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Purpose: Metastatic melanoma lymph nodes (MMLns) might be challenging to detect on MR-WBI, as both MMLns and normal lymph nodes (NLns) can show restricted water diffusion. Our purpose is to assess the potential contribution of the DIXON sequence in differentiating MMLns from NLns. Material and methods: We followed a cohort of 107 patients with stage IIIb/c and IV skin melanoma for 32 months using MR-WBI with DIXON, STIR, and DWI/ADC sequences. We compared signal intensity (SI) values of MMLns and NLns in the four series of the DIXON sequence (in/out-of-phase, fat_only, and water_only series). The fat fraction (SIfat_only/SIin) and the long:short axis ratio of MMLns were calculated. The fat fraction was also calculated in the fatty hila of NLns. Results: All MMLns (8 from 7 patients) showed SIout>SIin with a mean fat fraction of 10%. In 40 normal fatty hila (25 patients), the proportion of SIout>SIin was 100% and mean fat fraction was 89% (pSIin pattern was identified in 41/113 cases from 19/40 patients. The median long:short axis ratio in MMLns was 1.13 (range 1.03–1.25). Conclusion: The combination of three features of MMLns (SIout>SIin, low-fat fraction and rounded shape) might hold promise in differentiating NLns from MMLns in patients with skin melanoma. Further research is warranted due to the small number of MMLns in our cohort.

The Nitrogen Footprint (N-Footprint) is the total amount of reactive nitrogen (Nr) released to the environment as a result of an entity's consumption patterns. N-Footprint assessments have mainly been consumer-oriented and country-sized, although concern has recently focused on single products, especially particular foods.While traditionally obtained from several software and/or calculators, the N-Footprint is here proposed to be evaluated by combining the Life Cycle (LCA) approach with a specific N based impact assessment modelling, as derived from Intergovernmental Panel on Climate Change guidelines.The theoretical procedure is then applied to a real livestock case study (the Mora Romagnola pig that provides high quality pork), mainly based on primary data. The total amount of Nr released was about 40 kg per pig (live weight), mainly due to direct components (i.e. manure management ∼ 85%). The results highlight the importance of more comprehensive and systematic quantification of emissions, especially direct ones that are neglected in the classical database and software. The Virtual N-Factor (VNF) was 2.3, which indicates that about 30% of N input by weight is incorporated in the meat, while most of it (∼70%) is dispersed to different environmental compartments (38% atmosphere, 35% soil, 27% water). A comparative analysis to check the reliability of outcomes and the robustness of the accounting procedure is also offered and show that these results are consistent with those reported in the literature for other pork products.The main benefit of this procedure is that it produces a unique aggregate result of the entity of human pressure on nitrogen cycle. This ensures a high comparability for results, transparency, and reproducibility of the method.

A 34-year-old healthy male presented as a trauma activation after sustaining a gunshot wound to his face. CT head imaging was suggestive of a ballistic fragment adjacent to a posterior wall sphenoid sinus fracture with likely a small volume of adjacent blood products. He was ultimately diagnosed with hypopituitarism which included central diabetes insipidus, central hypothyroid, and adrenocorticotropic hormone deficiency secondary to cortisol deficiency. This case illustrates the spectrum of endocrine dysfunction that can occur with skull base injuries, and the appropriate pituitary-function screening and treatment that should be performed if there is clinical concern. Early recognition and prompt treatment of pituitary insufficiency can facilitate overall rehabilitation after TBI.

