Predicting postoperative hypocortisolism in patients with non-aldosterone-producing adrenocortical adenoma: a retrospective single-centre study.

BACKGROUND: Limited information exists on postoperative hypocortisolism and hypothalamus-pituitary-adrenal axis recovery in patients with adrenal incidentaloma following unilateral adrenalectomy. We evaluated frequency of postoperative hypocortisolism and predictors for recovery in non-aldosterone-producing adrenocortical adenoma patients after unilateral adrenalectomy. METHODS: A retrospective analysis of 32 adrenal incidentaloma patients originally included in the ITACA trial (NCT04127552) with confirmed non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy from September 2019 to April 2023 was conducted. Preoperative assessments included adrenal MRI, anthropometrics, evaluation of comorbidities, adrenal function assessed via ACTH, urinary free cortisol, and 1 mg dexamethasone suppression test. ACTH and serum cortisol or Short Synacthen test were performed within 6 days, 6 weeks, 6 months, and a year after surgery. RESULTS: Six days postoperative, 18.8% of patients had normal adrenal function. Among those with postoperative hypocortisolism, 53.8% recovered by 6 weeks. Patients with earlier adrenal recovery (6 weeks) had lower preoperative 1 mg dexamethasone suppression test (median 1 mg dexamethasone suppression test 76.2 [61.8-111.0] nmol/L vs 260.0 [113.0-288.5] nmol/L, p < 0.001). Univariate analysis showed preoperative 1 mg dexamethasone suppression test negatively related with baseline ACTH levels (r = - 0.376; p = 0.041) and negatively associated with the 6-week baseline (r = - 0.395, p = 0.034) and 30-min cortisol levels during Short Synacthen test (r = - 0.534, p = 0.023). Logistic regression analysis demonstrated preoperative 1 mg dexamethasone suppression test as the only biochemical predictor for 6-week adrenal recovery: ROC curve identified a 1 mg dexamethasone suppression test threshold of 131 nmol/L predicting 6-week recovery with 89.5% sensitivity and 72.7% specificity (AUC 0.87; 95% CI 66.9-98.7, p < 0.001). Other preoperative assessments (tumor size, ACTH levels and anthropometrics) were not associated with postoperative hypothalamus-pituitary-adrenal axis function, but the presence of diabetes was associated with a lower probability of recovery (OR = 24.55, p = 0.036). ACTH levels increased postoperatively in all patients but did not predict hypothalamus-pituitary-adrenal axis recovery. CONCLUSIONS: The preoperative 1 mg dexamethasone suppression test cortisol value and presence of diabetes are the only relevant predictor of hypothalamus-pituitary-adrenal axis recovery in patients with non-aldosterone- producing adrenocortical adenoma undergoing surgery, regardless other clinical and biochemical variables. Notably, pre- and postoperative ACTH levels did not predict hypothalamus-pituitary-adrenal axis recovery. These findings point towards the potential for saving resources by optimizing their allocation during follow-up assessments for patients with non-aldosterone-producing adrenocortical adenoma undergoing unilateral adrenalectomy.

First report of Central-line-associated bloodstream infection (CLAB- SI) due to Enterococcus raffinosus (ER) in a cancer patient.

Abstract: Despite the advances made by therapeutic technologies, healthcare-associated infections (HAIs) are currently still a worldwide problem. Central-line-associated bloodstream infections (CLABSIs) are one of the most common causes of HAIs. The cost of CLABSIs is considerable, both for the increase in morbidity and financial resources expenses. Coagulase-negative staphylococci are the common pathogens responsible for CLABSIs, followed by Staphylococcus aureus, Enterococci, and Candida spp. The Enterococcus genus comprises of more than 50 species but E. faecalis and E. faecium are the most common causes of infections in humans. Enterococcus Raffinosus (ER) is a non-faecalis and non-faecium enterococcus even if ER has rarely been proven to be a human pathogen, recent reports of infections caused by enterococci that are relatively resistant to beta-lactam antibiotics by non-p-lactamase mechanisms have included strains of ER. Here we describe a first report of CLABSI due to Enterococcus Raffinosus in a cancer patient.

Undertreatment with Osimertinib in patient with multiple chemical sensitivity. A case report.

