[Risk factors analysis for elective caesarean section in Campania region (Italy)]. / Analisi dei fattori di rischio del parto con taglio cesareo elettivo in Campania.

OBJECTIVE: to assess both clinical and non clinical factors associated with elective caesarean section practice and to highlight those typologies of expectant mothers who underwent elective caesarean delivery even in the absence of clinical risk factors. SETTING AND PARTICIPANTS: Birth Certificates archive has been used as data source: 62888 available records of all the births that occurred in the Campania region in 2005 both in public and private hospitals. Only those births pertained to women without previous caesarean sections were analyzed. MAIN OUTCOME MEASURES: type of delivery, dichotomized as elective caesarean section and vaginal delivery. RESULTS: after adjusting the data for known risk factors, elective caesarean section practice emerged as much more prevalent in private hospitals than in public ones (53.1% vs 24.3%, p<0.001). A multivariate logistic regression model showed a significant association between primiparity and elective caesarean section. This association was stronger in private hospitals (OR for interaction between parity and hospital typology 1.81, CI 95% 1.62-2.04). Being older than 34 years, having recoursed to medically assisted procreation and a previous voluntary termination of pregnancy cause an increase in the odd of resorting to elective caesarean section (p<0.01). Being foreigner, high educational qualification and young age were protective factors for elective caesarean section (respectively, OR 0.36 CI 95% 0.31-0.42, OR 0.81 CI 95% 0.77-0.86 e OR 0.84 CI 95% 0.78 -0.90). Five different typologies of primiparous women were found by means of a hierarchical classification procedure. A high percentage of elective caesarean section was found in women assisted in private structure with no clinical risk. CONCLUSIONS: in Campania there is an excess of elective caesarean sections among primiparous women without manifest clinical risk factors; this excess is higher when the delivery occurs in Private Hospitals. Public health policy and actions aimed at reducing caesarean section rates should be addressed mainly to this typology of women.

Immune dysregulation and dyserythropoiesis in the myelodysplastic syndromes.

The myelodysplastic syndromes (MDS) are clonal disorders characterised by ineffective haematopoiesis with high risk of leukaemia progression. The relevance of immune-dysregulation for emergence, dominance and progression of dysplastic clones has been suggested, but valuable criteria to obtain insight into these connections are lacking. This study showed significant increase of CD8 lymphocytes and mature B cells in the bone marrow (BM) compared to peripheral blood (PB) of low risk MDS patients. Different BM levels of Regulatory T cells (Treg) identified two sub-groups in these patients; only the sub-group with lower Treg percentage showed BM recruitment of CD8 lymphocytes. Different levels of CD54 on BM CD8 cells revealed two sub-groups of Intermediate-1 (Int-1) patients. The sub-group with higher CD54 expression on BM CD8 showed high levels of this molecule also on CD4 cells. BM recruitment of CD8 lymphocytes in the low risk group and/or the presence of high CD54 expression on BM CD8 in Int-1 patients were associated with more pronounced dyserythropoiesis and erythropoietin treatment. Our data shed light on the involvement of immune-mediated mechanisms in Low and Int-1 risk MDS patients and suggest that BM versus PB levels of immune effectors could represent useful criteria for a more homogeneous grouping of MDS patients.

Metals detected by ICP/MS in wound tissue of war injuries without fragments in Gaza.

BACKGROUND: The amount and identity of metals incorporated into "weapons without fragments" remain undisclosed to health personnel. This poses a long-term risk of assumption and contributes to additional hazards for victims because of increased difficulties with clinical management. We assessed if there was evidence that metals are embedded in "wounds without fragments" of victims of the Israeli military operations in Gaza in 2006 and 2009. METHODS: Biopsies of "wounds without fragments" from clinically classified injuries, amputation (A), charred (C), burns (B), multiple piercing wounds by White Phosphorus (WP) (M), were analyzed by ICP/MS for content in 32 metals. RESULTS: Toxic and carcinogenic metals were detected in folds over control tissues in wound tissues from all injuries: in A and C wounds (Al, Ti, Cu, Sr, Ba, Co, Hg, V, Cs and Sn), in M wounds (Al, Ti, Cu, Sr, Ba, Co and Hg) and in B wounds (Co, Hg, Cs, and Sn); Pb and U in wounds of all classes; B, As, Mn, Rb, Cd, Cr, Zn in wounds of all classes, but M; Ni was in wounds of class A. Kind and amounts of metals correlate with clinical classification of injuries, exposing a specific metal signature, similar for 2006 and 2009 samples. CONCLUSIONS: The presence of toxic and carcinogenic metals in wound tissue is indicative of the presence in weapon inducing the injury. Metal contamination of wounds carries unknown long term risks for survivors, and can imply effects on populations from environmental contamination. We discuss remediation strategies, and believe that these data suggest the need for epidemiological and environmental surveys.

