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Introduction: Environmental factors may contribute to myasthenia gravis (MG) development, sometimes with seasonal patterns of exposure. However, whether seasonality has an impact on MG incidence remains unclear. We aimed to investigate the association between seasonality and MG onset., Methods: We reviewed data of MG patients with acetylcholine receptor (AChR)-IgG and disease onset between January 2010-December 2019, from two Italian cohorts: 1) an hospital-based cohort and 2) a population-based cohort. MG cases were assigned to four season-trimesters based on month of onset to determine seasonal association with MG incidence., Results: We enrolled 316 patients:214 in the hospital-based and 102 in the population-based cohort. Median age at onset was 66 years (range, 8-92); Female accounted for 41.1 %. The median number of new MG cases per season-trimester was significantly higher in summer than other trimesters (p = 0.009), and associated with higher environmental temperatures., Discussion: Our findings suggest that MG onset may be more common in summer and at higher environmental temperatures. Identifying the determinants of this association may improve our understanding of disease pathophysiology., Competing Interests: Declaration of competing interest RI has received consultancy fees and speaker honoraria from Alexion, Argenx, UCB and Dianthus Therapeutics. ES has received speaker honoraria and support for attending scientific meetings from Alexion, Horizon and Roche. He serves as an editorial board member for BMC Neurology and Frontiers in Neurology. The remaining authors have no conflicts of interest., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The role of hyperuricemia on short-term clinical prognosis in outpatients with heart failure and reduced ejection fraction (HFrEF) has few investigations and inconclusive results. We evaluated the prognostic impact of serum uric acid (SUA) on short-term clinical outcome among ambulatory patients with chronic HFrEF enrolled in a nationwide cardiology registry, stratified by the presence of chronic renal dysfunction (CKD)., Methods: 2246 outpatients with LVEF ≤40 %, vital status at 1-year follow-up known, and with SUA and creatinine available were stratified accordingly to SUA tertiles (≤5.6 5.7-7.3, >7.3 mg/dl) and by CKD as defined by an estimated glomerular filtration rate < 60 ml/min/1.73m 2 ., Results: Patients in the 2nd and 3rd SUA tertile were older, more symptomatic (NYHA class III-IV), with a lower EF, higher creatinine and heart rate. They had more commonly atrial fibrillation and CKD. At 1-year follow-up, patients in the 2nd and 3rd SUA levels tertile had an increased risk of cardiovascular death and/or HF hospitalization than those in the first tertile (HR 1.72 95 % CI 1.26-2.35, and HR 2.20 95 % CI 1.63-2.97, respectively). After multivariable adjustment, SUA was no longer associated with adverse outcome in the overall cohort. When the multivariable analysis was separately performed in patients with or without CKD, SUA was independently associated with cardiovascular death/HF hospitalization (p = 0.02) only in the latter group., Conclusions: Mildly to moderately elevated SUA levels are associated to one-year survival in outpatients with HFrEF, but hyperuricemia resulted an independent marker of outcome only in patients without CKD., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Recently, cardiac intensive care units (CICUs) have undergone a significant transformation related to the evolution in management of acute coronary syndrome and influenced by other factors such as the epidemiological transition, the increasing complexity of clinical cases, the technological advancement, and the growth of clinical and scientific expertise of cardiologists. In the context of this evolution, a functional reorganization of CICUs in Italy has to be implemented in order to meet the changing needs of the population with cardiovascular disease requiring critical care. Therefore, the Italian Association of Hospital Cardiologists (ANMCO) proposes this position paper for the reorganization of CICUs into three levels with increasing functional complexity, based on the hospital characteristics, the available technology, and clinical cases treated. The system would be functionally integrated into a regional CICU organization modeled on a time-dependent care network. This proposed network aims to standardize diagnostic and therapeutic protocols and establish unified data collection registries to facilitate self-assessment and support clinical research. The document delineates specific requirements for each CICU level, including the management of clinical cases, the expertise of intensive care cardiologists, the technological facilities, and the medical and nursing staff needed to ensure optimal care delivery.

The historical restriction of magnetic resonance imaging (MRI) for patients with cardiac implantable electronic devices (CIEDs) has been lifted by certified MRI-conditional systems in recent years. Mixed-brand CIED systems consisting of a generator from one manufacturer and at least one lead from another manufacturer are not certified for MRI. We evaluated the temporal trend in the prevalence of mixed-brand systems in the era of MRI-conditional systems. Data were analyzed on 5853 CIEDs implanted de novo between 2012 and 2022 in 81 Italian centers linked to the nationwide Home Monitoring Expert Alliance network. The percentage of mixed-brand implants was calculated by device type (pacemaker, implantable cardioverter-defibrillator [ICD], cardiac resynchronization therapy [CRT] device) and over time. A mixed-brand system was implanted in 4.1% (95% CI, 3.6-4.6%) of analyzed patients or, by device type, in 4.5% (3.5-5.7%) of pacemaker patients, 1.1% (0.7-1.7%) of ICD patients, and 6.8% (5.7-7.9%) of CRT pacemaker/defibrillator patients (p < 0.001). Prevalence of mixed-brand implants exhibited significant temporal fluctuations, first declining from 6.6% (2012-2014) to 1.3% (2019), and then increasing to 5.1% (2022). Temporal changes were statistically significant for pacemakers (p < 0.001) and CRT devices (p = 0.001), but not for ICDs (p = 0.438). In the decade between 2012 and 2022, mixed-brand CIED systems were more prevalent in patients treated with pacemakers and CRT devices than in ICD recipients. A decline in the prevalence of mixed-brand systems was observed after the introduction of MRI-conditional systems, reaching a minimum in 2019, followed by a progressive increase in the subsequent years., (© 2024. The Author(s).)

Background and Objectives: Vision significantly contributes to postural control, balance, coordination, and body kinematics, thus deeply influencing everyday functionality. Sight-impaired subjects often show upper body anatomofunctional and kinetic chain alterations negatively impacting daily living efficiency and autonomy. The present study aimed to investigate and train, for the first time, upper body sensorimotor control in an Italian blind baseball team to boost global and segmental functionality while contemporarily prevent injuries. Materials and Methods: The whole team underwent a validated test battery using both quantitative traditional tools, such as goniometric active range of motion and muscular/functional tests, and an innovative biofeedback-based device, a Libra proprioceptive board. Consequently, a 6-week adapted training protocol was designed and leaded to improve sensorimotor control and, hence, counteract disability-related deficits and sport-specific overuse syndromes. Results: Statistically significant improvements were observed in all the investigated parameters. Noteworthy, an overall boost of global and segmental stability was detected through an orthostatic dynamic balance enhancement during the Y Balance test ( p = 0.01) and trunk multiplanar control improvement on the Libra board ( p = 0.01). Concurrently, the comparison of baseline vs. post-intervention outcomes revealed a consistent increase in upper body mobility ( p < 0.05 for all the assessed districts), core recruitment ( p = 0.01 for all the administered functional tests), and proprioceptive postural control ( p = 0.01 for the Libra board validated test). Conclusions: Our findings suggest that a tailored sensorimotor training, conceived and led by an adapted physical activity kinesiologist, may effectively improve upper body functional prerequisites and global proprioceptive control, thus potentially promoting autonomy, quality of life, and physical activity/sport practice adherence in visually impaired individuals.

