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After medical management with high dose proton pump inhibitors proves to be refractory, a 63-year-old man with gastroesophageal reflux disease (GERD) prese

Background Although the prevalence of sarcopenic obesity is increasing, nowadays a universally accepted definition still does not exist. Because, this clinical entity is defined as the combination of obesity and sarcopenia, the diagnosis appears to be strictly linked to criteria used for sarcopenia and the available prevalence data are not uniform. To investigate the prevalence of sarcopenic obesity in older persons according to EWGSOP2 and FNIH criteria. Second, to evaluate the prevalence of diabetes in patients with sarcopenia diagnosed by the two definitions. Methods Observational multicenter study performed in 2014 on older patients admitted to 12 Italian hospitals (GLISTEN Study). Data were collected through standardized questionnaires, which assessed: socio-demographic data, cognitive status, functional abilities, pharmacological therapy, comorbidities, and blood tests. Moreover, muscle mass and strength and physical performance were evaluated. Results Six hundred and ten were included in the analyses. Among sarcopenic patients, the prevalence of sarcopenic obesity was 30.8% with FNIH and 0% with EWGSOP2 criteria. According to EWGSOP2 criteria, 23.7% of sarcopenic and 30.8% of non-sarcopenic patients were affected by diabetes (p = 0.101); otherwise, using FNIH criteria, 36.3% of sarcopenic and 26.9% of non-sarcopenic patients were diabetic (p = 0.030). After adjustment for potential confounders, diabetic patients had a 73% higher probability of being sarcopenic according to FNIH criteria (OR 1.73; 95% CI 1.13–2.64). Conclusions The EWGSOP2 and FNIH sarcopenia criteria are differently related to the prevalence of obesity and diabetes. The EWGSOP2 criteria seem to be not suitable to identify people with sarcopenic obesity.

The public health risk posed by Listeria monocytogenes in ready-to-eat (RTE) foods depends on the effectiveness of its control at every stage of the production process and the strain involved. Analytical methods currently in use are limited to the identification/quantification of L. monocytogenes at the species level, without distinguishing virulent from hypovirulent strains. In these products, according to EU Regulation 2073/2005, L. monocytogenes is a mandatory criterion irrespective of strain virulence level. Indeed, this species encompasses a diversity of strains with various pathogenic potential, reflecting genetic heterogeneity of the species itself. Thus, the detection of specific L. monocytogenes virulence genes can be considered an important target in laboratory food analysis to assign different risk levels to foods contaminated by strains carrying different genes. In 2015-2016, a severe invasive listeriosis outbreak occurred in central Italy, leading to the intensification of routine surveillance and strain characterization for virulence genetic markers. A new multiplex real-time polymerase chain reaction targeting main virulence genes has been developed and validated against the enzyme-linked fluorescent assay (ELFA) culture-based method. Results of the improved surveillance program are now reported in this study.

Staphyloccoccus aureus is the major cause of mastitis in small ruminants in the Mediterranean farms causing severe losses to dairy industry. Antibiotic treatment has been the most common approach to control these infections. Aim of this study was to investigate antimicrobial resistance (AMR), virulence factors and biofilm-related genes of 84 Sicilian strains of S. aureus isolated from sheep and goats milk during two different periods δT1 (2006-2009) and δT2 (2013-2015). Kirby Bauer method and Polymerase Chain Reaction (PCR) were utilized to monitor AMR and related genes (mecA, tetK, tetM, ermA, ermC). Moreover, toxin genes (tsst-1, sea-see, seg-sej, and sep) and biofilm genes (bap, ica, sasC) were studied. Twenty-six isolates (30.9%) showed multidrug resistance. The two groups showed similar results with exception for higher values of resistance for tilmicosin and lower for sulfamethoxazole and vancomycin of the second group. MecA gene was detected in one isolate. Tetracycline resistance was higher than 20%, with an increase in δT2 group. Toxin genes were found in 5 isolates (5.9%), belonging of δT2 group, while 57 of isolates (67.8%) showed biofilm related genes. The high presence of multi-resistant isolates suggests the need of more responsible use of antibiotic therapy for the control of these infections.

Gastroesophageal reflux disease (GERD) is prevalent and may be associated with both esophageal and extraesophageal syndromes, which include various pulmonary conditions. GERD may lead to pulmonary complications through the "reflux" (aspiration) or "reflex" (refluxate-triggered, vagally mediated airway spasm) mechanisms. While GERD may cause or worsen pulmonary disorders, changes in respiratory mechanics due to lung disease may also increase reflux. Typical esophageal symptoms are frequently absent and objective assessment with reflux monitoring is often needed for diagnosis. Impedance monitoring should be considered in addition to traditional pH study due to the involvement of both acidic and weakly acidic/nonacidic reflux. Antireflux therapy may improve outcomes of some pulmonary complications of GERD, although careful selection of a candidate is paramount to successful outcomes. Further research is needed to identify the optimal testing strategy and patient phenotypes that would benefit from antireflux therapy to improve pulmonary outcomes.

Although the results of a laparoscopic repair of a paraesophageal hernia are convincing and accepted, controversies still persist regarding indications for elective repair, the need for a concurrent fundoplication, the use of mesh, and the need for a Collis gastroplasty. This article is a description of our surgical approach to the patient with a paraesophageal hernia in need of a repair.

Proper workup, patient selection, and careful surgical technique based on hiatoplasty and fundoplication lead to over 90% of excellent/good results in gastroesophageal reflux disease (GERD) control. These results must be used as benchmarks when a new procedure is created (or recreated). The knowledge of the timeline of the evolution of the procedures to treat GERD may prevent the repetition of past errors. Literature review focused on the history of the procedures to treat GERD. Critical review of the history shows that the ideal antireflux procedure needs to rebuild the natural gastroesophagic barrier. An adequate barrier demands concomitant hiatoplasty, angle of His accentuation, and augmentation of the lower esophageal sphincter. All this is achieved with a fundoplication. Foreign bodies at the level of the esophagogastric junction have shown dreadful consequences. Newly developed procedures that recreate errors from the past will undoubtedly lead to poor results for GERD treatment.

