Azienda Ospedaliero-Universitaria Research Articles

Death of Healthy Volunteers and Professionals on Duty for Cadaveric Graft Shipment

Death of a living organ donor is universally considered a disaster, having devastating effects on public opinion. Deceased donor transplantation poses ethical questions but cannot rise the concerns on donor safety typical of living donation. Hence, it is generally considered “safer.” However, considering the organizational and logistical complexity of cadaveric donation, accidental death of healthy volunteers and professionals caring for graft shipment is a disagreeable price. Perhaps, unconsciously, we all know we have to pay this price for the success of transplantation: what we do not know is exactly how much we do have to pay. Englesbe and Merion (1) reported sporadic fatalities in the United States (Aviation Safety Network [2] IDs 19900911-1 and 20070604-0, wikibase 38890), France (wikibase 43982), Brazil (ID 19760122-1 [3]), and Germany. Englesbe and Merion did not mention another fatality that occurred in Spain (one death: ID 20001125-0). Many more “near-misses” have been reported, for example, from Germany (wikibase 72222) and United Kingdom (ID 20101119-0). Anyway, no registry exists for transplant- related accidents, and surgeon surveys looking for accidents have been performed only in the United States (1). The overall worldwide (excluding Italy) fatality is 28 in the past 30 years. Anyway, this is likely an underestimation because of poor reporting, and ratios of fatal accidents per donated organ are almost impossible to calculate without a registry. We attempted estimation of this death risk for Italy, whereas between 2004 and 2009, at least nine persons died as a consequence of three mishaps occurred during organ shipment. Englesbe and Merion (1) reported only the one that occurred on February 24, 2004 (20040224-0), where six persons (including two heart surgeons, one physician assistant, and three pilots) died when their plane crashed into a mountain near Cagliari (Sardinia). On April 22, 2005, a volunteer shipping two kidneys died in a car crash between Siena and Pisa (both in Tuscany) (4). Finally, on February 7, 2009, two pilots died when their aircraft crashed in Trigoria (Rome), shortly after taking off from Ciampino to Modena (Emilia Romagna; ID 20090207-0). In the same period (2004–2009) in Italy, there were 6737 deceased organ donors leading to 18,722 organ transplants. Consequently, the risk of death of a healthy volunteer or professional is 0.13% when estimated per deceased donor and 0.048% when estimated per transplanted organ (5). Admittedly, this is a rough estimation because, at least in Italy and between 2004 and 2009, this risk might have been even greater. Indeed, although at the numerator we could have missed some deaths, the denominator should be probably lower than 18,722, because not all transplanted organs were shipped. Death of volunteers and health professionals involved in organ transplantation has probably a lower impact on medical community and public opinion than death of living organ donors. Actually, these fatalities are not too different as they are; anyhow, deaths of persons fallen to allow others to be transplanted. We emphasize that deceased donor-related incidents and deaths should be surveyed as systematically as live donation is. The creation of an international registry summarizing the ratios of fatalities per transplanted organ could encourage improvement of safety measures and suggest different organization of transplant networks. Ugo Boggi1 Gabriella Amorese2 Daniele Focosi3 1Division of General and Transplant Surgery in Uremic and Diabetic Patients Azienda Ospedaliero-Universitaria Pisana Pisa, Italy 2Division of Anesthesia and Intensive Care Azienda Ospedaliero Universitaria Pisana Pisa, Italy 3Division of Immunohaematology Azienda Ospedaliero Universitaria Pisana Pisa, Italy

Commentary on: Economic evaluation of human papilloma virus vaccination in the European Union: a critical review

