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Introduction Femoral neck fractures (FNF) are frequent injuries and not rarely complicated by non-union, implant failure, and avascular necrosis. Some of these fractures represent a dilemma for trauma surgeons. Which fracture should be fixed? Which replaced with a prosthesis? How? The aim of this narrative review is to investigate the literature in order to provide the most updated and evidence-based knowledge about FNF’ treatment. Materials and methods A literature research has been performed to find the essential key points to consider when dealing with FNF and their treatment. The most representative papers and the new meta-analysis were matched with authors’ experience to give a concise but comprehensive view of the problem. Timing, age, comorbidities, vascularization of the femoral head, displacement, instability, comminution of the fracture, bone quality, and surgeon experience seem to be the major topics to consider in the decision making. We then focus on the optimal fixation or replacement as suggested by the literature. Results Age is the main independent factor to consider. Timing seems essential in the elderly population to reduce mortality and important in the younger patients to reduce complications. Vascular supply should be always considered. Displacement, instability, and comminution of the fracture are negative prognostic factors for fixation as well as, theoretically, bone quality. In the elderly hip replacement is mostly indicated. A stable and solid fixation is mandatory to allow early mobilization. Sliding Hip Screws (SHS) seem preferable to cannulated screws for displaced/unstable (Pauwels II-III, posterior comminution) and basicervical fracture patterns or in smokers. There is a tendency toward Total Hip Arthroplasty (THA) also in the elderly if the patient is an indipendent ambulator without severe comorbidities. Dual mobility cups are gaining popularity in THA for FNF. Conclusions FNF are frequent injuries and represent, in some cases, a dilemma for the trauma surgeon. Age, timing, comorbidities, bone quality, femoral head vascularization, fracture displacement, intrinsic instability, and comminution as surgeon experience should be carefully evaluated before surgery. A case-to-case analysis of the patient-related factors helps the surgeon to make the right choice and reduce the well-known complications.

Aims The association between hyperglycemia at hospital admission and relevant short- and long-term outcomes in elderly population is known. We assessed the effects on mortality of hyperglycemia, disability, and multimorbidity at admission in internal medicine ward in patients aged ≥ 65 years. Methods Data were collected from an active register of 102 internal medicine and geriatric wards in Italy (RePoSi project). Patients were recruited during four index weeks of a year. Socio-demographic data, reason for hospitalization, diagnoses, treatment, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), renal function, functional (Barthel Index), and cognitive status (Short Blessed Test) and mood disorders (Geriatric Depression Scale) were recorded. Mortality rates were assessed in hospital 3 and 12 months after discharge. Results Of the 4714 elderly patients hospitalized, 361 had a glycemia level ≥ 250 mg/dL at admission. Compared to subjects with lower glycemia level, patients with glycemia ≥ 250 mg/dL showed higher rates of male sex, smoke and class III obesity. These patients had a significantly lower Barthel Index (p = 0.0249), higher CIRS-SI and CIRS-CI scores (p = 0.0025 and p = 0.0013, respectively), and took more drugs. In-hospital mortality rate was 9.2% and 5.1% in subjects with glycemia ≥ 250 and p = 0.0010). Regression analysis showed a strong association between in-hospital death and glycemia ≥ 250 mg/dL (OR 2.07; [95% CI 1.34–3.19]), Barthel Index ≤ 40 (3.28[2.44–4.42]), CIRS-SI (1.87[1.27–2.77]), and male sex (1.54[1.16–2.03]). Conclusions The stronger predictors of in-hospital mortality for older patients admitted in general wards were glycemia level ≥ 250 mg/dL, Barthel Index ≤ 40, CIRS-SI, and male sex.

As a result of improved implants total ankle replacement (TAR) is becoming a more reliable option for end stage ankle arthritis. As with any surgery there are numerous complications that can occur intraoperatively and postoperatively with TAR. The primary aim of this study is to use recent data on implants currently on the market to develop a well-defined and comprehensive complication classification system which stratifies risk of subsequent surgery for TAR. A systematic review of studies on TARs from 2013 to 2018 was performed. Inclusion criteria were studies published between 2013 and August 2018, studies having at least 20 patients, data with at least 1-year follow-up and use of implants currently on the market. Studies were excluded if they involved revision cases, case reports, basic science articles and studies published in non-peer-reviewed journals. Sixteen studies fit inclusion criteria involving 3,305 implants. Overall survival of all implants was found to be 93% with a pooled complication rate of 75.6% using criteria for classifying complications by Glazebrook et al. Previously published classification systems did not clearly define complication categories leading to inconsistency in complication reporting and inaccurate complication rates. There are also several complications that are unclassifiable with the classifications developed by Gadd et al and Glazebrook et al. Our proposed updated classification system provides more inclusive tier profiles to capture the complications that can occur with implants currently on the market. Furthermore, this system provides a stratification of risk that these complications pose to ultimate procedure success.

Wilkie's Syndrome is a very rare disease caused by reduction of aorto-mesenteric space with consequent duodenum compression. It can combine with left renal vein stenosis which, when symptomatic, is known as ''Nutcracker Syndrome''. We describe a clinical onset case with epigastric pain without vomiting in a normal weight patient. 28-year-old woman who came to our observation for intense epigastric pain after a weight loss of 14 kg in 4 months. Multidetector Computed Tomography and Ultrasound revealed gastric and duodenal overdistension with hydro-air levels, severe duodenum stenosis, and left renal vein compression. Wilkie's Syndrome is common in anorexic individuals suffering from recurrent postprandial vomiting, onset with severe epigastric pain, without vomiting, is quite unusual. High-calorie diet must be first therapeutic approach, in case of failure treatment of first choice should be endovascular stenting and, only in selected cases, surgical treatment should be used because it is very invasive and burdened with numerous complications. Failure to diagnose this disease can expose patients to serious health risks.

