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Background: Data regarding unequal diagnostic and therapeutic access in patients with acute stroke based on ethnicity and race are inconclusive in Europeans. The objectives of our study were to evaluate the effect of race/ethnicity on access to acute stroke care and treatments and outcomes., Methods: In this retrospective cohort study, we enrolled adult patients admitted to the emergency department of a comprehensive stroke center for suspected stroke. Based on race/ethnicity, patients were divided into two main groups: Western European Whites (WEW) and non-Western European Whites (nWEW). We also divided the nWEW group into four subgroups based on the Office of Management and Budget classification of human races and ethnicities (White-Others, Hispanic, Asian, Black). Univariate comparisons and logistic regression analyses were also performed., Results: 9167 patients were enrolled in the study: 582 in the nWEW and 8585 in the WEW group. Patients with ischemic stroke in the nWEW group were significantly younger than those in the other group (p < 0.001). Once adjusted for possible confounders, belonging to the nWEW group was found to be an independent predictor of a lower likelihood of receiving revascularization treatments (p = 0.006), regardless similar onset-to-door times. There were no differences in stroke outcomes and prevalence of stroke mimic diagnosis between the groups., Conclusions: Racial/ethnic disparities in healthcare represent a challenging issue, even in universal healthcare systems, that should be addressed promptly through education campaigns of healthcare personnel and implementation measures, such as integrating readily available interpreter staff for medical emergencies., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: This study aims to analyze the clinical characteristics, demographic features, and injury circumstances of patients admitted to the Emergency Department (ED) at Fondazione Policlinico Universitario A. Gemelli (IRCCS) in Rome, Italy, due to bicycle accidents., Methods: Data on clinical characteristics, accident timing, injury circumstances, and helmet use were collected for ED patients involved in bicycle accidents from January 2019 to December 2022. Subsequently, Abbreviated Injury Scale codes of all diagnoses were recorded and the Injury Severity Score was calculated., Results: Over the study period, 763 patients were admitted to the ED following bicycle accidents, with a 0.3 % fatality rate and a 30.4 % frequency of multitrauma. Multivariate analysis revealed that collisions with other vehicles increased trauma severity and the risk of ICU admission. Conversely, helmet use was associated with reduced severity of head trauma and a lower likelihood of ICU admission. Notably, toxicological investigations were not conducted for any ED-admitted patients., Conclusions: Although a low mortality rate and a low incidence of multi-trauma have been shown in comparison to other nations, it is necessary to adopt prevention strategies like safety devices, more cycle paths, and better infrastructures on the one hand, and stricter laws on the other. It is essential to require toxicological testing in Italy for all accidents involving this means of transport, and to make helmet use compulsory for all ages., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Serum markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and D-dimer, are currently used by clinicians and orthopedic surgeons in diagnosing and managing joint infections (JI), although conflicting results exist on their performance. The aim of this study was to evaluate their performance in assessing healing or unhealing of patients with JI or with prosthetic joint infection (PJI)., Methods: ESR, CRP and D-dimer serum levels were evaluated before, during and after antibiotic treatment in 61 patients (65.1 ± 12.6 years): 49 affected by PJI and 12 by JI, between 2020 and 2022. These patients had undergone orthopedic surgery and were treated with antibiotics., Results: ESR, CRP and D-dimer were significantly lower after treatment than before (p value: 0.001, 0.001 and 0.003, respectively) in healed and unhealed patients. A moderate correlation was found between the three inflammatory markers., Conclusions: Using a cut off value of 25 mm/h for ESR, 0.5 mg/L for CRP, and 700 ng/ml for D-dimer, it might be possible to discriminate healed from unhealed patients (PPV and NPV: ESR 65.5% and 68.8%, CRP 71.9% and 79.3%, D-dimer 76.9% and 81.8%). The combined use of these three inflammatory markers might be useful in the management of joint infections., Competing Interests: Declaration of Competing Interest The author has no financial or other conflicts of interest to disclose., (Copyright © 2023 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

In low-income countries (LIC), the management of bone infections is a huge challenge. A high number of patients are in the pediatric age group. Children and adolescents exhibit good bone healing potential offering treatment options that mainly rely on the biological response of the infected bone. The purpose of this article is to highlight treatment options for these patients in LIC, which is based on clinical cases that illustrate the principles of the treatment, focusing on bone reaction and healing potential. First, identification of emergency cases is of importance. Sepsis of the patient due to bone infections is a life-threatening disease that requires immediate surgical attention with abscess incision. It should be tailored to the surgeon's experience and local conditions to avoid unwanted complications, such as excessive bleeding, fracture or bone loss. In non-septic patients, uncomplicated cases should be distinguished from complicated cases as the first might often require only abscess incision, particularly in small children, without any other major surgical intervention. Biomechanical stability and bone formation capacity, soft tissue conditions and joint involvement are decisive factors differentiating uncomplicated from complicated cases. Central treatment column is the immobilization of the infected bone with simple methods, such as plaster of Paris, braces or external fixation. This is intended to provide sufficient stability to allow for new bone formation that subsequently downsizes the infection site and that can bridge previously infected non-union sites or bone defects. In most cases, antibiotic treatment is not performed as antibiotics are not available or affordable. Severe soft tissue defects remain a major challenge as microvascular surgical experience is often required for reliable coverage, for which referral to one of the very few specialized centers is recommended. Major bone defects should also be treated in centers with sufficient expertise for bone reconstruction procedures. Regular follow-ups are important to ensure healing and to avoid aggravation of the disease. Encouraging success rates can be achieved by these treatment principles. However, it should not be forgotten that poverty in these countries, including limited access to health care, remains one of the world's most important problems., Competing Interests: Declaration of Competing Interest All authors confirm that there is no conflict of interest regarding the submission of this manuscript., (Copyright © 2023. Published by Elsevier Ltd.)