Introduction: The treatment of patients with cardiogenic shock (CS) encompasses several health technologies including Impella pumps and venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, while they are widely used in clinical practice, information on resource use and quality of life (QoL) associated with these devices is scarce. The aim of this study is, therefore, to collect and comparatively assess clinical and socioeconomic data of Impella versus VA-ECMO for the treatment of patients with severe CS, to ultimately conduct both a cost-effectiveness (CEA) and budget impact (BIA) analyses., Methods and Analysis: This is a prospective plus retrospective, multicentre study conducted under the scientific coordination of the Center for Research on Health and Social Care Management of SDA Bocconi School of Management and clinical coordination of Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute in Milan. The Impella Network stemmed for the purposes of this study and comprises 17 Italian clinical centres from Northern to Southern Regions in Italy. The Italian network qualifies as a subgroup of the international Impella Cardiac Surgery Registry. Patients with CS treated with Impella pumps (CP, 5.0 or 5.5) will be prospectively recruited, and information on clinical outcomes, resource use and QoL collected. Economic data will be retrospectively matched with data from comparable patients treated with VA-ECMO. Both CEA and BIA will be conducted adopting the societal perspective in Italy. This study will contribute to generate new socioeconomic evidence to inform future coverage decisions., Ethics and Dissemination: As of May 2024, most of the clinical centres submitted the documentation to their ethical committee (N=13; 76%), six centres received ethical approval and two centres started to enrol patients. Study results will be published in peer-reviewed publications and disseminated through conference presentations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance., Methods: We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings., Results: The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22-55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P  = 0.229].For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P  = 0.277 vs. P  = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%)., Conclusion: In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope., (Copyright © 2024 Italian Federation of Cardiology - I.F.C. All rights reserved.)

The Italian Network on Congestive Heart Failure (IN-CHF) project, later known as IN-HF Online, was launched in 1995 to provide the Italian cardiology community with a digital tool, standardized across the country, for managing outpatients with heart failure (HF), that enabled the creation of a database for clinical, educational and scientific purposes. During its almost three decades of activity, this observational research program has achieved highly positive scientific results. Indeed, IN-HF fostered professional relationships among individuals working in different centers, established a cultural network for the care of HF patients, periodically updated on the scientific advances, and allowed the assessment of several clinical, epidemiological, and prognostic features. These findings have been published in numerous national and international journals, as summarized in the present overview.

Background: Despite being a major advancement in modern medicine, vaccines face widespread hesitancy and refusal, posing challenges to immunization campaigns. The COVID-19 pandemic accentuated vaccine hesitancy, emphasizing the pivotal role of beliefs in efficacy and safety on vaccine acceptance rates. This study explores the influence of efficacy and safety perceptions on vaccine uptake in Italy during the pandemic., Methods: We administered a 70-item questionnaire to a representative sample of 600 Italian speakers. Participants were tasked with assessing the perceived effectiveness and safety of each vaccine dose, along with providing reasons influencing their vaccination choices. Additionally, we conducted an experimental manipulation, exploring the effects of four framing messages that emphasized safety and/or efficacy on participants' willingness to receive a hypothetical fourth vaccine dose. Furthermore, participants were asked about their level of trust in the scientific community and public authorities, as well as their use of different information channels for obtaining COVID-19-related information., Results: Our study reveals a dynamic shift in vaccine efficacy and safety perceptions throughout the COVID-19 pandemic, potentially influencing vaccination compliance. Initially perceived as more effective than safe, this assessment reversed by the time of the third dose. Beliefs regarding safety, rather than efficacy, played a significant role in anticipating future vaccinations (e.g., the booster dose). Safety-focused messages positively affected vaccination intent, while efficacy-focused messages showed limited impact. We also observed a changing trend in reasons for vaccination, with a decline in infection-related reasons and an increase in social related ones. Furthermore, trust dynamics evolved differently for public authorities and the scientific community., Conclusions: Vaccine perception is a dynamic process shaped by evolving factors like efficacy and safety perceptions, trust levels, and individual motivations. Our study sheds light on the complex dynamics that underlie the perception of vaccine safety and efficacy, and their impact on willingness to vaccinate. We discuss these results in light of bounded rationality, loss aversion and classic utility theory., (© 2024. The Author(s).)

Neuroendocrine neoplasms (NENs) are rare tumors with diverse clinical behaviors. Large databases like the Surveillance, Epidemiology, and End Results (SEER) program and national NEN registries have provided significant epidemiological knowledge, but they have limitations given the recent advancements in NEN diagnostics and treatments. For instance, newer imaging techniques and therapies have revolutionized NEN management, rendering older data less representative. Additionally, crucial parameters, like the Ki67 index, are missing from many databases. Acknowledging these gaps, the Italian Association for Neuroendocrine Tumors (Itanet) initiated a national multicenter prospective database in 2019, aiming to gather data on newly-diagnosed gastroenteropancreatic neuroendocrine (GEP) NENs. This observational study, coordinated by Itanet, includes patients from 37 Italian centers. The database, which is rigorously maintained and updated, focuses on diverse parameters including age, diagnostic techniques, tumor stage, treatments, and survival metrics. As of October 2023, data from 1,600 patients have been recorded, with an anticipation of reaching 3600 by the end of 2025. This study aims at understanding the epidemiology, clinical attributes, and treatment strategies for GEP-NENs in Italy, and to introduce the Itanet database project. Once comprehensive follow-up data will be acquired, the goal will be to discern predictors of treatment outcomes and disease prognosis. The Itanet database will offer an unparalleled, updated perspective on GEP-NENs, addressing the limitations of older databases and aiding in optimizing patient care. STUDY REGISTRATION: This protocol was registered in clinicaltriasl.gov (NCT04282083)., (© 2024. The Author(s).)

Background: Recent data indicate that end-of-life management for patients affected by acute decompensated heart failure in cardiac intensive care units is aggressive, with late or no engagement of palliative care teams., Objective: To assess current palliative care and end-of-life practices in a contemporary Italian multicenter registry of patients with cardiogenic shock due to acute decompensated heart failure., Methods: A survey-based approach was used to collect data on palliative care and end-of-life management practices. The AltShock-2 registry enrolled patients with cardiogenic shock from 12 participating centers. A subset of 153 patients with cardiogenic shock due to acute decompensated heart failure enrolled between March 2020 and March 2023 was analyzed, with a focus on early engagement of palliative care teams and deactivation of implantable cardioverter-defibrillators (ICDs)., Results: "Do not resuscitate" orders were documented in patient records in only 5 of 12 centers (42%). Palliative care teams were engaged for 21 of 153 enrolled patients (13.7%). Among the 51 patients with ICDs, 6 of 17 patients who died (35%) had defibrillator deactivation. Of the 17 patients who died, 13 died in the hospital and 4 died within 6 months after discharge; 1 patient had ICD deactivation supported by palliative care services at home., Conclusions: Therapy-limiting practices, including ICD deactivation, are not routine in the Italian centers participating in this study. The results emphasize the importance of integrating palliative care as a simultaneous process with intensive care to address the unmet needs of these patients and their families., (©2024 American Association of Critical-Care Nurses.)

Visual input significantly affects kinesthesis skills and, hence, visually impaired individuals show less developed sensorimotor control, especially in an unfamiliar outdoor environment. Regular blind baseball practice can counteract such a deficit but, given the complex kinetic chain model required, a targeted workout proposal is needed to improve the main athletic gesture performance. On these premises, we investigated, for the first time, the running and pitching performance of a competitive Italian blind baseball team through quantitative tools and parameters such as Libra Easytech sensorized proprioceptive board, goniometric active range of motion, chronometric speed, and pitching linear length. Moreover, the perceived physical exertion was assessed by the Borg CR10 scale. Consequently, an adapted athletic training protocol was designed and tested on the field during the competitive season, with the aim to strengthen sport specific-gesture coordination and efficacy as well as to prevent injuries. Quantitative assessments showed an improvement in ankle stability index, bilateral upper limb and hip mobility, reactive agility, running braking phase control during second base approaching, and auditory target-related pitching accuracy along with a decrease in perceived physical exertion. This protocol might therefore represent an effective and easily reproducible training and evaluation approach to tailor management of visually impaired baseball players, and safely improve their athletic performance under the supervision of an adapted exercise specialist.