Context The variability of the positive predictive value (PPV) represents a significant factor affecting the diagnostic performance of multiparametric magnetic resonance imaging (mpMRI). Objective To analyze published studies reporting mpMRI PPV and the reasons behind the variability of clinically significant prostate cancer (csPCa) detection rates on targeted biopsies (TBx) according to Prostate Imaging Reporting and Data System (PI-RADS) version 2 categories. Evidence acquisition A search of PubMed, Cochrane library’s Central, EMBASE, MEDLINE, and Scopus databases, from January 2015 to June 2020, was conducted. The primary and secondary outcomes were to evaluate the PPV of PI-RADS version 2 in detecting csPCa and any prostate cancer (PCa), respectively. Individual authors’ definitions for csPCa and PI-RADS thresholds for positive mpMRI were accepted. Detection rates, used as a surrogate of PPV, were pooled using random-effect models. Preplanned subgroup analyses tested PPV after stratification for PI-RADS scores, previous biopsy status, TBx technique, and number of sampled cores. PPV variation over cancer prevalence was evaluated. Evidence synthesis Fifty-six studies, with a total of 16 537 participants, were included in the quantitative synthesis. The PPV of suspicious mpMRI for csPCa was 40% (95% confidence interval 36–43%), with large heterogeneity between studies (I2 94%, p Conclusions Our meta-analysis underlines that the PPV of mpMRI is strongly dependent on the disease prevalence, and that the main factors affecting PPV are PI-RADS version 2 scores and prior biopsy status. A substantially low PPV for PI-RADS 3 lesions was reported, while it was still suboptimal in PI-RADS 4 and 5 lesions. Lastly, even if the added value of a systematic biopsy for csPCa is relatively low, this rate can improve patient risk assessment and staging. Patient summary Targeted biopsy of Prostate Imaging Reporting and Data System 3 lesions should be considered carefully in light of additional individual risk assessment corroborating the presence of clinically significant prostate cancer. On the contrary, the positive predictive value of highly suspicious lesions is not high enough to omit systematic prostate sampling.

Objectives The authors aimed to identify risk factors associated with prolonged mechanical ventilation (PMV) after scheduled cardiac surgery under cardiopulmonary bypass (CPB). Design A single-center, observational study. Setting Tertiary hospital. Participants All adult patients who underwent scheduled cardiac surgery under cardiopulmonary bypass between January 2017 and December 2017. Interventions None. Measurement and Main Results Among the 568 patients included, 68 (12.0%) presented a PMV. The median ventilation time was 5.7 hours in the group without PMV and 85.2 hours in the group with PMV. A logistic regression found five variables independently associated with the occurrence of PMV: (1) prior cardiac surgery, (2) preoperative congestive heart failure, (3) preoperative creatinine clearance 4 mmol/L on admission. A predictive score to allow the authors to anticipate PMV was developed from the regression coefficient of perioperative factors independently associated with PMV. With a threshold of 2/13, the score had a sensitivity of 80.9%, a specificity of 80.5%, a positive predictive value of 37.2%, and a negative predictive value of 96.7%. The score then was validated in a distinct cohort. Conclusions The study authors have developed a simple score to predict PMV in patients undergoing cardiac surgery with CPB. This score could allow clinicians to identify a high-risk population that might benefit from specific management upon arrival in the intensive care unit.

Viral hepatitis in pregnancy may be caused by many types of viruses that cause systemic infection or target hepatocytes in their pathogenesis. Because viral hepatitis during pregnancy may represent acute or chronic infection or the reactivation of a prior infection, a high clinical suspicion, medical history review, and awareness of risk factors for the acquisition of infection are important management principles. The route of infection varies widely and ranges from fecal-oral transmission for the hepatitis A and E viruses to vertical transmission for hepatitis B, blood-borne transmission for hepatitis C, and sexual transmission for the herpes simplex virus. For this reason, the exposure details about travel, food preferences, drug use, and sexual contacts are important to elicit. Although routine prenatal screening is recommended for chronic viral hepatitis caused by hepatitis B and C, most other causes of viral hepatitis in pregnancy are detected in the setting of compatible signs and symptoms (fatigue, abdominal discomfort, jaundice, scleral icterus) or incidentally noted transaminitis on routine labs. Serologic testing is helpful for diagnosis with molecular testing as indicated to guide the management of hepatitis B and C. Preventive vaccines for hepatitis A and B with established safety of use in pregnancy are recommended for women who are at risk of acquisition. Postexposure prophylaxis for hepatitis A is a single dose of immunoglobulin and vaccination can be used if immunoglobulin G is not available. Antiviral therapy with tenofovir disoproxil fumarate is recommended as prophylaxis in pregnant women with active hepatitis B and an elevated viral load (>200,000 IU/mL) during the third trimester to prevent vertical transmission. The neonate exposed to hepatitis B at birth should receive immunoglobulin G and a monovalent birth dose vaccine within 12 hours, followed by completion of the 3-dosage vaccine series. The prevalence of hepatitis C in women of reproductive age has increased in the United States, and the role of antiviral therapy during pregnancy is of great interest. Cesarean delivery is not currently recommended for the sole purpose of reducing vertical transmission risk in pregnant women with viral hepatitis. Breastfeeding is recommended in women with hepatitis A, B, and C. New and promising prevention and treatment options for hepatitis B and C are under investigation. Investigators and regulatory authorities should ensure that these clinical trials for promising antivirals and vaccines are designed to include pregnant and lactating women.

Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.

