Glomerular filtration rate is associated with trabecular bone score in patients with type 2 diabetes mellitus.

AIMS: The present study aimed to evaluate the trabecular and cortical bone components using Trabecular Bone Score (TBS) and its association with estimated-Glomerular Filtration Rate (e-GFR) in T2DM patients. METHODS: An assessment both of bone mineral density (BMD) and vertebral bone microarchitecture was performed in all patients using TBS iNsight® software version 3.0.2.0. Furthermore, the total population was divided into two groups based on the value of the eGFR (eGFR < o > at 60 ml/min/1.73 m2). RESULTS: TBS value was lower in patients with low e-GFR than that in patients with higher e-GFR (1.246 ± 0.125 vs 1.337 ± 0.115, respectively, p = 0.013 adjusted by gender and age) while there was no difference in total BMD value between two groups. In the multivariate model taking into account several possible confounders, such as age, gender, duration of diabetes, BMI, LDL cholesterol, serum calcium and HbA1c, the correlation between e-GFR and TBS remained significant (p: 0.046). CONCLUSIONS: In individuals with T2DM and reduced kidney function, TBS provides information independent of BMD, age and gender. TBS may be a useful additional tool to predict fracture risk in this unique population.

Indoor vs. outdoor airborne element array: A novel approach using moss bags to explore possible pollution sources.

This study investigated by the moss-bag approach the pattern of air dispersed elements in 12 coupled indoor/outdoor exposure sites, all located in urban and rural residential areas. The aims were to discriminate indoor vs. outdoor element composition in coupled exposure sites and find possible relation between moss elemental profile and specific characteristics of each exposure site. Elements were considered enriched when in 60% of the sites, post-exposure concentration exceeded pre-exposure concentration plus two folds the standard deviation. Of the 53 analyzed elements, 15 (As, B, Ca, Co, Cr, Cu, Mn, Mo, Ni, Sb, Se, Sn, Sr, V, Zn) were enriched in moss exposed outdoor, whereas a subset of 7 elements (As, B, Cr, Mo, Ni, Se, V) were enriched also in indoor moss samples. The cluster analysis of the sites based on all elements, clearly separated samples in two groups corresponding to mosses exposed indoor and outdoor, with the latter generally exceeding the first. Among outdoor sites, urban were most impacted than rural; whereas other factors (e.g., heating and cooking systems, building material, residence time and family life style) could affect element profile of indoor environments. Based on the indoor/outdoor ratio, As derived from outdoor and indoor sources, B, Mo and Se were enriched mostly in outdoor sites; Ni, Cr and V were specifically enriched in most indoor samples, supporting the presence of indoor emitting sources for these elements. A PCA of all indoor sites based on enriched elements and site characteristics showed that traffic affected indoor pollution in urban areas. The moss bag approach provided useful information for a global assessment of human exposure.

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study).

BACKGROUND: Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment. METHODS: This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015. RESULTS: A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis. CONCLUSION: Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Performance of three cardoon cultivars in an industrial heavy metal-contaminated soil: Effects on morphology, cytology and photosynthesis.

In the present work the cytomorphological and physiological effects on three cardoon cultivars - Sardo, Siciliano, Spagnolo - grown in a metal-polluted soil, were investigated, to assess the traits concurring to the high tolerance to metal stress observed in cv. Spagnolo compared to the other two cultivars. The plants were grown for one month on a real polluted soil collected at a dismantling battery plant, highly enriched by heavy metals, especially Cd and Pb, and their leaves were analyzed by a multidisciplinary approach. TEM observations highlighted severe ultrastructural damage in Sardo and Siciliano, and preserved cytological traits in Spagnolo. Both pigment content and photochemistry indicated a decline in photosynthesis in Sardo and Sicilano and a substantial stability of the same parameters in Spagnolo. Protein analysis indicated a decrease in D1 level in all cultivars; in Spagnolo the D1 decrease was more pronounced and associated to a significant increase in Rubisco, a pattern likely preserving photosynthetic efficiency and high biomass production. In conclusion, Spagnolo cardoon was able to face metal stress through a prompt, multiple response balancing structural and functional traits.

Ultrastructural, protein and photosynthetic alterations induced by Pb and Cd in Cynara cardunculus L., and its potential for phytoremediation.

