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Observational prospective population-based incidence study. The main objective of this study was to assess the incidence of traumatic spinal cord injuries (TSCIs) and incidence rates, in order to provide estimates by age, gender, characteristics and cause. This study was conducted at acute-care spinal cord injury (SCI) hospitals and SCI centers from 11 Italian regions, between 1 October 2013 and 30 September 2014. Data of all consecutive patients with acute TSCI who met the inclusion criteria were obtained through case reporting by clinicians. The data were collected into a web database. Incidence rates and incidence rate ratios were calculated and stratified by age, gender, cause, level and completeness. From 50% of the entire population of Italy, 445 new cases of TSCI were included. The crude incidence rate of TSCI was 14.7 cases per million per year (95% CI: 13.4–16.4); the overall male to female ratio was 4:1 and the mean age was 54. Complete information was available in 85% of the sample and revealed tetraplegia in 58% and incomplete lesion in 67% of cases. The leading cause of TSCI was falls (40.9%) followed by road traffic accidents (33.5%). The leading cause was falls for patients over 55 and road traffic accidents for patients under 55. The changing trend of TSCI epidemiology concerns the increase in the average age of TSCI people and the increase of both cervical and incomplete lesions. The etiology shows the primacy of falls over road traffic accidents and suggests the need for a change in prevention policies.

The aim of our study was to diagnose and to control three aspects of the evolution of lung disease in CF: the absence of infection, the intermittent colonization and chronic infection by Pseudomonas aeruginosa. Therefore a study of anti-pseudomonas antibodies (Ab) (anti-protease, anti-elastin and antihexo-toxin A) for diagnosis and follow-up of CF patients was considered. Moreover, we related the presence of Ab to the sputum culture, to FEV1, to patient age and to genotype. Tbe Ab were dosed in 121 patients by quantitative ELISA method. Values < 1: 500 were considered negative, values> 1: 500 and < 1:1250 borderline, and > 1:1250 positive. 16.5% of patients did not have Ab, 17% had borderline values and 69.5% had positive values. All the patients with negative Ab had negative sputum culture; 47% of patients with borderline values had at least one positive culture while 53% were negative. 87% of patients with positive values had chronic colonization, 13% intermittent colonization. The increase in the Ab rate is statistically related to a more severe lung disease (p < 0.013). The presence of a severe mutation (?F 508) is related to positive values of Ab. Evaluation of anti-Pseudomonas aeruginosa is an important tool for diagnosis and follow-up of CF lung disease

Background In Italy, the spread of the COVID-19 pandemic has stressed the entire healthcare system and required a huge re-organization of many Divisions, including those of Gastroenterology. Aims to assess the impact of COVID-19 pandemic on Gastroenterology Divisions across Italy. Methods All members of the Italian Society of Gastroenterology (SIGE) were invited to answer a web-based survey. Results Data of 121 hospitals from all 20 Italian regions were analyzed. Overall, 10.7% Gastroenterology Divisions have been converted to Covid Units. Outpatients consultations, endoscopic and ultrasound procedures were limited to urgencies and oncology indications in 85.1%, 96.2% and 72.2% of Units, respectively, and 46.7% of them suspended the screening for colorectal cancer. Moreover, 72.2% of the staff received a training for use of personal protective equipment, although 45.5% did not have sufficient devices for adequate replacement. Overall, 132 healthcare workers in 41 Gastroenterology Divisions were found to be infected. Conclusion This is the first study to evaluate, at a country level, the impact of COVID-19 outbreak on Gastroenterology Divisions. Substantial changes of practice and reduction of procedures have been recorded in the entire country. The long-term impact of such modifications is difficult to estimate but potentially very risky for many digestive diseases.