A significant decline in the admission to intensive cardiac care unit (ICCU) has been noted in Italy during the COVID-19 outbreak. Previous studies have provided data on clinical features and outcome of these patients, but information is still incomplete. In this multicenter study conducted in six ICCUs, we enrolled consecutive adult patients admitted to ICCU in three specific time intervals: from February 8 to March 9, 2020 [before national lockdown (pre-LD)], from March 10 to April 9, 2020 [during the first period of national lockdown (in-LD)] and from May 18 to June 17, 2020 [soon after the end of all containment measures (after-LD)]. Compared to pre-LD, in-LD was associated with a significant drop in the admission to ICCU for all causes (- 35%) and acute coronary syndrome (ACS; - 49%), with a rebound soon after-LD. The in-LD reduction was greater for women (- 49%) and NSTEMI (- 61%) compared to men (- 28%) and STEMI (- 33%). Length-of-stay, and in-hospital mortality did not show any significant change from to pre-LD to in-LD in the whole population as well as in the ACS group. This study confirms a notable reduction in the admissions to ICCUs from pre-LD to in-LD followed by an increment in the admission rates after-LD. These data strongly suggest that people, particularly women and patients with NSTEMI, are reluctant to seek medical care during lockdown, possibly due to the fear of viral infection. Such a phenomenon, however, was not associated with a rise in mortality among patients who get hospitalization., (© 2021. Società Italiana di Medicina Interna (SIMI).)

In the Adriatic Sea, massive rainfall events are causing flooding of rivers and streams, with severe consequences on the environment. The consequent bacterial contamination of bathing water poses public health risks besides damaging tourism and the economy. This study was conducted in the framework of WATERCARE, an EU Interreg Italy-Croatia Project, which aims at reducing the impact of microbial contamination on Adriatic bathing water due to heavy rainfall events drained in the local sewage network and; enhancing the quality of local waters; and providing support for the decision-making processes regarding the management of bathing water in line with EU regulations. The study involved the development of an innovative water quality integrated system that helps meet these objectives. It consists of four components: a real time hydro-meteorological monitoring system; an autosampler to collect freshwater samples during and after significant rainfall events; a forecast system to simulate the dispersion of pollutants in seawater; and a real-time alert system that can predict the potential ecological risk from the microbial contamination of seawater. The system was developed and tested at a pilot site (Fano, Italy). These preliminary results will be used to develop guidelines for urban wastewater and coastal system quality assessments to contribute to develop policy actions and final governance decisions., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Aims: Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists., Methods and Results: A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006)., Conclusion: Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: During the COVID-19 pandemic in-person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home-delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centers., Methods: According to individual patient preference or the organizational decision of the center, patients were assigned to the home-delivery group or the standard in-clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centers were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months., Results: RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min [25th-75th percentile: 10-20]. 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID-19 pandemic and possibly beyond., Conclusions: Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high-quality care., (© 2021 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

Covid-19 pandemics has fostered a pervasive use of facemasks all around the world. While they help in preventing infection, there are concerns related to the possible impact of facemasks on social communication. The present study investigates how emotion recognition, trust attribution and re-identification of faces differ when faces are seen without mask, with a standard medical facemask, and with a transparent facemask restoring visual access to the mouth region. Our results show that, in contrast to standard medical facemasks, transparent masks significantly spare the capability to recognize emotional expressions. Moreover, transparent masks spare the capability to infer trustworthiness from faces with respect to standard medical facemasks which, in turn, dampen the perceived untrustworthiness of faces. Remarkably, while transparent masks (unlike standard masks) do not impair emotion recognition and trust attribution, they seemingly do impair the subsequent re-identification of the same, unmasked, face (like standard masks). Taken together, this evidence supports a dissociation between mechanisms sustaining emotion and identity processing. This study represents a pivotal step in the much-needed analysis of face reading when the lower portion of the face is occluded by a facemask.

Background and Aims: Familial hypercholesterolaemia (FH) is a powerful risk factor for cardiovascular (CV) events. High levels of low-density lipoprotein cholesterol (LDL-C) since birth are linked to the early onset of atherosclerotic disease. A genetic mutation determining FH is present in about one subject out of 250; FH should be more represented among subjects with a documented diagnosis of coronary artery disease (CAD). The POSTER Study evaluated the prevalence of FH in Italian patients with a recent CAD event., Methods: Eighty-two cardiology centres enrolled patients with a documented CAD event; CV risk profile, drug therapy and biochemical parameters were collected. Dutch Lipid Clinic Network (DLCN) criteria were used to define patients with a potential FH diagnosis (score ≥6); these patients underwent molecular testing for genetic diagnosis of FH., Results: Overall, 5415 patients were enrolled and the main index events were myocardial infarction with ST-elevation, non ST-elevation acute coronary syndrome (ACS), or a recent coronary revascularization (34.8%, 37.2%, and 28% respectively). Mean age was 66 ± 11 years, men were 78%; about 40% were already treated with statins, proportion that increased after the acute event (96.5%). Based on the DLCN score, the prevalence of potential FH was 5.1%, 0.9% of them had a diagnosis of definite FH (score >8). These patients were younger than patients with a score <6 (56 ± 10 vs 66 ± 11, p < 0.001), and LDL-C levels were in most of them (~87%) >190 mg/dL. FH was genetically confirmed in 42 subjects (15.9%); genetic diagnosis was defined as not conclusive for FH in 63 patients (23.9%). Finally, in 159 subjects (60.2%) no pathogenic mutations in the tested genes were identified, defining them as negative for monogenic familial hypercholesterolemia., Conclusions: Results underscore a relatively high prevalence of potential FH in patients with a recent CAD event. Therefore, an early identification of these subjects may help improve the management of their high CV risk and, by cascade screening, identify possible FH relatives., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Atrial fibrillation is common in the setting of acute coronary syndromes (ACS) although its impact on ACS remains controversial., Aim: To describe in-hospital management of patients with atrial fibrillation and ACS evaluating the impact of atrial fibrillation on in-hospital and mid-term outcome., Methods: We analysed the data of two prospective multicentre nationwide registries (IN-ACS Outcome and MANTRA) to assess clinical characteristics, management, and outcomes of patients with ACS and atrial fibrillation. Study outcomes included death from any cause and a composite end-point of death/re-infarction/stroke/major bleeding within index admission and 6 months' follow-up., Results: Out of 12 288 ACS patients, 1236 (10.1%) had atrial fibrillation at admission or developed it during hospitalization. Atrial fibrillation patients were older, more often female, and had higher burden of comorbidities. In-hospital mortality was higher among atrial fibrillation patients (8.7 vs. 2.4%, P < 0.001). Patients with atrial fibrillation had a higher incidence of re-infarction (3.5 vs. 1.7%, P < 0.0001) and ischemic stroke (1.7 vs. 0.4%, P < 0.001) compared with those in sinus rhythm. Major bleedings were also more frequent among atrial fibrillation patients (1.9 vs. 0.9%, P < 0.001). In-hospital and at 6 months' follow-up death from any cause occurred more often in atrial fibrillation patients than in those without atrial fibrillation (9.4 vs. 3.5%, P < 0.0001). At multivariable analysis, atrial fibrillation was an independent predictor of the in-hospital composite end-point (OR 1.67, 95% CI 1.35-2.06, P < 0.0001) but not at 6 months' follow-up. The independent role of atrial fibrillation on the in-hospital composite end-point was also confirmed by propensity score analyses., Conclusion: Atrial fibrillation was an independent predictor for adverse in-hospital outcome in ACS. This effect disappeared at mid-term follow-up, whereas noncardiac comorbidities emerged as prognostic factors of adverse outcomes.