The effects of cadmium and lead were investigated in Cynara cardunculus L. Plant uptake by root and shoot, changes in cell ultrastructure and photosynthetic efficiency, photosynthetic key protein levels, as well as regulation of stress-induced Hsp70 were examined. Cynara cardunculus accumulated Cd and Pb in their tissue, with a different trend for the two metals. The prompt translocation of Cd to the shoot may justify the ultrastructural injuries, especially observed in chloroplasts. However, Cd- treated plants did not show any decline in photochemistry; it is likely that Cd in shoot tissue triggers defense mechanisms, increasing the level of proteins involved in photosynthesis (i.e., Rubisco and D1 increased 7 and 4.5 fold respectively) as a compensatory response to neutralize chloroplast damage. The accumulation of Pb mainly in root, can explain the increase in Hsp70 level (23 folds) in this tissue. Pb reached the shoots, even at low amounts, causing an overall significant change in some photochemical parameters (QY and NPQ decreases and increases of 25%, respectively). The results suggest a higher sensitivity of C. cardunculus to Pb than Cd, although maximal photochemical efficiency suggests that this species seems to tolerate Pb and Cd and hence, it is a suitable candidate for phytoremediation.

Pharmacogenomics-Based Point-of-Care Clinical Decision Support Significantly Alters Drug Prescribing.

Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green = genomically favorable, yellow = genomic caution, red = high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. In all, 2,279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio (OR) = 26.2 (9.0-75.3), P < 0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR = 2.4 (1.7-3.5), P < 0.0001). No pharmacogenomically high-risk medications were prescribed during the entire study when physicians consulted the CDS tool. Pharmacogenomic information improved prescribing in patterns aimed at reducing patient risk, demonstrating that enhanced prescription decision-making is achievable through clinical integration of genomic medicine.

Patient Perceptions of Care as Influenced by a Large Institutional Pharmacogenomic Implementation Program.

Despite growing clinical use of genomic information, patient perceptions of genomic-based care are poorly understood. We prospectively studied patient-physician pairs who participated in an institutional pharmacogenomic implementation program. Trust/privacy/empathy/medical decision-making (MDM)/personalized care dimensions were assessed through patient surveys after clinic visits at which physicians had access to preemptive pharmacogenomic results (Likert scale, 1 = minimum/5 = maximum; mean [SD]). From 2012-2015, 1,261 surveys were issued to 507 patients, with 792 (62.8%) returned. Privacy, empathy, MDM, and personalized care scores were significantly higher after visits when physicians considered pharmacogenomic results. Importantly, personalized care scores were significantly higher after physicians used pharmacogenomic information to guide medication changes (4.0 [1.4] vs. 3.0 [1.6]; P < 0.001) compared with prescribing visits without genomic guidance. Multivariable modeling controlling for clinical factors confirmed personalized care scores were more favorable after visits with genomic-influenced prescribing (odds ratio [OR] = 3.26; 95% confidence interval [CI] = (1.31-8.14); P < 0.05). Physicians seem to individualize care when utilizing pharmacogenomic results and this decision-making augmentation is perceived positively by patients.

Nurses' Job satisfaction: an Italian study.

BACKGROUND: The aim of the work presented was to assess job satisfaction of a number of nurses from different departments working in public hospitals in Italy. The assessment was carried out through the combined use of questionnaires, which measured different aspects of job satisfaction, such as coping abilities, stress level and optimism/pessimism. The literature supports the fact that nurses' job dissatisfaction is closely connected with high levels of stress, burnout and physical and mental exhaustion, together with high workload levels and the complexity of care. The growing interest in measuring the levels of nurses' job satisfaction is attributable to a number of problems that have been raised worldwide, two of which are becoming ever so important: turnover and shortage of nurses. The research question is: Which are the main motivating factors of Italian nurses' job satisfaction/dissatisfaction? METHODS: The study used a convenience (non probability) sample of 1,304 nurses from 15 different wards working in Italian public hospitals from a number of cities in northern, central and southern Italy. The survey instrument was a questionnaire consisting of 205 items which included 5 different questionnaires combined together. RESULTS: The results show a low level of job satisfaction (IWS= 11.5, JSS=126.4). However, the participants were overall happy about their job and considered autonomy and salary important factors for job satisfaction. CONCLUSION: Research has shown that the nurses' level of satisfaction in Italian hospitals is low. The results revealed dissatisfaction with task requirements, organizational policies and advance in career. Nurses interviewed did not feel stressed and showed to be optimistic overall. New research on the subject should be conducted by focusing on ward differences, North and South of Italy and on gender differences.

Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a definitive treatment? Retrospective analysis of 63 cases.

BACKGROUND: The ideal treatment of perforated diverticulitis and the indications for elective colon resection remain controversial. Considering the significant morbidity and mortality rates related to traditional resection, efforts have been made to reduce the invasiveness of surgery in recent decades. Laparoscopic peritoneal lavage has emerged as an effective alternative option. We retrospectively investigated the effectiveness of laparoscopic peritoneal lavage for perforated diverticulitis and the possibility that it could be a definitive treatment. METHODS: We included patients treated with laparoscopic peritoneal lavage for perforated diverticulitis. The inclusion criteria were all emergency patients with generalized peritonitis due to Hinchey III perforated diverticulitis and some cases of Hinchey II and IV. RESULTS: Sixty-three patients were treated with laparoscopic peritoneal lavage. Six patients (9.5 %) had Hinchey II diverticulitis; 54 patients (85.7 %) had Hinchey III; and three patients (4.8 %) had Hinchey IV. The mean operative time was 87.3 min (±25.4 min), and the overall morbidity rate was 14.3 %. One patient died because of pulmonary embolism, and there were six early reinterventions because of treatment failure. Delayed colon resection was performed in four of the remaining 57 patients (7 %) because of recurrent diverticulitis. In the other 53 patients (93 %), we saw no recurrence of diverticulitis and no intervention was performed after a median follow-up period of 54 months (interquartile range 27-98 months). CONCLUSIONS: Laparoscopic peritoneal lavage for perforated diverticulitis can be considered a safe and effective alternative to traditional surgical resection, and using this approach, most elective colon resection might be avoided.

Abnormal or delayed development of the posterior membranous area of the brain: anatomy, ultrasound diagnosis, natural history and outcome of Blake's pouch cyst in the fetus.

OBJECTIVES: To review the normal and pathological development of the posterior membranous area (PMA) in the fetal brain, to define sonographic criteria with which to diagnose a Blake's pouch cyst (BPC) in the fetus and to review the ultrasound features, associations and outcome of 19 cases of BPC seen at our center over the last 5 years. METHODS: We conducted a MEDLINE search using the terms 'Blake's pouch', with or without 'fourth ventricle' or '4(th) ventricle', with or without 'roof' and identified articles describing normal and/or abnormal development of the PMA, whether or not they were cited in the limited clinical literature on BPC. A description of the normal and abnormal development of BPC was derived by collating these articles. The clinical retrospective study included 19 cases of posterior fossa anomalies with a final diagnosis of BPC seen at our institution. The following variables were assessed: referral indication, gestational age at diagnosis, ultrasound and magnetic resonance imaging (MRI) findings, associated anomalies, natural history and pregnancy and neonatal outcome. A transvaginal three-dimensional (3D) ultrasound examination was performed in all cases and 15 cases underwent MRI. To confirm the diagnosis, postnatal MRI, transfontanellar ultrasound or autopsy were available in all cases. RESULTS: Among the 19 cases reviewed, referral indications were: suspicion of vermian abnormality in 11 (58%) cases and other non-central nervous system anomaly in eight (42%) cases. Sonographically, all cases showed the following three signs: 1) normal anatomy and size of the vermis; 2) mild/moderate anti-clockwise rotation of the vermis; 3) normal size of the cisterna magna. On 3D ultrasound, the upper wall of the cyst was clearly visible in 11/19 cases, with choroid plexuses on the superolateral margin of the cyst roof. On follow-up, the BPC had disappeared by 24-26 gestational weeks in six of the 11 cases which did not undergo termination of pregnancy (TOP), and remained unaltered until birth in the other five cases. There were associated anomalies in eight (42%) cases, in five of which this consisted of or included congenital heart disease. Karyotype was available in 14 cases, two of which were abnormal (both trisomy 21). Regarding pregnancy outcome, there were eight (42%) TOPs, two (10%) neonatal deaths and nine (48%) survivors. One neonate, in whom the BPC had disappeared by the time of birth, had obstructive hydrocephaly confirmed. Another neonate was diagnosed with Down syndrome after birth. Excluding the Down syndrome baby, neurodevelopmental outcome was normal at the time of writing in all eight cases. CONCLUSIONS: Based on our analysis of ultrasound features, we propose that for BPC to be diagnosed in a fetus the following three criteria should be fulfilled: 1) normal anatomy and size of the vermis; 2) mild/moderate anti-clockwise rotation of the vermis; 3) normal size of the cisterna magna. Furthermore, we found that BPC can undergo delayed fenestration at 24-26 weeks in more than 50% of cases. Finally, it seems that BPC shows a risk of association with extracardiac anomalies (heart defects in particular) and, to a lesser extent, trisomy 21.

