Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry

Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the "Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry" (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68 % men; 64 ± 12 years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44 %) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child-Pugh score; hepatocellular carcinoma was present in 20 %. The prevalence of ultrasound-detected portal vein thrombosis was 17 % (n = 126); it was asymptomatic in 43 % of the cases. Notably, more than half of the portal vein thrombosis patients (n = 81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p < 0.001), Child-Pugh Class B + C (p < 0.001), hepatocellular carcinoma (p = 0.01), previous upper gastrointestinal bleeding (p = 0.030) and older age (p = 0.012) were independently associated with portal vein thrombosis. Portal vein thrombosis is a frequent complication of cirrhosis, particularly in patients with moderate-severe liver failure. The apparent undertreatment of patients with portal vein thrombosis is a matter of concern and debate, which should be addressed by planning interventional trials especially with newer oral anticoagulants. Clinicaltrials.gov identifier NCT01470547.

[Cardiovascular diseases and cancer incidence in general population: results from MATISS cohort]

OBJECTIVES

to assess the incidence of fatal and non-fatal major cardiovascular diseases and cancers in people with different cardiovascular risk profile of a longitudinal cohort.

DESIGN

longitudinal study carried out in a large sample of general population, with a median follow-up of 17.7 years.

SETTING AND PARTICIPANTS

MATISS longitudinal cohort, 7,491 men and women aged 20-75 years, free of cancer or cardiovascular diseases at baseline. Two cardiovascular risk groups (low-intermediate cardiovascular risk and high cardiovascular risk) and two educational levels (low level: primary school; middle/high level: middle/high school, university) have been considered.

MAIN OUTCOME MEASURES

for both cancer and cardiovascular events the standardized incidence rates have been calculated, taking into account the cardiovascular risk profile and the educational level.

RESULTS

people with a high-risk profile have higher incidence of major cardiovascular diseases and cancers. Furthermore, incidence rates are higher in people with lower educational level, except for cardiovascular diseases in men.

CONCLUSIONS

this study shows that, in the considered population, cancer incidence rates are higher than cardiovascular diseases rates; moreover, cancer incidence is higher in people with high-risk cardiovascular profile. The increase of prevalence of favourable risk profile in the general population could represent effective community strategies for prevention of cardiovascular diseases and cancer. Major attention should be dedicated towards people at lower socioeconomical level.

Risk of atrial fibrillation among bisphosphonate users: a multicenter, population-based, Italian study

Bisphosphonate treatment is used to prevent bone fractures. A controversial association of bisphosphonate use and risk of atrial fibrillation has been reported. In our study, current alendronate users were associated with a higher risk of atrial fibrillation as compared with those who had stopped bisphosphonate (BP) therapy for more than 1 year.

INTRODUCTION

Bisphosphonates are widely used to prevent bone fractures. Controversial findings regarding the association between bisphosphonate use and the risk of atrial fibrillation (AF) have been reported. The aim of this study was to evaluate the risk of AF in association with BP exposure.

METHODS

We performed a nested case-control study using the databases of drug-dispensing and hospital discharge diagnoses from five Italian regions. The data cover a period ranging from July 1, 2003 to December 31, 2006. The study population comprised new users of bisphosphonates aged 55 years and older. Patients were followed from the first BP prescription until an occurrence of an AF diagnosis (index date, i.e., ID), cancer, death, or the end of the study period, whichever came first. For the risk estimation, any AF case was matched by age and sex to up to 10 controls from the same source population. A conditional logistic regression was performed to obtain the odds ratio with 95% confidence intervals (CI). The BP exposure was classified into current (<90 days prior to ID), recent (91-180), past (181-364), and distant past (≥365) use, with the latter category being used as a reference point. A subgroup analysis by individual BP was then carried out.

RESULTS

In comparison with distant past users of BP, current users of BP showed an almost twofold increased risk of AF: odds ratio (OR) = 1.78 and 95% CI = 1.46-2.16. Specifically, alendronate users were mostly associated with AF as compared with distant past use of BP (OR, 1.97; 95% CI, 1.59-2.43).

CONCLUSION

In our nested case-control study, current users of BP are associated with a higher risk of atrial fibrillation as compared with those who had stopped BP treatment for more than 1 year.

Individualizing risk of multidrug-resistant pathogens in community-onset pneumonia

Introduction

The diffusion of multidrug-resistant (MDR) bacteria has created the need to identify risk factors for acquiring resistant pathogens in patients living in the community.

Objective

To analyze clinical features of patients with community-onset pneumonia due to MDR pathogens, to evaluate performance of existing scoring tools and to develop a bedside risk score for an early identification of these patients in the Emergency Department.

Patients and Methods

This was an open, observational, prospective study of consecutive patients with pneumonia, coming from the community, from January 2011 to January 2013. The new score was validated on an external cohort of 929 patients with pneumonia admitted in internal medicine departments participating at a multicenter prospective study in Spain.

Results

A total of 900 patients were included in the study. The final logistic regression model consisted of four variables: 1) one risk factor for HCAP, 2) bilateral pulmonary infiltration, 3) the presence of pleural effusion, and 4) the severity of respiratory impairment calculated by use of PaO2/FiO2 ratio. A new risk score, the ARUC score, was developed; compared to Aliberti, Shorr, and Shindo scores, this point score system has a good discrimination performance (AUC 0.76, 95% CI 0.71-0.82) and calibration (Hosmer-Lemeshow, χ2 = 7.64; p = 0.469). The new score outperformed HCAP definition in predicting etiology due to MDR organism. The performance of this bedside score was confirmed in the validation cohort (AUC 0.68, 95% CI 0.60-0.77).

Conclusion

Physicians working in ED should adopt simple risk scores, like ARUC score, to select the most appropriate antibiotic regimens. This individualized approach may help clinicians to identify those patients who need an empirical broad-spectrum antibiotic therapy.

User-only design to assess drug effectiveness in clinical practice: application to bisphosphonates and secondary prevention of fractures

PURPOSE

Different strategies applicable to control for confounding by indication in observational studies were compared in a large population-based study regarding the effect of bisphosphonates (BPs) for secondary prevention of fractures.