Many are the definitions of Circular Economy as well as the policies and strategies for its implementation. However, gaps still exist in quantifying the effects of circularity. The existing approaches are usually sector- or product-specific, limited to microscale systems, and/or fail to simultaneously assess the environmental impacts of the studied system. This paper introduces a generally applicable method in which a set of LCA-based indices of circularity are able to detect the effects of circularity/symbiosis strategies on the environmental performance of meso- and macro-systems. These indices quantify the overall system's circularity level by comparing the impacts of a system in which the components interact with each other (with a certain level of circularity) with an equivalent linear system (where no circularity takes place). The method works both on existing and projected systems, being able to track the effects of future circularity policies. This method obviates the limitations and the gaps mentioned above: it applies to meso- and macro-systems, it is not bound to a specific sector, it allows to capture the environmental impacts, and it is sensitive to the temporal dimension. This approach provides a tool to inform managers and policymakers for planning circularity actions and monitor their effectiveness while also capturing the temporal dimension., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The current study compares results of a group-based intervention developed to reduce symptoms of posttraumatic stress, depression, and anxiety in parents of premature infants with a prior study using an individual version of the treatment manual., Methods: 26 mothers of preterm infants (25-34 weeks' gestational age; >600 g) received 6 sessions of trauma-focused cognitive behavior therapy (CBT). Outcomes were compared with those of a previously published RCT, which tested an individual therapy based on the same model in a group of 62 mothers. Results were also compared across in-person and telehealth treatment., Results: From baseline to follow up, the individual intervention showed greater improvement in trauma symptoms assessed with the Davidson Trauma Scale (d = 0.48, p = 0.016), although both conditions showed clinically significant improvement. Similar patterns were found for maternal depression and anxiety. In-person treatment was found to be superior to telehealth treatment administered during the COVID-19 pandemic, although the difference was not significant., Conclusions: Group-based trauma focused CBT is an effective treatment modality for parents of premature infants with symptoms of psychological distress but not as effective as individual therapy using the same treatment model., Competing Interests: Declaration of competing interest None to report., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience., Methods: All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up., Results: From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively., Conclusions: Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Pulmonary sequestration consists of a nonfunctioning mass of lung tissue, either sharing the pleural envelope of the normal lung (intralobar) or with its own pleura (extralobar), lacking normal communication with the tracheobronchial tree and receiving its arterial supply by one or more systemic vessels. It is the second most common congenital lung anomaly according to pediatric case series, but its real prevalence is likely to be underestimated, and imaging plays a key role in the diagnosis and treatment management of the condition and its potential complications. We will give a brief overview of the pathophysiology, clinical presentation and imaging findings of intra- and extralobar pulmonary sequestration, with particular reference to multidetector computed tomography as part of a powerful and streamlined diagnostic approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Snakebite is a neglected tropical disease with a massive global burden of injury and death. The best current treatments, antivenoms, are plagued by a number of logistical issues that limit supply and access in remote or poor regions. We explore the anticoagulant properties of venoms from the genus Micrurus (coral snakes), which have been largely unstudied, as well as the effectiveness of antivenom and a small-molecule phospholipase inhibitor-varespladib-at counteracting these effects. Our in vitro results suggest that these venoms likely interfere with the formation or function of the prothrombinase complex. We find that the anticoagulant potency varies widely across the genus and is especially pronounced in M. laticollaris. This variation does not appear to correspond to previously described patterns regarding the relative expression of the three-finger toxin and phospholipase A 2 (PLA 2 ) toxin families within the venoms of this genus. The coral snake antivenom Coralmyn, is largely unable to ameliorate these effects except for M. ibiboboca. Varespladib on the other hand completely abolished the anticoagulant activity of every venom. This is consistent with the growing body of results showing that varespladib may be an effective treatment for a wide range of toxicity caused by PLA 2 toxins from many different snake species. Varespladib is a particularly attractive candidate to help alleviate the burden of snakebite because it is an approved drug that possesses several logistical advantages over antivenom including temperature stability and oral availability., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Human induced pluripotent stem cell derived cardiomyocytes (hiPSC-CMs) resemble fetal cardiomyocytes and electrical stimulation (ES) has been explored to mature the differentiated cells. Here, we hypothesize that ES applied at the beginning of the differentiation process, triggers both differentiation of the hiPSC-CMs into a specialized conduction system (CS) phenotype and cell maturation. We applied ES for 15 days starting on day 0 of the differentiation process and found an increased expression of transcription factors and proteins associated with the development and function of CS including Irx3, Nkx2.5 and contactin 2, Hcn4 and Scn5a, respectively. We also found activation of intercalated disc proteins (Nrap and β-catenin). We detected ES-induced CM maturation as indicated by increased Tnni1 and Tnni3 expression. Confocal micrographs showed a shift towards expression of the gap junction protein connexin 40 in ES hiPSC-CM compared to the more dominant expression of connexin 43 in controls. Finally, analysis of functional parameters revealed that ES hiPSC-CMs exhibited faster action potential (AP) depolarization, longer intracellular Ca 2+ transients, and slower AP duration at 90% of repolarization, resembling fast conducting fibers. Altogether, we provided evidence that ES during the differentiation of hiPSC to cardiomyocytes lead to development of cardiac conduction-like cells with more mature cytoarchitecture. Thus, hiPSC-CMs exposed to ES during differentiation can be instrumental to develop CS cells for cardiac disease modelling, screening individual drugs on a precison medicine type platform and support the development of novel therapeutics for arrhythmias., Competing Interests: Declaration of competing interest The authors confirm that there are no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Proteomic characterization of Micrurus browni browni venom showed approximately 41 components belonging to 9 protein families, mainly phospholipases A 2 (PLA 2 s) and three-finger toxins (3FTxs). Venom gland transcriptome yielded 39 venom transcripts belonging to 10 protein families. Functional characterization identified a multimeric toxin, here designated Brownitoxin-1, which comprises at least one PLA 2 and one 3FTx. Its components have no or very low lethality individually but become extremely lethal when combined; both were partially characterized. Other two lethal components were identified: A neurotoxic PLA 2 , and a postsynaptic α-neurotoxin. LD 50 s as well as PLA 2 and nAChR-blocking activities were determined for whole venom and isolated components. Application of venom to murine neuromuscular preparations caused a progressive decrease of twitch force that was irreversible after washing. Inhibition of PLA 2 activity with p-bromophenacyl bromide (pBPB) showed that approximately 90% of toxicity is dependent on this activity. Non-lethal components include diverse 3FTxs, at least three enzymatically active PLA 2 s and the nociceptive toxin MitTx. No evidence of specificity towards prey was observed. This work is one of the most complete characterizations of a coral snake venom so far and its findings highlight the relevance of protein complexes in venom function. SIGNIFICANCE: This study represents a profound analysis of the venom of the coral snake Micrurus browni browni, including a venom proteome, venom gland transcriptomic data and functional studies of whole venom and isolated toxins. It significantly contributes to the understanding of North American coral snake venoms, which are currently largely unknown. It includes characterization of relevant venom components, one of which represents the first description of a lethal multimeric neurotoxin in coral snake venom. This work highlights the importance of protein complexes in coral snake venom and could serve as a basis for the finding of several other multimeric toxins. Finally, we report the absence of taxon specificity, which has been previously reported in the venoms of other snakes of the same genus., Competing Interests: Declaration of competing interest The authors declare no conflict of interest regarding the present work., (Copyright © 2020 Elsevier B.V. All rights reserved.)

