Assessing the decoupling of economic growth from environmental impacts in the European Union: A consumption-based approach.

Pursuing a responsible and sustainable development, the United Nations urged to decouple economic growth from environmental impacts. Several European Union (EU) policies have been implemented towards such goal. Although multiple authors have evaluated the decoupling of the economic growth from the resource use or environmental concerns, the environmental assessment mostly focused on pressures rather than impacts, and used single indicators assumed to be a proxy of the overall effects on the environment. Furthermore, no studies were found using a process-based life cycle approach to quantify the environmental impacts of consumption. To solve such research gap, this paper assesses the decoupling in the EU focusing on potential environmental impacts, complementing a production-based approach with two options for accounting for the impacts of consumption. The aim of this paper is to evaluate the decoupling of the economic growth (in terms of Gross Domestic Product) from the environmental impacts due to EU-28 consumption, assessed by means of life cycle assessment (LCA). The decoupling is then assessed in impact terms rather than limited to pressures by using the Environmental Footprint (EF2017) indicators, which allows assessing 16 different impacts. The Consumption Footprint indicator quantified the environmental impacts of EU apparent consumption, including the territorial impacts (Domestic Footprint) and the embodied impacts in both imports and exports (Trade Footprint). The inventory of pressures for the trade component is compiled either with a bottom-up approach (process-based LCA of representative traded goods) or a top-down approach (input-output-based LCA). Methodological aspects influencing the decoupling assessment and the resulting outputs are presented and discussed. According to the results, the environmental impacts of EU-28 consumption showed decoupling during the last decades (2005-2014), between relative to absolute decoupling depending on the inventory modeling approach taken. Some countries showed higher decoupling levels than others displaying a heterogeneous map of EU-28 decoupling, which was led by acidification, particulate matter, land use and eutrophication impacts. Notwithstanding current limitations, the assessment of decoupling using consumption-based environmental indicators is very promising for supporting policy-making towards addressing the actual impacts driven by the EU production and consumption system.

Concomitant medullary thyroid carcinoma with paraganglioma-like pattern and papillary thyroid carcinoma.

SUMMARY: A 74-year-old man was referred to the Endocrinology Unit because of multinodular goiter. The dominant nodule (1.7 × 1.9 × 2.4 cm), at the medium-superior third of the left lobe, was inhomogeneously hypoechoic, with irregular margins, macrocalcifications and intranodular vascularization. Fine-needle aspiration biopsy (FNAB) was performed. The cytological diagnosis was TIR 2, benign, according to the 2013 Italian thyroid cytology classification system. Moderately high serum calcitonin (s-Ct) (61.5 pg/mL, n.r. 0-7.5) and normal CEA were detected. The Ct level in FNAB wash-out fluid (Ct-FNAB) was 1450 pg/mL. Based on s-Ct and Ct-FNAB levels, patient underwent total thyroidectomy. Macroscopically, a dominant circumscribed nodule of 2 ecm was described; the histological and immunohistochemical features identified medullary thyroid carcinoma (MTC) with paraganglioma (PG)-like pattern positive for Ct, CEA and chromogranin and negative for S-100 sustentacular cells (SC). Moreover, papillary carcinoma of 3 mm in the right lobe was also associated. No areas of hyperaccumulation of the tracer were documented at Ga68 PET/CT. No RET-proto-oncogene mutations were found. Post-surgery s-Ct levels were within normal range (4 pg/mL). Two years after thyroidectomy, the patient is still disease-free. We reported a case of sporadic and rare variant of MTC: this is the ninth described case of PG-like MTC. In this case, cytologically benign, the clinical suspicion arose from high Ct values at FNAB wash-out fluid. Even if clinical behavior of this variant seems indolent, additional studies are necessary to understand prognoses and predictive factors. LEARNING POINTS: Several unusual histological variants of medullary thyroid carcinoma (MTC) have been described such as spindle cell, giant cell, clear cell, melanotic, squamous, angiosarcoma-like variants; even rarer is the paraganglioma (PG)-like pattern. We here describe a case of medullary PG-like thyroid carcinoma in a 74-year-old man. This is a rare histological variant of MTC hardly diagnosed by cytology, since immunohistochemical investigations are necessary. Measurement of calcitonin both in serum and in wash-out fluid from fine-needle aspiration could be an additional tool for an early and non-invasive identification of these variants.