METHODS

The cohort was drawn from healthcare utilization databases of 13 Italian territorial units. Patients aged 55 years or more who were hospitalized for fracture during 2003-2005 entered into the cohort. A nested case-control design was used to compare BPs use in cohort members who did (cases) and who did not experience (controls) a new fracture until 2007 (outcome). Three designs were employed: conventional-matching (D1 ), propensity score-matching (D2 ), and user-only (D3 ) designs. They differed for (i) cohort composition, restricted to patients who received BPs straight after cohort entry (D3 ); (ii) using propensity score for case-control matching (D2 ); and (iii) compared groups of BPs users versus no users (D1 and D2 ) and long-term versus short-term users (D3 ).

RESULTS

Bisphosphonate users had odds ratios (95% confidence interval) of 1.20 (1.01 to 1.44) and 0.95 (0.74 to 1.24) by applying D1 and D2 designs, respectively. Statistical evidence that long-term BPs use protects the outcome onset with respect to short-term use was observed for user-only design (D3 ) being the corresponding odds ratio (95% confidence interval) 0.64 (0.44 to 0.93).

CONCLUSIONS

User-only design yielded closer results to those seen in RCTs. This approach is one possible strategy to account for confounding by indication.

Oral bisphosphonates do not increase the risk of severe upper gastrointestinal complications: a nested case-control study

Background

Data on the effect of oral bisphosphonates (BPs) on risk of upper gastrointestinal complications (UGIC) are conflicting. We conducted a large population-based study from a network of Italian healthcare utilization databases aimed to assess the UGIC risk associated with use of BPs in the setting of secondary prevention of osteoporotic fractures.

Methods

A nested case–control study was carried out within a cohort of 68,970 patients aged 45 years or older, who have been hospitalized for osteoporotic fracture from 2003 until 2005. Cases were the 804 patients who experienced hospitalization for UGIC until 2007. Up to 20 controls were randomly selected for each case. Conditional logistic regression model was used to estimate odds ratio (OR) associated with current and past use of BPs (i.e. for drug dispensation within 30 days and over 31 days prior the outcome onset, respectively) after adjusting for several covariates.

Results

Compared with patients who did not use BPs, current and past users had OR (and 95% confidence interval) of 0.86 (0.60 to 1.22) and 1.07 (0.80 to 1.44) respectively. There was no difference in the ORs estimated according with BPs type (alendronate or risedronate) and regimen (daily or weekly), nor with co-therapies and comorbidities.

Conclusions

Further evidence that BPs dispensed for secondary prevention of osteoporotic fractures are not associated with increased risk of severe gastrointestinal complications is supplied from this study. Further research is required to clarify the role BPs and other drugs of co-medication in inducing UGIC.

Risk of severe upper gastrointestinal complications among oral bisphosphonate users

BACKGROUND

Oral bisphosphonates (BPs) are the primary agents for the treatment of osteoporosis. Although BPs are generally well tolerated, serious gastrointestinal adverse events have been observed.

AIM

To assess the risk of severe upper gastrointestinal complications (UGIC) among BP users by means of a large study based on a network of Italian healthcare utilization databases.

METHODS

A nested case-control study was carried out by including 110,220 patients aged 45 years or older who, from 2003 until 2005, were treated with oral BPs. Cases were the 862 patients who experienced the outcome (hospitalization for UGIC) until 2007. Up to 20 controls were randomly selected for each case. Conditional logistic regression model was used to estimate odds ratio (OR) associated with current use of BPs after adjusting for several covariates. A set of sensitivity analyses was performed in order to account for sources of systematic uncertainty.

RESULTS

The adjusted OR for current use of BPs with respect to past use was 0.94 (95% CI 0.81 to 1.08). There was no evidence that this risk changed either with BP type and regimen, or concurrent use of other drugs or previous hospitalizations.

CONCLUSIONS

No evidence was found that current use of BPs increases the risk of severe upper gastrointestinal complications compared to past use.

Prevalence of chronic cerebrospinal venous insufficiency in multiple sclerosis: a blinded sonographic evaluation

Objectives:

To verify the prevalence of chronic cerebrospinal venous insufficiency in patients affected by different clinical forms of multiple sclerosis and in healthy subjects using the Zamboni ultrasound protocol combined with M-mode ultrasound examination.

Materials and methods:

We enrolled 112 patients with multiple sclerosis and 67 healthy subjects from 20 to 67 years of age. All the patients underwent Duplex and color-Doppler sonography of the neck vessels, transcranial colour duplex sonography, M-mode study of the valve system and of venous abnormalities. Subjects were positive for chronic cerebrospinal venous insufficiency when at least two of five hemodynamic criteria of the Zamboni protocol were fulfilled. Chronic cerebrospinal venous insufficiency condition was further analyzed by a multivariate analysis including age, sex, disease duration, subtypes of multiple sclerosis and expanded disability status scale score as independent variables.

Results:

No healthy subjects was positive for chronic cerebrospinal venous insufficiency, while in the sample of patients affected by multiple sclerosis the diagnosis was made in 59.8% of cases ( p < 0.0001). The first criterion was the most frequent in patients affected by multiple sclerosis and chronic cerebrospinal venous insufficiency (respectively 54.4% and 76.1%, p < 0.001). The second, third and fourth criteria were never present in healthy subjects but were detected in patients with multiple sclerosis. The positivity of the second criterion was associated with diagnosis of chronic cerebrospinal venous insufficiency in 100% of cases. The third criterion had a prevalence of 52.2% in the subgroup of chronic cerebrospinal venous insufficiency patients. It was positive in 36 multiple sclerosis patients and was associated with chronic cerebrospinal venous insufficiency diagnosis in all cases except one. The multivariate analysis showed that age, disease duration, sex, subtypes of multiple sclerosis and expanded disability status scale score were not considered predictors of this haemodynamic condition.

Conclusion:

Chronic cerebrospinal venous insufficiency is a haemodynamic condition strongly associated with multiple sclerosis and is not found in normal controls. The addition of M-mode ultrasound to the diagnostic protocol allows improved observation of venous valve abnormalities.

Allergic rhinitis as a possible risk factor for malocclusion: a case-control study in children

BACKGROUND

Prolonged oral respiration is known to cause postural alterations, which can lead to dental malocclusions. Allergic rhinitis, a common cause of upper airway obstruction in children, must therefore be seen as a possible risk factor in the development of malocclusions.

AIM

Aim of this study was to investigate the association between allergic rhinitis and malocclusions in primary and early-mixed dentition.

DESIGN

A case-control study was carried out involving 275 Italian children aged 5-9. The case group and the control group were composed of 125 individuals affected by malocclusions and by 150 healthy patients, respectively. Through a questionnaire, we assessed the presence of professionally diagnosed allergic rhinitis. Data were analysed to identify associations between these variables and the presence of malocclusions.

