Acta Bio Medica Atenei Parmensis <p><strong>Important Announcement:</strong> <strong>OJS Upgrade</strong></p> <p><strong>We are moving to new platform in a few days so please don’t submit articles until this Announcement will be removed from the site. During this time the site will be unavailable.</strong></p> <p>&nbsp;</p> <p><span id="result_box" class="long_text">Expression of the Society of Medicine and Natural Sciences of Parma and Centre on Health System's Organization, Quality and Sustainability, Parma.<br></span></p> <p><span id="result_box" class="long_text">Acta Bio Medica is now one of the few Italian generals reviewed publications on major international databases. <br></span><span title="Divisa in sezioni di ricerca, aggiornamento monografico e casi clinici, rappresenta uno strumento di formazione ad ampio spettro attento alle più recenti acquisizioni della moderna scienza medica.">Divided into sections on research, case studies and updated monograph, is a training tool for broad spectrum close to the most recent advances of modern medical science.</span></p> <p><strong><strong>Language:</strong> </strong>English<strong> <br>Frequency:</strong> Three-monthly (4 issues/year)<br><strong>Format:</strong> 20 x 27 cm</p> <p><span title="Divisa in sezioni di ricerca, aggiornamento monografico e casi clinici, rappresenta uno strumento di formazione ad ampio spettro attento alle più recenti acquisizioni della moderna scienza medica.">&nbsp;</span></p> <p><span title="Divisa in sezioni di ricerca, aggiornamento monografico e casi clinici, rappresenta uno strumento di formazione ad ampio spettro attento alle più recenti acquisizioni della moderna scienza medica.">&nbsp;</span></p> mattioli 1885 srl en-US Acta Bio Medica Atenei Parmensis 0392-4203 Birth of a new Journal section on Emergency Medicine Not available Gianfranco Cervellin Tiziana Meschi ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 391 392 10.23750/abm.v88i4.7001 Complications associated with brachioplasty: a literature review <p class="p1"><em>Background:</em><strong> </strong>Paralleling the growth of bariatric surgery, the demand for post-bariatric body-contouring surgery is increasing.<strong> </strong>Weight loss is the main cause, although not the only one, that drives patients to arm lift surgery. Several surgical techniques have been proposed over the years. Our aim was to consider the complications and outcomes according to the performed technique, through a wide review of the literature. <em>Methods:</em><strong> </strong>A search on PubMed/Medline was performed using “brachioplasty”, “upper arm lifting”, and “techniques” as key words. Embase, Medline (OvidSP), Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar were searched as well. As inclusion criteria, we selected the clinical studies describing techniques of brachioplasty. We excluded the papers in which complications related to brachioplasty were not specified. We also excluded literature-review articles. <em>Results:</em><strong> </strong>We found 27 studies from 1995 to 2015. Overall, 1065 patients were treated. Different techniques were applied. Complications were observed in 308/1065 patients (28.9%). The most frequent complications were hypertrophic scarring, seroma and hematoma. Surgical revision rate ranged from 0 to 21 percent. Nerve damage occurred in a modest percentage of patients (16/1065, 1.5%). No major complications, such as thromboembolism and sepsis, were observed. <em>Conclusions:</em><strong> </strong>Brachioplasty is a safe surgical procedure. All the brachioplasty techniques showed positive outcomes, in term of patients’ satisfaction and clinical results. Nevertheless, minor complications occurred in a high percentage of patients, regardless the performed surgical procedure. Patients should be informed about the possible formation of hypertrophic scars and nerve injuries. </p> Andrea Sisti Roberto Cuomo Luca Milonia Juri Tassinari Antonio Castagna Cesare Brandi Luca Grimaldi Carlo D'Aniello Giuseppe Nisi ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 393 402 10.23750/abm.v88i4.5609 The law on artificial insemination: an italian anomaly <p class="p1">The law on medically assisted procreation in Italy, from its entering into force, has undergone numerous amendments. This has been due to the fact that those citizens, directly affected by its imposed prohibitions, have not given in, bringing their requests before the courts, both nationally and internationally. Over the years, the courts through numerous rulings have significantly