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Purpose To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. Methods A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. Results A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar Conclusion A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified. Level of evidence Level V.

BACKGROUND: Managing Helicobacter pylori infection requires constant decision making, and each decision is open to possible errors. AIM: The aim was to evaluate common mistakes in the eradication of H. pylori, based on the "European Registry on Helicobacter pylori management". METHODS: European Registry on Helicobacter pylori management is an international multicentre prospective noninterventional registry evaluating the decisions and outcomes of H. pylori management by European gastroenterologists in routine clinical practice. RESULTS: Countries recruiting more than 1000 patients were included (26,340 patients). The most common mistakes (percentages) were: (1) To use the standard triple therapy where it is ineffective (46%). (2) To prescribe eradication therapy for only 7 to 10 days (69%). (3) To use a low dose of proton pump inhibitors (48%). (4) In patients allergic to penicillin, to prescribe always a triple therapy with clarithromycin and metronidazole (38%). (5) To repeat certain antibiotics after eradication failure (>15%). (6) Failing to consider the importance of compliance with treatment (2%). (7) Not to check the eradication success (6%). Time-trend analyses showed progressive greater compliance with current clinical guidelines. CONCLUSION: The management of H. pylori infection by some European gastroenterologists is heterogeneous, frequently suboptimal and discrepant with current recommendations. Clinical practice is constantly adapting to updated recommendations, although this shift is delayed and slow.

The human intestine contains over a thousand species of diners microrganisms, collectively known as “intestinal microbiota”, essential to the integrity of the mucosal barrier function. Alterations such as quantitative of microbiota (composed mainly of bacteria, viruses and fungi), which are able to alter this delicate balance, are involved in neurological and systemic diseases (among others, Ulcerative Colitis and Crohn’sdisease, irritable bowel syndrome, stomach and colon cancers, allergies and intolerances, diabetes, atherosclerosis, etc.). Laboratory and human studies also showed an interesting relationship between gut microbiota and obesity [1,2]. Obesity is a medical condition which affects a growing number of people, especially in Western countries. In the United States more than 50% of the population is overweight and about 1/3 is frankly obese. It is also a predisposing condition for a number of diseases that can seriously compromise the health of the individual. No doubt a high-calorie diet and lack of physical activity are the leading causes of obesity, but certainly fascinating is the study of the complex mechanisms involved in the regulation of energy balance and their alterations. In this regard, recent studies suggest that the gut microbiota can play an important role in the pathogenesis of obesity and metabolic syndrome as able to influence nutrient absorption and distribution of energy. Mice bred in sterile conditions (the so-called “germ free”, scilicet without microbiota) need a significantly higher amount of calories compared to the counter part grown under conventional conditions to maintain the same body weight and, in equal diet, have a considerably lower amount of fat mass. Very interesting is that the subsequent colonization of germ-free mice with a normal colonic microbiota determines a rapid and significant increase in body weight and body fat of these animals. Underlying these evidences there are a variety of mechanisms. Bacteria of the microbiota, in fact, appear likely to reduce intestinal expression of a factor, the fastinginduced adipose factor (Fiaf), which is itself an inhibitor of lipoproteinlipase. It follows an abnormal activation of this enzyme, which favor the release of fatty acids from circulating lipoproteins VLDL and chylomicrons with subsequent accumulation of triglycerides in the adipose tissue. Intestinal bacteria are also able to reduce expression, whether in the liver that muscular, of an enzyme, AMPK (adenosine monophosphate-activated protein kinase), which is critical in stimulating β-oxidation of fatty acids. Another recently described mechanism involves rather short-chain fattyacids produced by bacterial fermentation of carbohydrates, which are able to regulate the expression of intestinal hormones, such as Peptide YY, which regulate the production and digestive enzyme release. Finally, monosaccharides produced by fermenting bacteria action of the microbiota, once absorbed and transported to the liver by the portal circle, are able to bind and activate a cytoplasmic factor ( the carbohydrate responsive element binding –ChREBP), which, migrating from the cytoplasm to the nucleus, activates enzymes involved in lipogenesis. Finally, another highlight on the possible role of intestinal flora in obesity comes from the evaluation of the role of lipopolysaccharide (LPS) of the wall of gram negative bacteria in chronic systemic inflammation and therefore insulin resistance and obesity. High-fat diets in particular alter composition of the microbiota (increase Gram negative bacteria/Gram positive) leading to increased levels of circulating LPS; this, in turn, is able to induce the production of pro-inflammatory cytokines (TNF-α, IL1, IL-6, plasminogen activator inhibitor) [3,4] which in turn regulate the glucose tolerance, encouraging the development of insulin resistance [5]. It follows then a possible role of LPS in chronic inflammation associated with diets [6,7] high in fat, with a predisposition to the development of insulin resistance and thus of diabetes. Is easy to understand, therefore, that both experimental animals and humans there are significant differences in the composition of the microbiota [8-15] between qualitative and quantitative obese and lean. In particular, recent studies have clearly demonstrated a significant reduction of bacteria belonging to the family of Bacteroidetes and a proportional increase of bacteria belonging to the familyof Firmicutes and Archea. This results in an increase in the intestinal lumen, of non-digestible polysaccharides capable of breaking down hydrolases, including the β-fructosidases and increased transport proteins needed in absorption of products of fermentation, including the Phospho transferases. Always in obese, the preponderance of methane-producing bacteria, which use hydrogen to produce methane, maintains a constant low hydrogen partial pressure, thus optimizing the processes of bacterial fermentation [16-18]. Ultimately, these quantitative and qualitative changes in metabolic way of bacterial flora guarantee guests to extract maximum energy value from the diet, taking calories also in even potentially low foods, like fibers. The surprising is that these alterations of gut microbiota are absolutely reversible: a low-calorie diet, in fact, is able to balance Bacteroidetes/Firmicutes, reformulate the metabolic structure of the intestinal flora and induce a weight loss that goes along with the balance of the intestinal ecosystem. At present, antibiotics, probiotics, prebiotics and synbiotics are tools used to modulate the bacterial flora in terms of quality and quantity [19-21]. It is clear that an ever deeper knowledge in this field and new data on bacteria able to influence the metabolism, such as Akkermansiamuciniphila, or inflammation, such as Fecalibacteriumprausnitzii may in the future to suggest therapeuticactions on complex microbial intestinal balance which is the basis of obesity and its complications.