RESULTS

Children with a history of allergic rhinitis had a threefold increased risk to develop one or more dento-skeletal alterations [OR = 3.16; 95% CI (1.79-5.58), P < 0.001]. Statistically significant associations were found between allergic rhinitis and the development of posterior crossbite and increased overjet. No significant association was found for anterior openbite.

CONCLUSIONS

Allergic rhinitis is a significant risk factor for the development of malocclusions in general and is associated with the development of posterior crossbite and increased overjet.

Cholesterol-adjusted vitamin E serum levels are associated with cardiovascular events in patients with non-valvular atrial fibrillation

BACKGROUND

Non-valvular atrial fibrillation is associated with an increase in thromboembolism, i.e. stroke, and atherosclerotic events, i.e. myocardial infarction. Vitamin E possesses anti-coagulant as well as anti-atherosclerotic properties. Our aim was to assess whether vitamin E is associated with cardiovascular events in patients with non-valvular atrial fibrillation.

METHODS

Serum levels of cholesterol-adjusted vitamin E were measured in 1012 patients with non-valvular atrial fibrillation. Patients were followed for a mean time of 27.0 months, and cardiovascular events, such as cardiovascular death and fatal and nonfatal stroke or myocardial infarction, were recorded.

RESULTS

During the follow-up period, cardiovascular events occurred in 109 (11%) patients (18 fatal and 14 nonfatal myocardial infarction; 13 fatal and 19 nonfatal ischemic strokes; 45 cardiovascular deaths). Lower vitamin E serum levels were found in patients who experienced cardiovascular events compared to those who did not (3.8±1.2 vs. 4.4±1.8 μmol/mmol cholesterol; p<0.001). Using a Cox proportional hazard model, age, diabetes, history of stroke and myocardial infarction and vitamin E serum levels (HR 0.77; 95% CI: 0.67-0.89; p=0.001) independently predicted cardiovascular events. Patients with vitamin E<4.2 μmol/mmol cholesterol (median values) had an increased risk of cardiovascular events (HR 1.87; 95% CI: 1.25-2.80: p=0.002).

CONCLUSIONS

Low vitamin E serum levels are associated with an increased risk of cardiovascular events in patients with non-valvular atrial fibrillation.

Prevalence of adenoma of gallbladder, ultrasonographic and histological assessment in a retrospective series of 450 cholecystectomy

BACKGROUND

Adenomyomas of the gallbladder are difficult to examine during standard ultrasound examination of the abdomen. They sometimes undergo malignant transformation and their optimal management still remains a problem. The authors have aimed to investigate the ultrasonographic and histopathological prevalence of gallbladder adenomyomas focusing on the diagnostic performance of ultrasound examination.

MATERIALS AND METHODS

A retrospective series of 450 consecutive patients who underwent cholecystectomy is reported. Data regarding characteristics of the patients, US and histology examination of the gallbladder were collected. Sensitivity, specificity, positive and negative predictive values of ultrasound scan were calculated with respect to histological examination of the gallbladder.

RESULTS

The study group consisted of 261 female and 189 male. Ultrasound scan detected adenomyomas in 22 patients, confirmed by histopathology in 13 and found to be not present in 9. Incidental adenomyomas were found in 16 patients of 428 who underwent cholecystectomy for gallstones. Prevalence was 4.9% and 6.4% for ultrasound scan and histopathology respectively. Ultrasound scan showed sensitivity of 43.3% (c.i.:25.4%-62.5%), specificity of 97.8% (c.i.:95.9%-99%) with a positive predictive value of 59% (c.i.:36.3%-79.2%) and with a negative predictive value of 96.2% (c.i.:93.7%- 97.6%). On histopathology, adenomyomas localized in the fundus were predominant. Two female patients with adenomyomas of the fundus (diameter 5 mm) and single stone showed intestinal metaplasia with high-grade dysplasia.

CONCLUSIONS

The diagnosis of gallbladder adenomyomas by ultrasound scan still remains a problem because of its low sensitivity, which is mainly due to the association with gallstones. Histopathological findings in the perilesional mucosa confirm the hypothesis of a metaplasia-dysplasia-carcinoma sequence already shown in the colon-rectum. At present, the selection of patients requiring cholecystectomy is still controversial.

Assessing the risk of osteonecrosis of the jaw due to bisphosphonate therapy in the secondary prevention of osteoporotic fractures

SUMMARY

There is evidence that the use oral bisphosphonates can lead to osteronecrosis of the jaws (ONJ). Although the occurrence of ONJ appears rare among oral bisphosphonates (BPs) users, it is important to know that it exists and can be opportunely minimized.

INTRODUCTION

The purpose of this study is to evaluate the association between BPs prescribed for the secondary prevention of osteoporotic fractures and the occurrence of ONJ.

METHODS

An Italian record linkage claims database with a target population of around 18 million individuals (6 million over 55 years of age) constituted the data source. We conducted a nested case-control study within a cohort of individuals aged 55+ years old, who were discharged from hospitals with a primary diagnosis of incident osteoporotic fracture. The date related to the discharge diagnosis of ONJ was the index date. Conditional logistic regression for matched data was fitted to estimate the odds ratio (OR) along with 95 % confidence intervals (95 % CI) for the likely association between use of BPs and the risk of ONJ.

RESULTS

Any one of the 61 ascertained cases of ONJ (incidence rate, 36.6 per 100,000 person-years) was matched to 20 controls for a total of 1120 controls. When the exposure to BPs was modeled according to recency (i.e., exposure time window prior to the index date) of use, the adjusted OR (95 % CI) for current users was 2.8 (1.3-5.9) against never users. The cumulative use of BPs has shown to increase the incidence of ONJ among patients with primary osteoporotic fractures, although not statistically significant risk has been observed.

CONCLUSIONS

Although the risk of BP-related ONJ appears low in non-oncological indications, it is important to be aware that it exists and to know how it may be predicted and possibly minimized.

Recurrent gallstone ileus: case report and literature review

The gallstone ileus is a rare complication of cholelithiasis and it represents the 1-4% of small intestinal mechanical obstruction. Gallstone is generally wedged in the terminal ileum, even if unusual locations have been described. The literature reports a very high morbidity and mortality, often because misdiagnosis or delayed diagnosis. There is no unique opinion in literature about the choice between one-stage and two-stage surgery. We report a clinical case that summarizes the diagnostic and therapeutic difficulties of gallstone ileus.

