bluuebunny/crossref_metadata_2025 huggingface dataset:
Arterial hypertension and aortic root dilatation: an unsolved mystery
Authors: Milan Alberto , Tosello Francesco , Abram Sara , Fabbri Ambra , Vairo Alessandro , Leone Dario , Veglio Franco
Published: April 2013

Introduction: Acute and chronic aortic syndromes are associated with substantial morbidity and mortality. Silent risk factors such as arterial hypertension and aortic root dilatation can increase the likelihood of aortic dissection or rupture. The relationship between arterial hypertension and the dimensions of the aortic root dimension is a topic of active debate. Materials and methods: We reviewed the literature on the physiopathology, diagnosis, natural history, and management of thoracic aortic aneurysms. Results: Biological variables influencing the size of the aorta include age, sex, body surface area, pressure values, and stroke volume. Pathologic enlargement of the thoracic aorta can be caused by genetic, degenerative, inflammatory, traumatic, or toxic factors. Studies investigating the correlation between aortic dimensions and arterial pressures (diastolic, systolic, or pulse) have produced discordant results. Discussion: Classically, emphasis has been placed on the importance of hypertension-related degeneration of the medial layer of the aortic wall, which leads to dilatation of the thoracic aorta, reduced aortic wall compliance, and increased pulse pressures. However, there are no published data that demonstrate unequivocally the existence of a pathogenetic correlation between arterial hypertension and aortic root dilatation. Furthermore, there is no evidence that antihypertensive therapy is effective in the management of nonsyndromic forms of aortic root dilatation. An interesting branch of research focuses on the importance of genetic predisposition in the pathogenesis of thoracic aortic aneurysms. Different genetic backgrounds could explain differences in the behaviour of aortic walls exposed to the same hemodynamic stress. Further study is needed to evaluate these focal physiopathological aspects.
Catheter based radiofrequency ablation of renal nerves for the treatment of resistant hypertension
Authors: Schlaich Markus P. , Hering Dagmara , Esler Murray D.
Published: April 2013

Introduction Resistant hypertension is a common and growing clinical problem characterized by the failure to attain target blood pressure levels despite adequate use of at least three antihypertensive agents. Objectives The aim of this article is to emphasize the role of novel approaches to treat resistant hypertension. Materials and methods After an excursus on the physiological role of renal nerves on kidney function, volume homeostasis and blood pressure control, this article describes the radiofrequency ablation technology to obtain kidneys denervation. Results Activation of the sympathetic nervous system plays a prominent role as a major regulator of circulatory and metabolic control. The kidneys have a particularly dense afferent sensory and efferent sympathetic innervation and are thereby strategically positioned to be origin as well as target of sympathetic activation. In this context, recent evidence suggests that a novel catheter-based approach to functionally denervate the human kidneys using radiofrequency ablation technology may provide a safe and effective treatment alternative for resistant hypertension and its adverse consequences. Conclusions Despite the availability of numerous safe and effective pharmacological therapies to treat elevated blood pressure, novel therapeutic approaches are warranted to improve the management and prognosis of patients with refractory hypertension. Several clinical trials are currently conducted and planned to further substantiate the blood pressure lowering efficacy of this novel renal denervation procedure.
Trialogue. Managing hyperglycaemia in internal medicine. Instructions for use: Consensus document of the Associazione Medici Diabetologi (AMD), Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti (FADOI) and Società Italiana di Diabetologi
Authors: Beltramello Giampietro , Manicardi Valeria , Trevisan Roberto
Published: April 2013

Hyperglycaemic patients admitted to hospital have worse clinical outcomes with higher operational costs than normoglycaemic patients. Identifying, defining and treating hyperglycaemia promptly and appropriately is essential during hospitalization; adequate “continuity of care” must be assured after discharge. This requires a multidisciplinary clinical collaboration between the internist and the diabetes team, which plays a central role in the treatment course and should be involved soon after patient admission to the hospital. This document aims to establish guidelines and recommendations for good clinical practice in managing hyperglycaemic Internal Medicine patients, with or without previous diagnosis of diabetes. The Associazione Medici Diabetologi (AMD), Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti (FADOI) and Società Italiana di Diabetologia (SID) have decided to publish a document useful for internists in the management of hospitalised patients with hyperglycaemia. The Trialogue project, coordinated by the Board of Scientific experts from the three Scientific Societies, was initiated for this purpose. A questionnaire consisting of 16 multiple choice questions on the management of hyperglycaemia in hospital was answered by 660 physicians from over 250 internal medicine units distributed throughout Italy. Analysis of responses has yielded an overview of routine clinical practice and provided a wealth of ideas to better identify critical points in the treatment of hospitalized patients with hyperglycaemia. These recommendations were developed with the aim of providing mutually agreed practical guidance (instructions for use) that can be readily applied by healthcare professionals in routine clinical practice.
The bioethics of end-of-life care in Internal Medicine: decision making and setting of care
Authors: Traisci Giancarlo
Published: April 2013