The article by Koleva et al. [1] in current issue is unusual reading for the public of IEM. First, systematic reviews of economic evaluations are still uncommon in general medical journals. Second, this review on HPV vaccination deals with a very important public health topic, which, on the other hand, is not a typical theme for this journal. There are good reasons for the Clinical Evidence and HTA section of IEM to present such articles. Cost effectiveness reviews represent a methodological challenge and, as such, are relevant and intriguing regardless of their object. Furthermore, cost-issues are by their nature a general medical issue, because the cost of resources spent in one field of health care compete with the money spent in others. Finally, an economic publication on a vaccine in a general medical journal is a chance for readers to be challenged by the diverse methodological problems which are encountered in the complex area of screening and vaccines [2]. Coming to Koleva et al.’s message [1], we notice that the authors are critical regarding cost-effectiveness of HPV vaccination as measured in the reviewed studies, despite the fact that all but one concluded in favour of vaccination. However, they mention other reviews of economic evaluations which reach similar conservative conclusions [3, 4].They finally observe that vaccination cost-effectiveness was sensitive to the assumptions made in sensitivity analyses and that non-sponsored evaluations were somehow more cautious and restrictive. Koleva et al. [1] are particularly dubious about the validity of life-long modelling of the effects of screening vaccination campaigns, based on a few years follow-up of RCTs and on assumptions borrowed from current data. The comments raised by Koleva et al. [1] are reasonable. Nevertheless, we have to deal with the limits that we face in performing EEs. In particular, everybody would agree that, for clinical and health policy decisions, it would be desirable to have long term data to work on, rather than referring to assumptions in statistical models. Conditions under which decisions are made are very often different from the desired ones. Models allow to ‘‘rationalize future uncertainty’’, framing uncertainty within probabilistic models. This is an imperfect method, with large margins of subjectivity, but on the other hand it makes possible—based on more or less optimistic scenarios—to generate forecasts based on epidemiological and clinical data available today, using such predictions to inform decision making. Furthermore, the process is dynamic and it allows to update the estimates by including the evidence provided by new studies. Regarding the level of subjectivity associated with the selection of model components, if the hypotheses are not ‘‘specious’’, but ‘‘reasonable’’ and ‘‘standard/coherent’’ with the literature [5, 6], then the emerging scenario will present a few levels of ‘‘controlled and conscious subjectivity’’. In other words, the limits of the results and the G. Virgili (&) Department of Specialized Surgical Sciences, University of Florence and Azienda Ospedaliero-Universitaria Careggi, V.le Morgagni 85, 50134 Florence, Italy e-mail: gianni.virgili@unifi.it

Verteporfin photodynamic therapy for retinal hemangioblastoma associated with Von Hippel-Lindau disease in a 9-year-old child

Ophthalmic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy Corresponding author: Michele Figus, MD PhD Via Paradisa, 2 Edificio 30/A, Oculistica Universitaria 56100 PISA - ITALY E-mail: figus@ocupisa.it Received 1 June 2010; accepted 28 July 2010 This is an Accepted Article that has been peer-reviewed and approved for publication in the

Applicability of Greulich and Pyle method for age assessment in forensic practice on an Italian sample

The main importance in age estimation lies in the assessment of criminal liability and protection of unaccompanied minor immigrants, when their age is unknown. Under Italian law, persons are not criminally responsible before they reach the age of 14. The age of 18 is important when deciding whether juvenile or adult law must be applied. In the case of unaccompanied minors, it is important to assess age in order to establish special protective measures, and correct age estimation may prevent a person over 18 from benefiting from measures reserved for minors. Since the Greulich and Pyle method is one of the most frequently used in age estimation, the aim of this study was to assess the reproducibility and accuracy of the method on a large Italian sample of teenagers, to ascertain the applicability of the Atlas at the critical age thresholds of 14 and 18years. This retrospective study examined posteroanterior X-ray projections of hand and wrist from 484 Italian-Caucasian young people (125 females, 359 males) between 11 and 19years old. All radiographic images were taken from trauma patients hospitalized in the Azienda Ospedaliero Universitaria Ospedali Riuniti of Ancona (Italy) between 2006 and 2007. Two physicians analyzed all radiographic images separately. The blind method was used. In the case of an estimated age of 14years old, the true age ranged from 12.2 to 15.9years (median, 14.3years, interquartile range, 1.0years) for males, and 12.6 to 15.7years (median, 14.2years, interquartile range, 1.7years) for females. In the case of an estimated age of 18years, the true age ranged from 15.6 to 19.7years (median, 17.7years, interquartile range, 1.4years) for males, and from 16.2 to 20.0years (median, 18.7years, interquartile range, 1.8years) for females. Our study shows that although the GPM is a reproducible and repeatable method, there is a wide margin of error in the estimation of chronological age, mainly in the critical estimated ages of 14 and 18years old in both males and females.

Hemorheologic profile in healthy women undergoing controlled ovarian stimulation

We investigated the hemorheologic profile in 110 women undergoing controlled ovarian stimulation and provide evidence that smokers and women with body mass index>25 kg/m2 exhibit alterations of rheologic profile. A progressive increase of whole-blood viscosity throughout the ovarian stimulation cycle was observed; deformability and aggregation of erythrocytes decreased from baseline to the beginning of recombinant FSH administration, then remained unchanged throughout the next days; hematocrit mildly decreased during the last days of recombinant FSH administration; and fibrinogen and cholesterol levels decreased and increased, respectively, throughout the stimulation cycle.