SPR detection of human hepcidin-25: a critical approach by immuno- and biomimetic-based biosensing

The human hepcidin-25 hormone has a key role in iron regulation in blood. The clinical relevance of this hepatic ~2.8 kDa cysteine-rich peptide is rapidly increasing, since altered levels can be associated with inflammatory events and iron dysfunctions, such as hereditary hemochromatosis and iron overload. Moreover, hepcidin has also attracted the anti-doping field for its possible role as indirect marker of erythropoietin blood doping. Methods currently reported are based on immunoassays (ELISA and RIA), or various types of mass spectroscopy (MS)-based protocols, semi-quantitative or quantitative. Despite the great effort in optimizing robust and simple assays measuring hepcidin in real matrices, at present this challenge remains still an open issue. To explore the possibility to face hepcidin detection through the development of affinity-based biosensors, we set up a comparative study by surface plasmon resonance (SPR) technology. An immuno-based, on anti-hepcidin-25 IgG, and a biomimetic-based, on a synthetic peptide corresponding to the hepcidin-binding site on ferroportin (HBD), biosensors were developed. Here we report behaviors and analytical performances of the two systems, discussing limits and potentialities.

Bariatric surgery: cost-effectiveness and budget impact

Bariatric surgery is to date the most effective treatment for morbid obesity and it has been proven to reduce obesity-related comorbidities and total mortality. As any medical treatment, bariatric surgery is costly and doubts about its affordability have been raised. On the other hand, bariatric surgery may reduce the direct and indirect costs of obesity and related comorbidities. The appreciation of the final balance between financial investments and savings is critical from a health economic perspective. In this paper, we try to provide a brief updated review of the most recent studies on the cost-efficacy of bariatric surgery, with particular emphasis on budget analysis. A brief overview of the economic costs of obesity will also be provided. The epidemic of obesity may cause a significant reduction in life expectancy and overwhelming direct and indirect costs for citizens and societies. Cost-efficacy analyses included in this review consistently demonstrated that the additional years of lives gained through bariatric surgery may be obtained at a reasonable and affordable cost. In groups of patients with very high obesity-related health costs, like patients with type 2 diabetes, the use of bariatric surgery required an initial economic investment, but may save money in a relatively short period of time.

Anatomical variations of the proximal radius and their effects on osteosynthesis

PURPOSE

In fractures of the radial head and neck requiring open reduction and internal fixation, osteosynthesis may be safely applied in a limited zone. We conducted a morphometric study of the proximal radius at the level of the safe zone to identify different morphologic types of this anatomical region.

METHODS

We analyzed 44 dried cadaveric radii. We measured the whole length of the radius, the length of the neck and head, and the minimum and maximum diameter of the radial head. The morphologic aspect of the neck-head curvature of the safe zone was evaluated qualitatively and quantitatively.

RESULTS

The proximal radius at the level of the safe zone exhibited different radii of bending. In particular, we identified a morphologic type A, which showed a flat profile (25% of cases), morphologic types B and C, which showed a low concave curvature (64%), and a marked concave curvature (11%), respectively, of the safe zone.

CONCLUSIONS

The profile of the proximal radius in the safe zone shows substantial morphologic variations that should be taken into account when operating on fractures of the proximal radius, to avoid malunions, pain, and stiffness of the elbow joint. A preoperative radiograph of the contralateral uninjured radius may be helpful in selecting the most appropriate internal fixation device to reconstruct the proximal radius after comminuted fractures.

CLINICAL RELEVANCE

Knowledge of the proper bending radius of the safe zone allows the surgeon to select the most appropriate plate, and to achieve good fracture reduction and anatomical restoration of the proximal radius.

The relationship between acromion thickness and body habitus: practical implications in subacromial decompression procedures

To define the bone's amount that should be removed during an acromioplasty has always been a challenge. We aimed to verify the correlations between scapular dimensions and acromial thickness, assess the differences between the two genders, investigate the relationship between acromial type and thickness. We examined 500 dried scapulae, measuring the major axis of the scapular body and the acromial thickness; these were also catalogued according to gender. Acromial shape was classified according to Bigliani's method. Frequencies: Type I 38.9 %, Type II 39.4 %, Type III 21.7 %. The mean acromial thickness was 0.85 cm, and it resulted wider in men. There was a direct linear relationship between scapular dimensions and acromial thickness. The range of thickness of Type III acromion was significantly different from the others. We should be aware that gender, scapular dimensions and acromial shape should be evaluated preoperatively since they influence the acromial thickness.

Mammographic features in infertile women as a potential risk for breast cancer: a preliminary study

The purpose of the present study was to evaluate breast mammographic features, particularly mammographic density in a selected population of infertile women and to assess if these women should be considered at higher risk for breast cancer. The prevalence of female infertility in Western countries is approximately 10-15% and since causes affecting the female are involved in 35-40%, concerns have developed about the future health of these women, specifically whether infertility could represent a risk factor for future cancer development. Moreover, infertility is now often treated with medication and procedures that could modify the hormonal environment and be cofactors in the cellular changes towards cancer development. Mammographic breast density is a useful marker for breast cancer risk and breast density is considered one of the strongest risk factors for breast cancer. Breast density is associated with known breast cancer risk factors such as reproductive and menstrual factors including serum estrogen and progesterone concentrations. In Italy the National Federation for Breast Cancer (FONCAM) guidelines suggest the usefulness of mammography from 35 years of age for women who undergo infertility hormone therapy (FONCAM Guidelines, 2005). According to this recommendation 294 women aged > or = 35, with primary infertility, sent to our breast service before joining an IVF program were recruited and then underwent clinical examination and X-ray mammography. Women were divided into two groups: dense breast (DB) and non-dense breast (NDB). Univariate analysis was employed to evaluate if there was an association between mammographic density and other risk factors. Evaluation of mammographic features showed the presence of BI-RADs C and D in the sample of 200 (68%) patients with DB and in 94 (32%) patients with NDB BI-RADS A and B. Univariate analysis showed that there were no statistically significant differences between the groups BD and NDB as regards age at mammography, age at menarche, BMI and family history for breast cancer, while ovulatory etiology of infertility was found to be associated with high mammographic density (p < 0.05). In conclusion, bearing in mind that 68% of our study sample had high breast density, we can assume that patients with primary infertility might represent a group at high risk for breast cancer, particularly if infertility is due to an ovulatory factor. We suggest breast screening from the age of 35 in infertile patients who undergo treatment with fertility drugs in accordance with FONCAM recommendations. This might allow the identification of higher risk patients who need more closely monitored breast examinations.

