Out-of-hospital cardiac arrest outcomes' determinants: an Italian retrospective cohort study based on Lombardia CARe.

This study on the Lombardia Cardiac Arrest Registry (Lombardia CARe,) the most complete nationwide out-of-hospital cardiac arrest (OHCA) registry in Italy, aims at evaluating post-OHCA intra-hospital mortality risk according to patient's characteristics and emergency health service management (EMS), including level of care of first-admission hospital. Out of 12,581 patients included from 2015 to 2022, we considered 1382 OHCA patients admitted alive to hospital and survived more than 24 h. We estimated risk ratios (RRs) of intra-hospital mortality through log-binomial regression models adjusted by patients' and EMS characteristics. The study population consisted mainly of males (66.6%) most aged 60-69 years (24.7%) and 70-79 years (23.7%). Presenting rhythm was non-shockable in 49.9% of patients, EMS intervention time was less than 10 min for 30.3% of patients, and cardiopulmonary resuscitation (CPR) was performed for less than 15 min in 29.9%. Moreover, 61.6% of subjects (n = 852) died during hospital admission. Intra-hospital mortality is associated with non-shockable presenting rhythm (RR 1.27, 95% CI 1.19-1.35) and longer CPR time (RR 1.39, 95% CI 1.28-1.52 for 45 min or more). Patients who accessed to a secondary vs tertiary care hospital were more frequently older, with a non-shockable presenting rhythm and longer EMS intervention time. Non-shockable presenting rhythm accounts for 27% increased risk of intra-hospital death in OHCA patients, independently of first-access hospital level, thus demonstrating that patients' outcomes depend only by intrinsic OHCA characteristics and Health System's resources are utilised as efficiently as possible.

"Leo&Giulia standing for public health": an animated series to promote the values of public health among school-aged children. Best practices and field-trial protocol.

Background: The "Leo&Giulia standing for public health" project is an innovative digital health education model targeting primary school children. The project, developed during the COVID-19 pandemic, aims to educate primary school-aged children about public health issues through an animated cartoon series. It highlights the importance of early-life health promotion and the potential role of educational settings in shaping health behaviours. Study design: A 2-year school-based cluster-randomized controlled community trial will be conducted among 8-10-year-old pupils in the province of Pavia, Northern Italy. Methods: The intervention group will receive an educational programme via a new episode of "Leo&Giulia" animated series, focusing on smoking prevention. The study will assess changes in knowledge, attitudes towards smoking, and communication about smoking risks among peers and parents. The trial involves baseline and follow-up assessments through questionnaires targeting both children and parents. Results (expected): We assume that children in the intervention group will demonstrate increased knowledge and awareness of smoking-related health risks and develop negative attitudes towards tobacco use compared to the control group. Enhanced communication about tobacco harms among peers and between children and parents, as well as increased parental involvement in anti-smoking socialization practices, are expected secondary outcomes. Discussion and Conclusions: "Leo&Giulia" integrates health education into the school curriculum, leveraging the appeal of animated content to engage children in public health topics. The project is expected to contribute to the field of health education by demonstrating the effectiveness of digital health interventions in childhood, foreseeing potential long-term impacts on health behaviors and in shaping future public health strategies.

Fish Intake in Relation to Fatal and Non-Fatal Cardiovascular Risk: A Systematic Review and Meta-Analysis of Cohort Studies.

Epidemiological studies have shown that eating fish significantly reduces cardiovascular disease (CVD) incidence and mortality. However, more focused meta-analyses based on the most recent results from prospective cohort studies are needed. This systematic review and meta-analysis aims to update the association between fish intake and cardiovascular disease (CVD) risk using recent prospective studies. A systematic review and meta-analysis following the PRISMA guideline was conducted based on a random effects synthesis of multivariable-adjusted relative risks (RRs) of high vs. low categories of fish intake in relation to CVD incidence and mortality. Non-linear meta-regression was applied to investigate the shape of the association between fish intake and CVD risk. Sensitivity analysis and stratifications by type of CVD outcome, type of fish intake and type of cooking were performed. Based on 18 papers reporting 17 independent estimates of CVD risk (1,442,407 participants and 78,805 fatal and non-fatal CVD events), high vs. low intake of fish corresponded to about 8% reduced CVD risk (RR = 0.93 [0.88-0.98]). According to a non-linear dose-response meta-regression, 50 g of fish intake per day corresponded to a statistically significant 9% reduced fatal and non-fatal CVD risk (RR = 0.92 [0.90-0.95]). Similarly, fish intake in the range of a weekly intake of two to three portions of fish with a size of 150 g resulted in 8% fatal and non-fatal CVD risk reduction (RR = 0.93 [0.91-0.96]). The recommended two portions of fish a week reduces the risk of CVD outcomes by approximately 10%. A full portion of fish a day reduces CVD risk by up to 30%.

