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Background Thoracoabdominal aortic aneurysms (TAAAs) are defined as those aortic aneurysms involving renovisceral arteries. They account for around 10% of aortic aneurysms, and their treatment is burdened by considerable mortality and morbidity. Open surgical repair has been practised as the standard of care since the 1950s. In 2001 endovascular repair was introduced to reduce treatment invasiveness, and the technology is still evolving. The potential benefits of endovascular repair over open surgery should be carefully weighed in a multidimensional framework. Methods We applied the Health Technology Assessment (HTA) framework (EUnetHTA core model with 9 dimensions) to conduct a report comparing the two technologies. A multidisciplinary working group was established. We derived and pooled: i) secondary data derived from systematic literature reviews, and ii) original data from IRCCS San Raffaele Hospital, Milan, a national referral centre for TAAA (qualitative and economic data). Results Endovascular repair resulted superior to the traditional open surgery in terms of efficacy and safety, as justified by the meta-analysis we performed. Despite the higher costs, a significant impact on budget and slightly lower cost-effectiveness, the endovascular protheses’ adoption could provide conspicuous benefits in terms of social and ethical dimensions without affecting long-term organisational and legal aspects. Conclusions The multi-criteria decision analysis carried out from a hospital point of view shows that there is no significant difference (final score endovascular repair 0.68 vs open surgery 0.63) between the two procedures considering all the dimensions. Still, the endovascular repair is slightly superior to the open surgery in terms of safety, effectiveness, social, ethical, legal, and organisational impact. From the policy maker’s point of view, technologies with a score superior to 0.6 are equally valuable, and the final decision should be left to the clinicians. Key messages • Further research is needed to compare endovascular prostheses and open surgery’s long-term population benefits, balancing clinical, economic, organisational and patient-related outcomes. • HTA methodology offers substantial support to compare in-use technologies, informing clinicians’ and decision-makers’ choices to strengthen healthcare provision equity and preparedness.

The aim of this work is to study the effects of the titanium plasma spray (TPS) coating process on the fatigue resistance of a titanium-6Al-4V substrate. The combination of TPS processes and Ti alloy substrate is widely applied on components intended for cementless total hip replacement (THR). In order to understand the coating process mechanism behind the implants’ fatigue resistance decrease, one air-developed coating (Ti-APS) and one controlled atmosphere developed coating (Ti-CAPS) were considered. The effects of the most representative parameters of the plasma spray process on the fatigue resistance were analysed: the sandblasting process, the plasma and the coating powder. Fatigue resistance studies were performed by means of rotating bending fatigue testing. After fatigue failure specimens underwent morphological analyses both on the primary crack surface and on the cross-sectional area complemented by of the metallographic analyses of the coating. The titanium substrate fatigue resistance decreased after being blasted with direct relationship with the grain size. Ti-CAPS process showed a relatively limited further influence on the fatigue resistance reduction with respect to only sandblasted samples. By contrary a remarkable fatigue limit decreased was seen for Ti-APS coated samples against Ti-CAPS and simply sandblasted samples. The experiment pointed out the critical importance of cracks oxidation as a fatigue failure driving factor.

Introduction Plantar fasciitis (PF) is one of the most frequent causes of thalalgia and disability. The effectiveness of extracorporeal shock wave therapy is an ideal alternative to conservative treatments. Objective To evaluate the effectiveness of the treatment with Piezoelectric Focal Shock Waves with echographic support and maintenance of the effect at 3 and 6 months. Materials and methods Causi-experimental, retrospective statistical study, June 2015 to June 2017, of 90 patients, 36.6% men and 63.3% women, with a mean age of 52 years, diagnosed with PF. Three sessions (one weekly for 3 weeks) of shock wave therapy (PiezoWave F10 G4 generator) were performed, with echographic support and weekly revision and at 3 and 6 months. Main variables: pain, using Visual Analogue Scale before and after each session and at 3 and 6 months and Roles and Maudsley Scale at the end of treatment and at 3 and 6 months. Results 2000 pulses per session were applied, medium energy intensity .45 mJ/mm2, median frequency 8 MHz and median depth of focus of 15 mm. Statistically significant improvement was observed in the Visual Analogue Scale between the 3 treatment sessions and after 3 and 6 months post-treatment, obtaining a statistically significant improvement in all values (p Conclusion Treatment with piezoelectric focal shock waves in PF may reduce pain from the first session and achieves a subjective perception of improvement, maintaining these results at 6 months post-treatment.