High levels of adhesion molecules are associated with impaired endothelium-dependent vasodilation in patients with peripheral arterial disease.

Soluble intercellular adhesion molecule-1 (sICAM-1) and vascular cellular adhesion molecule-1 (sVCAM-1) were measured alongside flow-mediated vasodilation (FMD) in 34 patients with intermittent claudication and 14 control subjects. Patients with plasma sICAM-1 >253 ng/mL (median value) showed lower FMD than those with sICAM-1 < 253 ng/mL (5.6 +/- 1.8% vs 9.6 +/- 4.2%, p < 0.01). Similarly, in the 17 patients with plasma sVCAM-1 > 414 ng/mL, FMD was lower than in the remaining 17 patients (6.1 +/- 1.9% vs 9.2 +/- 4.5%, p < 0.05). Additionally, when endothelial dysfunction was defined as FMD < or = 5.5%, patients with FMD below this value had higher plasma concentrations of sICAM-1 and sVCAM-1 than those with FMD > 5.5%. Therefore, our findings indicate a close association between elevated plasma levels of adhesion molecules and endothelial dysfunction. As impaired endothelial function is one of the first steps in atherogenesis, our findings have clinical relevance since they serve as the basis for further evaluation of sICAM-1 and sVCAM-1 as potential plasma markers for progression of atherosclerosis in a population at high risk.

Angiogenesis: prognostic significance in laryngeal cancer.

The aim of this study was to evaluate the role of angiogenesis in the progression of laryngeal squamous cell carcinoma (LSCC). We correlated disease-free survival with microvessel count (MC) in the hot spot areas of 97 randomly selected caucasian males with LSCC followed for 60 to 90 months after surgery with or without radiotherapy. The results obtained indicate that: a) MC higher than 130 microvessels/mm2 is a cut-off value that distinguished patients who relapsed during the follow up period; b) multivariated analysis indicates that MC (p < 0.00001) is an independent predictor of disease free-survival; c) multivariated analysis selectively done on cases with relapse demonstrates that MC correlates with the presence of metastasis (or/and M) with local relapse (T). We suggest that MC is useful in the assessment of prognosis in LSCC and probably will permit selection of patients that could benefit from anti-angiogenic therapy associated with chemotherapy and/or radiotherapy.

Concurrent lymph node metastases of medullary and papillary thyroid carcinoma in a case with RET oncogene germline mutation.

We report the case of a 72 yr-old woman who underwent total thyroidectomy and resection of neck lymph nodes because of a firm nodule in the right lobe, which was consistent with medullary thyroid carcinoma (MTC) on cytological examination. Histology showed multifocal bilateral MTC; a 2 mm papillary thyroid carcinoma (PTC) was also detected in the right lobe, next to a focus of MTC; five cervical lymph nodes contained MTC. In one right perithyroidal lymph node, concurrent metastases of MTC and PTC were demonstrated. DNA analysis showed a point mutation in exon 14 at codon 804 of the RET proto-oncogene locus, as frequently found in cases of familial MTC (FMTC). To our knowledge, this case represents the first documented case of concurrent lymph node metastases of MTC and PTC in a patient with RET proto-oncogene germline mutation. We report this unique case, discuss related thyroid malignancies, and suggest possible underlying pathogenetic mechanisms.

Pregnancy luteoma with granulosa cell proliferation: an unusual hyperplastic lesion arising in pregnancy and mimicking an ovarian neoplasia.

A pregnancy luteoma (PL) was incidentally found at a term cesarean section in a 27-year-old black woman without any endocrine abnormality. The lesion involved only the left ovary; it had a nodular and focal pseudoalveolar growth pattern and was associated with areas of tubular sertoliform component, consistent with granulosa cell proliferation. Immunohistochemistry revealed a diffuse positivity to Inhibin A, CD99, cytokeratin and vimentin. The ultrastructure was typical of steroid-producing cells. PL is a tumor-like lesion arising in pregnant women and often misdiagnosed as a neoplastic lesion; awareness of this rare entity and its differential diagnoses may avoid unnecessary surgery in young patients.

Intermittent claudication and risk of cardiovascular events.