Aim To describe the methods and feasibility of the nutritional intervention carried out within the SPRINTT Randomized cotrolled trial. We also illustrate how nutrition interventionists identified participants at risk of malnutrition and the lessons learnt from the nutrition intervention. Findings SPRINTT nutrition intervention was well-received by the majority of the participants. It was mainly carried out using tailored nutrition counselling, but also other means of delivering the intervention were successfully used. Compared with a standard nutrition prescription, an individualized protocol to diagnose malnutrition and follow-up by tailored nutrition counselling helped achieve nutritional targets more effectively in spite of diversity of population in nutritional habits and in some cases reluctance to accept changes. Message The SPRINTT nutrition intervention was feasible and allowed flexibility to the varying needs and cultural differences of this heterogeneous population of frail, older Europeans. It may serve as a model to educate and improve nutrition among community-dwelling older people at risk of mobility limitations. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-020-00438-4., Background The “Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies” (SPRINTT) project sponsored a multi-center randomized controlled trial (RCT) with the objective to determine the effect of physical activity and nutrition intervention for prevention of mobility disability in community-dwelling frail older Europeans. We describe here the design and feasibility of the SPRINTT nutrition intervention, including techniques used by nutrition interventionists to identify those at risk of malnutrition and to carry out the nutrition intervention. Methods SPRINTT RCT recruited older adults (≥ 70 years) from 11 European countries. Eligible participants (n = 1517) had functional limitations measured with Short Physical Performance Battery (SPPB score 3–9) and low muscle mass as determined by DXA scans, but were able to walk 400 m without assistance within 15 min. Participants were followed up for up to 3 years. The nutrition intervention was carried out mainly by individual nutrition counseling. Nutrition goals included achieving a daily protein intake of 1.0–1.2 g/kg body weight, energy intake of 25–30 kcal/kg of body weight/day, and serum vitamin D concentration ≥ 75 mmol/L. Survey on the method strategies and feasibility of the nutrition intervention was sent to all nutrition interventionists of the 16 SPRINTT study sites. Results Nutrition interventionists from all study sites responded to the survey. All responders found that the SPRINTT nutrition intervention was feasible for the target population, and it was well received by the majority. The identification of participants at nutritional risk was accomplished by combining information from interviews, questionnaires, clinical and laboratory data. Although the nutrition intervention was mainly carried out using individual nutritional counselling, other assisting methods were used as appropriate. Conclusion The SPRINTT nutrition intervention was feasible and able to adapt flexibly to varying needs of this heterogeneous population. The procedures adopted to identify older adults at risk of malnutrition and to design the appropriate intervention may serve as a model to deliver nutrition intervention for community-dwelling older people with mobility limitations. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-020-00438-4.

Salmonellosis is the second most commonly reported gastrointestinal infection in humans after campylobacteriosis, and an important cause of foodborne outbreaks in the EU/EEA. The vast majority (72.4%) of the salmonellosis foodborne outbreaks reported in EU in 2019 were caused by Salmonella Enteritidis, even if their total number due to this serovar decreased. In spring 2020, a foodborne outbreak of S. Enteritidis occurred in the Marche region (Central Italy), involving 85 people. The common exposure source was a cheese, pecorino “primo sale”, produced with raw sheep milk. The cheese batches were produced by two local dairies, with a livestock production facility, also including a sheep farm, being part of one dairy. Bacteriological analysis of samples collected allowed the detection of S. Enteritidis in animal faeces, environmental samples, raw-milk bulk tanks and milk taken from single animals. These data confirm that, despite the scarce scientific evidence, S. Enteritidis can infect sheep and be shed into the animals’ milk. Hence, this is a real risk for public health when unpasteurized milk is used in production of such cheese. The present paper describes the results of the investigations conducted to clarify this outbreak.

Objective: To compare the prognostic value of dynapenia, as evaluated by handgrip, and body mass index (BMI) on length of stay (LOS), days of bed rest, and other hospitalization-related outcomes in a population of older adults admitted to 12 italian acute care divisions. Methods: Data on age, weight, BMI, comorbidities, ADL, physical activity level, muscle strength, were recorded at hospital admission. LOS, days of bed rest, intrahospital falls, and discharge destination were also recorded during the hospitalization. Subjects with BMI

Listeria monocytogenes (Lm) can persist in food processing environments (FPEs), surviving environmental stresses and disinfectants. We described an intensive environmental monitoring plan performed in Central Italy and involving food producing plants (FPPs) and retail grocery stores (RSs). The aim of the study was to provide a snapshot of the Lm circulation in different FPEs during a severe listeriosis outbreak, using whole genome sequencing (WGS) to investigate the genetic diversity of the Lm isolated, evaluating their virulence and stress resistance profiles. A total of 1217 samples were collected in 86 FPEs with 12.0% of positive surfaces at FPPs level and 7.5% at RSs level, 133 Lm isolates were typed by multilocus sequencing typing (MLST) and core genome MLST (cgMLST). Clonal complex (CC) 121 (25.6%), CC9 (22.6%), CC1 (11.3%), CC3 (10.5%), CC191 (4.5%), CC7 (4.5%) and CC31 (3.8%) were the most frequent MLST clones. Among the 26 cgMLST clusters obtained, 5 of them persisted after sanitization and were re-isolated during the follow-up sampling. All the CC121 harboured the Tn6188_qac gene for tolerance to benzalkonium chloride and the stress survival islet SSI-2. The CC3, CC7, CC9, CC31 and CC191 carried the SSI-1. All the CC9 and CC121 strains presented a premature stop codon in the inlA gene. In addition to the Lm Pathogenicity Island 1 (LIPI-1), CC1, CC3 and CC191 harboured the LIPI-3. The application of intensive environmental sampling plans for the detection and WGS analysis of Lm isolates could improve surveillance and early detection of outbreaks.

Pig experiments often require anaesthesia, and a rapid stress-free induction is desired. Induction drugs may alter the subsequent anaesthesia. Therefore, the aim of the present study was to compare, in pigs, the effects of two different injectable anaesthetic techniques on the induction and on the physiological variables in a subsequent eight hours of total intravenous anaesthesia (TIVA). Twelve domestic castrates (Swedish Landrace/Yorkshire) 27‒31 kg were used. The pigs were randomly assigned to different induction drug combinations of zolazepam–tiletamine and medetomidine intramuscularly (ZTMe) or midazolam, ketamine intramuscularly and fentanyl intravenously (MiKF). Time from injection to unconsciousness was recorded and the ease of endotracheal intubation assessed. The TIVA infusion rate was adjusted according to the response exhibited from the nociceptive stimulus delivered by mechanically clamping the dewclaw. The time from injection to unconsciousness was briefer and intubation was easier in the ZTMe group. Results from the recorded heart rate, cardiac index and arterial blood pressure variables were satisfactorily preserved and cardiovascular function was maintained in both groups. Shivering was not observed in the ZTMe group, but was observed in four of the pigs in the MiKF group. The requirement of TIVA was lower in the ZTMe group. In conclusion, ZTMe had better results than MiKF in areas such as shorter induction time, better intubation scoring results and less adjustment and amount of TIVA required up to six hours of anaesthesia. The results may have been due to a greater depth of anaesthesia achieved with the ZTMe combination at the dose used.