The "mediastinal syndrome" is an oncological urgency but, in some situations as in the case report described below, it can present itself in a subtle and inextricable way with symptoms and signs that, if singularly evaluated, can be nonspecific. In particular, we report the case of facial edema and a rash that, developing in an unusual and progressive way during about 2 months, concealed a voluminous mediastinal formation due to the localization of non-Hodgkin B-cell lymphoma that caused a "superior caval vein syndrome".

The purpose of this open-label study was to investigate the effect of a curcumin-phospholipid lecithin formulation (Meriva®) on visual acuity and optical coherence tomography (OCT) retinal thickness in patients with chronic diabetic macular edema.Curcumin-phospholipid lecithin formulation (Meriva®, Indena S.p.A, Milan, Italy) was administered as tablets (Norflo®, Eye Pharma, Genoa, Italy) twice a day. Visual acuity and macular edema as measured by OCT before and after curcumin-phospholipid formulation treatment were assessed.The study included 12 eyes from 11 patients who completed at least a 3-month follow-up period. After 3 months of therapy, no eyes showed reduction in visual acuity, 16% showed stabilization, and 84% showed improvement. The improvement was statistically significant (p = 0.0072). After 3 months of therapy, 92% of eyes showed reduction of macula edema, 8% showed stabilization, and 0% showed an increase (p = 0.009).Our results, albeit preliminary, suggest that a curcumin-phospholipid formulation (Meriva®), administered as Norflo® tablets, may be feasible in the improvement of visual acuity and reduction of macular edema in patients with diabetic retinopathy.

Long-term physical inactivity can cause the atrophy of skeletal muscle. The aim of this study is to explore the underlying mechanisms of physical inactivity-induced atrophy of skeletal muscle.14 Sprague- Dawley (SD) male rats were divided into 2 groups including normal control (NC) and hindlimb suspension (HS) groups. After two weeks of HS stimulation, the ratio between skeletal muscle weight and body weight, and cross-sectional area (CSA) of skeletal muscle fibers, were measured. Western blot was applied to evaluate the expression of proteins associated with atrophy and autophagy. The transmission electron microscope was used to observe the ultra-microstructure and the mitochondrial quality of skeletal muscle.The rats subjected to 2-week HS treatment presented an evident atrophy of the skeletal muscle with a significantly reduced ratio between skeletal muscle weight and body weight, and smaller cross-sectional area (CSA) of skeletal muscle fibers when compared with control rats. Meanwhile, HS stimulation resulted in the damage of mitochondria, the increased expression of MuRF1 and Atrogin-1/MAFbx, and enhanced apoptosis, as well as dysfunctional autophagy in skeletal muscle.HS-induced skeletal muscle atrophy involves the activation of AMPK/FoxO3 signal pathway, evidenced as AMPK phosphorylation, FoxO3 activation, and Atrogin-1 and MuRF1 up-regulation. FoxO3-mediated autophagy plays an important regulatory role in HS-induced skeletal muscle atrophy.