The reverse shoulder arthroplasty conceived by Paul Grammont in 1985 has gradually gained popularity as a treatment for multiple shoulder diseases. Unlike previous reverse shoulder prosthesis characterized by unsatisfactory results and a high glenoid implant failure rate, the Grammont design has immediately shown good clinical outcomes. This semi constrained prosthesis solved the issues of the very first designs by medializing and distalizing the center of rotation with an increased stability of the replacement of the component. The indication was initially limited to cuff tear arthropathy (CTA). It has then been expanded to irreparable massive cuff tears and displaced humeral head fractures. The most frequent problems of this design are a limited postoperative external rotation and scapular notching. Different modifications to the original Grammont design have been proposed with the aim of decreasing the risk of failure and complications and improving the clinical outcomes. Both the position and version/inclination of the glenosphere and the humeral configuration (e.g. neck shaft angle) influence the RSA outcomes. A lateralized glenoid (whether with bone or metal) and a 135° Inlay system configuration leads to a moment arm which is the closest to the native shoulder. Clinical research will focus on implant designs reducing bone adaptations and revision rate, strategies to prevent more effectively infections. Furthermore, there is still room for improvement in terms of better postoperative internal and external rotations and clinical outcomes after RSA implanted for humeral fracture and revision shoulder arthroplasty., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: To evaluate, in a prospective observational cohort study of adults ≥65 years old, the frailty status at the emergency department (ED) admission for the in-hospital death risk stratification of patients needing urgent cholecystectomy., Methods: Clinical variables and frailty status assessed in the ED were evaluated for the association with major complications and the need for open surgery. The parameters evaluated were frailty, comorbidities, physiological parameters, surgical approach, and laboratory values at admission. Logistic regression analysis was used to identify independent risk factors for poor outcomes., Results: The study enrolled 358 patients aged ≥65 years [median age 74 years]; 190 males (53.1%)]. Overall, 259 patients (72.4%) were classified as non-frail, and 99 (27.6%) as frail. The covariate-adjusted analysis revealed that frailty (P< 0.001), and open surgery (P = 0.015) were independent predictors of major complications. Frailty, peritonitis, constipation at ED admission, and Charlson Comorbidity Index ≥ 4 were associated with higher odds of open surgical approach (2.06 [1.23 - 3.45], 2.49 [1.13 - 5.48], 11.59 [2.26 - 59.55], 2.45 [1.49 - 4.02]; respectively)., Discussion: In patients aged ≥65 years undergoing urgent cholecystectomy, the evaluation of functional status in the ED could predict the risk of open surgical approach and major complications. Frail patients have an increased risk both for major complications and need for "open" surgical approach., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Objectives: To evaluate, in a cohort of adults ≥80 years old, the frailty status at the emergency department (ED) admission, for the in-hospital death risk stratification of patients needing major surgical procedures., Design: Single-center prospective observational cohort study., Setting and Participants: The study was conducted in the ED of a teaching hospital. We enrolled all patients ≥80 years old consecutively admitted to the ED for conditions requiring urgent surgical procedures, between 2018 and 2021., Methods: Clinical variables and frailty status assessed in the ED were evaluated for the association with all-cause in-hospital death. The parameters evaluated were frailty [assessed by the Clinical Frailty Scale (CFS)], comorbidities, physiological parameters, type of surgery needed, laboratory values at admission. Cox regression analysis was used to identify independent risk factors for poor outcomes., Results: The study enrolled 1039 patients aged ≥80 years [median age 85 years (interquartile range 82-89); 445 males (42.8%)]. Overall, 127 patients (12.2%) were classified as nonfrail (CFS score 1-3), 722 (69.5%) as mild frail (CFS score 4-6), and 190 (18.3%) as frail (CFS score 7-9). The covariate-adjusted analysis revealed that severe frailty [hazard ratio (HR) 12.55, 95% CI 2.96-53.21, P = .016], ≥3 comorbidities (HR 2.08, 95% CI 1.31-3.31, P = .002), shock at ED presentation (HR 3.58, 95% CI 2.16-5.92, P < .001), anemia (HR 1.88, 95% CI 1.17-3.04, P = .009), and neurosurgery procedures (HR 3.97, 95% CI 1.98-7.96, P < .001) were independent risk factors for in-hospital death., Conclusions and Implications: In patients aged ≥80 years undergoing urgent surgical procedures, the evaluation of functional status in the ED could predict the risk of in-hospital death. Frail patients have an increased risk of death and major complications, whereas those with mild frailty have a similar prognosis compared with the more fit ones. Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80 years needing neurosurgery or abdominal surgery., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Optimal treatment of carbapenem-resistant Gram-negative bacteria (CR-GNB) infections is uncertain because of the lack of good-quality evidence and the limited effectiveness of available antibiotics. The aim of this survey was to investigate clinicians' prescribing strategies for treating CR-GNB infections worldwide., Methods: A 36-item questionnaire was developed addressing the following aspects of antibiotic prescribing: respondent's background, diagnostic and therapeutic availability, preferred antibiotic strategies and rationale for selecting combination therapy. Prescribers were recruited following the snowball sampling approach, and a post-stratification correction with inverse proportional weights was used to adjust the sample's representativeness., Results: A total of 1012 respondents from 95 countries participated in the survey. Overall, 298 (30%) of the respondents had local guidelines for treating CR-GNB at their facility and 702 (71%) had access to Infectious Diseases consultation, with significant discrepancies according to country economic status: 85% (390/502) in high-income countries versus 59% (194/283) in upper-medium-income countries and 30% (118/196) in lower-middle-income countries/lower-income-countries). Targeted regimens varied widely, ranging from 40 regimens for CR-Acinetobacter spp. to more than 100 regimens for CR-Enterobacteriaceae. Although the majority of respondents acknowledged the lack of evidence behind this choice, dual combination was the preferred treatment scheme and carbapenem-polymyxin was the most prescribed regimen, irrespective of pathogen and infection source. Respondents noticeably disagreed around the meaning of 'combination therapy' with 20% (150/783) indicating the simple addition of multiple compounds, 42% (321/783) requiring the presence of in vitro activity and 38% (290/783) requiring in vitro synergism., Conclusions: Management of CR-GNB infections is far from being standardized. Strategic public health focused randomized controlled trials are urgently required to inform evidence-based treatment guidelines., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The aim of this study was to evaluate the risk of fracture as a consequence of trauma and its association with kidney function status in a cohort of elderly patients., Methods: This is an observational, cross-sectional study. We evaluated all fall-related trauma of patients ≥ 65 years in the emergency department (ED) between 2016 and 2018. According to CDK-EPI formula, we stratified the study population in different stages of chronic kidney disease (CKD) for glomerular filtrate rate (GFR) ≥ 15 and < 60, not on hemodialysis. The hip fracture rate was adjusted at multivariate analysis for age, sex, comorbid conditions, and CKD status., Results: We enrolled 5620 patients: 3482 patients had GFR ≥60, 1045 had GFR ≥45 and <60, 722 had GFR ≥30 and <45, and 371 had GFR ≥15 and <30. We recorded 636 (11.3%) hip fractures. After adjusting for significant covariates (age, sex, known osteoporosis, osteoporosis therapy, anemia, and dementia), patients with GFR ≥ 45 and <60 and GFR ≥30 and <45 exhibited an increased risk of femur fracture (odds ratio 2.01 [1.36-2.97] and 1.64 [1.08-2.48], respectively). Patients with GFR ≥15 and <30 had a higher risk of fracture, although not reaching statistical significance., Conclusions: Our study confirms that patients with non-end stage CKD have an increased risk of femur fracture after a fall. Our data supports the hypothesis that this risk could be associated with increased bone fragility in CKD patients. Active osteoporosis therapy was found to be an effective preventive factor in our cohort., Competing Interests: Conflicts of interest The authors have no conflicts or competing interest, (Copyright © 2021 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Acute cholecystitis (AC) is a life-threatening emergency in elderly patients., Aims: To compare the commonly used management strategies for elderly patients with AC as well as resulting morbidity, mortality and length of hospital stay (LOS)., Methods: All patients ≥ 65 years admitted to our emergency department for AC between January 1st, 2014 and December 31st, 2018 were included in the study. We compared patients that received medical treatment to patients who received operative procedures. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and LOS., Results: A total of 1075 patients were enrolled: 483 patients received a medical treatment and 592 patients underwent interventional procedures. After PSM, 770 patients (385 for each treatment group) were included in the analysis. The analysis revealed that both mortality and cumulative major complications were similar in medical and interventional group. We found that among comorbidities, Charlson comorbidity index and congestive heart failure were significantly higher in the medical treatment group (5 [4-6] vs. 4 [3-6] and 11.7% vs. 4.7%, respectively; p<0.001). LOS was slightly lower in the medical treatment group (7.0 days [4.9-11.1] vs. 7.9 [4.9-13.5]; p = 0.046)., Conclusion: Medical management outcomes for AC in elderly patients were similar to operative treatments in terms of mortality and cumulative major complications. A conservative approach should always be considered., Competing Interests: Conflict of interest None declared., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Importance: One of the most frequent concerns of the increasing number of patients undergoing shoulder