Dr. Guglielmo M. Trovato, M.D., currently is Clinical Professor of Internal Medicine at the Catania University Medical School, and Chief Physician in the Medical Unit of Diagnostica e Terapia Medica of the University Hospital – Policlinico di Catania . In clinical investigations, the diagnostic non-invasive tools (echocardiography, medical ultrasound), Research is focused to homocysteine/MTHFR, BNP, Insulin Resistance and adipogenic adenoviruses in NAFLD, Renal Disease, CHF and hypertension
Research Item (151)
Purpose Thoracic ultrasound (TUS) has been proposed as an easy-option replacement for chest X-ray (CXR) in emergency diagnosis of pneumonia, pleural effusion, and pneumothorax. We investigated CXR unforeseen diagnosis, subsequently investigated by TUS, considering its usefulness in clinical risk assessment and management and also assessing the sustainability of telementoring. Patients and methods This observational report includes a period of 6 months with proactive concurrent adjunctive TUS diagnosis telementoring, which was done using freely available smartphone applications for transfer of images and movies. Results Three hundred and seventy emergency TUS scans (excluding trauma patients) were performed and telementored. In 310 cases, no significant chest pathology was detected either by CXR, TUS, or the subsequent work-up; in 24 patients, there was full concordance between TUS and CXR (ten isolated pleural effusion; eleven pleural effusion with lung consolidations; and three lung consolidation without pleural effusion); in ten patients with lung consolidations, abnormalities identified by CXR were not detected by TUS. In 26 patients, only TUS diagnosis criteria of disease were present: in 19 patients, CXR was not diagnostic, ie, substantially negative, but TUS detected these conditions correctly, and these were later confirmed by computed tomography (CT). In seven patients, even if chest disease was identified by CXR, such diagnoses were significantly modified by ultrasound, and CT confirmed that TUS was more appropriate. The overall respective individual performances of CXR and TUS for the diagnosis of a pleural–pulmonary disease in emergency are good, with accuracy >95%. Conclusion About 20% of pneumonia cases were detectable only by CXR and 20% only by TUS and not by CXR; ie, about 40% of patients may have been misdiagnosed if, by chance, only one of the two tools had been used. The concurrent use of TUS and CXR increases the overall sensitivity and specificity. The contribution of expert telementoring and final reappraisal is a valuable and sustainable element for emergency physicians’ training and performance, contributing reasonably to mitigation of clinical risks.
AIM To investigated in non-alcoholic-fatty-liver-disease (NAFLD), with ultrasound (US)-detected fatty liver, and in a group of non-alcoholic and otherwise healthy subjects, relationship of neglected features of lifestyle with NAFLD and obesity. METHODS Five hundred and thirty-two NAFLD and 667 non-NAFLD healthy subjects, age 21-60 years were studied. Severity of liver steatosis was assessed by US bright liver score. The adherence to mediterranean diet score (AMDS) was assessed on the basis of a 1-wk recall computerized questionnaire which included a detailed physical activity reports (Baecke questionnaire). The western dietary profile score, as a simplified paradigm of unhealthy diet, a questionnaire quantifying sun exposure score and a sleep habits questionnaires provided a further comprehensive lifestyle assessment. RESULTS Body mass index (BMI), insulin resistance (HOMA), and triglycerides, poorer adherence to a mediterranean diet profile, sedentary habits, minor sun exposure and use of “western diet” foods are greater in NAFLD. Multiple linear regression analysis, weighted by years of age, displays BMI, HOMA and AMDS as the most powerful independent predictors of fatty liver severity; however, also the physical activity score, the western diet habit and the sun exposure score are acting inside the model with significant independent effects. CONCLUSION Articulated clinical intervention, according to our results, are justified in NAFLD and can be pursued addressing by focused intervention nutritional profile, physical exercise mainly in open-air subsets for enhancing sun exposure and healthier sleep duration and rhythm.
Clinical assessment and workup of patients referred to cardiologists may need an extension to chest disease. This requires more in-depth examination of respiratory co-morbidities due to uncertainty or severity of the clinical presentation. The filter and integration of ecg and echocardiographic information, addressing to the clues of right ventricular impairment, pulmonary embolism and pulmonary hypertension, and other less frequent conditions, such as congenital, inherited and systemic disease, usually allow more timely diagnosis and therapeutic choice. The concurrent use of thoracic ultrasound (TUS) is important, because, despite the evidence of the strict links between cardiac and respiratory medicine, heart and chest US imaging approaches are still separated. Actually, available expertise, knowledge, skills and training and equipment’s suitability are not equally fitting for heart or lung examination and not always already accessible in the same room or facility. Echocardiography is useful for study and monitoring of several respiratory conditions and even detection, so that this is nowadays an established functional complementary tool in pulmonary fibrosis and diffuse interstitial disease diagnosis and monitoring. Extending the approach of the cardiologist to lung and pleura will allow the achievement of information on pleural effusion, even minimal, lung consolidation and pneumothorax. Electrocardiography, pulse oximetry and US equipment are the friendly extension of the physical examination, if their use relies on adequate knowledge and training and on appropriate setting of efficient and working machines. Lacking these premises, overshadowing or misleading artefacts may impair the usefulness of TUS as an imaging procedure.
Imaging workup of patients referred for elective assessment of chest disease requires an articulated approach: Imaging is asked for achieving timely diagnosis. The concurrent or subsequent use of thoracic ultrasound (TUS) with conventional (chest X-rays-) and more advanced imaging procedures (computed tomography and magnetic resonance imaging) implies advantages, limitations and actual problems. Indeed, despite TUS may provide useful imaging of pleura, lung and heart disease, emergency scenarios are currently the most warranted field of application of TUS: Pleural effusion, pneumothorax, lung consolidation. This stems from its role in limited resources subsets; actually, ultrasound is an excellent risk reducing tool, which acts by: (1) increasing diagnostic certainty; (2) shortening time to definitive therapy; and (3) decreasing problems from blind procedures that carry an inherent level of complications. In addition, paediatric and newborn disease are particularly suitable for TUS investigation, aimed at the detection of congenital or acquired chest disease avoiding, limiting or postponing radiological exposure. TUS improves the effectiveness of elective medical practice, in resource-limited settings, in small point of care facilities and particularly in poorer countries. Quality and information provided by the procedure are increased avoiding whenever possible artefacts that can prevent or mislead the achievement of the correct diagnosis. Reliable monitoring of patients is possible, taking into consideration that appropriate expertise, knowledge, skills, training, and even adequate equipment’s suitability are not always and everywhere affordable or accessible. TUS is complementary imaging procedure for the radiologist and an excellent basic diagnostic tool suitable to be shared with pneumologists, cardiologists and emergency physicians.
Patients and methods: 660 NAFLD and 791 non-NAFLD subjects, referred to the same out-patients medical unit for lifestyle-nutritional prescription, were studied. Congestive heart failure, myocardial infarction, malignancies, diabetes mellitus, extreme obesity, underweight-bad-nourished subjects and renal insufficiency were exclusion criteria. Liver steatosis was assessed by Ultrasound-Bright-Liver-Score (BLS), left ventricular ejection fraction (LVEF), trans-mitral E/A doppler ratio (diastolic relaxation) and left ventricular myocardial mass (LVMM/m(2)) by echocardiography. Doppler Renal artery Resistive Index (RRI), insulin resistance (HOMA) and lifestyle profile were also included in the clinical assessment. Results: LVMM/m(2) is significantly greater in NAFLD, 101.62±34.48 vs. 88.22±25.61, p<0.0001 both in men and in women. Ejection fraction is slightly smaller only in men with NAFLD; no significant difference was observed for the E/A ratio. BMI (30.42±5.49 vs. 24.87±3.81; p<0.0001) and HOMA (2.90±1.70 vs. 1.85±1.25; p: 0.0001) were significantly greater in NAFLD patients. By Multiple-Linear-Regression, NAFLD and unhealthy dietary profile are associated also in lean non-diabetic subjects with lower systolic function, independently of BMI, dietary profile, physical activity, RRI and insulin resistance. Conclusion: NAFLD may be a meaningful early clue suggestive of diminishing heart function, with similar determining factors. NAFLD is amenable to management and improvement by lifestyle change counseling, addressing a dual target: reducing fatty liver, which is easily monitored by ultrasound, and, independently, maintaining a normal heart function.
