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ObjectiveTo characterise in vivo the microstructural abnormalities of multiple sclerosis (MS) normal-appearing (NA) cortex and cortical lesions (CLs) and their relations with clinical phenotypes and disability using neurite orientation dispersion and density imaging (NODDI).MethodsOne hundred and seventy-two patients with MS (101 relapsing–remitting multiple sclerosis (RRMS), 71 progressive multiple sclerosis (PMS)) and 62 healthy controls (HCs) underwent a brain 3T MRI. Brain cortex and CLs were segmented from three-dimensional T1-weighted and double inversion recovery sequences. Using NODDI on diffusion-weighted sequence, intracellular volume fraction (ICV_f) and Orientation Dispersion Index (ODI) were assessed in NA cortex and CLs with default or optimised parallel diffusivity for the cortex (D//=1.7 or 1.2 µm2/ms, respectively).ResultsThe NA cortex of patients with MS had significantly lower ICV_f versus HCs’ cortex with both D// values (false discovery rate (FDR)-p 2/ms. No CL microstructural differences were found between MS clinical phenotypes. MS NA cortex ICV_f and ODI were significantly correlated with disease duration, clinical disability, lesion burden and global and regional brain atrophy (r from −0.51 to 0.71, FDR-p from ConclusionsA significant neurite loss occurs in MS NA cortex. CLs show a further neurite density reduction and a reduced ODI suggesting a simplification of neurite complexity. NODDI is relevant to investigate in vivo the heterogeneous pathology affecting the MS cortex.

Background Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). Methods An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. Results Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy. Conclusion This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

BACKGROUND Aquaporin-4 (AQP4) water channel is involved in hippocampal plasticity and is the target of neuromyelitis optica spectrum disorders (NMOSD) autoimmunity. We measured volumes of hippocampal subfields and their association with cognitive performance in AQP4-seropositive NMOSD patients. METHODS Global and regional hippocampal volumes were derived from 28 AQP4-seropositive NMOSD patients and 101 healthy controls (HC) from 3D-T1-weighted images. Normalized brain volumes were also calculated. A neuropsychological evaluation, including the Brief Repeatable Battery of Neuropsychological Tests, was performed in patients. Based on HC data, we estimated mean z-scores of volumes in the whole NMOSD group and compared them according to the status of global and domain-selective cognitive impairment. RESULTS Global cognitive impairment was detected in 46.4% of NMOSD patients, with attentive (60.7%) and executive (21.4%) domains being the most affected. NMOSD patients had left hippocampal atrophy at global (p = 0.012) and regional level (fimbria, Cornu Ammonis [CA] 3, molecular layer, dentate gyrus [DG], and subicular complex, p values ranging between 0.033 and

OBJECTIVES The aims of this study were to present a deep learning approach for the automated classification of multiple sclerosis and its mimics and compare model performance with that of 2 expert neuroradiologists. MATERIALS AND METHODS A total of 268 T2-weighted and T1-weighted brain magnetic resonance imagin scans were retrospectively collected from patients with migraine (n = 56), multiple sclerosis (n = 70), neuromyelitis optica spectrum disorders (n = 91), and central nervous system vasculitis (n = 51). The neural network architecture, trained on 178 scans, was based on a cascade of 4 three-dimensional convolutional layers, followed by a fully dense layer after feature extraction. The ability of the final algorithm to correctly classify the diseases in an independent test set of 90 scans was compared with that of the neuroradiologists. RESULTS The interrater agreement was 84.9% (Cohen κ = 0.78, P < 0.001). In the test set, deep learning and expert raters reached the highest diagnostic accuracy in multiple sclerosis (98.8% vs 72.8%, P < 0.001, for rater 1; and 81.8%, P < 0.001, for rater 2) and the lowest in neuromyelitis optica spectrum disorders (88.6% vs 4.4%, P < 0.001, for both raters), whereas they achieved intermediate values for migraine (92.2% vs 53%, P = 0.03, for rater 1; and 64.8%, P = 0.01, for rater 2) and vasculitis (92.1% vs 54.6%, P = 0.3, for rater 1; and 45.5%, P = 0.2, for rater 2). The overall performance of the automated method exceeded that of expert raters, with the worst misdiagnosis when discriminating between neuromyelitis optica spectrum disorders and vasculitis or migraine. CONCLUSIONS A neural network performed better than expert raters in terms of accuracy in classifying white matter disorders from magnetic resonance imaging and may help in their diagnostic work-up.