Constipation is a common symptom affecting up to 30% of the Western population and is strongly associated with the presence of intestinal methanogens, which may directly inhibit motor activity. Two recent studies performed on adult and children affected by chronic constipation showed that the supplementation with L. reuteri significantly improved bowel movements. Whether its action is related to a decreasing of methane (CH4) production has never been tested. We have therefore designed a study aimed at testing this hypothesis.Data of 20 adults (12 females, mean age 36.2 ± 13.7) affected by functional constipation, treated with the probiotic L. reuteri (DSM 17938) for 4 weeks who performed a H2/CH4 lactulose breath test (LBT) in our institution showing a CH4 production higher than 5 ppm were retrospectively analyzed from March to June 2015. Data recorded in their stool diary, reporting the frequency of defecations and stool consistency were also analysed, as well as the result of the LBT performed at the end of the treatment with L. reuteri.Four weeks of L. reuteri administration was associated with a significant decrease of mean CH4 production determined by LBT (from 20.8 ± 15 to 8.9 ± 8.6; p0.0001 CI 95%) and of AUC value (from 5101.5 ± 3571.13 to 2128.4 ± 2110.8; p0.0001 CI 95%). Moreover, a total disappearance of CH4 production (5 ppm at LBT) was observed in 11 patients, while, we did not observe any significant decrease of H2 production (from 13.2 ± 8.8 to 11.4 ± 7.3, CI 95%, n.s.).This study highlights for the first time the beneficial effect of Lactobacillus reuteri (DSM 17938) on chronic constipation, via a significant decrease of CH4 production.

Several experimental studies and clinical trials support the potential of Boswellia serrata extracts (BSE) for the treatment of various inflammatory diseases. The aim of this registry study was to assess the safety and the efficacy of a novel lecithin-based delivery form of Boswellia serrata extract (Casperome®) in the supportive management of osteo-muscular pain.52 healthy young rugby players with acute knee pain and inflammation were recruited. Informed participants freely decided to follow either a standard management (SM) to control joint pain (control group = 27) or SM associated with oral daily supplementation with Casperome® (supplement group =25). Parameters associated with osteo-muscular pain and inflammation, and measurements of joint health and functions were assessed at the inclusion and after a 4-week supplementation.A significant beneficial effect of Casperome® vs SM alone was observed for all the parameters evaluated, namely: local pain on effort; pain-free walking distance (treadmill test); minimal joint effusion; structural damage (joint, tendons, muscles) and intramuscular hematomas; thermal imaging of the anterior knee; Visual Analog Scale for Pain (VAS Pain); need for concomitant drugs and medical attention; measurement of inflammatory biomarkers.Our registry study suggests that Casperome® supplementation could represent an effective and safe, integrated approach for the treatment of osteo-muscular pain and inflammation.

Despite a growing interest toward the interplay between H. pylori and gastric microbiota, few data are available about this correlation. The aim of this study was to explore the relationship between H. pylori infection and gas production during lactulose breath test.Data of patients undergoing both 13C-urea breath test (UBT) and lactulose breath test (LBT) under standard conditions in our GI unit were retrospectively analyzed. GI symptoms, such as dyspepsia, bloating, abdominal pain/discomfort, and epigastric pain on an eleven-point scale were also analyzed and correlate with the results of those tests. H2 and CH4 were calculated using the trapezoidal rule; a considerable CH4 production was defined by AUCCH4 ≥1200 ppm*4h. Statistical analyses were performed with Fisher's exact test and independent samples Mann-Whitney test.Data of 136 patients during a period of time of 3 months were analyzed. 36 patients (26.5%) showed a positive UBT. We do not find any difference as regards age, sex, symptom complaints, and small intestinal bacterial overgrowth between HP negative and positive patients. A greater methane production was observed in infected rather than non-infected patients (47.2% vs. 26% respectively, p=0.02). Furthermore, 25% infected and 10% non-infected produced greater amounts of CH4 compared to H2, resulting in a AUCCH4/AUCH2 ratio1 (p=0.046).This study shows for the first time, a significant association between H. pylori infection and methane production, suggesting that H. pylori might influence gut microbiota composition. Further studies are needed to clarify mechanisms underlying this phenomenon.

Boswellia serrata extracts (BSE) have been traditionally used for the treatment of several inflammatory diseases. The aim of this study was to evaluate the efficacy of a novel delivery form of BSE (Casperome®) in Ulcerative Colitis (UC) during minimally symptomatic remission phase.In this open-label, observational, registry study, informed participants with UC in remission phase (n = 43) freely decided to receive the oral daily Casperome® supplementation (n = 22) or no supplementation (n = 21) for 4 weeks. Several parameters associated with minimally symptomatic UC in remission were evaluated at the inclusion and the end of the study.A significant beneficial effect of Casperome® was observed for all the parameters evaluated, namely: diffuse intestinal pain, evident and occult blood in stools, bowel movements and cramps, watery stools, malaise, anemia, rectal involvement, number of white blood cells as well as need for concomitant drugs and medical attention. Faecal concentration of calprotectin, a marker of bowel inflammation, resulted ameliorated in Casperome® supplemented patients.Our study showed that Casperome® supplementation attenuates symptoms associated with mild UC in remission, reducing the use of drugs and medical consultations. Therefore, our study suggests that Casperome® supplementation could represent a promising alternative approach to manage minimally symptomatic UC and maintain the remission phase.

