copulatory sperm selection. Results showed that progeny were almost exclusively produced by the sperm of the second male, suggesting that a last-male sperm precedence is expressed at high levels in this species, and providing interesting insights for an area-wide RPW management strategy such as the SIT.

Background: Many potential chemopreventive agents have been used in PCa prevention, including selenium (Se) and lycopene (Ly). However, their role has been matter of debate over the years, due to potential of promotion of PCa., Purpose: In this study we aimed at evaluating the incidence risk of prostate cancer (PCa) in a cohort of patients treated with Se and Ly., Methods: The Procomb trial design has been previously published (ISRCTN78639965). From April 2012 to April 2014 209 patients were followed and underwent prostate biopsy when PSA ≥4 ng/ml and/or suspicion of PCa. The all cohort was composed by patients treated with Se and Ly (Group A = 134 patients) and control (Group B = 75 patients)., Results: During the follow-up time of 2 years, a total of 24 patients (11.5%) underwent prostate biopsy, of which 9 (4.3%) where diagnosed with PCa and 15 (7.2%) where diagnosed with benign prostatic hyperplasia. We did not observe statistical differences in terms of mean changes of PSA between the two groups (p-value for trend = 0.33). The relative risk (RR) for PCa was 1.07 and 0.89 in group A and B, respectively (p = 0.95). At the multivariate Cox regression analysis supplementation with Se and Ly was not associated with greater risk of PCa (hazard ratio: 1.38; p = 0.67)., Conclusion: In this analysis we did not show evidences supporting a detrimental role of Selenium and Lycopene supplementation in increasing PCa after 2 years of therapy, nor supporting a protective role., (Copyright © 2017. Published by Elsevier GmbH.)

Background: Phytotherapy has been used to treat patients with lower urinary tract symptoms (LUTS). We evaluated the efficacy and tolerability of combination therapy between Serenoa Repens (SeR), Lycopene (Ly), and Selenium (Se) + tamsulosin versus single therapies., Methods: PROCOMB trial (ISRCTN78639965) was a randomized double-blinded, double-dummy multicenter study of 225 patients between 55 and 80 years old, PSA ≤ 4 ng/ml, IPSS ≥12, prostate volume ≤60 cc, Qmax ≤15 ml/sec, postvoid residual urine (PVR) <150 ml. Participants were randomized group A (SeR-Se-Ly), group B (tamsulosin 0.4 mg), group C (SeR-Se-Ly + tamsulosin 0.4 mg). The primary endpoints of the study were the reduction of IPSS, PVR, and increase of Qmax in group C versus monotherapy groups., Results: The decrease for combination therapy was significantly greater versus group A (P < 0.05) and group B (P < 0.01) for IPSS and versus group A (P < 0.01) for PVR from baseline to 6 months. A greater decrease in IPSS was observed for Group C versus group A (P < 0.01) and increase in Qmax versus group B (P < 0.01), from 6 months to 12 months. At one year, the changes of IPSS and Qmax were greater for Group C versus monotherapies (each comparison <0.05). The proportions of men with a decrease of at least three points (each comparison P < 0.05) and decrease of 25% for IPSS (each comparison P < 0.01) were greater for Group C., Conclusion: SeR-Se-Ly + tamsulosin therapy is more effective than single therapies in improving IPSS and increasing Qmax in patients with LUTS., (© 2014 Wiley Periodicals, Inc.)

In the present study we describe the morphology of the male reproductive apparatus and sperm ultrastructure of the red palm weevil - an invasive pest of several palm tree species - as well as the most important steps of spermatogenesis. The reproductive apparatus consists of a pair of testes (each formed by two lobes) a long tube-like accessory gland, a prostate gland and a small accessory gland. Characteristic features of the sperm are 90-100 μm total length, 10 μm nucleus, two mitochondrial derivatives, two accessory bodies, one well-developed puff-like structure and a typical insect 9+9+2 flagellar axoneme. One of the methods used for the biological control of pests is the Sterile Insect Technique (SIT), for the evaluation of which we make a preliminary comparison of the sperm ultrastructure of non-irradiated and irradiated weevils (at a dose of 80 Gray)., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Several epidemiological studies showed that gestational diabetes mellitus is the most frequent metabolic disorder of pregnancy, the pathogenesis of which has yet to be completely clarified. The aim of this study was to investigate the presence and processing of caspase 3 (Casp3) and poly(ADP-ribose) polymerase 1 (PARP1) in cord blood lymphocytes as markers of apoptosis in relation to glycaemic control during intrauterine life. Our results showed a specific positive correlation between the levels of active Casp3 (17-19 kDa) and the inactive form of PARP1 (89 kDa) in lymphocytes isolated from newborn babies of diabetic women with unbalanced glycaemic control, with a direct correlation between the activation of casp3 and the inactivation of PARP1, that makes lymphocytes unresponsive towards lipopolysaccharide stimulation, highlighting an altered functional response. Besides more studies are required to fully correlate the activation of the apoptotic process during the intrauterine life with the foetal health later in life, our study indicates that a cord blood lymphocyte, an easily accessible source, is informative about the activation of apoptotic stimuli in circulating cells of newborn babies in relation to the glycaemic control reached by the mother during pregnancy., (Copyright © 2013 John Wiley & Sons, Ltd.)