Background The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes. Methods The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint. Results Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar. Conclusion Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.

Background The geometrical characterization of ascending thoracic aortic aneurysms in clinical practice is limited to diameter measurements. Despite growing interest in hemodynamic assessment, its relationship with ascending thoracic aortic aneurysm pathogenesis is poorly understood. This study examines the relationship between geometry of the ventriculo-aortic junction and blood flow patterns in ascending thoracic aortic aneurysm disease. Methods Thirty-three patients with ascending thoracic aortic aneurysms (exclusions: bicuspid aortic valves, connective tissue disease) underwent 4-dimensional flow magnetic resonance imaging. After image segmentation, geometrical parameters were measured, including aortic curvature, tortuosity, length, and diameter. A unique angular measurement made by the trajectory of the left ventricular outflow tract axis and the proximal aorta was also conducted. Velocity profiles were quantitatively and qualitatively analyzed. In addition, 11 patients (33%) underwent wall shear stress mapping of the ascending thoracic aortic aneurysm region using computational fluid dynamics simulation. Results Greater left ventricular outflow tract aortic angles were associated with larger aortic diameters at the levels of the sinus (coefficient = 0.387, P = .014) and ascending aorta (coefficient = 0.284, P = .031). Patients with left ventricular outflow tract aortic angles greater than 60° had marked asymmetric flow acceleration on the outer curvature in the proximal aorta, ascertained from 4-dimensional flow analysis. For patients undergoing computational fluid dynamics assessment, regression analysis found that higher left ventricular outflow tract aortic angles were associated with significantly higher wall shear stress values in the outer curve of the aorta (coefficient 0.07, 95% confidence interval 0.04-0.11, P = .002): Angles greater than 50° yielded time-averaged wall shear stress values greater than 2.5 Pa, exhibiting a linear relationship. Conclusions Our findings strengthen the hypothesis of flow-mediated ascending thoracic aortic aneurysm disease progression and that left ventricular outflow tract aortic angle may be a predictor of disease severity.

A total of 66 Listeria monocytogenes (Lm) isolated from 2013 to 2018 in a small-scale meat processing plant and a dairy facility of Central Italy were studied. Whole Genome Sequencing and bioinformatics analysis were used to assess the genetic relationships between the strains and investigate persistence and virulence abilities. The biofilm forming-ability was assessed in vitro. Cluster analysis grouped the Lm from the meat plant into three main clusters: two of them, both belonging to CC9, persisted for years in the plant and one (CC121) was isolated in the last year of sampling. In the dairy facility, all the strains grouped in a CC2 four-year persistent cluster. All the studied strains carried multidrug efflux-pumps genetic determinants (sugE, mdrl, lde, norM, mepA). CC121 also harbored the Tn6188 specific for tolerance to Benzalkonium Chloride. Only CC9 and CC121 carried a Stress Survival Islet and presented high-level cadmium resistance genes (cadA1C1) carried by different plasmids. They showed a greater biofilm production when compared with CC2. All the CC2 carried a full-length inlA while CC9 and CC121 presented a Premature Stop Codon mutation correlated with less virulence. The hypo-virulent clones CC9 and CC121 appeared the most adapted to food-processing environments, however, even the hyper-virulent clone CC2 warningly persisted for a long time. The identification of the main mechanisms promoting Lm persistence in a specific food processing plant is important to provide recommendations to Food Business Operators (FBOs) in order to remove or reduce resident Lm.

In the past, a severe inflammation was a difficulty to complete a laparoscopic cholecystectomy for the increased risk of vasculo-biliary injuries. Today, if in laparoscopy a “critical view of safety” (CVS) is not possible, to avoid damages, several laparoscopic rescue procedures have been proposed. The first one and the most safe is to change technique abandoning the research of CVS to perform a laparoscopic subtotal cholecystectomy. Mandatory is that the decision of changing the surgical strategy should be made before doing vascular or biliary injuries. In this chapter, all the tricks to complete the usual cholecystectomy are reported. But when the safety of the patient is in danger, we report all the alternative laparoscopic techniques to finish the procedure safely. Finally, all the outcomes conclude the chapter.

Background: Blood flow patterns can alter material properties of ascending thoracic aortic aneurysms (ATAA) via vascular wall remodeling. This study examines the relationship between wall shear stress (WSS) obtained from image-based computational modelling with tissue-derived mechanical and microstructural properties of the ATAA wall using segmental analysis.Methods: Ten patients undergoing surgery for ATAA were recruited. Exclusions: bicuspid aortopathy, connective tissue disease. All patients had pre-operative 4-dimensional flow magnetic resonance imaging (4D-MRI), allowing for patient-specific computational fluid dynamics (CFD) analysis and anatomically precise WSS mapping of ATAA regions (6–12 segments per patient). ATAA samples were obtained from surgery and subjected to region-specific tensile and peel testing (matched to WSS segments). Computational pathology was used to characterize elastin/collagen abundance and smooth muscle cell (SMC) count.Results: Elevated values of WSS were predictive of: reduced wall thickness [coef −0.0489, 95% CI (−0.0905, −0.00727), p = 0.022] and dissection energy function (longitudinal) [−15,0, 95% CI (−33.00, −2.98), p = 0.048]. High WSS values also predicted higher ultimate tensile strength [coef 0.136, 95% CI (0 0.001, 0.270), p = 0.048]. Additionally, elevated WSS also predicted a reduction in elastin levels [coef −0.276, 95% (CI −0.531, −0.020), p = 0.035] and lower SMC count ([oef −6.19, 95% CI (−11.41, −0.98), p = 0.021]. WSS was found to have no effect on collagen abundance or circumferential mechanical properties.Conclusions: Our study suggests an association between elevated WSS values and aortic wall degradation in ATAA disease. Further studies might help identify threshold values to predict acute aortic events.

Background: Recently the Berlin Aging Study II (BASE-II) showed that polypharmacy is associated with clinically relevant sarcopenia among community-dwelling older persons. Here we report findings from the GLISTEN study about the association of polypharmacy with sarcopenia among older medical in-patients. Methods: The GLISTEN study investigated prevalence and clinical correlates of sarcopenia in older patients admitted to geriatric and internal medicine acute care wards of 12 Italian hospitals. Results: In this sample of older medical in-patients with high prevalence of sarcopenia (34.7%) and polypharmacy (70.2%) we did not observe a significant association of polypharmacy with sarcopenia. Conclusions: Present findings demonstrate that the association of polypharmacy with sarcopenia, observed in the BASE-II study, is not evident in the GLISTEN sample, being our patients significantly older, more multi-morbid, with high prevalence of sarcopenia and polypharmacy, suggesting that this association might vary according to the heterogeneous health, functional, and nutritional characteristics of older people.