A Systematic Review of Clinical Practice Guidelines for Caries Prevention following the AGREE II Checklist.

Untreated oral diseases are detrimental to overall well-being and quality of life and are in close relationship with social and economic consequences. The presence of strong evidence for caries primary and secondary prevention is a compulsory tool for the development of clinical practice guidelines (CPGs). This paper was aimed to assess systematically the importance of clinical practice guidelines in caries prevention management considering both the adult and pediatric populations and evaluate them using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Checklist. Records were extracted from EMBASE, SCOPUS, PubMed/Medline and seven other relevant guideline databases between 6 January and 14 February 2023. Two reviewers independently conducted the appraisal using the web-based platform My AGREE PLUS. Twenty-one guidelines/papers met the inclusion criteria and were reviewed. Eight CPGs included both primary and secondary prevention interventions, whereas thirteen presented a single preventive model. Overall, 12 guidelines were published in the USA. The mean AGREE II scores ranged from 35.4% to 84.3%. Of the total twenty-one included guidelines, twelve were classified as "Recommended", ranging from 56.3% to 84.3%, the others were described as "Recommended with modification", ranging from 35.4% to 68.9%. From the AGREE II analysis carried out, the CPGs included in this survey adopted a punctual methodological rigor but lacked applicative power. The present survey showed that the public, as the primary beneficiary, played a limited role in the development of the twenty-one CPGs. Hence, methodological improvement can better support high-quality CPG development in the future.

The Effect of COVID-19 Pandemic on Overall and Cause-Specific Mortality in Pavia, Northern Italy: Updated Estimates for the Year 2021.

Excess mortality estimates are considered relevant indicators of direct and indirect pandemic effects on the population. Scant data have been published on cause-specific excess mortality. Using individual-level administrative data covering the Pavia province of Italian northern Lombardy region, we provided all-cause and cause-specific raw (RMR) and age-standardized (ASMR) mortality rates in 2021 and 2015-2019, the rate ratio, and 95% confidence intervals, overall and by sex. We obtained the excess deaths in 2021 as the difference between the number of observed and expected deaths from all causes and the two leading causes of death (all neoplasms and circulatory system diseases) by fitting over-dispersed quasi-Poisson regression models, accounting for temporal, seasonal and demographic changes. The total ASMR in 2021 was 972.4/100,000 (6836 certified deaths), with the highest ASMRs for circulatory system diseases (272.6/100,000) and all neoplasms (270.3/100,000), followed by COVID-19 (94.8/100,000 and 662 deaths). Compared to the expected, we estimated a total of 6.2% excess deaths in 2021 (7.2% in males and 5.4% in females), with no excess deaths from all neoplasms and a 6.2% reduction from circulatory system diseases. COVID-19 continued to affect total mortality in 2021, albeit to a lesser extent than in 2020, consistently with national patterns.

Leadership Effectiveness in Healthcare Settings: A Systematic Review and Meta-Analysis of Cross-Sectional and Before-After Studies.

To work efficiently in healthcare organizations and optimize resources, team members should agree with their leader's decisions critically. However, nowadays, little evidence is available in the literature. This systematic review and meta-analysis has assessed the effectiveness of leadership interventions in improving healthcare outcomes such as performance and guidelines adherence. Overall, the search strategies retrieved 3,155 records, and 21 of them were included in the meta-analysis. Two databases were used for manuscript research: PubMed and Scopus. On 16th December 2019 the researchers searched for articles published in the English language from 2015 to 2019. Considering the study designs, the pooled leadership effectiveness was 14.0% (95%CI 10.0-18.0%) in before-after studies, whereas the correlation coefficient between leadership interventions and healthcare outcomes was 0.22 (95%CI 0.15-0.28) in the cross-sectional studies. The multi-regression analysis in the cross-sectional studies showed a higher leadership effectiveness in South America (ß = 0.56; 95%CI 0.13, 0.99), in private hospitals (ß = 0.60; 95%CI 0.14, 1.06), and in medical specialty (ß = 0.28; 95%CI 0.02, 0.54). These results encourage the improvement of leadership culture to increase performance and guideline adherence in healthcare settings. To reach this purpose, it would be useful to introduce a leadership curriculum following undergraduate medical courses.