To determine the natural history of intermittent claudication, 110 patients were followed up for a mean period of 24.4 +/- 1.2 months. Four patients died during the follow-up. Of the survivors, 24 experienced a nonfatal cardiovascular event, myocardial infarction being the most frequent. Cumulative cardiovascular morbidity was 29% at 3 years. Cox proportional-hazards analysis showed initial ankle-brachial pressure index (ABPI) as a significant predictor for nonfatal cardiovascular events (p<0.002). With an initial ABPI >0.70, cardiovascular morbidity rate was 12% compared with 33% for those with initial ABPI ranging from 0.70 to 0.50, and 60% for those with ABPI <0.50 (p<0.005). Critical limb ischemia occurred in only four patients, amputation was required in two, and arterial reconstruction in five. Of the 85 patients who participated in the treadmill test, maximum walking capacity worsened in 26% and improved in 27%. This study elucidates the neglected area of cardiovascular morbidity in intermittent claudication. It has shown that ABPI identifies a subgroup of patients for whom the risk of cardiovascular events is especially pronounced. On the other hand, based on objective evaluation of the patient status, the relatively benign prognosis for the claudicant limb has been confirmed.

Group B streptococcal pharyngitis in the compromised adult: therapeutic considerations.

Group B streptococci (GBS) have been infrequently recognized as a cause of pharyngitis. We report three cases of GBS pharyngitis in patients with underlying diseases, two of whom were treated with and responded incompletely to oral beta-lactam antibiotics. The susceptibility of 20 clinical isolates of GBS was tested by a broth dilution method to six antibiotics which could conceivably be used in the therapy of GBS pharyngitis. Penicillin G, clindamycin, and erythromycin were most active with mean minimal inhibitory concentrations (MIC) of 0.06 µg/ml or less. Rifampin and cefaclor were least active with mean MICs of 0.71 ug/ml or more. Ampicillin was intermediate in its activity. Therapy traditionally used for Group A streptococcal (GAS) pharyngitis may, at times, be suboptimal for GBS pharyngitis in compromised patients. This may be due to higher minimal bactericidal concentrations (MBC) of GBS than GAS, to inadequate penetration of penicillins into pharyngeal tissues or to host factors. It is suggested that GBS can cause pharyngitis in adults, particularly the compromised patient, and that in cases where there is a poor response to penicillin or ampicillin therapy, alternative drugs (erythromycin or clindamycin) may be used.

Microcirculation and tissue metabolism in peripheral arterial disease.

It is now clear that different pathophysiologic mechanisms have a profound influence on the extent of the functional impairment in intermittent claudication. In particular, metabolic derangements, including impaired oxygen delivery and/or extraction, reduced nitric oxide synthesis, reduced glucose oxidation, accumulation of toxic metabolites and reduction in carnitine availability are correlated with disease severity. Therefore, metabolic interventions aimed at counteracting these alterations may represent a valid therapeutic approach to the treatment of this condition. To date, verapamil and L-arginine efficacy has been proven in few patients; a large scale clinical trial, conversely, reports that propionyl-L-carnitine appears to be an effective and well tolerated drug for the treatment of intermittent claudication.

[A new questionnaire for assessing the quality of life of patients with intermittent claudication]. / Un nuovo questionario per la valutazione della qualità della vita nel paziente affetto da claudicatio intermittens.

BACKGROUND: Quality of life assessment is becoming increasingly relevant for evaluating the impact of disease and treatments and for deciding priorities when allocating resources. This is especially true in intermittent claudication where the goal of therapy is not the cure of the disease but rather to alleviate its symptoms and improve the patient's functional capabilities. At present, however, no generic scale fits all criteria for the ideal quality of life measuring in intermittent claudication. METHODS: We developed a questionnaire aimed at evaluating the specific limitations encountered by claudicants in the physical activity and in the social and emotional functioning. The present study evaluated the questionnaire for validity, reliability, and sensitivity to change, attributes considered to be essential for a questionnaire to be useful. RESULTS: In 30 patients with intermittent claudication, the scores of the four sections of the questionnaire significantly correlated with the scores of the corresponding sections of the Nottingham Health Profile. This indicates that the questionnaire is valid. For each of the four subscales, the intraclass correlation coefficient was > 0.75, thus showing a high test re-test reliability. Also the internal consistency is strong with alpha coefficient ranging from 0.79 to 0.89. Finally, the questionnaire was administered to 9 patients before and 4 weeks after percutaneous transluminal angioplasty for claudication. After the intervention, the improvement in walking performance paralleled the improvement in quality of life. This indicates that the questionnaire is sensitive to change. CONCLUSIONS: Our questionnaire appears to be a valid and reliable quality of life measure in intermittent claudication.