Maternal diabetes has assumed epidemic relevance in recent years and animal studies have provided some evidence that it may cause abnormalities in renal development and a reduction in nephron endowment in the offspring; however, human data are lacking. The renal cortex contains ∼95% of the glomeruli and its volume could be taken as a surrogate measure of glomerular number; based on this assumption, we measured renal cortex volume and in addition, microalbuminuria in a homogeneous sample of 42 children of diabetic (pregestational, n = 13, and gestational, n = 29) mothers, compared with 21 healthy children born of non-diabetic mothers. The offspring of diabetic mothers showed a significant reduction of renal cortex volume and higher albumin excretion compared with controls, possibly attributable to a reduction in the number of nephrons and the difference was statistically significant (P < 0.001). Although further studies on a larger sample are necessary, our preliminary findings suggest that maternal diabetes may affect renal development with sequelae later in life, requiring closer monitoring and follow-up. Furthermore, the importance of strict maternal diabetes management and control must be emphasized.

Abnormal liver function is occasionally observed in patients affected by anorexia nervosa. Although numerous studies report a strong relation between malnutrition and liver damage, the pathogenesis remains still unclear. We describe a case of a young girl with severe anorexia nervosa who developed acute liver damage with multiorgan involvement during extremely poor nutritional status. In this patient severe malnutrition constituted a predisposing factor for multiorgan dysfunction. In the absence of other identifiable factors, we hypothesized that a marked increase in liver enzymes and other biochemical abnormalities could be a consequence of a precipitating cause as acute hypoperfusion, suggested by clinical symptoms (marked dehydration, hypotension, bradycardia, hypothermia) and laboratory data. Rapid normalization of liver function tests and other biochemical parameters with rehydration and gradual nutritional support confirmed this hypothesis.

No data exist about the possibility that vertebral fracture in PMR patients could be independent of steroid therapy. For this reason, we aimed to investigate this topic by a case cohort study with a 1-year follow-up for each patient. We selected ten consecutive patients who experienced vertebral fractures (VF-group) during the first month of 1-year follow-up period and without any other significant associated condition. As a control group we studied ten control patients, without vertebral fractures and with a follow-up of 1 year, randomly selected among a larger group of patients affected by polymyalgia rheumatica. The following data were analysed: eritrosedimention rate (ESR), visual analogical scale score (VAS), methyprednisolone daily dosage. Each patient had been monthly evaluated by the aforementioned clinical and laboratoristic parameters during the 1-year follow-up period. The VF-group resulted with a higher and statistically significant median corticosteroid 12-month total dosage [mean 3,480 mg (95%CI 2,805-3,030) vs. 2,760 mg (2,666.25-3,247.5)]. The VF-group had statistically significant higher ESR and VAS AUC when compared to control group (median ESR AUC, 484.75 vs. 288.25; P = 0.0001; median VAS AUC, 70.75 vs. 43.5 P < 0.0001); ESR at the baseline (cut-off >80 mm) showed a specificity of 90% (95%CI 56-100) and sensitivity of 70% (95%CI 35-93). VAS difference from first to second month (cut-off

The sharing of information and the growth of knowledge together represent a foundation for the promotion of quality improvement of health care systems. This paper concerns knowledge, not only from an epistemological point of view, but also from a pragmatic one. In our paper, knowledge is discussed as the hub to promote better decision making and continuous professional development. Effective thinking is particularly needed. The critical point is to think about how health care systems can develop both an effective knowledge management network and how health-care organizations can actually be based on it. In this way, knowledge and knowledge hierarchy are defined according to Russel Achkoff's vision. Generally, knowledge is crucial in decision-making, and Evidence-Based Medicine has its roots in knowledge. In particular, information management is the basis for a significant production of knowledge to promote good health-care decision-making. Thus, relationships between knowledge management and Evidence-Based Medicine are discussed, and a new paradigm is proposed: the Evidence-Based Knowledge Management. Finally, the role of Evidence-Based Knowledge Management within Clinical Governance is discussed together with some considerations about clinical governance implementation problems in Italy.

This is a preliminary report on a case-series of rheumatoid patients that underwent various kinds of elective surgery but did not withdraw etanercept therapy in spite of physician advise. Elective surgery consisted of right knee surgical prosthesis, bilateral cataract, bilateral hallux valgus, right hip prosthesis, bladder stone by cystoscopy and left inguinal hernia. All the patients had a regular healing rate. During follow-up (6-12 months) no one of these patients were suffering from infective complications after surgery. According to same recent literature results, our data suggest that it is the time to value rheumatoid patient preferences through a correct information about cost-benefit of this treatment to establish together with patients if etanercept therapy has to be discontinued before and after elective surgery. Finally, we think that adverse drug reaction surveillance has to be boosted, and editors of leading scientific journal should publish more papers on case-series about drug safety and tolerability in particular conditions.

The authors evaluated the retrieval power of PubMed "Clinical Queries," narrow search string, about therapy in comparison with a modified search string to avoid possible retrieval bias. PubMed search strategy was compared to a slightly modified string that included the Britannic English term "randomised." The authors tested the two strings joined onto each of four terms concerning topics of broad interest: hypertension, hepatitis, diabetes, and heart failure. In particular, precision was computed for not-indexed citations. The added word "randomised" improved total citation retrieval in any case. Total retrieval gain for not-indexed citations ranged from 11.1% to 21.4%. A significant number of Randomized Controlled Trial(s) (RCT)s (9.1-18.2%) was retrieved for each of the selected topics. They were often recently published RCTs. The authors think that correction of the Clinical Queries filter (when they focus on therapy and use narrow searches) is necessary to avoid biased search results with loss of relevant and up-to-date scientifically sound information.