Plurality and individuality of hepatocellular carcinoma: PPPM perspectives Krishna Chander Sridhar, Olga Golubnitschaja Department of Radiology, Univeristy of Bonn, Bonn, Germany Correspondence: Olga Golubnitschaja (firstname.lastname@example.org) – Department of Radiology, Univeristy of Bonn, Bonn, Germany The EPMA Journal 2016, 7(Suppl 1):A72 The EPMA Journal 2016, Volume 7 Suppl 1 Page 35 of 42 Keywords: Predictive preventive personalized medicine, Innovative screening methods, Patient-specific therapy, Multilevel diagnostics, Molecular markers, CTCs and CNAPS, Stratification Hepatocellular Carcinoma (HCC) may arise due to various risk fac- tors such as genetic predisposition, chronic hepatic infections, al- coholabuse,hemochromatosis,cirrhosis,obesity,fatty liver disease, etc. [1, 2]. Low mean 5-year survival rate (15 %) and high treatment costs imply the need for more effective treatments tai- lored to the person . The predictive, preventive and personal- ized medicine (PPPM) aims at paradigm change in management of HCC from delayed to advanced approaches creating innovative screening programs, early/predictive diagnostics and targeted therapy . For that, better patient stratification is needed utilizing multilevel diagnostics. Molecular mechanisms which underlie tumor manifestation, progression and aggressiveness may vary substantially inHCC dependingonanumber of factorssuchas localization of the primary tumor, tumor’scharacteristics / sub- type, family history, life-style and co-morbidities. Consequently, a creation of individualized patient profiles is of particular import- ance in patient stratification, predictive/early diagnostics and tar- geted treatments of HCC (see Fig. 4). Further, highly sensitive and specific biomarker-panels play a crucial role in sub-categorization of HCC, e.g. to distinguish between local and distanced metastatic activities, where the latter are functionally linked to circulating en- tities such as circulating tumour cells (CTC) and circulating nucleic acids in plasma and serum (CNAPS) . The integrative PPPM-strategies advancing HCC management (both curative and palliative) may have great impacts on improved screen- ing of individuals at risk, life-quality of targeted patient cohorts, bet- ter healthcare economy and benefits to diagnostic and pharmaceutical industry. References 1. Berliner L, Lemke HU (eds.). An Information Technology Framework for Predictive, Preventive and Personalized Medicine: A Use-Case with Hepato- cellular Carcinoma. In: Advances in Predictive, Preventive and Personalised Medicine, Vol 8in Cham: Springer International Publishing; 2015 2. Fox RK. Surveillance for Hepatocellular Carcinoma. Hepatitis C Online, http:// www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/surveillance- hepatocellular-carcinoma/core-concept/all (2013) Accessed 15 Aug 2015. 3. Thein HH, Isaranuwatchai W, Campitelli MA, Feld JJ, Yoshida E, Sherman M, et al. Healthcare costs associated with hepatocellular carcinoma: a population-based study. Hepatology 2013;58(4):1375-84. 4. Zhao YJ, Ju Q, Li GC. Tumor markers for hepatocellular carcinoma. Mol Clin Oncol. 2013;1(4):593-598.
This chapter will deal with the available information on the effects of coffee and its components on renal function in health and disease. Only studies performed on human beings are discussed, and coffee's relationship with blood pressure and circulation control will be presented. Effects of coffee on the metabolism of substances, such as uric acid, with a significant relevance in the genesis of urinary stones and infections will be a topic of this chapter. Patients on dialysis or transplanted were also studied and an overview on available information will be provided. Few sentences will be dedicated to the argument of renal and prostate cancer, which has a very wide research literature.
The concurrent effect of the most important factors exerting beneficial effects for prevention and even the cure of nonalcoholic fatty liver disease (NAFLD), including food, beverages, and nutrients, are still not sufficiently taken into account. The effects on NAFLD severity of greater quantity of coffee intake should be studied concurrently with the dietary profile and putative beneficial food such as olive oil. Actually, there is a gender difference, and coffee benefits are evident in women but not in men. It is likely that coffee has the role of a behavioral marker, and probably of a promoter of healthy nutritional profile and lifestyle, with advantages against the occurrence and the greater severity of NAFLD.
Surgery and anesthesia-related conditions, pregnancy, childbearing and infancy, fertility and sexual-related ailments, menopause, thyroid, respiratory (mainly asthma and chronic obstructive pulmonary disease) are not sufficiently addressed by clinical and epidemiological research dealing with coffee habits. Also infectious disease, including Malaria and AIDS, anemia and other hematological conditions, migraine and vertigo, stroke and its neurological consequences, sport and exercise medicine and occupational aspects of coffee use, with its relationship with age and gender usually imply belief and bias in the counseling of coffee use and limitations. A caution of its use in pregnancy is warranted since coffee habits is associated with concerns at least for small for age newborn.
- Oct 2015
In un qualsiasi iter diagnostico la clinica orienta verso un'ipotesi e guida l'imaging che a sua volta può confermare tale ipotesi. La diagnosi finale è un insieme di tasselli clinico-laboratoristici e strumentali. In questo contesto l'ecografia è un esame complementare che insieme all'imaging tradizionale di primo livello (RX standard del torace) può aggiungere informazioni utili e talora risolutive rispetto al solo imaging radiologico di primo livello. Come per altri distretti anche e soprattutto per lo studio ecografico del torace, si richiede la imprescindibile conoscenza dei principi fisici e dei fondamentali essenziali degli ultrasuoni. Infatti a differenza degli altri distretti, od apparati esplorabili dagli ultrasuoni, in ambito pleuro-polmonare non può esistere nessun pre-settaggio codificabile della macchina, in quanto la velocità degli ultrasuoni in ambito polmonare è meno di un terzo (circa 400 metri/secondo) rispetto agli altri organi. Il tutto si traduce, quindi, in una riflessione quasi totale del fascio ultrasonoro a livello della zona di confine parete toracica - spazio pleurico, con inevitabile formazione di soli artefatti. Fanno eccezione tutte quelle lesioni adese al 70% circa della pleura accessibile ecograficamente ed i versamenti. E' per questo motivo che la conoscenza della fisica degli ultrasuoni, nonchè la cultura relativa alle caratteristiche dell'apparecchiatura che si vuole utilizzare, è un dato imprescindibile per qualsiasi ecografista. Un'ultima considerazione, infine, sulla formazione in ecografia toracica: non esistono scorciatoie didattiche rispetto all'utilizzo degli ultrasuoni in altri distretti. Nulla si improvvisa ed è fondamentale un percorso formativo che porti alla comprensione di tutti gli aspetti essenziali per l'utilizzo degli ultrasuoni, dalla conoscenza delle apparecchiature nel loro funzionamento, alla cultura della fisica degli ultrasuoni, fino al training completo ed esaustivo sull'anatomia normale e sulle patologie ecograficamente rilevabili.
- Sep 2015
Background and aims: Fatty liver is associated with alcohol habits and/or overweight-obesity. We challenged if some lifestyle feature are associated with fatty liver and, particularly, with non-alcoholic-fatty-liver-disease (NAFLD). Among them, sleep shortage due to nightlife habits and oversized fashion preferred clothing were assessed. This last consists of the fashion of clothing larger than normal and reflects attitude of social or age groups, conceivably indicating more global and widespread trend and behavior. Methods: We studied a group of 708 non-diabetic youngsters, 458 women and 250 men, aged between 15 and 35 years, 21.72±3.71 years, referred for minor digestive ailments to clinical assessment, ultrasound detection of fatty liver and nutritional counselling. Detail of the personal history regarding lifestyle, food intake frequency and alcohol intake, dietary and physical exercise profile, sleep duration and clothing habits were recorded. Results: The prevalence of NAFLD in this cohort of young person is 67/708 (9.4%). Even if quantitatively very low in both groups, the average alcohol intake, always below 20 g/day, is greater in the NAFLD subjects, g. 5.83±4.32, vs. normal liver subjects, g. 2.02±3.20.The number of meals/day and adherence to a Mediterranean diet profile are smaller in NAFLD subjects. By multiple linear regression, BMI, sedentary life, oversized clothing for the actual size, sleep shortage and lower frequency of daily food intake are associated with the presence of NAFLD. Conclusion: Onset and continuation of fatty liver disease, beyond food and exercise quantity and quality, with their effects on obesity, may be associated also with other aspects of lifestyle. This article is protected by copyright. All rights reserved.
Systemic sclerosis (SSc) patients in the early stages of pulmonary fibrosis (PF) often have few or no symptoms, normal to borderline pulmonary function tests, and negative chest X-ray (CXR); high-resolution computed tomography (HRCT) is the only reliable means of detecting the early signs of PF. However, thoracic ultrasound (TUS) enables detection of pleural thickening, pleural/subpleural nodules, and other subpleural lung abnormalities across 70% of the subpleural surface. We reassessed concordance between TUS abnormalities and HRCT findings in SSc patients, to see whether TUS pleural line thickness (normally < 3.0 mm) could be used to earmark those with asymptomatic PF for timely HRCT assessment. In total, 175 SSc patients (nine males, 166 females), aged 46.46 ± 15.33 years, were given CXR, TUS, HRCT, echocardiography, and pulmonary function tests. In the 26 patients without HRCT signs of PF, pleural line thickness was ≤ 3.0 mm. In diffuse SSc, 97/137 patients showed pleural line thickening (between 3.0 and 5 mm) and subpleural nodules in 32/97; and 35/137 showed major pleural line thickening (≥ 5.0 mm) with nodules, with good concordance with HRCT patterns indicating lung fibrosis severity. HRCT was normal in 5/137, with pleural line thickness ≤ 3.0 mm. TUS imaging of pleural/subpleural structures can detect ultrasonographic signs of initial PF prior to the onset of respiratory symptoms and function test abnormalities and, together with current criteria, could thereby enable exclusion of PF in SSc patients. Indicating some patients for selective referral to HRCT can thereby delay unwarranted procedures, provided that pulmonary function and TUS images are stable.