arthroplasty is the possibility to resume sport after surgery., Objective: The aim of this systematic review was to determine the rate of return to sport after reverse total shoulder arthroplasty (RSA) and the subjective level of performance., Evidence Review: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review. A systematic electronic search was performed using the PubMed (MEDLINE), Embase and Cochrane Library databases. All the studies analysing the rates were pooled; data were extracted and statistically analysed. The eligibility criteria were studies with at least 20 adult patients recruited. All studies had to relate return to sports after RSA., Findings: A total of six studies were included for a total of 457 patients. Mean age and average follow-up were, respectively, 74.7 years (range 33-88 years) and 3.6 years (range 1-9.4 years). The mean rate of return to sport ranged from 60% to 93%. The mean time for resuming sports was 5.3 months. The overall rate of return to sport after reverse shoulder arthroplasty was 79%. The mean level of sports at the time of the survey was worsened in 7.9%, improved in 39.6% and had no change in 55.2% of the cases., Conclusions and Relevance: Based on the current available data, return to sports after reverse shoulder arthroplasty is possible and highly frequent. The subjective level of practice undergoes no change or improves in most of the cases. More studies and better-designed trials are needed in order to enrich the evidence on specific sports recovery after the procedure., Level of Evidence: IV., Competing Interests: Competing interests: None declared., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate, in a cohort of adults aged ≥80 years, the overlapping effect of clinical severity, comorbidities, cognitive impairment, and frailty, for the in-hospital death risk stratification of COVID-19 older patients since emergency department (ED) admission., Design: Single-center prospective observational cohort study., Setting and Participants: The study was conducted in the ED of a teaching hospital that is a referral center for COVID-19 in central Italy. We enrolled all patients with aged ≥80 years old consecutively admitted to the ED between April 2020 and March 2021., Methods: Clinical variables assessed in the ED were evaluated for the association with all-cause in-hospital death. Evaluated parameters were severity of disease, frailty, comorbidities, cognitive impairment, delirium, and dependency in daily life activities. Cox regression analysis was used to identify independent risk factors for poor outcomes., Results: A total of 729 patients aged ≥80 years were enrolled [median age 85 years (interquartile range 82-89); 346 were males (47.3%)]. According to the Clinical Frailty Scale, 61 (8.4%) were classified as fit, 417 (57.2%) as vulnerable, and 251 (34.4%) as frail. Severe disease [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.31-2.59], ≥3 comorbidities (HR 1.54, 95% CI 1.11-2.13), male sex (HR 1.46, 95% CI 1.14-1.87), and frailty (HR 6.93, 95% CI 1.69-28.27) for vulnerable and an overall HR of 12.55 (95% CI 2.96-53.21) for frail were independent risk factors for in-hospital death., Conclusions and Implications: The ED approach to older patients with COVID-19 should take into account the functional and clinical characteristics of patients being admitted. A sole evaluation based on the clinical severity and the presence of comorbidities does not reflect the complexity of this population. A comprehensive evaluation based on clinical severity, multimorbidity, and frailty could effectively predict the clinical risk of in-hospital death for patients with COVID-19 aged ≥80 years at the time of ED presentation., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: QTc interval monitoring, for the prevention of drug-induced arrhythmias is necessary, especially in the context of coronavirus disease 2019 (COVID-19). For the provision of widespread use, surrogates for 12‑lead ECG QTc assessment may be useful. This prospective observational study compared QTc duration assessed by artificial intelligence (AI-QTc) (Cardiologs®, Paris, France) on smartwatch single‑lead electrocardiograms (SW-ECGs) with those measured on 12‑lead ECGs, in patients with early stage COVID-19 treated with a hydroxychloroquine-azithromycin regimen., Methods: Consecutive patients with COVID-19 who needed hydroxychloroquine-azithromycin therapy, received a smartwatch (Withings Move ECG®, Withings, France). At baseline, day-6 and day-10, a 12‑lead ECG was recorded, and a SW-ECG was transmitted thereafter. Throughout the drug regimen, a SW-ECG was transmitted every morning at rest. Agreement between manual QTc measurement on a 12‑lead ECG and AI-QTc on the corresponding SW-ECG was assessed by the Bland-Altman method., Results: 85 patients (30 men, mean age 38.3 ± 12.2 years) were included in the study. Fair agreement between manual and AI-QTc values was observed, particularly at day-10, where the delay between the 12‑lead ECG and the SW-ECG was the shortest (-2.6 ± 64.7 min): 407 ± 26 ms on the 12‑lead ECG vs 407 ± 22 ms on SW-ECG, bias -1 ms, limits of agreement -46 ms to +45 ms; the difference between the two measures was <50 ms in 98.2% of patients., Conclusion: In real-world epidemic conditions, AI-QTc duration measured by SW-ECG is in fair agreement with manual measurements on 12‑lead ECGs. Following further