Ports receive a variety of contaminants related to a wide range of anthropogenic activities - including ship ballast water (BW) - that ultimately find their way to sediments. Benthic meiofauna from four Adriatic ports (Ancona, Trieste, Koper, and Split) was assessed for the main environmental pollutants, to evaluate the effects of human activities on meiobenthos and identify the most appropriate descriptor to assess the ecological quality of marine ecosystems. Sediment analysis demonstrated that Trieste and Split were the most contaminated ports, followed by Koper and Ancona. All meiofaunal parameters showed high spatial and temporal variability, in line with the marked heterogeneity of the four ports. Sand, total organic carbon, and pollutants seemed to be the variables that best explained meiofaunal patterns. Community structure and rare taxa were the meiofaunal descriptors that reflected the environmental status and biological response most accurately. The present data suggest that meiofauna can be used to assess the biological impact of BW., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Italian baseball played by visually impaired and blind athletes is an adapted team sport which maintains the peculiar fast-moving features of this popular sport. It is also a mixed team game played together with sighted subjects. Here, we performed a national survey aimed at assessing the differences in psychological well-being (PWB) and quality of life (QoL) between visually impaired baseball players from Italian teams and non-players using a structured online questionnaire. Forty-three visually impaired baseball players and thirty-four visually impaired sedentary individuals completed a structured self-report survey including the validated 18-item Italian versions of the PWB (PWB-18) scale and the Short Form-12 (SF-12) questionnaire to assess the QoL. PWB-18 and SF-12 reference data from the Italian normally sighted population were also employed for comparison with the visually impaired baseball player group. Visually impaired baseball players reported better scores in all dimensions of the PWB-18 scale and significant higher scores in both physical and mental QoL evaluated by SF-12 than the non-player group. In addition, PWB-18 scale findings revealed significant differences between visually impaired baseball players and the reference normally sighted population consisting in lower scores for autonomy, environmental mastery, positive relations with others and purpose in life dimensions. Conversely, the mean scores for PWB-18 personal growth and self-acceptance dimensions were not significantly different between the two groups. The SF-12 questionnaire results demonstrated a significantly higher physical score in visually impaired players compared with the reference population. Instead, the SF-12 mental score of visually impaired athletes tended to be lower, though this difference was not statistically significant. Collectively, our findings suggest that the practice of Italian baseball may have a positive impact on PWB and QoL of visually impaired individuals., Competing Interests: The authors have declared that no competing interests exist.

Introduction: In a society that perpetuates the strive for a perfect appearance, a fit body has become synonymous with success, but simultaneously hard to achieve. This represents a fertile ground for the development of Exercise Addiction (EA) alongside other disorders, such as Body Dysmorphic Disorder (BDD). This study aims to explore the diffusion of EA in fitness settings in the United Kingdom, Italy, Netherlands, Hungary and the previously unexplored association with appearance anxiety, BDD, self-esteem and the use of fitness supplements., Methods: A large cross-sectional sample (N = 1711) was surveyed in fitness settings using the Exercise Addiction Inventory (EAI), Appearance Anxiety Inventory (AAI) and Rosenberg's Self Esteem Scale (RSE) in addition to questions surrounding the use of fitness supplements., Results: Compulsive exercise, appearance anxiety and low self-esteem were present in this sample according to the psychometric measures used (EAI, AAI, RSE). 11.7% scored over the cut off for EA, with alarming peaks in the Netherlands (20.9%) and the United Kingdom (16.1%). 38.5% were found at risk of BDD, mainly female (47.2%). 39.8% used fitness enhancing supplements without medical consultation (95.5%). This cohort of supplement users scored higher in both EAI and AAI. The logistic regression model revealed a strong association between the consumption of sport products and the level of EA across the sample with an odds ratio (OR) of 3.03. Other co-variable factors among female were appearance anxiety (AAI; OR 1.59) and to a lesser extent self-esteem (RSE) (OR 1.08)., Conclusions: This study identified a high risk of EA, appearance anxiety and BDD amongst a cohort of gym users internationally. The previously-unexplored association between these disorders and the unsupervised use of a variety of fitness products, including illicit drugs, highlights the need for informed and integrated responses targeting such vulnerable individuals., Competing Interests: The authors have declared that no competing interests exist.

A new cell type named telocyte (i.e. cell with distinctive prolongations called telopodes) has recently been identified in the stroma of various organs in humans. However, no study has yet reported the existence of telocytes in the synovial membrane of diarthrodial joints. This work was therefore undertaken to search for telocytes in the normal human synovium using transmission electron microscopy, immunohistochemistry and immunofluorescence. Ultrastructural analyses demonstrated the presence of numerous spindle-shaped telocytes in the whole synovial sublining layer. Synovial telocytes exhibited very long and thin moniliform telopodes and were particularly concentrated at the boundary between the lining and sublining layers and around blood vessels. Light microscopy confirmed the presence of CD34-positive telocytes in the aforementioned locations. Moreover, synovial telocytes coexpressed CD34 and platelet-derived growth factor receptor α. Double immunostaining further allowed to unequivocally differentiate synovial telocytes (CD34-positive/CD31-negative) from vascular endothelial cells (CD34-positive/CD31-positive). The in vitro examination of fibroblast-like synoviocyte primary cultures revealed the coexistence of different cell types, including CD34-positive telocytes projecting typical moniliform telopodes. In conclusion, our work provides the first evidence that telocytes do exist in the human synovium and lays the groundwork for future studies on synovial telocytes in a variety of degenerative and destructive joint diseases.

Purpose: The purpose of this study was to evaluate the effectiveness of a specific adapted physical activity (APA) protocol on upper limb disability and quality of life in breast cancer survivors and to assess longitudinally the possible role of APA on long-term benefits., Methods: Breast cancer survivors from an Italian cohort were assessed by fitness tests (shoulder-arm mobility, range of motion, and back flexibility) before and after 8-week APA. Quality of life and back and surgical shoulder pain intensity were evaluated by Short Form-12 and numerical rating scale questionnaires, respectively. At 1.5-year post-APA follow-up, survivors were evaluated as at baseline/post-APA to assess long-term effects., Results: A statistically significant improvement in shoulder-arm mobility, pain perception, and quality of life was observed in breast cancer survivors after APA intervention. Longitudinal analyses indicated an overall decrease in the achieved benefits at 1.5-year post-APA., Conclusions: The survivorship phase of breast cancer requires a multidisciplinary collaboration involving either the cancer-care medical team or APA professionals to manage psychophysical outcomes. A specific APA protocol may represent an effective countermeasure to reduce post-treatment upper limb disability and improve the quality of life in breast cancer survivors. Participation in structured APA protocols should be maintained over time to preserve the achieved benefits.

Aims: Accurate selection of patients with left bundle branch block (LBBB) may help increasing response to cardiac resynchronization therapy (CRT). There is no agreement on LBBB definition. The aim of the study was to investigate the prevalence of 'true-LBBB' according to Strauss in patients undergoing CRT., Methods and Results: The study population included 414 consecutive patients (71.9% men; mean age 69.7 ± 9.6 years), who underwent CRT according to 2010 European Society of Cardiology (ESC) guidelines. Patients were classified into three groups: traditional LBBB according to American Heart Association, LBBB according to Strauss and intraventricular conduction delay (IVCD). Subsequently, they were re-classified into classes of recommendations, according to the current 2013 ESC Guidelines. Traditional LBBB was recorded in 229 patients (55%), an LBBB according to Strauss in 153 (37%) and an IVCD in 32 (8%). Patients with an LBBB according to Strauss showed a significantly more prolonged QRS duration (P < 0.001), greater baseline end-systolic and end-diastolic volumes (P = 0.011 and P = 0.013, respectively) compared with those with IVCD. The prevalence of mid-QRS notching in at least two contiguous leads was 100% in LBBB according to Strauss; 24% in traditional LBBB and 21.9% in IVCD (P < 0.001). At multivariate analysis, PR interval less than 200 ms and QRS of at least 150 ms were independent predictors of mid-QRS notching [odds ratio (OR) 1.78; 95% confidence interval (95% CI) 1.10-2.88; P = 0.02 and OR 2.88; 95% CI 1.80-4.62;P < 0.0001]. Applying stricter criteria for LBBB according to Strauss, a significant reduction in Class I recommendation and an increase in Class II was observed (90.1 vs. 37%; P < 0.0001 and 9.9 vs. 63%; P < 0.0001)., Conclusions: Applying stricter criteria, only 37% of patients undergoing CRT showed a true-LBBB according to Strauss. Accurate identification of true-LBBB may have a potential additional value in better selecting patients.