In clinical practice, the clinician is challenged with symptoms and/or signs at times apparently insoluble by diagnostic and/or therapeutic means. We propose that in these cases, we have to use an EBM approach in which evidence may be looked up in every available clinical report and bibliographic databases are used for searching that evidence. We report on a case of ulcerative skin lesions apparently insoluble by expert dermatologists following a conventional diagnostic and therapeutic process. We use this case report for illustrating a systematic approach to resolve diagnostic and therapeutic questions using a bibliographic database search (like MEDLINE and EMBASE). Both a systematic approach to bibliographic databases and a critically appraised topic on case reports (or case series) are needed to 'rehabilitate' low-level evidences (that is a case report or case series) to a higher level when we approach decision-making of uncommon clinical pictures. We demonstrate the possibility of using bibliographic databases to search and retrieve useful information for decision-making of uncommon clinical pictures. The method we have proposed can be applied in every area of the world, especially in rural areas. Finally, an Internet-shared database of uncommon clinical pictures with critically appraised topics could be useful in saving more time.

Medical ethics is the science of survival. It studies the working out of judgments on right or wrong referred to the human being as a biological entity interacting with the whole ecosystem. Medical ethics in clinical research raises numerous moral and technical issues. Methodological aspects are essential for carrying out the aim of clinical research. Medical ethics documents are inspired by the Nuremberg Code and culminate in the recently updated Helsinki Declaration of 1964. In Italy 2 ministerial decrees in 1997 and 1998 laid the basis for the work of a medical ethics committee. They acknowledge the European Good Clinical Practice Guidelines and set professional needs within ethical committees. In clinical research the use of ionising radiation merits special consideration. In the recent past, serious human rights abuses in radiation experiments of the 1950s and 1960s have been found. As regards research in this field we can refer to the publication of the International Commission on Radiological Protection (ICRP) and to the report of the World Health Organisation (WHO). Legislative decree no. 187 of May 26, 2000, which transposed the 97/43/ EURATOM Directive represents the most comprehensive and recent normative reference to clinical research using ionising radiation. However, law no. 39 of March 1, 2002 is important for the partial modifications of previous decrees (art. 108 of L.D. no. 230 of March 17, 1995 and, art. 4 and attachment III of L.D. no. 187 of May 26). In this paper medical ethics, research, methodological issues and aspects of ionizing radiation are discussed.

Relevance of latent infection in the epidemiology of tuberculosis (TB) is expected to increase in many developed countries. Indeed, many demographic, social and public health changes could contribute to the expansion of groups or communities at significantly higher risk than the general population for infection to Mycobacterium tuberculosis or progression from latent to active disease. Tuberculin skin testing (TB), the gold standard for diagnosis of M. tuberculosis infection, is imperfect and prone to false positive and negative results, unless strictly targeted and carefully standardized for reliable performance and interpretation. This paper proposes a pre-test risk assessment questionnaire and standardized criteria for evaluation of TB test according to international guidelines.

The internet is a communication medium and content distributor that provide information in the general sense but it could be of great utility regarding as the search and retrieval of biomedical information. Search engines represent a great deal to rapidly find information on the net. However, we do not know whether general search engines and meta-search ones are reliable in order to find useful and validated biomedical information. The aim of our study was to verify the reproducibility of a search by key-words (pediatric or evidence) using 9 international search engines and 1 meta-search engine at the baseline and after a one year period. We analysed the first 20 citations as output of each searching. We evaluated the formal quality of Web-sites and their domain extensions. Moreover, we compared the output of each search at the start of this study and after a one year period and we considered as a criterion of reliability the number of Web-sites cited again. We found some interesting results that are reported throughout the text. Our findings point out an extreme dynamicity of the information on the Web and, for this reason, we advice a great caution when someone want to use search and meta-search engines as a tool for searching and retrieve reliable biomedical information. On the other hand, some search and meta-search engines could be very useful as a first step searching for defining better a search and, moreover, for finding institutional Web-sites too. This paper allows to know a more conscious approach to the internet biomedical information universe.

Studies performed to date on the prevalence of biliary lithiasis (BL) in chronic renal failure patients on hemodialysis (HD) have given contradictory results. The aims of the present study were to evaluate the prevalence of BL and its main associated risk factors in a population of hemodialysis patients, and to compare the results with those we had obtained previously in an overt population of the same zone. The study included 171 patients (83 M, 88 F), mean age 62.5 years and mean duration of dialysis 66.7 months. The screening protocol also included body mass index (BMI), a number of biochemical parameters and an ultrasound scan of the gallbladder and biliary tract. The general prevalence of BL was 33.3% (30.1% in men and 36.4% in women), and this figure was significantly higher than that found in our previous study. Prevalence increased with age in both sexes (Mantel-Haenszel Chi-squared = 5.4, p < 0.03), but not with duration of dialysis. The main risk factors, evaluated with multiple logisstic regression, were the presence of diabetes mellitus and high serum phosphorus levels. Specific symptoms were also significantly associated in BL patients. No association was found with parity, BMI or serum lipid alterations. In conclusion, the prevalence of BL in a Sicilian population of HD patients was higher than that found in an overt population of the same area and the associated main risk factors were not coincident. Further studies are needed to establish the role played by the phase of end-stage renal disease before HD and to correct the metabolic disturbances to limit a high percentage of morbidity in a disease already in itself sufficiently disabling.