We report a structural and functional venomics characterization of the black-tailed horned pitviper, Mixcoatlus melanurus. The venom phenotype of this small and elusive pitviper endemic to México comprise peptides and proteins of 16 toxin families whose relative abundance mirror those of neurotoxic (type II) venoms described for some species within genera distributed in Central Asia (Gloydius) and the Americas (Sistrurus, Crotalus, Ophryacus, and Bothriechis). A novel β-neurotoxic heterodimeric PLA 2 , termed Melanurutoxin was characterized. With a relative abundance of 14.8% of the total M. melanurus venom proteome and a median lethal dose of 0.31 μg/g mouse body weight, Melanurutoxin accounted for 37.8% of the lethality of the whole venom (0.82 μg/g). The low percentage (1.1%) of snake venom metalloproteinases (PIII-SVMPs) and the high content of Melanurutoxin and bradykinin-potentiating peptides (BPP, 16%) found in the type-II venom proteome of M. melanurus correlate with the severe hypotension and neurotoxicity leading to neuromuscular blockade, flaccid paralysis and respiratory arrest observed in ex vivo neuromuscular junction experiments and in vivo experimental murine envenoming. Mexican antivenoms manufactured by Birmex and Bioclon showed low neutralization potency per vial (95 LD 50 s, Birmex; 114 LD 50 s, Antivipmyn®), and failed to reverse completely the paralysis and the hypotensive effect induced by the black-tailed horned pitviper, Mixcoatlus melanurus. We suggest that the impaired ability of these antivenoms to neutralize the neurotoxicity of M. melanurus venom may be attributed to the use of immunization mixtures that include venom of taxa, C. basiliscus (Birmex) and C. simus (Antivipmyn®), that contain only small amounts of Melanurutoxin-like β-neurotoxic heterodimeric PLA 2 s. BIOLOGICAL SIGNIFICANCE: This study represents the first proteomics and funcional investigations conducted on the venom of the black-tailed horned, Mixcoatlus melanurus, a pitviper species endemic to México. The venom's features unveiled through combination of bottom-up venomics and ex vivo and in vivo functional assays provided complementary evidence pointing to severe hypotension and neurotoxicity leading to neuromuscular blockade, flaccid paralysis and respiratory arrest as the predominant mechanism of murine prey immobilization and death caused by M. melanurus. A novel β-neurotoxic heterodimeric PLA 2 , coined Melanurutoxin, was identified as a major contributor to the lethality of the whole venom. Our study also showed the inefficacy of two commercial Mexican antivenoms to reverse competely the paralytic and hypotensive effects induced by M. melanurus venom in the murine model. We hypothesize that the impaired ability of these antivenoms to neutralize the neurotoxicity of M. melanurus venom should be ascribed to the use as immunogens of venoms that contain only small amounts of Melanurutoxin-like β-neurotoxic heterodimeric PLA 2 s., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Venoms of the three species of Ophryacus (O. sphenophrys, O. smaragdinus, and O. undulatus), a viperid genus endemic to Mexico, were analyzed for the first time in the present work. The three venoms lacked procoagulant activity on human plasma, but induced hemorrhage and were highly lethal to mice. These venoms also displayed proteolytic and phospholipase A 2 activities in vitro. The venom of O. sphenophrys was the most lethal and caused hind-limb paralysis in mice. Proteomic profiling of O. sphenophrys venom showed a predominance of metalloproteinase (34.9%), phospholipase A 2 (24.8%) and serine protease (17.1%) in its composition. Strikingly, within its PLA 2 components, 12.9% corresponded to a Crotoxin-like heterodimer, here named Sphenotoxin, which was not found in the other two species of Ophryacus. Sphenotoxin, like Crotoxin, is composed of non-covalently bound A and B subunits. Partial amino acid sequence was obtained for Sphenotoxin B and was similar (78-89%) to other subunits described. The mouse i.v. LD 50 of Sphenotoxin at 1:1 M radio was 0.16 μg/g. Also, like Crotoxin, Sphenotoxin induced a potent neuromuscular blockade in the phrenic nerve-diaphragm preparation. Ophryacus is the fifth genus and O. sphenophrys the third non-rattlesnake species shown to contain a novel Crotoxin-like heterodimeric β-neurotoxin. BIOLOGICAL SIGNIFICANCE: Ophryacus is an endemic genus of semi-arboreal pitvipers from Mexico that includes three species with restricted distributions. Little is known about the natural history of these species and nothing is known about the properties of their venoms. Research on these species' venoms could generate relevant information regarding venom composition of Mexican pitvipers. Additionally, research into the presence of neurotoxic Crotoxin-like molecules outside of rattlesnakes (genera Crotalus and Sistrurus) has identified this molecule in several new genera. Knowing which genera and species possess neurotoxic components is important to fully understand the repercussions of snakebites, the interaction with prey and predators, and the origin, evolution, and phylogenetic distribution of Crotoxin-like molecules during the evolutionary history of pitvipers. Our study expands current knowledge regarding venom's compositions and function from Mexican pitvipers, providing a comparative venom characterization of major activities in the three Ophryacus species. Additionally, the discovery and characterization of a novel Crotoxin-like molecule, here named Sphenotoxin, in O. sphenophrys, and the detailed protein composition of O. sphenophrys venom supports the hypotheses that Crotoxin-like -β-neurotoxins are more widespread than initially thought., (Copyright © 2018. Published by Elsevier B.V.)