Introduction In the field of Internal Medicine, the management of the terminal phase of an illness raises important issues involving clinical care, with particular reference to the physician-patient relationship. The present report describes the professional code of conduct relative to the assessments and decision making involved in end-of-life care. Materials and methods The article summarizes and discusses Italian common deontological low and the current positions of national and international experts in the field of end-of-life care. Results The ethical issues regarding euthanasia, withdrawal/withholding of health care, and medical treatment that uselessly prolongs the life of a terminal patient are defined and analyzed in conjunction with the outcomes suggested by the palliative medicine. Discussion Physicians caring for patients at the end of their lives must give consideration to bioethical approach.
Intermediate care as a solution for managing chronic diseases: The Stroke Care program in Emilia Romagna (Italy)
Authors: Bartoli Simona , Ferro Salvatore , De Palma Rossana
Published: April 2013

Introduction Chronic conditions represent an urgent health-care challenge for three main reasons: 1) their frequency is increasing all over the world, mainly as a result of longer life expectancy; 2) they require complex, long-term response that goes beyond the acute-care hospital setting; and 3) they place a heavy burden on health-care systems. Materials and methods The authors conducted a critical review of the literature to obtain an overview of the theoretical frameworks and strategies that have been developed to tackle chronic diseases, with special emphasis on intermediate care. Results Several frameworks and models of care delivery for people with long-term conditions were frequently discussed in the literature. Thus far, however, no consensus has been reached on the definition of “intermediate care”. The authors report the experience of the Stroke Care program in the Emilia Romagna Region of Italy as an example of integrated care delivery. Discussion The management of chronic diseases is considered a priority. Although there is no consensus definition of the term “intermediate care”, the authors attempted to highlight its main characteristics. Their analysis of the Stroke Care program provides an illustration of how theory and practice are combined.
Update on fibromyalgia
Authors: Atzeni Fabiola , Cazzola Marco , Sarzi-Puttini Piercarlo
Published: April 2013

IntroductionFibromyalgia (FM) is a chronic pain syndrome characterized by widespread pain, fatigue, sleep alterations, and distress. It affects at least 2% of the adult population. The etiology of FM is not completely understood, and the syndrome is influenced by stress, physical illness, and a variety of pain conditions. Emerging evidence indicates that augmented pain processing within the central nervous system plays a primary role in the pathophysiology of this disorder. Diagnosis may be difficult because of the multifaceted nature of the syndrome and its overlap with other chronically painful conditions. This article reviews the most recent data in the literature on FM.Materials and methodsThere are currently no instrumental tests or specific diagnostic markers for FM. In fact, many of the existing indicators are regarded as significant for research purposes only.ResultsDifferential diagnosis requires an extensive clinical examination and complete patient history. Chest-X-rays and abdominal ultrasonography are the first steps in the general evaluation of a patient with suspected FM.ConclusionsA variety of pharmacological treatments have been used to treat FM, including antidepressants, nonsteroidal anti-inflammatory drugs, opioids, sedatives, muscle relaxants, and antiepileptics. Physical exercise and multimodal cognitive-behavioral therapy seem to be the most widely accepted and beneficial forms of non-pharmacological therapy.
More research is needed for generic drugs
Authors: Garattini Silvio
Published: April 2013

Not available
Efficacy and safety of new oral anticoagulants compared with warfarin in cardioembolic prophylaxis of patients with non valvular atrial fibrillation. More lights than shadows
Authors: Masotti Luca , Di Napoli Mario , Ageno Walter , Imberti Davide , Godoy Daniel , Panigada Grazia , Napoli Niccolò , Landini Giancarlo , Cappelli Roberto , Iori Ido , Prisco Domenico , Agnelli Giancarlo
Published: April 2013

IntroductionThe prophylaxis of thromboembolic events represents a key point in the modern management of patients with non valvular atrial fibrillation (AF), both paroxysmal and persistent/permanent. Up to now, vitamin K antagonist (VKA) drugs are the first choice in thromboembolic prophylaxis. Their treatment limitations have lead to development and clinical experimental use of new molecules aimed to overcome their limits. The new oral anticoagulants, such as dabigatran, a direct inhibitor of thrombin or rivaroxaban and apixaban, direct inhibitors of activated factor X, have been compared to warfarin in randomized clinical phase three trials (RCTs) for thromboembolic prevention in patients with non valvular AF with the aim to demonstrate their non inferiority when compared to warfarin. The results of these trials have been recently published. In this article the authors review the results of efficacy and safety of these three more recently published large RCTs.Conclusions All RCTs, RE-LY for dabigatran, ROCKET-AF for rivaroxaban and ARISTOTLE for apixaban met the study end-points and demonstrated a good safety profile of each new oral anticoagulant, so promising a new era for thromboembolic prevention therapy in AF.
The mechanisms of muscle wasting in COPD and heart failure
Authors: Vescovo Giorgio
Published: April 2013