To investigate the effects of different methylenetetrahydrofolate reductase (MTHFR) 677C>T gene polymorphism and hyperhomocysteinemia for the development of renal failure and cardiovascular events, which are controversial. We challenged the relationship, if any, of MTHFR 677C>T and MTHFR 1298A>C polymorphisms with renal and heart function. The present article is a reappraisal of these concepts, investigating within a larger population, and including a subgroup of dialysis patients, if the two most common MTHFR polymorphisms, C677T and A1298C, as homozygous, heterozygous or with a compound heterozygous state, show different association with chronic renal failure requiring hemodialysis. MTHFR polymorphism could be a favorable evolutionary factor, i.e., a protective factor for many ominous conditions, like cancer and renal failure. A similar finding was reported in fatty liver disease in which it is suggested that MTHFR polymorphisms could have maintained and maintain their persistence by an heterozygosis advantage mechanism. We studied a total of 630 Italian Caucasian subject aged 54.60 ± 16.35 years, addressing to the increased hazard of hemodialysis, if any, according to the studied MTHFR genetic polymorphisms. A favorable association with normal renal function of MTHFR polymorphisms, and notably of MTHFR C677T is present independently of the negative effects of left ventricular hypertrophy, increased Intra-Renal arterial Resistance and hyperparathyroidism. MTHFR gene polymorphisms could have a protective role on renal function as suggested by their lower frequency among our dialysis patients in end-stage renal failure; differently, the association with left ventricular hypertrophy and reduced left ventricular relaxation suggest some type of indirect, or concurrent mechanism.
Relationship between adipose tissue and fatty liver, and its possible evolution in fibrosis, is supported by clinical and research experience. Given the multifactorial pathogenesis of non-alcoholic fatty liver disease (NAFLD), treatments for various contributory risk factors have been proposed; however, there is no single validated therapy or drug association recommended for all cases which can stand alone. Mechanisms, diagnostics, prevention and treatment of obesity, fatty liver and insulin resistance are displayed along with recommendations and position points. Evidences and practice can get sustainable and cost-benefit valuable outcomes by participatory interventions. These recommendations can be enhanced by comprehensive research projects, addressed to societal issues and innovation, market appeal and industry development, cultural acceptance and sustainability. The basis of participatory medicine is a greater widespread awareness of a condition which is both a disease and an easy documented and inclusive clue for associated diseases and unhealthy lifestyle. This model is suitable for addressing prevention and useful for monitoring improvement, worsening and adherence with non-invasive imaging tools which allow targeted approaches. The latter include health psychology and nutritional and physical exercise prescription expertise disseminated by continuous medical education but, more important, by concrete curricula for training undergraduate and postgraduate students. It is possible and recommended to do it by early formal teaching of ultrasound imaging procedures and of practical lifestyle intervention strategies, including approaches aimed to healthier fashion suggestions. Guidelines and requirements of research project funding calls should be addressed also to NAFLD and allied conditions and should encompass the goal of training by research and the inclusion of participatory medicine topics. A deeper awareness of ethics of competences in health professionals and the articulation of knowledge, expertise and skills of medical doctors, dieticians, health psychologists and sport and physical exercise graduates are the necessary strategy for detectin a suboptimal health status and achieving realistically beneficial lifestyle changes. "The devil has put a penalty on all things we enjoy in life. Either we suffer in health or we suffer in soul or we get fat" (Albert Einstein); the task of medical research and intervention is to make possible to enjoy life also without things that make sufferance in health and souls and which excessively increase body fat.
TUS imaging, diagnostic yield, and complications of TUS-guided FNAB were reassessed. The records of 133 patients with MPM and 801 patients with LC were analyzed. In 55 of the patients with MPM and in all 801 of those with LC (2008-2013), TUS-guided FNAB was performed using 20-gauge needles and US transducers with a central hole for needle passage.³ Such thin needles provided specimens of adequate size (length: 1.0-2.5 cm). In 20 patients, the procedure was repeated for insufficient sampling. Four patients had partial, self-limited pneumothorax; no severe complication was observed. The TUS signs observed in histologically confirmed MPM were irregular thickening of the pleural line (> 5.0 mm) and associated micronodules (5-10 mm); a lower percentage showed plaque nodulations (5-10 mm), all with slight or relevant pleural effusion. We emphasize that the concordance of CT images and TUS is greater in patients with MPM than in patients with LC, probably due to the strictly pleural-subpleural position of the tumor mass (Fig 1). Moreover, the FNAB-dedicated probes³ enable reaching the lesion to be biopsied under the coaxial view (Fig 1C), getting specimens of length, thickness, and quality adequate for pathology assessment.
- Oct 2014
Obesity and liver steatosis are usually described as related diseases. Obesity is regarded as exclusive consequence of an imbalance between food intake and physical exercise, modulated by endocrine and genetic factors. Non-alcoholic fatty liver disease (NAFLD), is a condition whose natural history is related to, but not completely explained by over-nutrition, obesity and insulin resistance. There is evidence that environmental infections, and notably adipogenic adenoviruses (ADV) infections in humans, are associated not only with obesity, which is sufficiently established, but also with allied conditions, such as fatty liver. In order to elucidate the role, if any, of previous ADV36 infection in humans, we investigated association of ADV36-ADV37 seropositivity with obesity and fatty liver in humans. Moreover, the possibility that lifestyle-nutritional intervention in patients with NAFLD and different ADV36 seropositive status, achieves different clinical outcomes on ultrasound bright liver imaging, insulin resistance and obesity was challenged. ADV36 seropositive patients have a more consistent decrease in insulin resistance, fatty liver severity and body weight in comparison with ADV36 seronegative patients, indicating a greater responsiveness to nutritional intervention. These effects were not dependent on a greater pre-interventional body weight and older age. These results imply that no obvious disadvantage - and, seemingly, that some benefit - is linked to ADV36 seropositivity, at least in NAFLD. ADV36 previous infection can boost weight loss and recovery of insulin sensitivity under interventional treatment.
Clinical research and practice require affordable objectives, sustainable tools, rewarding training strategies and meaningful collaboration. Our unit delivers courses on project design and management promoting ideas, useful skills, teaching and exploring implementation of networks and existing collaborations. We investigated the effectiveness of a sustainable approach of comprehensive diagnosis and care and its usefulness within concrete models of research project teaching methodology. The model of predictive, preventive and personalized medicine (PPPM) of adolescent hypertension, developed since 1976 and still active, was displayed. This is a paradigm of comprehensive PPPM aimed at the management of a recognized, but actually neglected, societal and clinical problem. The second model was addressed to the analysis of performance of an outpatient diagnostic and therapy unit and its relationship with the emergency department. Part of the patients, 4,057 cancer patients presenting at the emergency care, were addressed to the outpatient diagnostic and therapy unit for further assessment, treatment and follow-up. The stay in DH was 6.3 ± 2.1 non-consecutive days, with shortage of costs, vs. in-hospital stays. Research planning courses, based on these models, ensued in an increase of competitive project submission and successful funding. Active promotion of interdisciplinary knowledge and skills is warranted. Misleading messages and information are detrimental not only to healthy and sick people but, equally, to all health professionals: efforts for basing on evidence by research any statement are needed. The actual pre-requisite of personalized medicine is the coherent and articulated promotion of the professional quality of staff. Health professionals should and can be skilled in sustainable non-invasive diagnostic procedures, in non-pharmacological intervention, in translational research (from epidemiology to personalized therapy) and in timely dissemination of the information. Recommendations are provided according to PPPM: proposed models are based on financial sustainability and patient's satisfaction criteria and are addressed to research projects and dissemination also by e-learning. The guidelines of the EU calls in personalized medicine are able to provide a critical added value by accurate planning, transparency of assessment and unbiased reports, dissemination and exploitation.
