Highlights from "Italian Standards of care for Diabetes Mellitus 2009-2010".

The Italian Standards for the Treatment of Diabetes Mellitus represent a consensus document of the two Italian scientific diabetes societies (AMD and SID), providing specific recommendations for the diagnosis and treatment of diabetes and its complications. The level of scientific evidence behind every recommendation has been classified in accordance with the National Guidelines Plan. An original processing system was employed: the document prepared by the Editorial Team was published online for 20 days, and the suggestions and criticisms of about 30 persons were evaluated and integrated to those provided by a panel of diabetologists and members of other healthcare professions dedicated to diabetes care, as well as lay members. Lastly, the document was approved by AMD and SID National Steering Committees. In this version, some highlights of the full document (www.siditalia.it; www.aemmedi.it) concerning the main and most representative recommendations on diagnosis and treatment of diabetes and its complications as well as on diabetes care in some specific contexts, are reported.

[Firearms related suicide/homicide rate among the security guards population in Italy]. / Suicidi e omicidi con l'arma di ordinanza. Analisi della casistica nelle guardie particolari giurate in Italia.

OBJECTIVE: The main aim of this study is evaluating the suicide/homicide rate of the Italian security guards population compared to other armed and general populations during a recent period. METHODS: The authors reviewed the incidence of suicides and homicides among security guards from 1996 to 2006 and, where information was available, a comparison was made with Italian population adapted by age. Comparisons with the general population were also made. RESULTS: The average rate of firearms related suicide among the security guards population during the established period was 11.7 per 100,000 persons-years (95% CI = 6.6-16.7) compared to a guns-related suicide rate of 0.7 per 100,000 person-years, (95% CI = 0.6-0.7) and a non-guns related rate of 5.5 per 100,000 persons-years, (95% CI = 5.2-5.9) for the general population adjusted for age. The overall homicide rate among security guards during the period was 11.4 per 100,000 person-years (95% CI = 6.2-15.4) compared with the homicide rate for the Italian population of 5.4 per 100,000 persons-years, (95% CI = 7.3-15.4). CONCLUSION: The rate of suicide and homicide among the Italian security guards population was higher than the suicide/homicide rate in the general population. These results show that the phenomenon we have described needs attention and specific prevention activities.

[Electrical manifestations of dead myocardium associated to proximal blocks of intermediate degree]. / Aspectos eléctricos de la asociación de miocardio inactivable y bloqueos tronculares de grado intermedio.

The electrical manifestation of dead myocardium associated to incomplete bundle branch block, i.e., with a limited "jumping wave" phenomenon, are exposed. Our description is based on previous experimental studies and validated by electro-anatomical comparisons. In previous experimental reports, the electrical manifestations of dead myocardium in the presence of varying degrees of associated block have also been described. The main electrocardiographic changes are related to the location and extent of damaged region and to degree of bundle branch block. If a left bundle branch block coexists with dead myocardium, small Q waves are registered in left unipolar leads exploring the damaged area. In these leads, the signs of subepicardial or transmural injury are increased. When a right proximal block coexists, the main changes concern the morphologies registered in the unipolar right epicardial and precordial leads. The electrical changes are due to the spatial orientation of the electromotive forces of ventricular depolarization and repolarization. The electrocardiographic changes described here can be satisfactorily understood in the light of the present knowledge on the ventricular electrical phenomenon.

Long-term validity of the At Risk Mental State (ARMS) for predicting psychotic and non-psychotic mental disorders.

BACKGROUND: The long-term clinical validity of the At Risk Mental State (ARMS) for the prediction of non-psychotic mental disorders is unknown. METHODS: Clinical register-based cohort study including all non-psychotic individuals assessed by the Outreach And Support in South London (OASIS) service (2002-2015). The primary outcome was risk of developing any mental disorder (psychotic or non-psychotic). Analyses included Cox proportional hazard models, Kaplan-Meier survival/failure function and C statistics. RESULTS: A total of 710 subjects were included. A total of 411 subjects were at risk (ARMS+) and 299 not at risk (ARMS-). Relative to ARMS-, the ARMS+ was associated with an increased risk (HR=4.825) of developing psychotic disorders, and a reduced risk (HR=0.545) of developing non-psychotic disorders (mainly personality disorders). At 6-year, the ARMS designation retained high sensitivity (0.873) but only modest specificity (0.456) for the prediction of psychosis onset (AUC 0.68). The brief and limited intermittent psychotic symptoms (BLIPS) subgroup had a higher risk of developing psychosis, and a lower risk of developing non-psychotic disorders as compared to the attenuated psychotic symptoms (APS) subgroup (P<0.001). CONCLUSIONS: In the long-term, the ARMS specifically predicts the onset of psychotic disorders, with modest accuracy, but not of non-psychotic disorders. Individuals meeting BLIPS criteria have distinct clinical outcomes. SIGNIFICANT OUTCOMES: In the long-term, the ARMS designation is still significantly associated with an increased risk of developing psychotic disorders but its prognostic accuracy is only modest. There is no evidence that the ARMS is associated with an increased risk of developing non-psychotic mental disorders. The BLIPS subgroup at lower risk of developing non-psychotic disorders compared to the APS subgroup. LIMITATIONS: While incident diagnoses employed in this study are high in ecological validity they have not been subjected to formal validation with research-based criteria.