Background/Aims: Lactose malabsorption (LM) consists in the incomplete absorption of lactose, due to lactase deficiency. According to previous studies, headache can be triggered by food intolerance. We investigated the onset and severity of headache during the LBT and a correlation with LM. Patients and Methods: We enrolled 93 (74F/19M; mean-age 42 ± 16 yrs) outpatients who performed a LBT according to the guidelines. Patients reported on a Visual-Analogue-Scale the intensity of headache before and at the end of the test. We considered as significant an increase of headache in VAS peak >10mm. Results: 67/93 (72%) resulted LM, while 53% (49/93) referred a headache worsening. Within the group of LM headache worsened in 50.7%, compared to 57.7% in non-malabsorbers (p=0.36). In the subgroup of patients with habitual headaches there is a significant worsening compared to non-habitual ones (70.7% vs 38.5%; p=0.003) regardless of the LBT result. Conclusion: The present study denies the existence of an association between LM and headache. We found that headache significantly worsened in patients usually suffering from headache, regardless LM. We think that this data should be considered, since we suppose that the onset of headache during a LBT could affect the correct execution of the test.

Gut barrier is a functional unit organized as a multi-layer system and its multiple functions are crucial for maintaining gut homeostasis. Numerous scientific evidences showed a significant association between gut barrier leaking and gastro-intestinal/extra-intestinal diseases.In this review we focus on the relationship between gut barrier leaking and human health. At the same time we speculate on the possible new role of gut barrier protectors in enhancing and restoring gut barrier physiology with the final goal of promoting gut health.The alteration of the equilibrium in gut barrier leads to the passage of the luminal contents to the underlying tissues and thus into the bloodstream, resulting in the activation of the immune response and in the induction of gut inflammation. This permeability alteration is the basis for the pathogenesis of many diseases, including infectious enterocolitis, inflammatory bowel diseases, irritable bowel syndrome, small intestinal bacterial overgrowth, celiac disease, hepatic fibrosis, food intolerances and also atopic manifestations. Many drugs or compounds used in the treatment of gastrointestinal disease are able to alter the permeability of the intestinal barrier. Recent data highlighted and introduced the possibility of using gelatin tannate, a mucosal barrier protector, for an innovative approach in the management of intestinal diseases, allowing an original therapeutic orientation with the aim of enhancing mucus barrier activity and restoring gut barrier.These results suggest how the mucus layer recovering, beside the gut microbiota modulation, exerted by gut barrier protectors could be a useful weapon to re-establish the physiological intestinal homeostasis after an acute and chronic injury.

Joint disease reduces the rheological properties of synovial fluid, increasing the susceptibility of the articular cartilage to damage. Thus, a therapeutic strategy, called viscosupplementation, was proposed in which intra-articular injections of a suitable material are used to restore the viscoelastic properties of the synovial fluid. Solutions of high-MW native HA, which is the main component of the synovial fluid, were a natural choice to reach this goal, but HA-derived materials, engineered to achieve greater elastoviscosity and intra-articular residence time, were also developed. In the last twenty years the clinical experience showed that viscosupplementation is effective in joint diseases such as osteoarthritis, with beneficial effects on pain, function and patient global assessment. However, a marked variability between different preparations on different outcome parameters was reported to exist.In the present paper the available data on Hyalubrix®, a specific 1.5% formulation of natural HA with MW in the range 1500-2000 kDa, were reviewed, trying to outline, in the framework of the available intra-articular therapies, the role it can play for the symptomatic management of patients with degenerative joint arthropathy.

Pain is the most common reason people see doctors in developed Countries and a very common cause of access in Emergency Department (ED). The combination acetaminophen/codeine represents the standard medication in the second step of the WHO analgesic scale and codeine is one of the most commonly used opioid analgesic for a variety of pain conditions. However, many aspects related to safety and efficacy are still undefined.To summarize and review the results of the most relevant studies on the efficacy and safety profile of acetaminophen/codeine combination in the treatment of pain of different origin.We performed a literature search to identify and evaluate all relevant english-language randomized controlled trials (RCTs), meta-analyses and reviews about the codeine plus paracetamol combination in the treatment of pain from any source.Acetaminophen/codeine combination is effective in the treatment of moderate to severe pain in all setting analyzed in this study, which include headache, postoperative, osteoarticular and post-traumatic. The best results in terms of safety and efficacy have been obtained in postoperative pain. Efficacy of acetaminophen/codeine combination is not inferior to NSAIDs.Acetaminophen/codeine combination is effective in the treatment of pain, through a synergistic action of the two molecules, and is not inferior to NSAIDs. Side effects of acetaminophen/codeine are usually minor, differently from NSAIDs, which may induce some potentially life threatening conditions.