Erratum: Efficacy of imatinib dose escalation in patients with chronic myeloid leukemia in chronic phase

An investigator was inadvertently omitted from this article. Prof. Valeria Santini of Azienda Ospedaliero-Universitaria (AOU) Careggi, Universitá degli Studi di Firenze, Florence, Italy, should have appeared in the list of investigators. The authors regret this error.

Utilities and QALYs in health economic evaluations: glossary and introduction

Economics studies the optimal allocation of resources for the production of benefits to the society. By definition, resources are limited, and healthcare systems must face this condition every day. This may explain why economic evaluations are increasingly used as a key component of decision making. For instance, they represent a mainstay in any Health Technology Assessment (HTA) exercise and are subject to a guidelines’ development process [1]. After the assessment of the efficacy and safety of health interventions, economic evaluations enter to compare alternative options in terms of costs and consequences. Full economic evaluations consist of a comparison of both costs (resource use) and consequences (outcomes, effects) of alternative strategies [2]. If Cochrane reviews are intended to help providers, practitioners and patients in making informed decisions about health care interventions, they cannot afford to ignore their economic aspects. Cochrane reviews assemble, select, critique and combine reliable data from multiple research studies on the effectiveness and other issues related to healthcare interventions. The latest version of the Cochrane Handbook for Systematic Reviews of Interventions [3], freely accessible at http://www.cochrane-hand book.org, acknowledges that incorporating economic perspectives and evidence into Cochrane reviews can enhance their usefulness and applicability for healthcare decisionmaking. An entire chapter (‘‘Incorporating economics evidence’’), provides guidance on how authors of systematic reviews can collect the best evidence on the economic aspects of interventions in addition to the best evidence on their clinical effectiveness [4]. A leading point here is to expand our knowledge on efficiency (optimal use of resources) after having established effectiveness (whether treatments work) [5]. The main types of full economic evaluations (costeffectiveness, cost-utility and cost-benefit analyses) compare alternative interventions in terms of both costs (resource use) and consequences (effects) and can be included in Cochrane reviews, as well as studies that only focus on costs and resource use, without comparing health alternatives, i.e. partial economic evaluations [4]. Cost-effectiveness analyses measure the effects of an intervention and its comparators in identical units of outcome (e.g. mortality), thus comparing them in terms of ‘cost per unit of effect’ [5]. In a cost-benefit analysis both resource use and effects of alternative interventions are G. Virgili (&) Department of Specialised Surgical Sciences, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy e-mail: gianni.virgili@unifi.it

Management of chronic anterior uveitis relapses: efficacy of oral phospholipidic curcumin treatment. Long-term follow-up.

Curcumin has been successfully applied to treat inflammatory conditions in experimental research and in clinical trials. The purpose of our study is to evaluate the efficacy of an adjunctive-to-traditional treatment with Norflo tablets (curcumin-phosphatidylcholine complex; Meriva) administered twice a day in recurrent anterior uveitis of different etiologies. The study group consisted of 106 patients who completed a 12-month follow-up therapeutic period. We divided the patients into three main groups of different uveitis origin: group 1 (autoimmune uveitis), group 2 (herpetic uveitis), and group 3 (different etiologies of uveitis). The primary end point of our work was the evaluation of relapse frequency in all treated patients, before and after Norflo treatment, followed by the number of relapses in the three etiological groups. Wilcoxon signed-rank test showed a P < 0.001 in all groups. The secondary end points were the evaluation of relapse severity and of the overall quality of life. The results showed that Norflo was well tolerated and could reduce eye discomfort symptoms and signs after a few weeks of treatment in more than 80% of patients. In conclusion, our study is the first to report the potential therapeutic role of curcumin and its efficacy in eye relapsing diseases, such as anterior uveitis, and points out other promising curcumin-related benefits in eye inflammatory and degenerative conditions, such as dry eye, maculopathy, glaucoma, and diabetic retinopathy.