Introduction: Multiple chemical sensitivity (MCS), is a syndrome characterised by increased sensitivity to the exposure of environmental chemicals (1). There are considerable difficulties in reaching a good estimate of the prevalence of disease and the main pathogenetic hypotheses take into account both the organic and psychiatric/psychological factors. Treatment with epidermal growth factor tyrosine kinase receptor inhibitors (tkis), like Osimertinib, results in improved progression-free survival (PFS) compared to chemotherapy, in Non-small-cell lung carcinoma (NSCLC) with epidermal growth factor receptor (EGFR) mutation (2). Case report: We describe the case of a 74 year old woman with history of MCS and fibromyalgia in treatment with Osimertinib for EGFR-mutated NSCLC. Patient initially refused any form of active therapy for lung cancer, but thanks to teamwork and the important support of the psychologist, the patient decided to start treatment with Osimertinib at a reduced dose, not 80 mg but 40 mg. Subsequently, after few days , of his own free will and without informing the staff physicians, the patient changed the treatment schedule by taking one quarter of the dose of the medicine every other day, justifying this choice in therapeutic modification because of her fear and intolerance to any type of medicine and/ or chemical substance, being influenced by MCS. Management & outcome: Despite the changes in the treatment plan, a PET scan performed after two months showed a sigificative lung response and the stability of bone metastases. Discussion. Our case describes a significative response with Osimertinib despite the change in dosage and schedule in a patient with MCS. Our experience deserves to be considered in the light of its particularity and uniqueness as it shows an excellent response to treatment with Osimertinib despite the change made to the dosage and schedule, in a patient presenting in her medical history this rare pathological condition: MCS syndrome.

What hides beneath the scar: sexuality and breast cancer what women don't say: A single-center study.

Background: Breast is a symbol of femininity, motherhood and sexuality. Breast cancer (BC) is the leading cause of cancer death in women worldwide and most frequent cancer in Italy: in 2019, 53.500 new cases were diagnosed. BC and its treatment, the disturbances of body image, and mental health problems such as anxiety and depression could influence sexuality. Very often the aspect of sexuality in BC is likely not to be fully investigated: cultural barriers may also contribute to lack of attention to these issues. In Italy, there are very few Breast Units that provide the figure of the sexologist and psycho-oncologist. Methods: We enlisted 141 BC patients (pts), mean age was 54 years afferent to Breast Unit S. Maria Goretti Hospital, Latina, from March 2019 to March 2020. All pts had undergone surgical intervention. Participants were invited to complete a structured questionnaire, which included four close-up questions regarding self-image, sexual activity, sexual satisfaction, analyzing these aspects before and after BC and its treatments. Finally the participants were asked if they needed the sexologist and psycho-oncologist. Results: Only 2/141 pts (1.41%) refused to participate in our study. Of 139 participants, 68 (48.92%) had disturbances of body image, 26 (18.7%) had sexuality greatly negatively affected, and 103 (74.1%) every kind of sexual dissatisfaction after BC. 38 pts (27.3%) would require the help of the sexologist. 135 ( 97%) would require the help of the psycho-oncologist. Despite the negative influence in their body-image and sexuality, few pts require the help of the sexologist, but nearly all pts require the help of the psycho-oncologist. Conclusion: In our study nearly all pts require the help of the psycho-oncologist, but few pts of the sexologist. Further studies will be needed to understand the reasons for this disparity: at the moment we are carrying out another project following this illustration, with the aim of understanding why this disparity.

Impacto de los tratamientos hipolipemiantes en los resultados cardiovasculares según la puntuación de calcio coronario. Revisión sistemática y metanálisis / Impact of lipid-lowering therapies on cardiovascular outcomes according to coronary artery calcium score. A systematic review and meta-analysis