Targeting cell cycle has become the gold standard for metastatic breast cancer (MBC), being cyclin-dependent kinase inhibitors (CDKIs) cornerstones of its treatment, alongside radiotherapy (RT). To date, no definite evidence regarding safety and efficacy of the combination of CDKIs plus radiotherapy (RT) is currently available. Purpose of this review is to collect data in favor or against the feasibility of the association of CDKIs + RT, describing its potential adverse events. Our review shows how CDKI + RT allows an overall satisfying disease control, proving to be effective and causing a grade of toxicity mainly influenced by the site of irradiation, leaning to favourable outcomes for sites as liver, spine or brain and to poorer outcomes for thoracic lesions or sites close to viscera; controversial evidence is instead for bone treatment. Toxicity also varies from patient to patient. To sum up, our contribution enriches and enlightens a still indefinite field regarding the feasibility of CDKIs + RT, giving cues for innovative clinical management of hormone-responsive MBC.

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

In Parkinson's disease, current predominant treatment with intermittent oral administration of levodopa ( l -dopa) remains the reference standard, but it has pharmacological drawbacks that trigger motor fluctuations and dyskinesia. To overcome these challenges, we demonstrate greater efficacy in either an acute 1-methyl-4-phenyl-1,2,3,6-terahydropyridine (MPTP) or chronic 6-hydroxydopamine (6-OHDA) lesioning model when dopamine is prepared under anaerobic (A-dopamine) conditions and continually administered intracerebroventricularly proximal to the striatum. This regimen was compared with dopamine prepared aerobically and administered by the same route, as well as with conventional peripheral l -dopa treatment. A-dopamine restored motor function and induced a dose-dependent increase in nigrostriatal dopaminergic neurons in MPTP mice. In the 6-OHDA rat model, circadianally administered A-dopamine improved motor activity without tachyphylaxia or dyskinesia. Indicative of a new therapeutic strategy for patients with l -dopa-related complications, continuous cerebral dosing of A-dopamine has greater efficacy over a large therapeutic index without undesirable side effects.

Bdellovibrio bacteriovorus is a predator micro‐organism towards other Gram‐negative bacteria. We tested B. bacteriovorus to control Escherichia coli growth on chicken slices and canned beef. Moreover, we analysed B. bacteriovorus's lytic ability on eight toxigenic or multidrug‐resistant E. coli strains. In chicken slices, the predator induced the highest prey reduction (4.3 log) respect to control at 6 h. In canned beef, the predator induced the highest prey reduction (2.1 log) respect to control at 6 h. Moreover, B. bacteriovorus showed lytic ability towards all tested E. coli strains. B. bacteriovorus could control E. coli and other pathogenic and spoilage bacteria in those meat‐based foods that have a shelf life

Obesity currently affects 78.6 million people (33%) in the United States and is expected to increase to over 50% of the population by 2030. This epidemic is fueled by the growing rate of obesity in adolescents. The new science of obesity indicates that there is a tipping point at which genetic resetting occurs and it is reached when adipose tissue dysfunction occurs. It is becoming clear that obesity is less an ongoing personal choice than a fact of biology. With this review, we aim to describe the epidemiology of obesity and the associated comorbidities.

The extent of lymphadenectomy for esophageal adenocarcinoma remains controversial. Outstanding issues include the appropriate technical approach such as transthoracic versus transhiatal, or open versus minimally invasive, both of which have implications on overall lymph node harvest numbers and morbidity. Recent data on the relationship of total number of lymph nodes harvested and oncologic survival have been conflicting, due in part to a likely differential impact of lymphadenectomy on survival based on tumor stage and response to neoadjuvant therapy. While standardizing the extent of lymphadenectomy may be desirable, a more useful approach might be to tailor lymphadenectomy considering the multidimensional impact of surgical technique and multimodal treatment strategy.

none 11 no This work was supported by Italian Ministry of Health (grant IZSUM 10, 2011). Toxigenic and antimicrobial susceptibility patterns and genetic relatedness of 42 non-O1/O139 V. cholerae strains, the majority of them isolated from seafood and marine water of the Adriatic sea, Italy, and 9 clinical strains, two of which with seawater of the Adriatic as the source of infection, were studied. All strains had hlyA El Tor gene but lacked ctxA gene. Four and two isolates, respectively, also had stn/sto and tcpA Class genes. More than 90% of strains showed susceptibility to cefotaxime, ciprofloxacin, cloramphenicol, tetracycline, trimethoprim þ sulfamethoxazole and intermediate or full resistance to tetracycline and erythromycin. Six strains of seafood and clinical source were multi-drug resistant. PFGE analysis allowed to type all the strains with 50 banding patterns. Twenty-one strains, 11 and 8 from seafood and seawater, respectively, and 2 of clinical origin, were grouped into 9 different clusters. We report the presence of toxigenic and multidrug resistant non-O1/O139 V. cholerae strains in Adriatic, some of which genetically related, and support that they represent a potential reservoir of toxin and antibiotic resistance genes. mixed Donatella, Ottaviani; Laura, Medici; Giulia, Talevi; Maira, Napoleoni; Patrizia, Serratore; Emanuele, Zavatta; Giorgia, Bignami; Laura, Masini; Serena, Chierichetti; Stefano, Fisichella; Francesca, Leoni Donatella, Ottaviani; Laura, Medici; Giulia, Talevi; Maira, Napoleoni; Patrizia, Serratore; Emanuele, Zavatta; Giorgia, Bignami; Laura, Masini; Serena, Chierichetti; Stefano, Fisichella; Francesca, Leoni

The outcomes for enhanced recovery after surgery (ERAS) have yet to be thoroughly studied in minimally invasive esophageal surgery. In this review, we examine the literature to provide an overview of the current state of ERAS in minimally invasive esophageal surgery.We searched the PubMed database up to January 2018 for relevant literature. We reviewed two randomized controlled trials, one Cochrane Review, two meta-analyses, three systematic reviews, three prospective cohort studies, three retrospective case-control studies, one consecutive series, and several other studies pertaining to ERAS in minimally invasive esophageal surgery.Compared with conventional perioperative care, ERAS pathways after minimally invasive esophageal procedures reduce postoperative hospital length of stay, encourage earlier return of bowel function, increase cost savings, and do not significantly change perioperative complication rates.We recommend that patients undergoing minimally invasive esophageal surgery enter a postoperative ERAS pathway to maximize recovery. ERAS pathways offer the best opportunity for successful postoperative recovery without negatively impacting patient safety.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Surgical quality improvement efforts have focused on tracking and reducing postoperative mortality and morbidity. However, the prevalence of intraoperative adverse events (IAEs) and their association with postoperative surgical outcomes has been poorly studied. In this study, we detected IAEs using both retrospective chart review and prospective provider reporting. We then examined the association of IAEs with postoperative outcomes. The overall IAE detection rate per case was 0.7 and 0.07 (P 0.0001) based on chart review and provider reporting, respectively. Types of IAEs varied between detection methods. Provider-reported IAEs were more serious, i.e., had a stronger association with 30-day postoperative complications than chart-identified IAEs (risk-adjusted odds ratios were 1.52 vs 1.02, respectively, both p 0.0001). Our findings suggest that IAEs can be detected using either retrospective chart review or prospective provider reporting. However, provider reporting appears more likely to detect serious (albeit infrequent) IAEs compared to chart review.