Panic disorder is characterized by the spontaneous and unexpected occurrence of panic attacks. During panic attacks, patients (pts) refer to the Emergency Department (ED). The diagnostic work-up for any panic attack is expensive since symptoms at presentation mimic other diseases such acute coronary syndrome or neurological emergencies. The aim of the present study was to describe a 10 years cohort of pts diagnosed with panic disorder in the ED in terms of ED visit recurrence.Case-control study, in a tertiary care, involving pts presenting to the ED and diagnosed with panic attack according to the International Classification of Diseases 9nt Revision (ICD-9). From January 2001 to Dec 2009 were extracted from the electronic clinical database 469 pts and were divided into "recurrent ED visit" (multiple ED access for panic attack) (N=361) and "no recurrent ED visit" (only one ED access for panic attack in 9 years) (N=108).At univariate analysis cases and controls differed for male prevalence (p0.01), neurological symptoms at presentation (p = 0.02) and history of other psychiatry disorder (p0.01). In multivariate analysis independent predictors were male gender, age under 40 year old, palpitations at presentations, 1 or more cardiovascular risk factors and previous other psychiatry conditions.Male under 40 years old with palpitations or cardiovascular risk and other psychiatric diseases, have a higher recurrence of panic attacks. General psychiatric evaluation and treatment with benzodiazepine in ED is not useful to prevent recurrences. Identifying those patients at high risk of panic attack and ED visit recurrence might be useful to establish ad-hoc interventions, improve patients' morbidity and save precious resources.

Background: Helicobacter pylori, the main cause of gastritis and peptic ulcer, has been associated with idiopathic chronic urticaria (ICU), an immunological skin disorder of unknown origin. Eosinophilic cationic protein (ECP) is a cytotoxic molecule secreted by the activated eosinophils involved in the pathogenesis of ICU. We assessed serum/gastric juice ECP levels and gastric mucosal eosinophil infiltration in ICU patients infected or not with H. pylori and evaluated the modification after bacterium eradication. Methods: 33 patients with ICU and 25 dyspeptic controls underwent upper gastrointestinal endoscopy for histological evaluation and assessment of H. pylori infection. One-week triple therapy was given to H. pylori-positive patients. Serum and gastric juice ECP levels, eosinophil infiltration from gastric mucosal sections and urticaria symptoms were evaluated in all patients at enrolment and 8 weeks after eradication. Results: 19 of 33 (57%) ICU patients and 16 of 25 (64%) controls were found to be infected with H. pylori. Serum ECP was significantly higher in ICU patients compared to controls, regardless of infectious status. Gastric juice ECP and gastric eosinophil infiltration were significantly higher in infected ICU patients when compared both to uninfected ICU patients and controls. H. pylori eradication determined a significant decrease in gastric juice ECP and gastric eosinophil infiltration only in ICU patients. Moreover, a total or partial remission of urticaria symptoms was observed only in ICU patients in whom the bacterium was eradicated. Conclusions: Although H. pylori infection affects gastric juice ECP and eosinophil infiltration of ICU patients, the role of the bacterium in the pathogenesis of this skin disorder still remains uncertain. Copyright (C) 2001 S.Karger AG, Basel

La finalidad de este artículo, más que proponer nuevas cuestiones acerca del canon 1095, es la de presentar de forma unitaria cuanto el autor ha ido escribiendo sobre algunos de estos temas en diversos artículos, pues la experiencia de estos casi treinta años de vigencia del canon muestra claramente la dificultad de interpretarlo correctamente. Entre los temas que han sido ampliamente desarrollados por la jurisprudencia y por la doctrina, se hace referencia a los siguientes: a) el significado de la in- madurez afectiva o psico-afectiva; b) la calificación jurídica del «defecto de libertad interna»; c) la ad- misibilidad o no de la incapacidad relativa; d) la relación entre la discreción de juicio y la capacidad para asumir, y la cuestión de la autonomía del numeral tercero del canon 1095. Éste último aspecto es tratado con más detalle, pues es importante para entender y aplicar adecuadamente el canon 1095. Rather than raise new questions regarding Canon 1095, the purpose of this paper is to collate the author’s views and arguments on such issues as presented in a range of previous articles. Thirty years of study in this regard discloses the difficulty involved in interpreting it correctly. The following topics, which have been addressed in considerable detail in terms of both jurisprudence and doctrine, are refer- enced here: a) the meaning of emotional or psychoemotional immaturity; b) the juridical definition of the “lack of internal freedom”; c) the admissibility or non-admissibility of relative incapacity; d) the rela- tionship between discretion of judgment and the capacity to assume obligations, and the issue of autonomy mentioned in number three of canon 1095. This final aspect is discussed in most detail because it is key to any clear understanding and application of Canon 1095.