Resumen Introduccion y objetivos La Fascitis plantar (FP) es una causa frecuente de talalgia y discapacidad. Pretendemos valorar la efectividad del Tratamiento con Ondas de Choque (TOC) Focales Piezoelectricas con apoyo ecografico y mantenimiento del efecto a 3 y 6 meses. Material y Metodos Estudio retrospectivo cuasi-experimental junio 2015 a Junio 2017, con 90 pacientes, 36,6% hombres y 63,3% mujeres, edad media 52 anos, diagnosticados de FP. Se realizaron 3 sesiones (una semanal durante 3 semanas) de tratamiento con Ondas de Choque (Generador PiezoWave F10 G4), con apoyo ecografico, con revision semanal, a los 3 y 6 meses. Variables principales: dolor, cuantificado mediante Escala Visual Analogica (EVA) antes y despues de cada sesion, a los 3 y 6 mesesy Escala de Roles y Maudsley al final del tratamiento y a los 3 y 6 meses. Se aplicaron 2000 pulsos por sesion, energia media 0,45 mJ/mm2, mediana de frecuencia 8 MHz y mediana de profundidad del foco 15 mm. Resultados Se obtuvo mejoria estadisticamente significativa mediante EVA entre las 3 sesiones de tratamiento y al cabo de 3 y 6 meses post-tratamiento, obteniendo una mejoria estadisticamente significativa en todos los valores (p Conclusion El TOC piezoelectricas focales con apoyo ecografico puede constituir una buena opcion terapeutica en FP. Reduce el dolor desde la primera sesion, y consigue una percepcion subjetiva de la mejoria mantenida a los 6 meses post-tratamiento.

Editor's Choice - Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Plantar fasciitis (PF) is one of the most frequent causes of thalalgia and disability. The effectiveness of extracorporeal shock wave therapy is an ideal alternative to conservative treatments.To evaluate the effectiveness of the treatment with Piezoelectric Focal Shock Waves with echographic support and maintenance of the effect at 3 and 6 months.Causi-experimental, retrospective statistical study,June 2015 to June 2017, of 90 patients, 36.6% men and 63.3% women, with a mean age of 52 years, diagnosed with PF. Three sessions (one weekly for 3 weeks) of shock wave therapy (PiezoWave F10 G4 generator) were performed, with echographic support and weekly revision and at 3 and 6 months.pain,using Visual Analog Scale before and after each session and at 3 and 6 months and Roles and Maudsley Scale at the end of treatment and at 3 and 6 months.2000 pulses per session were applied, medium energy intensity 0.45 mJ /mm2, median frequency 8 MHz and median depth of focus of 15 mm. Statistically significant improvement was observed in the Visual Analog Scale between the 3 treatment sessions and after 3 and 6 months posttreatment,obtaining a statistically significant improvement in all values (p0.05).Treatment with piezoelectric focal shock waves in PF may reduces pain from the first session and achieves a subjective perception of improvement, maintaining these results at 6 months post -treatment.

Background. Healthcare-associated infections (HAIs) are an important issue in terms of quality of care. HAIs impact patient safety by contributing to higher rates of preventable mortality and prolonged hospita- lizations. In Italy, analysis of the currently available accreditation systems shows a substantial heteroge- neity of approaches for the prevention and surveillance of HAIs in hospitals. The aim of the present study is to develop and propose the use of a synthetic assessment tool that could be implemented homogenously throughout the nation. Methods. An analysis of nine international and of the 21 Italian regional accreditation systems was conducted in order to identify requirements and indicators implemented for HAI prevention and control. Two relevant reviews on this topic were further analyzed to identify additional evidence-based criteria. The project team evaluated all the requirements and indicators with consensus meeting methodology, then those applicable to the Italian context were grouped into a set of “focus areas”. Results. The analysis of international systems and Italian regional accreditation manuals led to the iden- ti cation respectively of 19 and 14 main requirements, with relevant heterogeneity in their application. Additional evidence-based criteria were included from the reviews analysis. From the consensus among the project team members all the standards were compared and 20 different thematic areas were identi ed, with a total of 96 requirements and indicators for preventing and monitoring HAIs. Conclusions. The study reveals a great heterogeneity in the de nition of accreditation criteria between the Italian regions. The introduction of a uniform, synthetic assessment instrument, based on the review of national and international standards, may serve as a self-assessment tool to evaluate the achievement of a minimum standards set for HAIs prevention and control in healthcare facilities. This may be used as an assessment tool by the Italian institutional accreditation system, also useful to reduce regional disparities.

Background Treosulfan may offer advantages over busulfan for haematopoietic stem cell transplant (HSCT) conditioning, but it is unlicensed in children and the only published dosing information came from a 7-patient first-in-child pharmacokinetic study. We aimed to investigate treosulfan’s pharmacokinetics, efficacy and safety in a GOSHCC-funded trial. Methods Patients were recruited from GOSH and Newcastle. All received fludarabine +/-serotherapy and treosulfan dosing was based on scaling of adult exposure and expected pharmacokinetic maturation (14 g/m2 in children, 12 g/m2 in infants aged less than 1 year, 10 g/m2 in children aged 3 months or below). Pharmacokinetic sampling was performed during the first and third doses, and population pharmacokinetic modelling performed. Short-term toxicity and long-term (at least 1 year post transplant) outcomes were measured. Successful myeloid engraftment (chimerism greater than 20% at last follow-up) death were the primary outcome measures. Multivariate modelling was used to investigate predictors of these outcomes, and a quadratic model in a generalised linear modelling framework used to define a therapeutic index. Results 84 patients were recruited (34 in a pilot phase, 50 in the main study) and provided pharmacokinetic data. A two-compartment model with allometric scaling for body size gave an adequate fit. Age (younger patients had lower per m2 clearance) and renal function (higher creatinine correlated with lower clearance) were significant covariates. After excluding 10 patients from the pilot study who did not meet the main study inclusion criteria, multivariate analysis on the remaining 74 patients (8 of whom had poor engraftmnet, 9 of whom died) showed low treosulfan area under the curve (AUC) was associated with poor engraftment (p=0.047), and high AUC with probability of death (p=0.006). CD34 dose (p=0.02) and mis-matched haplotype donor (p=0.02) were the only other variables associated with success and death respectively. AUC was similar across age and weight. A cumulative AUC of 4703 mg h/L maximised the probability of success, whereas >80% probability of success was associated with AUCs between 3500 and 6319 mg h/L. Only 65% of our study patients were in this target range. Conclusions We have shown poor engraftment and mortality are both associated with treosulfan AUC, and the therapeutic index seems narrow enough to warrant personalised dosing.