Analysis of sputum markers in the evaluation of lung inflammation and functional impairment in symptomatic smokers and COPD patients

The pivotal role of neutrophils and macrophages in smoking-related lung inflammation and COPD development is well-established.

We aimed to assess whether sputum concentrations of Human Neutrophil Peptides (HNP), Neutrophil Elastase (NE), Interleukin-8 (IL-8), and Metalloproteinase-9 (MMP-9), major products of neutrophils and macrophages, could be used to trace airway inflammation and progression towards pulmonary functional impairment characteristic of COPD.

Forty-two symptomatic smokers and 42 COPD patients underwent pulmonary function tests; sputum samples were collected at enrolment, and 6 months after smoking cessation.

HNP, NE, IL-8, MMP-9 levels were increased in individuals with COPD (p < 0.0001). HNP and NE concentrations were higher in patients with severe airways obstruction, as compared to patients with mild-to-moderate COPD (p = 0.002). A negative correlation was observed between FEV₁ and HNP, NE and IL-8 levels (p < 0.01), between FVC₁/FVC and HNP, NE and IL-8 levels (p < 0.01), and between NE enrolment levels and FEV₁ decline after 2 years (p = 0.04).

ROC analysis, to discriminate symptomatic smokers and COPD patients, showed the following AUCs: for HNP 0.92; for NE 0.81; for IL-8 0.89; for MMP-9 0.81; for HNP, IL-8 and MMP-9 considered together 0.981.

The data suggest that the measurement of sputum markers may have an important role in clinical practice for monitoring COPD.

Early childhood caries underweight or overweight, that is the question

AIM

The purpose of this retrospective case study is to describe the body mass index in a group of children, from 3 to 6 years old with ECC and a similar group of caries-free children.

MATERIALS AND METHODS

This case-control analysis involves two groups of children: the first was of 244 healthy children, 3 to 6 year-old and caries-free; the second was of 586 otherwise healthy children, same age, with Early Childhood Caries divided into three subgroups according the AAPD definition. Demographics, dmft, number teeth with pulpal involvement, BMI percentile, weight at birth, weight and height of both parents were measured during the clinical evaluation. Statistical analyses were performed using standard statistical software (SPSS Version 13). BMI distribution of the subjects with caries was graphically compared with the use of confidence intervals to a similar caries-free sample.

RESULTS

Results are expressed as mean ± SD and frequencies (percentages), depending on the data type. The distribution of BMI percentiles of the ECC group was: underweight = 10%; normal weight = 55.90%; at risk of overweight = 22.22 %; overweight = 11.11%. Significantly, more children in the case group were underweight than in the control group (10% vs. 4.94%).

CONCLUSION

The ECC population does not have a typical weight distribution, and the underweight finding in a significant number of Severe ECC (S-ECC) children may be due to the chewing alteration related to the dental pain due to caries and to missing teeth after hard tissues breakdown.

The safe zone for avoiding suprascapular nerve injury during shoulder arthroscopy: an anatomical study on 500 dry scapulae

HYPOTHESIS/BACKGROUND

Suprascapular nerve injury may be a complication during shoulder arthroscopy. Our aim was to verify the reliability of the existing data, assess the differences between scapulae in the 2 genders and in the same subject, obtain a safe zone useful to avoid iatrogenic nerve lesions, and analyze the existing correlations between the scapular dimensions and the safe zone.

METHODS

We examined 500 dried scapulae, measuring 6 distances for each one, referring to the scapular body, glenoid, and the course of the suprascapular nerve, also catalogued according to gender and side. Differences due to gender were assessed comparing mean ± sd of each distance in males and females; paired t test was used to compare distances deriving from each couple. Successively, we calculated our safe zone and Pearson's correlation.

RESULTS

We found nonsignificant differences between the right and left distances deriving from each couple; differences due to gender were stated. We defined 3 kinds of safe zones referring to: 500 scapulae; males (139 scapulae) and females (147 scapulae). The correlation indexes calculated between the axis of the scapular body and glenoid, and the posterosuperior distance (referring to the suprascapular nerve) were 0.624, 0.694, 0.675, 0.638; while those with the posterior distance were 0.230, 0.294, 0.232, 0.284.

DISCUSSION/CONCLUSIONS

Knowledge of the safe zone, for avoiding suprascapular nerve injury, is important; gender and specific scapular dimensions should be evaluated, as they influence the dimensions of the safe zone. The linear predictors should be used to obtain specific values of the posterosuperior limit in each patient.

The applicability of the Mayo Clinic congruent radial head plate: cadaveric study

In the last few years, several anatomical plates have been introduced to improve the results of ORIF in Mason Type II and III radial head fractures. However, no study analyzed whether currently used plates match adequately the profile of the proximal radius in the "safe zone". In the present investigation, we evaluate the congruence between the proximal radius and a currently used plate. Forty-four radial dried cadaveric bones were analyzed. The plate congruence was evaluated qualitatively and quantitatively. The congruence of the tested plate with the proximal radius was good in 27.3% of specimens, while it was moderate or poor in the remaining 43.2% and 29.5% of cases, respectively. The profile of the proximal radius in the "safe zone" shows substantial morphologic variations which should be taken into account to avoid a malunion of the proximal radius. A preoperative radiograph of the contralateral uninjured radius may be helpful in order to select the most appropriate plate profile in comminuted radial head and neck fractures.

Minilaparotomic myomectomy for large symptomatic uterine myomas: a prospective study

AIM

The aim of this paper was to evaluate the feasibility, morbidity, and reproductive performance of fertile women undergoing minilaparotomic myomectomy for large uterine myomas.

METHODS

Ninety-nine consecutive women with symptomatic myomas underwent myomectomy through a skin incision ≤8 cm. Operative, postoperative and reproductive data were prospectively collected.

RESULTS

Median (range) age and Body Mass Index (BMI) were 37 years (23-44) and 23 (18-43), respectively. Median (range) myoma diameter was 7 cm (4-20), and the median number of myomas removed was 1 (range 1-31). Myomas were intramural in 76 (76%) cases. Median incision length was 7 cm (range 4-13) and median duration of surgery was 70 min (range 40-180). Operative time and length of skin incision were not correlated with the progressive number of interventions. An incision larger than 8 cm was necessary in 7 (7%) patients and the length of incision was significantly correlated with the diameter of the largest myoma (P<0.01). The feasibility of minilaparotomy was significantly reduced when the diameter of the largest myoma was >12 cm (P<0.05). Operative time was significantly longer in patients having >1 myoma (P<0.05). Three (3%) patients underwent blood transfusion. Median (range) postoperative stay was 2 days (range 2-12). Fever occurred in 8 (8%) patients, and wound complications in 5 (5%).