[E rosette inhibition in alcoholic liver disease]. / Inhibición de rosetas E en la enfermedad hepática alcohólica.

Various studies performed in chronic alcoholic patients have demonstrated immunologic alterations, which have been described more often in patients with alcoholic hepatitis or liver cirrhosis. We have observed that the serum of some patients with alcoholic liver cirrhosis produces the inhibition of E rosette formation by T lymphocytes. This observation induced us to study E rosette formation and its probable inhibition by the serum of chronic alcoholic patients. Subjects were split into three groups: Group 1: n = 21. Normal individuals. Group 2: n = 15. Chronic alcoholic patients without cirrhosis. Group 3: n = 26. Chronic alcoholic patients with histologically demonstrated liver cirrhosis. E rosette and E rosette inhibition (TIRE) sera tests were performed utilizing subject's sera tested against lymphocytes of normal individuals not related to group 1. The results found are listed in detail in Table 1 (mean = -SD) and Figure 1 (median), for each of the test groups. We applied unifactorial variance analysis and observed highly significant differences between the groups studied in all tests performed. It was found that tests that utilized I.E. discriminate most efficiently among the three groups of patients and that those which utilize unabsorbed assay serum (S/A) yield the best differentiation. Using this last assay it was observed that 20/21 control individuals showed less than 15% inhibition. On this basis, we decided to separate the results into 15% regular intervals (Table 3). Inhibition above 30% was found only in cirrhotic patients with the exception of one individual of the control group and one non-cirrhotic alcoholic patient with no alcoholic liver disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Equilibrium and orthognathodontic surgery: correlations in a group of patients undergoing treatment]. / Posturologia e chirurgia ortognatodontica. Correlazioni in un gruppo di pazienti trattati.

BACKGROUND: The aim of this study was to evaluate the main parameters provided by the static stabilometric test (mean X, mean Y, mean velocity, length of tracing, standard deviation of velocity, ellipse area) in the follow-up of patients suffering from skeletal occlusive pathology undergoing orthognathodontic surgery to confirm the re-establishment of postural equilibrium. METHODS: Fifteen patients with skeletal dysgnathia were correlated with a group of 10 healthy subjects. The same parameters were analysed in the dysgnathic subjects at 6 and 12 months after surgical correction. The patients enrolled in this study underwent surgery at the Division of Maxillofacial surgery of Turin University. Student's "t"-test and multivariate statistical analysis (Cox regression) were used for the statistical analysis of results. RESULTS: A significant variability was noted in some of the main parameters analysed (mean X, mean Y, tracing length) between the two populations (healthy and dysgnathic) compared to visual signs (eyes opened-closed). The change in stabilometric values within the group of dysgnathic patients was highly significant 6 and 12 months after surgery, not only in terms of visual signs but also the cervical component (retroflexion of the head), above all the value of mean Y (p = 0.001). CONCLUSIONS: An analysis of these results shows that static stabilometry can be a valuable aid both during the preoperative evaluation and during the follow-up in patients undergoing jaw surgery since it can quantify the improvement of body balance.

Hashimoto's thyroiditis associated with idiopathic retroperitoneal fibrosis: case report and review of the literature.

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease of unknown origin, characterised by an inflammatory proliferative fibrosing process occurring in the retroperitoneum. Hashimoto's thyroiditis (HT) is a form of chronic thyroiditis that in some cases shows an extensive replacement of thyroid parenchyma by fibrous tissue. We report the rare association of IRF with HT in a 68-year-old woman presenting with pulmonary oedema, acute renal failure due to bilateral hydronephrosis and a firm diffuse goitre with hypothyroidism. The so far reported cases of IRF associated with chronic thyroiditis are reviewed, and the possible aetiopathogenetic link between these two entities is discussed.