This is the first study investigating the effect of oxycodone in polytrauma patients. The management of pain in polytrauma patients has become a very relevant issue. Nonsteroidal anti-inflammatory drugs (NSAIDs) represent the most used drugs in polytrauma patients, even though their use is associated with an increased hemorrhagic risk. Previous studies have demonstrated the efficacy of oxycodone for the treatment of acute pain. The aim of this study was to assess the efficacy of oxycodone administration in polytrauma patients, with minor injuries.15 polytrauma patients (10 males, mean age 40 +/- 13 years; 5 females, mean age 49 +/- 26 years) were admitted to the Emergency Department of the Catholic University, A. Gemelli Hospital in Rome, Italy. All patients underwent physical examination, FAST ultrasound, total body CT scanning and blood tests. Three patients had multiple costal fractures, three had pelvic fracture, two had tibial fracture, five had vertebral fractures, one patient had clavicle fracture and ulnar fracture, one patient a severe trauma of the left leg, which required amputation. Five patients also reported minor head trauma, with a Glasgow Coma Score (GCS) 15. All patients reported abdominal trauma, while none of them had severe thoracic or kidney damage. Patients with head trauma also underwent a second CT head scanning 12 hours after admission, which excluded the occurrence of cerebral damage. All patients were then treated with oral administration of oxycodone 10 mg two times per day (bid) for 3 days. Pain intensity, before and after the administration of oxycodone, was evaluated using a scale ranging from 0 to 10.The mean pain score at admission was 8 +/- 0.7. All patients reported significant pain improvement after the administration of oxycodone (8 +/- 0.7 vs 1.8 +/- 0.9; p0.0001). A dosage increase of oxycodone from 20 to 40 mg bid was required in only one patient with a clavicle fracture. The main side effects were light-headache (5 patients), constipation (4 patients) and nausea (3 patients).These data indicate that oxycodone is a safe and effective drug for pain relief in polytrauma patients without severe thoracic, kidney or brain damage.

The goal of this prospective randomized study was to compare the isokinetic recovery of thigh strength after anterior cruciate ligament (ACL) reconstruction by using patellar or quadriceps tendon as graft at the 6th month follow-up.The authors evaluated 48 patients who underwent arthroscopic ACL reconstruction using patellar tendon (PT group) or quadriceps tendon (QT group) as autograft after a 6 months follow-up undergoing the following tests: the Ergojump Bosco System springboard and Universal's FITNET computerized isokinetic system.The counter movement jump (CMJ) test showed a 24% (p0.01) strength deficit in patients operated with patellar tendon and 11% in the quadriceps tendon group. Also in the leg press test the greater differences in strength (p0.05) were verified in the patellar tendon group, above all the peak torque (PT) test carried out at 3 repetitions (15%).The strength deficit found in the subjects operated with quadriceps tendon were statistically lower in comparison to that verified in the patellar tendon group. A good recovery in thigh strength after 6 months in patients operated with quadriceps tendon could encourage the use of this kind of graft in order to achieve an easier rehabilitation and a faster release of the patient to daily and sports activity.

Dry eye, a chronic disease of lachrymal fluid and corneo-conjunctival epithelium, could significantly impact visual function, affects quality of life and work productivity. Beside several conventional treatments, nutritional supplements based on bilberry extract have been identified as effective contributors to eye health. Here, we aim at investigating the bioavailability of a standardized bilberry extract, its ability to alleviate dry eye symptoms and its antioxidant potential.Either bilberry dried standardized extract derived from Vaccinium myrtillus L. fresh frozen fruits (Mirtoselect®) or a highly purified anthocyanin-rich extract, devoid of the non anthocyanin component and supported on maltodextrins, were each orally administrated to 5 male rats. Blood samples were collected at 5, 10, 15, 20, 30, 45, 60, 90, 120 minutes after treatment, processed and analyzed by UV spectrophotometric method. In a parallel analysis, 22 otherwise healthy subjects suffering from dry eye symptoms were enrolled randomly assigned to receive the more bioavailable bilberry extract or placebo. Ophthalmological and clinical examinations including Schirmer's test, pupil constriction, diacron-reactive oxygen metabolites (d-ROMs) test and biological antioxidant potential (BAP) test were performed at inclusion and after the 4-week study period.The area under the curve of plasmatic levels of anthocyanosides in rats resulted 202.34±24.23 µg·min/ml for Mirtoselect® and 130.93±4.93 µg·min/ml for the highly purified anthocyanin-rich bilberry extract, notwithstanding the fact that the highly purified anthocyanin-rich extract group received an anthocyanins dosage much higher than the Mirtoselect® group (354 mg/Kg in anthocyanosides vs. 136 mg/Kg in anthocyanosides). 21 subjects, 11 subjects in the bilberry extract (Mirtoselect®) group and 10 subjects in the placebo group completed the clinical study. Schirmer's test values indicating the volume of tear secretion were significantly improved in the bilberry extract group (p=0.019), whereas no significant changes were observed in the placebo group. A subset analysis revealed that Mirtoselect® could be more effective in subjects with higher tendency of dry eye. In terms of antioxidant potential, the bilberry extract produced significant improvement of BAP (p=0.003) and an increase of modified BAP/d-ROMs ratio, an indicator of overall balance between antioxidant potential and oxidative stress.Our results suggested that natural, standardized bilberry extract (Mirtoselect®) is a natural more bioavailable delivery form anthocyanins, suggesting a strong matrix effect exerted by the non-anthocyanin component. Furthermore, it can improve tear secretion and plasmatic antioxidant potential in subjects suffering from DED symptoms.