Background Wild birds are considered to be reservoirs of human enteric pathogens and vectors of antimicrobial resistance dissemination in the environment. During their annual migration, they play a potential role in the epidemiology of human associated zoonoses. The aim of this study was to investigate the frequency of isolation and antimicrobial susceptibility profiles of microorganisms found in the cloaca of common European passerines. Methods One hundred and twenty-one cloacal swabs were collected during a monitoring program of migratory birds in the Forest Reserve for Protection “Metaponto” (Basilicata, Italy). All samples were cultured using standard bacteriological methods and antibiotic susceptibility testing (agar disk diffusion test) of isolated strains was performed. Results The bacteriological analysis produced 122 strains belonging to 18 different species. The most commonly isolated species were Enterobacter cloacae and Providencia rettgeri (21 strains, 17.2%). Potentially pathogenic species including Klebsiella pneumoniae, Serratia marcescens and Pseudomonas spp. have also been identified. Isolates showed significant frequencies of antimicrobial resistance. The highest frequency of resistance was observed against amoxicillin (n = 79, 64.8%); ampicillin (n = 77, 63.1%); rifampicin (n = 75, 61.5%); amoxicillin–clavulanic acid (n = 66, 54.1%). Thirty-one strains (25.4%) showed resistance to imipenem and 8 (6.6%) to meropenem. Conclusions Migratory birds play an important role in the ecology, circulation and dissemination of potentially pathogenic antimicrobial resistant organisms. They can therefore be considered sentinel species and environmental health indicators. Our results suggest that the integration of epidemiological surveillance networks during ringing campaigns of wild species can be an effective tool to study this phenomenon.

Innovation has been a central focus of the Department of Surgery at the Brigham and Women's Hospital since its very inception. Here we review examples of innovations originating in this Department and analyze factors that have been critical to successful innovation. Finally, we discuss challenges to sustainability of innovation in this Department.Narrative review of the literature, interviews, and personal observations.Examples of innovations reviewed here were each dependent on three critical elements: 1) multidisciplinary collaboration among surgical innovators and individuals outside of surgery who offered complementary skills and expertise, 2) a rich institutional environment that sustained a diverse complement of innovators working in close proximity, and 3) Department Chairmen who facilitated the work of innovators and promoted their contributions, rather than seeking personal prestige or financial gain. Contemporary challenges to sustainability of innovation include the prevailing emphasis on clinical efficiency and on cost containment.We have identified factors critical to successful innovation in a Department of Surgery. The relevance of these factors is unlikely to be diminished, even in the changing landscape of modern medicine.

Background Phone triaging patients with suspected malignant pleural mesothelioma (MPM) within the Veterans Healthcare Administration (VHA) system offers a model for rapid, expert guided evaluation for patients with rare and treatable diseases within a national integrated healthcare system. To assess feasibility of national open access telephone triage using evidence-based treatment recommendations for patients with MPM, measure timelines of the triage and referral process and record the impact on “intent to treat” for patients using our service. Methods A retrospective study. The main outcome measures were: (1) ability to perform long distance phone triage, (2) to assess the speed of access to a mesothelioma surgical specialist for patients throughout the entire VHA, and (3) to determine if access to a specialist would alter the plan of care. Results Sixty veterans were screened by our phone triage program, 38 traveled an average of 997 miles to VA Boston Healthcare system. On average, 14 d elapsed from initial phone contact until the patient was physically evaluated in our general thoracic clinic in Boston. The treatment plan was altered for 71% of patients evaluated at VA Boston Healthcare system based on 2012 International Mesothelioma Interest Group guidelines. Conclusions Our initial experience demonstrates that in-network centralized care for Veterans with MPM is feasible within the VHA. National open access phone triage improves access to expert surgical advice and can be delivered in a timely manner for Veterans using our service. Guideline-based treatment recommendations (“intent to treat”) changed the therapeutic course for the majority of patients who used our service.

Currently, there are no data in the literature on the topical treatment with Thymus vulgaris essential oil (EO) in bacterial skin infections of dogs. This study evaluates the effectiveness of Thymus vulgaris EO for topical use in dogs with skin 18 half-breed dogs, affected by skin infections housed in a rescue shelter were studied. The bacteria isolated from these dogs were identified by MALDI-TOF-MS. The susceptibility of the isolated microorganisms to Thymus vulgaris L. EO was estimated in vitro by bacteriological test (CLSI 2015), in comparison to some antimicrobials drugs (amoxicillin-clavulanic acid, doxycy-cline, thiamphenicol and marbofloxacin) and to Citrus bergamia EO. The dogs, divided in two groups at random, were treated topically for 7 days with Thymus vulgaris L. EO (Group 1: n. 10 animals) and Citrus bergamia Risso e Poiteau EO (Group 2: n. 8 animals) respectively. The bacteria isolated were: Staphylococcus pseudintermedius (7 samples), Staphylococcus sciuri (4), ESBL Escherichia coli (3) and Proteus mirabilis (4). In all animals treated with Thymus vulgaris EO, the clinical signs decreased rapidly within 5 days from the administration, with complete remission 7 days after the treatment. No bacterial growth was observed from skin swabs after 7 days of treatment. None of the treated animals showed local or general side effects. The use of Thymus vulgaris EO could be a possible alternative or additional treatment to antibiotics in dermatological infections, particularly in cases refractory to conventional therapy.