Deceptive practices by participants in clinical research are prevalent. It has been shown that as high as 75% of participants withheld information to avoid exclusion from studies. Self-reported adherence has been found to be largely inaccurate. Overcoming deception is a critical issue, since the safety of study participants, the integrity of research data and research resources are at risk. In this review article, we examine deception from the perspective of investigators conducting clinical trials; we describe the types (concealment, fabrication, drug holidays and collusion), prevalence, risks, and predictors of deception, and propose an approach to reduce the impact of deception, especially on adherence, in clinical trials., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The role played by radiation therapy after pleurectomy/decortication or surgical biopsy in malignant pleural mesothelioma is uncertain. We treated patients with accelerated hypofractionated radiotherapy using helical tomotherapy and intensity-modulated arc therapy in an attempt to keep lung toxicity to a minimum. The present study reports the feasibility and toxicity of this approach., Material and Methods: Between 2008 and 2012, 36 patients with malignant pleural mesothelioma underwent accelerated hypofractionated radiotherapy to the hemithorax after pleurectomy/decortication (19 patients) or biopsy (17 patients). The prescription dose was 25Gy in five fractions over 5 consecutive days., Results: We observed three patients with G3 pneumonitis, five cases of grade 2 dyspnea and six cases of grade 2 cough. The median follow-up was 37 months (range: 3-54 months). The median overall survival for patients who underwent pleurectomy/decortication followed by radiotherapy was 21.6 months [95% confidence interval (95% CI): 15.5-24.1] compared to 19.4 months for patients not submitted to surgery., Conclusion: Treatment of intact lung with pleural intensity-modulated arc irradiation in malignant pleural mesothelioma patients with malignant pleural mesothelioma proved safe and feasible, with an acceptable rate of pneumonitis. Survival rates were encouraging for both biopsy-only and pleurectomy/decortication groups. We are currently conducting a phase II dose escalation trial in a similar patient setting to prospectively evaluate the impact of radiotherapy on toxicity, disease-free survival and overall survival., (Copyright © 2017 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.)

Aortic dissection is a complex disease associated with high mortality and morbidity. Among the different possible clinical presentations, type A aortic dissection complicated at the onset by mesenteric malperfusion is characterized by poor outcome compared with patients not presenting such complication. We report the case of a patient with acute type A aortic dissection presenting with mesenteric malperfusion, in whom trans-pericardial color Doppler ultrasound (CDUS) examination was used to assess intraoperative and postoperative blood flow in the mesenteric artery. Trans-pericardial CDUS is demonstrated as a fast and simple diagnostic method with a good matching compared with contrast-enhanced computed tomography scan imaging, if correctly approached. We believe that this technique could be an important adjunctive tool for the intraoperative and perioperative management and decision-making in all patients with type A dissection presenting with mesenteric ischemia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To evaluate the influence of the severity of prematurity based on birth weight on maternal distress and sensitivity and on infant development., Methods: Sixty-eight mothers and their preterm babies (30 babies classified into Extremely-Low-Birth Weight-ELBW and 38 into Very-Low-Birth Weight-VLBW) were assessed at 9months of infant corrected age, using: Griffiths Scales for infant development, CARE-Index for maternal sensitivity during 5-minute of mother-infant interaction, and Parenting Stress Index-Short Form (PSI-SF) for maternal distress. Sixty-six healthy full-term infants (FT) and their mothers were assessed with the same procedure., Results: ELBW, VLBW and FT groups showed similar levels at CARE-Index and PSI-SF. Nevertheless, considering infant development as outcome, a significant interaction between birth weight and maternal distress emerged, with higher Hearing & Language mean quotients in association with Non-Distressed mothers, but only in VLBW infants, compared to FT ones. Also the interaction between birth weight and maternal sensitivity influenced infant development: higher quotients (Eye-hand coordination, Hearing & Language, Locomotor) were significantly associated with sensitive mothers but only in ELBW infants., Conclusion: The severity of prematurity, in interaction with the degree of maternal distress and sensitivity, influenced the level of infant development., Practical Implications: Taken together, these results suggest the relevance of considering severity of prematurity and maternal variables in order to implement appropriate interventions for supporting parenting role after a preterm birth and promoting an adequate infant development., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aim: To retrospectively study the frequency and magnitude of complications associated with computed tomography (CT) colonography in clinical practice., Methods: A questionnaire on complications of CT colonography was sent to Italian public radiology departments identified as practicing CT colonography with a reasonable level of training. The frequency of complications and possible risk factors were retrospectively determined. Responses were collated and row frequencies determined. A multivariate analysis of the factors causing adverse events was also performed., Results: 40,121 examinations were performed in13 centers during the study period. No deaths were reported. Bowel perforations occurred in 0.02% (7 exams). All perforations were asymptomatic and occurred in patients undergoing manual insufflation. Five perforations (71%) occurred in procedures performed following a recent colonoscopy. There was no significant difference between perforations associated with rectal balloon (0.017%) and those that were not (0.02%). Complications related to vasovagal reaction (either with or without spasmolytic) occurred in 0.16% (63 exams). All vasovagal reactions resolved in less than 3h, without any sequelae., Conclusions: Perforation rate at CT colonography in Italy is comparable with elsewhere in the world, occurring regardless of the experience of radiology centers. Although the risk is very small, it may not be negligible when compared with the risk of diagnostic colonoscopy., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