Aims: Unplanned readmissions early after a discharge from acute heart failure hospitalization are common and have become a reimbursement benchmark and marker of hospital quality. However, the competing risk of short-term post-discharge mortality is substantial., Methods and Results: Using data from the prospective, nationwide Registry IN-HF Outcome, we analysed the incidence and predictors of 30-day mortality or readmissions and associated days-alive-out-of-hospital (DAOH) in 1520 patients discharged alive after admission for acute heart failure. Within 30 days after discharge, 94 patients (6.2%) were readmitted (91% for cardiovascular causes; 60% recurrent heart failure) and 42 (2.8%) died, 10 of which occurred during readmission. Overall, 126 patients (8.3%) met the combined endpoint. By multivariable logistic regression, worsening chronic heart failure as clinical presentation [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.21-2.77, P = 0.005), inotropes during admission (OR 2.19, 95% CI 1.40-3.43, P = 0.0006), length of stay (OR 1.02, 95% CI 1.01-1.04, P = 0.002) and renin-angiotensin system inhibitors at discharge (OR 0.52, 95%CI 0.35-0.77, P = 0.001) independently predicted 30-day all-cause mortality and/or readmission (c-statistic = 0.695). Per cent 30-day DAOH was lower in patients with in-hospital inotrope use, no renin-angiotensin system inhibitors prescription at discharge, New York Heart Association III-IV class at discharge, and correlated inversely with length of stay and age., Conclusion: A clinical and biohumoral profile consistent with chronic advanced heart failure and end-organ damage identifies acute heart failure patients discharged home from cardiology units, who are at highest risk of early death and/or readmission. These findings have practical implications for tailoring specific follow-up., (© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.)

Aims: Although acute heart failure (AHF) is a potential complication of acute aortic syndromes (AAS), its clinical details and management implications have been scarcely evaluated. This study aimed to assess prevalence, pathophysiological mechanisms, impact on treatment, and in-hospital mortality of AHF in AAS., Methods and Results: Data were collected from a prospective AAS registry (398 patients diagnosed between 2000 and 2013). Patients with AHF were identified by the presence of dyspnoea as the presentation symptom or radiological signs of pulmonary congestion or cardiogenic shock, including patients with cardiac tamponade (CT). AHF frequency was 28% (Stanford type A 32% vs. type B 20%, P = 0.01). Four mechanisms leading to AHF were identified, alone or in combination: CT (26%), aortic regurgitation (25%), myocardial ischaemia (17%), and hypertensive crisis (10%). In type A patients, aortic regurgitation and CT were the most frequent mechanisms, whereas myocardial ischaemia and hypertensive crisis were the most frequent in type B patients. Although no difference was noted for diagnostic times, AHF at presentation led to a longer surgical delay in type A AAS. In-hospital mortality was higher in patients with AHF compared with those without (34% vs. 17%, P < 0.001). After multivariable analysis, AHF was associated with increased risk of in-hospital death (adjusted odds ratio 1.97, 95% confidence interval 1.14-3.36, P = 0.014)., Conclusion: AHF occurs in more than a quarter of patients with AAS of both type A and type B, is due to a variety of pathophysiological mechanisms, and is associated with increased surgical delay and in-hospital mortality., (© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.)

Advanced heart failure (HF) is a deadly condition. Fortunately, an increasing array of effective (but often expensive) therapies has become available. The management of patients with advanced HF is complex and requires a high level of expertise. The American Board of Internal Medicine was the first regulatory board to recognize the need for a subspecialty in Advanced HF and Transplant Cardiology. More recently, the HF Association of the European Society of Cardiology has proposed a curriculum for HF specialists that includes the optional module of advanced HF therapy. However, the successful completion of such a curriculum does not result in a European Certification in Heart Failure, because no European Board of Medicine does exist. While in some European countries the secondary specialty of HF has been implemented, no country has a subspecialty in advanced HF. The ANMCO HF Area has proposed a survey to 25 Italian centers with accredited programs for heart transplant or ventricular assist device implant as destination therapy with the aim to assess the actual need of a certification of clinical competence in advanced HF and a certification of institutional competence for the centers with the highest expertise in advanced HF management. The survey indicated that there is a perceived need. A first step towards education of advanced HF specialists could be the implementation of CME courses by Scientific Societies. As regards certification of institutional competence for the centers with the highest expertise in advanced HF management, the government appears to be the only entity that can grant it.

Background: Physical activity interventions are known to be effective in improving the physical and psychological complaints of breast cancer survivors., Purpose: To investigate the impact of a specific exercise training program on upper limb mobility and quality of life in breast cancer survivors., Methods: The study included 55 women recruited at the Cancer Rehabilitation Centre in Florence after the completion of breast cancer treatment and rehabilitative physiotherapy. All participants underwent an 8-week specific exercise training to improve upper limb mobility function and quality of life. Anthropometric parameters were measured, and each subject underwent a battery of fitness tests to assess shoulder-arm mobility, range of motion, and back flexibility before and after specific exercise program. All participants filled out the Short Form-12 and numerical rating scale questionnaires to assess the quality of life and to quantify back and shoulder pain intensity., Results: The evaluation of shoulder-arm mobility and self-reported questionnaire data revealed a statistically significant improvement after completion of our specific exercise program., Conclusion: An organized specific program of adapted physical activity can be effective in reducing the main adverse effects of surgery and oncological therapy, and may significantly improve shoulder-arm mobility and quality of life in breast cancer survivors.

Background: Concerns about protecting patient's privacy can interfere with proper stress adaptation which is associated with physician's health. It is important to investigate relevant organizational confounders to this phenomenon to enable interventions that can ameliorate the subjective burden of patient confidentiality., Objectives: This study investigates factors in the psychosocial work environment that can explain patient confidentiality's prominence in social support seeking among physicians, and if these factors covary differently with support seeking according to country., Participants: University hospital physicians in four European cities (N=2095) in Sweden, Norway, Iceland and Italy participated in a cross-sectional survey., Methods: Questionnaire comprised items on psychosocial work environment, basic socio-demographics, presence of formal and informal meetings at work, and measurement of confidentiality as a barrier for support., Results: High role conflict, availability of formal or informal meetings, lack of control over decisions, and lack of control over work pace were predictors of confidentiality as a barrier to support. There were differences between countries in how these factors covaried with confidentiality as a barrier to support. High role conflict was the strongest predictor of confidentiality as a barrier to support across all samples., Conclusions: Psychosocial work factors predicted confidentiality as a barrier to support seeking among physicians. It is important to create routines and an organizational framework that ensures both the patient's right to privacy and physician's ability to cope with emotional demanding situations from work.

Concerns about protecting patient's privacy are experienced as a limitation in the opportunity to obtain and utilize social support by many physicians. As resources of social support can modify the process of burnout, patient confidentiality may increase risk of this syndrome by interfering with proper stress adaptation. This study investigates if experiencing limitations in seeking social support due to confidentiality concerns are associated with burnout. University hospital physicians in four European countries completed measures of burnout, (Index) of Confidentiality as a Barrier for Support (ICBS), and factors of social resources and job demands. Linear regression analysis showed that ICBS was significantly associated with the burnout dimension of Exhaustion and not with Disengagement. These findings were present when controlling for factors known to diminish or increase the likelihood of burnout. These results are the first to demonstrate that patient confidentiality is associated with burnout in the process of stress management among physicians., (Copyright © 2013 John Wiley & Sons, Ltd.)

Background: Correlations between psychiatric disorders and overweight/obesity are reported in the literature. However, temperament/personality traits have been less frequently studied even though the correlation with Axis-1 diseases is well defined. The present study aims to detect correlations between psychiatric disorders, temperament traits and body image perception in overweight and obese patients who seek surgical lipostructuring treatment., Methods: Seventy overweight/obese patients (age 18-60 years, BMI 25-34.9 at recruitment) referring to the outpatient service for obesity-related lipodystrophism were enrolled in the period March 2008-March 2012. Psychiatric disorders, temperament traits, and body image perception were evaluated and compared with a control group (N = 33) from the general population sharing clinical/demographic features., Results: Patients had higher scores in lifetime depression, with moderate/mild concern with body shape. Regarding personality traits, tests revealed higher scores on subscale RD4 (dependence/independence) in patients, whereas controls scored higher on the "openness to experience" NEO Five Factory Inventory sub-scale. Obese patients had a higher prevalence of obsessive characteristics., Conclusions: The affective sphere is an important feature in obese patients, as are obsessive traits, since negative body shape perception and temperament and personality characteristics appear to be involved in leading patients to seek surgical advice. These aspects should be involved in medical/surgical outcomes and compliance with treatment. The future possibility of identifying patients who show alterations in these traits or psychic characteristics may represent a possible instrument to avoid early post-treatment relapse and to implement the service offered to patients, with appropriate psychiatric care before and after surgery.