Introducción y objetivos: La puntuación de calcio arterial coronario (CAC) mejora la precisión de la estratificación del riesgo de enfermedad cardiovascular ateroesclerótica (ECVA) en comparación con los factores de riesgo cardiovascular tradicionales. Se evaluó la interacción de la carga ateroesclerótica coronaria determinada por la puntuación de CAC con el beneficio pronóstico de los tratamientos hipolipemiantes en el contexto de la prevención primaria. Métodos: Se revisaron las bases de datos MEDLINE, EMBASE y Cochrane en busca de estudios que incluyeran a individuos sin ECVA previa y con datos sobre la puntuación de CAC y el tratamiento hipolipemiante según los valores de CAC. El objetivo primario fue la aparición de ECVA. Se evaluó el efecto del tratamiento hipolipemiante agrupado y estratificado por grupos de CAC (0, 1-100 y> 100) mediante un modelo de efectos aleatorios. Resultados: Se incluyeron 5 estudios (1 aleatorizado, 2 de cohortes prospectivas y 2 retrospectivas) que incluyeron a 35.640 individuos (el 38,1% mujeres) con medias de edad de 62,2 (rango, 49,6-68,9) años, colesterol unido a lipoproteínas de baja densidad de 128 (114-146) mg/dl y seguimiento de 4,3 (2,3-11,1) años. La aparición de la ECVA aumentó de manera constante en los estratos crecientes de CAC tanto en los pacientes con como en aquellos sin tratamiento hipolipemiante. Al comparar a los pacientes con (34,9%) y sin (65,1%) exposición al tratamiento hipolipemiante, este se asoció con menos aparición de ECVA en los pacientes con CAC> 100 (OR=0,70; IC95%, 0,53-0,92), pero no en aquellos con CAC de 1-100 o 0. Los resultados concordaron al agrupar los datos ajustados. Conclusiones: Entre los individuos sin ECVA previa, una puntuación de CAC> 100 identifica a los sujetos con mayor probabilidad de beneficiarse del tratamiento hipolipemiante, mientras que un CAC indetectable indica ausencia de beneficio (AU)

Introduction and objectives: Coronary artery calcium (CAC) score improves the accuracy of risk stratification for atherosclerotic cardiovascular disease (ASCVD) events compared with traditional cardiovascular risk factors. We evaluated the interaction of coronary atherosclerotic burden as determined by the CAC score with the prognostic benefit of lipid-lowering therapies in the primary prevention setting. Methods: We reviewed the MEDLINE, EMBASE, and Cochrane databases for studies including individuals without a previous ASCVD event who underwent CAC score assessment and for whom lipid-lowering therapy status stratified by CAC values was available. The primary outcome was ASCVD. The pooled effect of lipid-lowering therapy on outcomes stratified by CAC groups (0, 1-100,> 100) was evaluated using a random effects model. Results: Five studies (1 randomized, 2 prospective cohort, 2 retrospective) were included encompassing 35 640 individuals (female 38.1%) with a median age of 62.2 [range, 49.6-68.9] years, low-density lipoprotein cholesterol level of 128 (114-146) mg/dL, and follow-up of 4.3 (2.3-11.1) years. ASCVD occurrence increased steadily across growing CAC strata, both in patients with and without lipid-lowering therapy. Comparing patients with (34.9%) and without (65.1%) treatment exposure, lipid-lowering therapy was associated with reduced occurrence of ASCVD in patients with CAC> 100 (OR, 0.70; 95%CI, 0.53-0.92), but not in patients with CAC 1-100 or CAC 0. Results were consistent when only adjusted data were pooled. Conclusions: Among individuals without a previous ASCVD, a CAC score> 100 identifies individuals most likely to benefit from lipid-lowering therapy, while undetectable CAC suggests no treatment benefit (AU)

Nasal HPpSIS administration enhances NGF and tumor suppressor protein, p73 in human brain cancer tissues: preliminary data.

OBJECTIVE: Nerve Growth Factor (NGF) is a neurotrophic factor known to play a critical role in growth, survival, differentiation and neuroprotection of peripheral sensory and sympathetic neurons, as well as brain neurons. We have recently reported that nasal administration of high-pressure isotonic physiological saline solution (HPpSIS) enhances the level of NGF and the expression of NGF receptors in neurons of the olfactory bulbs and forebrain cholinergic neurons of laboratory animals. In the present study, we sought to determine whether the same treatment affects the levels of NGF within the brain tumor tissue. PATIENTS AND METHODS: This study was conducted on eight adult patients, 4 males and 4 females with malignant anterior cranial fossa tumor. Before surgery, four subjects, two males and two females received nasal administration of HPpSIS for ten consecutive days. RESULTS: The levels of NGF in surgical removed peripheral tumor brain samples of patients treated with nasal HPpSIS administration are more elevated compared to the levels of NGF in peripheral brain tissues of HPpSIS untreated patients. CONCLUSIONS: We observed that nasal administration of HPpSIS enhances not only the basal brain NGF levels and the expression of NGF receptors but also the tumor suppressor protein p73. The possible functional significance of these observations will be described and discussed.