Impact of the COVID-19 pandemic on physical activity among university students in Pavia, Northern Italy.

AIM: To evaluate the University of Pavia students about physical activity (PA) changes before, during and after the COVID-19 pandemic. METHODS: The International Physical Activity Questionnaires (IPAQ) survey was employed to evaluate the PA in three periods: the pre-pandemic period, during national stay-at-home order (March 9th - May 4th 2020), current PA. Exercise intensity for each period was defined using the Metabolic Equivalent of Task (Met) as unit of measurement. The questionnaire was administered online to university students from June 9th to July 4th 2021, structured in four sections, also collecting demographic data. RESULTS: 55,6% of the study population reported a significant decrease in PA during lockdown. The number of active/very active subjects dropped from 72.2% in pre-pandemic period to 29.6% during containment measures. 50% reported a substantial increase in moving out of the lockdown. Stay-at-home order was associated with an increase in sedentary lifestyle (68.5%), which sharply decreased moving out from lockdown (two-third of study population). Average time in minutes spent sitting was 612 before pandemic, 844 during the pandemic and 670 after social restrictions. CONCLUSIONS: Lockdown had a negative impact on PA among the university students leading to an increase in sedentary behaviours. Following the gradual relaxation of the restrictive measures, situation has improved, without however returning to pre-pandemic level. It is of fundamental importance to study new strategies to promote healthy lifestyles while coping with the on-going pandemic.

Characteristics and determinants of population acceptance of COVID-19 digital contact tracing: a systematic review.

BACKGROUND AND AIM: As recently outlined in the WHO-ECDC Indicator framework (1) to evaluate the public health effectiveness of digital proximity tracing solutions, one of the main barriers to digital contact tracing (DCT) is population acceptance, which, in turns, is influenced by digital literacy, attitudes and practice. DCT came to public prominence during the COVID-19 pandemic but evidence on its population acceptance have not been comprehensively analyzed.  Methods: We carried out a systematic review (PROSPERO: CRD42021253668) following the PRISMA guidelines to collect, systematize and critically appraise the available evidence on population DCT acceptance.  Original studies reporting on different measures of population DCT acceptance were included. CONCLUSIONS: The systematic review was based on 41 articles meeting our a priori defined inclusion criteria, comprising aa total of 186144 surveyed subjects, 50000 tweets, 5025 Reddit posts and 714 written comments. Data extraction and synthesis required a qualitative outcome grouping, performed ex-post, in 14 different benchmarks components. They constitute a narrative analysis of actionable points for public health policy. Population acceptance is a key component of  DCT effective adoption and infection control during infectious diseases outbreaks. Assessing DCT acceptance's determinants in different settings, populations an cultural contexts it is of fundamental importance to inform the planning, implementation and monitoring of public health interventions. The results of our in-depth qualitative and quantitative analysis  will provide context for prospective improvements and actionable items and should guide future research aimed at exploring how digitalization can serve people-centred care.

Public health effectiveness of digital contact tracing in the COVID-19 pandemic: A systematic review of available data.

Background and aim Contact tracing is a key element of epidemiologic investigation and active surveillance during infectious diseases outbreaks. Digital contact tracing (DCT) are new technologies that have been increasingly adopted in different countries to support conventional contact tracing efforts to control the COVID-19 pandemic. However, scant evidence is available on its public health effectiveness. We applied the Indicator Framework issued in 2021 jointly by the World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) to assess the available evidence on DCT adoption and impact in the context of the COVID-19 pandemic. Methods We carried out a systematic review following the PRISMA guidelines (Prospero registration number: CRD42021253662) to retrieve, pool, and critically appraise studies published in English from November 2019 to April 2021. We excluded mathematical models of effectiveness. Only studies representative of the general population or specific populations were included . In line with the WHO-ECDC indicator framework, outcomes of interest were grouped in indicators of: i) DCT use, ii) DCT success, and iii) DCT performance. Results We identified 1.201 citations searching the PubMed, Embase, Web of Science and The Cochrane Library. After screening, 10 studies were included. All included studies reported measures of DCT use, varying widely by study population and setting (percentage of DCT apps download from 0.01% to 58.3% in included studies). Almost no data quantified an association between DCT adoption rate and infection transmission at the community level.  Only one reported measures of DCT success (ratio of exposure notifications received to positive test results entered), while no studies were retrieved reporting measures of DCT performance. Conclusions DCT has large potential to control epidemics. Its adoption is hindered by several normative, technical and acceptance barriers in different regions and countries. Our review shows that while some evidence is available on its adoption and use in selected settings, very scant data is available on its effectiveness in the fight against COVID-19. As digitalization provides new tools for infection control at the population level, solid research is needed to quantify the public health effects of their application.