Background: We aimed to study centrally obese subjects without other diseases, to establish whether a short-term hypoenergetic balanced regimen is able to positively modify left ventricular (LV) patterns., Methods: We studied 32 obese subjects (out of 52 recruited for this study) with central fat distribution and without associated diseases. Each subject had undergone a moderately hypoenergetic diet for a four-month follow-up period and had a regular loss in weight. Some relevant clinical and echocardiographic parameters were evaluated. Baseline data and those evaluated at the end of the follow-up period were used for outcome analysis., Results: We found a considerable reduction in LV mass and other LV structural parameters including relative wall thickness (RWT). Moreover, we found an improvement of both LV ejection fraction and filling parameters. As regards the relation ship between parameter changes, LV mass was correlated to LV internal diameter and mainly to LV wall thickness. LV mass change was also correlated to a reduction of diastolic BP and RWT. Only improvements in LV filling were correlated to WHR reduction. None of the changes in cardiac variables resulted significantly correlated to BMI change. Other interesting correlations are reported in the text., Conclusions: Our study points out that improvements in LV structure and function are rapidly possible with a moderately hypoenergetic regimen in obese otherwise healthy subjects. The main changes were those in LV wall thickness even if a more complex cardiovascular adjustment was recognised. All this could be very important to possibly prevent future cardiovascular events (including heart failure), so largely linked to obesity of central type.

Background: We aimed to analyze the importance of echocardiography in our Internal Medicine Institute. We think that this technique could have a large impact in the evaluation of the internistic inpatient who is usually affected by multiple pathological problems., Methods: Analysis was performed according to the ACC/AHA guidelines for the application of echocardiography. The data of 1211 consecutive inpatients were analyzed., Results: Sixty-three per cent of all the patients had two or more associated diseases. Moreover, patients in whom echocardiography could be considered appropriate or useful were 67%. Our results point out that echocardiographic examination is generally a technique of great importance for the evaluation of internistic inpatients., Conclusions: This study could represent a useful background for a cost/benefit analysis that should evaluate the utility of a specifically-dedicated echocardiographic laboratory for optimal, autonomous management of internal medicine inpatients.

OBJECTIVE: To evaluate the relationships among micro-albuminuria, blood pressure and measurements of left ventricular structure and function in centrally and peripherally obese subjects compared with members of a lean control group. METHODS: Centrally obese subjects were subdivided according to whether they had levels of micro-albuminuria higher than 30 mg/24 h (micro-albuminuric group) or lower than or equal to 30 mg/24 h (normo-albuminuric group). For all the subjects we measured heart rate, casual mean blood pressure (MBP), 24 h MBP, total cholesterol level, high-density lipoprotein cholesterol, lipoprotein (a) level, fasting immunoreactive insulin level, plasma renin activity, plasma aldosterone level and micro-albminuria (UAE) by current methods. Left ventricular mass indexed for body height, left ventricular diastolic and systolic diameters, interventricular septal thickness and left ventricular ejection fraction were measured by echocardiography. Peak filling rate was also calculated by radionuclide study. Family history of cardiovascular disease was evaluated for all the obese subjects.RESULTS: Lipoprotein (a) level, total cholesterol level, 24 h MBP and interventricular septal thickness were significantly (P < 0.05) greater for micro-albuminuric than they were for normo-albuminuric centrally obese subjects, whereas high-density lipoprotein cholesterol level and left ventricular ejection fraction were significantly (P < 0.05 lower. In addition, UAE levels of centrally obese subjects were significantly (P < 0.05) higher than those of peripherally obese subjects. UAE of all the centrally obese subjects was correlated directly to lipoprotein (a) level (r = 0.33, P < 0.009), 24 h MBP (r = 0.41, P < 0.002), interventricular septal thickness (= 0.36, P < 0.005) and family history of cardiovascular disease (r = 0.33, P < 0.007). Multiple regression analysis indicated that UAE was independently related to 24 h MBP and family history of cardiovascular disease. CONCLUSION: Our data indicated that measurement of micro-albuminuria is useful for evaluating cardiovascular risk profiles of obese subjects with a central fat distribution.

Thirty adult patients with distal, monolateral deep vein thrombosis of the lower limbs were randomly treated for sixty days either with subcutaneous Ca-Heparin or with Sulodexide, administered IM for ten days and orally for fifty days. The thrombus accretion above the knee, the venous pressures of the affected leg, the clinical symptomatology, and some laboratory coagulative tests were monitored throughout the administration period. Local tolerability of the two treatments was also evaluated. The two applied treatments evidenced a net antithrombotic activity, preventing thrombus accretion above the knee, improving with the same efficacy the venous pressures in the affected legs, and similarly reducing clinical symptoms, with a quick and statistically significant trend toward normalization. Blood fibrinogen was significantly lowered by both drugs, while only Ca-heparin yielded a prolongation of activated partial thromboplastin time. Local tolerability of treatments was better for the mainly oral Sulodexide administrations, while subcutaneous Ca-heparin often induced small, though transient, hematomas.