Clinical ultrasound approaches should be driven by physio-pathology knowledge and with explicit and realistic diagnostic and therapeutic goals. Thoracic ultrasound is valuable for reaching early and affordable preliminary diagnosis and for safe interventional guidance of cavity evacuations or of fine needle aspiration biopsy (FNAB) procedures by the continuous visual control of the operator. Using thoracic ultrasound elastography, only squamous cell lung carcinoma displays the feature of a significantly greater stiffness. No clear-cut diagnostic key is yet available and the clinical usefulness of TUS elastography is currently limited with a view to characterizing tumors. Nevertheless, TUS elastography does allow good noninvasive imaging of lung nodules, providing information on their stiffness, and can improve the safety of FNAB. Dear Editor, The brilliant and challenging editorial “Elastography Everywhere – Now Even the Lungs!” is particularly timely and well addressed. It focuses on the fact that clinical ultrasound approaches should be driven by physio-pathology knowledge to reach realistic diagnostic and therapeutic goals. The author, Mostbeck , articulates several relevant comments and criticisms in his reappraisal of the study of Adamietz et al. , who claim that their preliminary report of a case series dealing with 8 patients with a total of 18 histologically proven metastases of the lung is the first one in the literature and should show the feasibility of real-time elastography (RTE). Moreover, they claim that “in contrast to B-mode sonography, RTE is able to detect and visualize peripheral, non-pleural adherent pulmonary lesions”. We agree with most of the content of Mostbeck’s editorial , even if somewhat more could be added, including the fact that there are previous reports of ultrasound (US) elastography of primary lung cancer confirmed by US-guided biopsy. In addition, the statement that “ultrasound (US) and contrast-enhanced ultrasound (CEUS)  are currently not commonly used for the detection and visualization of pulmonary nodules”  is partially incorrect, in our opinion. The field of thoracic US (TUS) is very important as the research objects are very prevalent, severe and – hopefully – treatable diseases such as pneumonitis , pneumothorax, effusions, fibrosis and autoimmune diseases  and lung cancer . For all these entities, the added value of TUS is valuable for reaching an early, tentative preliminary diagnosis. However, even more important is the fact that TUS allows safe interventional guidance of cavity evacuations or of fine-needle aspiration biopsy (FNAB) procedures under the continuous visual US control of the operator . The assessment of lung nodules by state-of-the-art US techniques, including elastography, is not really a completely “exotic” application  and, in our opinion, is no longer a pioneering methodology . In 2013, we reported at the American Society of Clinical Oncology (ASCO) meeting a thoracic ultrasound elastography study on lung nodules in 57 proven primary lung cancer patients . The conclusion was not over-enthusiastic: “Only squamous cell lung carcinoma displays the feature of a significantly greater stiffness, no clear-cut diagnostic key is yet available, and the clinical usefulness of TUS elastography is currently limited with a view to characterizing tumors. Nevertheless, TUS elastography does allow good noninvasive imaging of lung nodules, provides some information on their stiffness and on the presence of abscess cavities, and can improve the safety of FNAB also through a more accurate on-site definition of the lesion location which, of course, is finely defined by CT ”. A reappraisal of elastography applications for a better definition of lung nodules primary to US-guided FNAB  , along with information on CEUS usefulness, which has been previously reported , was also included in a recent review . Actually, the possible benefits of using TUS elastography and contrast-enhanced US (CEUS) were not really assumed to better detect lung cancer or to gain information on different histologic cancer subtypes (as cut-off values are not sufficiently established), but to detect the site, position and “quality” (fluid content, vasculature) of lung nodules with more detail, especially when FNAB of these lesions guided by US is considered. The information on “rigidity” is a collateral but, in our opinion, not a determinant detail . There are also other merits of Mostbeck’s editorial  since he addresses the need of managing TUS and TUS elastography as imaging procedures complementary to radiology, acknowledging the limitation of TUS, especially the visibility of lung nodules restricted to pleural-based and very subpleural nodules: “Every man takes the limits of his own field of vision for the limits of the world (Arthur Schopenhauer)”. Radiologists and pneumologists are probably more diffident if not skeptical about the merits of TUS because part of the available literature is devoted to studies relying on artifacts, addressing clinical syndromes and decisional trees, in which the relationship with imaging of lung disease is quite remote   . The technical difficulties of TUS require adequate and continuous training, particularly if the professional goal is to perform trans-thoracic FNAB with minor trauma and diminished risks for the patient, whenever possible, i. e. when the lesions are sufficiently visible by US. It is noteworthy to remember that in these subsets, and particularly in malignant pleural mesothelioma   , endo-bronchial ultrasound (EBUS) procedures are less useful and “fruitful”, since more peripheral parts of the lung are not reachable by EBUS. Last but not least, the present hard “caveats” addressed by Mostbeck are welcome since some US aspects of lung imaging by US are unrealistic due to its aerial physical properties.
Background: Despite the usefulness of elastography in assessing the stiffness/elasticity of tissues, and its proven diagnostic accuracy in thyroid, breast, and prostate cancers, among others, it is not yet applied in transthoracic ultrasound (TUS) scans to investigate lung nodules. Purpose: To investigate the potential clinical utility of TUS elastography in diagnosing lung cancer proven by fine-needle aspiration biopsy (FNAB). Material and methods: TUS elastography was performed in 95 consecutive patients (71 men, 24 women; age, 62.84 ± 7.37 years) with lesions suspected of involving the chest wall or the pleura detected on chest X-ray or computed tomography (CT). Patients with pleural effusions were not enrolled, but were further evaluated by pleural fluid cytology. Patients were excluded from the study if a diagnosis had already been made based on sputum cytology and/or bronchoscopic histology (making TUS biopsy unnecessary) or if their lung lesions could not be visualized under standard US. Under FNAB, 34 consolidations were ascribed to pneumonia and 65 to cancer. Under TUS, tissue stiffness, detected using a convex multifrequency 2-8-mHz probe and a MyLab™Twice - ElaXto, was scored from 1 (greatest elasticity) to 5 (no elasticity). Subpleural solid masses (2-5 cm) were initially detected by TUS and subsequently assessed by FNAB. Results: Histological diagnoses were: small cell lung cancer (4/61), adenocarcinoma (29/61), squamous cell carcinoma (SCC) (12/61), large cell lung carcinoma (12/61), and lymphomas (4/61). Patients' age and mass sizes (3.06 ± 0.88 cm) were not significantly associated with any histological type. A significant lower elasticity of SCC (4.67 ± 0.492) was observed versus other types of lung cancer (P < 0.005), and versus pneumonia (2.35 ± 0.48). Conclusion: Since only squamous cell lung carcinoma displays the feature of significantly reduced elasticity, and since no clear-cut diagnostic key is yet available, the clinical usefulness of TUS elastography is currently limited with a view to characterizing tumors. Nevertheless, it does enable good non-invasive imaging of lung nodules, providing information on their stiffness, and can improve the accuracy and yield of FNAB.
We read with a great interest the paper by Miglioranza et al. [(1)], which sought to deﬁne the performance of lung ultrasound (LUS) compared with a clinical congestion score, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in
Interest in transthoracic ultrasound (US) procedures increased after the availability of portable US equipment suitable for use at the patient's bedside. It is possible to detect space-occupying lesions of the pleura, pleural effusion, focal or diffuse pleural thickening and subpleural lesions of the lung, even in emergency settings. Transthoracic US is useful as a guidance system for thoracentesis and peripheral lesion biopsy, where it minimises the occurrence of pneumothorax and haemorrhage. Transthoracic US imaging is strongly influenced by physical interaction of the ultrasonic beam at the tissue/air interface, which gives rise to reverberations classified as simple (A-line), "comet tail" and "ring down"(B-line) artifacts. Although these artifacts can be suggestive of a disease condition, they are essentially imaging errors present even in normal subjects and in empty-pleura post-pneumonectomy patients. In order to clarify some confusion and to report on the state of the art, we present a review of the literature on transthoracic US in diseases of the pleura and peripheral lung regions and our own clinical experience over 3 decades. The review focuses on quality assurance procedures and their value in diagnostic imaging and patient monitoring and warns against possible inappropriate indications and misleading information. Thoracic US is much more than "fishing for the moon in the well".
Non-Alcoholic Fatty Liver Disease (NAFLD) is related to unhealthy habits, mainly to unfavorable dietary profiles. MTHFR gene encodes MethyleneTetraHydroFolate Reductase, a regulatory enzyme whose polymorphisms are associated with hyperhomocysteinemia. Among polymorphisms, C677T, a thermolabile form, but not A1298C, thermostable, was associated with fatty liver and insulin resistance. to investigate if NAFLD, in subjects referred for nutritional assessment and counselling, has any difference of prevalence and severity when associated with isolated MTHFR A1298C polymorphism and hyperhomocysteinemia. 94 subjects, age 55.65±15.43 years, BMI 27.88±5.17 kg/m2, 26 with MTHFR Wild type genotype (1298AA) and 68 with MTHFRA1298C single polymorphism were studied: of them, 35 were homozygous (MTHFR1298CC), 33 were heterozygous (MHTFR 1298AC). Insulin resistance was assessed by HOMA-IR, NAFLD by UltraSound Brigh-Liver-Score (BLS). MTHFR subgroups (wild and A1298C single polymorphism) were not different for age, gender, dietary profile and BMI. In NAFLD, MTHFR 1298AC (heterozygous) vs. homozygous wild genotype (MTHFR 1298AA) patients had more severe NAFLD (BLS: 1.12±1.14 vs. 0.54±0.76, p < 0.029), greater insulin resistance (HOMA 3.20±2.35 vs. 2.12±1.12; p < 0.036), higher AST and gammaGT. MTHFR1298AC gene heterozygous polymorphisms can be weakly predictive for NAFLD severity. This mutation occurs frequently in populations with low prevalence of overall mortality and of atherosclerosis-associated disease: it could have maintained and maintain its persistence by an heterozygosis advantage mechanism, within significant adherence to healthy nutritional profiles. Interactions of nutrition, genetics and health are a part of the aging process throughout the life span and a greater consideration to the genetic characteristics of populations and individuals is warranted.
The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)
- Nov 2013
The methodology used in their study is based on International Classification of Diseases, Ninth Revision diagnosis codes, linking them with outcomes of interest: in the thoracentesis cohort, pneumothorax and/or in the paracentesis cohort, bleeding complications (hemorrhage, hematoma, or hemoperitoneum). Briefly, the risk of pneumothorax was 3.09% in the group not receiving ultrasound guidance and 2.26% in the ultrasound group; for patients having paracentesis procedures, the risk of bleeding complications was 0.27% with ultrasound guidance and 1.25% without ultrasound. Nonetheless, the occurrence of these types of complications is exceedingly high in comparison with our personal experience. This can be due to the actual procedures and the devices used. Transducers with the parallel needle can guide only obliquely, angulated vs the ultrasound beam, causing, even with a lower frequency, the same complications of the blind punctures. The advantages of ultrasound-guided transthoracic thoracentesis,² pericardiocentesis3,4 and abdominal paracentesis⁵ are related to the use of probes that have a central hole2,3 through which the needle set is introduced (Fig 1). By this device, which is the most suitable and reliable for these purposes and is available for most equipment, we can follow the needle at all times in its road, with an image exactly on the line of the target and the transducer, linear array, or convex.