Luthans e Avolio (2009) sottolineano come ha definizione del comportamento organizzativo positivo implichi un focus sulle risorse individuali di stato, piuttosto che di tratto, dunque su risorse suscettibili di ampliamento e potenziamento. Gli stessi autori hanno riconosciuto la speranza, l'autoefficacia, l'ottimismo e la resilienza quali risorse positive maggiormente aderenti a tale criterio e hanno sviluppato il costrutto di Capitale Psicologico, o PsyCap, come stato psicologico positivo derivante dalla combinazione di queste quattro risorse. Alla luce della malleabilità del PsyCap e della sua associazione con esiti positivi del lavoro, nell’ambito organizzativo sono stati sviluppati e implementati i primi interventi tesi a potenziare questa risorsa personale. Sebbene la teoria sul Capitale Psicologico e l’attenzione verso i suoi risvolti applicativi non sia nata principalmente in questo ambito, è facilmente intuibile il suo valore nella progettazione di interventi con finalità orientativa, con particolare riferimento alle attività di vocational guidance di gruppo.

Radial and longitudinal strain assessment in the carotid artery wall using speckle tracking

Extent IV thoracoabdominal aortic aneurysm (TAAA) open repair is considered relatively safer to repair than other extents of TAAA in terms of both perioperative mortality and spinal cord ischemia. Our purpose is to report our experience and to perform a literature review regarding extent IV TAAA open repair in order to provide an updated benchmark for comparison with any other alternative strategy in this aortic segment.From 1993 to 2015 we performed 736 open repairs for TAAA (177 extent I, 196 extent II, 141 extent III, 222 extent IV). In extent IV group there were 164 men (73.9%) and the mean age was 67.4±9.3 years (range 32-84). The aneurysm etiology was degenerative in 198 patients (95.6%). Twelve patients (5.4%) underwent emergent operation. Totally abdominal approach was used in 22.0% of the cases. Until 2006 left heart bypass (LHBP) and cerebrospinal fluid drainage (CSFD) were almost never performed during extent IV repair. Since 2006 we changed our approach with a more aggressive use of LHBP (22.9%) and CSFD (43.4%) in 83 consecutive extent IV. Renal arteries perfusion was performed with 4 °C Ringer's solution until 2009 and with 4 °C Custodiol solution since September 2009 to date. Literature search was performed on several databases (PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials). Research was updated on March 1th 2015.Perioperative mortality in our overall group of TAAA and in the extents IV was 10.7% and 4.9%, respectively (P=0.01); spinal cord ischemia rate 11.4% and 2.7%, respectively (P=0.0001). In the extents IV treated between 2006 and 2015 we observed a further trend of outcomes improvement with a rate of perioperative mortality and spinal cord ischemia of 1.2%, and 2.4%, respectively. Database searches yielded a total of 767 articles. Excluding non-pertinent titles or abstracts, we retrieved in complete form and assessed 27 studies according to the selection criteria. Nine studies were further excluded because of our prespecified exclusion criteria. The final 18 manuscripts included a total of 2098 patients. In this group median mortality rate was 4.8% (interquartile range 3-6) and the mean incidence of spinal cord ischemia was 1.56±1.54%.Perioperative outcomes after extent IV TAAA open repair were significantly better compared to our overall TAAA series. A more aggressive use of CSFD, LHBP and renal perfusion with Custodiol solution allowed a further trend of outcomes improvement in our series of extent IV TAAA open repair. Literature analysis confirmed during extent IV open repair very satisfactory perioperative outcomes with rates of mortality and spinal cord ischemia dropped to under 5% and 2%, respectively.