In the present study the prevalence of obesity and its association with ischemic heart disease, recognized according to clinical criteria (chest pain or previous infarction) and/or instrumental data, were described in 8,847 normotensive subjects and in 867 hypertensive subjects, hospitalized during a ten years period (1983-1992), through a cross-sectional study. In view of this all the subjects were considered as lean or obese according to their body mass index (BMI) and to sex specific cut-off values reported in the Italian Consensus Conference on Obesity. In particular, according to BMI values, the subjects were grouped as lean, overweight, moderate and severe obese subjects. Our results indicated that 3,982 normotensive subjects (45%) could be considered lean, whereas 2,654 of them (30%) were overweight, 1,769 of them (20%) were moderate obese and 442 of them (5%) were severe obese. On the contrary only 206 hypertensives (23.7%) might be considered lean, whereas 313 (36.1%) were overweight, 302 (34.8%) were moderate obese and 46 (5.3%) were severe obese. According to age subgrouping (lower than or equal to 65 years or higher than 65 years) the distribution of hypertensives within the lean, overweight, moderate and severe obese groups did not change significantly, but, according to sex subgrouping, the distribution of hypertensives within the BMI groups was significantly different (chi 2, p < 0.001). When we considered the degree of hypertension, distribution of hypertensives was significantly different according to c2 test (p < 0.004), suggesting that the percentage of the subjects with severe hypertension increased only in subjects with severe obesity. Concomitant ischaemic heart disease (IHD) was also documented in 350 normotensives (4%) and in 119 hypertensives (13.8%). The prevalence of IHD was not significantly different in lean, overweight, moderate and severe obese hypertensives, also when sex and smoking habits were considered. Our data indicated a strong association between obesity and hypertension. In addition they may be consistent with the suggestion that obese hypertensives were not characterized by a lower risk of ischaemic heart disease (IHD), than lean hypertensives.

Our investigation aimed at verifying diastolic abnormalities in rheumatoid patients, without clinically evident cardiovascular disease and other confounding complaints, by using pulsed Doppler examination of transmitral blood flow. We selected 40 patients fulfilling revised American Rheumatism Association (ARA) criteria for the diagnosis of rheumatoid arthritis having no symptoms of cardiac disease or clinical findings of other extracardiac diseases. We also studied 40 rheumatoid-matched healthy volunteers as a control group. An echocardiographic examination was carried out on each subject. Left ventricular structural and functional measurements were obtained. Interventricular, septal thickness and left ventricular mass index were significantly higher in rheumatoid patients than in the control group. We also found in rheumatoid patients higher mean values of peak A velocity and A/E ratio. When multiple linear regression analysis was performed on the data of rheumatoid patients we found an independent relationship only between A/E ratio and left ventricular mass. In conclusion, our results confirm diastolic abnormalities in rheumatoid patients and point out that these abnormalities also affect echo-Doppler parameters of left ventricular filling. Moreover, further analysis of our data may suggest the possibility that structural left ventricle changes could be responsible for left ventricular filling impairment.

This study was designed to analyse the relationship between arterial hypertension and changes in arterial blood flow and vascular wall damage of the lower limbs in hypertensive patients with various degrees of hypertension. Six hundred and fifty-four hypertensive patients (421 males and 233 females) aged 35 to 70 years and 88 healthy subjects (63 males and 25 females) aged 39 to 60 years were studied. Strain-gauge plethysmography of the lower limbs was used to calculate arterial calf blood flow (RF), arterial calf blood flow after post-ischaemic hyperaemia (PF), basal and minimal vascular resistances (BVR and MVR), time to reach peak flow (tPF), time until 50% reduction of peak flow (tT1/2) and total recovery time (tT). In 108 (67 males and 41 females) of the hypertensive patients, a morphological study by echo-Doppler duplex scanning of the popliteal artery was performed to measure medial-intimal thickening and popliteal lumen diameter. Our results indicate that regional haemodynamics of the lower limbs worsened in hypertensives in comparison with control subjects. In addition, the change in peripheral haemodynamics was related to the degree of hypertension. Moreover, medial--intimal thickening was significantly (P < 0.05) higher in severe hypertensives than mild hypertensives. Popliteal lumen diameter was significantly (P < 0.05) lower in severe hypertensives than moderate and mild hypertensives. In all these subjects mean blood pressure was correlated directly (r = 0.31; P < 0.001) with medial-intimal thickening and inversely (r = -0.37; P < 0.001) with popliteal lumen diameter. Multiple regression analysis indicated that mean blood pressure, age and serum cholesterol were independently correlated to medial-intimal thickening. This relationship was not influenced by the diabetic patients and smokers among the groups. Our results indicate that hypertension impairs peripheral flow and encourages the development of medial-intimal thickening.