The innovative article by Lin et al. (1) raises the possibility that certain infections may modulate not only obesity but also diabetes risk. Obesity is currently regarded as an imbalance between food intake and physical exercise, modulated by endocrine and genetic factors. Nonetheless, evidence is available that environmental infections, and notably adipogenic adenoviruses in humans, are associated with obesity, being causative factors of obesity in animals (1–3). How obesity relates to type 2 diabetes is still a mosaic of information and more comprehensive approaches may help advance effective and cost-effective interventions for both conditions, including more tailored therapy (4). The conjectural model that an improvement in …
Obesity is associated with numerous metabolic comorbidities. Weight loss is an effective measure for alleviating many of these metabolic abnormalities. However, considering the limited success of most medical weight-management approaches in producing a sustained weight loss, approaches that improve obesity-related metabolic abnormalities independent of weight loss would be extremely attractive and of practical benefit. Metabolically healthy obesity supports the notion that a better metabolic profile is possible despite obesity. Moreover, adequate expansion of adipose tissue appears to confer protection from obesity-induced metabolic comorbidities. To this end, the 10th Stock conference examined new approaches to improve metabolic comorbidities independent of weight loss. In particular, human adenovirus 36 (Ad36) and specific gut microbes were examined for their potential to influence lipid and glucose homeostasis in animals and humans. While these microbes possess some undesirable properties, research has identified attributes of adenovirus Ad36 and gut microbes that may be selectively harnessed to improve metabolic profile without the obligatory weight loss. Furthermore, identifying the host signalling pathways that these microbes recruit to improve the metabolic profile may offer new templates and targets, which may facilitate the development of novel treatment strategies for obesity-related metabolic conditions.
Background: Association of methylenetetrahydrofolate reductase (MTHFR) 677C>T gene polymorphism with hyperhomocysteinemia, renal failure, and cardiovascular events is controversial. We investigated the relationship of MTHFR 677C>T polymorphisms with left ventricular hypertrophy (LVH) and renal insufficiency. Methods: Glomerular filtration rate (GFR) and left myocardial ventricular mass/m2 were assessed in 138 non-diabetic subjects (age, 50.93 ± 14.85 years; body mass index, 27.95 ± 5.98 kg/m(2)), 38 no-mutation wild MTHFR C677CC, 52 heterozygous MTHFR C677CT, and 48 homozygous MTHFR C677TT, all with adequate adherence to current international healthy dietary guidelines. Serum homocysteine, insulin resistance, high-sensitivity C-reactive-protein (hsCRP), parathyroid hormone, and renal artery resistive index (RRI) were challenged by odds ratio analysis and multiple linear regression models. Results: MTHFR 677C>T polymorphism showed higher GFR (73.8 ± 27.99 vs. 58.64 ± 29.95; p= 0.001) and lower renal failure odds (OR, 0.443; 95% confidence interval, 0.141-1.387) in comparison with wild MTHFR genotype. A favorable effect on GFR of MTHFR polymorphism is presented independently by the negative effects of LVH, increased intra-renal arterial resistance, and hyperparathyroidism; GFR is the significant predictive factor to LVH. Conclusions: Renal insufficiency in non-diabetic subjects is explained by interactions of MTHFR C677T polymorphism mutation with LVH, hsCRP, intact parathyroid hormone (iPTH), and RRI. Sign of these predictive effects is opposite: subjects with MTHFR 677C>T polymorphism have lower likelihood of renal insufficiency; differently, wild-type MTHFR genotype subjects have lower GFR and greater hsCRP, iPTH, RRI, and LVH.
Health and disease of individuals and of populations are the result of three groups of risk factors: genetics, environment and behavior. Assessment, interventions and tailored changes are possible with integrated approaches more effective if respectful of individuals and different cultures. Assessment tools and integrated interventional strategies are available, but widespread knowledge, skills and competence of well trained individual Medical Doctors still lack. Mediterranean diet is an appropriate reference paradigm because encompasses consistent research background, affordable sustainability, widespread comprehensibility and attractiveness inside a cultural framework of competences and skills in which the Medical Doctors can personally manage the need of prediction (early diagnosis), prevention (intervention on healthy persons) and tailored therapy and follow-up for patients. This profile is flexible and adjustable according to specific needs and preferences due to different economic and ethno-cultural milieus. It can enhanced through on-site/e-learning Continuous Medical Education (CME), by training and using friendly and affordable equipments.
This report is the collective product of word-leading experts working in the branches of integrative medicine by predictive, preventive and personalised medicine (PPPM) under the coordination of the European Association for Predictive, Preventive and Personalised Medicine. The general report has been prepared as the consortium document proposed at the EPMA World Congress 2011 which took place in Bonn, Germany. This forum analyzed the overall deficits and trends relevant for the top-science and daily practice in PPPM focused on the patient. Follow-up consultations resulted in a package of recommendations for consideration by research units, educators, healthcare industry, policy-makers, and funding bodies to cover the current knowledge deficit in the field and to introduce integrative approaches for advanced diagnostics, targeted prevention, treatments tailored to the person and cost-effective healthcare.
- Jul 2012
- Healthcare Overview
Italy has a public healthcare service for all the residents called “Servizio Sanitario Nazionale” or SSN (National Health Service) which is similar to the UK National Health Service. It is publicly run and funded mostly from taxation: some services requires small co-pays, while other services (like the emergency medicine and the general doctor) are completely free of charge. The general policy directives are toward a positive evolution of healthcare system in Italy, along the line of the most appreciated supranational, independent health organizations. Nonetheless, the excessive drive of management and government, centered on the processes and on the efficiency of systems, not adequately related with reliable outcome indexes, contributes to increasing costs without proportionate perceived and actual benefits. The macroscopic bug is in the medical doctors’ professional autonomy, i.e. there is a defective operative efficacy in affordable and mostly important skills and knowledge applications. A greater clustering of knowledge and skills in medical profession, comprehensive of dietary/physical exercise assessment and prescription, and enhancing the point-to-care diagnostic competences of all medical doctors is recommended. Widespread and affordable diffusion of ultrasound competences and facilities, training in life supports and essential procedures (also by friendly e-applications, e-learning and simulation theater tools) will allow a sustainable process of predictive, preventive and personalized medicine. By this, consistent screening, diagnosis and follow-up activities of healthy and unhealthy groups and populations will be realistic. This is the economic and cultural challenge of predictive, preventive and personalized medicine that will allow to realize a more advanced and effective healthcare system scenario in Italy and in a global context.
Aims: The study is aimed at investigating if perceived stress in Stable Atrial Fibrillation (AF) has any gender-associated feature and relationships with lifestyle indicators and education level, and which relationship self efficacy, anxiety and depression and illness perception have, if any. Patients and methods: 88 consecutive patients referred for stable AF are studied by Psychological Stress Measure (PSM) test, Illness Perception Questionnaire (IPQ-R), Generalized Self-Efficacy scale (GSE) and Hospital Anxiety and Depression Scale (HADS). Mediterranean diet, physical activity increase and smoking withdrawal counseling were provided. Results: AF patients have higher PSM associated with gender (women), older age, anxiety and depression. Higher GSE, greater Adherence to Mediterranean Diet profile and coffee habits (greater coffee users) are associated with a reduced hazard of perceived stress. By multiple linear regression, PSM is explained by Anxiety and IPQr (statistically significant are emotional representation and illness coherence subscales), which account for 92.2% of the variance (p<0.0001). Conclusion: Our results outline that psychological stress is greater in women in comparison with men. Illness perceptions are important in the context of perceived stress in AF. This effect appears to be modulated by greater self-efficacy and by Adherence to Mediterranean Diet profile, that when higher, are associated with a reduced hazard of perceived stress. We suggest that therapeutic interventions on illness perceptions can be warranted in order to achieve a lower psychological distress in AF patients.
Aim: Although it is commonly believed that a strong causal link exists between psychological stress and hypertension, as well with other factors, such as obesity, just what kind of empirical evidence supports this assumption is still controversial. The aim of the study is to investigate if perceived stress have any interference with intrarenal resistance and hence with mechanisms related to Essential Hypertension (EH) and if Anxiety, Depression, Self efficacy and Illness Perception can account for perceived stress. Patients and methods: Obesity, insulin resistance (HOMA), Doppler Renal Resistive Index (RRI) and glomerular filtration rate (GFR) are studied along with Psychological Stress Measure (PSM), Illness Perception Questionnaire (IPQ-R), Generalized Self-Efficacy scale (GSE) and Hospital Anxiety and Depression Scale (HADS) in 119 hypertensive patients referred for stable lasting EH, and 150 normal controls. Lower salt/lower calories Mediterranean diet, physical activity increase and smoking withdrawal counseling were provided. Results: By Odds Ratios, higher risk of EH is associated with greater perceived stress, older age, lower GFR, obesity, greater RRI and insulin resistance. By Multiple Linear Regression the most significant variable that accounts for higher RRI are abdominal obesity and arterial pulse pressure; the only significant independent psychological variable that accounts for abdominal obesity are PSM and identity IPQ subscale. Self-Efficacy anxiety and Illness perception subscales (IPQr), accounts significantly for 62.0% of the variance to PSM, with possible effects on RRI and on the pathophysiological hypertension cascade. Conclusion: Worst identity and treatment control perceptions of EH, and a lower self-efficacy are the main psychological factors accounting for a greater stress. Interventions aimed to reduce perceived stress can be warranted in EH.