Background: Atrial dilatation and atrial standstill are etiologically heterogeneous phenotypes with poorly defined nosology. In 1983, we described 8-years follow-up of atrial dilatation with standstill evolution in 8 patients from 3 families. We later identified 5 additional patients with identical phenotypes: 1 member of the largest original family and 4 unrelated to the 3 original families. All families are from the same geographic area in Northeast Italy., Methods and Results: We followed up the 13 patients for up to 37 years, extended the clinical investigation and monitoring to living relatives, and investigated the genetic basis of the disease. The disease was characterized by: (1) clinical onset in adulthood; (2) biatrial dilatation up to giant size; (3) early supraventricular arrhythmias with progressive loss of atrial electric activity to atrial standstill; (4) thromboembolic complications; and (5) stable, normal left ventricular function and New York Heart Association functional class during the long-term course of the disease. By linkage analysis, we mapped a locus at 1p36.22 containing the Natriuretic Peptide Precursor A gene. By sequencing Natriuretic Peptide Precursor A, we identified a homozygous missense mutation (p.Arg150Gln) in all living affected individuals of the 6 families. All patients showed low serum levels of atrial natriuretic peptide. Heterozygous mutation carriers were healthy and demonstrated normal levels of atrial natriuretic peptide., Conclusions: Autosomal recessive atrial dilated cardiomyopathy is a rare disease associated with homozygous mutation of the Natriuretic Peptide Precursor A gene and characterized by extreme atrial dilatation with standstill evolution, thromboembolic risk, preserved left ventricular function, and severely decreased levels of atrial natriuretic peptide.

Background and Purpose: The mechanism of dissemination of locally advanced head and neck cancer (LAHNC) is far to be resolved. Circulating tumour cells (CTC) have been identified as a prognostic factor in metastatic breast and prostate cancer. This prospective multi-centric analysis studied the possible role of CTC identification in LAHNC., Materials and Methods: CTC were searched in 73 patients with LAHNC (oropharynx, n=39; nasopharynx, n=10; larynx, n=10; paranasal sinuses, n=6, of whom 3 with sinonasal undifferentiated carcinoma, SNUC; hypopharynx, n=5; oral cavity, n=3). All of them (apart from SNUC) had squamous cell cancers. The relationship between CTC positivity and other clinical prognostic factors has been investigated. Response to treatment and survival has been related with changes in CTC number during the treatment., Results: CTC were frequently identified in oro- and hypopharyngeal cancer and in SNUC. They were more frequent in stage IV than in stages I-III disease (18% versus 6%, p=NS (not significant)). Partial or complete response (CR) was related with the absence or disappearance of CTC during treatment (p=0.017). A decrease in the CTC number or their absence throughout the treatment seems also related with non-progressive disease, after both complete or incomplete remission and with the proportion of patients alive and NED (no evidence of disease) (p=0.009)., Conclusions: These preliminary data suggest a possible role of CTC determination in head and neck cancer. Additional and longer follow up data need to be collected to confirm these findings., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

This paper explores the genetic structure and signatures of natural selection in different sub-populations from the Island of Sardinia, exploiting information from nearly 700,000 autosomal SNPs genotyped with the Affymetrix Genome-Wide Human SNP 6.0 Array. The genetic structure of the Sardinian population and its position within the context of other Mediterranean and European human groups were investigated in depth by comparing our data with publicly available data sets. Principal components and admixture analyses suggest a clustering of the examined samples in two significantly differentiated sub-populations (Ogliastra and Southern Sardinia), as confirmed by AMOVA (F(ST)=0.011; P<0.001). Differentiation of these sub-populations was still evident when they were pooled together with supplementary Sardinian samples from HGDP and compared with several other European, North-African and Near Eastern populations, confirming the uniqueness of the Sardinian genetic background. Moreover, by applying several statistical approaches aimed at assessing differences at the SNP level, the highest differentiated genomic regions between Ogliastra and Southern Sardinia were thus investigated via an extended haplotype homozygosity (EHH)-based test to point out potential selective sweeps. Using this approach, 40 genomic regions were detected, with significant differences between Ogliastra and Southern Sardinia. These regions were subsequently investigated using a long-range haplotype test, which found significant REHH values for SNPs rs11070188 and rs11070192 in the Ogliastra sub-population. In the light of these results and the overlap of the different computed statistics, the region encompassing these loci can be considered a strong candidate to have undergone selective pressure in Ogliastra.

Purpose: Suicidal thoughts, burnout and other signs of psychological distress are prevalent among physicians. There are no studies concerning help-seeking for psychological distress among university hospital physicians, who face a particularly challenging, competitive work environment. We compare psychologically-distressed university hospital physicians who have not sought needed help with those who have sought such help. We thereby aim to identify factors that may hinder help-seeking and factors that may trigger seeking help., Methods: Analysis was performed among university hospital physicians reporting recent suicidal thoughts and/or showing other indications of current psychological ill-health. These distressed physicians were a subgroup (42.7%) from the cross-sectional phase I HOUPE study (Health and Organization among University Hospital Physicians in Europe): 366 from Sweden and 150 from Italy. Having sought professional help for depression or burnout was the outcome variable. Multiple logistic regression was performed with socio-demographic factors as covariates., Results: Altogether 404 (78.3%) of these distressed physicians had never sought professional help for depression/burnout. Physicians who were currently involved in medical research, taking night call, surgical specialists, male, or Italian were least likely to have sought help. Physicians who faced harassment at work or who self-diagnosed and self-treated were more likely to have sought help., Conclusion: Very few of these university hospital physicians with signs of psychological distress sought help from a mental-health professional. This has implications for physicians themselves and for patient care, clinical research, and education of future physicians. More study, preferably of interventional design, is warranted concerning help-seeking among these physicians in need.

Aims and Background: Circulating tumor cells have a prognostic role in metastatic breast cancer. The aim of the study was to confirm the ability of circulating tumor cells, detected by the US Food and Drug Administration approved Cell Search assay, to predict the outcome of patients treated in a community general hospital., Patients and Methods: A prospective mono-institutional study was conducted at the Department of Medical Oncology at Spedali Civili, Brescia, Italy, from January 2009 to September 2010. A total of 93 consecutive patients with metastatic breast cancer were enrolled. Patients underwent a blood sample collection to detect circulating tumor cells at baseline and, subsequently, at the first follow-up examination (after 3-4 weeks from the beginning of a systemic therapy). A third sample was drawn at disease progression (at the beginning of a subsequent new course of therapy). The prognostic cutoff value of circulating tumor cells was fixed at 5 cells/7.5 ml of blood., Results: At baseline, median overall survival and progression-free survival in the subgroup ≥5 circulating tumor cells/7.5 ml of blood were significantly shorter (5 months and 3 months, respectively) than in the subgroup with <5 circulating tumor cells (8 months and 7 months, respectively) (P = 0.003 and P <0.001). At the first follow-up, the subgroup with more than 5 circulating tumor cells/7.5 ml of blood had a median overall survival of 4 months versus 8 months in the subgroup with <5 circulating tumor cells (P <0.001) and a median progression-free survival of 3 months versus 7 months respectively (P <0.001). At multivariate analysis, the level of circulating tumor cells at the first follow-up and at baseline remained significant as a predictor of progression-free and overall survival. The number of metastatic sites was significantly associated with overall and progression-free survival and correlated with the number of circulating tumor cells., Conclusions: Our study confirms the role of circulating tumor cells as predictors of prognosis in metastatic breast cancer patients treated in general clinical practice.