This study was designed to evaluate coagulation and fibrinolysis activity and their relationship with left ventricular function in young obese subjects with central fat distribution. We assessed coagulation and fibrinolysis activity by evaluation of factor VII activity, fibrinogen and plasminogen, plasminogen activator inhibitor (PAI), and tissue plasminogen activator antigen basally (tPA1) and after venous occlusion (tPA2). These measures were evaluated in young (< 40 years) obese subjects with central fat distribution (n = 19) and in comparable lean subjects (n = 20). Blood glucose, triglycerides, total and high-density lipoprotein (HDL) cholesterol, apolipoprotein (apo) A1 and apo B, fasting immunoreactive insulin, and lipoprotein(a) levels were also measured by current methods. Left ventricular ejection fraction (LVEF) and peak filling rate (PFR) determined by radionuclide angiocardiography and left ventricular mass (LVM) and LVM indexed for body height (LVM/H) determined by echocardiographic study were calculated. Central obesity was evaluated by the waist to hip ratio (WHR) according to the criteria of the Italian Consensus Conference of Obesity. Factor VII (P < .001), fibrinogen (P < .001), plasminogen (P < .001), PAI activity (P < .001), tPA1 (P < .02), fasting blood glucose (P < .01), apo B (P < .02), and immunoreactive insulin (P < .01) were significantly higher in obese than in lean subjects. In contrast, HDL cholesterol (P < .01), tPA2 (P < .01), LVEF (P < .001), and PFR (P < .02) were significantly lower in obese than in lean subjects. In all subjects, WHR correlated directly with fibrinogen and inversely with tPA2; LVEF correlated inversely with tPA1, PAI, and fibrinogen; and PFR correlated inversely with factor VII activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To investigate the role of alterations in renal haemodynamics and function and in plasma renin activity on obesity-induced hypertension., Design: Renal haemodynamics and function, salt-regulating hormones and structural cardiac parameters were evaluated in 20 lean normotensives and in 64 obese subjects with central or peripheral fat distribution, 43 of them were normotensives and 21 of them were hypertensives. Obesity and central fat distribution were defined according to sex-specific 85th percentile respectively of Body Mass Index (BMI) and Waist to Hip Ratio (WHR)., Measurements: Serum immunoreactive insulin (IRI), plasma renin activity (PRA), plasma aldosterone (PA), microalbuminuria (UAE) and 24h urinary excretion of sodium (NaU) were evaluated by current methods. Renal haemodynamics was evaluated by radionuclide study according to Schlegel's and Gate's methods. By radionuclide study, effective renal plasma flow (ERPF), effective renal blood flow (ERBF), glomerular filtration rate (GFR), filtration fraction (FF) and renal vascular resistances (RVR) were measured. Left ventricular mass (LVM) and indexed for body height (LVM/H), cardiac output (CO) and total peripheral resistances (TPR) by ecocardiography were also calculated., Results: CO, LVM and LVM/H were significantly (P < 0.05) higher in all the obese groups than lean controls. In addition, LVM and LVM/H were significantly (P < 0.05) higher in obese hypertensives than obese normotensives either with central fat distribution. TPR values were significantly (P < 0.05) higher in central obese hypertensives than peripheral obese hypertensives and than central obese normotensives. Moreover, IRI levels were significantly (P < 0.05) higher in central normotensive and hypertensive obese subjects than lean subjects. ERBF and ERPF were significantly (P < 0.05) lower and PRA levels were significantly higher only in central obese than lean subjects. On the contrary RVR were significantly (P < 0.05) higher in both obese hypertensive groups and in central obese normotensives than lean subjects. Comparisons between peripheral and central obese groups indicated that PRA, RVR and UAE were significantly (P < 0.05) higher and ERBF and ERPF values were significantly (P < 0.05) lower in both central obese groups than comparable subjects with peripheral obesity. Multiple regression analysis indicated that RVR increased significantly (P < 0.05) with WHR and PRA but not with CO and IRI., Conclusions: Our results indicate that obesity with body fat distribution of central type, more than obesity of peripheral type, is associated to abnormalities in renal haemodynamics and function. These data are consistent with the indication that change in renal haemodynamics take place at an early stage in the obesity-induced hypertension.

Objectives: To investigate the influence of heredity on obesity-associated hypertension, we evaluated casual and 24-h blood pressure, left ventricular mass and some metabolic and hormonal measurements in normotensive obese subjects., Design: Healthy, normotensive obese subjects (n = 81) with positive or negative family history of hypertension were studied. Both groups were also subdivided according to a positive or a negative family history of obesity. Accordingly, 45 obese subjects had a positive family history of hypertension, 25 of these having a positive (subgroup A) and 20 having a negative family history of obesity (subgroup B). The other 36 obese subjects had a negative family history of hypertension, 19 of these having a positive (subgroup C) and 17 having a negative family history of obesity (subgroup D)., Methods: Casual and 24-h systolic (SBP), diastolic (DBP) and mean blood pressure (MBP) were evaluated. Serum fasting blood sugar, total cholesterol and triglycerides levels, urinary excretion of sodium, immunoreactive fasting insulin, plasma ANF levels, plasma renin activity (PRA), plasma aldosterone level, plasma adrenaline and noradrenaline levels and echocardiographic total left ventricular mass (LVM) and LVM:height ratio were also calculated., Results: Twenty-four-hour DBP, 24-h MBP, LVM, LVM:height ratio, total cholesterol and PRA values were significantly higher in normotensive obese offspring of hypertensive parents than in obese offspring of normotensive parents. Twenty-four-hour DBP and MBP, LVM, LVM:height ratio, insulin level, insulin:glucose ratio and PRA were significantly higher in subgroup A than in subgroup B. Fasting blood sugar level, 24-h DBP and MBP, insulin level, insulin:glucose ratio, PRA, noradrenaline, adrenaline and plasma aldosterone levels were significantly higher in subgroup C than in subgroup D. Multivariate analysis also indicated that 24-h MBP and PRA levels were significantly influenced by the association between a positive family history of hypertension and obesity., Conclusions: The present results suggest that a family history of obesity might increase the risk of developing hypertension in obese subjects. An elevated PRA may precede the development of hypertension in obese subjects who are at risk for developing hypertension.