- Apr 2012
Adenoviruses Ad36 and Ad37 increase adiposity in animals and are associated with obesity in humans; effects on the liver have been reported. The association of Adenovirus Ad36 seropositivity (Ad36+) with obesity but not with the severity of nonalcoholic fatty liver disease (NAFLD) has been previously shown. We investigate whether nondiabetic Ad37+ patients show a different prevalence of NAFLD and ultrasound Bright Liver score. A total of 268 adult nondiabetic patients (146 men, 122 women) were included after lifestyle counseling including a personalized Mediterranean diet, increase in physical activity, and smoking withdrawal. After an Ad37+/Ad36+ assay, overweight obesity, insulin resistance, C-reactive protein, and bright liver prevalence and severity were compared according to Ad37+. Sixty-five of 268 patients were Ad37+ and 82/268 patients were both Ad37 seronegative (Ad37-) and Ad36-. The prevalence of obesity, defined as body mass index≥30, was not significantly different in Ad37+ (11/65; 16.9%) vs. Ad37- (15/82; 18.2%) patients; Bright Liver was present in 22/65 (33.8%) Ad37+ patients vs. 13/82 (15.8%) Ad37- patients (P<0.019). By odds ratio (OR), a consistent risk for NAFLD was associated with Ad37+, greater insulin resistance, and C-reactive protein. By a predictive multiple linear regression model, 40.0% of variance toward NAFLD and 50.4% toward the severity of Bright Liver score was explained significantly and independently by Ad37+ and by body mass index. Ad37+ status in nondiabetic patients on an appropriate diet is significantly associated with NAFLD; because fatty liver improves even without weight loss by a "healthy" diet, and not only by lower food caloric intake, Ad37+ may be an adjunctive hallmark of an unfavorable clinical-metabolic profile, if not a causative factor of NAFLD.
- Oct 2011
The renal resistive index (RRI) reflects intrarenal vascular resistance and stiffness, which are associated with chronic kidney disease. The links connecting renal function, intrarenal arterial resistance, and parathyroid hormone (PTH) with hypertension and metabolic factors remain elusive. The aim of this study is to investigate the possible relationship of RRI with glomerular filtration rate, PTH, hypertension, obesity (body mass index and waist-to-hip ratio), bioelectrical impedance analysis in body composition assessment, serum lipids, and insulin resistance assessed by homoeostasis model insulin resistance index. This study was carried out on 387 (246 women, 141 men) nondiabetic patients, between >25 and <75 years, referred to an Internal Medicine Clinic and Day Hospital for essential hypertension, overweightness-obesity, and/or dyslipidemia. Lower salt/lower calorie Mediterranean diet, physical activity increase, smoking withdrawal, and lifestyle counseling, provided by a health psychologist support, were prescribed. Higher hypertension risk, present in 42.5% of the overall group of eligible patients (164/387), is associated with high PTH and high RRI, along with greater renal insufficiency, insulin resistance, and obesity. There is a straight linear relationship of RRI to PTH (0.202; p=0.009) in arterial hypertension, which is not observed in normal blood pressure patients. By gender-adjusted multiple linear regression analysis, it was found that fat mass, waist-to-hip ratio, and PTH account significantly for 62.3% of the variance to RRI in hypertensive patients. Increased arterial stiffness and intrarenal arterial resistance are associated with higher PTH in arterial hypertension; obesity (defined by greater fat mass and waist-to-hip ratio) and PTH are the independent conditions that account significantly for higher RRI.
- Sep 2011
Obesity and liver steatosis are both currently attributed to inappropriate lifestyle and nutrition. Higher prevalence of human adenovirus Ad36 seropositivity (Ad36+) is reported only in obesity. To investigate whether a lifestyle-nutritional intervention achieves different outcomes in NAFLD patients, i.e., if is blunted or enhanced according to Ad36 seropositivity status. One-year nutritional intervention was planned and accomplished for 62 non-alcoholic fatty liver disease overweight-obese patients, studied by liver ultrasound, evaluating Bright Liver Score (BLS), by Homeostatic Model assessment of Insulin Resistance (HOMA), by body composition and Ad36+ assay. Lower salt/lower calories Mediterranean diet, physical activity increase, smoking withdrawal and lifestyle counseling, provided by a health psychologist, were given. Ad36 seropositive patients have baseline greater BMI with the same level of BLS. Different prevalence of post-interventional response, significantly greater among Ad36+ patients, is observed: greater decrease of obesity, assessed by BMI, greater reduction of insulin resistance, assessed by HOMA and higher prevalence of bright liver disappearance. A BMI-adjusted multiple linear regression model explains significantly 23.8% (p < 0.04) of the variance; significant predictive variables are Ad36 seropositivity (p < 0.012) and fat mass loss (p < 0.011) accounting for the variance of the occurrence of bright liver disappearance. Ad36 previous infection is significantly associated with enhanced weight loss, bright liver disappearance, and recovery of insulin sensitivity through the chosen tailored nutritional interventional treatment. Nonetheless, Ad36 seronegative NAFLD patients' fatty liver pattern improves, at a lower extent, also without significant weight loss: an effect of dietary changes profile, Mediterranean diet, not only of lowered food caloric intake, is conceivably operating.
- Jan 2011
Relationships of renal function and liver disease are described in acute and chronic liver failure. The aim of the study is to investigate which relationship, if any, is present between severity of non-alcoholic fatty liver disease (NAFLD), assessed by bright liver score (BLS) versus mild-moderate renal insufficiency assessed by glomerular filtration rate (GFR) and by ultrasound intra-renal arterial resistive index (RRI). Moreover, which difference, if any, can be found in NAFLD patients with normal versus increased transaminases. The study enrolled 323 NAFLD and 176 non-NAFLD consecutive patients, comparable for age, gender distribution, GFR, and RRI referred to a university clinical day hospital after an ultrasound diagnosis of bright liver, for clinical-nutritional counselling. Personalized computerized mediterranean diet, physical activity increase, and smoking withdrawal integrated counselling were provided. In NAFLD patients, homoeostasis model (HOMA) has a significant correlation with BLS. According to the severity of BLS, grade II-III versus grade I patients have significantly higher values of HOMA, body mass index (BMI), triglycerides, and longitudinal right liver length. By odds ratio, more severe BLS, increased HOMA, and transaminases are associated with lower GFR. Increased transaminases are associated with higher grades of BLS, HOMA, and BMI. By multiple linear regression waist-to-hip ratio, RRI, and BLS, as significant independent factors (p < 0.0001), explain significantly variance to GFR. This is not observed in normal control group, in which only RRI is a factor explaining GFR. Greater RRI, abdominal obesity, and greater BLS account for a lower GFR in NAFLD patients suggesting the hypothesis that inter-related factors can be operating early in the natural history of obesity-related kidney and liver disease.
- Nov 2010
The relationship between nutrition and atherosclerosis is known, even dissociated from protein malnutrition. Cardiovascular impact of several nutrients is known; among them the action of coffee is still debated and cardiovascular effect of caffeine has been investigated without definite results. The aim of this study is to investigate whether coffee habits, and/or quantity of coffee consumption, have any relationship with renal resistive index (RRI), a hallmark of arterial stiffness (AS). The relationship of AS with nutritional status assessed by body composition and serum albumin, insulin resistance (assessed by HOMA), and renal function assessed by glomerular filtration rate (GFR) is concurrently investigated. Methods: This study was done with 221 consecutive patients, without diabetes, cancer, liver, renal, and heart disease, referred for clinical noninvasive assessment and nutritional counseling: 124 essential hypertensive and 97 nonhypertensive patients were eligible. Personalized Mediterranean diet, physical activity increase, and smoking withdrawal counseling were provided. By multiple linear regression, fat-free mass (FFM), HOMA (positive relationship), and number of cups of coffee/day (negative relationship) account for 17.2% of the variance to RRI. By odds ratios lower risk to increased RRI is associated with higher serum albumin, higher hemoglobin, and FFM; greater risk is associated with hypertension, insulin resistance (HOMA ≥ 3.0), and renal insufficiency (GFR ≤ 90); coffee, assessed by number of cups/day, reduces risk. Coffee use is inversely associated with RRI. Habitual coffee users have risk protection to higher RRI; lower serum albumin, insulin resistance, and renal insufficiency are associated with greater RRI.
- Aug 2010
The study investigates lifestyle and effective anti-hypertensive intervention in overweight-obese patients can influence insulin-resistance (HOMA-IR) and US Renal-Resistive-Index (RRI). After a 1-year interventional program (including a personalized Mediterranean diet, physical activity increase, smoking withdrawal counseling), 156 Essential Hypertension (EH) patients still have abnormal HOMA-IR, significantly higher in comparison to 159 control group patients. Body mass index (BMI) and cholesterol-high-density-lipoprotein improvement are the best predictors of a HOMA-IR decrease; RRI improves in EH according to lifestyle interventions, but no predictor to RRI is identified. Persistence of IR can be tentatively assumed as a steady sign, persistent also after extended lifestyle intervention in EH, further warranting more intensive dietary interventions.