Comparison of traditional surgery and laser treatment of incontinent great saphenous vein. Results of a meta-Analysis.

AIM: This paper aims to compare EVLA to traditional surgery, by evaluating the incidence of recurrences. MATERIAL OF STUDY: We performed a meta-analysis to challenge both surgical and LASER treatment, using, as clinical outcome, the presence or the absence of reflux. A systematic review of literature about the treatment of varicose veins was performed, searching in the following databases: PUBMED-MEDLINE, Cochrane Library. Search terms considered were: stripping, HL/S, surgery, LASER, EVL*, varicose vein, GSV, saphenous vein. Only RCTs based at least on sixmonths follow-up were considered eligible in the study. Methodological quality of the included studies was evaluated using Cochrane Collaboration Bias Risk Assessment Tool. Effects of the dichotomous variables taken in consideration were evaluated using pooled risk-ratios with 95% C.I. Articles were evaluated initially from abstracts; eligible papers were fulltext examined. RESULTS: We have considered 2 groups, A and B. A Group: 756 legs treated with conventional surgical procedure; B Group: 755 legs treated with EVLA technique. A Group showed 175 post-procedure recurrences, while B showed 97 recurrences. The average O.R. was 1.72; minimum O.R. was of .497 while the maximum was of 8.064. DISCUSSION: The obtained OR average value is 1.72 with a 95% C.I. of 0.94-3.12, which includes the value 1, contrary to the criteria for rejection of the null hypothesis. For this reason there is not a statistically significant difference between the results obtained by the two techniques. CONCLUSIONS: The endovascular laser ablation (EVLA) does not prove to be superior in terms of recurrence, to the surgical technique. However, it remains a viable treatment option in patients with impaired great saphenous vein, reducing postoperative pain and hospital stay. KEY WORDS: Laser therapy, Meta-analysis, Saphenous vein, Surgery, Venous insufficiency.

Interexaminer reliability and validity for diagnosis of temporomandibular disorders of visual leg measurements used in dental kinesiology.

AIMS: To determine the reliability and the validity of visual leg measurements used in dental kinesiology, which suggests that a masticatory dysfunction, such as occurs in temporomandibular disorders (TMD), can influence the length and the internal rotation of lower limbs. METHODS: The leg-length inequality test and the internal foot-rotation test were performed independently by 3 different examiners on 41 subjects who were also screened for TMD. Data were analyzed by means of kappa statistics and by calculation of sensitivity and specificity values. RESULTS: Chance-corrected reliability was generally poor for both the leg-length inequality test (0.33 < or = k < or = 0.39) and the internal foot-rotation test (0.15 < or = k < or = 0.27). Sensitivity and specificity values of the tests to differentiate TMD and healthy subjects were below acceptable thresholds; they ranged from 0.41 to 0.57. CONCLUSION: Visual evaluations of leg-length inequality and internal foot rotation were unreliable and are not valid for TMD diagnoses. The results of chiropractic visual leg measurement procedures in dentistry should be interpreted with caution, particularly when clinical decisions may lead to nonreversible dental treatment.

The current status of endoscopy in transsphenoidal surgery: an international survey.