validation, AI-assisted SW-ECGs may be suitable for QTc interval monitoring., Registration: ClinicalTrial.govNCT04371744., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Increasing multidrug resistance rates in Neisseria gonorrhoeae have raised concerns and an urgent call for new antibiotics for treatment of gonorrhoea. Several decades of subdued drug development in this field and the recent failures of two new antibiotics to show non-inferiority compared with the current first-line antibiotics ceftriaxone plus azithromycin highlight the need for improved preclinical tools to predict clinical outcome of new drugs in the development process., Objectives: To summarize current pharmacokinetic/pharmacodynamic (PK/PD) knowledge and dose-finding strategies for antibiotics against gonorrhoea., Sources: Literature review of published papers and discussions by global experts at a special workshop on this topic., Content: We review current knowledge of gonococcal specific PK/PD principles and provide an update on new in vitro and in vivo models to correlate drug exposure with clinical outcome, and identify challenges and gaps in gonococcal therapeutic research., Implications: Identifying the ideal antimicrobial agent and dose for treating uncomplicated urogenital and pharyngeal gonococcal disease requires appropriate validated non-clinical PK/PD models. Recent advances in adapting in vitro and in vivo models for use in gonorrhoea are an important step for enabling the development of new drugs with reduced risk of failure in Phase 3 clinical development and diminish the risk of emergence of resistance., (Copyright © 2020. Published by Elsevier Ltd.)

Prosthetic joint infection (PJI) is a common complication of the knee and hip arthroplasty and represents a huge challenge for physicians. PJI raises serious social, economic and clinical concerns in the public health that need a comprehensive approach to better focus on proven strategies for disease prevention and treatment. History and clinical signs on joint site are useful means for suspecting PJI that need to be confirmed through major and minor diagnostic criteria. The pathogen isolation and the resulting antibiogram are crucial to guide the correct antibiotic strategy and together with surgical treatment (prosthesis revision and spacer implantation) represent the cornerstones to eradicate the infection before attempting a new arthroplasty. External fixator with removal of the spacer may be an option before performing a new arthroplasty when the infection does not heal. Arthrodesis may also be considered if the arthroplasty is contraindicated. Limb amputation is the last chance when pathogen eradication failed and might lead to life-threatening situations., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction., Methods: This case-control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann-Whitney test., Results: Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann-Whitney test showed no significant difference between the two groups (p > 0.05)., Conclusion: LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The gastrointestinal (GI) tract is a complex and dynamic network with interplay between various gut mucosal cells and their defence molecules, the immune system, food particles, and the resident microbiota. This ecosystem acts as a functional unit organized as a semipermeable multi-layer system that allows the absorption of nutrients and macromolecules required for human metabolic processes and, on the other hand, protects the individual from potentially invasive microorganisms. Commensal microbiota and the host are a unique entity in a continuum along the GI tract, every change in one of these players is able to modify the whole homeostasis. In the stomach, Helicobacter pylori is a gram-negative pathogen that is widespread all over the world, infecting more than 50% of the world's population. In this scenario, H. pylori infection is associated with changes in the gastric microenvironment, which in turn affects the gastric microbiota composition, but also might trigger large intestinal microbiota changes. It is able to influence all the vital pathways of human system and also to influence microbiota composition along the GI tract. This can cause a change in the normal functions exerted by intestinal commensal microorganisms leading to a new gastrointestinal physiological balance. This review focuses and speculates on the possible interactions between gastric microorganisms and intestinal microbiota and on the consequences of this interplay in modulating gut health., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Non-variceal upper gastrointestinal bleeding (NVUGIB) is an important cause of mortality and morbidity worldwide. Little information is available on the clinical management of non-variceal upper gastrointestinal bleeding in Italy in relation to the current organization of the Italian Emergency Health Services into Level-I and Level-II Emergency Departments (ED), the latter being more complex structures with greater resources., Methods: A retrospective survey on clinical, endoscopic, and survival data was conducted by the regional sections of the 3 main Italian gastroenterological societies, AIGO, SIED and SIGE, recording all consecutive episodes of non-variceal upper gastrointestinal bleeding referred to 7 centres (4 of which were Level-II Emergency Departments) in Rome, Italy, during