Infectious thoracic aortitis is a rare disease, especially since the incidence of syphilis and tuberculosis has dropped in western countries. However, the risk to develop an infectious aortitis and subsequent mycotic aneurysm formation is still present, particularly in case of associated endocarditis, sepsis, and in immunosuppressive disorders. Moreover, the number of surgical and endovascular thoracic aortic repairs is continuously increasing, and infective graft complications are observed more frequently. Several etiopathogenetic factors may play a role in thoracic aortic and prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. Also, fistulization of the esophagus or the bronchial tree is commonly associated with these diseases, and it represents a critical event requiring a multidisciplinary management. Knowledge on underlying micro-organisms, antibiotic efficacy, risk factors, and prevention strategies has a key role in the management of this spectrum of infectious diseases involving the thoracic aorta. When the diagnosis of a mycotic aneurysm or a prosthetic graft infection is established, treatment is demanding, often including a number of surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for infectious diseases of the thoracic aorta are still burdened with very high morbidity and mortality. In this manuscript, we review the literature regarding the main issues related to thoracic infectious aortitis and aortic graft infections, and we report our personal series of patients surgically treated at our institution for these conditions from 1993 to 2014.

The aim of this study is to describe our clinical experience with an extra-large self-expandable stent specifically designed to treat aortic lesions (E-XL, Jotec GmbH, Hechingen, Germany), now commercially available in Europe. The E-XL was used at our Institution in 14 patients (mean age, 56±12 years; 9 males) with the following indications: improve proximal fixation (4 cases), type I endoleak (2 cases), aortic dissection with static malperfusion (1 case) and dynamic malperfusion (7 cases). Early results have been shown to be safe and effective in different clinical settings, including in emergency cases. This peculiar aortic stent could be useful in the armamentarium of the endovascular surgeon.

Reinterventions following previous ascending aorta and aortic arch repair are uncommon, but technically challenging and often burdened with high morbidity and mortality. The aim of this article is to present a single-center experience in the treatment of this complex pathology, using different surgical approaches.Between 1999 and 2014, 17 patients (14 males, mean age 73±16 years) underwent ascending aorta and aortic arch redo surgery at our Department. A prospectively maintained database including thoracic aortic procedures was reviewed retrospectively to collect data on redo patients.In 13 cases the index procedure was an endovascular or hybrid procedure on the aortic arch performed at our Department, for an in-house reintervention rate of 6.9% (13/188). In 10 cases the cause of reintervention was stent-graft distal migration, treated by means of endovascular relining in all cases, associated with adjunctive supra-aortic trunks debranching via sternotomy in 6 cases. In 5 cases the cause of reintervention was retrograde ascending aortic dissection, in 1 case ascending aortic anastomotic pseudoaneurysm following supra-aortic trunk debranching, and in 1 case mediastinitis following implantation of an endovascular plug previously used to treat an ascending aortic pseudoaneurysm. In these last 7 cases, all patients were treated by means of ascending and arch surgical replacement under deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP). No 30-day mortality was observed. Major perioperative morbidity included 1 paraplegia, 1 minor stroke, 1 bleeding requiring reintervention, and 3 cases of respiratory failure requiring prolonged intubation (2) or tracheostomy (1).In our experience, incidence of serious complications requiring reinterventions following ascending aorta or aortic arch repair is not negligible. Redo surgery in ascending aorta and aortic arch is feasible in high-volume and experienced centers, as it often requires hybrid repair via midline sternotomy, or surgical replacement under DHCA and ACP.

The INCRAFT® AAA Stent Graft System is the advanced endovascular aneurysm repair (EVAR) technology for the treatment of infrarenal abdominal aneurysms. This new system is designed to address the unmet needs of current endografts by combining unique features and adding new refinements compared to existing endografts delivered through a flexible 14-Fr ultra-low system. The INCRAFT® AAA Stent Graft System introduces innovative features without deviating from proven stent-graft design principles. It is a three-piece modular system, made of low porosity polyester and segmented nitinol stents. However, the introduction of cap-free delivery and partial proximal repositioning enhances the ability of the device to better match individual aortoiliac anatomy with a high deliverability and placement accuracy in a easy to use system. Moreover, the INCRAFT® System allows a "customization" of the implant during the procedure with bilateral in-situ length adjustment features. The present data from the ongoing clinical trials confirm excellent results with this system, but postmarket studies will be necessary to verify the effectiveness of this system in the real-world setting.

A new hepatitis-associated RNA virus of the Flaviviridae family has been identified and named GB virus C/ hepatitis G virus (HGV). We carried out a case-control study to evaluate the association of HGV infection with hepatocellular carcinoma (HCC). We recruited 170 patients hospitalized for HCC (143 male and 27 female, mean age 64 years) and 306 patients hospitalized for nonliver diseases (controls) in Brescia, Italy. HGV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) and antibodies against HGV E2 protein (anti-E2) by an immunoassay test. HGV RNA was found in 8 cases (4.7%) and 4 controls (1.3%). The relative risk (RR) for HGV RNA positivity adjusted for demographic variables and hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV) RNA, and alcohol was 7.3 (95% confidence interval, 1.7-30.6; P = .009). No HGV RNA-positive subject was also positive for anti-E2. Anti-E2 prevalence did not differ significantly between cases (20%) and controls (15.3%), and no RR increase was found by this marker. Among subjects with HGV exposure (HGV RNA plus anti-E2 positive), a greater proportion of cases (40%) than controls (14%) had transfusion history. The possible role of HGV in HCC etiology seems modest because the population-attributable risk is lower (4%) than those for HBsAg (22%), HCV RNA (36%), and heavy alcohol intake (52%). This study supports the hypothesis of an association between HGV infection and HCC, although at present there are insufficient data on the causality of the association. (Hepatology 1997 Dec;26(6):1653-7)