Background: Spinal epidural abscesses are rare and are misdiagnosed in up to 75% of cases. Fever, back pain, and neurological deficits are part of the classical triad. Here, the authors report a patient with a L2–L5 spinal epidural abscess with the left paravertebral extension attributed to acute pyelonephritis. Case Description: A 54-year-old female presented with persistent low back pain and lower extremity weakness accompanied by paresthesias. Previously, she had been hospitalized with the left acute pyelonephritis. The lumbosacral MRI documented a T12/L5 anterior epidural abscess with ring enhancement on the contrast study; the maximum diameter of the abscess at the L2–L3 level contributed to severe cauda equina compression. She underwent a L2/L4 decompressive laminectomy with drainage of the intraspinal/extradural and paravertebral components. Intraoperative microbiological sampling grew Staphylococcus aureus for which she then received targeted antibiotic therapy. Fifteen days later, she was walking adequately when discharged. Conclusion: Thoracolumbar epidural abscesses are rare. They must be considered among the differential diagnoses when patients present with acute back pain, fever, and new neurological deficits following prior treatment for acute pyelonephritis.

Background:Burkitt’s lymphoma is a non-Hodgkin B-cell lymphoma, occurring mostly in Equatorial Africa. According to the WHO, classification is three different variants: sporadic, endemic, and immunodeficient-associated. Here, we present a patient with “sporadic” primary epidural Burkitt’s lymphoma resulting in chronic low back pain (LBP).Case Description:A 63-year-old female presented with a 2-month history of LBP and the left lower extremity sciatica. The thoracolumbar MRI showed a L5 irregular, osteolytic epidural lesion that was hypointense on T1-weighted images, hyperintense on STIR studies, and inhomogeneously enhanced with contrast. Additional hypointense lesions were also seen at the L2, L3, and L4 levels. The patient underwent a L4-L5 laminectomy for piecemeal epidural resection of tumor, and a L4-S1 transpedicular screws/rod fusion. In addition, a L2-L3 radiofrequency ablation was performed. The histological examination documented a primary “sporadic” spinal Burkitt’s lymphoma. The patient subsequently was treated with both radiotherapy/chemoradiotherapyConclusion:Primary “sporadic” spinal Burkitt’s lymphoma is rare. Following tumor resection, adjunctive radiation and chemotherapy are typically warranted.

Proton pump inhibitors (PPIs) are among the most commonly prescribed drugs due to the increasing incidence of acid-related disorders, but a large number of prescriptions are issued with inappropriate indications. Despite PPIs being effective and well tolerated, there have been growing concerns about potential adverse effects associated with long-term use of these drugs. Indeed, pharmacovigilance agencies have issued broad-based product warnings on the association between treatment with PPIs and long-term complications, including increased risk of fractures and impaired magnesium absorption. On the contrary, despite plausible underlying biological mechanisms, the available clinical evidence for most side effects is weak or contradictory, and the benefits of PPI treatment seem to outweigh the potential adverse effects. This review aims to discuss the most important and established side effects of long-term use of PPIs and provide practical considerations for their clinical management.

Background: Epidural dumbbell-shaped chordomas are localized slow growing, and malignant/aggressive neoplasms. Here, we present a 62-year-old male with a T3-T4 dumbbell-shaped chordoma and reviewed the appropriate literature. Case Description: A 62-year-old male presented with a three-month history of thoracic pain. When the thoracolumbar magnetic resonance (MR) showed a T3-T4 dumbbell-shaped intracanalicular/extradural tumor, he underwent tumor removal. After the histological examination proved the lesion was a spinal chordoma, he underwent a secondary radical transthoracic tumor resection. Postoperatively, the patient was able to walk without assistance, and at 6-month follow-up, was neurologically intact with only residual paresthesias. Conclusion: Malignant spinal chordomas may mimic benign neurinomas on MR scans. Here, biopsy of the lesion to confirm the diagnosis of chordoma was critical and directed subsequent definitive transthoracic tumor resection.