a one-year period. A total of 624 consecutive patients (64% males, mean age 67.6 ± 16.2 years) were included. Thirty-day mortality was 4.6%. Main factors associated with survival at both univariate and multivariate analysis were the presence of full Rockall score <5 and the admission to a Level-II Emergency Departments (p<0.001). Level-I Emergency Departments admitted patients with a full Rockall score ≥ 5 (p=0.02) more frequently than patients with negative endoscopic findings (p<0.001)., Conclusions: Referral of non-variceal upper gastrointestinal bleeding patients to Emergency Departments with more resources (Level-II) is associated with reduced mortality. Yet, unfortunately, high-risk patients were more often admitted to Level-I Emergency Departments, which suggests the need for a better organization of the emergency referral system., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Treatment of Helicobacter pylori infection is becoming a very relevant problem especially in industrialized Countries. Although different therapeutic regimens are currently available, treatment failure remains a growing problem in daily medical practice. Several factors could play a role in the eradication failure, but the most relevant are antibiotic resistance and patient's compliance. While Helicobacter pylori resistance to amoxicillin is rare, clarithromycin and metronidazole resistance varies significantly from close to zero up to 25%. However, metronidazole in vitro resistance exhibits a lower impact on eradication success because resistance in vitro does not reflect that in vivo. Specific guidelines have then been published, mostly based on antibiotic resistance among different geographic areas. Basically, first-line and second-line regimens have been well defined; concerning third-line treatment Maastricht III guidelines suggest to adopt a culture-based approach. Culture is, however, expensive, invasive and available only in few specialized centres. An alternative approach may be to use an empirical strategy, based on the avoidance of repeating similar eradicating schemes in the same patients during the course of different eradicating regimens. For this approach we propose the acronym DANCE (Different Antibiotic No Culture Eradicating) strategy. When correctly applied, this approach showed to reach successful eradication in up to 99.5% of Helicobacter pylori-positive patients., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Although risks and life-threatening complications associated with lead extraction are well characterized, practice patterns vary regarding whether procedures are performed in an operating room (OR) or electrophysiology (EP) laboratory with cardiothoracic surgical backup., Objective: Our objective was to compare procedural outcomes and complications associated with lead extraction in the OR vs. EP laboratory., Methods: Prospectively acquired data were pooled from 2 referral centers. Lead extraction procedures were performed between 2000 and 2010, encompassing a transition phase from the OR to EP laboratory. Analyses were conducted using generalized estimating equations., Results: A total of 1,364 leads (533 OR; 831 EP laboratory) were targeted in 684 consecutive procedures, 41.2% of which were in the OR. Laser sheaths and snares were used for 699 (51.2%) and 101 (7.4%) leads, respectively. Overall, 775 (93.1%) vs. 487 (91.4%) leads were completely extracted in the EP laboratory vs. OR [odds ratio 1.3, 95% confidence interval 0.9 to 2.1]. Complications occurred in 2.24% vs. 2.84%, respectively (P = .431). Two patients died because of superior vena caval lacerations (0.29%), 1 in each group. Rapid surgical intervention was helpful in 6 (0.9%) patients [4 OR (2 subclavian vein lacerations, 1 tricuspid valve laceration, 1 tamponade); 2 EP laboratory (tamponades)], with subsequently favorable outcomes. The only independent predictor of complications was older lead age [odds ratio 1.11 per year, 95% confidence interval 1.02 to 1.20]., Conclusion: Lead extraction in the EP laboratory with surgical backup is associated with a similarly low rate of complications and mortality as procedures performed in the OR., (Copyright © 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Hemidiaphragmatic paralysis is the most frequent complication associated with cryoballoon ablation for atrial fibrillation. To date, no preventive strategy has proved effective., Objective: We sought to assess the feasibility of diaphragmatic electromyography during cryoballoon ablation, explore the relationship between altered signals and phrenic nerve palsy, and define characteristic changes that herald hemidiaphragmatic paralysis., Methods: Cryoballoon ablation was performed in the right superior pulmonary vein or superior vena cava in 16 mongrel dogs weighing 37.7 ± 2.4 kg, at sites determined by phrenic nerve capture. During ablation, the phrenic nerve was paced at 60 bpm from the superior vena cava while recording diaphragmatic compound motor action potentials (CMAPs) by esophageal decapolar catheters. Diaphragmatic excursion was monitored by fluoroscopy and abdominal palpation., Results: Before ablation, the CMAP amplitude was 592 (interquartile range 504, 566) μV, initial latency 21.5 ± 4.2 ms, peak latency 64.7 ± 21.1 ms, and duration 101.7 ± 13.3 ms. Hemidiaphragmatic paralysis was obtained in all dogs 62 ± 34 seconds into the cryoapplication. The CMAP