OBJECTIVE: A survey-based study was designed to assess opinions related to transsphenoidal endoscopy, to evaluate the current global attitudes of neurosurgeons regarding the use of this procedure, and to solicit basic data from key institutions worldwide, with the advantage that large series of cases become available for analysis. METHODS: A web-based multi-item questionnaire was distributed to the surgical departments of 393 neurosurgical centers by means of an invitation e-mail. The questionnaire was composed of 2 sections: section 1 focused on the surgical technique for pituitary adenomas (standard technique), and section 2 concentrated on surgery for skull base tumors (extended technique). Each section was composed of 2 parts: multiple choice questions and free textual responses. RESULTS: From a total of 393 neurosurgical centers, from 23 countries, that received the questionnaire, 87 of them (22%) submitted complete or incomplete responses. The surgical procedure, in 60 cases had been performed by a neurosurgeon, in 53 cases by a neurosurgeon and an otolaryngologist, and in 4 cases by an otolaryngologist only. The endoscope (2- and 3-dimensional) was used in 85.2% of transsphenoidal procedures versus the microscope in 14.8% of cases. The endonasal route was used for approach in 93.2% versus the sublabial route in 6.8% of cases. Computer-guided navigation was used by survey population in 71 cases, micro-Doppler in 51 cases, and Cavitron Ultrasonic Surgical Aspirator in 43 cases. Several hundreds of extrasellar tumors were operated using the extended technique. CONCLUSIONS: Transsphenoidal endoscopy for pituitary and anterior skull base tumors has become established as a routine method of dealing with a variety of lesions. The level of interest in the neurosurgical surgery community is reflected by the geometric expansion of contributions to the literature on endoscopic surgery.

Prenatal telemedicine: clinical experience with conventional and computerised antepartum telecardiotocography.

OBJECTIVE: To describe the clinical results of the first working year of a telemedicine project based on computerised telecardiotocography. STUDY DESIGN: The project is based on the "TOCOMAT" system, which remotely recorded and processed cardiotocograms performed at five peripheral units from high and low risk patients, then transferred them to a University Operative Centre, where they were displayed, stored and analysed by the 2CTG system and by two expert observers. RESULTS: 457 traces were analysed. The perinatal outcome was good, except for two high-risk fetuses. Both patients and carers had favourable reactions. The management of patients with pregnancies at risk was improved by the interaction of the physicians involved with the experts at the Operative Centre. CONCLUSIONS: Telemedicine could enable the decentralization of perinatal surveillance, improving quality of life for pregnant and newborn and rationalizing costs for prenatal care.

Evolutionary epistemology and dynamical virtual learning networks.

This paper is an attempt to define the main features of a new educational model aimed at satisfying the needs of a rapidly changing society. The evolutionary epistemology paradigm of culture diffusion in human groups could be the conceptual ground for the development of this model. Multidimensionality, multi-disciplinarity, complexity, connectivity, critical thinking, creative thinking, constructivism, flexible learning, contextual learning, are the dimensions that should characterize distance learning models aimed at increasing the epistemological variability of learning communities. Two multimedia educational software, Dynamic Knowledge Networks (DKN) and Dynamic Virtual Learning Networks (DVLN) are described. These two complementary tools instantiate these dimensions, and were tested in almost 150 online courses. Even if the examples are framed in the medical context, the analysis of the shortcomings of the traditional educational systems and the proposed solutions can be applied to the vast majority of the educational contexts.

A general model of dioxin contamination in breast milk: results from a study on 94 women from the Caserta and Naples areas in Italy.

BACKGROUND: The Caserta and Naples areas in Campania Region experience heavy environmental contamination due to illegal waste disposal and burns, thus representing a valuable setting to develop a general model of human contamination with dioxins (PCDDs-PCDFs) and dioxin-like-PCBs (dl-PCBs). METHODS: 94 breastfeeding women (aged 19-32 years; mean age 27.9 ± 3.0) were recruited to determine concentrations of PCDDs-PCDFs and dl-PCBs in their milk. Individual milk samples were collected and analyzed according to standard international procedures. A generalized linear model was used to test potential predictors of pollutant concentration in breast milk: age, exposure to waste fires, cigarette smoking, diet, and residence in high/low risk area (defined at high/low environmental pressure by a specific 2007 WHO report). A Structural Equation Model (SEM) analysis was carried out by taking into account PCDDs-PCDFs and dl-PCBs as endogenous variables and age, waste fires, risk area and smoking as exogenous variables. RESULTS: All milk samples were contaminated by PCDDs-PCDFs (8.6 pg WHO-TEQ/98g fat ± 2.7; range 3.8-19) and dl-PCBs (8.0 pg WHO-TEQ/98g fat ± 3.7; range 2.5-24), with their concentrations being associated with age and exposure to waste fires (p < 0.01). Exposure to fires resulted in larger increases of dioxins concentrations in people living in low risk areas than those from high risk areas (p < 0.01). CONCLUSIONS: A diffuse human exposure to persistent organic pollutants was observed in the Caserta and Naples areas. Dioxins concentration in women living in areas classified at low environmental pressure in 2007 WHO report was significantly influenced by exposure to burns.