The management of offshore platforms at the end of their production phase is a complex issue for technological, socioeconomic, ecological and safety reasons. The decommissioning or reconversion of offshore platforms in the context of a circular economy (CE) will lead to new knowledge acquisition, changing values and changing behaviours towards sustainability consistent with the ‘new’ business objectives. Multiuse platforms at sea (MUPSs) represent an interesting solution for development of marine infrastructures, including areas in which to start and develop various creative economic activities that are in harmony with the needs of environmental protection including renewable energy, sea shellfish farming, decarbonisation plants, tourism, and recreation. Particularly, the research activity focused on a deep literature review of offshore platform decommissioning and sustainable business model (SBM) in a CE context. This allowed us to access the sustainable business model canvas (SBMC), a conceptual tool that represents a holistic view of the different managerial multiuse options and their social and environmental impacts. Besides, to test the SBMC, we adopt an empirical analysis by semi-structured questionnaires given to a sample of stakeholders in the decommissioning industry. The methodology was enriched by interviews with key informants to better investigate the business ecosystem and the feasibility of decommissioning applied to the case of an Italian offshore platform located in the Adriatic Sea. This article aims to contribute to supporting SBMs development following a holistic approach in relationship with all stakeholders and propose a multi-criteria decision-making analysis for evaluating and comparing alternative decommissioning options.

Introduction Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium. Methods The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses. Results A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p Discussion and conclusion Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Purpose To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient’s symptoms and clinical history. Methods This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. Results We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23–91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55–91.65%) that was higher in the mild phenotype (94.4%; CI 90.0–97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6–6.7, p

Background and Purpose: Pediatric nontraumatic intracerebral hemorrhage accounts for half of stroke in children. Early diagnostic of the causative underlying lesion is the first step toward prevention of hemorrhagic recurrence. We aimed to investigate the performance of arterial spin labeling sequence (ASL) in the acute phase etiological workup for the detection of an arteriovenous shunt (AVS: including malformation and fistula), the most frequent cause of pediatric nontraumatic intracerebral hemorrhage. Methods: Children with a pediatric nontraumatic intracerebral hemorrhage between 2011 and 2019 enrolled in a prospective registry were retrospectively included if they had undergone ASL-magnetic resonance imaging before any etiological treatment. ASL sequences were reviewed using cerebral blood flow maps by 2 raters for the presence of an AVS. The diagnostic performance of ASL was compared with admission computed tomography angiography, other magnetic resonance imaging sequences including contrast-enhanced sequences and subsequent digital subtraction angiography. Results: A total of 121 patients with pediatric nontraumatic intracerebral hemorrhage were included (median age, 9.9 [interquartile range, 5.8–13]; male sex 48.8%) of whom 76 (63%) had a final diagnosis of AVS. Using digital subtraction angiography as an intermediate reference, visual ASL inspection had a sensitivity and a specificity of, respectively, 95.9% (95% CI, 88.5%–99.1%) and 79.0% (95% CI, 54.4%–94.0%). ASL had a sensitivity, specificity, and accuracy of 90.2%, 97.2%, and 92.5%, respectively for the detection of the presence of an AVS, with near perfect interrater agreement (κ=0.963 [95% CI, 0.912–1.0]). The performance of ASL alone was higher than that of other magnetic resonance imaging sequences, individually or combined, and higher than that of computed tomography angiography. Conclusions: ASL has strong diagnostic performance for the detection of AVS in the initial workup of intracerebral hemorrhage in children. If our findings are confirmed in other settings, ASL may be a helpful diagnostic imaging modality for patients with pediatric nontraumatic intracerebral hemorrhage. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifiers: 3618210420, 2217698.

Prostate cancer (PCa) represents the most common tumor in male and one of the most relevant causes of death in Western countries. Androgen deprivation therapy (ADT) constitutes a widely used approach in advanced PCa. When PCa progresses in spite of ADT and castrate levels of testosterone, the severe clinical condition termed as metastatic castration-resistant prostate cancer (mCRPC) takes place. The only approach to mCRPC has been represented by chemotherapy with taxanes for many years. Nevertheless, recently introduced treatments such as 2nd generation antiandrogens (i.e. enzalutamide and abiraterone), cell immunotherapy with sipuleucel-T or targeted alpha therapy with 223Ra-dichloride, have dramatically changed mCRPC prognosis. These novel therapies call for an unmet need for imaging biomarkers suitable for patients’ pre-treatment stratification and response assessment. In this scenario, nuclear medicine can provide several metabolic and molecular probes for investigating pathological processes at a cellular and sub-cellular level. The aim of this paper is to review the most relevant findings of the literature published to date on this topic, giving particular emphasis to the pros and cons of each tracer and also covering future prospects for defining personalized therapeutic approaches.

OBJECTIVES: SARS-CoV-2 exhibits tropism for the gastrointestinal tract, however lesions in enterocytes and their correlation with disease severity and patient prognosis are still unknown. METHODS: SARS-CoV-2 patients were enrolled in five medical centres in the Sao Paulo State, Brazil. Clinical characteristics and laboratory findings of patients were recorded. At admission, 7th and 14th day of hospitalisation, plasma and urine samples were collected. The levels of cytokines (IFN-I³, IL-6 and TNF-α) and the biomarker intestinal fatty acid-binding protein (I-FABP) were measured. RESULTS: COVID-19 patients displayed ≈48-, 74- and 125-fold increased urinary I-FABP levels at admission (n=283; p

BACKGROUND/OBJECTIVES Neighborhoods are complex, multidimensional systems. However, the interrelation between multiple neighborhood dimensions is seldom considered in relation to youth adiposity. We created a neighborhood typology using a range of built environment features and examined its association with adiposity in youth. SUBJECTS/METHODS Analyses are based on data from the QUALITY cohort, an ongoing study on the natural history of obesity in Quebec youth with a history of parental obesity. Adiposity was measured at baseline (8-10 years) and follow up, ~8 years later. Neighborhood features were measured at baseline through in-person neighborhood assessments and geocoded administrative data and were summarized using principal components analysis. Neighborhood types were identified using cluster analysis. Associations between neighborhood types and adiposity were examined using multivariable linear regressions. RESULTS Five distinct neighborhood types characterized by levels of walkability and traffic-related safety were identified. At ages 8-10 years, children in moderate walkability/low safety neighborhoods had higher BMI Z-scores [β: 0.41 (0.12; 0.71), p = 0.007], fat mass index [β: 1.22 (0.29; 2.16), p = 0.010], waist circumference [β: 4.92 (1.63; 8.21), p = 0.003], and central fat mass percentage [β: 1.60 (0.04; 3.16), p = 0.045] than those residing in moderate walkability/high safety neighborhoods. Attenuated associations were observed between neighborhood types and adiposity 8 years later. Specifically, residents of moderate walkability/low safety neighborhoods had a higher FMI [β: 1.42 (-0.07; 2.90), p = 0.062], and waist circumference [β: 5.04 (-0.26; 10.34), p = 0.062]. CONCLUSIONS Neighborhoods characterized by lower traffic safety appear to be the most obesogenic to children, regardless of other walkability-related features. Policies targeting neighborhood walkability for children may need to prioritize vehicular traffic safety.