changed a law clearly incapable of protecting the rights of those involved. Currently Italy has an acceptable law on M.A.P. which is the result of the strong willing of citizens affected by problems of sterility or infertility. The aim of this paper is to present an historical summary of the troubled path which the issue, from every perspective, has faced and is still facing today. As well, it will document how, in Italy, the case-law and, therefore, the law’s interpretation and application by the judges have contributed, in the end, to shaping a positive legislation. </p><p align="center"><strong> </strong></p> rossana cecchi Vittoria Masotti Arturo Umberto Meo Raffaella Rinaldi ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 403 408 10.23750/abm.v88i4.6066 Autolytic debridement and management of bacterial load with an occlusive hydroactive deressing impregnated with polyhexamethylene biguanide <p class="p1"><em>Background:</em> Debridement and control of bacterial load are key-points of wound care. The aim of this study is to evaluate the effectiveness of autolytic debridement and management of bacterial load (bioburden) of an occlusive hydro-active dressing impregnated with polyhexamethylene biguanide (PHMB). <em>Methods: </em>We used an occlusive dressing of hydro-active for leg ulcers’ treatment (TenderWet-plus® – Hartmann).  Inclusion criteria were: presence of a fibrinous ulcer with multiple etiopathogenesis, in absence of clinical infection, no hypersecretion and diameter within 5 cm. Swab for bacterial bioburden control were made at start of the study, after 3 and 7 days. We made also a measurement of the amount of granulation tissue and of pain with VAS scale; bacterial bioburden control inside the dressing was made too. <em>Results:</em> 28 leg ulcers were treated (12 venous, 5 diabetic, 8 thraumatic, 3 mixed) in 25 patients. The ulcer has been completely covered with fibrin in almost all cases and the bacterial load was represented mainly by <em>Staphylococcus aureus</em> (80% of the cases) with a load within 10.000UFC/plate in 81,5% of the cases. Control at 3 and 7 days have shown the appearance of granulaton tissue up to 67,8% of the wound surface. Bacterial bioburden (load) remained constant in 50% of the cases, decreased in 15%, increased in 35% of the cases. <em>Conclusion:</em> TenderWet-plus® has proven to be effective and quick in autolytic debridement and at the same time be able to handle the bacterial load in most cases. It can then be used for home treatment. </p><p> </p> Stefano Mancini Roberto Cuomo Mauro Poggialini Carlo D'Aniello Giuseppe Botta ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 409 413 10.23750/abm.v88i4.5802 BRASS score and complex discharge: a pilot study <p><em>Aims: </em>A highly functional continuity of patient care, which is linked to the reduction of the risk of long-term hospitalization, above all for ‘at-risk’ patients. Research into an objective, reliable instrument for redirecting individual results to organizational aims to extend the entire country, is a fundamental step to move from a reactive assistance approach to a pro-active one. <em>Methods: </em>An observational and descriptive retrospective study was carried out July - November 2014 in two Italian state hospitals, completing the BRASS Index within 48/72 hours of admission. <em>Results: </em>The study group consisted of 122 inpatients. A correlation presented itself, albeit low (ñ=0.05191), between age and the number of ‘revolving door’ admissions; a medium correlation (ñ=0.485131) between age and risk band (according to BRASS). <em>Conclusions: </em>The BRASS Index is straightforward and swift, and can prove a valuable tool in directing nurses’ attention to those patients most at risk of prolonged hospitalization. </p> Valentina Cammilletti Fortunata Forino Marina Palombi Daniele Donati Daniela Tartaglini Marco Di Muzio ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 414 425 10.23750/abm.v88i4.6191 Italian version of Dyspnoea-12: cultural-linguistic validation, quantitative and qualitative content validity study <p><em>Background: </em>Dyspnoea-12 is a valid and reliable scale to assess dyspneic symptom, considering its severity, physical and emotional components. However, it is not available in Italian version due to it was not yet translated and validated. For this reason, the aim of this study was to develop an Italian version Dyspnoea-12, providing a cultural and linguistic validation, supported by the quantitative and qualitative content