[On the electrical manifestations of some heart diseases associated with ventricular preexcitation]. / Manifestaciones eléctricas de alteraciones miocárdicas asociadas a preexcitación ventricular.

Electro-Vectorcardiographic curves, corresponding some heart diseases, must be analyzed in the light of the ventricular depolarization sequence, as well as on the heart's position and rotation. A more than 30-msec interval between the end of the initial slurring (delta) and the vertex of the R wave in the left unipolar leads or the main axis of the vectorcardiographic ventricular curves, allows us to infer the coexistence of left ventricular hypertrophy. On the other hand, segmental irregularities or distorsions of the electric curves suggest the presence of a limited myocardial zone unable to be activated. Extensive or multiple deformations of these curves are more suggestive of a diffuse myocardial damage. Sometimes signs of preexcitation, due to a pharmacological action, can also appear.

Effects of calcium antagonists on renal hemodynamics and progression of nondiabetic chronic renal disease.

In recent years, substantial investigative attention has focused on therapeutic regimens that could retard the progression of chronic renal insufficiency. Emphasis has been placed on the effects of antihypertensive treatment on renal hemodynamics and preservation of renal function. It has been suggested that some classes of antihypertensive agents may confer a greater renoprotective effect, especially agents that lower glomerular capillary pressure. Conversely, by virtue of their ability to preferentially dilate the afferent arteriole calcium antagonists theoretically could favor an increase in glomerular capillary pressure thereby accelerating the decline of renal function. In this review we survey the literature critically and conclude that in patients with essential hypertension and in patients with chronic renal insufficiency, calcium antagonists effectively reduce systemic blood pressure while maintaining glomerular filtration rate and effective renal plasma flow. Preliminary results from a few long-term studies suggest that calcium antagonists may even attenuate the decline in renal function of patients with chronic renal failure. The majority of studies in humans, however, have been nonrandomized, of too short duration, or confounded by investigative difficulties precluding definite conclusions whether calcium antagonists have renoprotective effects. Although the possibility that calcium antagonists may retard progression of renal disease remains to be ascertained, the available evidence indicates that calcium antagonists may be used in patients with renal functional impairment without further exacerbating renal function.

Increased glutamate in CSF and plasma of patients with HIV dementia.

BACKGROUND: Experimental evidence suggests that excitotoxicity might play a major role in HIV-induced neurodegeneration. However, few studies have investigated the role of endogenous glutamate in patients with HIV dementia. OBJECTIVE: To analyze CSF and plasma glutamate levels in 30 patients with AIDS with different dementia severity compared with 10 patients with other neurologic disorders, 11 healthy control subjects, and 10 patients with Alzheimer-type dementia. METHODS: CSF and plasma glutamate levels were measured by reverse-phase high-performance liquid chromatography followed by fluorometric analysis. RESULTS: Glutamate CSF levels were increased fivefold in the patients with HIV vs normal control subjects (p = 0.001), patients with Alzheimer-type dementia (p < 0.0001), and patients with other neurologic disorders (p < 0.01). CSF glutamate levels were also related to the degree of dementia (p < 0.02) and brain atrophy (p < 0.002). Plasma levels were also higher in the patients with HIV (p < 0.0001) but did not correlate with either clinical or imaging features. CONCLUSION: Increased CSF glutamate may originate within the CNS and may play a pathogenetic role in HIV dementia, thus supporting the treatment of these patients with glutamate receptor antagonists.

Ultrasonographic imaging and Doppler analysis of renal changes in non-insulin-dependent diabetes mellitus.