Background: Chronic subdural hematoma (cSDH) represents a complex and unpredictable disease, characterized by high morbidity and mortality, especially in elderly patients. Factors affecting the postoperative brain reexpansion along to cSDH recurrence have not been yet adequately investigated. The authors presented the case of a schizophrenic patient affected by trabecular type cSDH that presented a delayed brain reexpansion despite a craniotomy and membranotomy. Case Description: A 51-year-old female patient with diagnosis of schizophrenia was admitted to the emergency department with GCS score of 5/15 and right anisocoria. An urgent brain CT revealed a trabecular right cSDH (35 mm in maximum diameter) with recent bleeding. After surgery, a brain CT scan showed a markedly reduced brain reexpansion and pneumocephalus. Nevertheless, postoperative 7-day brain CT documented a progressive brain reexpansion with reduced midline shift. Conclusion: According to our opinion, anatomopathological alterations in schizophrenia reduce normal brain compliance and increasing elastance, thus modifying the normal timing of reexpansion after cSDH drainage, also after craniotomy and membranotomy. Although postoperative pneumocephalus is a well-known cause of hindered reexpansion, this could be due to anatomical alterations in schizophrenia. Such factors must be considered in the preoperative planning but mostly in the postoperative management.

Background: Tethered spinal cord syndrome (TCS) can occur after the surgical repair of lipomeningoceles (LMCs). In these cases, the tethering results from postoperative adhesions between the spinal cord and the overlying repaired dura. A watertight dural closure using the residual dura and/or the surrounding tissues does not always provide enough space for the spinal cord and risks retethering. Here, we report a 16-year-old patient with secondary TCS following lipomeningocele repair who successfully underwent release of the tethered filum terminale utilizing a novel dural splitting reconstructive technique to attain a water-tight closure without the need for a duroplasty. Methods: A 16-year-old patient had a LMC repaired at birth. She now presented with progressive low back pain, and gait disturbances. The MRI documented secondary spinal cord tethering at the prior spinal dysraphism repair site. Results: A secondary release of the filum terminale utilizing a novel dural splitting technique to avoid the need for a duroplasty was performed. Conclusion: Here, in a 16-year-old patient with a recurrent tethered cord syndrome following repair of a LMC at birth, we utilized a novel dural splitting reconstruction technique and averted the need for a duroplasty.

Background: Hiatal hernia is diagnosed by barium-swallow esophagogram or esophagogastroduodenoscopy, with possible suboptimal results. High-resolution manometry clearly identifies crural diaphragm and lower esophageal sphincter. Objectives: To assess the diagnostic accuracy of high-resolution manometry in detecting hiatal hernia compared to esophagogram and esophagogastroduodenoscopy, using as reference the surgical invivo measurement. Methods: Patients were studied with esophagogram, esophagogastroduodenoscopy, high-resolution manometry and invivo evaluation of the esophago-gastric junction. Esophago-gastric junction was classified as type I (no separation between crural diaphragm and lower esophageal sphincter); type II (≥1, ≤ 2 cm separation); type III (>2 cm). During invivo measurement, distance between the esophago-gastric junction and crural diaphragm proximal border was recorded. Results: Surgery identified 53 hiatal hernias in 100 patients. Forty-seven percent were classified as type I esophago-gastric junction, 35% type II and 18% type III. Referenced to invivo evaluation, high-resolution manometry showed superior diagnostic sensitivity and specificity (94.3% and 91.5%, respectively) to esophagogram and esophagogastroduodenoscopy, with 92.6% predictive value of a positive test and 93.5% predictive value of a negative test. The kappa value for high-resolution manometry and invivo evaluation was 0.85. High-resolution manometry showed optimal sensitivity and specificity in detecting types I, II and III esophago-gastric junction. Conclusions: High-resolution manometry enables an accurate diagnosis of hiatal hernia and a better classification than endoscopy and radiology, reaching optimal agreement with invivo assessment.