validity. <em>Methods:</em> This was a methodological study, divided into two phases: phase one is related to the cultural and linguistic validation, phase two is related to test the quantitative and qualitative content validity. Linguistic validation followed a standardized translation process. Quantitative content validity was assessed computing content validity ratio (CVR) and index (I-CVIs and S-CVI) from expert panellists response. Qualitative content validity was assessed by the narrative analysis on the answers of three open-ended questions to the expert panellists, aimed to investigate the clarity and the pertinence of the Italian items. <em>Results:</em> The translation process found a good agreement in considering clear the items in both the six involved bilingual expert translators and among the ten voluntary involved patients. CVR, I-CVIs and S-CVI were satisfactory for all the translated items. <em>Conclusions: </em>This study has represented a pivotal step to use Dyspnoea-12 amongst Italian patients. Future researches are needed to deeply investigate the Italian version of  Dyspnoea-12 construct validity and its reliability, and to describe how dyspnoea components (i.e. physical and emotional) impact the life of patients with cardiorespiratory diseases. </p> Rosario Caruso Cristina Arrigoni Katia Groppelli Arianna Magon Federica Dellafiore Francesco Pittella Anna Maria Grugnetti Massimo Chessa Janelle Yorke ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 426 434 10.23750/abm.v88i4.6341 An ICET- A survey on Hypoparathyroidism in Patients with Thalassaemia Major and Intermedia: A preliminary report <p class="p1">Hypoparathyroidism (HPT) is a rare disease with leading symptoms of hypocalcemia, associated with high serum phosphorus levels and absent or inappropriately low levels of parathyroid hormone (PTH). In patients with thalassemias it is mainly attributed to transfusional iron overload, and suboptimal iron chelation therapy. The main objectives of this survey were to provide data on the prevalence, demographic and clinical features of HPT in thalassemia major (TM) and intermedia (TI) patients living in different countries, and to assess its impact in clinical medical practice.<strong> </strong>A<em> </em>questionnaire was sent to all Thalassemia Centres participating to the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine (ICET-A) Network.Seventeen centers, treating a total of 3023 TM and 739 TI patients, participated to the study. HPT was reported in 206 (6.8%) TM patients and 33 (4.4%) TI patients. In general, ages ranged from 10.5 to 57 years for the TM group and from 20 to 54 years for the TI group. Of the 206 TM patients and 33 TI patients with HPT, 117 (48.9%) had a serum ferritin level &gt;2.500 ng/ml (54.3% TM and 15.1% TI patients) at the last observation. Hypocalcemia varied in its clinical presentation from an asymptomatic biochemical abnormality to a life-threatening condition, requiring hospitalization. Calcium and vitamin D metabolites are currently the cornerstone of therapy in HPT. In TM patients, HPT was preceded or followed by other endocrine and non-endocrine complications. Growth retardation and hypogonadism were the most common complications (53.3% and 67.4%, respectively). Although endocrine complications were more common in patients with TM, non-transfused or infrequently transfused patients with TI suffered a similar spectrum of complications but at a lower rate than their regularly transfused counterparts.In conclusion, although a large international registry would help to better define the prevalence, comorbidities and best treatment of HPT, through the result of this survey we hope to give a clearer understanding of the burden of this disease and its unmet needs. HPT requires lifelong therapy with vitamin D or metabolites and is often associated with complications and comorbidities.Therefore, it is important for endocrinologists and other physicians, who care for these patients, to be aware of recent advances of this disorder.