A new hepatitis-associated RNA virus of the Flaviviridae family has been identified and named GB virus C/ hepatitis G virus (HGV). We carried out a case-control study to evaluate the association of HGV infection with hepatocellular carcinoma (HCC). We recruited 170 patients hospitalized for HCC (143 male and 27 female, mean age 64 years) and 306 patients hospitalized for nonliver diseases (controls) in Brescia, Italy. HGV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) and antibodies against HGV E2 protein (anti-E2) by an immunoassay test. HGV RNA was found in 8 cases (4.7%) and 4 controls (1.3%). The relative risk (RR) for HGV RNA positivity adjusted for demographic variables and hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV) RNA, and alcohol was 7.3 (95% confidence interval, 1.7-30.6; P = .009). No HGV RNA-positive subject was also positive for anti-E2. Anti-E2 prevalence did not differ significantly between cases (20%) and controls (15.3%), and no RR increase was found by this marker. Among subjects with HGV exposure (HGV RNA plus anti-E2 positive), a greater proportion of cases (40%) than controls (14%) had transfusion history. The possible role of HGV in HCC etiology seems modest because the population-attributable risk is lower (4%) than those for HBsAg (22%), HCV RNA (36%), and heavy alcohol intake (52%). This study supports the hypothesis of an association between HGV infection and HCC, although at present there are insufficient data on the causality of the association.

In the last two decades, results of endovascular aortic repair (EVAR) for the treatment of infrarenal abdominal aortic aneurysms (AAAs) have significantly improved thanks to the evolution of stent-grafts and endovascular delivery systems. However, further development is still needed to reduce the incidence of complications and secondary reinterventions. We present our initial experience with the Treovance abdominal aortic stent-graft (Bolton Medical, Barcelona, Spain), a new-generation trimodular endovascular device, developed to increase flexibility, lower profile, improve deployment and sealing mechanisms.We treated 8 patients with anatomically suitable non-ruptured AAA.Primary technical success was obtained in all patients, and no 30-day device-related complications nor deaths were reported. One patient experienced graft limb occlusion at 3 months, and underwent surgical conversion. At 1-year follow-up (completed in 6 patients), no device-related complications nor type I or III endoleak were observed.Initial personal experience with the Treovance abdominal stent-graft was satisfactory with regard to technical success and short-term clinical results. This new-generation endovascular device performed well even in angulated or heavily calcified anatomies.

Abdominal aortic aneurysms (AAAs) are classified as juxtarenal if their proximal extent is next to the origin of the renal arteries but does not involve them. An AAA is suprarenal if it extends above at least one renal artery and ends below the celiac axis. Juxtarenal AAAs need inter-renal or suprarenal clamping, with the aortic reconstruction usually made at the infrarenal level. Aneurysms requiring suprarenal clamping, often supraceliac, and the reconstruction (direct attachment or bypass) of at least one renal artery, are often defined as suprarenal AAAs. Endovascular aortic repair (EVAR) is feasible in most of cases of infrarenal AAAs and has been shown to be as effective as open repair (OR) in reducing aneurysm-related mortality and perioperative mortality with shorter length of stay. However, the feasibility of standard EVAR with an on-label use of commercially available devices is limited in the juxtarenal aorta. In our series, approximately, 20% to 30% of patients with an AAA are considered not eligible for standard EVAR owing to their anatomy, and in the most of the cases are patients with juxtarenal AAAs. Fenestrated and branched endografts and newer "off the shelf" techniques (such as chimney, periscope, sandwich) have been recently described, all with the purpose of widening the therapeutic range of EVAR to the treatment of aneurysms with involvement of renal and visceral arteries. However, safety, efficacy, long-term results, and cost-effectiveness of these expensive techniques have still to be carefully assessed. For these reasons, the OR is currently still considered the gold standard for treatment of juxtarenal AAAs, reserving endovascular strategies mainly for high-risk patients having comorbidities or other contraindications for conventional repair. If compared to open repair of infrarenal AAAs, juxtarenal AAA OR is technically more complex and might require specific organ-protection strategies in order to minimize ischemia-reperfusion injury to kidneys and visceral organs. Because of the complexity of the surgical procedure and of the multiple clinical problems, an optimal operative strategy for the treatment of juxtarenal AAAs has not been established yet. The choice of the surgical access, clamping level, methods of organ protection and their impact on renal, respiratiry, cardiac and gastrointestinal morbidity are still debated issues.