Risedronate and pamidronate treatment in the clinical management of patients with severe Paget's disease of bone and acquired resistance to bisphosphonates.

The aim of this study was to evaluate the efficacy and safety of risedronate and pamidronate in 30 patients (mean age = 57.86 +/- 8.90 years) with severe Paget's disease of bone (PDB), showing acquired resistance to intravenous (IV) clodronate treatment. Fifteen patients were treated with oral risedronate (30 mg/day for 8 weeks). Treatment was repeated in patients without evidence of PDB remission [total alkaline phosphatase (tALP) serum levels in the normal range] at day 120. Fifteen patients were treated with IV pamidronate (30 mg/day for 3 days). Pamidronate treatment (60 mg/day for 3 days) was repeated in patients without evidence of PDB remission at day 120. At day 60, a significant decrease in tALP serum levels was obtained in all pagetic patients. At day 360, 13 (86.6%) patients treated with risedronate achieved PDB remission, 9 patients during the initial treatment and 4 after retreatment. Two patients showed a significant decrease in tALP serum levels without clinical remission after two risedronate treatments. At the same time, 12 (80%) patients treated with pamidronate achieved PDB remission, 6 patients during the first treatment and 6 after retreatment. Three patients showed a significant decrease in tALP serum levels but no clinical remission after two pamidronate courses. Two of these patients showed a relapse during the study. The incidence of minor side effects and transient hyperparathyroidism related to bisphosphonate treatment was significantly lower after risedronate therapy. In patients with resistant PDB, oral risedronate therapy has comparable efficacy to IV pamidronate with a lower incidence of treatment-related side effects.

Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient.

OBJECTIVES: The purpose of this study was to compare the results of physical examinations (PEs) performed by board-certified cardiologists with the results of point-of-care (POC) echocardiography in a group of patients with cardiovascular disease. BACKGROUND: Although cardiovascular PE is crucial in the evaluation of patients with suspected heart disease, the skills required to diagnose abnormal cardiovascular findings have been declining. Echocardiography is a powerful noninvasive cardiovascular diagnostic tool; however, echocardiographic evaluation of patients is not performed at the time of patient encounter (POC echocardiography), beacuse current platforms are cumbersome and expensive for individual physician use. The development of miniaturized echocardiographic equipment has the potential to overcome some of these limitations. METHODS: Thirty-six subjects had a complete cardiovascular examination by four board-certified cardiologists. The physicians subsequently imaged each patient using a miniaturized echocardiographic platform. The yield of PE and POC echocardiography were compared using a complete echocardiographic study as the gold standard, performed on an upper-end platform. RESULTS: Cardiac examination failed to detect 59% of the overall cardiovascular findings. Physician-performed echocardiography with the prototype device missed 29% of the overall cardiovascular pathology. When considering only the major cardiovascular findings, the cardiologists' PEs still failed to correctly detect 43%. Point-of-care echocardiography reduced this to 21% without significant interphysician variation. CONCLUSIONS: Point-of-care echocardiography using a miniaturized echocardiographic platform substantially improved the detection of important cardiovascular pathology compared with PE. Use of this device by a cardiovascular specialist with training in echocardiography as a routine adjunct to PE appears to be useful.

Beta blockers for CHF. Adrenergic blockade dramatically reduces morbidity and mortality.