Cryptorchidism With Short Spermatic Vessels: Staged Orchiopexy Preserving Spermatic Vessels

Patients with cryptorchidism can have such short spermatic vessels that it is impossible to place the testicle in a satisfactory scrotal position using conventional orchiopexy. In these cases the most commonly used operation is 1 to 2-stage Fowler-Stephens orchiopexy. We present our surgical experience using staged inguinal orchiopexy without section of the spermatic vessels in patients with short spermatic vessels. We used 2-stage inguinal orchiopexy in 38 children with intra-abdominal testis or testis peeping through the internal ring and short spermatic vessels (7 bilateral). Spermatic vessels were not sectioned, but were lengthened through progressive traction of the spermatic cord wrapped in polytetrafluoroethylene pericardial membrane (Preclude). In the first stage we mobilized the spermatic cord in the retroperitoneal space and then wrapped it in the polytetrafluoroethylene membrane. We subsequently attached the testis to the invaginated scrotal bottom. At 9 to 12 months we performed the second stage, which involved removing the polytetrafluoroethylene membrane. From the first to the second stage we observed progressive descent of the testicle toward the scrotum. At 1 to 8-year followup after the second stage all 45 testicles were palpable in a satisfactory scrotal position with stable or increased testicular volume. This technique represents an alternative to Fowler-Stephens orchiopexy, which can be associated with a greater risk of testicular ischemia.

Targeted delivery of albumin bound paclitaxel in the treatment of advanced breast cancer

Taxanes are chemotherapeutic agents with a large spectrum of antitumor activity when used as monotherapy or in combination regimens. Paclitaxel and docetaxel have poor solubility and require a complex solvent system for their commercial formulation, Cremophor EL(R) (CrEL) and Tween 80(R) respectively. Both these biological surfactants have recently been implicated as contributing not only to the hypersensitivity reactions, but also to the degree of peripheral neurotoxicity and myelosuppression, and may antagonize the cytotoxicity. Nab-paclitaxel, or nanoparticle albumin-bound paclitaxel (ABI-007; Abraxane(R)), is a novel formulation of paclitaxel that does not employ the CrEL solvent system. Nab-paclitaxel demonstrates greater efficacy and a favorable safety profile compared with standard paclitaxel in patients with advanced disease (breast cancer, non-small cell lung cancer, melanoma, ovarian cancer). Clinical studies in breast cancer have shown that nab-paclitaxel is significantly more effective than standard paclitaxel in terms of overall objective response rate (ORR) and time to progression. Nab-paclitaxel in combination with gemcitabine, capecitabine or bevacizumab has been shown to be very active in patients with advanced breast cancer. An economic analysis showed that nab-paclitaxel would be an economically reasonable alternative to docetaxel or standard paclitaxel in metastatic breast cancer. Favorable tumor ORR and manageable toxicities have been reported for nab-paclitaxel as monotherapy or in combination treatment in advanced breast cancer.

The CHOLEGAS study: multicentric randomized, blinded, controlled trial of gastrectomy plus prophylactic cholecystectomy versus gastrectomy only, in adults submitted to Gastric cancer surgery with curative intent

BackgroundThe incidence of gallstones and gallbladder sludge is known to be higher in patients after gastrectomy than in general population. This higher incidence is probably related to surgical dissection of the vagus nerve branches and the anatomical gastrointestinal reconstruction. Therefore, some surgeons perform routine concomitant cholecystectomy during standard surgery for gastric malignancies. However, not all the patients who are diagnosed to have cholelithiasis after gastric cancer surgery will develop symptoms or require additional surgical treatments and a standard laparoscopic cholecystectomy is feasible even in those patients who underwent previous gastric surgery. At the present, no randomized study has been published and the decision of gallbladder management is left to each surgeon preference.DesignThe study is a randomized controlled investigation. The study will be performed in the General and Oncologic Surgery, Department of Oncology – Azienda Ospedaliero-Universitaria Careggi – Florence – Italy, a large teaching institution, with the participation of all surgeons who accept to be involved in, together with other Italian Surgical Centers, on behalf of the GIRCG (Italian Research Group for Gastric Cancer).The patients will be randomized into two groups: in the first group the patient will be submitted to prophylactic cholecystectomy during standard surgery for curable gastric cancer (subtotal or total gastrectomy), while in the second group he/she will be submitted to standard gastric surgery only.Trial RegistrationClinicalTrials.gov ID. NCT00757640

Prognostic Value of ECG Among Patients with Acute Pulmonary Embolism and Normal Blood Pressure