RANK/RANKL/OPG pathway: genetic association with history of ischemic stroke in Italian population.

OBJECTIVE: RANKL is a member of the TNF superfamily that stimulates chemokine release, monocyte/macrophage matrix migration and matrix metalloproteinase activity and plays an important role in atherosclerosis. In our study, we have evaluated whether RANKL gene polymorphisms are involved in ischemic stroke in Italian subjects. PATIENTS AND METHODS: In a retrospective study we have included 487 patients (242 males, 245 females) with history of ischemic stroke and 543 control subjects without history of ischemic stroke (277 males, 276 females). The rs9533156, and rs2277438 gene polymorphisms of the RANKL gene were analyzed by PCR and restriction fragment length polymorphism. RESULTS: We found that the rs9533156 gene polymorphism of the RANKL gene was significantly (55.0% versus 36.5%, p < 0.0001) and independently (adjusted OR 6.28 [2.34-4.21]) associated with history of ischemic stroke. No statistically significant difference was found between the two groups in our population for the rs2277438 gene polymorphism (p = 439). Furthermore, we have confirmed that rs 3134069, rs 2073617 and rs 2073618 polymorphisms of the OPG gene were significantly and independently associated with cerebrovascular disorders. CONCLUSIONS: The present study identifies, for the first time, the genetic variant of RANKL as an independent risk factor for ischemic stroke.

Fibroblast growth factor 23 serum level in type 2 diabetic italian subjects with peripheral arterial disease and critical limb ischemia.

OBJECTIVE: Fibroblast growth factor 23 (FGF23) was demonstrated to be involved in the occurrence and development of cardiovascular disease (CVD). The aim of this study was to investigate the potential role of FGF23 on presence and severity of peripheral arterial disease (PAD) in type 2 diabetic patients. PATIENTS AND METHODS: In this study, we analyzed FGF23 serum levels in 413 type 2 diabetic patients with PAD and in 598 diabetic controls without lower limbs atherosclerosis. RESULTS: We found that FGF23 median serum levels were significantly higher in patients than in diabetic controls (69.3 (58.8-75.1) pg/mL in PAD and 42.98 (37.1-49.8) pg/mL in subjects without PAD (p < 0.001) and were significantly and independently associated with critical limb ischemia (CLI) [OR, 7.69 (2.64-16.31); p = 0.001]. CONCLUSIONS: We have found, for the first time, that FGF23 could be associated with presence and severity of PAD in Italian patients with type 2 diabetes.

Growth hormone receptor isoforms and fracture risk in adult-onset growth hormone-deficient patients.

INTRODUCTION: Growth hormone deficiency is considered the most important factor determining skeletal fragility in hypopituitary patients. Osteoblasts and chondrocytes express growth hormone (GH) receptor. Two GH receptor isoforms (GHRi) have been identified: they differ for the presence/absence of a protein fragment encoded by exon 3 of GHR gene. Consequently, three genotypes were identified: carriers of both the full-length proteins (flfl-GHR), carriers of one full-length protein and one deleted protein (fld3-GHR) and carriers of both deleted proteins (d3d3-GHR). This polymorphism confers a higher sensitivity to endogenous GH and to recombinant human GH (rhGH); its effect on bone metabolism and skeletal fragility is unknown. The aim of this article was to investigate the role of GHRi in predicting skeletal fragility in adult-onset GHD (AO-GHD) patients. SUBJECTS AND METHODS: A cross-sectional study was conducted to investigate the association between the d3-GHR isoform and the prevalence of morphometric vertebral fractures (VFs) in AO-GHD. Ninety-three AO-GHD were enrolled. Forty-nine patients carried flfl-GHRi (52·7%), and 44 patients (47·3%) carried at least one allele of the d3-GHR isoform. Thirty-two VFs were documented. Fifty-seven patients underwent rhGH replacement therapy. RESULTS: Median age was significantly higher in fractured patients as compared to nonfractured ones; d3-carrier patients showed a lower VF risk as compared to flfl-GHRi (OR: 0·37, 95% IC: 0·24-0·55, P < 0·0001). This finding was also confirmed in AO-GHD undergoing rhGH replacement therapy. CONCLUSION: This study suggests that d3-GHR may protect AO-GHD particularly when treated with rhGH from the risk of VFs.