To contribute to the application of the Childhood Atopic Dermatitis Impact Scale (CADIS), 135 Italian parents of children with atopic dermatitis (AD) aged birth to 6 years completed: CADIS, Infants Dermatitis Quality of Life Index (IDQOL) or Children's Dermatology Life Quality Index (CDLQI), and Dermatitis Family Impact 10-item questionnaire (DFI). A subsample of 66 caregivers completed the CADIS again, 48 hours later. Disease severity was measured with the Severity Scoring of Atopic Dermatitis (SCORAD) index. Exploratory factor analyses almost replicated the general factor structure of the original CADIS, established on a US sample. However, some differences emerged, probably due to cultural differences. A reduced version of the original CADIS was also obtained, based on the exploratory factor analyses, to facilitate use in clinical settings. The original and the shorter versions were tested for reliability: overall Cronbach's α and test-retest reliability for the child- and parent-related scales were acceptable. Regarding concurrent validity, estimates showed the CADIS to correlate adequately with SCORAD, IDQOL-CDLQI, and DFI. Multiple comparison tests for discriminant validity revealed significant differences between extreme groups based on AD severity for all five domains of CADIS. The original CADIS showed adequate validity and reliability in Italy as well, and the shorter version showed promising psychometric properties.

We report the successful treatment of a life-threatening thoracoabdominal aneurysm in a young patient affected by type I Loeys-Dietz syndrome. To overcome anatomic and surgical difficulties, we used an original strategy and a specially designed surgical tool. The clinical and technical aspects of this approach are presented., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Neboglamine is a functional modulator of the glycine site on the N-methyl-d-aspartate (NMDA) receptor. Dysfunction of this receptor has been associated with negative and cognitive symptoms in schizophrenia. Thus, we tested the hypothesis that neboglamine behaves as a potential antipsychotic. We compared the effects of neboglamine, D-serine, clozapine, and haloperidol on the expression of Fos-like immunoreactivity (FLI), a marker of neuronal activation, in rat forebrain. We also studied the effects of these agents on phencyclidine (PCP)-induced behaviour in rats, a model predictive of potential antipsychotic activity. Neboglamine, like haloperidol and clozapine, significantly increased the number of FLI-positive cells in the prefrontal cortex, nucleus accumbens, and lateral septal nucleus (3.2-, 4.8-, and 4.5-fold over control, respectively). Haloperidol dramatically increased FLI (390-fold over control) in the dorsolateral striatum, a brain region in which neboglamine and clozapine had no effect. The pattern of FLI induced by neboglamine closely matched that of d-serine, an endogenous agonist at the glycine site of NMDA receptors. Consistent with this finding, neboglamine restored NMDA-mediated neurotransmitter release in frontal cortex punches exposed to the NMDA antagonist PCP. In the behavioural model, all test compounds significantly inhibited PCP-induced hyperlocomotion. Unlike haloperidol and clozapine, neither neboglamine nor D-serine affected the basal levels of locomotor activity. Moreover, oral neboglamine dose-dependently inhibited both the hyperlocomotion and the frequency of rearing behaviour induced by PCP. These results, while confirming that the NMDA glycine site is a feasible target for activating the frontostriatal system, support the clinical evaluation of neboglamine as a treatment for schizophrenia., ((c) 2009 Elsevier Ltd. All rights reserved.)

Objective: The daytime log-cortisol slope appears to be of growing importance in studying the relationship between stress and health. How best to estimate that slope with minimal burden to the participants and the cost of the study is a decision often made without empiric foundation., Methods: In 50 older participants, the authors examined cortisol assay comparability across laboratories, assay reliability, test-retest reliability of slopes, and comparability of slope estimates for two, three, and four samples per day., Results: The authors demonstrate in an older sample that 1) assay reliability is a relatively minor issue, that one assay per saliva sample suffices; 2) the use of a sample obtained at wake time for each participant appears to be a preferred anchor for the slope estimate in comparison to a sample 30 minutes postwake time; 3) self-reported times appear preferable to automatic time recording; and 4) test-retest reliability of slopes, however, is not sufficiently high to base a slope estimate on one day; minimally two days and preferably three should be required., Conclusions: Whether these conclusions apply to other populations, or using other protocols, is not assured, but the study itself provides a model that can be used to check research decisions. Unnecessarily imposing a burdensome protocol has both ethical and scientific ramifications and should be carefully avoided.

Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.

Peri-anastomotic graft stenosis is a possible complication of coronary artery bypass graft operations. Early failure of myocardial revascularization may result from graft stenosis with inherent difficulties in perioperative diagnosis and subsequent management. We report the case of a 58-year-old man who experienced early preanastomotic left internal thoracic artery bypass stenosis that progressively resolved during a 2-year period without reoperation or interventional angioplasty. Although the mechanisms underlying graft stenosis remain unclear, this case emphasizes the role of repeated coronary angiography in the choice of treatment.