</p> Vincenzo De Sanctis Ashraf T. Soliman Duran Canatan Heba Elsedfy Mehran Karimi Shahina Daar Hala Rimawi Soteroula Christou Nicos Skordis Ploutarchos Tzoulis Praveen Sobti Shruti Kakkar Yurdanur Kilinc Doaa Khater Saif A Alyaarubi Valeriya Kaleva Su Han Lum Mohamed A Yassin Forough Saki Maha Obiedat Salvatore Anastasi Maria Concetta Galati Giuseppe Raiola Saveria Campisi Nada Soliman Mohamed Elshinawy Soad Al Jaouni Salvatore Di Maio Yasser Wali Ihab Zaki Elhakim Christos Kattamis ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 435 444 10.23750/abm.v88i4.6837 Experience of Oesophageal atresia management in a tertiary Bangladeshi hospital <p class="p1"><em>Objectives:</em> <em>Background and aim:</em> This study has been conducted to determine the clinical presentations and surgical outcome of patients with OA admitted in a tertiary level hospital in Bangladesh. <em>Methods:</em> A prospective analysis was conducted for 32 patients with confirmed OA between July 2007 and June 2015. Of them surgical correction was done in 25 cases. The other 7, in whom surgery could not be done, were excluded from the study. <em>Results: </em>Of the 25 cases, that had been operated, 15 were full term and 52% were more than 48 hours old. Type-C OA with TOF was the commonest type (96%). 24 cases were operated through Right Thoracotomy. Of them 52% were done by Single Lung (left) ventilation. ‘Division of the fistula’ with ‘end to end anastomosis’ was done in all of them. Only 1 patient had a Gastric pull up surgery. Of the 25 cases, 16 survived (64%). In follow up all the patients were found thriving and showed no problem in swallowing. <em>Conclusion: </em>Our study which shows 64% survival is a great achievement for us but not satisfactory in international standard. However, the experience and encouragement that we are gathering, will guide us to achieve better result in near future. </p> Md Kabirul Islam ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 445 449 10.23750/abm.v88i4.5743 Thiopental is better than propofol for electroconvulsive therapy <p class="p1"><em>Background and aim of the work:</em> electroconvulsive therapy is a psychiatric procedure requiring general anesthesia. The choice of the hypnotic agent is important because the success of the intervention is associated to the occurrence and duration of motor convulsion. However, all available anesthetic agents have anti-convulsant activity. We compared the effect of thiopental and propofol on seizures. <em>Methods: </em>We designed a retrospective study at Mood Disorders Unit of a teaching Hospital. Fifty-six consecutive patients undergoing electroconvulsive therapy were enrolled<strong>. </strong>Patients received fentanyl followed by either thiopental or propofol. We evaluated the incidence and the duration of seizure after electric stimulus at the first session of electroconvulsive therapy for each patient. Adverse perioperative effects were recorded. <em>Results: </em>Patients were 60±12.1 years old and 64% was female. There was a statistically significant higher number of patients who had motor convulsion activity in the thiopental group when compared to the propofol group (25 vs 13, p=0.023). Seizure duration was statistically significant longer in the thiopental group than in the propofol group (35 sec vs 11 sec, p=0.046). No hemodynamic instability, oxygen desaturation episodes, prolonged recovery time from anesthesia and adverse effects related to anesthesia were recorded. <em>Conclusions:</em> Thiopental induction has a favourable effect on seizure when compared to propofol in patients undergoing electroconvulsive therapy.</p><p> </p> Massimiliano Nuzzi Dario Delmonte Barbara Barbini Laura Pasin Ornella Sottocorna Giuseppina Maria Casiraghi Cristina Colombo Giovanni Landoni Alberto Zangrillo ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 450 456 10.23750/abm.v88i4.6094 Rest 2D speckle tracking echocardiography may be a sensitive but nonspecific test for detection of significant coronary artery disease <p class="p1"><em>Aims:</em><strong> </strong>To detect the significance of coronary artery disease in the patients, who are suspected, was assumed to be one of the advantages of 2D STE, as a novel non-invasive imaging modality with acceptable accuracy. <em>Methods:</em> In this study, 216 patients who were suspected to have coronary artery disease and candidate for coronary angiography, underwent rest two-dimensional speckle tracking echocardiography (2D STE) and negative global systolic longitudinal strain was evaluated. Results: Negative global systolic left ventricular longitudinal strain under 18% in rest 2D-STE was significantly prevalent in patients with significant CAD in coronary angiography (P value&lt;0.0001).Our results revealed sensitivity of 91.1%, specificity of 63.0%, positive predictive value of 80.4%, negative predictive value of 81.0% and accuracy of 80.5% for rest 2D-STE in detection of significant CAD. <em>Conclusion:</em> Here in we showed that rest Two-dimensional speckle tracking echocardiography could be a sensitive but nonspecific imaging modality to determine significant coronary artery disease. Future studies with large size will reveal more detailed findings.