The role of high-mobility group box protein 1 in collagen antibody-induced arthritis is dependent on vascular endothelial growth factor.

High-mobility group box 1 (HMGB1) has been implicated in angiogenesis and rheumatoid arthritis (RA). The aim of this study was to define more clearly the role of HMGB1 in the synovial angiogenesis and pathogenesis of an immune model of arthritis. BALB/c mice were injected with monoclonal anti-collagen antibody cocktail followed by lipopolysaccharide to induce arthritis. HMGB1 and vascular endothelial growth factor (VEGF) were over-expressed in the areas of the synovium where more inflammation and neoangiogenesis were present. The selective blockade of HMGB1 or VEGF resulted alternatively in a lower severity of arthritis evaluated by the arthritis index. Furthermore, exogenous HMGB1 administration caused a worsening of arthritis, associated with VEGF up-regulation and increased synovial angiogenesis. The selective inhibition of VEGF also resulted in no induction of arthritis in mice receiving exogenous HMGB1. Cytokine enzyme-linked immunosorbent assay (ELISA) analyses performed on peripheral blood and synovial fluid demonstrated a significant reduction of interleukin (IL)-1ß, IL-6 and tumour necrosis factor (TNF)-α in mice where HMGB1 and VEGF pathways were blocked. Interestingly, the selective blockade of HMGB1 and VEGF resulted in an increase of the peripheral IL-17A concentration. The development of arthritis mediated by HMGB1 and the synovial angiogenesis can be blocked by inhibiting the VEGF activity. The proinflammatory and proangiogenic cytokine IL-17A was increased when HMGB1 is inhibited, but the synovial angiogenesis was nevertheless reduced in this model of arthritis. Taken together, these findings shed new light on the role of this nuclear protein in the pathogenesis of arthritis in an RA-like model.

Kinetics of in vitro response to Beta-lactoglobulin in children allergic to and tolerant of cow´s milk protein

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Surgical management of knee dislocations with ligament reconstruction associated with a hinged external fixator.

INTRODUCTION: Knee dislocations are defined as ligament injuries involving at least two of the four most important knee ligaments. Results from recent studies have shown a tendency towards improvement of the functional outcomes with use of an articulated external fixator during the postoperative period following multiligament reconstruction. Our hypothesis was that good knee stability and early gain of range of motion could be achieved with the use of the external fixator after ligament reconstructions. METHODS: Fourteen patients with knee dislocations were evaluated after multiligament reconstruction in association with use of a lateral monoplanar external fixator for six weeks. Reconstructions were performed using grafts from a tissue bank. Range of motion was measured after one, two, three, six, twelve months and at the final evaluation at a mean time of 49 months. The assessments were made using objective and subjective IKDC, Lysholm and Tegner scales. RESULTS: The mean scores were 71.7 for the subjective IKDC score, 81.5 for the Lysholm score. No patient was able to return to previous Tegner score. Out of the 45 ligament reconstructions performed, only four failed during the follow-up time. The mean range of motion of the knee presented a progressive increase from the first to the twelfth month, from 67.8° to 115.7°. Two cases of superficial infection on the site of the external fixator pins were observed. CONCLUSION: The use of an external fixator enabled early rehabilitation with range of motion gains starting from the first postoperative month, a low rate of reconstruction failure and minimal complications. Nevertheless, none of the patients returned to the level of activity prevailing prior to the injury. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

Thrombin and thrombin-derived peptides promote proliferation of cardiac progenitor cells in the form of cardiospheres without affecting their differentiation potential.