// Massimiliano Berretta 1 , Chiara Della Pepa 2 , Paolo Tralongo 3 , Alberto Fulvi 4 , Ferdinando Martellotta 1 , Arben Lleshi 1 , Guglielmo Nasti 5 , Rossella Fisichella 6 , Carmela Romano 5 , Chiara De Divitiis 5 , Rosaria Taibi 1 , Francesco Fiorica 7 , Raffaele Di Francia 8, 9 , Anna Di Mari 3 , Lino Del Pup 10 , Anna Crispo 11 , Paolo De Paoli 12 , Adriano Santorelli 13 , Vincenzo Quagliariello 5 , Rosario Vincenzo Iaffaioli 5 , Umberto Tirelli 1 , Gaetano Facchini 2 1 Department of Medical Oncology, National Cancer Institute, Aviano (PN), Italy 2 Division of Medical Oncology, Department of Uro-Gynaecological Oncology, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy 3 Division of Medical Oncology, “Umberto I” Hospital, Syracuse, Italy 4 Department of Medicine and Surgery of Integrated Treatment, Division of Thoracic Oncology, “San Camillo Forlanini” Hospital, Rome, Italy 5 Department of Abdominal Oncology, Division of Medical Oncology B, National Cancer Institute, “G. Pascale” Foundation, Naples, Italy 6 Department of Surgery, University of Catania, Catania, Italy 7 Department of Radiation Oncology University Hospital Ferrara, Division of Radiotherapy, “Arcispedale Sant’Anna” Hospital, Ferrara, Italy 8 Department of Hematology, Istituto Nazionale Tumori ‘Fondazione Giovanni Pascale’, IRCCS, Naples, Italy 9 Gruppo Oncologico Ricercatori Italiani, GORI, Pordenone, Italy 10 Division of Gynaecological Oncology, National Cancer Institute, Aviano (PN), Italy 11 Unit of Epidemiology, Struttura Complessa di Statistica Medica, Biometria e Bioinformatica, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Naples, Italy 12 Scientific Directorate, National Cancer Institute, Aviano (PN), Italy 13 Department of Plastic Surgery, Regenerative Medicine, Health Park Hospital, Naples, Italy Correspondence to: Massimiliano Berretta, email: mberretta@cro.it Keywords: complementary medicine, alternative medicine, survey, cancer, treatment Received: October 13, 2016 Accepted: November 20, 2016 Published: December 25, 2016 ABSTRACT Introduction: Complementary and Alternative Medicine (CAM) include a wide range of products (herbs, vitamins, minerals, and probiotics) and medical practices, developed outside of the mainstream Western medicine. Patients with cancer are more likely to resort to CAM first or then in their disease history; the potential side effects as well as the costs of such practices are largely underestimated. Patients and method: We conducted a descriptive survey in five Italian hospitals involving 468 patients with different malignancies. The survey consisted of a forty-two question questionnaire, patients were eligible if they were Italian-speaking and receiving an anticancer treatment at the time of the survey or had received an anticancer treatment no more than three years before participating in the survey. Results: Of our patients, 48.9% said they use or have recently used CAM. The univariate analysis showed that female gender, high education, receiving treatment in a highly specialized institute and receiving chemotherapy are associated with CAM use; at the multivariate analysis high education (Odds Ratio, (OR): 1.96 95% Confidence Interval, CI, 1.27-3.05) and receiving treatment in a specialized cancer center (OR: 2.75 95% CI, 1.53-4.94) were confirmed as risk factors for CAM use. Conclusion: Roughly half of our patients receiving treatment for cancer use CAM. It is necessary that health professional explore the use of CAM with their cancer patients, educate them about potentially beneficial therapies in light of the limited available evidence of effectiveness, and work towards an integrated model of health-care provision.

Postoperative pain remains undertreated in critically ill patients. We hypothesized that the adequacy of pain control in our Surgical Intensive Care Unit (SICU) was above the reported average of 71 % in the literature and that the introduction of the critical care pain observation tool (CPOT) could improve it. We used a Lean Six Sigma methodology to improve our processes and quantify our improvement.We retrospectively review 713 consecutive veterans admitted to our SICU. Between December 2014 and February 2015, postoperative pain was assessed every 2 h and rated "acceptable," "unacceptable," or "unable to assess". Between March 2015 and October 2015, postoperative pain was assessed with CPOT. Concurrently, we implemented a postoperative pain education program and documented this activity in the electronic medical record.The baseline adequacy of pain control was 78 %, which improved to 99 % after the introduction of CPOT. We concurrently achieved a 100 % median documentation of postoperative pain education in the electronic medical record. The introduction of CPOT improved the process σ from 2.3 to 3.8. The process of documenting pain education achieved a process σ of 3.1.The proportion of veterans with acceptable pain control in our SICU is higher than that reported in the literature and the application of a Six Sigma methodology that involved the introduction of the CPOT has allowed us to improve the perception of pain control and comply with the newest regulatory directives.

In the last century, the exponential increase of industrial food production led to the disappearance of &ldquo, Italian traditional niche products&rdquo, However, national regulations allowed the preservation of several of these products, including the burrata cheese. Twenty-one samples from three different batches of &ldquo, Burrata di Andria&rdquo, Protected Geographical Indication (PGI) were purchased from dairy factories of the PGI consortium. Moisture value of PGI Burrata cheese was significantly higher than that before the PGI release. Moreover, a significantly lower NaCl value was detected in PGI raw milk Burrata cheeses with respect to non-PGI ones, while an opposite situation was detected in pasteurized milk Burrata cheeses. As for pH, in all PGI products lower values were observed with respect to non-PGI products, which resulted significant only in pasteurized ones. No Salmonella spp., Listeria monocytogenes, and Bacillus cereus were detected, while nine samples were positive for a nonpathogenic strain of Yersinia enterocolitica. Total viable count (TVC) and Escherichia coli resulted significantly lower in pasteurized than in raw milk PGI Burrata cheese samples. Although samples analyzed can be considered microbiologically safe, these were borderline and/or unsatisfactory for E. Coli and coagulase-positive staphylococci (CPS) according to process hygiene criteria established by European regulation. Therefore, different strategies should be adopted to improve products hygiene in the considered dairy factories.

Background Continuous compensation of dopamine represents an ideal symptomatic treatment for Parkinson's disease (PD). The feasibility in intracerebroventricular administration (i.c.v.) of dopamine previously failed because of unresolved dopamine oxidation. Objectives We aim to test the feasibility, safety margins and efficacy of continuous i.c.v. of anaerobic-dopamine (A-dopamine) with a pilot translational study in a non-human primate model of PD. Methods Continuous and circadian i.c.v. of A-dopamine was administered through a micro-pump connected to a subcutaneous catheter implanted into the right frontal horn of 8 non-human primates treated with 1-methyl-4- phenyl-1,2,3,6-tetrahydropyridine (MPTP). A-dopamine was assessed at acute doses previously reported for dopamine as well as evaluating the long term therapeutic index of A-dopamine in comparison to anaerobically prepared L-dopa or methyl ester L-dopa. Results Over 60 days of a continuous circadian i.c.v. of A-dopamine improved motor symptoms (therapeutic index from 30 to 70 mg/day) without tachyphylaxia. No dyskinesia was observed even with very high doses. Death after 1 to 10 days (without neuronal alteration) was only observed with doses in excess of 160 mg whereas L-dopa i.c.v. was not effective at any dose. The technical feasibility of the administration regimen was confirmed for an anaerobic preparation of dopamine and for administration of a minimal infusion volume by micro-pump at a constant flow that prevented obstruction. Conclusion Continuous circadian i.c.v. of A-dopamine appears to be feasible and shows efficacy without dyskinesia with a safe therapeutic index.