Breath tests (BT) represent a valid and non-invasive diagnostic tool in many gastroenterological disorders. Their wide diffusion is due to the low cost, simplicity and reproducibility and their common indications include diagnosis of carbohydrate malabsorption, Helicobacter pylori infection, small bowel bacterial overgrowth, gastric emptying time and orocaecal transit time. The review deals with key points on methodology, which would influence the correct interpretation of the test and on a correct report. While a clear guideline is available for lactose and glucose breath tests, no gold standard is available for Sorbitol, Fructose or other H2 BTs. Orocaecal transit time (OCTT) defined as time between assumption of 10 g lactulose and a peak10 ppm over the baseline value, is a well-defined breath test. The possible value of lactulose as a diagnostic test for the diagnosis of small bowel bacterial overgrowth is still under debate. Among (13)C breath test, the best and well characterized is represented by the urea breath test. Well-defined protocols are available also for other (13)C tests, although a reimbursement for these tests is still not available. Critical points in breath testing include the patient preparation for test, type of substrate utilized, reading machines, time between when the test is performed and when the test is processed. Another crucial point involves clinical conclusions coming from each test. For example, even if lactulose could be utilized for diagnosing small bowel bacterial overgrowth, this indication should be only secondary to orocaecal transit time, and added into notes, as clinical guidelines are still uncertain.

Most studies on atherosclerotic processes include peripheral arterial disease diagnosis only if patients report symptoms suggestive of peripheral arterial disease and/or an instrumental demonstration of lower limbs perfusion deficit is provided, rather than the sole presence of atherosclerotic lesions localized at lower limbs, this attitude leading to ignore early stages of the disease. To overcome these limitations, we have proposed a new ultrasonographic semiquantitative score to better identify all disease stages. The aim of this study is to compare ultrasonography versus ankle-brachial index in the association between peripheral arterial disease and cardiovascular risk factors.This cross-sectional observational study included subjects undergoing lower limbs evaluation through ultrasonography and ankle-brachial index determination because of symptoms suggestive of peripheral arterial disease or presence of known cardiovascular risk factors. Associations between ultrasonography and ankle-brachial index with cardiovascular risk factors were assessed by first fitting logistic regression models and then comparing the respective areas under the Receiver Operating Characteristic and 95% confidence intervals.The areas under the Receiver Operating Characteristic for each cardiovascular risk factors were consistently larger in magnitude for ultrasonography compared with ankle-brachial index, this comparison being statistically significant for age, male gender, smoking status, hypertension, diabetes mellitus and previous cardiovascular events.Our study demonstrates that ultrasonography is a better method to screen peripheral arterial disease respect to ankle-brachial index in order to identify all disease stages. These findings are useful in particular when including peripheral arterial disease as organ damage marker in cardiovascular risk stratification.

Helicobacter pylori (H. pylori) is a Gram-negative bacterium able to colonize the gastric mucosa as well as gastric metaplastic areas of the duodenum, producing inflammation. The clinical outcome depends on sophisticated interactions between bacterial factors, such as the expression of determinants of virulence and pathogenicity, and host characteristics. The severity of inflammation, may then vary among different subjects, leading to the occurrence of different gastroduodenal diseases, ranging from chronic gastritis to gastric cancer and MALT-lymphoma, to some defined extragastric manifestations. Many diagnostic tests are available for the detection of H. pylori infection including noninvasive methods, such as serology, (13)C-urea breath test (UBT), and fecal antigen tests and invasive techniques, including a combined use of endoscopic biopsy-based methods, such as rapid urease testing, histology, culture, and molecular methods. UBT is a highly sensitive and specific and allows to diagnose the presence or absence of infection of H. pylori, through the oral administration of a solution containing urea labelled with the non-radioactive natural carbon 13. This review article analyzes microbiological and clinical features of H. pylori as well as the different diagnostic tests able to detect this bacterium with a special focus on UBT.

Levothyroxine therapy is used in case of deficiency of the thyroid hormones in the human organism. Many conditions, either physiological or paraphysiological or clearly pathological, can alter the levothyroxine absorption in the human body. Levothyroxine absorption can indeed be impaired by age, patient's compliance, fasting, the intake of certain foods (such as dietary fibers, grapes, soybeans, papaya and coffee) or by some drugs (such as proton-pump inhibitors, antacids, sucralfate, et cetera). Additionally, many gastrointestinal diseases, such as the conditions that disrupt the integrity of the intestinal barrier and the diseases that impair gastric acidity, may alter the bioavailability of levothyroxine. Since the enormous, widespread diffusion of thyroid diseases, a large number of patients have to face such issues. Therefore, the development of new levothyroxine oral formulations, other than solid tablets, may represent an interesting therapeutic approach, at the same time simple and effective, to face this problem. Recently, two different levothyroxine formulations have been proposed: the liquid formulation and the softgel formulation. Such formulations represent an innovative, effective and cheap therapeutic approach to hypothyroid patient with problems of impaired absorption of levothyroxine.