Value of routine measurement of serum calcitonin concentrations in patients with nodular thyroid disease: A multicenter study.

BACKGROUND: The routine measurement of serum calcitonin (CT) has been proposed for patients with nodular thyroid disease (NTD), to detect unsuspected medullary thyroid carcinoma (MTC) before surgery. OBJECTIVE: To assess the prevalence of hypercalcitoninemia and MTC in NTD patients; to compare the ability of CT measurement and fine needle aspiration cytology (FNAC) to predict MTC; to identify age groups of NTD patients who should be better candidates than others to undergo routine measurement of CT. PATIENTS AND METHODS: 1425 consecutive patients, referred from April 1, 2003, through March 31, 2004, to four Italian endocrine centers due to NTD, were grouped depending on age, and underwent basal and, in some cases, pentagastrin (Pg)-stimulated CT measurement, FNAC and, when indicated, surgery. Serum CT concentrations were measured by an immunoluminometric assay (ILMA). RESULTS: Hypercalcitoninemia was found in 23 out of 1425 patients. MTC was discovered in 9 patients, all >40 yr old and showing high CT levels. Sensitivity of basal and Pg-stimulated CT to predict MTC before surgery was 100% for both tests, whereas specificity was 95 and 93%, respectively. CT specificity reached 100% when a cutoff value of 20 pg/ml was taken. FNAC showed an overall 86% sensitivity. When >10 mm MTC nodules were considered, FNAC sensitivity approached 100%. On the contrary, a correct cytological diagnosis was obtained in only one out of five patients with <10 mm MTC nodules (microMTC); in one patient with histologically proved microMTC, FNAC even demonstrated a benign lesion. Hypercalcitoninemia or MTC were associated with chronic thyroiditis in 30 or 33% of cases, respectively. C-cell hyperplasia was found in 57% of hypercalcitoninemic patients without MTC. CONCLUSIONS: Basal CT measurement detects elevated CT values in 1.6% of NTD patients. Although CT is not a specific marker of MTC, its routine measurement represents a useful tool in the pre-operative evaluation of NTD patients, particularly those >40 yr old presenting with nodules <10 mm, even when FNAC does not show malignant features. To our knowledge, this is the first trial using ILMA to assess the ability of pre-operative CT measurement to predict MTC in a large series of NTD patients.

Thyroid hemiagenesis and incidentally discovered papillary thyroid cancer: case report and review of the literature.

Thyroid hemiagenesis (TH) is a rare congenital abnormality in which one thyroid lobe fails to develop. Its prevalence is uncertain, because the absence of one thyroid lobe does not usually cause clinical symptoms. The detection of TH is usually incidental when the evaluation of other thyroid disorders is requested. It is more frequently found in female than in male patients (3:1 ratio) and in the left lobe compared to the right lobe. We report the case of a 54-yr-old man, presenting with a large multinodular right-sided goiter, with mediastinal extension and dysphagia. Thyroid scan and ultrasound study showed the absence of the left lobe. The patient underwent surgery for compressive symptoms, and the operation confirmed the absence of the left lobe. Histological examination demonstrated a multi-nodular goiter with papillary carcinoma. To our knowledge, this case represents the first reported case of association between TH and papillary thyroid carcinoma in a male patient, and the second in which the tumor arose in the right lobe.

Postpartum thyroiditis presenting as a cold nodule and evolving to Graves' disease.

We describe the case of a 30-year-old woman who, five months after giving birth, was referred with a solitary nodule in her anterior neck. Laboratory analysis, ultrasonography, pertechnetate (Tc99m) thyroid scan and cytological examination of fine needle aspiration biopsy performed on the nodule led us to diagnose postpartum thyroiditis (PPT). Twenty-eight months after parturition, overt hyperthyroidism developed, with raised thyroperoxidase and thyroid stimulating hormone receptor antibody titres, diffuse high uptake of Tc99m at thyroid scan, and high vascular flow throughout the gland at Color-Power imaging. The diagnosis of Graves' disease (GD) was established. The differential diagnosis of thyrotoxicosis in the postpartum period, and the possible aetiological relationships between PPT and GD are discussed. To our knowledge, this is the first published report of a PPT presenting as a cold nodule, and evolving to GD.