</p> Mohammad Parsa Mahjoob Saeed Alipour Parsa Asghar Mazarei Morteza Safi Isa Khaheshi Shooka Esmaeeli ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 457 461 10.23750/abm.v88i4.5445 Retrospective analysis of the effects of a highly standardized mixture of Berberis aristata, Silybum marianum, and monacolins K and KA in diabetic patients with dyslipidemia <p class="p1"><em>Background:</em><strong> </strong>Berberine, an alkaloid with both glucose- and cholesterol-lowering action, is also characterized by an anti-diarrheal effect. Consequently, berberine-based therapies are recommended for diabetic patients with irritable bowel syndrome (IBS) or gut discomfort caused by metformin. <em>Aim:</em><strong> </strong>As the anti-glycemic and cholesterol-lowering action of berberine is improved by co-administration with P-glycoprotein inhibitors and naturally derived statins, we have analyzed the effect of the food supplement Berberol®K (hereafter referred to as BSM) containing, berberine, silymarin, and a highly standardized red yeast rice containing monacolins K and KA in the ratio 1:1 but no secondary monacolins, dehydromonacolins, or citrinin (Monakopure™-K20). <em>Methods:</em><strong> </strong>We retrospectively evaluated the effects of BSM in 59 diabetic patients with dyslipidemia and compared the results to those obtained in patients without treatment. Enrolled subjects had a diagnosis of IBS (and diarrhea), had diarrhea caused by metformin, or were statin intolerant. <em>Results:</em><strong> </strong>After 6 months of BSM treatment, significant reductions of approximately 5%, 23%, 31%, and 20% were observed in glycated hemoglobin (HbA1c), total cholesterol (TC), low density lipoprotein-cholesterol (LDL), and triglyceride (TG) levels, respectively, and only five of the 31 treated subjects reported diarrhea compared with 22 of the 28 untreated patients. Regarding safety, treatment with BSM did not significant modify creatine phosphokinase (CPK), creatine, aspartate aminotransferase (AST) or alanine aminotransferase (ALT). <em>Conclusion:</em><strong> </strong>BSM is a safe and effective food supplement likely useful as add-on therapy in diabetic subjects with dyslipidemia, especially if they are statin intolerant or with diarrhea caused by IBS or metformin. </p> Francesco Di Pierro Pietro Putignano Nicola Villanova ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 462 469 10.23750/abm.v88i4.5851 High protein intake in human/maternal milk fortification for ≤1250 gr infants: intrahospital growth and neurodevelopmental outcome at two years <p><em>Background and aim of the study:</em> Extrauterine growth restriction and failure to thrive remain a major problem in Extremely Low Birth Weight infants. Nutritional support in preterm babies has the objective to improve the achieve rate of growth similar to those of the fetus in utero at the equivalent gestational age. The aim of the study was to evaluate feeding tolerance, intrahospital growth, neurological outcome and anthropometric data until 24 months of corrected age (mca) from different protein intake assumed by preterm babies &lt;1250 g during their stay in NICU. <em>Methods:</em> The study evaluates auxological/neurodevelopmental outcomes until 24 months of corrected age (mca) in preterm infants with different protein intake (control group-CG: 3,5g Kg‾¹ perday; intervention group-PSG: 4,8g Kg‾¹ per day). <em>Results:</em> PSG group showed a significant higher length growth at 9 mca (p 0,04) and hearing/language score of Griffiths Mental Development Score (GMDS) at 12 (p 0,03) and 18 mca  (p&lt;0,05) comparing with CG. PSG-ELBW preterms showed an higher intrahospital head circumference (p 0,02) and length growth rate (p 0,04), greater Performance (p 0,04) and Hearing/Language (p 0,03) scores of GMDS at 3 and 12 mca. PSG-SGA preterms showed significantly higher scores in GMDS scores at 18 and 24 mca except for the locomotor domain. <em>Conclusions:</em> Supplemental enteral proteins lead to benefits of reduced postnatal growth restriction and better neurological outcome in preterm infants &lt;1000 g and in those SGA &lt;1250 g.