Traits of orthorexia nervosa and muscle dysmorphia in Italian university students: a multicentre study.

PURPOSE: This study aimed to evaluate the prevalence of traits of orthorexia nervosa (ON) and muscle dysmorphia (MD) in a group of undergraduates, investigate the associations between the risk of these conditions and the type of university course attended, the individual characteristics (gender, BMI, amount of physical activity, supplements and medicines use, dieting) and the risk of eating disorders (EDs). METHODS: A self-reported questionnaire consisting of a socio-demographic section and three tests validated for the evaluation of a risk of ON (ORTO-15), MD (MDDI-ITA) and EDs (EAT-26) was completed by 918 students from three Italian universities. RESULTS: 29.0% of participants demonstrated traits of ON and 5.0% of MD, without differences in prevalence in the three areas of study investigated (health-scientific, economic-humanistic, sport sciences); students of sport sciences exhibited a significantly higher score for MDDI-ITA (F = 6.493, p = 0.002). Participants with ON and MD traits were more on a diet (OR = 0.47, p ≤ 0.001 and OR = 0.428, p = 0.020, respectively) and showed a higher prevalence of EDs risk (OR = 3.55, p < 0.001 and OR = 10.23, p ≤ 0.001, respectively). The simultaneous presence of ON, MD, and EDs traits was seen in 5.4% of the students and the three test scores were correlated. CONCLUSIONS: The prevalence of ON and MD traits was found similar to that reported in the literature on undergraduates. Some associations observed improvement in the knowledge about these conditions, especially the association of participants with ON and MD traits with dieting and EDs traits and the correlation of the three test scores suggests a connection among these potential conditions. LEVEL OF EVIDENCE: Level V, descriptive cross-sectional survey.

Risk Management in healthcare: results from a national-level survey and scientometric analysis in Italy.

Risk management in healthcare, intended as all processes employed to detect, monitor, assess, mitigate, and prevent risks in healthcare facilities and safeguard patient safety, is a crucial component of Italy' National Health Service. Aim of the current study is to assess the role and progress of  research and training, in the field of Risk Management. We carried out a scientometric analysis to quantify and describe scientific outputs on Risk Management at the global and national level, over the last forty years; in addiction, we conducted a national-level cross-sectional survey to systematically retrieve and assess research and training activities within Italian postgraduate medical programmes in Hygiene and Preventive Medicine.   We report increasing scientific production on Risk Management-related topics from 1980 to 2017 at the global level (12% annual increase rate). Clinical Trials and Systematic reviews/meta-analysis make up for respectively 5% and 6% of global scientific output. Italy ranks 4th for scientific production, after USA, UK and Germany. 88% of Italian postgraduate medical programmes in Hygiene and Preventive medicine research on Risk Management, 42% through international collaborations. The main research themes are Healthcare-Associated Infections (HAIs) (97%), analysis of organizational models for safety in healthcare (62%), while training is focused on internships (87%) and academic lectures (73%). While research provides the evidence required to plan, implement and monitor effective interventions in healthcare risk management, training allows its dissemination in a synergic action to promote the value of patient safety and quality of care.

Why do people renounce dental health care? An analysis of data from the Italian population.