The immense impact of the COVID-19 pandemic on health systems has motivated the scientific community to search for clinical prognostic factors for SARS-CoV-2 infection. Low cycle threshold values (Ct) of diagnostic real-time RT-PCR assays in hospitalized patients have been associated with a poor prognosis in several studies, whereas other studies did not find this association. We explored whether SARS-CoV-2 Ct values at diagnosis were associated with a poor outcome (admission to hospital and death) in 604 community patients diagnosed at primary health centers. Although lower Ct values were found in patients who died of COVID-19, the Ct value was not significantly associated with a worse outcome in a multivariate analysis, while age remained an independent prognostic factor. We did not find evidence to support the role of Ct values as a prognostic factor of COVID-19 in community cases.

Background: Individuals with cystic fibrosis (CF) experience symptoms affecting quality of life and may benefit from palliative care (PC). Objectives: To present results of content analysis from open-ended survey questions assessing knowledge and experiences with PC among CF stakeholders. Design, Setting, Subjects: Online surveys were sent to CF stakeholders through CF-specific listservs predominantly in the United States. Measurements: Responses to five open-ended questions about CF PC—delivery, health care provider training, and lung transplant—underwent content analysis. Responses were coded using NVivo12 Software™. Results: Forty-eight CF adults, 59 caregivers, and 229 providers responded to the open-ended survey questions. Analysis showed 5 primary categories related to CF PC: (1) stakeholder perceptions of PC for CF, (2) delivering PC to people with CF, (3) conversations about PC for CF, (4) perceptions that PC services are underutilized for people with CF, and (5) beliefs that PC services are critical for people with CF considering or pursuing lung transplant. Analysis showed variation among and within groups in defining PC for CF, when, and how to deliver it. Many respondents felt PC was underutilized in CF. Most saw PC as particularly important when considering lung transplant, managing anxiety around transplant, and for goals of care discussions. Some believed PC and lung transplant were mutually exclusive. Conclusion: Respondents felt PC is underutilized for CF, and that people with CF may miss out on the benefits of PC. Among stakeholders, respondents felt people with CF would benefit from access to primary and secondary PC services.

Objective The aim of this study is to evaluate demographic and clinical characteristics of a population affected by traumatic and non-traumatic spinal cord injury (SCI) and to analyze functional outcomes after rehabilitation. Methods This study involved 112 SCI patients (75 male and 37 female) admitted at the Neurorehabilitation Unit of the University Hospital of Messina. The neurological outcomes were evaluated according to the American Spinal Injury Association Impairment Scale (AIS) and by using length of stay, Functional Independence Measure (FIM) and Barthel Index (BI). Results NT-SCI patients were significantly older, numerous (75,89%) and affected by greater lesions when admitted, than T-SCI ones. Most of lesions were incomplete (93%) and associated with paraplegia (71%). FIM and BI outcomes are similar in both groups, even if T-SCI patients showed greater improvement when discharged. No significant differences were found in the length of stay. The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (29,41%). Linear regression models explained 26% of the variance of LOS and 38% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Etiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome. Conclusion SCI patient's rehabilitation should be carried out by taking into account etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program. In particular, older age negatively influence the degree of disability on admission and the entity of functional recovery in both populations. Non-traumatic lesions could have minor benefits after rehabilitation therapy if compared with traumatic ones.

HBeAg is a marker of HBV-activity, and HBeAg-loss predicts a favorable clinical outcome. Here, we characterize HBeAg-levels across different phases of HBV infection, their correlation with virological/biochemical markers and the virological response to anti-HBV therapy. Quantitative HBeAg (qHBeAg, DiaSorin) is assessed in 101 HBeAg+ patients: 20 with acute-infection, 20 with chronic infection, 32 with chronic hepatitis and 29 with immunosuppression-driven HBV-reactivation (HBV-R). A total of 15/29 patients with HBV-R are monitored for &gt, 12 months after starting TDF/ETV. qHBeAg is higher in immunosuppression-driven HBV-R (median[IQR]:930[206–1945]PEIU/mL) and declines in chronic hepatitis (481[28–1393]PEIU/mL, p = 0.03), suggesting HBeAg production, modulated by the extent of immunological pressure. This is reinforced by the negative correlation between qHBeAg and ALT in acute infection (Rho = −0.66, p = 0.006) and chronic hepatitis (Rho = −0.35, p = 0.05). Interestingly, qHBeAg strongly and positively correlates with qHBsAg across the study groups, suggesting cccDNA as a major source of both proteins in the setting of HBeAg positivity (with limited contribution of integrated HBV-DNA to HBsAg production). Focusing on 15 patients with HBV-R starting TDF/ETV, virological suppression and HBeAg-loss are achieved in 60% and 53.3%. Notably, the combination of qHBeAg &gt, 2000 PEIU/mL + qHBsAg &gt, 52,000 IU/mL at HBV-R is the only factor predicting no HBeAg loss (HBeAg loss: 0% with vs. 72.7% without qHBeAg &gt, 52,000 IU/mL, p = 0.03). In conclusion, qHBeAg varies over the natural course of HBV infection, according to the extent of immunological pressure. In the setting of HBV-R, qHBeAg could be useful in predicting the treatment response under immunosuppression.