</p> Augusto Biasini Fiorella Monti Maria Chiara Laguardia Marcello Stella Lucia Marvulli Erica Neri ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 470 476 10.23750/abm.v88i4.5316 Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities <p class="p1"><em>Aim</em>: To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D). <em>Methods</em>: Children &lt;10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management. <em>Results</em>: From 1<sup>st</sup> January 2014 to December 31<sup>st </sup>2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program. <em>Conclusions</em>: The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members. </p> Brunella Iovane Antonina Marta Cangelosi Ilaria Bonaccini Carla Mastrorilli Dora Di Mauro Valentina Fainardi Giovanni Chiari Marilena Maltese Carlo Caffarelli Maurizio Vanelli ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 477 482 10.23750/abm.v88i4.6779 Synovial cysts of the hip. <p class="p1"><em>Background:</em><strong> </strong>Synovial cysts of the hip are relatively rare lesions comparing to other joints. Patients are usually asymptomatic, but in some cases symptoms such as pain and/or compression of vessels or nerve could be present. Purpose of the study was to define clinical features and optimal management of synovial cyst of the hip joint through an accurate review of the literature. <em>Methods:</em> We present three consecutive cases treated with three different therapeutic strategies: surgical excision, wait-and-see and needle aspiration. An accurate review of the literature has been performed to identify patients who had been treated for synovial cyst of the hip. <em>Results:</em><strong> </strong>Due to the rarity of the disease, there are no significant data in literature supporting the gold standard of treatment. Treatment of the synovial cyst depends on their size, symptoms and comorbidities. <em>Conclusions:</em><strong> </strong>Most of the Authors recommend surgical treatment for symptomatic synovial cysts and needle aspiration as an option treatment in asymptomatic patients without vessel or nerve compression. In patients that referred symptoms in correspondence with the hip joint, not strictly related with radiograph findings, a CT or MRI examinations should be performed to exclude possible differential diagnosis.</p> Andrea Angelini Gabriele Zanotti Antonio Berizzi Guido Staffa Elio Piccinini Pietro Ruggieri ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 483 490 10.23750/abm.v88i4.6896 Laparoscopic gastric bypass with remnant gastrectomy in a super-super obese patient with gastric metaplasia: a surgical hazard? <p class="p1">The endoscopic inaccessibility of the gastric remnant after Roux-en-Y gastric bypass (RYGBP) for morbid obesity represents an important issue for patients with familiar history of gastric cancer (GC) or affected by premalignant lesions, such as intestinal metaplasia. If a different bariatric procedure is contraindicated, RYGBP with remnant gastrectomy represents a reasonable alternative, significantly reducing the risk of GC but potentially increasing postoperative morbidity. For this reason, only few cases have been reported in the recent Literature and none regarding a super-super obese patient. We present the case of a 55-year-old super-super obese man with a family history of GC and antral gastritis with extensive intestinal metaplasia at preoperative upper endoscopy, who underwent laparoscopic RYGBP with remnant gastrectomy.</p> Francesco Tartamella Gabriele Petracca Andrea Romboli Federico Marchesi ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 491 495 10.23750/abm.v88i4.6671 Melanoma in situ mimicking a Lichen planus-like keratosis <p class="p1">The incidence of melanoma has steadily increased over the past three decades. Melanoma in situ (MIS),  defined as melanoma that is limited to the epidermis, contributes to a disproportionately high percentage of this rising incidence. Amelanotic melanoma presents as an erythematous macule or plaque and may initially be misdiagnosed as an inflammatory disorder. We report a case of amelonatic MIS raised on non-sun-exposed skin, inducing a lichen planus-like keratosis as inflammatory reaction, which clinically masked the melanoma.