RATIONALE AND OBJECTIVES: We used ultrasonographic imaging and Doppler analysis to assess renal changes in patients with non-insulin-dependent diabetes mellitus (NIDDM) and normal renal function, as established by normal serum creatinine levels and the absence of macroalbuminuria. METHODS: Renal parenchymal echogenicity, renal volume, and resistive index (RI) were blindly evaluated for 85 NIDDM patients and 42 age-matched control subjects (C). Results were analyzed and correlated with the following clinical parameters: patient age, duration of diabetes, blood pressure, blood glucose and cholesterol levels, and the presence of microalbuminuria. RESULTS: Normal renal parenchymal echogenicity was seen in all but one NIDDM patient; however, in comparison with C, diabetic patients had significantly higher renal volume (mean +/- standard deviation, 314.01 +/- 72.74 vs 227.64 +/- 58.76) and RI (mean +/- standard deviation, 0.71 +/- 0.05 vs 0.64 +/- 0.02). An RI higher than 0.70 was found in 55 of 85 (65%) NIDDM patients; an increased RI was directly correlated with patient age, whereas an inverse correlation existed between an increased RI and renal volume. No statistically significant differences were observed for the duration of diabetes, arterial hypertension, blood levels of glucose and cholesterol, and the presence of microalbuminuria. CONCLUSIONS: NIDDM patients with normal renal function show a significant increase in renal volume and RI in comparison with C. Demonstration of these findings may aid in the detection of early renal involvement in NIDDM patients. However, further investigations are needed to understand fully the correlation of such changes with the pathology of diabetic nephropathy and to provide an interpretation of the pathophysiologic mechanisms underlying changes in intrarenal vascular impedance in NIDDM patients.

On the electrocardiographic diagnosis of biventricular infarctions.

To diagnose posterior and anterior biventricular infarctions it is necessary to record from right and left thoracic and high abdominal unipolar leads. These supplementary leads are dependable, can be repeated as many times as needed and show the evolution from signs of myocardial injury to those of dead tissue (Q waves of 0.04 sec or more). This electrocardiographic evolution increases the diagnostic value of the electrical exploration, since the injury current can be observed also in other conditions. The diagnosis of right ventricular infarction can be established even in the presence of RBBB. Signs of a dead zone in the free right ventricular wall are more frequently observed in posterior biventricular infarctions than in anterior ones. In these cases, the signs of subepicardial injury are more accentuated in the right thoracic unipolar leads than in V3, indicating anterior right ventricular involvement. These signs are also observed in experimental studies made in animals. This electrocardiographic exploration opens a wide field for the diagnosis of myocardial infarction, particularly in biventricular involvement, including old myocardial scars, and in discarding signs of pericarditis manifested only by the upward displacement of the ST segment. A review of the medical literature concerning diagnosis of biventricular infarctions is presented.

Effects of verapamil in ventricular tachycardias. An experimental and clinical study.

To determine the effect of verapamil in ventricular tachycardias, we performed an experimental and clinical study. Experimental ventricular tachycardias (VT) were produced in dog hearts with minute aconitine crystals introduced into the periphery of a left ventricular area, damaged by intramural injection of 1.0-1.5 ml phenol. The response of these tachycardias to 0.2 mg/kg verapamil was analyzed. Verapamil was infused into the superior vena cava over 15-20 min. Leads II, aVL, intraventricular right and left unipolar records, as well as one of the superior vena cava, were registered under control conditions, in the presence of VT, and after application of verapamil. Recordings were obtained at constant intervals, waiting for the recovery of sinus rhythm (SR) and the posterior reappearance of tachycardia. Experiments were performed for 6 to 8 h under continuous infusion of Hartmann's solution. Throughout these periods, variations in systemic systolic pressure were recorded. From 75 animals submitted to this treatment, 30 (40%) recovered transiently the SR, whereas the drug exerted no antiarrhythmic effect in 19 (25%), and arterial systolic pressure fell importantly in 10 (13%) animals. In two more groups, of 15 dogs each, the VT response to verapamil was compared with the response to lidocaine and flecainide. Endovenous verapamil (5-10 mg) was administered to 10 patients, coursing with VT and having a structurally normal heart, after this arrhythmia was induced by electrical stimulation. The response to verapamil was satisfactory in nine patients (90%), in which VT originated in the septal and apical regions of the left ventricle. Verapamil seems to be effective in experimental and clinical ventricular tachycardias related to calcium-dependent potentials, in which the sustaining mechanism could either be triggered activity or reentry.