In this paper, by adopting a systemic framework, we argue that place's adaptive connotation be considered as a mere result of endogenous processes but as a viable system that will remain viable if it can continue to answer the needs of its numerous heterogeneous internal and external socio-economic agents. Place can be seen as a complex adaptive system characterized by a more or less planned evolution, driven by both top-down and bottom-up processes, and composed of various interconnecting parts that, at the same time, can be seen as wholes at different levels as an holoarchy. The model of the holoarchy allows to consider the place as the result of both planned and spontaneous relationships between social and economic (sub)systems and components, implemented in order to achieve a common goal. We than apply this framework to the analysis of a case study in the tourism industry in Naples (Italy).

Purpose This paper aims to identify and elucidate the culinary territorial (regional) characteristics that may support the development of stakeholder relations with and perceptions of a territorial system. It further focuses on these support interactions between destination managers and stakeholders and how online technology can transform them into a word-of-mouth source. Design/methodology/approach The authors present a theoretical framework, stemming from a case study of a tour operator and its technological (social media, etc.) dynamics on the relational aspects between destination management and stakeholders. Through a combination of qualitative tools and secondary data analysis, this paper analyzes the interrelationships of authenticity and place-as-brand concept, considered as the set of human characteristics associated with a brand in a “living like” travel experience. Findings Culinary tourism is seen as a relevant and significant factor in facilitating interaction between the destination community and its stakeholders, and a meaningful element, which when technologically communicated and enhanced, strengthens both the perception and the brand image of a destination. Practical implications Such new technology-enhanced insights into tourists’ experience could be exploited to plan and implement destination management and development strategies in a way that would be expected, accepted and welcomed by stakeholders, including tourists themselves. In this context, this paper presents and prescribes the role of culinary characteristics and stakeholder relationship management to develop new culinary business models and different destination community approaches toward practical implementation at both the individual (business) and the collective (authorities) levels. Originality/value The proposed framework fills the gap in the role of culinary tourism resources particularly in those areas where food has no viable certification even if it essentially constitutes a manifestation of traditions.

Introdução: Além de grande prevalente na população idosa, a sarcopenia tem se tornado precursora do declínio funcional nessa população. Torna-se necessário encontrar meios alternativos para rastreio. Objetivos: O objetivo do presente estudo foi avaliar a sensibilidade e especificidade do instrumento de rastreio da sarcopenia SARC-F. Métodos: A amostra foi constituída por 153 idosos de ambos os sexos. O screening da sarcopenia foi avaliado pelo questionário SARC-F. Para diagnóstico da sarcopenia avaliou-se força, função e massa muscular através do protocolo adaptado do European Working Group on Sarcopenia in Older People (EWGSOP). A sensibilidade e especificidade do questionário foram avaliadas por meio da curva ROC. Resultados: 13,72% dos idosos avaliados foram classificados como sarcopênicos. Os parâmetros mais relacionados com a sarcopenia foram maior idade e falta de prática de exercícios físicos. O sexo não foi um parâmetro que teve relação na classificação. A sensibilidade foi de 60,0% e especificidade de 80,92% com uma área sobre a curva de 0,70. Conclusão: Nossos dados apoiam o uso do SARC-F como uma ferramenta de rastreio que pode ser usada em ambientes comunitários e hospitalares como ferramenta de triagem rápida.

Staging to capture kidney function and pathophysiologic processes according to severity is widely used in chronic kidney disease or acute kidney injury not requiring dialysis. Yet the diagnosis of "end-stage kidney disease" (ESKD) considers patients as a single homogeneous group, with negligible kidney function, in need of kidney replacement therapy. Herein, we review the evidence behind the heterogeneous nature of ESKD and discuss potential benefits of recasting the terminology used to describe advanced kidney dysfunction from a monolithic entity to a disease with stages of ascending severity. We consider kidney assistance therapy in lieu of kidney replacement therapy to better reconcile all available types of therapy for advanced kidney failure including dietary intervention, kidney transplantation, and dialysis therapy at varied schedules. The lexicon "kidney dysfunction requiring dialysis" (KDRD) with stages of ascending severity based on levels of residual kidney function (RKF)-that is, renal urea clearance-and manifestations related to uremia, fluid status, and other abnormalities is discussed. Subtyping KDRD by levels of RKF could advance dialysis therapy as a form of kidney assistance therapy adjusted based on RKF and clinical symptoms. We focus on intermittent hemodialysis and underscore the need to personalize dialysis treatments and improve characterization of patients included in clinical trials.

Baru nuts (Dipteryx alata Vog.) are a native species from Brazil, rich in phenols and other antioxidants, with high socioeconomic value and possible pharmaceutical applications. Here we investigated baru nut ethanolic extract (BNEE) antioxidant and wound healing activities in human NCI-H441 and A549 lung epithelial cell lines for a possible use in conditions related to oxidative stress and wound healing impairments, such as chronic obstructive pulmonary disease (COPD). BNEE was characterised with high DPPH free radical scavenging activity and high total phenolics content, amongst them gallic acid, that was identified and quantified by HPLC. BNEE was not cytotoxic at concentrations studied, reduced the levels of reactive oxygen species before and during oxidative stress and increased wound healing in cell monolayers. These are the first steps to investigate the beneficial properties of baru in diseases related to oxidative stress and wound healing impairments such as COPD.