Endovascular repair of the thoracic aorta (TEVAR) has been recently considered an appealing alternative to open treatment of traumatic aortic injuries. However, the use of this technique in emergency is often limited by hemodynamic instability, severe associated lesions and unavailability of adequate materials. Dedicated stent-grafts are not currently available. We report our results in treating blunt traumas of the thoracic aorta using three different commercially available stent-grafts. METHODS Between 2003 and 2010, 28 patients (22 males, mean age 38.9±12.1 years) underwent TEVAR for a traumatic aortic lesion. A total-body computed tomography angiography (CTA) was performed in all cases to establish the diagnosis of aortic rupture and evaluate associated injuries. After TEVAR, patients were followed-up with CTA of the chest before discharge from the hospital, at 6 months and yearly thereafter.Fifteen patients (54%) were hemodynamically unstable at presentation, and 20 patients (71%) presented severe associated lesions. The mean injury severity score (ISS) was 36.2. Twenty-four patients were treated emergently, whereas four patients underwent prior clinical stabilization of severe associated injuries. Primary technical success rate was 100%. No patient required conversion to open thoracic surgical repair. No paraplegia or stroke was observed. Procedure-related complications included an external iliac artery lesion during introducer sheath removal. The left subclavian artery was intentionally covered in 7 cases (25%), and revascularized in two hemodynamically stable patients prior to stent-graft deployment. Two patients died perioperatively due to multiorgan failure, for a total in-hospital mortality of 7%. Twenty-four patients (92% of survivors) adhered to the follow-up protocol (mean 37.3±17.5 months), and they are all alive without instances of reintervention.In our experience, endovascular treatment of acute traumatic thoracic aortic injuries using different commercially available stent-grafts allows to obtain satisfactory short term results.

The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33.1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9.8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alternative to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients.

Endovascular aortic repair (EVAR) has emerged as a promising, less invasive alternative to conventional open surgery for the treatment of infrarenal abdominal aortic aneurysms (AAAs). In the last 20 years, the application rate of EVAR and its clinical results have significantly improved thanks to the evolution of stent-grafts and endovascular delivery systems. However, further development is still needed to reduce the incidence of complications and secondary re-interventions. The Treovance abdominal aortic stent-graft (Bolton Medical, Barcelona, Spain) is a new-generation endovascular device, developed to increase flexibility, lower profile, improve deployment and sealing mechanisms. In particular, it is provided with some innovative features as a double layer of proximal barbs (suprarenal and infrarenal) for supplemental fixation, dull barbs between modules to avoid potential leg disconnections, detachable outer sheath provided with a new-design hemostatic valve, and a double improved mechanism (slow motion and "pin and pull") for precise stent-graft deployment. A European prospective, non-randomized, multi-institutional, "first-in-human" trial (the ADVANCE trial) was conducted from March to December 2011 to assess the safety and performance of the Treovance stent-graft system before commercialization. Thirty patients with anatomically suitable non-ruptured AAAs were enrolled at five clinical sites in Italy, Spain, and Germany. EVAR was completed successfully in all patients. The stent-graft was delivered and deployed safely even in heavily angulated or calcified anatomies. No 30-day device-related complications nor deaths were observed. Preliminary experience with the Treovance abdominal stent-graft within the ADVANCE trial was satisfactory with regard to technical success and perioperative clinical results. Follow-up data are needed to assess mid- and long-term clinical outcomes, along with durability of this new-generation endovascular device.

Optimal treatment for synchronous aortic aneurysms is still debated. Staged repair is advocated as the standard of care. Its disadvantage however is the consistent risk of rupture of the untreated aortic segment during recovery; moreover a considerable percentage of patients either refuse the second stage or is lost to follow-up. We present the case of a patient with a ruptured aortic arch aneurysm after open-surgery for a type III thoracoabdominal aortic aneurysm. Our therapeutic decision is described and discussed, with all the related advantages and disadvantages.

Prion diseases are fatal neurodegenerative disorders of humans and animals, which result from the conformational conversion of a normal, cell surface glycoprotein (PrP(C)) into a pathogenic isoform (PrP(Sc)) that is the main component of infectious prions (1,2) . Familial prion diseases, which include 10% of the cases of Creutzfeldt-Jakob disease and all cases of Gerstmann-Sträussler syndrome and fatal familial insomnia, are linked in an autosomal dominant fashion to point and insertional mutations in the PrP gene on chromosome 20 (3,4). These mutations are presumed to favor spontaneous conversion of PrP to the PrPSc state. One way to experimentally model familial prion diseases is to express PrP molecules carrying disease-associated mutations in either cultured mammalian cells or transgenic mice. The authors review their own work using these two kinds of model systems, which have provided complementary information about the PrPC?PrP(Sc) conversion process, and about the pathogenic effects of mutant PrP.

Direct osteointegration of titanium and titanium alloys implants is one of the main goals of biomaterials research for dental and orthopedic applications. Chemical, mechanical or biological treatments are investigated searching for fast and durable implant to bone bonding. The aim of the present work is to assess the in vitro mineralisation capabilities and to investigate the mechanical and physico-chemical properties of a new biomimetic treatment on titanium. The new surface treatment was obtained using Anodic Spark Deposition technique, and consists of a first ASD treatment performed in solutions containing phosphate ions followed by a second ASD treatment in a solution rich in calcium ions. The resulting surface is finally treated by alkali etching. The physio-chemical and mechanical properties of this material are analyzed and the mineralization potential is considered by surface analysis after soaking it in different solutions of simulated body fluid (SBF). The developed biomimetic treatment was then compared to other treatments from the literature. The proposed treatment was found to possess a very high mineralization capaci-ty, that makes its application very interesting in terms of speed and strength of direct implant osteointegration. (Journal of Ap-plied BiomaterialsBiomechanics 2003; 1: 33-42).