Background: Male and female physicians are at elevated suicide risk. The work environment has become a focus of attention as a possible contributor to this risk. The potential association between work environment and suicidal thoughts has been examined among female physicians in several countries, and significant findings have been reported., Objective: The purpose of this study was to examine the role of the work environment in relation to suicidal thoughts among male university hospital physicians in 2 European countries., Methods: Cross-sectional multivariate analysis was performed to identify significant associations between work-related factors and suicide risk among male physicians from the Health and Organization among University Hospital Physicians in Europe (HOUPE) study. The dependent variable was termed recent suicidal thoughts, which includes having thought about suicide and/or having thought about specific ways to commit suicide within the previous year. Adjusted odds ratios (ORs) and CIs are reported., Results: Of the 456 Swedish (56%) and 241 Italian (39%) male physicians who participated, 12% of the physicians from each country reported affirmatively regarding recent suicidal thoughts. Degrading work experiences were associated with recent suicidal thoughts for the Swedish and Italian physicians (OR = 2.1; 95% CI, 1.01-4.5; OR = 3.3; 95% CI, 1.3-8.0, respectively). Role conflict was associated with recent suicidal thoughts among the Swedish physicians (OR = 1.6; 95% CI, 1.1-2.2). Support at work when difficulties arose appeared to be protective for the Swedish physicians (OR = 0.7; 95% CI, 0.5-0.96). Italian physicians with little control over working conditions had an increased risk of recent suicidal thoughts, whereas confidential discussions about work experiences appeared to be protective (OR = 0.6; 95% CI, 0.4-0.9)., Conclusion: Attention should be paid to the work environment as it relates to suicide risk among male university hospital physicians, particularly to bolstering social support and preventing harassment., (Copyright © 2011 Elsevier HS Journals, Inc. All rights reserved.)

A genotyping assay was setup to assess the prevalence, in the population of a Northern Italian city, of the C/T-13910 single nucleotide polymorphism, closely associated to lactose malabsorption in many world areas including Sardinia. The results were compared to published Italian data, in order to evaluate the worth of a future validation of the assay for use in routine practice. DNA was extracted from blood samples of 123 randomly chosen healthy blood donors coming from the same city area, and was analyzed by a real-time polymerase chain reaction (PCR) genotyping assay; the frequency of the hypolactasia-associated CC-genotype was compared to the weighted average of results extracted from studies reporting the frequency of hypolactasic phenotype or genotype in nearby or distant Italian regions. Sixty-five percent of donors carried the CC-genotype, a percentage similar to other northern Italian cities, but significantly higher than what previously determined in surrounding Italian regions at the phenotype level, i.e. by breath test. This discrepancy parallels recent reports of non concordance between results of genotyping and hypolactasic phenotype in some world areas, including a neighbouring Northern Italian city. A north-south gradient of CC-prevalence was also observed. These results reinforce the notion of wide inter-regional variations in the frequency of C/T-13910 polymorphism and of incostant concordance with hypolactasic phenotype, even in subjects from the same country. Given the unsatisfactory results recently obtained from validation of a related assay in a neighbouring city, the authors decided not to proceed further and keep the assay only as a diagnostic aid in special situations.

Background: Eosinophilic esophagitis is an esophageal disorder characterized by esophageal and/or upper gastrointestinal tract symptoms, and by dense esophageal eosinophilia associated with a normal gastric and duodenal mucosa. Prevalently reported in children, eosinophilic esophagitis has recently been reported with increased frequency also in adults., Aims: The purpose of this study was to report our experience with eosinophilic esophagitis in Italy, since there are only very few series of such patients in our country., Patients and Methods: We retrospectively reviewed the histological data of consecutive patients with a diagnosis of esophagitis or reflux disease in the period September 2004-September 2008. Eosinophils were counted where they appeared most numerous in the biopsy, with a cutoff > 15 eosinophils in more than one high-power field as diagnostic of eosinophilic esophagitis. Patients were excluded if gastric or duodenal biopsies showed a prominent eosinophilic infiltrate., Results: Twenty two patients (14 adults, 8 children, age range 2-59 years) were identified according to the above criteria. The average eosinophil count was 86/ high-power field (range 31-150), associated with other pathologic features (eosinophilic microabscesses eosinophil degranulation, basal zone hyperplasia, papillary elongation). The main clinical complaints were dysphagia, food impaction, and heartburn, and endoscopic findings consisted of mucosal thickening and inelasticity, longitudinal shearing, rings, and white specks, without difference between adults and children for both clinical and endoscopic variables., Conclusions: Eosinophilic esophagitis is not rare in Italy, and displays clinical, endoscopic, and pathologic features similar to those described in other countries.

The research on stress, mobbing, and substance dependence in workers employed in the building of the great infrastructures is part of the project Euridice-Ten. The 75% of the workers employed took part in the research through an anonymous and structured questionnaire. The Clinica del Lavoro of the University of Milan elaborated the data. They point out a high risk of stress, a low level of control, a marked risk of mobbing, a high chronic fatigue in the most exhausting jobs, sleep disorders, problems in the social life as well as at home, in nourishment and at work. Many workers drink too much alcohol and the 9% of the workers know workers who use cocaine.

Background: Suicide rates among physicians are higher than in the general population, and rates among female physicians are particularly high. More female than male physicians report suicidal thoughts, with suicidal ideation being a well-recognized precursor of suicide. The urgent need to find the reasons for suicide risk in female physicians is underscored by society's increasing dependence on this group of health care providers., Objective: The aim of this paper was to identify potential risk and protective factors associated with recent suicidal ideation in female physicians., Methods: A cross-sectional survey analysis of work-related health, organizational culture, career paths, and working conditions was performed among permanently employed female physicians from the HOUPE (Health and Organisation among University Physicians in four European countries) study: 385 in Sweden and 126 in Italy. The main outcome measure was recent (within the prior 12 months) suicidal thoughts., Results: Overall, 13.7% and 14.3% of the participants from Sweden and Italy, respectively, reported suicidal thoughts within the prior 12 months. Among the physicians from Sweden, the most powerful multivariate model for such thoughts included 2 independent variables related to work: degrading experiences/harassment at work (odds ratio [OR], 3.03; 95% CI, 1.48-6.23), and work meetings to discuss stressful situations (OR, 0.36; 95% CI, 0.19-0.69). The model included self-diagnosis and self-treatment as a significant factor. Work meetings to discuss stressful situations were also in the multivariate model for the Italian physicians (OR, 0.21; 95% CI, 0.05-0.86), together with being given work assignments without adequate resources (OR, 5.0; 95% CI, 1.32-18.8). Significant non-work-related factors in the Italian model were younger age and seeking professional help for depression or burnout., Conclusions: In both Sweden and Italy, work stressors have been identified that may increase the risk for suicide for female physicians. A potential protective factor was meetings to discuss stressful work experiences. These findings suggest that such meetings should be more broadly implemented.

There is controversy about the existence of a predisposition to burn incidents (accident proneness). Our objective was to examine, in a group of burn patients, the conditions or "unconscious" subjective predisposition, the presence of impulsiveness that may have contributed to bringing about the "burn" event, and to assess the presence of psychiatric diagnoses and specific characteristics of temperament. 25 consecutive burn patients were interviewed by using specific psychometric tests. The sample was divided into two groups: "control" group (N=10), composed of subjects who had accidentally been involved in the incident and "case" group (N=15) composed of subjects who had very likely and more or less "knowingly" put themselves at risk of injury. We observed a marked statistically significant difference with case group subjects appearing to be more impulsive than the ones in control group. Higher levels of impulsiveness may predispose case group patients to a greater risk of burn. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns.