The femoral artery is the usual site of arterial cannulation in thoracic aorta operations through left posterolateral thoracotomy that require cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA). The advantage of this perfusion route is in limiting the duration of circulatory arrest. It is associated, however, with the risk of retrograde embolization or, in cases involving aortic dissection, malperfusion of vital organs. To prevent these risks, we have used the extrathoracic left common carotid artery as the perfusion route. From December 1999 to January 2003, we used cannulation of the left extrathoracic common carotid artery in 42 thoracic aorta operations through posterolateral thoracotomy with an open proximal anastomosis technique during DHCA. The indication for thoracic aortic repair was atherosclerotic ulcer in 7 cases, chronic aortic aneurysm in 18, acute type B dissection in 5, and chronic type B dissection in 12. Cannulation of the extrathoracic left common carotid artery was successful in all patients. Postoperative recovery was uneventful, with no cerebrovascular events in all cases. No cannulation-related complications were observed. One patient died from cardiac insufficiency on postoperative day 5. No peripheral neurological deficits (paraplegia or paraparesis) were observed. Postoperative complications included atrial fibrillation in five patients, reoperation to control hemorrhage in six, respiratory insufficiency in nine, and renal insufficiency in six. These results indicate that cannulation of the left extrathoracic common carotid artery is a useful, reliable method for proximal perfusion during CPB in patients undergoing repair of the descending thoracic aorta through left posterolateral thoracotomy. By providing effective perfusion of the brain, this technique can prolong safe DHCA time. Another advantage is the prevention of cerebral emboli, ensuring retrograde flow to the aortic arch.

In patients with diffuse aneurysmal disease, the "elephant trunk" technique, which uses surplus intravascular graft length to facilitate subsequent operations on the downstream aorta, is an accepted method of treatment. Nevertheless, in the presence of large aneurysms without a definite neck beyond the left subclavian artery, there is an increased risk of rupture at the level of the distal anastomosis. My colleagues and I herein describe a modified elephant trunk technique performed with a new prosthesis, which was conceived to overcome the difficulties and the risks inherent in a large aneurysmal neck.

This report describes a ruptured internal iliac artery aneurysm that presented as a rectus sheath hematoma (RSH). The patient developed abdominal pain and a large, tense lower abdominal wall mass without peritoneal signs. Computed tomography scan demonstrated a massive RSH contiguous with a ruptured left internal iliac artery aneurysm. Hypovolemic shock prompted immediate laparotomy, aneurysmorrhaphy of the ruptured aneurysm, and evacuation of the rectus hematoma. This uncommon presentation of internal iliac aneurysm rupture should caution against a simple diagnosis of "spontaneous" RSH in a patient with a potentially ruptured iliac aneurysm.

Background: The purpose of this study was to determine whether patients who undergo thoracic aorta repairs with the aid of hypothermic circulatory arrest experience impairments in cerebral autoregulation, and to ascertain the influence of three different techniques of cerebral protection on autoregulatory function., Methods: Sixty-seven patients undergoing elective aortic arch procedures with hypothermic circulatory arrest were tested for cerebral dynamic autoregulation using continuous transcranial Doppler velocity and blood pressure recordings. Twenty-three patients were treated using hypothermic circulatory arrest without adjuncts (group 1), 25 using antegrade cerebral perfusion (group 2), and 19 using retrograde cerebral perfusion (group 3)., Results: There were no hospital deaths. Two major strokes occurred in this series; 9 patients experienced temporary neurologic dysfunction: in all these patients severe impairment of cerebral autoregulation was observed. Cerebral autoregulation in the immediate postoperative period was preserved only in patients treated with antegrade cerebral perfusion. Severe impairments were observed in the other two groups in which the degree of autoregulatory response was inversely correlated to the duration of the cerebral protection time during hypothermic circulatory arrest. Postoperative improvement of autoregulatory function was observed in the majority of patients. Our data suggest the exposure to brain damage in the presence of autoregulation impairment, thus indicating that postoperative hypotensive phases may further contribute to neurologic impairment., Conclusions: The status of cerebral autoregulation in the postoperative period after hypothermic circulatory arrest procedures is profoundly altered. The degree of impairment is influenced by the cerebral protection technique. This study indicates the beneficial role of antegrade perfusion during hypothermic circulatory arrest for the preservation of this function and suggests that postoperative cerebral autoregulation impairment can be regarded as an expression of central nervous system injury.

Background: Scientific evidence exists to support the claim that either general o regional anesthesia can be safely used for CEA: each of the techniques has either theoretical and practical advantages or drawbacks. Since the issue of whether, for CEA, one anesthetic technique is better than another has not yet been explored by randomized trials, any contribution that could reduce the disadvantages of any of the two approaches may contribute to overcome individual diffidence and visceral antagonism. The proposed approach represents a technical improvement of locoregional CEA technique., Methods: One hundred consecutive patients undergoing elective or urgent primary CEA under locoregional anesthesia were prospectively randomized in two equal size groups. In group 1 traditional (medial) approach to carotid bifurcation was employed; in group 2 the retrojugular approach (RJA) was used. Surgical and anesthesia scores were developed to assess the differences between the two groups in terms of surgical ease, the quality of exposure, patients comfort, level and quality of anesthesia., Results: Demographic and clinical characteristics of group 1 and group 2 patients were comparable. No major complication or death was observed in this series. Significant score differences were observed in favour of the retrojugular route. Using this route an improved and wider exposure was obtained, moreover, we achieved a better analgesia, with lesser additional anesthetic doses requirements, a faster approach to the carotid bifurcation, an enhanced patient comfort and a reduced interference on the surgical procedure by deglutition movements., Conclusions: The retrojugular route represents the ideal route for locoregional CEA; this exposure, with respect to the traditional approach, minimizes many of the disadvantages commonly considered as major deterrents of regional anesthesia for carotid surgery.