Objective To investigate the prognostic value of electrocardiography (ECG) alone or in combination with echocardiography in patients with acute pulmonary embolism and normal blood pressure. Methods Consecutive adult patients presenting to the emergency department at Azienda Ospedaliero-Universitaria Careggi with the first episode of pulmonary embolism were included. Patients with systolic blood pressure less than 100 mm Hg were excluded. ECG and echocardiography were performed within 1 hour from diagnosis and evaluated in a blinded fashion. Right ventricular strain was diagnosed in the presence of one or more of the following ECG findings: complete or incomplete right ventricular branch block, S1Q3T3, and negative T wave in V1-V4. The main outcome measurement was clinical deterioration or death during in-hospital stay. The association of variables with the main outcome was evaluated by multivariate Cox survival analysis. Results A total of 386 patients with proved pulmonary embolism were included in the study; 201 patients (52%) had right ventricular dysfunction according to echocardiography, and 130 patients (34%) showed right ventricular strain. Twenty-three patients (6%) had clinical deterioration or died. At multivariate survival analysis, right ventricular strain was associated with adverse outcome (hazard ratio 2.58; 95% confidence interval, 1.05-6.36) independently of echocardiographic findings. Patients with both right ventricular strain and right ventricular dysfunction (26%) showed an 8-fold elevated risk of adverse outcome (hazard ratio 8.47; 95% confidence interval, 2.43-29.47). Conclusion Right ventricular strain pattern on ECG is associated with adverse short-term outcome and adds incremental prognostic value to echocardiographic evidence of right ventricular dysfunction in patients with acute pulmonary embolism and normal blood pressure.

THE HOSPITAL-BASED, POST-ACUTE GERIATRIC EVALUATION AND MANAGEMENT UNIT: THE EXPERIENCE OF THE ACUTE GERIATRIC UNIT IN TRIESTE

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

Painful Schwannoma of the Breast Completely Removed by a Vacuum-Assisted Device With Symptom Resolution

The Breast JournalVolume 14, Issue 5 p. 496-497 Painful Schwannoma of the Breast Completely Removed by a Vacuum-Assisted Device With Symptom Resolution A. Linda MD, A. Linda MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorP. Machin MD, P. Machin MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorM. Bazzocchi MD, M. Bazzocchi MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorC. Zuiani MD, C. Zuiani MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this author A. Linda MD, A. Linda MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorP. Machin MD, P. Machin MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorM. Bazzocchi MD, M. Bazzocchi MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this authorC. Zuiani MD, C. Zuiani MD Department of Radiology, Azienda Ospedaliero-Universitaria, Udine, Italy andSearch for more papers by this author First published: 05 September 2008 https://doi.org/10.1111/j.1524-4741.2008.00629.xCitations: 5 Address correspondence and reprint requests to: Linda Anna, Department of Radiology, Azienda Ospedaliero-Universitaria Via Colugna 50, 33100 Udine, Italy, or e-mail: annalinda33@yahoo.it. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume14, Issue5September/October 2008Pages 496-497 RelatedInformation

A 48-year-old woman with dyspnoea on exertion, anemia and thrombocytopenia

Dr. Micheli: A 48-year-old woman was admitted to our hospital after a 2-month history of dyspnoea on exertion. She did not report fever, sweats, chills, chest pain or recent weight loss. Twenty years before she had undergone mitral commissurotomy for rheumatic mitral stenosis. One week before current admission, the patient was seen in the emergency department (ED) because of paroxysmal atrial fibrillation. Synchronized electrical cardioversion was performed with recover of sinus rhythm. Echocardiography showed mitral stenosis with a valve area 1 cm and mild pulmonary hypertension. Results of routine laboratory tests were normal except for anemia and thrombocytopenia (platelet count 35,000/mm, hemoglobin 11.1 g/dl). Seven months before admission, these values were in the normal range. After discharge, the patient continued to experience dyspnoea while walking for a short distance and orthopnea. Eleven years before she had undergone excision of a right breast carcinoma, and had received a 6-month cycle of adjuvant chemotherapy. No local or systemic relapse had subsequently been documented. She worked as a pianist. There was no history of allergies. She did not report diabetes mellitus, illicit drug use, smoke history, alcohol use, hypertension, dyslipidemia or family history of heart disease or cancer. She did not consume medications except propafenone that had been prescribed in the ED a few days before. On physical examination, the patient was not in acute distress. Blood pressure was 115/70 mmHg, pulse rate 98 beats/min, respiratory rate16 breaths/min, temperature 36 C and SpO2 98% while she was breathing room air. Lungs fields were clear on auscultation. A low-frequency holodiastolic murmur and mitral valve opening snap were heard over the cardiac apex. There was neither peripheral oedema nor increased jugular venous pressure. Peripheral pulses were normal and symmetrical. Abdomen was soft and non-tender. No masses or enlarged organs were detectable. There were no petechiae, ecchymoses, skin rash or lymphadenopathy. Neurologic examination was unremarkable. An electrocardiogram showed sinus rhythm. A blood gas analysis was normal. Thrombocytopenia (38,000/mm) was confirmed and pseudo-thrombocytopenia was excluded. On second hospital day, the patient abruptly developed left hemiplegia and dizziness. A CT scan of the head excluded acute intracranial hemorrhage. NIHSS was 12. The hospital Stroke Team was alerted within 30 min after the onset of symptoms but thrombolytic therapy was not performed because of the low platelet count. The patient underwent cerebral angiography that revealed diffuse bilateral microemboli not suitable for mechanical revascularization. Transesophageal echocardiography showed left appendage thrombosis. Intravenous heparin therapy S. Del Pace C. Alderighi R. Rasoini (&) R. Alterini S. Micheli G. Santoro Clinica Medica Generale e Cardiologia, Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Viale Morgagni 85, 50134 Florence, Italy e-mail: raffaele.rasoini@tiscali.it