CONCLUSION

Myomectomy by minilaparotomy is a feasible procedure in more than 90% of unselected patients with large symptomatic myomas. Feasibility is questionable when the myoma is >12 cm. This technique is a mini-invasive option to treat patients with large and multiple myomas.

[Oral health and pregnancy: promotion of oral health during the pre-natal training in the Latina province]

The aim of this study, conducted in the Province of Latina, was to verify knowledge, attitudes, and lifestyles in relation to oral health in a sample of pregnant women, assessing their subjective perception of oral health, and highlight prenatal dental prevention need specialist in the area and provide adequate information on the importance of good oral hygiene in order to achieve a better health level both of the mother and the child. The study was conducted on a sample of pregnant women between the 26th and 39th gestational week, in the period from June to October 2009, during the childbirth training courses in the Province of Latina. Each patient was administered a questionnaire for the assessment of oral habits during pregnancy and for the definition of specific knowledge on and perception of themselves and their own oral condition. The survey shows that more than one third of the sample reported visiting a dentist only in case of pain, over half (56.9%) did not undergo any dental visit during the gestational period, only 24 subjects (33.3%) having applied to a dental hygienist for professional oral hygiene and that only 7 out of 72 women had been prescribed a dental checkup by a gynecologist. The study showed that knowledge about dental problems that may arise during pregnancy is insufficient to guarantee a good threshold to oral health care for the mother hence the need to promote information programs, oral health and pregnancy prevention and training in the territory mainly directed to health-care specialists (gynecologists and obstetricians) and to pregnant women.

Experience of dental caries and its effects on early dental occlusion: a descriptive study

AIM

Describe the occurrence of dental caries in a sample of pre-school children and school children, aged 3 and 12, and study the possible association between caries and malocclusion.

METHODS

We selected and analyzed the medical records of a sample of 588 patients who had their first dental examination at the Pediatric Dentistry Unit, Department of Oral and Maxillofacial Sciences of Policlinico Umberto I, "Sapienza" University of Rome.

RESULTS

In the sample, 55.4% of the children had no decayed deciduous elements, while 44.6% had at least one decayed deciduous element. The prevalence of decayed permanent teeth was 10.2%, while 89.8% had no decayed permanent teeth. In the sample, 9.4% of the children showed advanced carious lesions, that needed tooth extraction and 6.6% needed a space maintainer for post-extractive interceptive treatment. In the sample, 26.7% of the examined patients had increased overjet, while 3.7% had decreased overjet and 25.4% of the sample had an increased overbite, 11, 2% had reduced over-bite values. A percentage over 10% of the sample had an anterior openbite in centric occlusion. The prevalence of posterior crossbite among entire samples was 19.8%.

CONCLUSIONS

Although the incidence of caries disease was high in the selected samples, the study did not show a statistically significant association between caries and clinical orthodontic abnormalities, except for the association between the midline deviation and the severe carious diseases, necessitating extraction.

[Factors associated with ileal-pouch related fistulas in 100 consecutives patients who underwent restorative proctocolectomy]

OBJECTIVE

The pouch-related fistulas range in literature from 2% to 16% and they can be cause of failure of the intervention of restorative proctocolectomy. Aim of this study was to examine factors associated with theirs development and to identify theirs possible etiology and pathogenesis.

MATERIALS AND METHODS

Retrospective study focusing on 100 consecutive patients who underwent restorative proctocolectomy with pouch-anal anastomosis (IPAA). Patients with fistula and patients without fistula have been identified and the fistula type, the time from surgery and the site relative to IPAA have been recorded. Patients' demographics, co-morbidity or related medical history, clinical indication for treatment, surgical method, histological diagnosis, length of follow-up, early and late postoperative complications have been reviewed, and data collected have been compared among the two groups through univariate analysis.

RESULTS

The overall incidence of fistulas was of 10% (10 cases); 8 cases had pouch-vaginal fistulas, involving the distal tract of the vagina, and associated with pouch-perineal fistulas in 2 cases; 1 case had pouch-vulval fistula; 1 case had a complex pouch-perineal fistula. Three fistulas were precocious, all associated with an IPAA leak; 2 of these cases also had pelvic sepsis while the third had delayed diagnosis of Crohn’s disease. Seven fistulas had a late development. Four fistulas occurred at the level of the IPAA; 5 fistulas were located below the IPAA, and 1 fistula originated above and below the IPAA. When the two groups of patients were compared we found that there was an higher percentage of perineal or anal disease (40.0% vs 2.2%; p <0.001), of extraintestinal manifestations of inflammatory bowel disease (IBD) (40.0% vs 3.3%, p <0.001), and of leak of the IPAA (40.0% vs 11.1%; p <0.05) in the group with fistula vs the group without fistula.

CONCLUSIONS

A direct link with the leak of the IPAA appears in all the early fistulas, while the cryptoglandular infection was suggested as a possible cause of the late fistulas located below the IPAA; the association with the extraintestinal manifestations of IBD could show a correlation between the fistulas and an higher specific activity of the underlying chronic inflammatory disease.

Role of Kabat physical rehabilitation in Bell's palsy: a randomized trial

CONCLUSION

When applied at an early stage, Kabat's rehabilitation was shown to provide a better and faster recovery rate in comparison with non-rehabilitated patients.

OBJECTIVE

To assess the validity of an early rehabilitative approach to Bell's palsy patients.

PATIENTS AND METHODS

A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35-42 years) affected by Bell's palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The evaluation was carried out by measuring the amplitude of the compound motor action potential (CMAP), as well as by observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy.

RESULTS

Patients belonging to the rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after onset of facial palsy, without presenting greater values of CMAP.

Functional rs20417 SNP (-765G>C) of cyclooxygenase-2 gene does not predict the risk of recurrence of ischemic events in coronary patients: results of a 7-year prospective study

OBJECTIVES

The -765G>C variation (rs20417 SNP) in the promoter of cyclooxygenase-2 (COX-2) gene has been demonstrated to lower COX-2 enzyme activity in the vasculature, thus affecting atherosclerotic plaque growth and stability. Therefore, this genetic variant may be a candidate influencing the residual risk.