BACKGROUND Multiple rapid swallowing (MRS) during high-resolution manometry (HRM) is increasingly utilized as provocative test to assess esophageal peristaltic reserve. The aim of this study was to evaluate the correlation between MRS response and impedance and pH (MII-pH) parameters in endoscopy negative heartburn (ENH) patients. METHODS We enrolled consecutive ENH patients, who underwent HRM and MII-pH study, with a selected MII-pH profile: abnormal MII-pH (pH+/MII+); normal MII-pH (pH-/MII-). HRM was performed with 10 wet swallows (WS) and one MRS. Mean distal contractile integral (DCI) during WS and MRS were calculated. MII-pH parameters including acid exposure time (AET), reflux events, baseline impedance levels (BI) and the efficacy of chemical clearance evaluated with the postreflux swallow-induced peristaltic wave (PSPW) index were measured. KEY RESULTS We analyzed 103 patients: 49 MII+/pH+ (27 male), and 54 MII-/pH- (19 male). Mean age was similar between the two groups. As expected, mean AET and number of refluxes were higher in pH+/MII+ (p < 0.05). HRM was normal in all selected patients. Mean DCI-WS was similar between two groups (p = n.s.). Mean DCI-MRS- was higher in MII-/pH- vs MII+/pH+ (p < 0.05). The increase in DCI-MRS was inversely correlated with AET (-0.699; p < 0.001) and directly correlated with BI values (0.631; p < 0.001) and PSPW index (0.626; p < 0.001). CONCLUSIONS & INFERENCES Following MRS, patients with abnormal impedance-pH test showed suboptimal contraction response as compared with those with normal impedance-pH test. Moreover, MRS response was inversely correlated with AET and directly correlated with BI values and PSPW index.

Background: The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients. Methods: Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. Key Results: Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p < 0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). Conclusions & Inferences: A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing. Esophagogastric junction (EGJ) plays an important role in defense mechanisms against reflux. Defining EGJ vigor with high-resolution manometry (HRM) may be useful to predict an abnormal impedance-pH testing in reflux disease. This study aims to establish a correlation between EGJ-contractile integral (EGJ-CI) and different reflux parameters, detected during impedance-pH monitoring in GERD patients. Esophagogastric junction contractile integral is calculated at HRM enclosing the upper and lower margins of the EGJ in a DCI toolbox, during three consecutive respiratory cycles and referenced to gastric pressure. The value computed with the DCI tool in mmHg*s*cm is then divided by the duration of the three respiratory cycles (in seconds) yielding EGJ-CI units of mmHg*cm. The value below 13 is established in a series of normal volunteers as a defective EGJ-CI. Reflux parameters determined at impedance-pH monitoring are total number of reflux, total esophageal acid exposure time (AET), and symptom association. Our findings show that, when a defective EGJ-CI is present, a gradual and significant increase IN reflux can be present.

Background & Aims: Analyses of impedance parameters such as the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI) have been proposed to increase the accuracy of diagnosis of reflux disease. We assessed whether these improve the diagnostic yield of impedance pH monitoring of reflux disease. Methods: We performed a prospective study of consecutive patients with proton pump inhibitor-responsive heartburn who underwent 24-hour impedance pH monitoring at hospitals in Italy from January 2011 through December 2013. Reviewers blindly analyzed off-therapy impedance pH tracings from 289 patients with proton pump inhibitor-responsive heartburn, 68 with erosive reflux disease and 221 with non-erosive reflux disease (NERD), along with 50 healthy individuals (controls). The PSPW index, the MNBI, the esophageal acid exposure time, the number of total refluxes, and the bolus exposure were calculated, as well as the symptom association probability (SAP) and the symptom index (SI). Results: In receiver operating characteristic analysis, the area under curve of the PSPW index (0.977; 95% confidence interval, 0.961-0.993) was significantly greater than that of the other impedance pH parameters in identifying patients with reflux disease (P < .001). The PSPW index and the MNBI identified patients with erosive reflux disease with the highest level of sensitivity (100% and 91%, respectively), as well as the 118 pH-positive (99% and 86%) and 103 pH-negative (77% and 56%) cases of NERD. The PSPW index and the MNBI identified pH-negative NERD with the highest level of sensitivity; values were 82% and 52% for the 65 SAP-positive and/or SI-positive cases and 68% and 63% for the 38 SAP-negative and SI-negative cases. Diagnoses of NERD were confirmed by pH-only criteria, including those that were positive on the basis of the SAP or SI, for 165 of 221 cases (75%) and by impedance pH criteria for 216 of 221 cases (98%) (P = .001). Conclusions: The PSPW index and the MNBI increase the diagnostic yield of impedance pH monitoring of patients with reflux disease. Analysis of impedance pH data by calculating the PSPW index and the MNBI can increase the accuracy of diagnosis of patients with reflux disease, compared with pH-only data.