Background: Rheumatoid arthritis (RA) is a systemic disease involving many organ systems and is frequently accompanied by cardiac alterations. However, there is considerable disagreement concerning the cardiac abnormalities found in patients with RA. The purpose of our investigation was to determine, by a non-invasive method such as echocardiography, the nature and extent of cardiac involvement in RA patients with no symptoms of cardiac disease, in comparison with a control sample., Methods: We selected 35 patients affected by rheumatoid arthritis (five men, 30 women), aged 51 +/- 11 years. No patient had either symptoms of cardiac disease or extra cardiac complaint. As a control group we studied 52 volunteers, aged 51 +/- 12 years, randomly selected among a larger group of subjects with no symptoms, signs and/or clinical findings of extra cardiac diseases. All were in sinus rhythm and without any cardiac symptom. Standard two-dimensional, M-mode and Doppler echocardiographic examination was carried out on each subject., Results: In RA patients we found a higher prevalence of several abnormalities. We found no statistically significant differences between the groups of RA patients based on the stage and duration of disease. We found no correlation between cardiac abnormalities and inflammatory indices or drug therapy., Discussion: At least three alterations seem to be typical of RA patients in the absence of any symptom of cardiac disease: (1) posterior pericardial effusion, (2) aortic root alterations and (3) valvular thickening. The prevalence of MVP is controversial and needs further investigation. These alterations are variously combined in each patient, and for this reason we think that it is possible to represent such a heart involvement as 'silent rheumatoid heart disease'. Moreover the knowledge of the presence of unrecognised cardiac abnormalities can be very important for the correct assessment and management of the RA patient.

The reliability of two-dimensional (2D) echocardiographic estimation of left ventricular ejection fraction (EF) is commonly recognized, but no satisfactory data are available about the accuracy of low or very low EF values determined by 2D echocardiography (ECHO-EF). The purpose of our study was to assess the reliability of low ECHO-EF values obtained using a simple time-economical algorithm such as the ellipsoid single-plane area-length method. Radionuclide angiography (RAD-EF) was taken as the standard of comparison. We studied 59 consecutive patients (31 women and 28 men) referred to our echocardiographic laboratory. Both 2D echocardiography and radionuclide angiography were blindly performed within 48 h of one another. EF was calculated by the two methods and then compared. Data were globally analyzed. Furthermore, data were divided and analyzed according to the ECHO-EF cut-off point of 50%. An ECHO-EF value of 50% was chosen to conventionally distinguish between low ECHO-EF values and normal-high ones. Data were plotted, and the line of equality and the regression lines were drawn. Regression line slopes, correlation coefficients, means and standard deviations were calculated. The agreement was analyzed by calculating the mean difference (RAD-EF-ECHO-EF) and the standard deviation of the differences. ECHO-EF was linearly related to RAD-EF even when data were split. In particular, as regards ECHO-EF < or = 50%, the regression line practically overlapped the line of equality, and the two methods showed both a strong correlation and a good degree of agreement.(ABSTRACT TRUNCATED AT 250 WORDS)

We used echocardiography to determine the prevalence of pericardial effusion in rheumatoid arthritis (RA) patients without cardiac systems and compared our results to those obtained in a control group of age-matched subjects. Thirty-six patients with RA (6 men, 30 women; mean age 51 +/- 11 years) were selected from a patient population in treatment at our outpatient Rheumatology Clinic. None of the patients had any symptoms of cardiac disease, and all patients with signs and/or systems of extracardiac disease were excluded from the study. The control group consisted of 60 volunteers (mean age 51 +/- 12 years) randomly selected from a larger group of subjects with neither symptoms, signs and/or clinical findings of extracardiac disease nor symptoms of cardiac disease. Standard two-dimensional and M-mode echocardiography was carried out on all subjects. In the RA patients, we found a high prevalence of pericardial involvement, especially minimal pericardial effusion. There was no statistically significant difference among subgroups of RA patients based on stage and duration of disease respectively. There was no correlation between pericardial involvement and inflammatory indexes or drug therapy. The minimal pericardial effusion found in our patients could be caused by the extra-articular inflammatory process and might be one aspect of a more complex picture characterized by silent cardiac involvement. The potential for symptomless pericardial alterations documented in our patients indicates that careful cardiac evaluation should be given high priority in the assessment and management of subjects with RA.