Background: In aortic dissection, visceral complications that result from aortic branch compromise have been described extensively, whereas intestinal ischemia not associated with the false lumen anatomy has rarely been discussed. The aim of this report is to identify clinical factors that may contribute to the development of this form of acute mesenteric ischemia, to profile the patients at greatest risk, and to review diagnostic and treatment methods that emerged from our experience., Methods: With a computerized database, we identified 371 patients who underwent treatment in our institution with a diagnosis of aortic dissection between July 15, 1985, and January 10, 2001. Mesenteric ischemia was present in 73 patients (19%). In 36 patients (9%), bowel ischemia was not associated with a false lumen anatomy or an extension of the dissection process. From a general analysis of the determinants of mesenteric ischemia in aortic dissection, we investigated, with univariate and multivariate analysis, the specific characteristics of these patients with nonocclusive ischemia. A retrospective analysis of the oxygen metabolic profile of patients who underwent operation also was performed., Results: The mortality rate in patients with nonocclusive mesenteric ischemia was 86%; sepsis and multiple organ failure were the causes of death in all nonsurvivors. Surgical treatment was beneficial only in the early phases of the disease. The results of the multivariate analysis showed the multifactorial origin of nonocclusive mesenteric ischemia; cerebral ischemia, thrombosis of the false lumen, severe coagulation disorders, chronic obstructive pulmonary disease, aortic calcinosis, prolonged hypotension, chronic renal insufficiency, and low cardiac output were independent predictors of the condition. In patients who underwent operation, the significant risk factors were severe coagulation disorders, postoperative cerebral ischemia, maximal oxygen extraction rate of more than 0.40, aortic calcinosis, chronic obstructive pulmonary disease, thrombosis of the false lumen, inotropic support, and chronic renal insufficiency. An oxygen extraction rate of more than 0.4 at 6 hours after operation was found to be an index of intestinal damage sufficient to initiate an evaluation for visceral ischemia. Significant differences with occlusive ischemia also were evidenced with this study., Conclusion: In aortic dissection, nonocclusive mesenteric ischemia shows some unique clinical and individual predisposing factors. Most instrumental investigations are of poor diagnostic value, and prognosis is poor, especially when mesenteric gangrene had already taken place. Prevention can be exercised only with a heightening of our awareness of this condition and with timely correction of metabolic disturbances. In suspected cases, an aggressive surgical attitude may represent the only means for reducing mortality.

To assess the diagnostic value of magnetic resonance cholangiography (MRC) when evaluating biliary complications in the follow-up of liver transplant patients. One hundred and thirteen patients prospectively underwent MR imaging and MR cholangiography at 1.5-T unit after orthotopic liver transplantation (OLT). After the acquisition of axial T1- and T2-weighted sequences, MRC involved a coronal, non breath-hold, respiratory-triggered, fat-suppressed, two-dimensional, thin-slab, heavily T2-weighted fast spin-echo sequence, and coronal breath-hold, thick-slab, single-shot T2-weighted sequences. The images and maximum intensity projections were evaluated by two readers in order to determine biliary anatomy and the presence of complications, whose final diagnosis was based on endoscopic retrograde cholangiography (ERC) in 50 patients, percutaneous trans-hepatic cholangiography (PTC) in five, and by integrating clinical follow-up with ultrasound and MR findings in 58 cases. MRC had a sensitivity of 93%, a specificity of 92%, a positive predictive value of 86%, a negative predictive value of 96%, and a global diagnostic accuracy of 93% in detecting all types of biliary complications in OLT patients. MRC is a reliable technique for detecting post-OLT biliary complications. We now restrict the use of ERC to patients for whom therapeutic procedures are advocated or whose MRC results are equivocal.

Aortic root and sinotubular junction dilatation and aneurysm of ascending aorta are considered relative contra-indications to implantation of a stentless valve prosthesis, because the modified aortic geometry leads to aortic incompetence and early failure of the prosthesis. Aortic root reconstruction can be performed according to various techniques. We present a surgical technique in which a tubular graft, replacing an ascending aortic aneurysm, allows sinotubular remodeling and satisfactory implantation of a stentless prosthesis. The native aorta is inserted into the vascular prosthesis at the level of the sinotubular junction which is wrapped in order to prevent commissure spreading. Sizing of the vascular and valve prosthesis is made according to annular diameter. Since October 1999, 6 patients have been operated using this technique with good results.

We present the case of a 79-year-old man suffering from chronic atrial fibrillation, severe left ventricular dysfunction, massive right atrial thrombosis, and pulmonary hypertension. Complete coronary sinus thrombosis was found incidentally during preoperative screening. Successful coronary sinus, right atrial, and pulmonary operative embolectomy was followed soon after by a dramatic improvement of cardiac performance; the patient's left ventricular function recovery, in particular, suggests that cardiac venous system played an important role in the genesis of myocardial impairment.