Introduction Periapical images are routinely made in endodontics to support diagnosis and treatment decisions, but conventional imaging may not readily demonstrate inflammatory changes. This study aims to quantify disagreement in the radiologic interpretation of apical periodontitis/rarefying osteitis between 2 expert examiners and to determine if differences exist based on anatomic location. Methods We used 1717 pretreatment periapical images made before orthograde endodontic treatment as part of the Predicting Outcomes of Root Canal Treatment (PREDICT) study conducted within the National Dental Practice-Based Research Network. Periapical changes were assessed independently by 2 board-certified specialists, an oral and maxillofacial radiologist and an endodontist, blinded to other clinical information. If the examiners disagreed about whether a diagnosis of apical periodontitis/rarefying osteitis was justified, an adjudication was made by a third examiner. Results The overall prevalence of this radiologic diagnosis in the periapical images was 55%, and interexaminer agreement measured with the Cohen kappa statistic was calculated to be 0.56 (95% confidence interval, 0.52–0.60). Diagnostic disagreements between the 2 examiners occurred for 377 teeth (22%), with disagreements more frequent for jaw location (P = .038) and tooth type (P = .021). Differences between root number (P = .058) and jaw location and tooth groups (P = .069) were found not to be statistically significant. Conclusions The variability of diagnostic disagreements across anatomic location and tooth type may reflect the inability of periapical images to reveal bone changes masked by the complexity and density of overlying anatomic structures, a limitation that could potentially be overcome with the use of 3-dimensional imaging.

Global warming affects the aquatic ecosystems, accelerating pathogenic microorganisms' and toxic microalgae's growth and spread in marine habitats, and in bivalve molluscs. New parasite invasions are directly linked to oceanic warming. Consumption of pathogen-infected molluscs impacts human health at different rates, depending, inter alia, on the bacteria taxa. It is therefore necessary to monitor microbiological and chemical contamination of food. Many global cases of poisoning from bivalve consumption can be traced back to Mediterranean regions. This article aims to examine the marine bivalve's infestation rate within the scope of climate change, as well as to evaluate the risk posed by climate change to bivalve welfare and public health. Biological and climatic data literature review was performed from international scientific sources, Greek authorities and State organizations. Focusing on Greek aquaculture and bivalve fisheries, high-risk index pathogenic parasites and microalgae were observed during summer months, particularly in Thermaikos Gulf. Considering the climate models that predict further temperature increases, it seems that marine organisms will be subjected in the long term to higher temperatures. Due to the positive linkage between temperature and microbial load, the marine areas most affected by this phenomenon are characterized as 'high risk' for consumer health.

This paper presents an automated, miniaturized, and portable system capable of detection and differentiation of cultured tumor cells and non-malignant cells. It is also capable of differentiation between single tumor cells and cell clusters. It is noninvasive, and operates without the need for cell labelling, device functionalization, and cell immobilization. The system is composed of a microfabricated electrical impedance spectroscopy (EIS) based sensor, a custom printed circuit board (PCB) and software running on a computer. The custom PCB replaces costly and specialized impedance analysis instruments and the software with a graphical user interface facilitates automated decisions - thus making the system easy to operate. Performance was tested with three human breast cell lines: healthy cell line BPE-3 and tumor cell lines MCF-7 and MDA-MB-231. The system successfully detected and differentiated between the three cell lines. The observed difference between the healthy cell line and the two tumor cell lines was more pronounced. And as cell detection and differentiation is based solely on biophysical properties of cells, disadvantages arising from affinity-based methods can be avoided. The presented miniaturized system possesses the potential to be developed into a low cost, portable and mass producible device for automated detection of CTCs in blood samples at point of care locations. The figure shows the microfabricated sensor consisting of a microfluidic channel with gold electrodes on the channel sidewalls employed to probe biological cells: (A) final device with PDMS layer to be bonded. (B) Microscope image of an electrode pair. (Scale bars 5mm and $100~\mu \text{m}$ ).

Summary The specific interaction between rhizobia and legume roots leads to the development of a highly regulated process called nodulation, by which the atmospheric nitrogen is converted into an assimilable plant nutrient. This capacity is the basis for the use of bacterial inoculants for field crop cultivation. Legume plants have acquired tools that allow the entry of compatible bacteria. Likewise, plants can impose sanctions against the maintenance of nodules occupied by rhizobia with low nitrogen‐fixing capacity. At the same time, bacteria must overcome different obstacles posed first by the environment and then by the legume. The present review describes the mechanisms involved in the regulation of the entire legume–rhizobium symbiotic process and the strategies and tools of bacteria for reaching the nitrogen‐fixing state inside the nodule. Also, we revised different approaches to improve the nodulation process for a better crop yield.

Objectives Lymph node invasion (LNI) is related to long-term survival in patients with muscle-invasive bladder cancer. However, in the case of variant histology (VH), data on pelvic lymph node dissection (PLND) and LNI are sparse. We described the pattern of care of PLND in patients with VHs of bladder cancer, exploring predictors of LNI. Methods Using the 2001–2016 SEER registry, 20 767 bladder cancer patients who underwent PLND were identified. Included histological variants were pure urothelial carcinoma (UC), micropapillary UC, sarcomatoid UC, lymphoepithelioma-like UC, adenocarcinoma, sarcoma, giant and spindle cell carcinoma, squamous cell carcinoma (SCC), and neuroendocrine tumor. Uni- and multivariable logistic regression analyses tested for LNI predictors. Cox regression was used to test for predictors of overall mortality (OM) among both LNI positive and LNI negative patients. Results Overall, 2464 (11.9%) harbored a VH. On multivariate analysis, only micropapillary UC was associated with higher risk (OR = 3.39) of LNI. This association was maintained when only the subset of patients treated without perioperative chemotherapy were analyzed (OR = 3.30). Similarly, higher T stage (T2 stage OR = 2.24; T3–4 stage OR = 9.44) and the use of chemotherapy (OR = 2.29) were associated with a higher risk of LNI. Among patients with LNI (5299, 25.5%), SCC (HR = 1.87), T3–4 stage (HR = 1.94), age at diagnosis (HR = 1.01) and geographic region (south) (HR = 1.22) were predictors of higher risk of OM. Conversely, chemotherapy (HR = 0.69) and number of removed LN (HR = −0.99) were associated with lower risk of OM. Finally, in a subgroup of patients without LNI, sarcomatoid UC (HR = 1.58) and giant and spindle cell carcinoma (HR = 1.83) were the only VH predictors of OM. Conclusions We described different patterns of care in patients with VHs of bladder cancer. Micropapillary UC was an independent risk factor for LNI. Among patients harboring LNI, those with SCC VH had higher OM compared to pure UC. Conversely, sarcomatoid UC and giant and spindle cell carcinoma were predictors of OM in patients without nodal involvement.