Many of the mechanisms leading to skeletal muscle wasting in COPD and heart failure are common to both conditions. These encompass neurohormonal activation and systemic inflammation. The mechanisms leading to muscle dysfunction are both qualitative and quantitative. Qualitative changes comprise the transition from aerobic metabolism and prevalent slow fibers composition toward anaerobic metabolism and fast fibers synthesis. Quantitative changes are mainly linked to muscle loss. These changes occur not only in the major muscles bulks of the body but also in respiratory muscles. The mechanisms leading to muscle wastage include cytokine-triggered skeletal muscle apoptosis and ubiquitin-proteasomeand non-ubiquitin-dependent pathways. The regulation of fiber type involves the growth hormone/insulin-like growth factor 1/calcineurin/transcriptional coactivator PGC1 cascade. The imbalance between protein synthesis and degradation plays an important role. Protein degradation can occur through ubiquitin-dependent and non-ubiquitin-dependent pathways. Very recently, two systems controlling ubiquitin-proteasome activation have been described: FOXO-ubiquitin ligase and NFkB ubiquitin ligase. These are triggered by TNFα and growth hormone/insulin-like growth factor 1. Moreover, apoptosis, which is triggered by tumor necrosis factor α, plays an important role. Another mechanism acting on muscle wastage is malnutrition, with an imbalance between catabolic and anabolic factors toward the catabolic component. Catabolism is also worsened by the activation of the adrenergic system and alteration of the cortisol/DEHA ratio toward cortisol production. Sarcomeric protein oxidation and its consequent contractile impairment can be another cause of skeletal muscle dysfunction in CHF.
Sepsis and meningoencephalitis due to Listeria monocytogenes in patients with liver cirrhosis: a case of nonhepatic encephalopathy?
Authors: Lari Federico , Bortolotti Roberta , Vacchetti Mariaelena , Bragagni Gianpaolo , Lenzi Marco
Published: April 2013

Introduction The appearance of neurological disorders in a patient with liver cirrhosis initially suggests hepatic encephalopathy, but other causes should be considered, including bacterial infections.Materials and methods An 80-year-old woman suffering from HCV-related cirrhosis was admitted for fever, confusion, and stupor. No improvement was seen after treatment with cephalosporins, lactulose, and fluids.Results Listeria monocytogenes was isolated from blood cultures and subsequently from a cerebrospinal fluid specimen as well. On the basis of the antibiogram, the antibiotic therapy was modified to include ampicillin, but shock and multiorgan failure developed and the patient died one week later.Discussion Bacterial infections are more common and more aggressive in patients with liver cirrhosis, probably because of the immune dysfunction associated with this disorder. The presence of neurological disorders in a patient with liver cirrhosis may be a sign of hepatic encephalopathy, but it is important to recall that there are other potential causes as well, including bacterial infections. In this case, it is possible that the patient's symptoms were the result of the CNS infection with L. monocytogenes, which was particularly aggressive as a result of her cirrhosis.
Judicial intervention in the medical profession: present and future regulation of disputes concerning professional liability
Authors: Santacroce Giorgio
Published: April 2013

Not available
Pulmonary comorbidities associated with chronic obstructive pulmonary disease
Authors: Luppi Fabrizio , Beghè Bianca , Roversi Pietro
Published: April 2013

Introduction Chronic obstructive pulmonary disease (COPD) is characterized by a relatively irreversible airflow limitation caused by chronic inflammation, in most cases tobacco-related. The impact of COPD on morbidity and mortality at the single-patient level depends upon the severity of COPD symptoms and the existence of other types of systemic and/or pulmonary disease, also known as co-morbid conditions.Materials and methods This review examines the pulmonary diseases commonly associated with COPD, in terms of their prevalence, clinical features, pathogenic mechanisms, prognoses, and implications for management of COPD.Results The incidence and prevalence of various pulmonary diseases are significantly increased in patients with COPD. These conditions include symptomatic bronchiectasis, combined pulmonary fibrosis and emphysema, lung cancer, sleep-related respiratory disorders, and pulmonary embolism. Some of these concomitant respiratory diseases have an independent negative impact on the prognosis of COPD patients, and their presence has important implications for treatment of these patients.Conclusions Physicians treating patients with COPD need to be aware of these coexisting pulmonary diseases. All patients with COPD should be carefully evaluated to identify pulmonary comorbidities, since they not only influence the prognosis but also have an impact on disease management. The treatment of COPD is no longer restricted exclusively to inhaled therapy. The therapeutic approach to this disease is becoming increasingly multidimensional in view of the fact that successful management of comorbidities might positively affect the course of COPD itself.
Intraductal papillary mucinous neoplasm of the pancreas. Personal series and synthetic review
Authors: Gallucci F. , Avolio D. , De Ritis R. , Ferrara L. , Valentino U. , Uomo G.
Published: April 2013

Intraductal papillary mucinous neoplasms (IPMNs) are rare pancreatic tumors, accounting for less than 1-2% of all neoplasms of the pancreas. The main characteristic of IPMNs is their favorable prognosis, as these pre-malignant or malignant lesions are usually slow-growing tumors and radical surgery is frequently possible. According to the localization of the lesions, three different tumor types have been identified: the main-duct IPMN, the branch-duct IPMN and the mixed-type IPMN (involving both the main pancreatic duct and the side branches). IMPNs do not present pathognomonic signs or symptoms. The obstruction of the main pancreatic duct system may cause abdominal pain and acute pancreatitis (single or recurrent episodes). The tumor may be incidentally discovered in asymptomatic patients, particularly in those with branch-duct IPMNs. In clinical practice, any non-inflammatory cystic lesion of the pancreas should be considered as possible IPMN. Computed tomography, magnetic resonance imaging with cholangiopancreatography and endoscopic ultrasonography can localize an IPMN and assess its morphology and size. The choice between non-operative and surgical management depends on the risk of malignancy and on the definitive distinction between benign and malignant IPMNs. Main-duct IPMNs have a high risk of malignant degeneration, especially in older patients. The clinical and radiological features, as well as treatment and outcome, of eight patients with IPMN (five with main-duct, two with branch-duct and one with mixed-type) observed by the authors over the last ten years are presented.
Aggressive blood pressure reduction in patients at high vascular risk: is it dangerous?
Authors: Angeli Fabio , Reboldi Gianpaolo , Poltronieri Cristina , Mazzotta Giovanni , Garofoli Marta , Ramundo Elisa , Biadetti Alessandra , Verdecchia Paolo
Published: April 2013