Background High-resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance-pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance-pH findings in patients with reflux symptoms. Methods Consecutive patients with suspected gastroesophageal reflux disease (GERD) were enrolled. All patients underwent HRM and impedance-pH testing off-therapy. EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and

Il Manuale di progettazione UFFICI rappresenta lo strumento più completo e aggiornato sul tema. Il volume, composto di circa 900 pagine a colori – ricco di bellissime fotografie, schemi esemplificativi, dettagli costruttivi e tabelle – rappresenta per l’architetto, l’ingegnere, l’arredatore, l’impiantista e per lo studioso in generale un fondamentale punto di riferimento. Originale e innovativa nell’impostazione editoriale, l’opera può essere letta in una visione omogenea pur essendo impostata in quattro grandi sezioni: Teorie e principi organizzativi; Realizzazioni; Il progetto dell’ufficio; Impianti. In Teorie e principi organizzativi si passa in rassegna, in maniera critica, l’evoluzione della tipologia degli uffici nella storia fino ad arrivare alla classificazione dell’ufficio contemporaneo. In questa prima parte, lo scritto, a carattere trattatistico molto approfondito e documentato, è continuamente intervallato da schede di approfondimento – segnalate con una grafica riconoscibile e immediata – nelle quali è l’immagine fotografica a determinare l’informazione. Nella seconda sezione, Realizzazioni, l’impaginazione del volume prende molto respiro divenendo la parte visivamente più accattivante del volume, è qui, infatti, che vengono mostrati i migliori progetti nazionali e internazionali di architettura contemporanea, alcuni dei quali ancora inediti poiché di recentissima costruzione. Gli edifici vengono presentati lasciando largo spazio alle fotografie, ai disegni e ai dettagli costruttivi. La terza sezione, Il progetto dell’ufficio, si può definire il corpo manualistico vero e proprio dell’intera opera, più di 200 pagine di informazioni utili al progettista si dispiegano in un compendio in cui il testo lascia del tutto il posto a schemi dimensionali astratti di soluzioni tipo che vengono supportati da fotografie di casi reali che illustrano le situazioni presentate. Si parte dalle regole ergonomiche dei singoli elementi di arredo fino ad arrivare, in una continua evoluzione di spazi ed elementi, alle combinazioni progettuali più complesse e articolate. In questa parte si presenta anche una selezione ragionata di tutto il panorama della produzione industriale sul tema dell’arredo d’ufficio. La quarta parte, Impianti, segue l’impostazione manualistica della parte precedente dando informazioni sintetiche e schematiche, ma sempre secondo Normativa, di tutto ciò che riguarda l’apparato ingegneristico della progettazione degli uffici. Si parla quindi di comfort ambientale, di acustica e di illuminazione, presentando le diverse tipologie di impianti e di soluzioni oggi presenti sul mercato. Il Manuale si chiude con una serie di apparati scientifici utili per orientarsi nel volume, quali: stralcio di Normativa, l’indice analitico critico dettagliato e la bibliografia ragionata, indispensabili documenti anche per studiosi e accademici.