Many studies demonstrated that human adult cardiac progenitor cells in the form of cardiospheres (CSps) could represent a powerful candidate for cardiac cell therapy. To achieve the clinical translation of this biotechnological product, the development of well-defined culture conditions is required to optimize their proliferation and differentiation. Thrombin, a serine protease acting through the protease-activated receptor 1 (PAR-1) signalling to modulate many cellular functions such as proliferation and differentiation in several cell types, is one of the factors included in the CSps medium. Therefore, the assessment of the effective dependence of the thrombin related cellular effects from PAR-signalling is strategic both for understanding the biological potential of these cells and for the GMP translation of the medium formulation, using synthesised analogs. In this study the effects of thrombin on human CSps and their potential relationship with the specific proteolytic activation of PAR-1 have been investigated in different culture conditions, including thrombin inhibitor hirudin and PAR-1 agonist/ antagonist peptides TFLLR and MUMB2. In this study we show that, in the presence of thrombin and TFLLR, CSps, in which PAR-1 expression was evidenced by immunofluorescence and western blot analysis, increase their proliferation activity (BrdU assay). Such increased proliferative rate was consistently associated with a higher phosphorylation level of the cell cycle inhibitor GSK3. Concerning the assessment of the potential effects of thrombin and its agonist on differentiation, both western blot and real-time PCR analysis for stemness, cardiac and vascular markers (such as cKit, cx43 and KDR) showed that CSps commitment was substantially unaffected, except for GATA4 mRNA, whose transcription was down-regulated in the presence of the natural protease, but not after treatment with TFLLR. In conclusion, activation of PAR-1-dependent signalling is important to support CSps proliferative potential, keeping unaltered or at best stable their differentiation properties. The availability of thrombin agonists, such as TFLLR, able to guarantee the required growth effect without affecting CSps lineage commitment, could represent a technological improvement for cost-effective, easy-to-handle and GMPtranslatable synthetic media.

Investigation of the 3-D actinic flux field in mountainous terrain.

During three field campaigns spectral actinic flux was measured from 290-500 nm under clear sky conditions in Alpine terrain and the associated O3- and NO2-photolysis frequencies were calculated and the measurement products were then compared with 1-D- and 3-D-model calculations. To do this 3-D-radiative transfer model was adapted for actinic flux calculations in mountainous terrain and the maps of the actinic flux field at the surface, calculated with the 3-D-radiative transfer model, are given. The differences between the 3-D- and 1-D-model results for selected days during the campaigns are shown, together with the ratios of the modeled actinic flux values to the measurements. In many cases the 1-D-model overestimates actinic flux by more than the measurement uncertainty of 10%. The results of using a 3-D-model generally show significantly lower values, and can underestimate the actinic flux by up to 30%. This case study attempts to quantify the impact of snow cover in combination with topography on spectral actinic flux. The impact of snow cover on the actinic flux was ~ 25% in narrow snow covered valleys, but for snow free areas there were no significant changes due snow cover in the surrounding area and it is found that the effect snow-cover at distances over 5 km from the point of interest was below 5%. Overall the 3-D-model can calculate actinic flux to the same accuracy as the 1-D-model for single points, but gives a much more realistic view of the surface actinic flux field in mountains as topography and obstruction of the horizon are taken into account.

Percutaneous ultrasound-guided treatment of shoulder tendon calcifications: Clinical and radiological follow-up at 6 months().

INTRODUCTION: Calcific tendinitis of the shoulder is a common condition characterized by chronic pain and/or very painful acute episodes. Different treatments are used during painful flare-up, but they are often ineffective. US-guided percutaneous needle aspiration/lavage is proving to be an effective means for eliminating these calcifications. MATERIALS AND METHODS: We treated 123 consecutive patients (mean age 48 years) with calcific tendinitis of the shoulder. Fifty-five patients had persistent symptoms requiring 2 or more treatments with lavage and intrabursal steroid infiltration. Before and after treatment, US studies were done independently by 2 radiologists with experience in musculoskeletal ultrasound. Results were concordant in over 90% of the cases. Constant Shoulder Scores were calculated before and 6 months after treatment. At 6 months, MRI was performed to identify impingement and/or bursitis. RESULTS: Post-treatment Constant scores were significantly improved in all 68 patients treated once (Group 1: mean scores 28.6 vs. 81.4) and in 52 of the 55 treated twice or more (Group 2: mean scores 34.1 vs. 71.1) (p < 0.0001 in both cases). Pretreatment Constant scores were similar in patients with and without shoulder impingement on MRI (31.2 vs. 30.9, respectively), but after treatment the impingement group's scores were significantly higher (82.2 vs. 73.3, respectively; p < 0.001). CONCLUSIONS: US-guided percutaneous needle aspiration/lavage is an effective and economic treatment for calcific tendinitis of the shoulder. Pretreatment MRI should be done to check for impingement since it is often associated with an incomplete response to the first treatment.