Formation of emergency medicine in Italy.

In Italy departments of emergency medicine and emergency medical service systems (EMS) were first set up at the end of the 1970s. Since that time many dramatic and significant changes have taken place in the care of the critically ill patient. In Italy the interest in emergency problems and the need for emergency intervention have increased considerably. Nevertheless several problems still have to be solved in order to obtain a standardized organization of the emergency system in Italy and uniform training of emergency care providers.

[A case of acute rhabdomyolysis and acute renal insufficiency caused by the simultaneous use of furosemide and bezafibrate]. / Un caso di rabdomiolisi acuta con insufficienza renale acuta da assunzione contemporanea di furosemide e bezafibrato.

A case of rhabdomyolysis with acute renal failure associated with bezafibrate and furosemide treatment is reported. The possible interaction between these drugs in determining myopathic toxicity is underlined.

Association of the Budd-Chiari syndrome with lupus anticoagulant. Case report and critical review.

The Budd-Chiari syndrome (BCS) was diagnosed in a 30-year-old male hospitalized with hepatomegaly, abdominal collateral vessels and hepatic veins and inferior vena cava thrombosis (IVC) in 1988. The presence of circulating lupus anticoagulant (LAC) was suspected and demonstrated on this occasion in view of an earlier diagnosis of systemic lupus erythematosus (SLE) and recurrent vein thrombosis dating from 1981. There are sporadic reports of an association of BCS with SLE and other autoimmune diseases. The recent literature also describes associations with hypercoagulability due to LAC. These are reviewed together with the personal case to provide the rationale for correct diagnosis and therapy.

[Regarding respiration and the so-called "animal heat." An historical sketch]. / En torno a la respiración y al llamado calor animal. Bosquejo histórico.

According to Aristotle and Galen, the essential function of the respiration phenomenon was to cool the blood. Towards the middle of the XVI Century, Miguel Servet suggested, in his treatise Christianismi restitutio..., that the inspired air could have other functions besides cooling the blood. Later, Joseph Black thought that respiration was a combustion. In the light of the advances in chemistry achieved in the XVII Century, the English scientist Adair Crawford and the French chemist Antoine-Laurent Lavoisier conceived, in the second half of that century, the first general and quantitative theories on the origin of animal heat. Both these authors had the conviction that the "inflammable element", which will be called oxygen, was not formed in the pulmonary territory, but could be absorbed by the blood. Oxygen, foreseen by Mayow at the end of XVII Century, was discovered by Joseph Priestley in 1774. Lavoisier gave the name of oxygen to this gas and firmly established that the respiration phenomenon consists essentially in a process of combustion. The mathematician Joseph-Louis Lagrange, native of Turin, suggested that animal heat originates in all breathing tissues. This phenomenon was verified and described in detail by the biologist Lazzaro Spallanzani, professor at the University of Pavia. Dissemination, in the scientific world, of the new chemical nomenclature and of the respiratory theory, closely related to it, was based fundamentally on the works "Méthode de nomenclature chimique..." (1787) and "Traité élémentaire de chimie..." (1789). During the XIX Century, studies on the phenomenon of animal respiration continued and fundamental discoveries in this subject were attained, such as conversion of hemoglobin to oxyhemoglobin once oxygen had been fixed. Now it is possible to study the regulating mechanisms of the energetic metabolism of the myocardium in vivo, which allows decisive interventions in certain cardiopathies, such as in acute ischemic cardiopathy.

[The centennial of the Einthoven electrocardiograph. Part I]. / El centenario del electrocardiógrafo de Einthoven. Parte I.

The initial studies about the "irritability" of animal tissues by iatrophysic or iatromechanic scientists are reviewed. These studies led to discover the so called animal electricity envisaged by Luigi Galvani in the XVIII century and demonstrated by Carlo Matteucci and his followers in the XIX. Beginning with the Galvani's "reoscopic" frog, which allowed to assess the electrical current in a qualitative sense, it was possible to arrive, at the beginnings of the XX century, to the string electrocardiograph developed by Willem Einthoven in 1901. This opened the way that led to fabrication of ever more sophisticated instruments until the present systems of endocardial mapping by magnetic technology or by multipolar catheters, which permit to quickly identify the site of origin or the spreading ways of a tachycardia for their ablation with radiofrequency. Intracardiac echocardiography is also employed to define the anatomy of right atrium, during intracardiac cartography, in order to establish the most adequate sites for ablation. On the other hand, a logic, i.e. rational, method for the interpretation of results from the electrical exploration of the heart has been developed. This one was introduced by Frank N. Wilson in Ann Arbor and has been fittingly applied by Demetrio Sodi Pallares in Mexico. Important diagnostic advances and notable therapeutic inferences have been derived from these latter developments.