To assess left ventricular diastolic filling in mitral valve prolapse (MVP), we studied 22 patients with idiopathic MVP and 22 healthy controls matched for sex, age, body surface area and heart rate. A two-dimensional, M-mode and Doppler echocardiographic examination was performed to exclude any cardiac abnormalities. The two groups had similar diastolic and systolic left ventricular volumes, left ventricle mass and ejection fraction. Doppler measurements of mitral inflow were: E and A areas (the components of the total flow velocity-time integral in the early passive period of ventricular filling, E; and the late active period of atrial emptying, A), the peak E and A velocities (cm.s-1), acceleration and deceleration half-times (ms) of early diastolic rapid inflow, acceleration time of early diastolic flow (AT), total diastolic filling time (DFT) (ms), and the deceleration of early diastolic flow (cm.s-2). From these measurements were calculate: peak A/E ratio (A/E), E area/A area, the early filling fraction, the atrial filling fraction, AT/DFT ratio. All the Doppler measurements reported are the average of three cardiac cycles selected at end expiration. The mean peak A velocity, A/E velocity ratio, deceleration half time and atrial filling fraction were each significantly higher for subjects presenting a MVP (60 +/- 12 cm.s-1 vs 49 +/- 14, P < 0.008; 98 +/- 13% vs 64 +/- 12%, P < 0.0001; 120 +/- 36 ms vs 92 +/- 11, P < 0.002; 0.45 +/- 0.14 vs 0.36 +/- 0.08, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

In 285 patients with prevesical ureteral stone and 247 with upper ureteral stone, extracorporeal shock wave lithotripsy (ESWL) was performed with the Dornier MPL 9000 ultrasonographic targeting device. All these stones were treated "in situ" and without regional or general anaesthesia. At 3-month follow-up 96.8% of the patients treated for prevesical stone and 95.5% of those with upper ureteral stone were stone-free. ESWL was repeated once or twice in 99 cases; the average number of sessions was 1.2 for all patients (similar for prevesical and upper ureteral stones). Sparse use of ureteral stenting (6.2% of cases) did not seem to reduce the efficacy of ESWL or increase complications or need for retreatment. Intravenous fentanyl analgesia was given to 40.9% of the patients and intravenous infusion of a furosemide solution was employed in many cases to give adequate dilation of the urinary tract. In situ echo-guided ureteral ESWL is simple, safe and efficacious and can be the technique of choice for sonographically detectable ureteral stone.

In spite of the improvement of surgical techniques used alone or in combination with preoperative radiation therapy, more than 50% of the patients with infiltrating transitional cell carcinoma (TCC) of the bladder die of distant metastases. Systemic antiblastic polychemotherapy has been reported to achieve a complete remission rate of approximately 30% in patients with infiltrating bladder TCC, although there are still doubts relative to the duration of such complete remissions. This study investigated the efficacy and tolerability of a preoperative chemo- and radiotherapeutic treatment modality and the possibility of performing preservative surgery. Thirty-seven patients with bladder TCC stage T2-T4, N0, M0, have been subjected to neoadjuvant chemotherapy according to the "Rescue M-VEC" scheme of methotrexate 30 mg/m2 +folinic acid 15 mg. after 24 hours on days 1, 15, 22; vinblastine 3 mg/m2 on days 1, 15, 22; epidoxorubicin 30 mg/m2 on day 1 and cisplatin 70 mg/m2 on day 1. The course was repeated from day 29. After 2 "Rescue M-VEC" courses, the patients received pelvic cobalt tele-therapy (CTT) combined with cisplatin 24 mg/m2/week. The patients were then restaged. Those with complete remission (CR) received consolidation radiotherapeutic boost combined with cisplatin 24 mg/m2/week, avoiding radical cystectomy. Such treatment was also given to patients with significant partial remission (PR) who had undergone TUR or partial cystectomy. In all the remaining cases we carried out radical cystectomy. We obtained 45.7% CR, 31.4% PR and 22.8% were non-responders (NR), of 35 patients who were evaluable at restaging. Only 9 radical cystectomies were performed in this series. The overall survival rate was 80.6% at a mean follow-up of 18.1 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Unlabelled: The aim of our study was to seek out a possible different reactiveness to cardiovascular stimulation tests among normotensives with and without positive family history of essential hypertension. We have studied about 200 inhabitants of Ustica and 49 medicine students, all normotensives according to the World Health Organization and the Joint National Committee criteria. In an isolated room and in a supine position, blood pressure (BP) and heart rate were measured every 30 s for 15 min with an automatic sphygmomanometer. Averages of last 4 measurements were considered baseline values. Then we have carried out mental stress (MS), handgrip and active orthostatism test (AO) in the inhabitants of Ustica; cold pressor test and AO in students. Patients were divided in 2 groups, genetics and controls, on the basis of a positive family history of essential hypertension. The 2 groups, in every sample, were similar for sex, age, body mass index and alimentary and life habits., Results: a preliminary estimation of Ustica sample showed a different prevalence of positive history between hypertensives and normotensives (63.9% vs 46.61%; p less than 0.05) and no difference between hypertensive and borderline patients (63.9% vs 64.2%); BP and heart rate were slightly higher in controls; there was no statistical difference between genetics and controls., Conclusions: our results can be explained in various ways: pressor dysregulation in candidates for hypertension may be masked in a large group of normotensives; exaggerated pressor response do not exist in genetics or this pressor dysregulation is impossible to find out with the cardiovascular stimulation tests we have used; other mechanisms are responsible for genetic hypertension.