Diffusion and practice of ultrasound in emergency medicine departments in Italy.

INTRODUCTION: This paper reports data from a cognitive survey on the diffusion, practice and organization of ultrasound (US) in emergency medicine departments (EMDs) in Italy. The study was carried out by the Emergency Medicine Section of the Italian Society for Ultrasound in Medicine and Biology (SIUMB) in collaboration with the Italian Society for Emergency Medicine and Urgent Care (SIMEU). METHODS: We created a questionnaire with 10 items, relating to 4 thematic areas. The questionnaires were administered from September 2007 to February 2008, by email, telephone or regular mail. In August 2008 the data were subjected to nonparametric statistical analysis (Spearman's Rho and Pearson's chi-square - software SPSS). RESULTS: We analyzed 170 questionnaires from the EMDs of all Italian regions. A US scanner is present in 64.7% of the ERs, emergency US (E-US) is practiced only in 47.6% of the ERs, and only in 24% of these more than 60% of the ER team members have training in US. The diffusion of US in other operative units of the EMDs ranges from 8.2% to 26.5%. DISCUSSION: The presence of a US scanner in the ER is essential for the practice and training and is correlated with the level of the EMD. The use of US appears to be less common in less equipped hospitals, regardless of the size of the ER and the availability of radiological services. Wider diffusion of US and greater integration with other services for the installment of the required equipment is to be hoped for.

Prognostic significance of the Ki-67 labeling index in growth hormone-secreting pituitary adenomas.

CONTEXT: Ki-67 is a marker of proliferation activity associated with invasiveness and prognosis in human tumors. OBJECTIVE: The aim of the study was to evaluate the Ki-67 index prognostic relevance in a group of acromegalic patients who underwent transsphenoidal surgery for a GH-secreting pituitary adenoma. MATERIAL AND METHODS: We selected 68 consecutive acromegalic patients referred to our hospital during a 5-yr period. The Ki-67 index was determined by immunohistochemistry on tissue samples obtained from each adenoma after surgery. Those patients who were not completely cured after surgery began medical therapy with somatostatin analogs (SSAs). Periodical pituitary magnetic resonance imaging and hormonal evaluation were performed during the follow-up. RESULTS: Twenty-eight of 68 patients were cured after surgery (41%). Among the 40 patients treated with SSAs, 13 were considered uncontrolled. Pituitary magnetic resonance imaging showed residual/recurrent disease in 25 of 68 patients after 6 months. No correlation was found between Ki-67 index and age, tumor size, GH, or IGF-I plasma levels. Tumors described as having cavernous sinus invasion had a higher mean Ki-67 index as compared with noninvasive tumors (P < 0.01). The Ki-67 index was significantly lower in tumors in patients cured after surgery as compared with patients considered not cured (P < 0.01) and in tumors in patients controlled by SSA therapy as compared with patients considered as uncontrolled (P < 0.05). CONCLUSION: The Ki-67 labeling index may predict clinical outcome in postsurgical management of acromegalic patients. We suggest routine Ki-67 evaluation in GH-secreting pituitary adenomas.

Happy Air: a school-based educational program to maximize detection of asthma in children.

OBJECTIVE: To investigate whether an active partnership among school, parents, and pediatricians allows early identification and treatment of asthmatic children. METHODS: An asthma educational program (Happy Air), based on a strong family-physician-school interrelationship, was performed in six primary schools (2,765 children) before administering a screening questionnaire to the parents. RESULTS: A high response rate (96%) demonstrated 2,649 responders available for the asthma screening: 135 children (5%) received a diagnosis of asthma, of which 37 (27%) were recognized de novo. CONCLUSION: The active participation of school and parents is the determining factor for the success of an asthma screening program.