Introduction The aim of this review was to summarize the current state of evidence regarding the optimal blood pressure goals in patients with high vascular risk. In particular, this review critically addresses the issue of the “J-curve” paradox – a hypothesis indicating that low treatment-induced blood pressure values are characterized by an increase, rather than a decrease, in the incidence of cardiovascular events. Materials and methods We reviewed evidence from studies published in peer-reviewed journals indexed in Medline, EMBASE and CINAHL that compared different BP goals. Results Post-hoc analyses of randomized trials specifically conducted to test the hypothesis of the “J-shaped curve” yielded conflicting results. However, trials directly comparing different blood pressure goals and meta-analyses showed that in-treatment blood pressure values below the usual goal of less than 140/90 mmHg improve outcomes in patients at increased vascular risk. Discussion The fear that an excessive reduction in blood pressure may be dangerous is inconsistent with the available data and probably conditioned by the adverse impact of other risk factors that may be more frequent in patients with low values of achieved blood pressure. The association between blood pressure reduction and cardiovascular risk seems to be linear and not J-shaped.
Value of autopsy in Internal Medicine: discrepancies between clinical and postmortem diagnosis
Authors: Tiratterra Fabrizio , Pignatelli Valeria , Placido Alberto , Valenti Agostino , Recine Umberto
Published: April 2013

Introduction The number of autoptic controls is progressively dropping worldwide during the last decades. Several social, cultural and normative causes may underlie this phenomenon. However, a hidden cause may be represented by the scepticism of physicians about the gain in information given by this practice. There is in fact a general thinking that available diagnostic techniques may be adequate for a correct diagnosis, even in the case of a mortal outcome. Nevertheless, several studies have shown quite relevant discrepancies between premortem and postmortem diagnosis. In this study, the authors evaluate the accuracy of clinical diagnosis in diseases leading the patient to death.Materials and methods Retrospective analysis including all patients died in the Department of Internal Medicine of a General Hospital in Rome during a three year time period (1st January 2007–31 December 2009). Age, sex, period of hospitalization, clinical diagnosis, autoptic diagnosis, cause of death, and level of discrepancy between clinical diagnosis and autoptic control have been collected. Main diagnoses have been classified as follows: (1) discrepancy with a possible influence on survival; (2) discrepancy with no or questionable influence on survival.Results Ninety-two cases (42 males, 50 females; mean age 79.3 years) have been included. Thirty-four main diagnoses (36.9%) have been classified as discrepant (15.2% classified as type 1 discrepancy and 21.7 as type 2).DiscussionA substantial discrepancy between clinical diagnosis and autoptic control is confirmed by the current study, which supports the role of autopsy as a tool for the improvement of medical practice.
Cancer of unknown primary origin: utility and futility in clinical practice
Authors: Airoldi Gianluca
Published: April 2013

Introduction Metastatic cancer of unknown primary (CUP) origin is one of the 10 most frequent cancers in humans; it accounts for approximately 3% to 5% of all solid malignancies. Patients with CUP present with metastatic disease whose site of origin cannot be identified at the time of diagnosis despite a thorough history, physical examination and appropriate laboratory testing, histopathology investigations and modern imaging technology (including computed tomography, magnetic resonance imaging, and positron emission tomography).Materials and methods A “state of the art” review was written reflecting all articles retrieved through a PubMed Medline search with the keywords “cancer of unknown primary”, “occult primary tumor”, and “metastases of unknown origin”, with no limits regarding date of publication, type of article, or field.Results CUP represents a heterogeneous group of malignancies that can be classified into distinct clinicopathological entities. Certain entities are included in favorable sub-sets that are responsive to systemic chemotherapy and/or locoregional treatment: these include poorly differentiated carcinomas involving the mediastinal–retroperitoneal nodes, peritoneal papillary serous adenocarcinomatosis in females, poorly differentiated neuroendocrine carcinomas, isolated axillary node adenocarcinomas in females, cervical and inguinal node involvement by squamous cell carcinoma, and any other single metastatic site of limited extension. In these cases, identification of the primary tumor may be important and warrants special diagnostic efforts. However, in most cases, the primary site remains unknown, even after autopsy. Therefore, invasive endoscopic and laparoscopic procedures are rarely warranted in the absence of symptoms. Patients who belong to the non-favorable sub-sets (mainly metastatic CUP involving the liver, lung/pleura, brain, bones, or multiple sites) or have a poor performance status have a dismal prognosis (average median survival of 4-8 months).Discussion The current evidence does not support the hypothesis that palliative chemotherapy improves survival and/or quality of life in CUP patients who do not fit into any of the favorable sub-sets. Therefore, only low-toxicity empirical chemotherapy regimens should be offered to patients with a good performance status, and quality of life issues should be given priority for any choice of treatment.
Study of cystatin C (Cys C) in relation to the calculation of the glomerular filtration rate and bioelectrical impedance analysis parameters in obese patients with and without type 2 diabetes
Authors: Liani Mario , Trabassi Ernesto , Tresca Ettore , Ciantra Giulia , Liani Rossella
Published: April 2013