Several large clinical trials have shown that beta blockers can reduce morbidity and mortality in patients with CHF. Therefore, current guidelines for treatment of CHF now include beta blockers as standard therapy for patients with left ventricular systolic dysfunction (ejection fraction < or = 40%) and mild to moderate heart failure. Beta-blocker therapy for CHF should be started cautiously and increased gradually to avoid exacerbating symptoms of heart failure. At this time, data for therapy in patients with NYHA class I or IV symptoms are limited, and it is unclear whether all beta blockers confer benefit or whether some are better than others. Several trials are under way to answer these questions. Until more evidence is available, only those agents that have proved beneficial in mortality trials should be used to manage CHF.

Effectiveness of palivizumab: evaluation of outcomes from the 1998 to 1999 respiratory syncytial virus season. The Palivizumab Outcomes Study Group.

BACKGROUND: Respiratory syncytial virus (RSV) remains a significant cause of morbidity, especially in premature infants and immunocompromised children, resulting in approximately 100 000 hospitalizations annually. A study was performed to evaluate the outcomes of those given palivizumab (Synagis; MedImmune, Inc., Gaithersburg, MD) during the 1998 to 1999 RSV season, its first season in general use. METHODS: A retrospective chart review of 1839 patients from 9 United States sites was conducted, representing all patients given palivizumab at each site. Those evaluated were to have a gestational age of < or =35 weeks, were to be <2 years old at their first injection and were to have received at least one dose of palivizumab (humanized monoclonal antibody against RSV) between September, 1998, and May, 1999. Gestational age, comorbidities, frequency of injections, hospitalizations and length of hospital stays were assessed. RESULTS: The antigen- or culture-positive RSV hospitalization rates for those given prophylaxis were 2.3% (42 of 1839) overall, 16/399 (4.0%) with chronic lung disease of infancy and 26 of 1227 (2.1%) born prematurely without chronic lung disease of infancy. Twenty-six patients had a gestational age of >35 weeks and were included in the analysis. CONCLUSIONS: Only 2.3% of children receiving palivizumab prophylaxis were hospitalized with RSV lower respiratory infection. This compares favorably with the rates observed in the pivotal trial (IMpact-RSV trial in 1996 to 1997), in which prophylaxis reduced hospitalization from 10.6% in the placebo group to 4.8% in those children receiving prophylaxis.

Cholesterol reduction to prevent CAD. What do the data show?

Primary prevention of heart disease should be an important goal of every primary care physician. All patients should undergo careful assessment of future risk and should be counseled about lifestyle modification. Patients at high risk can further benefit from cautious use of lipid-lowering drugs, which have been shown to be effective in preventing cardiac events without substantially increasing risk of noncardiac morbidity and mortality.

Does hypertriglyceridemia increase risk for CAD? Growing evidence suggests it plays a role.

High triglyceride levels are associated with several risk factors that substantially increase the risk of CAD. The metabolic syndrome is a constellation of signs and symptoms (e.g., postprandial hypertriglyceridemia, low LDL cholesterol levels, insulin resistance) that has been linked to a high incidence of heart disease. Treatment of hypertriglyceridemia begins with an aggressive lifestyle modification program. Dietary restriction of alcohol and carbohydrates can significantly lower triglyceride levels in many patients. Pharmacotherapy should be considered for patients at high risk of cardiac disease.

Criteria predicting the absence of spermatozoa in the Sertoli cell-only syndrome can be used to improve success rates of sperm retrieval.

In patients with non-obstructive azoospermia, testicular sperm extraction (TESE) is a method of choice to recover spermatozoa as a male therapeutic approach in intracytoplasmic sperm injection (ICSI) programmes. However, the efficacy of TESE in this indication is burdened by a frequent failure of sperm recovery, which renders useless both the invasive testicular intervention and ovarian stimulation of the patient's spouse. One of the most frequent pathological pictures characterizing complete absence of spermatozoa is germinal aplasia (Sertoli cell- only syndrome or SCOS). Two different histological patterns of SCOS have been already described during the past five decades. These two patterns can be characterized as the congenital (pure) and the secondary (mixed) forms. Both patterns, with different prognosis to retrieve spermatozoa by therapeutic testicular biopsy, are frequently confused when TESE is performed during ICSI programmes. Useful criteria to predict the absence of spermatozoa can be obtained by a definite recognition of the two typical histological patterns during the diagnostic testicular biopsy. The diagnosis of congenital or acquired SCOS can be refined by endocrine, chemical, immunohistochemical and molecular biology aids. Reduction of both sperm retrieval failure and unnecessary ovarian stimulation can be achieved by combination of these methods.