Innovative strategies to reduce costs while maintaining patient satisfaction and improving delivery of care are greatly needed in the setting of rapidly rising health care expenditure. Intensive care units (ICUs) represent a significant proportion of health care costs due to their high resources utilization. Currently, the decision to admit a patient to the ICU lacks standardization because of the lack of evidence-based admission criteria. The objective of our research is to develop a prediction model that can help the physician in the clinical decision-making of postoperative triage.Our group identified a list of index events that commonly grants admission to the ICU independently of the hospital system. We analyzed correlation among 200 quantitative and semiquantitative variables for each patient in the study using a decision tree modeling (DTM). In addition, we validated the DTM against explanatory models, such as bivariate analysis, multiple logistic regression, and least absolute shrinkage and selection operator.Unlike explanatory modeling, DTM has several unique strengths: tree models are easy to interpret, the analysis can examine hundreds of variables at once, and offer insight into variable relative importance. In a retrospective analysis, we found that DTM was more accurate at predicting need for intensive care compared with current clinical practice.DTM and predictive modeling may enhance postoperative triage decision-making. Future areas of research include larger retrospective analyses and prospective observational studies that can lead to an improved clinical practice and better resources utilization.

Patients with gastroesophageal reflux disease (GERD) may present with a variety of symptoms, including heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. Therefore, the clinical presentation of GERD varies among individuals and conversely symptoms not always correspond to the presence of actual reflux. For that reason, the diagnosis poses certain challenges to the physician. To overcome these challenges, a thorough clinical examination followed by objective functional testing could improve diagnostic accuracy. In addition, a proper evaluation of patients with GERD can help in identifying those who will likely benefit the most from an antireflux procedure. The diagnostic work-up of these patients should include: symptomatic evaluation, upper endoscopy, barium swallow, high-resolution manometry, and ambulatory pH monitoring. Once a proper diagnosis of GERD is achieved, antireflux surgery is an excellent option for patients with partial control of symptoms with medication, for patients who do not want to be on long-term medical treatment (compliance/cost), or when complications of medical treatment occur.

Recent data reveal that the incidence of esophageal strictures is decreasing. However, they remain a common problem. Endoscopy is the main tool in evaluating these patients, as it provides a platform for both diagnosis and treatment. Most strictures respond to a combination of endoscopic dilation and medical therapy. Surgery is usually reserved to patients not responding to conservative treatment.

Summary Background & aims To date, studies assessing the relationship between sarcopenia and delirium, two of the most common geriatric syndromes, are lacking. We sought to explore this association by investigating the co-occurrence of these two conditions and the independent association between them in a population of hospitalized older adults. Methods Cross-sectional multicenter analysis of older adults consecutively admitted to 12 acute geriatric units (AGUs). Sarcopenia was assessed upon admission by evaluating the presence of low skeletal mass index (kg/m 2 ), and either low handgrip strength or low walking speed (European Working Group on Sarcopenia in Older People, EWGSOP criteria). Skeletal muscle mass was estimated using bioimpedance analysis. Participants underwent a comprehensive geriatric assessment upon admission; information concerning demographics, cognition (Short Portable Status Mental Questionnaire, SPMSQ) functional (Instrumental Activities of Daily Living, IADL and Basic-Activities of Daily Living, BADL), and health status (Charlson Index and specific diseases) was evaluated. The presence of delirium upon admission was ascertained as an explicit clinical diagnosis recorded by the researcher of each centre on the data form. All association estimates were reported as Prevalence Ratios (PRs) and 95% confidence intervals (CIs), using a Cox hazard proportional regression model with robust variance and constant time. Results Of the 588 analyzed patients (mean age = 80.9 ± 6.8, 53.2% females), 199 (33.8%) had sarcopenia upon admission to the AGU. According to a multivariable Cox regression, delirium upon admission (PR 1.66, 95% CI: 1.12–2.45), IADL total score (PR 0.93, 95% CI: 0.87–0.98), Body Mass Index values (BMI) ranging from 18.5 to 25.0 (PR 1.70, 95% CI: 1.33–2.18), BMI values >18.5 (PR 2.53, 95% CI: 1.81–3.53), previous stroke (PR 1.51, 95% CI: 1.10–2.07) and chronic heart failure (CHF) (PR 1.31, 95% CI: 1.02–1.68) were significantly and independently associated with sarcopenia upon admission to the AGU. Conclusion The study, carried out in a population of hospitalized older patients, shows that a diagnosis of delirium upon admission to the AGU was more frequent in those with sarcopenia than in others. Furthermore, the study found that delirium was independently associated with the risk of being sarcopenic upon admission to the AGU. Future studies are needed to confirm this association.

Antimicrobial-resistant (AMR) bacteria are a threat to global health. Epidemiological studies are necessary to gain a more detailed understanding of the transmission modality of resistant bacteria to wild animals and their diffusion into the environment to ensure a broader evaluation of the epidemiological role of wildlife. The study aimed to identify little-known epidemiological aspects by focusing on the isolation of Enterobacteriaceae in order to bring knowledge on the bacterial flora of wild mammals living in the National Park of Aspromonte (Calabria, Italy). Two hundred twenty-five faecal samples of wild mammals were collected and submitted to standard bacteriological examination for Enterobacteriaceae detection. Isolates were identified by mass spectrometry MALDI-TOF (matrix assisted laser desorption/ionisation - time of fligt mass spectrometry). The 30 isolates showing the highest number of resistances were screened for Extended Spectrum Beta Lactamase (ESBL) production. Antimicrobial susceptibility testing of the bacterial isolates was performed by the disk diffusion method. Two hundred sixty-three strains were isolated. The most frequently recovered bacterial species were Hafnia alvei, Escherichia coli and Citrobacter spp.. Potentially pathogenic species including Salmonella spp., Yersinia enterocolitica and Serratia marcescens have also been identified. Isolates displayed significant frequencies of antibiotic resistance. The resistance to amoxicillin (71.4%) was the most frequent, followed by amoxicillin/clavulanic acid (55.5%), ampicillin (49.8%), streptomycin (35.7%), doxycycline (16.3%), tobramycin (15.2%), tetracycline (13.3%) and gentamicin (10.6%). Nine strains showed resistance to imipenem and 1 to meropenem. All isolates were negative for the presence of ESBL-encoding genes. Wild animals can be regarded as sentinel species and used as environmental health indicators.