IntroductionAssessment of renal function based on quantification of the glomerular filtration rate (GFR) is essential for early detection of damage and progression of renal diseases. The purpose of our study was to determine the value of cystatin C (Cys C) assays in the calculation of the GFR and bioelectrical impedance analysis parameters in obese subjects aged 30-70 years with moderately damaged renal function.Materials and methodsCys C levels were measured with a new immunoturbidimetric kit (Roche Diagnostics) and an automated Cobas c6000 analyzer. In the GFR calculation, creatinine and Cys C levels were included. The GFR calculated with the equation that included Cys C in obese and normal-weight patients is not affected by changes in the lean body mass.ResultsObese patients (N = 70) had a mean (± SD) serum creatinine level of 1.52 ± 1.0 mg/dL and a mean Cys C level of 1.28 ± 0.59 mg/L. In this group, the GFR calculated on the basis of MDRD, Cys C, and creatinine clearance values showed similar filtered values between MDRD and Cys C and a DS value smaller in the case of Cys C. The correlation (R2) between GFR and its metabolite is higher in the case of Cys C when somatotype parameters (measured with bioelectrical impedance analysis) were introduced into the equation.ConclusionsWhen Cys C is included in calculations of GFR, the result shows a higher correlation degree compared to the MDRD system. Given that Cys C shows less intra-individual variability than creatinine, it can be applied in routine diagnostics in a larger number of patients.
Third cranial nerve palsy (ptosis, diplopia) accompanied by orbital swelling: case report of unusual clinical presentation of giant cell arteritis associated with polymyalgia rheumatica
Authors: Bravi Prassede , Tolaini Patricia
Published: April 2013

IntroductionGiant cell arteritis (GCA) is the most common systemic vasculitis in older individuals, characterized by granulomatosus inflammation of the wall of large and medium-sized arteries. The wide spectrum of arterial sites involved leads to ischemia of different organs resulting in a wide range of clinical signs and symptoms. Temporal artery is commonly involved (temporal arteritis). Unusual patterns of presentation, such as extraocular motility disorders and orbital swelling, may be early and transient manifestations of GCA and precede the permanent visual loss due to ischemic optic neuropathy.Case reportWe describe a patient with uncommon manifestations of GCA consisting of transient recurrent diplopia, ptosis, orbital swelling together with more typical clinical features of the disease such as musculoskeletal manifestations (polymyalgia rheumatica) and facial pain: all signs and symptoms promptly resolved under corticosteroid therapy without relapse.Conclusions A high level of suspicion of GCA in individuals over the age of 50 years is needed to prevent the development of severe complications. Clinicians should be aware of uncommon manifestations of the disease such as head–neck swelling and ophthalmoplegia: management guidelines have stated that prompt administration of adequate dose of corticosteroids as soon as ocular manifestations of GCA are noted may almost totally prevent blindness.
Madelung's disease: a case report
Authors: Scaglione Lorenzo , Ariano Renato , Rizzi Guido
Published: April 2013

IntroductionMadelung's disease, also known as Multiple Symmetric Lipomatosis (MSL) or the Launois-Bensaude syndrome, is characterized by subcutaneous lipid deposits, which, unlike lipomas, are nonencapsulated. The disease is diagnosed mainly in Mediterranean countries, and 90% of all cases involve male alcoholics. These masses are usually found on the neck, chest, abdomen, and arms. The symptoms are the result of acute sensorimotor axonal neuropathy caused by compression. Treatment (surgical and/or medical) does not produce significant or lasting results.Case reportWe describe the case of a 57-year old male alcoholic (daily ethanol intake: approximately 2 L of wine), who has been treated and followed by our staff for 6 years.Discussion and conclusionsAs this case illustrates, management of MSL is often associated with serious difficulties related to the patient's alcoholism. The effects of adipose tissue masses on the sensitive and motor nervous system are complicated by the effects of alcoholic neuropathy, requiring complex long-term monitoring. Treatment is often compromised by poor compliance related to patient's drinking problems. Madelung's disease is currently regarded as a rare disease, although we suspect that the incidence in Italy (and in the rest of the world) has probably been underestimated for various reasons.
A rare cause of osteonecrosis
Authors: Agostinis Paolo , Vergendo Maurizio , Bizzaro Nicola , Avellini Claudio , Durigon Nadia , Bardus Paola , Englaro Alfio , Quaglio Cristina , Di Piazza Vito
Published: April 2013