Extracorporeal shock wave lithotripsy (ESWL) represents the preferred treatment for most upper ureteric and renal calculi. Complication rates associated with ESWL are low, justifying the enthusiasm and acceptance of this treatment modality. As the technique has become more widely available, some deleterious effects on the kidneys and the surrounding tissues are increasingly recognized. We report on the rupture of a severely calcified abdominal aorta in a 65-year-old man who underwent 3 months of ESWL treatment earlier for renal calculi. The patient was seen with an acute recrudescence of a long-standing abdominal and left flank pain, which began immediately after the last of the three sessions of ESWL and was associated with an episode of hypotension that occurred an hour before admission. Patient history and chronologic course of events strongly suggest the role of ESWL in the genesis of abdominal aorta rupture.

Background: Fifteen (+/-)3,4-Methylenedioxymethamphetamine (MDMA) users, who did not show other drug dependencies or prolonged alcohol abuse, and 15 control subjects were included in the study., Methods: Prolactin (PRL) and cortisol (CORT) responses to the serotonergic agonist d-fenfluramine (D-fen), clinical psychobehavioral changes, and psychometric measures were evaluated 3 weeks and then 12 months after MDMA discontinuation., Results: MDMA users showed significantly reduced PRL and CORT responses in comparison with control subjects at 3 weeks (respectively, p < .001; p < .005). The responses of PRL to D-fen were unmodified at 12 months after prolonged abstinence and were significantly reduced in comparison with controls (p < .001). In contrast, CORT responses in MDMA users were restored after 12 months of abstinence, with significantly higher responses to D-fen, in comparison with 3-week responses (p < .05). MDMA users' high scores on the Novelty Seeking (NS) scale on the Tridimensional Personality Questionnaire (TPQ) appeared unchanged by long-term abstinence. In contrast, Buss Durkee Hostility Inventory (BDHI) (Buss and Durkee 1957) direct and guilt scores decreased significantly after 12 months of abstinence. PRL AUCs at 12 months were inversely correlated with the measures of MDMA exposure (r = -.538)., Conclusions: Our data indicate long-lasting 5-HT system impairment in abstinent MDMA users although the hypothesis of serotonergic changes attributable to a premorbid condition cannot be excluded. CORT restored responses to D-fen at 12 months, and the correlation of neuroendocrine changes with MDMA exposure suggest that the neuroendocrine impairment may be due to a partially reversible neurotoxic action of MDMA on the human brain.

The purpose of this study was to evaluate the diagnostic accuracy of MR cholangiopancreatography (MRCP) in the detection of common bile duct stones. A series of 286 consecutive patients were referred for MRCP, that was performed with a 1.5 T MR unit, through a non-breath-hold, respiratory-triggered, fat-suppressed, two-dimensional, heavily T2-weighted fast spin-echo sequence in the coronal plane. Axial T1 and T2-weighted sequences were first obtained. Axial, coronal, and Maximum Intensity Projection images were evaluated by three independent readers, who were asked to determine whether stones were present or not inside the biliary tract. The findings of MRCP images were compared with endoscopic retrograde cholangiopancreatography, percutaneous trans-hepatic cholangiography, intra-operative cholangiography, surgical, or imaging follow-up findings. Two-hundred and seventy-eight out of 286 MRCP examinations were judged diagnostic by the three reviewers. Among the 278 patients included in our study group, biliary tract lithiasis was proved in 76 cases (27%). On the basis of reviewers' reading, MRCP had sensitivity 92-93%, specificity 97-98%, positive predictive value 91-93%, negative predictive value 97-98%, and the diagnostic accuracy ranged between 95% and 96% in the detection of calculi. Interobserver agreement was excellent (K = 0.84, kappa statistic). MRCP showed a high diagnostic accuracy and an excellent inter-observer agreement in the detection of common bile duct stones.

Intramural hematoma of the aorta is a condition increasingly observed in clinical practice. Uncertainty exists whether such lesions represent a different pathology or simply the precursors of classic dissecting aneurysm. The patient was a 76-year-old woman with intramural hematoma of the ascending aorta. Clinical course, progression of the lesion to type A aortic dissection, and surgical treatment are described. Although natural history of intramural hematoma of the ascending aorta is not clearly elucidated, the case presented confirms that the evolution toward intimal flap formation is possible and that we cannot foresee the stabilization of these lesions. We stress that intramural hematoma of the ascending aorta has to be managed as an aortic type A dissection and that aggressive treatment is advisable.

Acute cardiac failure during descending thoracic aorta operations, although rare, may have catastrophic consequences. Under these circumstances, the use of partial veno arterial bypass is advantageous, allowing an assisted perfusion of both proximal and distal circulation districts. Traditionally, the ascending aorta or the aortic arch are the preferred sites of cannulation for proximal arterial reinfusion, but some limitations, such as extensive calcifications or extreme fragility of these segments, may hamper or at least delay this action. Herein, we describe a simple technique for rapid cannulation of proximal aorta in emergency circumstances.

In operations for aortic dissection anastomotic bleeding or secondary anastomosis dehiscence are common problems. The advent of Gelatin-resorcin-formaldehyde-glutaraldehyde (GRF) biologic glue has ameliorated type A dissection operative management. Glue containment is mandatory since detrimental effects of glue migration are described. We herein present a simple technique of anastomosis reinforcement and glue containment that helps in overcoming these complications.