- Jul 2010
Pain visual analog scales (VAS) have been validated for clinical use in fibromyalgia (FM) and rheumatoid arthritis (RA) patients. There are potential limitations, however, not only considering their use as a continuous measurement, but also with regard to the influence of personal illness perceptions, habitual physical activity and other life-style features. The aim of the study was to ascertain whether different illness perception, physical activity and clinical and laboratory characteristics can predict the severity of perceived pain assessed by VAS. This is an observational comparative study of forty consecutive out-patients, 20 of them with fibromyalgia and 20 with rheumatoid arthritis, treated by medical and physical therapy. Patients were assessed also by Pain VAS, Health Assessment Questionnaire (HAQ) disability index, Ritchie index, Baecke questionnaire for physical activity, Illness Perception Questionnaire (IPQr) and SF36. Pain VAS is explained differently by some of the studied variables: in the total group HAQ and Ritchie index explain 29.8% of the variance; in the RA patients number of joints with pain and Ritchie index explain 52.7% of the variance; in FM patients total SF36 score and IPQr personal control dimension explains 44.7% of the variance. No definite role of anxiety and/or depression was found as predictor of perceived pain and disability. Pain perception and complaint are explained by belief in FM patients: This seems to suggest the need for a more articulated cognitive approach; addressing both diagnostic and therapeutic interventions to anxiety/depression issues is not supported by our results.
- Mar 2010
The functional status of ischemic heart disease (IHD) is currently assessed using the Seattle Angina Questionnaire (SAQ), a tool for monitoring and predicting the patient's prognosis. Illness perceptions (IP) are associated with IHD behavioral risk factors. The aim of the study was to find whether different IP, as evaluated by the IP Questionnaire (IPQr), can predict any of the features of the SAQ, i.e., to determine whether the SAQ is influenced and/or biased by illness perceptions. Moreover, whether New York Heart Association class and Ejection Fraction (EF%) are predictors of IHD severity measured as need of subsequent stenting procedures was also assessed. Eighty IHD patients eligible for percutaneous coronary intervention (PCI) and drug-eluting stent implant were asked to complete the IPQr and the SAQ. Laboratory analyses, echocardiography, and coronary diagnostic and interventional procedures were performed concurrently. Physical limitations of the SAQ are predicted by IPQr emotional representation. Ischemic heart disease functional status is regulated by illness perceptions and beliefs. Thus, some of the inferences drawn from the SAQ regarding IHD prognosis and even interventional indications may be biased and compromise the prognostic reliability of the SAQ information on physical function. This can also have consequences for therapeutic indications.
- Feb 2010
The benefits of coffee on abnormal liver biochemistry, cirrhosis and hepatocellular carcinoma have been reported, but there is a lack of satisfactory explanation. Thus, this study aims to investigate if coffee use has any relationship with bright liver, measured by ultrasound bright liver score (BLS), in patients with non-alcoholic fatty liver disease (NAFLD), and which relationship, if any, is present with BMI and insulin resistance. This study was performed on 245 patients, 137 with NAFLD and 108 controls. Coffee drinking was defined according to the absolute number of cups of coffee (only espresso coffee), and also graded as 1 (0 cups of coffee/day), 2 (1-2 cups of coffee/day) 3 (≥3 cups of coffee/day). Insulin resistance was assessed by homoeostasis model-insulin resistance index (HOMA). Less fatty liver involvement is present in coffee vs. non-coffee drinkers. Odds ratios show that obesity, higher insulin resistance, lower HDL cholesterol, older age and arterial hypertension are associated with a greater risk of more severe BLS; to the contrary, coffee drinking is associated with less severe BLS. In the multiple logistic regression (MLR) model, number of cups of coffee, HOMA and BMI account for 35.8% of the variance to BLS. Coffee use is inversely associated with the degree of bright liver, along with insulin resistance and obesity, which, to the contrary, are directly associated with greater likelihood and severity of bright liver appearance. A possible opposite, if not antagonistic, role of coffee with regard to overweightness and insulin resistance, similar to that reported in hepatocarcinoma and cirrhosis, is envisaged in the natural history of NAFLD.
- Oct 2009
Infection with specific pathogens may lead to increased adiposity. The human adenovirus 36 (Ad36) is a relatively new factor in promoting adipogenesis. It seems to improve the metabolic profile, expanding adipose tissue and enhancing insulin sensitivity in animal models. The aim of this study was to investigate whether any association or predictor effect of Ad36 seropositivity is present in non-alcoholic fatty liver disease (NAFLD), a condition associated with obesity and insulin resistance (IR). Sixty-five NAFLD patients and 114 controls were investigated. Ultrasound bright liver score (BLS), body composition, IR evaluated by homeostasis model assessment of insulin resistance index (HOMA or HOMA-IR) and serum neutralization assay for antibodies to Ad36 were assessed. Ad36-seropositive patients have a lower risk of bright liver [OR 0.505 (95% confidence interval (CI) 0.265-0.962)]; greater IR leads to a higher risk of bright liver [OR 9.673 (95% CI 4.443-21.058)]. Among NAFLD, Ad36-seropositive vs. Ad36-seronegative patients did not show a significant IR difference. Ad36-seropositive NAFLD patients, with the same levels of HOMA and BLS, had greater body mass index and body fat mass, in comparison with seronegative NAFLD patients. By a multiple linear regression model, BLS was explained by HOMA (beta 0.513; P<0.0001), high density lipoprotein cholesterol (beta-0.219, P<0.006) and Ad36 seropositivity (beta-0.202, P<0.005); Ad36 seropositivity did not explain HOMA in the other multiple logistic regression model. Ad36 seropositivity is not associated with a significant difference of IR in NAFLD patients, but is associated with a greater adiposity. Ad36 seropositivity is associated with a lower occurrence of NAFLD and bright liver, which, conceivably, is not directly mediated by IR.
Infection with specific pathogens may lead to increased adiposity: a specific adiposity-promoting effect of Ad36 human adenovirus, without the involvement of neurological mechanisms, was reported. The aim of this study is to investigate whether non-diabetic patients with earlier Ad36 infection show greater degrees of overweight obesity, of Insulin Resistance (IR), assessed by homoeostasis-model assessment (HOMA), and/or of other related factors. Moreover, the relationship, if any, among these factors and an earlier Ad36 infection, and the hypothesis of a mechanism involving IR are investigated. Ad36 seropositivity is assessed in 68 obese and 135 non-obese subjects, along with body composition, HOMA and laboratory investigations. Age, body mass index (BMI), waist-hip ratio, blood pressure, insulin, HOMA and triglycerides are significantly greater in the Ad36 seropositive group. Ad36 seropositivity, along with HOMA and total cholesterol, explains BMI variance. No Ad36 seropositivity effect to HOMA could be envisaged by the same statistical model. A significant association of Ad36 seropositivity with obesity and with essential hypertension in human beings is suggested by our study; this association is mostly significant in women. Our results do not support that any Ad36 adipogenic adenovirus effect is operating in human obesity through an insulin-resistance-related mechanism. Ad36 seropositive status could also be a hallmark of a clinical-metabolic profile possibly preceding obesity and diabetes in non-obese patients.
- Oct 2008
In postmenopausal women, an increase in insulin resistance is associated with an increased risk of diabetes, cardiovascular disease and breast cancer. Hormone replacement therapy (HRT) can reduce insulin resistance and coffee use is reported to decrease the incidence of diabetes. The aim of our study was to assess possible concurrent effects of HRT and espresso coffee intake on insulin resistance and on interdependent nutritional and clinical features. A total of 478 healthy postmenopausal, non-diabetic women (aged 54.5 +/- 4.2 years) were studied: 360 had been on HRT for at least 2 years and 118 were not treated. Insulin resistance was assessed by a conventional homeostasis model (HOMA-IR). Results: Insulin resistance is directly related to body mass index (p < 0.0001), and not with age and blood pressure; hypertensive menopausal women have a slightly higher body mass index but the same degree of insulin resistance as normotensive women. Women on HRT show lower insulin resistance, but not lower prevalence of arterial hypertension. Coffee use is associated with a decrease in insulin resistance in non-obese women receiving HRT, but not in other subsets. The combination of coffee consumption and HRT could lower insulin resistance in postmenopausal women. In overweight women, greater insulin sensitivity is associated with intake of espresso coffee and not with HRT; in normal weight women, only HRT is associated with lower insulin resistance.
- May 2008
Nonalcoholic fatty liver disease (NAFLD) because of its association with obesity, diabetes and insulin resistance (IR), is the hepatic expression of metabolic syndrome. Exercise and nutritional intervention can improve and prevent these inter-related conditions; the relationships between the degree of IR and ultrasound (US) morphological post-interventional changes are not defined. The aim of our study was to assess the relationship, if any, in NAFLD patients, among IR, BMI and degree of bright liver, before and after 6 months of a moderately hypocaloric/balanced dietary/lifestyle treatment. Fifty outpatients with a clinical and US diagnosis of NAFLD were studied. Liver echogenicity [Bright Liver Score (BLS)] was scored on a four-graded scale. IR was assessed by homoeostasis model-insulin resistance (HOMA-IR). Body composition was assessed by bioimpedance assessment and skinfold measurements. A significant decrease of BLS was observed, with a concurrent decrease of body weight, body mass index (BMI) and HOMA-IR. Bright liver decrease has a trend parallel to IR, much less steep than the trend of bright liver reduction against US liver dimensions, body weight and BMI decrease. HOMA-IR is the only baseline variable that enters significantly in the multiple regression and, alone, explains 21.4% of variance in predicting bright liver degree. After dietary interventions, both HOMA-IR and BMI are significantly involved in the multiple regression and explain, together, 42.3% of variance in predicting bright liver degree; variation in BLS can be predicted by variation of body weight and of US longitudinal measurement of the liver. Liver US BLS appears to be a useful tool, both alone and along with other US measurements and body weight changes, for the assessment of clinical-metabolic amelioration in patients treated with dietetic interventions. The clinical-diagnostic role, if any, of other assessed laboratory analyses, in the subset of NAFLD, does not appear to be definite.