[Rational electrovectorcardiography]. / En torno a la electrovectocardiografía racional.

The mental process of electrocardiographists to adjust the electrocardiogram's or vectorcardiogram's interpretation with the sequence of myocardial depolarization and repolarization can be accomplished in two ways. The first one is through vectorial analysis and the second concerns the analysis of unipolar morphologies. The most suitable is to follow both ways. The first procedure constitutes the classic method accepted since Einthoven's time and refers to the vectorial representation of the electrical charges of the heart. This representation approaches the electrical moment of a unique dipole, when cardiac exploration is performed at the smallest adequate distance. This allows to establish the spatial position of the instantaneous vectors, or of the mean vector, by using different leads. The study of unipolar morphologies permits to know the distribution of the mentioned charges in the conducting medium. The adjustment of the electrical charges depends on the location of the wave fronts. These charges produce potential variations in the physical sense--Gaussian type--at the epicardial surface and also at any point of the conducting medium surrounding the heart as far as the skin. This procedure requires the use of Poisson's integral, based on the principle of Helmholtz' electromotive surface. Thereafter, it is mandatory to perform another adjustment for the results of both procedures and to scrutinize the inner cellular metabolic process, which can explain the behavior of the observed electrical phenomena and suggest the adequate treatment.

[Usefulness of vector analysis of the electrocardiogram]. / Utilidad del análisis vectorial del electrocardiograma.

An electrocardiogram corresponding to an obese, hypertensive woman 52 years old, is presented. It shows a left bundle branch block of advanced degree and the AQRSF at 70 degrees. In this case, the key of the electrocardiographic diagnosis is that the second vector originated by depolarization of the lower left septal mass is oriented downward, which is unusual in the presence of left bundle branch block. This fact may be due to a marked clockwise rotation. Therefore, it is possible that right ventricle pathologic conditions be associated to those involving the left ventricle. Cardiopulmonary tests determined the existence of a chronic pulmonary emphysema. Furthermore the study of this case shows the usefulness of vectorcardiographic exploration in clinical practice.

[Tauro-ursodeoxycholic acid vs. ursodeoxycholic acid in the dissolution of biliary calculi. Results of a single blind study]. / Tauroursodesossicolico (TUDCA) vs UDCA nella dissoluzione dei calcoli della colecisti. Risultati di uno studio in singolo cieco.

Out of 34 patients enrolled and randomized, 31 completed the 6 months study period. Fifteen were treated with TUDCA, and 16 with UDCA. Dosage for both drugs was 10 mg/kg body weight daily. Superiprisingly, TUDCA was not found to be more active than UDCA in dissolving, totally or partially, the gallbladder stones; indeed, total dissolution was more frequent in the UDCA group. Since the two groups were similar as to number and size of the stones, the better results with UDCA cannot be attributed to the characteristics of the calculosis but must be ascribed to the molecule used. Both drugs induced an improvement in dyspeptic symptoms, but from this point of view, too, UCDA was more effective than TUDCA (p < 0.01). Finally, tolerability was also significantly better for UDCA, although TUDCA was altogether acceptable.

The rational approach to the electrical exploration of the heart.

A rational approach is inevitable in any scientific activity. Such an approach is opposed not only to irrationality, at all inadmissible in scientific thinking, but also to empiric reasoning. Many years ago, Sodi Pallares introduced the rational method in the electrical exploration of the heart based on experimental findings obtained in his laboratory. This method has progressively been accepted and used with good results for diagnoses and has led to logical therapeutic inferences. To confirm the results from the logical interpretation of electrical tracings, we present some examples of its application in three fields: arrhythmias, myocardial infarction, and left ventricular hypertrophy. In the studied cases--two with tachycardia, one with a posterior infarct, and two with left ventricular hypertrophy--a very satisfactory correlation has been observed between the electrical exploration findings and those obtained through direct examination of the heart. It is desirable, and even profitable, to analyze in this way the electrical tracings to get as close as possible to reality, rejecting the stereotyped aspects of a simple routine exploration, which often induce errors and lead to some fallacious asseverations.