METHODS

In 285 coronary patients the incidence of major adverse cardiovascular events (MACEs), defined as a composite of cardiovascular deaths, non-fatal myocardial infarction and stroke, unstable angina and revascularization procedures, was monitored for a median of 7.8 years. The genotypes were obtained in 231 patients (81%) by PCR amplification and FAU I digestion.

RESULTS

89 MACEs (38.5%) were recorded during the follow-up in genotyped patients. Their incidence was not different in patients with GC or CC when compared with those with GG genotype (46.2 vs. 35.5% respectively; p = 0.14). Kaplan-Meyer analysis did not demonstrate any influence of COX-2 genotypes on the event-free survival time (log-rank p = 0.55). After controlling for confounders, the -765G>C carrier status was not associated with significant variation in the risk of MACE or its individual components.

CONCLUSIONS

These results suggest that the functional G-765C variant in the COX-2 gene is not a significant predictor of the recurrence of ischemic events in coronary patients.

Effectiveness of plaque indicators and air polishing for the sealing of pits and fissures

AIM

Sealing of pits and fissures is one of the most effective techniques in caries prevention: however incomplete removal of plaque debris, can cause lack of retention of the sealant.

MATERIALS AND METHODS

Sixty first permanent molars were sealed for this study. The teeth were divided into four groups. All teeth were isolated with a dental dam before cleaning and coronal polishing was performed with synthetic bristles or air polishing. Disclosing solution was used to reveal plaque. Three different operators performed cleanings and sealing.

RESULTS

The results show that the plaque indicator was necessary to ensure complete cleansing of pit and fissures. PROPHYflex3 was the easiest and most effective device for removing plaque and debris. Synthetic bristles failed to thoroughly cleanse the surface in most attempts.

CONCLUSION

Results suggest that pits and fissures should be cleaned with a plaque indicator and air polishers before placing a sealing material to ensure complete removal of plaque from the tooth.

Preoperative T and N staging of gastric cancer: magnetic resonance imaging (MRI) versus multi detector computed tomography (MDCT)

BACKGROUND AND AIM

Multi Detector Computed Tomography (MDCT) is widely used in the preoperative staging of gastric cancer. MRI has an emerging role in the evaluation of intestinal diseases, although its role in the staging of gastric cancers is still to be defined. The aim of our study was to compare the diagnostic accuracy of MDCT and Magnetic Resonance Imaging (MRI) in the diagnosis and preoperative staging of gastric cancer, in comparison with histopathology.

MATERIALS AND METHODS

Twenty-five patients with an endoscopic diagnosis of gastric cancer underwent preoperative contrast-enhanced MDCT and MRI, blind to the results of endoscopy. MDCT (64 slices) was performed after oral administration of 800-1000 mL of tap water and scopolamine injection five minutes before the examination. The scan was performed in the axial plane before and after intravenous injection of iodinate contrast medium. Multiplanar reconstruction images were obtained on coronal and sagittal planes. MRI was performed with a 1.5 T Magnet, using the same patient's preparation, by acquiring T2-weighted HASTE sequences, with or without fat saturation (FS), True FISP (True fast imaging with steady state precession) and T1-weighted VIBE (Volumetric interpolated breath-hold examination) sequences, with and without FS, before and after contrast agent (gadolinium) i.v. injection. Gold standards (GS) were surgical and histopathological findings. Two groups of radiologists, blind each other, analyzed MRI images and MDCT findings, and related to GS results.

RESULTS

Detection rate of gastric lesions and T staging for gastric cancer were similar for MRI and MDCT (92%); MRI imaging was superior than MDCT in staging the T parameter (60% versus 48%); the accuracy of MRI imaging and 64-MDCT did not differ significantly in the evaluation of N staging (68% versus 72%).

CONCLUSIONS

Both MRI and MDCT were comparable in staging gastric cancer. MRI was more accurate in evaluation of T stage than MDCT, although both imaging modalities showed low accuracy in detection of early gastric cancer and in differentiation of T2 from T3 stage.

Prospective study comparing multi-detector row CT and endoscopy in acute gastrointestinal bleeding

BACKGROUND

Upper and lower acute gastrointestinal bleeding (AGIB) is associated with high rates of mortality and morbidity. The latest computerized tomography (CT) imaging techniques play an important role in the treatment of this pathology.

METHODS

Twenty-nine patients with severe AGIB (11 upper, 18 lower), all hemodynamically stable, underwent endoscopy followed by a multi-detector row CT (MDCT) scan. Endoscopic and MDCT accuracy for the anatomical localization and etiology of AGIB was assessed, the diagnosis being considered correct when the two procedures were concordant or when the diagnosis was confirmed by angiographic, surgical, or post-mortem findings.

RESULTS

The sensitivity in identifying the site and etiology of bleeding was, respectively, 100% and 90.9% for the MDCT scan, compared with 72.7% and 54.5% for endoscopy in upper AGIB, and 100% and 88.2% for the MDCT scan, compared with 52.9% and 52.9% for endoscopy, in lower AGIB.

CONCLUSIONS

Considering the advantages of MDCT over endoscopy, we propose a new diagnostic algorithm for AGIB.

Subclinical vascular alterations in young adults with type 1 diabetes detected by arterial tonometry

BACKGROUND

Diabetes mellitus is characterized by a very high prevalence of atherosclerotic disease. Aims of this study were to determine arterial compliance parameters in type 1 diabetes (T1D) patients as an expression of early pre-clinical endothelial dysfunction and to evaluate the impact of glucose exposure parameters such as the duration of diabetes and glycosylated haemoglobin (HbA(1c)) on the risk of developing alterations in vascular compliance.

METHODS

23 patients with uncomplicated type 1 diabetes (mean age: 32.78 +/- 9.06 years, mean disease duration: 10.78 +/- 7.51 years, mean HbA(1c) levels: 7.7 +/- 1.9) and 26 age- and sex-matched healthy subjects (mean age: 32.3 +/- 8.51 years) were recruited. In these subjects, we evaluated arterial compliance by calibrated tonometry (HDI/Pulsewave() CR-2000). Parameters included the following: large artery elasticity (C1), small artery elasticity (C2), systemic vascular resistance (SVR) and total vascular impedance (TVI).