amplitude decreased exponentially, with no patterned changes in latencies and duration. Discriminatory analyses by receiver-operating curve characteristics identified a 30% reduction in CMAP amplitude as the most predictive cutoff value for hemidiaphragmatic paralysis (c-statistic 0.965; P<.0001). This criterion presaged diaphragmatic paralysis, as detected by abdominal palpation, by 31 ± 23 seconds., Conclusion: Diaphragmatic electromyographic signals could be reliably recorded during cryoballoon ablation. An exponential decrease in CMAP amplitude precedes diaphragmatic paralysis, with a 30% reduction yielding the best discriminatory potential. A promising safety margin was detected, which merits prospective validation., (Copyright © 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The poor and/or erratic oral bioavailability of polyphenolics can be improved using the PHYTOSOME delivery system, a strategy that enhances the rate and the extent of solubilization into aqueous intestinal fluids and the capacity to cross biomembranes. Phospholipids show affinity for polyphenolics, and form supramolecular adducts having a definite stoichiometry. This article reviews the preparation and characterization of PHYTOSOME complexes and their activity in various medicinal (cardiovascular, anti-inflammatory, hepatoprotective, anticancer) and cosmetic (skin aging) realms of application., (Copyright 2009 Elsevier B.V. All rights reserved.)

Objectives: We sought to determine the incidence, diagnostic value, and outcome of intracardiac masses observed by echocardiography after device removal. We hypothesized that these "ghosts" of leads could be associated with the diagnosis of cardiac device-related infective endocarditis (CDRIE)., Background: The echocardiographic appearance of residual floating masses in the right atrium after removal of permanent pacemakers and implantable cardioverter-defibrillators was recently described. However, the significance of these ghosts and their relationship with CDRIE are unknown., Methods: The pre-operative clinical, microbiological, and echocardiographic conditions; the indication; and the removal technique were analyzed in a retrospective cohort including all consecutive patients who underwent percutaneous lead removal. Three groups were formed according to the final diagnosis: CDRIE, local device infection, and noninfectious indications. The incidence of ghosts was compared among the 3 groups. All clinical, infectious, and extraction-related factors were studied for their association with ghosts. All patients with ghosts were followed after hospitalization., Results: Two hundred twelve patients underwent lead removal. Ghosts were observed in 17 patients (8% incidence), including 14 (16%) of 88 patients with CDRIE and 3 (5%) of 59 patients with local device infection. Ghosts were never observed among the remaining 65 noninfected patients. A significant association was found between CDRIE and the presence of a ghost (odds ratio: 7.63, 95% confidence interval: 2.12 to 27.45, p = 0.001). At 3 months, 2 patients with ghosts died suddenly, 2 underwent surgery, and 1 had a pulmonary embolism., Conclusions: Ghosts are observed in 8% of patients after percutaneous device extraction. Their presence is suggestive of device infection and seems to be associated with the diagnosis of CDRIE. The prognostic significance of such findings needs further investigation., (Copyright 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The recommended second-line therapy for Helicobacter pylori (H. pylori) eradication is a quadruple regimen that fails in up to 30% of patients. Several recent studies suggest levofloxacin-based triple therapies as an alternative rescue treatment. However, dosage and length of levofloxacin-based regimens have not been established., Aim: To compare the efficacy and tolerability of four second-line levofloxacin-based schemes for H. pylori eradication., Methods: One hundred and sixty patients (aged 18-70 years, 72 male patients) who were H. pylori positive after standard triple therapies were randomised to receive esomeprazole 20mg b.d. and amoxicillin 1g b.d. plus levofloxacin 500 mg o.d., for 7 or 10 days (Groups A and B) or levofloxacin 500 mg b.d. for 7 days or 10 days (Groups C and D). H. pylori status was assessed by 13-C Urea Breath Test or rapid urease test, before and 6 weeks after therapy. Incidence of side effects was evaluated by a questionnaire., Results: No dropouts were observed. Eradication of H. pylori infection was successful in: 65% of patients in Group A; 90% in Group B; 70% in Group C; 85% in Group D. Based upon duration of treatment, eradication rates were: 67.5% in 7 days groups and 87.5% in 10 days groups (p=0.004). Dosage of levofloxacin did not affect the eradication rates (77.5% both in the once daily and twice daily groups). Mild adverse events were reported overall in 16% of patients (22.5% in 7 days groups; 27.5% in 10 days groups; p=0.58; 12% in the once daily group; 32.5% in the twice daily group; p=0.04)., Conclusions: 10 days levofloxacin-based second-line regimens were effective in curing H. pylori infection in more than 85% of patients with a lower incidence of adverse effects in levofloxacin single-dosage scheme. The 10 days levofloxacin-based regimens were more effective than 7 days course of treatment showing that duration of therapy is the crucial factor affecting eradication rate.