</p> Andrea Sisti Amgiad Fallaha Juri Tassinari Giuseppe Nisi Luca Grimaldi Klaus Eisendle ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 496 498 10.23750/abm.v88i4.5699 The Schmidt Syndrome <p class="p1">Addison’s disease (AD) is a rare endocrine condition related to adrenal insufficiency. Autoimmune adrenalitis is commonly associated with autoimmune diseases. Autoimmune Addison’s Disease (AAD) describes Autoimmune Polyendocrine Syndrome (APS) in 60% of patients with an important immunitary pathogenesis imprinting. We describes a case of Autoimmune Polyendocrine Syndrome charachterize by adrenal insufficiency and thyroid disease (Schmidt Syndrome). In this case report, Addison’s disease had a slow onset in absence of the typical weight loss. In our considerations this is due to the concomitant hypothyroidism that masked some typical signs and also limited acute presentation. </p> Carmine Siniscalchi Valentina Moretti Simona Cataldo Anna Rocci Manuela Basaglia Maria Ilaria Tassoni Roberto Quintavalla ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 499 501 10.23750/abm.v88i4.5117 Concealed lung anatomy in Botticelli’s masterpieces the primavera and the birth of venus <p class="p1">Sandro Botticelli was one of the most esteemed painters and draughtsmen among Renaissance artists. Under the patronage of the De’ Medici family, he was active in Florence during the flourishing of the Renaissance trend towards the reclamation of lost medical and anatomical knowledge of ancient times through the dissection of corpses. Combining the typical attributes of the elegant courtly style with hallmarks derived from the investigation and analysis of classical templates, he left us immortal masterpieces, the excellence of which incomprehensibly waned and was rediscovered only in the 1890s. Few know that it has already been reported that Botticelli concealed the image of a pair of lungs in his masterpiece, <em>The Primavera</em>. The present investigation provides evidence that Botticelli embedded anatomic imagery of the lung in another of his major paintings, namely, The Birth of Venus. Both canvases were most probably influenced and enlightened by the neoplatonic philosophy of the humanist teachings in the De’ Medici’s circle, and they represent an allegorical celebration of the cycle of life originally generated by the Divine Wind or Breath. This paper supports the theory that because of the anatomical knowledge to which he was exposed, Botticelli aimed to enhance the iconographical meaning of both the masterpieces by concealing images of the lung anatomy within them. </p> Davide Lazzeri ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 502 509 10.23750/abm.v88i4.5981 An Osteological Museum inside the Varese Medical School? A proposal from the Medical, Antropological and Paleopatological point of view Not available Marta Licata Ilaria Gorini Silvia Iorio ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 510 511 10.23750/abm.v88i4.5920 Medical Humanities. Recognition and reorganization within the Italian University Not available Sara Patuzzo Rosagemma Ciliberti ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 512 513 10.23750/abm.v88i4.6407 Visits for alcohol-related problems in a large urban Emergency Department. Results of a 15-year survey. <p class="p1">Alcohol abuse is associated with a high burden of morbidity and mortality. Nevertheless, definitive epidemiological data on alcohol-related visits in the emergency department (ED) is substantially lacking. This study was aimed to analyze the epidemiological patterns and temporal trends of alcohol-related visits in the local ED, and assessing the healthcare burden of cases needing hospital admission. All patients visited for alcohol-related problems between the years 2002-2016 were anonymously identified from the hospital database. All cases were classified according to the main cause leading to ED, age and gender, time of presentation, disposition. Overall, 8014 cases were identified (2249 women and 5765 men). Women were younger than men. The overall trend during the study period was characterized by a constant increase in the number of alcohol-related ED admissions. A significant number of subjects had multiple alcohol-related visits. A total number of 747 patients were visited twice, 259 three times and 107 four times. A mostly nocturnal pattern of ED presentation was observed in both genders, peaking between midnight and 2 AM, and an increased number of visits was recorded during the weekends. The vast majority of patients (64%) could be discharged within 6 hours, but a considerable number needed longer observation and treatment in the ED. Overall, 7551 patients were discharged from the ED, whilst 462 patients needed hospital admission, 179 for traumatic injuries and 283 for non-traumatic causes. The decreasing age of subjects admitted to the ED with alcohol-related problems should now be regarded as a public healthcare issue.