OBJECTIVES: Oral diseases affect a large number of people in the world and have a great influence on their quality of life. Nevertheless, oral health promotion and prevention initiatives are lacking. The aim of this study was to identify characteristics of individuals in Italy who renounce dental care in order to better support institutional prevention campaigns. METHODS: Using data from the Italian National Institute of Statistic (ISTAT) survey "Health condition and use of health services", we divided the sample into two groups: individuals who renounced dental care even when needed and those who accessed dental healthcare. We then compared information about socio-economic and oral health profile of the two groups. RESULTS: People who renounced dental treatments are mostly young adults, smokers, belonging to the middle-low socioeconomic level, not married and unemployed. Economic resources are often the main reason behind renouncing dental treatments. CONCLUSIONS: Our study underlines that economic conditions play a leading role in renouncing dental care. In order to avoid additional costs to the Italian healthcare system, our proposal is to implement a specific prevention campaign for oral diseases, targeting young adults living in Italy.

Physical activity volume in relation to risk of atrial fibrillation. A non-linear meta-regression analysis.

Background Light physical activity is known to reduce atrial fibrillation risk, whereas moderate to vigorous physical activity may result in an increased risk. However, the question of what volume of physical activity can be considered beneficial remains poorly understood. The scope of the present work was to examine the relation between physical activity volume and atrial fibrillation risk. Design A comprehensive systematic review was performed following the PRISMA guidelines. Methods A non-linear meta-regression considering the amount of energy spent in physical activity was carried out. The first derivative of the non-linear relation between physical activity and atrial fibrillation risk was evaluated to determine the volume of physical activity that carried the minimum atrial fibrillation risk. Results The dose-response analysis of the relation between physical activity and atrial fibrillation risk showed that physical activity at volumes of 5-20 metabolic equivalents per week (MET-h/week) was associated with significant reduction in atrial fibrillation risk (relative risk for 19 MET-h/week = 0.92 (0.87, 0.98). By comparison, physical activity volumes exceeding 20 MET-h/week were unrelated to atrial fibrillation risk (relative risk for 21 MET-h/week = 0.95 (0.88, 1.02). Conclusion These data show a J-shaped relation between physical activity volume and atrial fibrillation risk. Physical activity at volumes of up to 20 MET-h/week is associated with reduced atrial fibrillation risk, whereas volumes exceeding 20 MET-h/week show no relation with risk.

[Hygienic and sanitary aspects in urban planning: contradiction in national and local urban legislation regarding public health]. / Aspetti igienico-sanitari in ambito urbanistico: conflittualità nelle norme urbanistiche nazionali e locali in tema di sanità pubblica.

Nowadays, the majority of world population lives in urban areas and this portion is going to increase in the coming decades. The health impact of urban areas is well established and described in scientific literature. Italian health and hygiene legislation dealing with urban health is fragmented and not coordinated with the regulation about environment and city planning. The overlapping of legal competences between different authorities and the conflict of attribution between the Central State and Regional Governments deeply contributed to generate uncertainty. The authors here analyse the Italian regulatory framework and depict its lacks in terms of public health protection.

Bariatric Surgery to Reduce Mortality in US Adults. A Public Health Perspective from the Analysis of the American National Health and Nutrition Examination Survey Linked to the US Mortality Register.

BACKGROUND: Type II obesity represents a major pandemic and public health threat in high-income countries. Type II obesity increases the risk of all-cause and specific-cause mortality, and it is widely acknowledged that bariatric surgery represents the only effective therapeutic option in these patients. The aim of the present study was to estimate US population attributable risk for all-cause and cause-specific mortality in type II obese subjects undergoing weight loss as resulting from bariatric surgery alone and supplemented with behavioral intervention. METHODS: The American National Health and Nutrition Examination Survey linked to the US death registry updated to 2011 was used to estimate type II obesity prevalence and all-cause and specific cause of death for type II obese adults undergoing weight loss. Multivariate adjusted proportional hazard Cox models were used to estimate mortality risks. Statistical analyses were performed on the most updated version of the database (June 2017). RESULTS: A monotone positive trend for type II obesity was observed during the period 1999-2014 (p < 0.001). According to trend analysis, the rate of type II obesity in US adults is expected to rise up to 8.5%. Two- to sevenfold increased risk of all-cause and specific-cause mortality was observed for type II obese participants when compared to type I obese and overweight participants. Population attributable risk for all-cause and specific-cause mortality for type II obese subjects undergoing weight loss was ranging between 6 and 34%. CONCLUSIONS: Bariatric surgery supplemented with behavioral intervention can result in a relevant reduction of mortality if extensively applied to the US population.

Is epicardial fat depot associated with atrial fibrillation? A systematic review and meta-analysis.