New crosslinked ultra high molecular weight polyethylenes (UHMWPEs) have recently been developed, characterized and introduced in clinical applications. UHMWPE cross-linking treatments are very promising for reducing osteolysis induced by wear debris. The irradiation type, gamma or beta, the dosage and the thermal treatment performed during or following the irradiation process are all factors affecting polyethylene wear resistance. Thermal stabilization treatments performed after or during the irradiation process at a temperature above melting point (i.e.130 degrees C) have been proven to effectively remove the free radicals generated during irradiation from UHMWPE, but their effect on the mechanical properties of UHMWPE are not completely clear. In addition to wear rate reduction, maintaining good mechanical properties is fundamental aspect in designing the new generation of crosslinked UHMWPE for artificial load bearing materials, especially considering the application in total knee replacements. In this study, we investigated the influence of different stabilization treatments, performed after gamma irradiation, on structural, wear and mechanical properties of UHMWPE. We performed four different stabilization treatments, with different temperatures and cooling rates, on 100 kGy gamma irradiated UHMWPE. Structural properties of UHMWPE were assessed by differential scanning calorimetry (DSC). To assess the mechanical performance of the materials, uni-axial tensile tests were performed according to the ASTM D638 standard, bi-axial tension performance was evaluated by small punch tests (ASTM F2183-02), toughness resistance was evaluated by the Izod method (ASTM F648), and cold flow resistance was analysed by a dynamic compressive test. Evaluation of wear resistance was by a multidirectional pin-on-disk screening machine. Materials considered were in ""aged"" and ""non-aged"" conditions. Results confirmed that cross-linking greatly enhances UHMWPE wear resistance, but introduces some detrimental effects on the mechanical properties. In this study, we found that the negative ef-fects on the mechanical properties of crosslinked UHMWPE can be modulated, to some extent, by choosing a thermal stabiliza-tion treatment at a correct temperature and cooling rate. (Journal of Applied BiomaterialsBiomechanics 2004; 2: 20-8).

introduction: Recently published case series of patients undergoing carotid endarterectomy suggested a reduction in the rate of perioperative neurologic events when compared to those reported in the large randomized trials performed in the 1990s, without great differences between high and low risk patients. methods: As a major center of Vascular Surgery we prospectively collected data on 8743 carotid endarterectomy procedures (eversion technique 75%, patch closure 17.5%) performed in the period 1992-2009. results: Perioperative mortality was 0.32% (27/8743) with myocardial infarction being the most frequent cause (9 patients). Perioperative neurological morbidity was 1.04% (91/8743) with 51 major and 40 minor strokes. In 201 cases (2.3%) a cervical hematoma (suture-line bleeding in 41 cases and or diffuse oozing in 160 cases) in the early postoperative period necessitated urgent wound revision. In 262 (3.0%) cases we observed permanent or transient lesions of cranial nerves in the postoperative period. There was no significant difference in the combined ipsilateral stroke and perioperative death rate in octogenarian patients (2.1% in octogenarians and 1.2% in younger patients, p>0.05), even though an increasing trend was evident. conclusions: Carotid endarterectomy has a reduced rate of perioperative complications when compared to those previously reported in literature. The low complication rate is related to improved preoperative patients evaluation, surgeons’ increasing experience and to surgical and anesthesiological techniques. Carotid angioplasty and stenting should have their results compared to these real world results of carotid endarterectomy in order to asses their reliability when treating extracranial cerebrovascular disease. Introduction: Recently published case series of patients undergoing carotid endarterectomy suggested a reduction In the rate of perioperative neurologic events when compared to those reported in the large randomized trials performed in the 1990s, without great differences between high and low risk patients. Methods: As a major center of Vascular Surgery we prospectively collected data on 8743 carotid endarterectomy procedures (eversion technique 75%, patch closure 17.5%) performed in the period 1992-2009. Results: Perioperative mortality was 0.32% (27/8743) with myocardial infarction being the most frequent cause (9 patients). Perioperative neurological morbidity was 1.04% (91/8743) with 51 major and 40 minor strokes. In 201 cases (2.3%) a cervical hematoma (suture-line bleeding in 41 cases and or diffuse oozing in 160 cases) in the early postoperative period necessitated urgent wound revision. In 262 (3.0%) cases we observed permanent or transient lesions of cranial nerves in the postoperative period. There was no significant difference in the combined ipsilateral stroke and perioperative death rate in octogenarian patients (2.1% in octogenarians and 1.2% in younger patients, p>0.05), even though an increasing trend was evident. conclusions: Carotid endarterectomy has a reduced rate of perioperative complications when compared to those previously reported in literature. The low complication rate is related to improved preoperative patients evaluation, surgeons’ increasing experience and to surgical and anesthesiological techniques. Carotid angioplasty and stenting should have their results compared to these real world results of carotid endarterectomy in order to asses their reliability when treating extracranial cerebrovascular disease.