The increasing number of new psychoactive substances (NPS) present in the illicit market render their identification in biological fluids/tissues of great concern for clinical and forensic toxicology. Analytical methods able to detect the huge number of substances that can be used are sought, considering also that many NPS are not detected by the standard immunoassays generally used for routine drug screening. The aim of this work was to develop a method for the screening of different classes of NPS (a total of 78 analytes including cathinones, synthetic cannabinoids, phenethylamines, piperazines, ketamine and analogues, benzofurans, tryptamines) from blood samples. The simultaneous extraction of analytes was performed by Dispersive Liquid/Liquid Microextraction DLLME, a very rapid, cheap and efficient extraction technique that employs microliters amounts of organic solvents. Analyses were performed by a target Ultrahigh Performance Liquid Chromatography tandem Mass Spectrometry (UHPLC-MS/MS) method in multiple reaction monitoring (MRM). The method allowed the detection of the studied analytes with limits of detection (LODs) ranging from 0.2 to 2ng/mL. The proposed DLLME method can be used as an alternative to classical liquid/liquid or solid-phase extraction techniques due to its rapidity, necessity to use only microliters amounts of organic solvents, cheapness, and to its ability to extract simultaneously a huge number of analytes also from different chemical classes. The method was then applied to 60 authentic real samples from forensic cases, demonstrating its suitability for the screening of a wide number of NPS.

Background Trauma is the leading cause of death from ages 1–44-y in the United States and the fifth leading cause of death overall, but there are few studies quantifying trauma education in medical school. This study reviews curriculum hours devoted to trauma education at a northeastern medical school. Materials and methods We reviewed the preclinical curriculum at a northeastern medical school affiliated with three adult and two pediatric level I trauma centers verified by the American College of Surgeons. We reviewed curricular hours and we categorized them according to the leading ten causes of death in the United States. We also compared the number of educational hours devoted to trauma to other leading causes of death. Results The total amount of time devoted to trauma education in the first 2 y of medical school was 6.5 h. No lectures were given on the fundamentals of trauma management, traumatic brain injury, or chest or abdominal trauma. The most covered topic was heart disease (128 h), followed by chronic lower respiratory disease (80 h). Curricular time for heart disease, chronic lower respiratory disease, cancer, diabetes, renal disease, and influenza and pneumonia far exceeded that devoted to trauma, after adjusting for the mortality burden of these diseases (P Conclusions Our study demonstrates that trauma education at a northeastern medical school is nearly absent. With the large burden of trauma and rise in mass casualty incidence, the preclinical curriculum might not be sufficient to expose students to the fundamentals of trauma management. A broader multi-institutional study may shed more insight on these curricular deficiencies in trauma education and detect if these deficiencies are widespread nationally.

Background Despite advances in diagnoses and therapy, esophageal adenocarcinoma remains a highly lethal neoplasm. Hence, a great interest has been placed in detecting early lesions and in the detection of Barrett esophagus (BE). Advanced imaging technologies of the esophagus have then been developed with the aim of improving biopsy sensitivity and detection of preplastic and neoplastic cells. The purpose of this article was to review emerging imaging technologies for esophageal pathology, spectroscopy, confocal laser endomicroscopy (CLE), and optical coherence tomography (OCT). Methods We conducted a PubMed search using the search string “esophagus or esophageal or oesophageal or oesophagus” and “Barrett or esophageal neoplasm” and “spectroscopy or optical spectroscopy” and “confocal laser endomicroscopy” and “confocal microscopy” and “optical coherence tomography.” The first and senior author separately reviewed all articles. Our search identified: 19 in vivo studies with spectroscopy that accounted for 1021 patients and 4 ex vivo studies; 14 clinical CLE in vivo studies that accounted for 941 patients and 1 ex vivo study with 13 patients; and 17 clinical OCT in vivo studies that accounted for 773 patients and 2 ex vivo studies. Results Human studies using spectroscopy had a very high sensitivity and specificity for the detection of BE. CLE showed a high interobserver agreement in diagnosing esophageal pathology and an accuracy of predicting neoplasia. We also found several clinical studies that reported excellent diagnostic sensitivity and specificity for the detection of BE using OCT. Conclusions Advanced imaging technology for the detection of esophageal lesions is a promising field that aims to improve the detection of early esophageal lesions. Although advancing imaging techniques improve diagnostic sensitivities and specificities, their integration into diagnostic protocols has yet to be perfected.

The advent of endoscopic techniques has transformed the surgical therapy of Zenker's diverticula. Although the treatment paradigm has shifted to minimally invasive approaches with endoscopic stapling-assisted or laser-assisted repair, traditional transcervical procedures can still play a role in selected cases. The goal of this article is to illustrate our tailored approach to patients with Zenker's diverticula and illustrate our open surgical and endoscopic techniques. The discussion will also include the evidence-based rationale for our preoperative assessment and choice of technique.

The emergence of bacterial resistance to antibiotic use in veterinary practice is considered a source of multidrug-resistant bacterial infections for humans. Although increasing incidence of antimicrobial resistance in small-animal practices has already been noted, limited information is available about the problem in domestic canaries (Serinus canaria domestica). This cross-sectional study describes the prevalence of Gram-negative bacteria among canaries exhibiting clinical disease signs and the antimicrobial sensitivity patterns of the bacterial isolates. During the breeding season, a bacteriological survey was carried out in 50 amateur breeding aviaries from the Messina Province (Sicily, South of Italy) to detect the prevalence of Gram-negative bacteria in sick birds. Fecal samples from breeder canaries were submitted for bacteriological examination. Of 50 breeding aviaries, 43 (86%) were positive for Gram-negative bacteria. Overall, 88 bacterial isolates, representing 12 genera of bacteria, were cultured. The most frequently recovered bacterial species was Escherichia coli (31/88 isolates, 35.2%). Other frequently isolated species were Enterobacter cloacae (9/88 isolates, 10.2%) and Proteus mirabilis (6/88 isolates, 6.8%). Potentially pathogenic species, including Salmonella Typhimurium (n = 5 strains), Enterobacter sakazakii (n = 4 strains), and Pseudomonas aeruginosa (n = 6 strains), were also identified. The 88 isolates displayed significant frequencies of antibiotic resistance. These results confirm the potential presence of multidrug-resistant bacteria in canary facilities, suggesting that measures to educate the public about this risk are necessary.