Aims: Atrial fibrillation (AF) is the leading rhythm disorder in western countries. A direct relationship between left atrium (LA) enlargement and electromechanical remodelling has been established. A causative link between epicardial fat (EF), visceral adipose tissue deposited around the heart, and AF has been hypothesized. Several reports suggested the association between EF and the presence of AF. The aim of this study was to verify the relationship between AF and EF depot, performing a meta-analysis of observational case series studies. Methods and results: Studies were identified by searching electronic databases by two independent investigators using 'atrial fibrillation' and 'epicardial fat' as keywords. Comparisons between healthy participants and AF cases were performed using a random effect meta-analysis estimating standardized mean difference among comparison groups. Meta regression was used to address the effect given by potential biological and technical confounders. Through a search result of 502 articles, only 7 were selected to conduct the present study. The comparison between all AF with respect to healthy participants resulted in a 32.0 ml of EF difference (95% confidence interval (CI) = 21.5, 42.5) showing that EF volume is higher in AF cases. A statistical significant difference of EF was observed when comparing both persistent and paroxysmal AF subtypes with respect to healthy participants (EF difference 48.0 ml (95% CI = 25.2, 70.8) and 15.7 ml (95% CI = 10.1, 21.4) for persistent and paroxysmal, respectively). A significant EF difference resulted also when comparing persistent to paroxysmal AF subtypes (29.6 ml (95% CI = 12.7, 46.5)). Conclusions: The present work expands the strength of previously reported association between EF amount and atrial arrhythmia.

Mitral regurgitation in heart failure: insights from CPET combined with exercise echocardiography.

AIMS: In heart failure patients with reduced ejection fraction (HFrEF), exercise-induced functional mitral regurgitation (MR) may affect functional capacity and outcome. We sought to study functional and cardiac phenotypes of HFrEF patients according to the MR degree. METHODS AND RESULTS: We performed rest and exercise echocardiography (Ex-Echo), simultaneously combined with cardiopulmonary exercise test (CPET), in 102 HFrEF patients, identifying 3 groups: non-severe (ERO <20 mm2) MR (group A), exercise-induced severe (ERO ≥20 mm2) MR (group B), and rest severe MR (group C). Patients were tracked for the composite end point of death and heart failure hospitalization. Group B (ERO: rest= 14 ± 5 mm2, Ex= 28 ± 6 mm2; P = < 0.001) had a functional impairment (workload = 56 ± 21 vs. 50 ± 17 watts, P = 0.42; peak VO2 = 11.8 ± 3.2 vs. 11.5 ± 3.0 mL/Kg/min, P = 0.70) similar to Group C (ERO: rest = 29 ± 7 mm2, Ex = 42 ± 7 mm2, P = < 0.001), associated with comparable advanced left ventricle remodelling (end diastolic indexed volume = 107 ± 34 vs. 115 ± 30 mL/m2, P = 0.27), characterized by exercise-induced pulmonary hypertension (PH) (Ex systolic pulmonary pressures = 63 ± 16 mmHg). Group C showed the worse cardiac phenotype (right ventricle dilatation, dysfunction, and rest PH) with severe ventilatory impairment (VE/VCO2 = 41.2 ± 11) compared with Groups A and B. Moreover, Group C had the higher rate of death and HF hospitalization. CONCLUSIONS: In HFrEF patients, severe dynamic MR produces functional limitation similar to rest severe MR, characterized by dynamic PH. Rest severe MR reflects the most advanced bi-ventricular remodelling associated with rest PH, the most unfavourable ventilatory profile, and the worst mid-term outcome.

High-sensitive cardiac troponin T (hs-cTnT) assay as serum biomarker to predict cardiac risk in myotonic dystrophy: A case-control study.

BACKGROUND: Myotonic dystrophy (DM) is a genetic disorder caused by nucleotide repeats expansion. Sudden death represents the main cause of mortality in DM patients. Here, we investigated the relationship between serum cardiac biomarkers with clinical parameters in DM patients. METHODS: Case-control study included 59 DM patients and 22 healthy controls. An additional group of 62 controls with similar cardiac defects to DM were enrolled. RESULTS: NT-proBNP, hs-cTnT and CK levels were significantly increased in DM patients compared to healthy subjects (p=0.0008, p<0.0001, p<0.0001). Also, hs-cTnT levels were significantly higher in DM compared to control group with cardiac defects (p=0.0003). Positive correlation was found between hs-cTnT and hs-cTnI in both DM patients and controls (p=0.019, p=0.002). Independently from the age, the risk of DM disease was positively related to an increase in hs-cTnT (p=0.03). On the contrary, the risk of DM was not related to hs-cTnI, but was evidenced a role of PR interval (p=0.03) and CK (p=0.08). CONCLUSIONS: The levels of hs-cTnT were significantly higher in DM patients. Analysis, with anti-cTnT, shows that this increase might be linked to heart problems. This last finding suggests that hs-cTnT might represent a helpful serum biomarker to "predict" cardiac risk in DM disease.