Aims: To characterize the epidemiology of disability in, and the level of care available to, older community-dwellers in an Italian urban sample., Methods: In a 2-phase survey, persons aged 65+ years, randomly selected from the patients lists of 98 primary care physicians (PCP), were screened (phase I) by their PCP with a structured questionnaire to detect the presence of: 1) need of help in performing Basic and 2) Instrumental Activities of Daily Living (BADL, IADL); 3) poor vision or 4) hearing; 5) weight loss; 6) use of home care services; 7) self-perceived inadequacy of income. Subjects reporting 2+ problems were further evaluated in face-to-face structured interviews (phase II)., Results: Of 5,445 participants, 597 (11%) screened positive in phase I and 416 were interviewed in phase II. Of these, 4, 29, 19 and 49% were disabled in 1-2 IADL, 3+ IADL, 1-2 BADL, and 3+ BADL. The extent of the support network increased with disability severity (p<0.01). The 274 participants with BADL disability received most of their help from close relatives (58.3+/-2.5%), followed by salaried assistants (20.5+/-2.1%), other relatives (19.5+/-1.9%), and public healthcare services (0.6+/-0.36%). Of the 397 care-givers interviewed, one-third were willing to institutionalize the older participants in case of further functional deterioration. This propensity was predicted only by a self-reported poor attitude towards caring., Conclusion: Many severely disabled older Italians receive care in their home by highly supportive family members. The level of assistance provided to them by public healthcare services is minimal.

Objective: Aim of this study was to provide data on the relationships between psychopathological variables and temporomandibular disorders (TMD). Sixty-three TMD patients were investigated using clinical and anamnestical psychiatric informations and psychopathological measures., Methods: Three groups of TMD patients were recruited according to the Research Diagnostic Criteria for TMD guidelines: a group of patients presenting myofascial pain alone (RDC/TMD axis I group I), a group with temporomandibular joint (TMJ) pain alone (RDC/TMD axis I group IIIa, IIIb), and a group presenting both myofascial and TMJ pain. Two secondary groups were identified on the basis of the presence/absence of myofascial pain. The study design provided a psychiatric interview and psychometric assessment including the Symptom Check List-90-Revised (SCL-90-R), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS)., Results: --Psychiatric evaluation: Myofascial pain patients had higher scores for personal psychiatric history and a history of more frequent psychotropic drug use. --HDRS and HARS: The sample presented scores indicating mild depressive symptoms and moderate anxiety symptoms. --SCL-90-R: The global sample showed acute levels of psychological distress as measured by the GSI score (Global Severity Index). Myofascial pain patients scored higher than TMJ pain patients in the GSI (p = .028), PAR (paranoia; p = .015), PSY (psychoticism; p = .032), and HOS (hostility; p = .034) subscales., Conclusions: TMD patients showed elevated levels of depression, somatization, and anxiety. These characteristics did not differ significantly between patients with myofascial or TMJ pain. Other specific psychopathological dimensions, detected with SCL-90-R, appeared to be closely associated to the myofascial component.

Background: The aim of this study was to observe the outcomes of high-risk patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis in a community setting., Methods: A prospective study of the in-hospital and 12-month outcomes was conducted in 17 cardiology centers where primary angioplasty was available, and in 30 where it was not. Three thousand seventy-four patients in the first 12 hours of an evolving infarction were recruited; among these, 2227 patients who met one or more pre-defined criteria of increased risk were included in the study., Results: Thrombolysis and primary angioplasty were respectively performed in 1090 and in 721 patients; 416 patients (18.7%) received no reperfusion treatment. The incidence of the primary combined in-hospital endpoint (death, non-fatal reinfarction and stroke) was similar in patients treated with thrombolysis (9.2%) and with primary angioplasty (10.7%) (odds ratio--OR 1.19, 95% confidence interval--CI 0.86-1.63, p = NS), and was higher (22.6%) in patients receiving no reperfusion treatment as compared to thrombolysis (OR 3.30, 95% CI 2.36-4.63, p < 0.0001). The occurrence of the 12-month endpoint (death, reinfarction, congestive heart failure and recurrent angina) was lower after primary angioplasty than after thrombolysis (26.8 vs 35.0%, OR 0.68, 95% CI 0.55-0.84, p = 0.0003), due to a lower incidence of angina. At multivariate analysis, older age, anterior infarction, Killip class > 1, high heart rate, and low systolic blood pressure on admission were all significantly associated with a higher incidence of both endpoints. The adjusted analysis confirmed that, despite similar in-hospital results after both reperfusion treatments, primary angioplasty was independently associated with better 1-year outcomes (relative risk 0.66, 95% CI 0.56-0.79, p < 0.0001)., Conclusions: In this observation in the community setting, a strategy of primary angioplasty in patients with high-risk myocardial infarction was not better than thrombolysis in terms of mortality or recurrent infarction, but was associated with less angina at 1 year.

Bile duct carcinomas are known to be difficult to cure, due to frequent locoregional recurrence even after radical resection. The Authors analyze their experience in a study about 53 patients treated between October 1991-January 2002.

Background: In industrialized countries the prevalence of congestive heart failure (CHF) is increasing. Many clinical factors have been shown to influence the prognosis of CHF. The effect of a wide QRS on mortality is debated; while left bundle branch block (LBBB) has been already identified as a negative prognostic factor, the effect of right bundle branch block (RBBB) is still unknown. The aim of this study was to compare the association of these two intraventricular conduction defects on the prognosis of CHF., Methods: Data were derived from the Italian Registry of CHF. Entry in the Registry required that patients had a diagnosis of CHF based on the European Society of Cardiology guidelines. We analyzed the 1-year follow-up data of 5517 outpatients with CHF of different etiologies. The presence of a wide QRS was defined if the duration was > 120 ms., Results: A wide QRS was present in 2066 patients (37.5%), 25.2% with LBBB, 6.1% with RBBB, 6.2% with other intraventricular defects. At univariate analysis patients with complete LBBB had a significantly higher 1-year mortality than those without (16.1 vs 11.9%) but this was not true for complete RBBB (11.9 vs 11.9%). Even after multivariate adjustment, complete LBBB still remained an independent predictor of death (relative risk 1.36, 95% confidence interval 1.15-1.61)., Conclusions: LBBB but not RBBB is an independent predictor of death in CHF.

Proportions of hybridization and introgression between the swallowtails Papilio hospiton, endemic to Sardinia and Corsica, and the holarctic Papilio machaon, were characterized using nine fully diagnostic and two differentiated allozyme loci and a mitochondrial DNA marker. Very low frequencies of F1 hybrids were detected in both Sardinia (0-4%, average 1.4%) and Corsica (0-3%, average 0.5%), as well as of first generation backcrosses (B1). No F2 were observed, in agreement with the hybrid breakdown detected in laboratory crosses. In spite of this minimal current gene exchange, specimens carrying introgressed alleles were found in high proportions in P. machaon but in lower proportions in P. hospiton. Introgression apparently occurred through past hybridization and repeated backcrossing, as evidenced by hybrid index scores and Bayesian assignment tests. Levels of introgression were low (0-1%) at two sex-linked loci and mitochondrial DNA, limited (0.4-2%) at three autosomal loci coding for dimeric enzymes, and high (up to 43%) at four autosomal loci coding for monomeric enzymes. Accordingly, selective filters are acting against foreign alleles, with differential effectiveness depending on the loci involved. The low levels of introgression at sex-linked loci and mitochondrial DNA are in agreement with Haldane's rule and suggest that introgression in P. machaon proceeds mainly through males, owing to a lower fitness of hybrid females. Papilio machaon populations showed higher levels of introgression in Sardinia than in Corsica. The role of reinforcement in the present reproductive isolation between P. machaon and P. hospiton is examined, as well as the evolutionary effects of introgressive hybridization between the two species.

Little is known concerning environmental factors that may control the distribution of virioplankton on large spatial scales. In previous studies workers reported high viral levels in eutrophic systems and suggested that the trophic state is a possible driving force controlling the spatial distribution of viruses. In order to test this hypothesis, we determined the distribution of viral abundance and bacterial abundance and the virus-to-bacterium ratio in a wide area covering the entire Adriatic basin (Mediterranean Sea). To gather additional information on factors controlling viral distribution on a large scale, functional microbial parameters (exoenzymatic activities, bacterial production and turnover) were related to trophic gradients. At large spatial scales, viral distribution was independent of autotrophic biomass and all other environmental parameters. We concluded that in contrast to what was previously hypothesized, changing trophic conditions do not directly affect virioplankton distribution. Since virus distribution was coupled with bacterial turnover times, our results suggest that viral abundance depends on bacterial activity and on host cell abundance.