Background: Cytotoxin-associated gene-A (CagA) antigen is expressed by some virulent strains of Helicobacter pylori (H. pylori). The role of CagA antigen in coronary instability is unknown. We performed a clinico-pathological study and a meta-analysis in the attempt to shed new light on this complex issue., Methods: In the clinico-pathological study, 38 patients with unstable angina (UA), 25 patients with stable angina (SA), 21 patients with normal coronary arteries (NCA) and 50 age and sex matched healthy volunteers were enrolled. Serology for CagA was assessed in all patients. Specimens of atherosclerotic plaques were obtained from all patients by directional coronary atherectomy, and prepared for immunohistochemistry using anti-CagA monoclonal antibodies. The meta-analysis includes 9 studies assessing the association between seropositivity to CagA strains and acute coronary events., Results: The titre of anti-CagA antibodies was significantly higher in patients with unstable angina (161+/-90 RU/ml) compared to those with stable angina (83+/-59 RU/ml p<0.02), NCA (47.3+/-29 RU/ml p<0.01) and healthy controls (73+/-69 p<0.02). Anti-CagA antibodies recognized antigens localized inside coronary atherosclerotic plaques in all specimens from both stable and unstable patients. In the meta-analysis, seropositivity to CagA was significantly associated with the occurrence of acute coronary events with an odds ratio (OR) of 1.34 (95% CI, 1.15-1.58, p=0.0003)., Conclusions: Taken together these findings suggest that in a subset of patients with unstable angina, an intense immune response against CagA-positive H. pylori strains might be critical to precipitate coronary instability mediated by antigen mimicry between CagA antigen and a protein contained in coronary atherosclerotic plaques.

There is no consensus on the ideal management of patients with chondral defects of the medial tibial plateau and varus malalignment of the knee. We performed a cohort study to evaluate the outcome of patients affected by these conditions, who underwent arthroscopic implantation of autologous chondrocytes and a medial opening wedge high tibial osteotomy. Eight patients (four men and four women; mean age, 50 years, range: 42 to 58) with chondral defects of the medial tibial plateau in a varus knee underwent arthroscopic implantations of autologous chondrocytes in conjunction with a medial opening wedge osteotomy. At final post-operative follow up of 28 months following the index procedure, the post-operative scores were improved for the IKDC score (four patients abnormal and four patients severely abnormal to four patients normal, three patients nearly normal and one patient abnormal), Lysholm score (65.7 range 49-88 to 94.6 range 89-100), Tegner score (3.7 range 3-5 to 7 range 5-8) and VAS score (7.2 to 2.0). In conclusion, the association of arthroscopic implantation of autologous chondrocytes with a medial opening wedge osteotomy of the proximal tibia is a viable option for the management of chondral defects in varus knees.

The fabella is a sesamoid bone that can very occasionally act as a source of atypical knee pain, often mistaken for a more common cause of clinical symptoms, such as an intra-articular loose body or an osteophyte. We report a case of symptomatic dislocation of an osteoarthritic, enlarged fabella, 4 years after total excision of the patella for a comminuted fracture, that was primarily overlooked and led to repeated diagnostic arthroscopy of the knee. A thorough history and physical examination of the joint as well as appropriate roentgenographic studies could have spared this patient an unnecessary arthroscopy and indicated the correct therapy.

Since the discovery of Helicobacter pylori, several studies have investigated the hypothetical role of this bacterium in various extragastric diseases, e.g. ischemic heart disease, idiopathic thrombocytopenic purpura, iron-deficiency anaemia, and other disorders. The majority of these studies are epidemiological or eradication trials, but there are also case reports and in-vitro studies. Idiopathic thromobocytopenic purpura is the disease that shows the strongest link with H. pylori infection. There is also evidence of a role of CagA-positive H. pylori infection in iron-deficiency anaemia and ischemic heart disease. The association between H. pylori infection and other extragastric diseases remains controversial, being mostly supported by 'case reports', small pilot studies, or just in-vitro data. Further studies are needed to identify whether there is any pathological implication for H. pylori infection in these diseases.