IntroductionHereditary hemochromatosis (HH) is an autosomal recessive disorder caused by mutations in the HFE gene, which increase intestinal iron absorption. The prevalence of C282Y homozygosity, which causes the disorder, is 0.5% in Caucasian populations. The clinical manifestations are related to excess iron in the tissues, especially the liver, heart, pancreas, pituitary, and skin. They include fatigue, loss of libido or impotence in males, liver disease, skin pigmentation, diabetes mellitus, cardiac enlargement—with or without heart failure, and conduction defects. The classic triad of cirrhosis, diabetes mellitus, and skin pigmentation (“bronze diabetes”) results from a combination of iron deposits and melanin. It occurs late in the disease, when the total body iron content is more than five times the normal value, about 20 grams. Left untreated, approximately half of all patients with HH eventually develop arthralgia or arthropathy. Chondrocalcinosis, chronic pseudo-osteoarthritis, and osteoporosis are the major rheumatic manifestations of HH. The cause of the arthropathy is still unknown. Iron deposits within joints may trigger a number of pathologic events, such as free radical generation and crystal deposition, which stimulate immune complex formation and inflammation.Materials and methodsWe describe the case of a 48-year-old male suffering from chronic bilateral ankle pain.ResultsThe work-up revealed osteonecrosis of ankle. The patient also presented high plasma ferritin levels and homozygosity for the C282Y mutation. Other than HH, which was confirmed by liver biopsy, the patient had no other risk factors for osteonecrosis.DiscussionHH represents a rare cause of osteonecrosis, and there are no prior reports of aseptic osteonecrosis of the ankle in a patient with this disease. The pathogenetic mechanism remains unknown.
Symptomatic benign prostatic hyperplasia: the role of 5-alpha-reductase inhibitors in the prevention of acute urinary retention and surgical therapy
Authors: Marigliano Norma , Galasso Domenico
Published: April 2013

Benign prostatic hyperplasia (BPH) is a disease that affects over 50% of males aged 50 years or older. In men aged >80 years, the incidence is 90%. BPH occurs in 9-25% of males aged 40 to 79 years. Fifty percent of patients with BPH are symptomatic. The symptoms include reduced urinary flow, nocturia, defective bladder emptying, urinary hesitancy, and dysuria. Disease progression can be associated with acute urinary retention (AUR). Prostatic obstruction includes mechanical and dynamic components, the latter mediated by alpha-muscarinic receptors. Treatment with alpha-1-blockers (alfuzosin, doxazosin, tamsulosin, and terazosin) leads to rapid amelioration of symptoms and urinary flow, usually within one or two weeks. The 5-alpha reductase inhibitors (5-ARIs) are “disease-modifying drugs.” They control the growth of the prostate by blocking the conversion of testosterone into dihydrotestosterone (DHT). Finasteride is a 5–ARI that is selective for type 2 receptors. Dutasteride is a powerful inhibitor of both 5- alpha reductase isoforms (type 1 and 2) and produces more complete suppression of DHT synthesis than finasteride. Dutasteride also has a much longer half-life than finasteride (five weeks versus five to six hours). The authors review the results of clinical trials involving finasteride and dutasteride, with and without alpha-1-blockers, highlighting the important role of dutasteride in improving acute urinary retention and eliminating the need for surgical therapy.
Hospitals and organizational models based on the intensity of treatment: the internist's point of view
Authors: Chesi Giuseppe , Boni Fabrizio
Published: April 2013

IntroductionThe type of patients being treated in our hospitals has changed significantly. Today's patients are much older with more complicated, polypathological problems. As a result, hospital organization and management structures must also change, particularly in Internal Medicine. A widely discussed approach, organization according to “intensity of treatment,” could be an appropriate solution from an organizational viewpoint that would also satisfy these new demands.Materials and methodsWith the aid of a questionnaire sent to internists working in the hospitals of Italy's Emilia-Romagna region and the review of the relevant medical literature, we defined structural, organizational, technological, managerial, and staffing characteristics to better determine and classify this model. We analyzed questionnaire responses of 31 internists heading operative units in their hospitals, a relatively homogeneous subgroup with experience in organizing and managing healthcare as well as its clinical aspects.ResultsAnalysis of these questionnaires revealed important points concerning the model: 1) an accurate identification of the medical care on which to base the model; 2) a well-defined strategy for differentiated allocation of staff to structural and technological areas depending on the level of medical care provided in the area; 3) an accurate definition of the types and features of patients targeted by each level of medical care; 4) an early exchange (starting from the patient's arrival in the Emergency Department) of information and medical knowledge among Emergency Department physicians and those present during the initial stages of hospitalization; 5) a precise definition of responsibilities in the different areas, operative and collaborative stages among different physicians and medical staff, the different disciplines involved in the process.ConclusionsAmong the physicians responsible for managing complex areas of Internal Medicine in Emilia-Romagna hospitals, organization of medical care on the basis of treatment intensity is generally considered the model most likely to meet the demands of the patients being treated in our hospitals. However, application of this model requires a well-defined organizational method. Levels of medical care and organizational instruments need to be precisely defined within this method. Simple differentiated organization of nursing care is clearly no substitute for an organizational model of this kind.
The life line
Authors: D’Amore Francesco
Published: April 2013