Pulsology Reloaded

The Losartan Intervention For Endpoint reduction in hypertension (LIFE) Study,1 the Second Australian National Blood Pressure Trial (ANBP2),2 and the Anglo-Scandinavian Cardiovascular Outcome Trials3 have shown that different antihypertensive treatments may have different impacts on the rate of events in hypertension while achieving comparable brachial blood pressure (BP) reduction. Thus, although brachial BP estimation by classic Riva–Rocci cuff sphygmomanometer and the Korotkoff auscultatory technique have provided almost all of our knowledge on epidemiology, prognosis, and treatment of hypertension,4,5 recent trials1–3 are revealing intrinsic limitations of the conventional approach, because the real goal of treatment in hypertension is the reduction in the number and the rate of untoward events. More recently, the Conduit Artery Function Evaluation (CAFE) Study6 described higher central BP as a key factor explaining the greater number and rate of events with atenolol than with amlodipine plus perindopril. Central pressure waveform and BP values can be estimated by applanation tonometry, a method supported by solid theoretical principles and modeling studies in experimental settings.7 Analysis of the systolic portion of the carotid pressure waveform allows for obtaining indices of the arterial viscous-elastic properties that correlate with end-organ damage and clinical outcomes in hypertension.8 Therefore, the indices of arterial waveform reflection and mechanics and central BP assessed by applanation tonometry have the potential to add significant information for risk stratification beyond and above brachial BP. In fact, the conclusions of the CAFE Study were well received.9 In addition, applanation tonometry has also been associated with 2D-guided M-mode vascular ultrasonography to assess simultaneously the viscous-elastic properties of the carotid artery, the intima–media thickness, and quantification of atherosclerosis.8 Assessment of cardiovascular target organ damage is curial for a global risk assessment …

Panretinal Photocoagulation and Photodynamic Therapy for Anterior Segment Neovascularization Secondary to Ischemic Central Retinal Vein Occlusion

To compare the effects of panretinal photocoagulation (PRP) and photodynamic therapy (PDT) for anterior segment neovascularization secondary to ischemic central retinal vein occlusion (CRVO). Fifty-seven eyes were randomized to receive standard PRP (19 eyes), selective PRP (20 eyes), or PDT (17 eyes). Selective PRP was performed only when iris neovascularization and/or angle neovascularization showed progression on weekly follow-up. Primary outcome measures were the extension of anterior segment neovascularization and the rate of neovascular glaucoma development. Secondary outcome measures included visual acuity results. After 12 months of follow-up, iris neovascularization extension was 0.52, 2.55, and 2.27 in the PRP, selective PRP, and PDT groups, respectively. Anterior segment neovascularization extension was 0.57, 1.50, and 1.27 in the PRP, selective PRP, and PDT groups, respectively. Both showed a statistically significant difference in the PRP group. The rate of neovascular glaucoma development was similar in the three groups. Although PRP was better at determining iris neovascularization and anterior segment neovascularization regression, the similar rate of neovascular glaucoma development found in the three groups indicates that anterior segment neovascularization secondary to ischemic CRVO can also be safely managed using selective PRP or PDT.