Right Ventricular Contractile Reserve and Pulmonary Circulation Uncoupling During Exercise Challenge in Heart Failure: Pathophysiology and Clinical Phenotypes.

OBJECTIVES: Right ventricular (RV) exercise contractile reserve (RVECR), its phenotypes, and its functional correlates are among the unresolved issues with regard to the role of the right ventricle in heart failure (HF) syndrome, and understanding these issues constitutes the objective of this study. BACKGROUND: Although the role of the right ventricle in HF syndrome might be fundamental, the pathophysiology of the failing right ventricle has not been extensively investigated. METHODS: Ninety-seven patients with HF (mean age 64 years, 70% men, mean left ventricular ejection fraction 33 ± 10%) underwent maximal exercise stress echocardiographic and cardiopulmonary exercise testing. RVECR and RV-to-pulmonary circulation (PC) coupling were assessed using the length-force relationship (tricuspid annular plane systolic excursion [TAPSE] vs. pulmonary artery systolic pressure) and the slope of mean pulmonary artery pressure versus cardiac output. On the basis of TAPSE, patients were categorized into 3 groups: those with TAPSE at rest ≥16 mm (group A, n = 60) and those with TAPSE at rest <16 mm, who were divided according to median TAPSE at peak exercise (15.5 mm) into 2 subgroups (group B, ≥15.5 mm, n = 19; group C, <15.5 mm, n = 18). RESULTS: Although they had similar left ventricular ejection fractions and rest RV impairment, compared with patients in group C, those in group B showed some degree of RVECR (upward shift of the length-force relationship), better RV-to-PC coupling (lower mean pulmonary artery pressure vs. cardiac output slope), and greater ventilatory efficiency (lower slope of minute ventilation to carbon dioxide output). Rest mitral regurgitation and net changes in pulmonary artery systolic pressure were the variables retained in the best regression model as correlates of RVECR. CONCLUSIONS: In patients with HF, RVECR unmasks different phenotypes. Impaired RV function at rest might not invariably lead to unfavorable RVECR and exercise RV-to-PC coupling. Testing these variables appears useful even in more advanced stages of HF to define various clinical conditions and, most likely, to define different levels of risk.

Rate of Death and Complications in Laparoscopic and Open Roux-en-Y Gastric Bypass. A Meta-analysis and Meta-regression Analysis on 69,494 Patients.

Morbid obesity is a life threatening condition. Currently, surgery represents the only effective and durable therapeutic option to treat it. The first aim of the study was to estimate and compare the major surgical complications and the 30-day rate of mortality between laparoscopic and open Roux-en-Y gastric bypass (LRYGB and RYGB). The second aim was to evaluate the change in outcomes, complications, and deaths, with increased experience over the time period of the review. A random effect of the meta-analysis and meta-regression was used to evaluate surgical complications (i.e., reoperation, stenosis, bleeding, surgical site infection, fistula, internal hernia, and incisional ventral hernia) and the rate of mortality after LRYGB and RYGB over time. A search of literature from 2000 to 2014 led to the selection of 17 papers. When looking at surgical techniques separately, we observed a higher rate of mortality for open surgery (death rate 0.82 %, 95 % CI = 0.49-1.23) compared to laparoscopic surgery (death rate 0.22 %, 95 % CI = 0.09-0.40). This difference resulted highly significant when the two techniques were formally compared (p < 0.001). The improving of surgery technique resulted in a mean rate of mortality reduction of 0.069 %. Laparoscopy represents the approach of choice for bariatric surgery. Contemporary reports of LRYGB show low mortality rates and progressive decline in postoperative complications. Laparoscopic bariatric surgery requires advanced laparoscopic skills, and probably an extended learning curve is not accounted for by current mortality statistics.