Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95, 2 1 ORIGINAL PAPER Degree in Medicine and Surgery, having discussed an experimental thesis entitled “Intracardiac pressure varia- tions after interruption of the inferior caval circulation” and earning top marks: 110/110 with distinction (1). - Endowed with great talent, Giuliani was appointed vol- untary Assistant at the Institute of General Clinical Surgery and Surgical Therapy of the University of Florence a few months later, on 1 November 1951. He immediately became known for his ability and diligence in carrying out his activities and for his outstanding skills, and his position was confirmed until 1954. In the period between 15 January 1952 and 31 May 1953, he carried out his obligatory military service; having achieved first place in his course (out of 302 candidates) (2) in the final exami- nations of the 10th Course for Additional Trainee Medical Officers, he was appointed Medical Officer with the rank of Second Lieutenant (3). Subsequently, Giuliani first served as an Assistant at the Institute of War Traumatology and Surgery of the School of Military Health in Florence from 15 June 1952 to 15 June 1953. One of the first publications of his long career was “L’ibernazione” (“Hibernation”), which was published in the Giornale di Medicina Militare (Journal of Military Medicine) in 1953 (4). In it, he outlined the biological, physiological and clinical bases of the practice of hiber- nation and offered some considerations regarding the purposes, indications and limitations of its application, particularly in the field of surgery (Figure 2). On 1 November 1954, Giuliani continued his career at the Surgical Clinic of the University of Florence, where he Luciano Giuliani was born near Arezzo, in Tuscany (Italy) in 1928. After taking his Degree cum Laude in Medicine and Surgery at the University of Florence in 1951, he became a voluntary assistant at the Institute of General Clinical Surgery and Surgical Therapy. He then took a diploma in Urology and General Surgery, having demonstrated his great technical and surgical ability, and was subsequently appointed assistant in charge and then extraordi- nary assistant. Endowed with uncommon surgical skills and a forceful personality, Giuliani tirelessly carried out his clinical and surgical activity, covering several roles and rapidly earning profound esteem and recognition in the field of urology. As a pupil of the great luminary of Italian surgery, Ulrico Bracci, Dr Giuliani keenly followed his master, embracing his teachings and surgical techniques, until 1969, when he was appointed to run the 2nd Urology Division at San Martino Hospital in Genoa. He subsequently took up the chair of Urology at the University of Genoa and became Director of the Specialty School in Urology. Within a few years, he earned a solid reputation both nationally and internationally through his innovative surgical techniques. He also gave considerable impetus to the Genoese School of Urology, reaching the highest echelons of the Italian and European Societies of Urology. At the beginning of the 1990s, he designed and founded a new urology clinic in Genoa; this imposing, avant-garde building was subdivided into four floors and equipped with 80 beds. In July 1994, he won the prestigious “Willy Grégoir Medal”, an accolade awarded to eminent personalities in European urology. In August of the same year, he died in the Institute that he himself had created at San Martino Hospital in Genoa. KEY WORDS: Luciano Giuliani; History of Medicine; History of Urology; Italian Urology; Genoese Urology School. Submitted 22 March 2023; Accepted 23 March 2023 LUCIANO GIULIANI: THE FIRST STEPS Dr Luciano Giuliani was born in Paindiscò (Arezzo) on 3 July 1928 (Figure 1). Having matriculated at the Faculty of Medicine of the University of Florence in the academic year 1945-46, he enthusiastically and assiduously devoted himself to his studies. In the years 1949-50 and 1950-51, he regularly frequented the departments and the laboratories of the Surgical Clinic as a student intern. On 25 July 1951, at the University of Florence, he took his Luciano Giuliani (1928-1994): Great master and founding father of modern Italian Urology Mariano Martini 1, 2, Giuseppe Martorana 3 1 Department of Health Sciences, University of Genoa, Genoa, Italy; 2 UNESCO Chair Anthropology of Health. Biosphere and Healing System, University of Genoa, Genoa, Italy; 3 University of Bologna, Bologna, Italy. DOI: 10.4081/aiua.2023.11329 Summary Figure 1. Prof. Luciano Giuliani (1928-1994). Archivio Italiano di Urologia e Andrologia 2023; 95, 2 M. Martini, G. Martorana 2 was appointed “Extraordinary Assistant”, a position that he held until 1 November 1956, when he moved to the newly-founded Urology Clinic. During this period, Giuliani also took a Specialty Diploma in Urology at the University of Pisa (18 July 1955), achiev- ing a mark of 70/70 (5). Following the establishment of the new Urology Clinic of the University of Florence in 1956, Giuliani was immedi- ately appointed Extraordinary Assistant. The following year (1957), he further consolidated his training by tak- ing a Specialty Diploma in General Surgery, achieving the top mark of 70 with distinction. The year 1957 was a particularly important one for Dr. Giuliani; in addition to earning the above-mentioned Specialty Diploma in General Surgery (29 July) with dis- tinction, he was appointed for the academic year 1957/58 as Designated Assistant to the Chair of the Urology Clinic (6), a position that was confirmed for the years 1958/59, 1959/60 and 1960/61. These were fundamental years and constituted the foun- dations on which he would later build his long and fruit- ful academic pathway in the field of urology. LUCIANO GIULIANI: A VERSATILE SURGEON AND A YOUNG ACADEMIC On 18 April 1958, following a public competition, Giuliani qualified for the position of Ordinary Assistant to the Chair of Urology of the University of Florence. The fol- lowing month, however, he interrupted this tenure in order to be reconfirmed Extraordinary Assistant. His title of Extraordinary Assistant was also confirmed for the aca- demic year 1958-59. Dr. Giuliani carried out his clinical and surgical activities in a continuous manner: first during his service at the Surgical Clinic in Florence as an assistant in the various departments of general and thoracic surgery and then in the urology department. Subsequently, he held the posi- tion of Head of Department with the function of “Vice- chief” at the Urology Clinic. Giuliani's temperament and versatility, coupled with his remarkable tenacity and determination, were evident right from the first years of his training. Indeed, during his military service, he dealt with military traumatology and surgery from both a theoretical and practical stand- point, without ever interrupting his university activities. Moreover, for several years, and consistently until 1956, he served as an assistant surgeon at the Ospedale Civile di Empoli during the summer closure of the University clin- ics, which enabled him to “stay on form” and to hone his surgical skills even during the summer period! In the early period of his career, Giuliani actively devoted himself to the various branches of surgery, acquiring exten- sive knowledge of thoracic, urological, orthopaedic, gynae- cological and obstetric surgery, in addition to general sur- gery. Moreover, in 1956, when still academically very young (28 years old), he was given responsibility for the practical training in Clinical Urology of sixth-year students at the University of Florence, where he subsequently taught the following subjects at the Specialty School in Urology: - functional diagnostics in urology (1st year); - functional pathology of the excretory pathway. During those years, Giuliani wrote several scientific arti- cles. Notable for its originality, methodological rigour and scientific impact, was “On the extra-hepatic biliary path- ways”, published in 1954 in the journal “La Chirurgia Generale” (7) (Figure 3). In it, the young author made innovative anatomical, physiological and pathophysiological observations (8). However, the young Giuliani was still fascinated by the uro- logical activity carried out in the dedicated department and coordinated by Prof. Bracci, Prof Fedeli's assistant; he there- fore began to participate more closely in this work. For his part, Prof. Bracci, with the encouragement and approval of his mentor Prof Fedeli, had long been oriented towards the entire field of urology, working first in the sur- gical clinic in Perugia and then, after 1947, in Florence. Indeed, after first qualifying to teach Surgical Pathology and Surgical Anatomy, he became a freelance teacher of Urology in 1942. Moreover, while still a young assistant, and a few years after following Prof Fedeli to Florence, he wrote a book Figure 2. S. Ten. Med Dott. L. Giuliani. L’ibernazione. Extract of Giornale di Medicina Militare (Journal of Military Medicine). Figure 3. “On the extra- hepatic biliary pathways” (1954) - “La Chirurgia Generale” (General Surgery) in Rivista di Biologia. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 3 Luciano Giuliani (1928-1994), pioneer of history of Urology on urological semiotics (1950) and introduced an innova- tive method regarding “access pathways in the surgery of the urinary apparatus” (which would be published in 1956). In 1955 (the year in which Giuliani took his specialty diploma in Urology), Prof. Bracci was chosen as one of the three winners (together with Prof Pavone in Palermo, and Prof Pisani in Milan) of the first national competitive examination for the post of Ordinary Prof of Urology. The following year, he was appointed Director of the Institute of Clinical Urology of the University of Florence, the first university chair of urology in Italy, and in 1957 the specialty school in Urology was instituted. Thus began a new era for Florentine urology in particular, and also for Italian urology in general. Bracci brought to urology all his knowledge of general surgery, developing themes which – albeit previously described and implemented – had, for various reasons, never been widely adopted, e.g. the use of the intestine in urology. Hitherto, the standard procedure had been ureterosigmoidostomy (USS); urinary infection was the most frequent cause of severe complications… sometimes more “malignant” than neoplastic disease progression... This aspect soon became the principal theme to investi- gate (as is well described in Bracci's report, published in 1959 in Chirurgia Urologica) (Figure 4). The main objective was to abandon the previous approach, which involved the mixing of faeces and urine, and to create a reservoir that displayed the following characteristics: – sufficient capacity to allow almost normal frequency of urination; – in the filling phase, the patient could feel the stimulus and would be prompted to urinate; – complete emptying and explorability; – no negative impact on the upper urinary apparatus. As the rectal neo-bladder met these requirements, it was adopted, in its variants, for years. Bracci proved to be a great innovator and succeeded in promoting his discipline, bringing together a group of young physicians, who enthusiastically embraced the teachings of their mentor. In those years, the Urology Clinic of the University of Florence was made up of: – ordinary assistants with "vice-chief" responsibilities: Alfiero Costantini, Luciano Giuliani, Mario Polito, Mario Tacciuoli; – ordinary assistants and volunteers: Tullio Lotti, Francesco Micali, Nicola Cerulli, Michelangelo Rizzo, Alessandro Basso, et al.; – physicians from different specialties who collaborated with the Chair of Urology: Elia Vernaglione, Anna Martini (anaesthetists) Gianfranco Bruscagli (cardiologist) Bruno Fedi (pathologist) Imola Rossi (chemist) Giancarlo Masini (radiologist). Among these, was Luciano Giuliani, who (as we have already mentioned above) became “extraordinary univer- sity assistant” at the newly founded Urology Clinic on 1st November 1957 (9). Giuliani soon became one of Bracci's closest collaborators: – from the surgical point of view: he was one of Bracci's favourite assistants in the operating theatre; – from the teaching point of view: he was entrusted with the practical training in Clinical Urology of sixth year students at the University of Florence; – from the scientific point of view: he immediately man- ifested his propensity for research; specifically, he sup- ported his mentor and conducted important studies in experimental surgery and urodynamics of the urinary derivations (10, 11). As the author of numerous publications of a clinical, radi- ological, pathological, surgical and experimental nature, generally in the field of urology, Dr Giuliani was awarded the prestigious “prize for scientific diligence” for the aca- demic years 1956/57 and 1958/59 at the University of Florence. Moreover, at the 32nd Congress of the Italian Society of Urology in September 1959, he received the “Premio Itala IV°” for the best urology publication of the year for his paper entitled: “Gastrocystoplasty: from the experimental idea to some practical considerations concerning plastic and replacement surgery of the bladder” (10). From 1959 onwards, Dr. Giuliani also worked systemati- cally in the departments of general and thoracic surgery directed by his mentor Ulrico Bracci at the Sanatorium of the Anti-tuberculosis Consortium in Florence, were he was able to increase his surgical skills and his clinical experi- ence (12). Prof. Ulrico Bracci was one of the great luminaries of 20th century Italian surgery and the founder of the first true Italian school of urology at the end of the 1950s in Florence and subsequently in Rome. Prof. Bracci played a fundamental role as an innovator and promoter of spe- cialisation in urology, becoming a dominus and a point of reference for Italian urologists for over 30 years. After again winning the “prize for scientific diligence” (1959/60), in 1960 Giuliani deservedly obtained his qual- ification as untenured lecturer in Urology (Special Surgical Pathology and Clinical Propedeutics), achieving first place among the candidates. In the same year, he actively collaborated in the Italian Society of Urology's official report (Brescia-Bergamo) on “Surgery for renal hypertension” (Figure 5). A year later, 1961, he took part in the report of the annu- al Congress on the “Surgical treatment of prostate cancer” Figure 4. Bracci U. Chirurgia Urologica (Urologic Surgery), 1959. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 M. Martini, G. Martorana 4 and just the surgery of prostate cancer is another example of Prof Bracci's boost to “more complex” urological surgery. This had previously been rarely undertaken, as the subtle course of the disease meant that the tumour was almost always discovered when it was no longer operable. This was the first time in Italy that the issue of radical prosta- tectomy had been presented in such an organic, complete and didactic manner. Thus, its anatomo-surgical founda- tions were laid (Figure 6). Giuliani, together with his mentor, played a central role in both the anatomo-surgical study and the writing of the text, with the collaboration of Prof Costantini and Prof. Tacciuoli. These were fundamental years for Giuliani and constituted the foundations on which he would later build his long and fruitful academic pathway in the field of urology. These were precisely crucial years for Giuliani, as is demon- strated by his “prizes for scientific diligence”. They were also very productive years for Prof. Bracci's whole team, of which Giuliani was a member, both from the clinical and scientific standpoints and from that of the promotion of the discipline of urology. Indeed, it was in those years that Italian urology laid down the foundations for the use of: – the intestine in urology (13); – radical prostatectomy (14); – pathways of access in the surgery of the urinary appa- ratus. All this involved demanding and innovative research work, all of which was designed and implemented during this fruitful Florentine period. Subsequently, it was devel- oped during Giuliani's Roman period. Indeed, in 1963, Prof Bracci was called to Rome to take up the first official chair of urology in the history of the capital. This marked the beginning of the so-called “Roman School of Urology”, a development that had considerable impact on the history of Italian urology. The Urology Clinic in Florence was left under the direction of Alfiero Costantini, while Bracci was followed by his pupils Giuliani and Tacciuoli, who supported their master in his teaching. Subsequently, Lotti, Micali and Polito also moved to Rome, followed later by Cerulli and Calderini. The years spent in Rome enabled the young Giuliani to grow and to acquire vast experience in the various areas of urology. Of the several scientific works produced during that fecund Roman period, we may cite the important contri- bution entitled “The functional recovery of excluded kidneys” (Figure 7) presented at the 40th Congress of the Italian Society of Urologia held in Bologna in October 1967 (15). THE GREAT LEAP FORWARD: GIULIANI IN GENOA The experience gained by Giuliani during the fruitful years in which he worked alongside his mentor Prof. Bracci in Rome, summed to his tireless activity during the previous Florentine period, enabled him to reach such a level of maturity as to warrant his autonomous direction of a clin- ic. The opportunity soon materialised – at one of Europe's largest hospitals of the day: San Martino Hospital in Genoa. Indeed, in 1969, the Department of Urology of San Martino Hospital was divided into two large branches: - 1st Urology Division, headed by Prof. Germinale, already tenured at San Martino Hospital; - 2nd Urology Division, directed by Prof. Giuliani. This was Giuliani's first fully autonomous position in Figure 5. Atti della Società italiana di Urologia - Urology's official report (Oberholtzer A, a cura di), XXXIII Congresso, Bergamo-Brescia, 13-16 Ottobre, 1960. Figure 6. Bracci U, Giuliani L, Costantini A, Tacciuoli M. The Surgical Treatment of Prostate Cancer. 1961. Vallecchi ed. Officine Grafiche. Firenze. Figure 7. Bracci U, Giuliani L, Polito M. La ripresa funzionale dei reni esclusi (The functional recovery of excluded kidneys) (1967). Ente Fiuggi, Cappelli Editore, Bologna. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 5 Luciano Giuliani (1928-1994), pioneer of history of Urology which he had sole responsibility for direction. At that time, he was working at the Urology Clinic in Rome as “University Vice-chief” to Prof. Ulrico Bracci, and had already emerged as a “ternate winner” in a competition for professors. - A couple of years after being given responsibility for the Urology Division at San Martino, in March 1971, Giuliani was unanimously declared Extraordinary Professor of Urology at the Faculty of Medicine and Surgery of the University of Genoa; thus, he became the first tenured pro- fessor of the Chair of Urology in Genoa and in Liguria. The 2nd Urology Division was thus renamed “Urology Clinic” and, over the years, Genoa became the capital of Italian urology. A short time later, in 1972, the Specialty School in Urology was also instituted at the University of Genoa, and was immediately entrusted to the direction of Prof. Giuliani. Prof. Giuliani was endowed with great intelligence and competence and possessed extraordinary surgical skills that enabled him to develop innovative, ground-breaking techniques. Naturally enough, he rapidly emerged on the national and international scientific scene, distinguishing himself through his forceful personality and great author- itativeness. Thus, he imparted an enormous thrust to the Genoese urology school, which soon became a point of reference for the scientific sector nationwide. In 1973, Giuliani was appointed President of the 46th National Congress of the Italian Society of Urology, which was held in Genoa. A few years later (1978) he was elect- ed President of the Italian Society of Urology (SIU), a post he held until 1982, when he was elected to the Executive Committee of the European Society of Urology (ESU). The year 1986 was an important one not only for the Genoese School of Urology, the city of Genoa and the Liguria region, but also for the whole of Italian urology. Indeed, it was in that year that Giuliani succeeded in founding and inaugurating the Centre for Calculosis of the Genoese Urology Clinic. He equipped this facility with an extracor- poreal lithotriptor (a very modern apparatus that shat- tered calculi by means of an extracorporeal approach); a truly extraordinary event, since this was the first public facility in Italy to be so equipped! Moreover, the “Genoese school”, directed by Prof. Giuliani and featuring a team made up of Belgrano, Carmignani, Giberti, Martorana, Puppo et al., also distinguished itself through the production of a sort of “graphic-editorial exer- cise” in urological surgery, which was designed to aid and improve teaching activities. Indeed, 1986 saw the publication of a complete “Atlas of surgery of kidney can- cer”, probably the first such atlas in the history of Italian publishing; it was subse- quently translated into English and dis- tributed internationally. The Atlas provided an analytical and highly detailed presentation – in a ration- al, schematic and realistic form (as far as this was possible in an atlas of surgical techniques) – of the times and sequences most characteristic of the principal opera- tions involved in the surgical treatment of kidney cancer (Figure 8). And a couple of years earlier, on the occasion of the National Congress of Urology, held in Bari in 1984, a scien- tific text was published for the Proceedings of the Italian Society of Urology (SIU) under the title: “Pathways of access in urology”, a volume featuring ample drawings (16-19). In 1988, with the retirement of Prof. Germinale, and after a brief interim period of direction by another Ligurian colleague, the Urology Division was merged with the Urology Clinic and Giuliani became responsible for the single facility, which was very extensive and equipped with numerous beds (20). This newly instituted single facility was a truly evocative return to the past, in that it brought urology back to the original structure directed by the great master Giorgio Nicolich Jr, which extended for almost 30 years, from 1938 to 1966 (21). In April 1992, Giuliani succeeded in an enterprise that was, at that time, truly extraordinary and titanic: the inau- guration of the new Genoese Urology Clinic (Figure 9)! The entire operation was personally drawn up and directly supervised by Giuliani himself, with considerable financial support from the Genoese banking institution Ca.Ri.Ge. Thus, Prof. Giuliani achieved his objective of constructing an imposing, modern, complete facility consisting of: - a 4-storey building equipped with 80 beds; Figure 8. Giuliani L. La Chirurgia del Carcinoma Renale (The surgery of kidney cancer). Atlas. Urology Clinic of the University of Genoa (1990), Mazzucchelli ed. Figure 9. The new Genoese Urology Clinic, inaugurated in 1992. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 M. Martini, G. Martorana 6 - a semi-intensive post-operative therapy department; - a surgical block devoted exclusively to urology; - a centre for calculosis; - a centre for urodynamics; - an outpatient clinic; - a teaching centre. CONCLUSIONS During the Congress of the European Society of Urology in Berlin in July 1994, Prof. Giuliani was awarded the highly prestigious Willy Grégoir Medal, an accolade conferred upon eminent personalities in European urology. A month later, on 18 August 1994, following a brief ill- ness, Giuliani died in the very Institute that he himself had created in Genoa; he was 66 years old. In December of the same year, the Institute was named in his honour, thus becoming the “Luciano Giuliani Institute of Clinical Urology”. Luciano Giuliani was a distinguished scientist and one of the most renowned scholars of urology in the interna- tional scientific firmament. Nicknamed “Grand Master”, Giuliani struck very deep roots and ploughed a furrow that ran uninterruptedly through the generations of his pupils, who were truly numerous and of high quality. When faced with a clinical problem, every urologist should remember that things are what they are today because in the past there have been people like the Maestro Giuliani and clin- ical experiences that have, thanks also to advances in technol- ogy, pharmacology and biomaterials, allowed constant evolu- tion, thereby enabling us to achieve ever-better results (da pre- fazione di Marco Carini) (13). ACKNOWLEDGEMENTS - Thanks to Prof. Carlo Terrone (University of Genoa) for the photo number 9 and for reading the text. - Thanks to Gianmaria Martini (independent scholar) for the help in bibliographic data. REFERENCES 1. Private Archive “Luciano Giuliani”. 2. Circular N°. 360 of G.M. 1951. Military School of Health, Florence. 3. Military School of Health, Florence. D.M. N°. 2598/C. of prot. Doc. of 13 October 1953, Prof. Col. G. Piazza. (Giuliani Private Archive). 4. Giuliani L. L’ ibernazione. G.Med.Milit. 1953; 103:335-344. 5. University of Pisa. Certificate N°. 3211, Matriculation N°. 7/259. 6. Rector's Decree N°. 2544 of 18 November, 1957 (Official Bulletin of the Ministry of Education, Part II, N°. 36 of 4 September, 1958, p. 5048. 7. Giuliani L. Sulle vie biliari extraepatiche (nota anatomica). La Chirurgia Generale 1954; 3:189-207. 8. Fedeli F. University of Florence. Institute of General Clinical Surgery and Surgical Therapy. Florence, 6 June 1959. 9. Rector's Decree N°. 2544 of 18 November, 1957 (Official Bulletin of the Ministry of Education, Part II, N°. 36 of 4 September, 1958, p. 5048. 10. Giuliani L. La gastrocistoplastica: dall'idea sperimentale ad alcune considerazioni pratiche in tema di chirurgia plastica e sosti- tutiva della vescica. Urologia 1958; 25 (suppl. 7). 11. Giuliani L, Pisani E. L'intestino nella chirurgia plastica e sostitu- tiva della vescica: valutazione cistografica e cistomanometrica dei risultati. Arch It Urol. 1959; 32:164. 12. Luciano Giuliani Private Archive. 13. Martorana G. L’uso dell’intestino in urologia. (The use of the intestine in urology). Bononia University Press. Bologna, 2021. 14. Bracci U, Giuliani L, Costantini A, Tacciuoli M. The Surgical Treatment of Prostate Cancer. Vallecchi ed. Officine Grafiche. Firenze, 1961. 15. Bracci U, Giuliani L, Polito M. La ripresa funzionale dei reni esclusi (The functional recovery of excluded kidneys). Relazione uffi- ciale al congresso della Società Italiana di Urologia, Capelli ed. Bologna, 1967. 16. Bracci U. Le vie d’accesso nella chirurgia dell’apparato urinario. Le vie d’accesso al rene. Macrì, Firenze, 1956. 17. Giuliani L, Carmignani G, Belgrano E, Martorana G. Le vie d’accesso in chirurgia urologica. Relazione ufficiale LVI Congresso, SILI, Bari, 3-6 ottobre 1984. 18. Giuliani L, Giberti C, Martorana G. Atlas of surgery for renal cancer. 2nd ed. Zambeletti S.p.A., Milano, 1989. 19. Giuliani L, Giberti C, Martorana G, Rovida S. Radical extensive surgery for renal cell carcinoma: long-term results and prognostic factors. J Urol 1990; 143:468.5. 20. Malinaric R, Mantica G, Martini M, et al. The Lifetime History of the First Italian Public Extra-Corporeal Shock Wave Lithotripsy (ESWL) Lithotripter as a Mirror of the Evolution of Endourology over the Last Decade. Int J Environ Res Public Health 2023; 20:4127. 21. Carmignani G, Traverso P. (Durand F). Brief history of Ligurian urology. Tipografia Araldica. Genova, 1997. Correspondence Mariano Martini, MD, PhD (Corresponding Author) mariano.martini@unige.it mariano.yy@gmail Department of Health Sciences, University of Genoa Largo R. Benzi 10, 16132 Genoa, Italy Giuseppe Martorana, MD University of Bologna, Bologna, Italy Conflict of interest: The authors declare no potential conflict of interest.