</p> Ivan Comelli Giuseppe Lippi Fabian Sanchis-Gomar Gianni Turcato Gianfranco Cervellin ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 514 518 10.23750/abm.v88i4.6646 Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems <p class="p1"><em>Background: </em>Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. <em>Aim of the work and Methods:</em> To critically analyze pneumonia “rebound” cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome. <em>Results:</em> 249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days. <em>Conclusions:</em> The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit. </p> Rodolfo Ferrari Pierluigi Viale Paolo Muratori Fabrizio Giostra Daniela Agostinelli Roberto Lazzari Riccardo Voza Mario Cavazza ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 519 528 10.23750/abm.v88i4.6685 Takotsubo cardiomyopathy in an ultra-centenarian woman <p><span style="font-family: Times New Roman;"><span style="font-size: medium;">A 101 years-old woman was admitted to our Emergency Department (ED) for acute dyspnea which onset nearly two hours before presentation. She had been on hydrochlorothyazyde-amiloride therapy due to mild hypertension. No other relevant features were present in the clinical history. The old lady had never been admitted to the hospital, and she was still living alone. A few days before hospital admission, one of the daughters became ill, so that a caregiver was paid for assisting her 12/24. This new circumstance was reluctantly accepted by the old lady. At ED presentation the patient was dyspnoic but alert. The electrocardiogram showed a marked elevation of the ST segment in V2-V6 leads. The echocardiogram showed the typical apical ballooning, characteristic of takotsubo cardiomyopathy. Blood test only showed a significant increase of cardiac troponin I. Considering the very good conditions of the patient, a coronary angiography was performed, that demonstrated a coronary tree totally free of lesions, thus confirming the clinical suspicion of takotsubo syndrome. The patient was admitted to the Coronary Care Unit, where she had a very good clinical course, and was discharged on day 6</span><sup><span style="font-size: small;">th</span></sup><span style="font-size: medium;"> after presentation. After one month of follow-up the clinical course was uneventful and the lady remained in good clinical and lifestyle conditions as before presenting to the ED. This unique case attests that takotsubo cardiomyopathy can be also observed at extreme ages, and should hence be considered in the differential diagnosis of acute dyspnea and chest pain in extremely elderly patients.</span></span></p> Laura Bonfanti Silvia Buratti Luigi Vignali Giuseppe Lippi Franco Masini Michele Bianconcini Gianfranco Cervellin ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 529 532 10.23750/abm.v88i4.6653 Glyphosate ingestion causing multiple organ failure: a near-fatal case report. <p class="p1">A 55 years old man self-presented to our Emergency Department (ED) reporting an attempted suicide by cutting the left forearm veins and ingesting approximately 200 mL of an herbicide (Myrtos®, containing 36% of glyphosate as isopropylamine salt). Laboratory tests showed metabolic acidosis. Hydration with normal saline and alkalinization with sodium bicarbonate was started according to suggestion of the poison control center, since an antidote was unavailable. Cardiorespiratory condition gradually worsened, so that non-invasive positive pressure ventilation (NIPPV) was applied and infusion of fluids was established. Nevertheless, the patient deteriorated and he needed to be transferred to the Intensive Care Unit (ICU), where he underwent orotracheal intubation and invasive mechanical ventilation. Noradrenaline and adrenaline were infused and fluid resuscitation with crystalloids was incremented. An esophagogastroduodenoscopy (EGD) showed diffuse mucosal erosions of upper digestive tract. No signs of visceral perforation were found during ICU stay. In the following days, the clinical conditions improved and a new EGD showed marked improvement of erosive lesions. After 12 days of ICU stay, the patient was extubated and then transferred to the Psychiatric Unit, in good clinical conditions. Gliphosate ingestion is associated with rapid development of multiple organ failure (MOF). Since an effective antidote is unavailable, major attention should be placed to aggressive life-support care and careful monitoring of complications. </p> Edoardo Picetti Michela Generali Francesca Mensi Giampaolo Neri Roberta Damia Giuseppe Lippi Gianfranco Cervellin ##submission.copyrightStatement## 2018-01-16 2018-01-16 88 4 533 537 10.23750/abm.v88i4.6322