RESULTS

Patients with longer duration of T1D (>10 years) showed significant alterations in C2 (4.97 +/- 2.7 mL/mmHg x 100) and in SVR (1464.67 +/- 169.16 dina x s x cm(-5)) when compared with both healthy individuals (C2: 8.28 +/- 2.67 mL/mmHg x 100, p = 0.001; SVR: 1180.58 +/- 151.55 dina x s x cm(-5), p = 0.01) and patients with recent-onset disease (<or=10 years) (C2: 10.02 +/- 3.6 mL/mmHg x 100, p < 0.001; SVR: 1124.18 +/- 178.5 dina x s x cm(-5), p < 0.000). Both disease duration and HbA(1c) independently predicted impaired arterial compliance.

CONCLUSIONS

Young adult T1D patients with no signs of disease complication have detectable vessel wall abnormalities, particularly of small arteries, suggestive of hyperglycaemia-related early endothelial dysfunction.

Evaluation of customer satisfaction at the Department of Paediatric Dentistry of "Sapienza" University of Rome

AIM

Healthcare facility management requires the optimisation of the quality of services offered.

METHODS

The Authors adopted a questionnaire as a means to assess customer satisfaction and needs. The Questionnaire has been designed to address adults, i.e., parents or guardians of children attending the Paediatric unit as patients. To estimate their degree of satisfaction, either regarding the environment where children are treated or about the direct interactions between the parents and the structure (waiting room, waiting time, treatment time and time needed to make the payments, costs, etc.), the questionnaire was submitted to a sample of approximately 600 customers, between March and June of 2005.

RESULTS

On one hand results provide a pleasant confirmation on customers' perception of the service, especially regarding the direct relationship between the parties; on the other, they highlight aspects that could be improved (waiting room, optimisation of waiting time), distinguishing between factors that need extra funding to be implemented, and those that, instead, could be simply improved through a better and more efficient organisation of labour and time.

CONCLUSION

The present analysis and previous experiences confirm that appraisal of the degree of customers' satisfaction by means of questionnaires is a valid and necessary instrument for the quality improvement of a healthcare service. Doing so, economic and human resources can be more efficiently allocated.

[Treatment of mild malnutrition and reduction of morbidity in major abdominal surgery: randomized trial on 153 patients]

OBJECTIVES

Severe malnutrition (defined as weight loss more than 10% in a period of six months) is considered an important risk factor in major abdominal surgery, because of a higher post-operative mortality and morbidity. The aim of our study is to assess the role of mild malnutrition (weight loss low than 10% in a period of six months) as a risk factor in major abdominal surgery and to evaluate the efficacy of therapy in order to improve outcomes in terms of in-hospital mortality, length of hospital stay and post-operative complications. Moreover, we evaluated serum albuminemia and lymphocyte count, important nutritional index, as predictive risk factors.

MATERIALS AND METHODS

We performed a randomized prospective trial, and admitted in our institution 153 adult patients, 43 with mild malnutrition and 110 without. The malnourished patients were randomized in two groups: the first one received oral immunonutrition (Impact Oral) for 7-10 days before surgery (22 pz), the second one received no nutritional support.

RESULTS

We observed a higher number of complications in the non-treated malnourished patients (57%) versus both the treated malnourished patients (13.6%) and the normal group (19%) (p<0.001). Increased morbidity was observed in patients with serum albuminemia <2.8 gr/dl (69.2%) and with lymphocyte count <1.500 mm3 (57%).

CONCLUSIONS

Nutritional enriched support demonstrated his efficacy in reducing morbidity, and length of hospital stay. Pre-operative oral immunonutrition might be suggested and established in all the patients with mild malnutrition that will be operated on major abdominal surgery.

Usefulness of atherogenic dyslipidemia for predicting cardiovascular risk in patients with angiographically defined coronary artery disease

The identification of factors contributing to residual cardiovascular risk is important to improve the management of patients with established coronary artery disease (CAD). This study was conducted to assess the predictive value of atherogenic dyslipidemia (defined as high triglycerides and low high-density lipoprotein [HDL] cholesterol) for long-term outcomes in patients with CAD. In 284 patients (238 men, 46 women; mean age at baseline 59.2 +/- 8.9 years) with coronary stenosis (>50% in > or =1 vessel), the presence of atherogenic dyslipidemia was prospectively associated with the incidence of major adverse cardiovascular events (MACEs) during a median follow-up of 7.8 years. MACEs were defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, the recurrence of angina, and revascularization procedures. MACEs were observed in 111 (39.1%) patients with CAD. MACEs occurred more frequently in patients with atherogenic dyslipidemia (50.9%) than in those with isolated low HDL cholesterol or high triglycerides (33.0%) or with normal HDL cholesterol and triglyceride concentrations (29.2%) (p <0.01 for trend). Kaplan-Meier survival analysis showed a decrease in event-free survival in patients with compared with those without atherogenic dyslipidemia (log-rank p = 0.006). Patients with atherogenic dyslipidemia presented with increased plasma concentrations of remnants, denser low-density lipoprotein, more atherogenic HDL particles, and insulin-resistant status. After adjustment for potential confounding variables, the magnitude of increased risk associated with atherogenic dyslipidemia was 1.58 (95% confidence interval 1.12 to 2.21, p = 0.008). In conclusion, these data provide evidence that atherogenic dyslipidemia is an independent predictor of cardiovascular risk in patients with CAD, even stronger than isolated high triglycerides or low HDL cholesterol.

[Anastomotic dehiscence in colorectal surgery. Analysis of 1290 patients]

The most frightening complication following colorectal surgery is the anastomotic leakage which is associated with an high mortality rate, and the analysis of risk factors for the anastomotic leak is of great interest. The aim of this retrospective study is to evaluate the risk factor for the anastomotic leakage in personal series of patients who underwent colorectal surgery. We have analyzed a consecutive series of 1290 patients who underwent colorectal open surgery from 1970 to 2004. The associations between anastomotic leak and several risk factors were studied by univariate analysis. The variables considered were the following: age; sex; type of disease; elective or emergency surgery; type of surgery; type, design and site (intra or extra peritoneal) of the anastomosis; stapled or manual anastomosis; distance from anal verge of the colorectal anastomosis; intraoperative complications; protective stoma. The rate of anastomotic leakage was 4.8% (62/1290 patients). Significant factors were: the type of surgery (higher risk after restorative proctocolectomy or rectal resection), the site extra peritoneal of the anastomosis, the type of the anastomosis (higher risk after coloanal or ileal-pouch anal or colorectal), the stapled anastomosis, the intraoperative complications. After colorectal anastomosis the risk of leakage has progressively higher for low, ultra-low and coloanal anastomosis. In these conditions a protective stoma seems to be suitable.