The effect of Na-exchange and catalyst activaton temperature for selective synthesis of amylenes has been studied using a pretreated bentonite as catalyst. The selectivity to 3-methyl-1-butene rose with the catalyst activation temperatures. The alkali-exchange had a similar influence. The Na-catalyst was more selective to less substituted products, but their activity was lower than that of acidic catalysts.

The effect of linear gas velocity, catalyst particle size, reaction temperature, space time, etc. on the dehydration of amyl alcohols (from fusel oil) was studied, using as catalyst a pre-treated bentonite. The analysis of the kinetic data, using Hougen-Watson type models, gives as the best model one in which amyl alcohol is absorbed on two active sites, the reaction rate being determined by the surface reaction of absorbed species. On a etudie l'effet de la vitesse lineaire du gaz, de la taille des particules du catalyseur, de la temperature de la reaction, du temps spatial, etc., sur la deshydration des alcools amyl (venant d'huile de fusel) en utilisant une bentonite pre-traitee comme catalyseur. Parmi les modeles de type Hougen-Watson utilises, le meilleur modele pour analyser les donnees cinetiques est celui pour lequel l'alcool d'amyl est absorbe sur deux sites actifs, la vitesse de reaction etant determinee par la reaction de surface des especes absorbees.

Postural control requests an automatic process that involves central and pheripheral inputs such as visual, vestibular and proprioceptive ones. The level of automatics is modulated by complex cognitive activities. The efficiency in postural control is modified by a cognitive task in old people with/without cognitive impairment. Odontostomatognatic inputs have shown to influence postural control in children and adults. In elderly the presence/absence of denture can modify the odontostomatognatic functioning, but there is no safe knowledge about the relationship between postural control and odontostomatognatic modification. We investigated possible differences in postural sways at rest between elderly subjects, with/without denture, with normal cognitive functioning and mild-moderate cognitive impairment. Moreover, we analyzed possible differences in postural sways during an interpolated cognitive task. Finally we investigated which indices, in aged subjects, of health status influence postural indices.

The surface roughness of 3 different resin restorative materials polymerized with a halogen and a plasma arc curing light, following finishing and polishing was evaluated in vitro.Using a metal mold, 10 block specimens were prepared from each material. A Mylar strip was placed on both sides of the mold. Five specimens from each material were cured with the halogen lamp, while the other 5 were polymerized with the plasma arc lamp. In both groups the surface exposed to curing light was finished and polished with the Enhance system (Dentsply). The opposite surface was not treated and served as a control. Both surfaces of each specimen were analyzed with a laser profilometer: the roughness average (R(a)) was evaluated. The Vickers microhardness of the polished surfaces was also calculated. All data were statistically analyzed with the Mann-Whitney test. A regression test was carried out to evaluate the possible correlation between roughness and microhardness.The smoothest surfaces were obtained when composites were cured against a Mylar strip. Roughness was significantly increased in both groups in the treated surfaces. A significant correlation between roughness and microhardness could not be demonstrated.This study demonstrated that the surface polymerized against a Mylar strip was the smoothest surface produced, while the roughness of the Mylar-formed surface was significantly increased by finishing and polishing. Surface roughness following polishing is material-dependent.

Surgical treatment of pararenal aortic aneurysms, if compared to open repair of infrarenal aneurysms, is characterized by more technical difficulties and haemodynamic problems. Since endovascular repair has become feasible in most cases of infrarenal aneurysms, surgical treatment of pararenal aneurysms is a matter of great interest for vascular surgery. Detection of pararenal aneurysms needs a careful preoperative diagnosis, assessment of cardiac, renal and pulmonary status of the patient and planning of the surgical intervention. The surgeon needs to face an extended proximal aorta exposure, to manage the left renal vein and to choose an appropriate clamping site. Then a skilled and quick reconstruction of the visceral arteries is fundamental to minimize organ disfunction. Coupled intraoperative selective perfusion of visceral arteries and systemic administration of nephroprotective drugs optimizes organ protection during ischemia. To better define challenges, risks and results, we reviewed our experience with the treatment of pararenal aortic aneurysms. In the period between January 1993 and May 2003, 98 consecutive patients underwent surgery for pararenal aneurysms at our Institution. We treated 98 pararenal aneurysms, divided in 68 juxtarenal and 30 pararenal ones. In the juxtarenal aneurysms group, the 30 days mortality rate was 5.8% (4/68); 3 of these patients underwent urgent operation for ruptured aneurysm. In the suprarenal aneurysms group, the 30 days mortality rate was 3.3% (1/30). In conclusion pararenal aneurysm repair is a safe procedure, especially if performed electively, and represents an interesting field of research to improve surgical and anesthesiologic techniques.