Not available
Catheter-based renal sympathetic denervation: a real therapeutic prospect for the treatment of refractory hypertension?
Authors: Cagli Vito , Manfellotto Dario , Stornello Michele
Published: April 2013

Not available
Legal value of clinical competence and its certification
Authors: Zagari Antonino
Published: April 2013

What is the legal value of the assessment and certification of professional skills and competence? The certification of skills can be defined as a process by which a third party gives written assurance that a person satisfies all requirements needed to operate to the highest professional standards in a specific field. Today, the certification of skill scan have a legal value in the context of professional responsibility when a judge has to assess the degree of expertise of a doctor who is under investigation for malpractice. From a legal point of view, it has some value regarding credits for professional appointments or career development within the state system. It is desirable that more and more both national and regional legislation should use the system of certification of skills through accredited third-parties to improve and assess the performance of professionals and the institutions and structures in which they operate. The system of certification of skills has to become part of the requirements for the accreditation of public and private facilities that provide services to the national health service. We believe that the certification of skills not only helps to recognize human intellectual capital, which is the main value of a healthcare organization, but also facilitates decisions about career paths and the construction of an effective training and study curriculum and portfolio.
Treatment of severe chronic hypotonic hyponatremia: a new treatment model
Authors: Burgio Antonio , Dovico Rossana , Burgio Luca
Published: April 2013

Recommended treatment of severe hypotonic hyponatremia is based on the infusion of 3% sodium chloride solution, with a daily correction rate below 10 mEq/L of sodium concentration, according to the Adrogué and Madias formula that includes the current desired change in sodium concentrations. However, such treatment needs close monitoring of the rate of infusion and does not take into account the body weight or age of the patient. This may result in hypercorrection and neurological damage. We made an inverse calculation using the same algorithms of the Adrogué and Madias formula to estimate the number of vials of sodium chloride needed to reach a correction rate of the serum sodium concentration below 0.4 mEq/h, taking into account the body weight and age of the patient. Three tables have been produced, each containing the number of vials to be infused, according to the patient’s age and body weight, the serum sodium concentration, and the rate of correction over 24 h to avoid the risk of brain damage. We propose a new practical model to calculate the need of sodium chloride infusate to safely correct the hyponatremia. The tables make treatment easier to manage in daily clinical practice in a wide range of patient ages and body weights.
An unhealthy holiday on Lake Bolsena
Authors: Brugioni Lucio , Tognetti Maurizio , Gozzi Cristina
Published: April 2013

A 70-year old man (OL) was hospitalized due to fever (up to 40°C) associated with malaise and abdominal pain. Tests showed hypereosinophilic syndrome, and increased liver and inflammation indexes. Abdominal echography showed a nonhomogeneous liver and the spleen was enlarged. Abdominal computed tomography showed multiple abscesses on the liver. The patient reported that he had recently gone on holiday to Lake Bolsena where he had eaten raw fish. A specialist in infectious diseases confirmed that in that area there is an infestation of Opisthorchis felineus. Analysis of blood and stool samples confirmed the presence of this parasite. The patient was treated with praziquantel with resolution of fever and improvement in clinical tests and general condition. Opisthorchis felineus is a parasite that commonly infects dogs and cats. Infection is sometimes transmitted to man and is usually related to eating raw fish. The parasite enters the liver and its eggs are found in the patient’s stool samples. Acute symptoms are: fever, diarrhea, abdominal pain, and malaise. Hypereosinophilic syndrome and increase in liver index are typical. Chronic infection could result in cholangiocarcinoma. Presence of the parasite is confirmed through specific analysis of blood and stool. Therapy consists of praziquantel or, as second choice, abendazol. In the 20th century, there were 4 epidemics in Italy, on Lakes Trasimeno and Bolsena in Central Italy. The latest epidemic was reported in that area in summer 2012.
Quadricuspid aortic valve
Authors: Almansori Mohammed
Published: April 2013

Quadricuspid aortic valve is an extremely rare congenital anomaly characterized by the development of aortic regurgitation, and associated with abnormally placed coronary ostia. We report a case of a quadricuspid aortic valve with mild aortic regurgitation.
Respiratory symptoms of megaesophagus
Authors: Di Stefano Fabio , Migliorato Lorenzo
Published: April 2013

Megaesophagus as the end result of achalasia is the consequence of disordered peristalsis and the slow decompensation of the esophageal muscular layer. The main symptoms of achalasia are dysphagia, regurgitation, chest pain and weight loss, but respiratory symptoms, such as coughing, particularly when patients lie in a horizontal position, may also be common due to microaspiration. A 70-year old woman suffered from a nocturnal cough and shortness of breath with stridor. She reported difficulty in swallowing food over the past ten years, but had adapted by eating a semi-liquid diet. Chest X-ray showed right hemithorax patchy opacities projecting from the posterior mediastinum. Chest computed tomography scan showed a marked dilatation of the esophagus with abundant food residues. Endoscopy confirmed the diagnosis of megaesophagus due to esophageal achalasia, excluding other causes of obstruction, such as secondary esophagitis, polyps, leiomyoma or leiomyosarcoma. In the elderly population, swallowing difficulties due to esophageal achalasia are often underestimated and less troublesome than the respiratory symptoms that are caused by microaspiration. The diagnosis of esophageal achalasia, although uncommon, should be considered in patients with nocturnal chronic coughs and shortness of breath with stridor when concomitant swallowing difficulties are present.
Metateoretiese vertrekpunte ten opsigte van wetenskaplike navorsing in gemeentebediening
Authors: Breed Gert
Published: April 2013