In patients with persisting symptoms after uterine arteries embolization (UAE), ovarian arteries embolization (OAE) may play a role to improve symptoms and decrease subsequent surgery rates. In a retrospective cohort, we aimed to investigate the efficacy and safety of OAE in females with recurrent or persistent symptoms following UAE. We performed a retrospective analysis of prospectively collected cases at a single reference academic hospital; we identified patients who benefited from OAE for persisting symptoms following UAE from 2008 to 2021. Outcome variables included the rates of subsequent surgery, a quality-of-life questionnaire with the UFS-QOL tool, the MRI reduction in uterine and fibroids volumes and the fibroid devascularization rate. Among 1300 women treated with UAE during the study period, 18 eventually received OAE and were included (mean age 44 ± 4.3 SD). There was no OAE procedural complication. There was a decrease in uterine volume and a complete devascularization of the dominant fibroid in 10/11 (90.9%) patients who underwent 12 months MRI. Three women underwent subsequent hysterectomy. Among 10/18 patients who answered the quality-of-life questionnaire after a mean follow-up of 70 months, eight reported an improvement or stability of symptoms. OAE for persisting symptoms after UAE was associated with improvement or stability of quality-of-life in most study subjects and less than a fifth of the cohort underwent hysterectomy after OAE. This study highlights the role of OAE as an adjunct to UAE.

This review focuses on the potential mediation in the acute kidney injury (AKI)-to-chronic kidney disease (CKD) transition by lymphocytes. We highlight evidence that lymphocytes, particularly Th17 cells, modulate the severity of both acute injury and chronic kidney disease. Th17 cells are strongly influenced by the activity of the store-operated Ca2+channel Orai1, which is upregulated on lymphocytes in animal models of AKI. Inhibition of this channel attenuates both acute and chronic kidney injury in rodent models. In addition, Oria1+ cells are increased in peripheral blood of patients with AKI. Similarly, peripheral blood cells manifest an early and sustained increase in Orai1 expression in a rat model of ischemia/reperfusion, suggesting that blood cell Orai1 may represent a marker informing potential Th17 activity in the setting of AKI or the AKI-to-CKD transition.

Introduction Quality perinatal care is recognized as an important birth process and outcome. During the coronavirus disease 2019 (COVID-19) pandemic, quality of perinatal care was compromised as the health care system grappled with adapting to an ever-changing, uncertain, and unprecedented public health crisis. Methods The aim of this study was to explore the quality of perinatal care received during the COVID-19 pandemic in the United States. Data were collected via an online questionnaire completed by people who gave birth in the United States after March 15, 2020. The questionnaire included the Mothers on Respect Index and the Mothers Autonomy in Decision Making validated measures. Low-quality perinatal care was defined as decreased respect and/or autonomy in the perinatal care received. Responses were geocoded by zip code to determine COVID-19 case-load in the county on the date of birth. Multivariate regression analyses described associations between respect and autonomy in decision-making for perinatal care and levels of COVID-19 outbreak across the United States. Results Participants (N = 707) from 46 states and the District of Columbia completed the questionnaire. As COVID-19 cases increased, participants' experiences of autonomy in decision-making for perinatal care decreased significantly (P = .04). Participants who identified as Black, Indigenous, and people of color, those who had an obstetrician provider, and those who gave birth in a hospital were more likely to experience low-quality perinatal care. Those with a midwife provider or who had a home birth were more likely to experience high-quality perinatal care in adjusted models. Discussion Variability in experiences of high-quality perinatal care by sociodemographic characteristics, birth setting, and provider type may relate to implicit bias, structural racism, and inequities in maternal health and COVID-19 outcomes for birthing people from marginalized communities.

Background Patients undergoing in-centre haemodialysis (HD) are particularly exposed to the dire consequences of COVID-19. The present systematic scoping review aims to identify the extent, range, and nature of articles related to COVID-19 and maintenance HD: it reports specifically the prevalence of the COVID-19 pandemic in the HD population, implementation of strategies for the prevention, mitigation and containment of the COVID-19 pandemic in HD centres, demographic and clinical characteristics, and outcomes of the pediatric and adult HD patients. Methods A multi-step systematic search of the literature in Pubmed, Scopus, Ovid Medline, Embase and Web of Science, published between December 1, 2019, and January 30, 2021 was performed. Two authors separately screened the titles and abstracts of the documents and ruled out irrelevant articles. A report of the papers that met inclusion criteria was performed; then, a descriptive analysis of the characteristics of the included articles and a narrative synthesis of the results were performed. Results The review process ended with the inclusion of 145 articles. Most of them were based on single-centre experiences, which spontaneously developed best practices. Most studies were conducted in high-income countries (69.7%) and a part of them (9.6%) were not in English. Prevalence of COVID-19 among dialysis patients accounted for 0%-37.6%. Preventive measures were reported in 54% of the included articles, with particular emphasis on education, triage, hygiene, and containment measures. Patients experienced a heterogeneous spectrum of symptoms that led 35%-88.2% of them to hospital admission. Median and mean hospital length of stay ranged from 8 to 28.5 and 16.2 to 22 days, respectively. Admission to intensive care units varied widely across studies (from 2.6% to 70.5%) and was associated with high mortality (42.8%–100%). Overall, prognosis was poor in 0%–47% of the hospitalized patients. Conclusions This systematic scoping review provides an overview of the current knowledge on the impact of COVID-19 on the frail world of HD patients. Furthermore, it may help to implement the existing strategies of COVID-19 prevention and provide a list of unmet needs (safe transport, testing, shelter). Finally, it may be a stimulus for performing systematic reviews and meta-analyses which will form the basis for evidence-based guidelines. Graphic abstract Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01136-5.