Fetal size charts for the Italian population. Normative curves of head, abdomen and long bones.

OBJECTIVE: To describe size charts developed from fetuses of Italian couples. METHOD: Prospective cross-sectional investigation conducted in three referral centers for prenatal diagnosis. The population of the study included fetuses between the 16th and the 40th week of gestation recruited prospectively and examined only once for the purpose of this study. Exclusion criteria comprised all maternal and/or fetal conditions possibly affecting fetal biometry. The following biometric variables were measured: biparietal diameter, head circumference, abdominal circumference, femur, tibia, humerus, ulna and radio length. The statistical procedure recommended for analyzing this type of data set was employed to derive normal ranges and percentiles. Birthweight was also recorded. Our centiles were then compared with results from other studies. RESULTS: The best-fitted regression model to describe the relationships between head circumference and abdominal circumference and gestational age was a cubic one, whereas a simple quadratic model fitted BPD, and length of long bones. Models fitting the SD were straight lines or quadratic curves. Neither the use of fractional polynomials (the greatest power of the polynomials being 3) nor the logarithmic transformation improved the fitting of the curves. CONCLUSION: We have established size charts for fetuses from Italian couples using the recommended statistical approach. Since the mean birthweight in this study is not statistically different from the official birthweight reported for the Italian population, these reference intervals, developed according to the currently approved statistical methodology, can be employed during second- and third-trimester obstetric ultrasound of fetuses from Italian couples.

TP53 codon 72 polymorphism and risk of conjunctival squamous cell carcinoma in Uganda.

BACKGROUND: The most common TP53 gene polymorphism, which alters the amino acid sequence of the oncosuppressor p53 protein, is located at the codon 72, resulting in either Pro72 or Arg72 p53 variant. Several studies have associated this polymorphism with different types of cancer. We have analyzed the distribution and the role of TP53 Arg72 and Pro72 alleles in conjunctival neoplasia. METHOD: The study included 41 invasive conjunctival squamous cell carcinoma (ICSCC), 33 conjunctival intraepithelial neoplasia of grade 3 (CIN3), 33 of moderate grade (CIN1 and CIN2), and 115 controls from Uganda, a sub-Saharan country with the highest incidence rate of conjunctival neoplasia in the World, particularly in the era of AIDS. The TP53 Arg/Arg codon 72 genotype was detected in 21.9% of ICSCC and in 18.2% of CIN3 but only in 6% of CIN1-2 and in 5.2% of controls (P<0.05). RESULTS: These data show an increased risk of ICSCC (odds ratio (OR)=6.2, 95% confidence interval (CI): 1.6-24.6) and CIN3 (OR=4.1, 95% CI: 1.0-18.0) associated with TP53 Arg homozygosity, not observed in CIN1-2 lesions (OR=0.8, 95% CI: 0.1-5.1). Moreover, the frequency of the Arg homozygosity was similar in HIV-positive and HIV-negative groups. We conclude that TP53 Arg/Arg codon 72 genotype is a relevant risk factor for invasive squamous cell carcinoma of the conjunctiva and for CIN3 in the Ugandan population. DISCUSSION: The absence of statistically significant difference in the distribution of TP53 Arg72 or Pro72 encoding alleles between HIV-positive and -negative subjects, affected by conjunctival neoplasia, suggests that HIV infection and/or the associated immunodeficiency represent further independent risk factors for ICSCC.

Conventional and computerized antepartum telecardiotocography. Experienced and inexperienced observers versus computerized analysis.

The study assessed the agreement in cardiotocogram interpretation between the 2CTG computerized system and experienced and inexperienced observers involved in a telecardiotocography project called 'TOCOMAT'. Both observers and computer analyzed FHR baseline, FHR variability, and number of large accelerations and of decelerations. The k coefficient was calculated for the statistical analysis. The interobserver agreement about the evaluation of the FHR baseline and of the large accelerations was good; it was poor about the assessment of the FHR variability and the decelerations. Similar results were obtained for the agreement among observers and computer. The use of a computerized system provides exact values for most CTG parameters; the experts, however, should rely both on clinical features and on the computerized interpretation, to make decisions about management.