Hierdie artikel is deel van ’n reeks oor die verrekening van die metateoretiese vertrekpunte in die wetenskap van Praktiese Teologie. Die eerste fase van die reeks bied die teoretiese onderbou vir die werklikheids-, hermeneuties- en wetenskapsteoretiese beskouing van die vak. Die tweede fase fokus op die invloed wat hierdie vertrekpunte op die wetenskaplike navorsing van die verskillende vakgroepe in die Praktiese Teologie het. Hierdie artikel handel oor die wetenskaplike benaderingswyse tot die navorsingsveld van gemeentebediening. In hierdie artikel word die persoonlike metateoretiese perspektief waarmee die vakgebied van gemeentebediening benader word, uitgespel en verantwoord ten opsigte van die volgende: die werklikheidsbeskouing waarmee daar op die navorsingsveld van gemeentebou gefokus word; die onderbou van die hermeneutiese beskouing wat nodig is om tot ’n verstaan te kom en tot ’n verantwoordbare verhouding tussen die elemente wat in die gemeentebouproses ter sprake kom; en ten slotte om die wetenskapsteoretiese benadering waarmee die navorsingsveld van gemeentebou op ’n wetenskaplik-verantwoorde wyse ondersoek kan word, te beskryf.
Circulation of bluetongue virus in goats in the Karamoja region of Uganda
Authors: Mulabbi Elijah N. , Ayebazibwe Chrisostom , Majalija Samuel , Batten Carrie A. , Oura Christopher A.L.
Published: April 2013

The presence of bluetongue virus (BTV) in indigenous goats from the Karamoja region of northern Uganda was investigated. A total of 300 goats were sampled (serum and whole blood) from five districts within the Karamoja region. The samples were analysed for the presence of bluetongue (BT) antibodies using a commercial Enzyme-linked immunosorbent assay (ELISA) and for the presence of BTV viral RNA by real-time Reverse transcription polymerase chain reaction (RT-PCR), because BTV is an RNA virus. Of the 300 goats tested, 269 (90%) were positive for BTV antibodies, indicating high levels of BTV circulation within the region. Out of the 150 whole blood samples tested for the presence of the virus by real-time RT-PCR, 84 (56%) were positive for BTV RNA. This study, which is the first of its kind in Uganda, showed a high seroprevalence of BT antibodies and active circulation of BTV in a high proportion of goats in the Karamoja region.
Examining mathematical discourse to understand in-service teachers’ mathematical activities
Authors: Berger Margot
Published: April 2013

In this article I use Sfard’s theory of commognition to examine the surprising activities of a pair of in-service mathematics teachers in South Africa as they engaged in a particular mathematical task which allowed for, but did not prescribe, the use of GeoGebra. The (pre-calculus) task required students to examine a function at an undefined point and to decide whether a vertical asymptote is associated with this point or not. Using the different characteristics of mathematical discourse, I argue that the words that students use really matter and show how a change in one participant’s use of the term ‘vertical asymptote’ constituted and reflected her learning. I also show how the other participant used imitation in a ritualised routine to get through the task. Furthermore I demonstrate how digital immigrants may resist the use of technology as the generator of legitimate mathematical objects.
Sensitivity of Antarctic phytoplankton species to ocean acidification: Growth, carbon acquisition, and species interaction
Authors: Trimborn Scarlett , Brenneis Tina , Sweet Elizabeth , Rost Björn
Published: April 2013

Despite the fact that ocean acidification is considered to be especially pronounced in the Southern Ocean, little is known about CO2‐dependent physiological processes and the interactions of Antarctic phytoplankton key species. We therefore studied the effects of CO2 partial pressure (PCO2) (16.2, 39.5, and 101.3 Pa) on growth and photosynthetic carbon acquisition in the bloom‐forming species Chaetoceros debilis, Pseudo‐nitzschia subcurvata, Fragilariopsis kerguelensis, and Phaeocystis antarctica. Using membrane‐inlet mass spectrometry, photosynthetic O2 evolution and inorganic carbon (Ci) fluxes were determined as a function of CO2 concentration. Only the growth of C. debilis was enhanced under high PCO2. Analysis of the carbon concentrating mechanism (CCM) revealed the operation of very efficient CCMs (i.e., high Ci affinities) in all species, but there were species‐specific differences in CO2‐dependent regulation of individual CCM components (i.e., CO2 and uptake kinetics, carbonic anhydrase activities). Gross CO2 uptake rates appear to increase with the cell surface area to volume ratios. Species competition experiments with C. debilis and P. subcurvata under different PCO2 levels confirmed the CO2‐stimulated growth of C. debilis observed in monospecific incubations, also in the presence of P. subcurvata. Independent of PCO2, high initial cell abundances of P. subcurvata led to reduced growth rates of C. debilis. For a better understanding of future changes in phytoplankton communities, CO2‐sensitive physiological processes need to be identified, but also species interactions must be taken into account because their interplay determines the success of a species.