PurposeThe purpose of this paper is to offer a comprehensive perspective on different facets of knowledge management and their effects on the performance of knowledge-intensive entrepreneurial ventures.Design/methodology/approachThe empirical setting involves small and medium-sized enterprises located in the State of São Paulo, Brazil. Primary data for 223 knowledge-intensive entrepreneurship (KIE) firms was obtained through questionnaires applied to ventures which applied to the innovative research in small business program, a small business innovation research-like initiative run by the São Paulo Research Foundation. Econometric results assessed the drivers of competitiveness in terms of firm growth, research and development intensification and technology transfer.FindingsResults highlight the complexity involved in establishing effective knowledge management processes in terms of driving KIE performance. Notwithstanding, some interesting insights on the moderation effects of strategic knowledge management (SKM) systems over technical skills could be identified with particular emphasis for the case of academic spin-offs. Ecosystem drivers present a good explanation power for technology transfer practices but fall short in providing answers for firm-level growth dynamics. It is also noteworthy that public and private investments in KIE firms are similarly associated with positive impacts – contrary to the view that private investors perform better than governmental sources in picking promising small ventures.Originality/valueThe assessment has provided novel evidence for a sample of KIE ventures concerning the appraisal of performance drivers associated with three dimensions of knowledge management, namely, technical knowledge, SKM and ecosystem features. Firms’ outcomes were addressed from a multidimensional perspective, thus providing a comprehensive perspective of the events under scrutiny.

Introduction and objective: This pilot study aimed to evaluate whether and to what extent cybersickness (CS) may affect a rehabilitation program using the Computer-assisted Rehabilitation Environment (CAREN), a virtual reality (VR) computer-assisted device for clinical rehabilitation. Methods: The study was carried out on 30 subjects, 15 patients with Parkinson's Disease (PD) and 15 healthy controls (HC), which underwent a set of four exergames programmed by our team for PD rehabilitation training. Results: All participants completed the Motion Sickness Susceptibility Questionnaire Short-form (MSSQ) before the training and the Motion Symptoms Assessment Questionnaire (MSAQ) immediately after a single CAREN session. Overall, mean MSAQ scores remained low after the session, suggesting that the users did not experience severe discomfort. We found no significant difference in MSAQ scores between the two groups, while there was a statistically significant difference for the subsection of MSAQ regarding the peripheral symptoms (i.e. sweating, cold sweating, feeling warm), which were higher in HC. Moreover, the results highlighted some correlation between MSSQ and MSAQ. Gastrointestinal symptoms in PD, as well as MSSQ and sopite-related symptoms in HC, were also correlated with susceptibility to CS. Conclusions: As CS is rarely reported after CAREN, this and similar devices may be considered comfortable and safe for patients' rehabilitation involving VR training, including PD persons.

Introduction. Influenza is a widespread acute respiratory disease and represents a serious Public Health problem, both from the NHS and society perspectives. The High Dose quadrivalent influenza vaccine (QIV HD) is a flu vaccine containing 4 times the antigens of a Standard Dose vaccine, resulting in demonstrated superior protection in the population aged 65 years and over. Methods. The analysis has been conducted from the perspective of the NHS. The CEA focuses on the comparison between QIV HD and the QIV SD vaccine. The BIM aims to estimate the potential economic impact for the National Health Service (NHS) resulting from the use of QIV HD in clinical practice in subjects aged 65 or over, when considering its introduction in combination with currently used vaccines, QIV SD and adjuvanted TIV. Results. In a scenario which considers hospitalizations possibly related to influenza, so including cardio-respiratory events, a dominant cost-effectiveness profile emerges in the comparison with QIV SD. In terms of budget impact, overall savings obtained by comparing the two scenarios regarding hospitalizations are equal to 92,766,429 € over the three years’ time horizon considered in the analysis. Conclusions. Nowadays, also considering the state of emergency due to the spread of the SARS-CoV-2 virus, it is crucial to implement innovative health technologies that improve the efficiency and sustainability of the health system. Also, it is essential to protect the elderly population, helping to avoid overload and healthcare systems disruption due to the many COVID-19 hospitalizations.

Background: Thymomas are a heterogeneous group of tumors which represent the most frequent tumor of the anterior mediastinum. Aims: To describe the clinical, histological, surgical and oncological characteristics of a cohort of patients with a diagnosis of thymoma surgically treated in two centers in Argentina and to evaluate the possibility of retrospectively implementing the 8th edition of TNM staging. Materials and Methods: 180 patients with thymoma surgically treated over a period of 41 years were studied. The following variables were analysed: age, sex, presence of myasthenia gravis at diagnosis, Masaoka staging (1994), TNM staging of thymus tumors, Histological classification (WHO 2015), neoadjuvant treatment with chemotherapy, post-operative radiation treatment and clinical evolution of myasthenia gravis defined according to the modified Osserman classification. Results: 96 men and 84 women were analysed. Median age 51 years (range 13-85). 85% of the patients analysed came from the public sphere. When analysing the institutional distribution by Masaoaka-Koga stage and TNM, a higher proportion of stages I was observed for both staging systems. Most myasthenic patients belonged to the WHO B2 histological classification (49%, p=0.04) and 15 patients received neoadjuvant treatment prior to surgery to improve the chances of resection, most of them classified as stages III of Masaoka (p=0.002) or IIIa of the TNM stage (p=0.001). 74 (46%) cases received post-operative RT when they presented Masaoka Koga stages II (p=0.000) and IIIa or more advanced TNM staging (p=0.000). 76% of the patients presented remission or stability of symptoms after surgical treatment and only 3/6 died due to myasthenic crisis in the immediate post-operative period. Conclusion: As reported in the literature, we have observed a higher frequency of B2 thymomas and their association with Myasthenia gravis. The histological criteria of the WHO 2015 classification, based on the ITMIG recommendations, favour precision in the definition of subtypes. The retrospective implementation of the 8th edition of TNM staging highlights the need to standardize protocols for pathological and surgical studies.