Osteopenia is a chronic bone condition characterized by decreased calcification, density, or bone mass that, if untreated, can lead to osteoporosis and bone fractures. Although its increasing prevalence, nowadays osteopenia is not adequately prevented and managed. In this study, we evaluated the efficacy, in term of changes in bone density, and safety of an oral formulation based on turmeric phytosome (Meriva®), in subjects suffering from low bone density.57 otherwise healthy subjects with low bone density were enrolled in this pilot, supplement study. Informed participants freely decided to follow either a standard management (SM) to control low bone density (control group=28) or SM associated with a curcumin-based oral supplementation (supplement group=29). The bone densities of heel, small finger and upper jaw were evaluated at inclusion and at different time points during the observational period (4, 12 and 24 weeks), in all subjects.The bone density of the heel measured by the Sahara densitometer remarkably improved in the Meriva®-supplemented group, with a significant decrease of ultrasounds transmission values at week 12 (-18.4%) and at week 24 (-21.0%), compared with baseline values. The bone densities of small finger and upper jaw also significantly increased during the study in supplemented subjects, reaching +7.1% and +4.8%, respectively, at week 24, with respect to values at inclusion. Noteworthy, no significant changes of heel, small finger and upper jaw densities were observed in the control group. Last, no safety and tolerability issues were reported during the observational period.This preliminary study suggests that a curcumin-based supplementation in combination with an appropriate lifestyle could be beneficial in the prevention and management of osteopenia.

While antioxidants and probiotics have been proposed for the treatment of functional dyspepsia, current data are still heterogeneous and studies are poorly designed. Extra-virgin olive oil, a common ingredient of Mediterranean diet, has shown antioxidant properties.To evaluate the effect of extra-virgin olive oil enriched with antioxidants or probiotics on functional dyspepsia.This study has been designed as a "proof of concept". Extra-virgin olive oil enriched with antioxidants or probiotics was blindly added to the common diet of 8 subjects with functional dyspepsia for 7 days. Dyspeptic symptoms were then evaluated in all patients.A significant improvement of dyspeptic symptoms was observed in subjects receiving the antioxidant or probiotic enriched oil diet, with a greater effect observed for the latter. Larger studies are now needed to confirm these data.

Irritable bowel syndrome (IBS) is a very common functional gastrointestinal (GI). Diagnosis of IBS is based on the fulfilment of the Rome III criteria. Common GI symptoms are lower abdominal pain, bloating and disturbed defecation, such as urgent diarrhoea and/or episodes of chronic constipation. Many agents have been employed in the management of IBS, although only few have been demonstrated to show a relevant efficacy.To evaluate the effectiveness of the administration of a mixture of beta-glucan, inositol and digestive enzymes (Biointo) in improving GI symptoms in patients affected by IBS.50 IBS patients (20 males, 30 females; mean age 51 +/- 19) were treated with Biointo (group A) while another group consisting of 40 IBS patients (15 males, 25 females; mean age 50 +/- 18) did not receive any therapy (group B).Biointol administration improved significantly bloating, flatulence and abdominal pain, with a slight increasing of urgency for bowel movements. On the contrary, Biointol did not show any significant effect on the other IBS symptoms.Currently, only few agents used in the management of IBS have been proven to be effective. Biointol administration has shown to improve some IBS symptoms, such as bloating, flatulence and abdominal pain, all connected to the presence of gas inside the intestinal lumen.

In recent years metagenomic analysis has become more accessible for the characterization of biological specimens. There has been an important increase of studies using this technique for subgingival human samples. To date, there are no updated systematic reviews on the relationship between oral microbiota and periodontal disease. The aim of the present systematic review was to update data about studies concerning the influences of changes in oral microbiota composition on the periodontal status in human subjects.An electronic search was conducted in four databases (MEDLINE, Scopus, CENTRAL and Web of Science) for articles published in English from January 2014 to April 2018. In vitro or animal studies, case reports, case series, retrospective studies, review articles, abstracts and discussions were excluded. Also, studies that evaluated less than 5 microbial species, only viruses or already known periodontal pathogens were excluded. Two independent researches selected the studies and extracted the data. The quality of evidence was assessed as high, moderate or low for each microorganism.Eight studies and three additional publications recovered from the bibliography search of the selected articles were included in the review. The Bacteria domain was the main detected among the others and it included 53 species. The review confirmed the presence of recognized periodontal pathogens such as the members of the red complex but also identified, with high weight of evidence, the presence of new pathogens.The results of this systematic review support high evidence for the association of 3 new species/genera with the etiology of periodontitis. Future investigations on the actual role of these new pathogens in the onset and progression of the disease are needed.