The Illness Perception Questionnaire (IPQr) is a validated psycho-social tool. Chronic illness out-patients, 48 women and 42 men, 61.36 +/- 14.55 yrs, showed a social stigma related to illness condition, even common and scarcely invalidating, more evident with a lower degree of instruction, associated to limited cognitive representation and to inappropriate control. Duration of illness directly influences perception of "chronicity"; age, instead, positively influences compliance and trust of patients. The study of illness perception, aimed to foresee, interprets and modifies behavioural patterns in health and disease, according to implicit and/or hidden personal and/or social theories, it can improve quality of clinical medical approach.
Psychological stress has been implicated as a cause of several psychosomatic disorders, but also as a factor that can unfavourably influence many diseases including diabetes mellitus. Measure of psychological stress in diabetes was performed by Psychological Stress Measure (PSM), a validated instrument, designed using 49 items drawn from descriptors generated by focus groups on stress. Clinical and psychological framework was assessed in a cohort of 100 type 2 diabetic patients (30 m, 70 f), aged 66.99 +/- 13.68 years considering disease grade, complications and level of instruction. Three other questionnaires were administered concurrently to all patients: Sickness Impact Profile (SIP), Functional Living Index (FLI) and SF-36 QOL. ANOVA statistical testing and Spearman correlation matrix were used also vs socio-cultural and clinical profile. Gender, obesity, diet compliance, smoking do not affect PSM response. Hypertensive patients and those with family history of diabetes show lower PSM scores, according to a sort of moderator effect on stress of concurrent and/or previous experience with chronic disease. Neuromuscular ailments are more prevalent in women; men vs women experience severe limitations of their working capacities and relational possibilities, with severe discomfort. In the whole, higher scores of PSM (greater stress p < 0.01) and lower scores of FLI (fair well-being perception; p < 0.01) are reciprocally related inside any school instruction level. Despite the great reciprocal association of the PSM vs FLI and SIP, no significant correlation is found between PSM vs SF-36 QOL. Socio-cultural elements interfere, and particularly instruction level quantified as school grades achieved, with the manner of living their disease. Interventions on psychological distress of type 2 diabetes mellitus patients is warranted, specially in the groups with lower levels of instruction which may need an attentive strategy for achieving a satisfactory coping with this disease.
Different clinical features of diabetic patients and type of complications are certainly a critical components of the global individual perception of quality of life (qol); but also personal socio-cultural characteristics interfere concurrently. Qol in diabetes was assessed considering disease grade, complications and level of instruction in a population of 100 diabetic patients (30 m, 70 f), aged 66.99 +/- 13.68 years. Two questionnaires were administered to all patients; Sickness Impact Profile (SIP) and Functional Living Index (FLI). SIP is an index of psycho-social, physical and motor functionality; FLI derives from a scale devised for cancer patients and adapted to diabetic patients. Both were analysed by Spearman correlation test, and assayed vs. sociocultural profile and clinical symptoms. Neuro-muscular ailments were more prevalent in women; men experience severe limitations of working capacities an relational possibilities, with severe discomfort. In the whole, higher scores of SIP (greater disability p: ns) and lower score for FLI (scant well-being perception r = 0.29: p<0.01) are related with lower school instruction level. Global QOL score is related as well with degree of instruction (r = 0.22: p<0.03). So QOL is altered during chronic diseases: however, in diabetes, qol impairment does not seem related with severity, treatment features and complications of diabetes. Socio-cultural elements, and particularly instruction level quantified as school grades achieved, interfere with the manner of living diabetic disease.
Unlabelled: Aim of the study was to ascertain if a common cultural feeling of young people toward health, disease, physician's role and doctor-patient relationship, is present, and if under- and post-graduate students concepts and opinions modify during their stay in a School of Medicine. The study (1999-2001) was performed by anonymous questionnaires with 75 students (m = 28; f = 47) of the State School of Medicine, tested at the 3rd year, and with 73 students (m = 29; f = 44) tested at the 5th year of course; moreover with 71 (m = 30, f = 41) postgraduate residents at the 3rd year of specialty (Internal Medicine, Cardiology and Surgery). A group of 76 (m = 33; f = 43) students of the last year of a high school was also tested as reference group. Results: Interference of medical under- and post-graduate school curricula on thoughts of youngsters toward health, disease, physician's role and doctor-patient relationship appears quite limited. Dissimilar way of thinking of medical vs. non-medical students was confined to some aspects concerning patient's possibility of healing, physician's role, behavior and function in chronic diseases. In the whole, our results suggest a trend, growing with the age of students, toward a more authoritarian and less "participative" approach with the patient: less confident relationship and more conflictual and antagonistic behaviors are widely considered and accepted. A general perspective with the construct of an authoritarian concept of health is superimposed as a net of rules and conditions on feelings' background of youngsters: postgraduate students regard themselves (and are perceived by younger students) as the guardians of an "healthy" system founded on scientific, economical and sociological grounds, as a work pointing to effectiveness, more than as a science with the target of efficacy. Conclusion: Impact of curricular studies of Medicine on youngsters is complex, but seems to modify only some and limited aspects of previously acquired thoughts and feelings on health and disease.
- Nov 2003
Circulatory effects of parathyroid hormone (PTH) were reported in experimental animal models, also in liver portal system. We devised to study non invasively relationship between plasmatic iPTH and portal blood flow rate in humans. The study was done in a group of healthy post-menopausal women aged 52.0 +/- 5.2 years (range 47-65), not treated with hormone therapy, with different body mass index. Women were studied by echocolor-doppler and by clinical and biochemical assays of common laboratory test and of iPTH, insulin and prolactin (RIA). A positive correlation between iPTH and mean portal flow rate was observed in the overall group. Women with BMI < 25 showed a more marked correlation between these two parameters, not observed in women with BMI > 25, with slight-moderate overweight. In this last group an inverse correlation between blood pressure and iPTH was observed. From these preliminary results, as previously observed in chronic disease, relationship among iPTH, regional flows and nutritional state can be operating also in physiological conditions.
- May 2002
Anaemia commonly occurs in cancer patients on chemotherapy, often necessitating blood transfusion, and, in most recent years, treatment with human recombinant cythropoietin (rHuEPO). However, several extra-hematological effects were reported for EPO, and multi-organ physiological effects on development and repair of tissues are described both on nerves and muscles. Moreover, EPO is presently used in oncological patients with the goal of preventing or limiting anemia secondary to chemotherapy. Ten patients with advanced lung cancer and without neurological impairment assessed by Siegal score and without severe anemia, were studied. Patients (age 56.2 +/- 8.3 years) were random assigned to two groups of 5 patients each: the control group and the EPO treated group. In both groups, at the end of the study, hemoglobin concentration was not different (above 9 mg/dl). In EPO treated group neurological score was 4.00 +/- 1.87, significantly lower (p < 0.004) in comparison with untreated group (score 9.20 +/- 4.32). From these preliminary data we suggest that EPO treatment in cancer patients can exert also a limiting effect on cisplatin peripheral neurotoxicity.
- Mar 2002
Causal association between perimenopausal changes and symptoms and disease is commonly accepted even if not definitely explained. Resistive index (RI) of renal artery assessed by Doppler echography is related to renal function and systemic circulatory adaptation in patients with chronic renal failure and hypertension. Echocardiographic measurement of left ventricular myocardial mass (LVMM) is a useful tool for assessing effects of arterial hypertension on heart. Aim of the study was to assess RI in normotensive postmenopausal women and relationship, if any, with blood pressure and LVMM. We studied 28 normotensive, non-obese postmenopausal women, age 52.21 +/- 5.40 years, with normal creatinine clearance. Renal colour-Doppler echography was performed assessing intra-parenchimal renal artery mean velocity (mVRA) and intra-parenchimal RI [(peak systolic velocity - end diastolic velocity)/peak systolic velocity]. Echocardiography was performed as well. RI of intra-parenchimal renal artery is 0.67 +/- 0.05 and it shows correlations vs. diastolic blood pressure (r=0.41; P<0.03) and vs. mean BP (r=0.47; P<0.01). LVMM has correlation (r=0.41; P>0.03) with RI. Age, body weight, body mass index, menarche age, fertility years and postmenopausal years do not show correlation with RI. Heart rate, creatinine clearance, hemoglobin, serum albumin do not show any correlation with RI. Higher RI is associated with alcohol intake, liver steatosis, biliary gallstones and family history of diabetes mellitus, but not with postmenopausal years, unrespective of surgical or non-surgical menopause. Among echocardiographic measurements only LVMM is correlated with RI; mVRA does not show correlation. LVMM and BP do not show other independent correlation except that the one already reported vs. RI. RI, as a pathophysiological measurement whose increase preludes to arterial hypertension, could help to ascertain perimenopausal women at risk for arterial hypertension and left ventricular hypertrophy, but does not seem directly associated with the loss of ovarian function.