Background: The pathogenetic mechanisms sustaining neuroinflammatory disorders may originate from the cerebrospinal fluid. Objective: To evaluate white matter damage with diffusion tensor imaging and T1/T2-weighted ratio at progressive distances from the ventricular system in neuromyelitis optica spectrum disorders and multiple sclerosis. Methods: Fractional anisotropy, mean, axial, and radial diffusivity and T1/T2-weighted ratio maps were obtained from patients with seropositive neuromyelitis optica spectrum disorders, multiple sclerosis, and healthy controls ( n = 20 each group). White matter damage was assessed as function of ventricular distance within progressive concentric bands. Results: Compared to healthy controls, neuromyelitis optica spectrum disorders patients had similar fractional anisotropy, radial and axial diffusivity, increased mean diffusivity ( p = 0.009–0.013) and reduced T1/T2-weighted ratio ( p = 0.024–0.037) in all bands. In multiple sclerosis, gradient of percentage lesion volume and intra-lesional mean and axial diffusivity were higher in periventricular bands. Compared to healthy controls, multiple sclerosis patients had reduced fractional anisotropy ( p = 0.001–0.043) in periventricular bands, increased mean ( p Conclusion: White matter damage is higher at periventricular level in multiple sclerosis and diffuse in neuromyelitis optica spectrum disorders. Fractional anisotropy preservation, associated with increased mean diffusivity and reduced T1/T2-weighted ratio may reflect astrocyte damage.

Background: Executive dysfunctions, including difficulties in attention, working memory, planning, and inhibition affect 15%–28% of multiple sclerosis (MS) patients. Objectives: To investigate structural and functional magnetic resonance imaging (MRI) abnormalities underlying executive function (EF) in MS patients. Methods: A total 116 MS patients and 65 controls underwent resting-state (RS) and diffusion-weighted sequences and neuropsychological examination, including Wisconsin Card Sorting Test (WCST) to test EF. Brain RS cognitive networks and fractional anisotropy (FA) from a priori selected white matter tracts were derived. Associations of WCST scores with RS functional connectivity (FC) and FA abnormalities were investigated. Results: In MS patients, predictors of working memory/updating were: lower corpus callosum (CC) FA, lower left working-memory network (WMN), right WMN RS FC for worse performance; lower executive control network (ECN), higher default-mode network (DMN), and salience network (SN) RS FC for better performance ( R2 = 0.35). Predictors of attention were lower CC genu FA, lower left WMN, and DMN RS FC for worse performance; higher left WMN and ECN RS FC for better performance ( R2 = 0.24). Predictors of worse shifting/inhibition were lower CC genu and superior cerebellar peduncle (SCP) FA, lower left WMN RS FC for worse performance; and higher ECN RS FC for better performance ( R2 = 0.24). Conclusions: CC and SCP microstructural damage and RS FC abnormalities in cognitive networks underlie EF frailty in MS.

To apply a deep-learning algorithm to brain MRIs of seronegative patients with neuromyelitis optica spectrum disorders (NMOSD) and NMOSD-like manifestations and assess whether their structural features are similar to aquaporin-4-seropositive NMOSD or multiple sclerosis (MS) patients. We analyzed 228 T2- and T1-weighted brain MRIs acquired from aquaporin-4-seropositive NMOSD (n = 85), MS (n = 95), aquaporin-4-seronegative NMOSD [n = 11, three with anti-myelin oligodendrocyte glycoprotein antibodies (MOG)], and aquaporin-4-seronegative patients with NMOSD-like manifestations (idiopathic recurrent optic neuritis and myelitis, n = 37), who were recruited from February 2010 to December 2019. Seventy-three percent of aquaporin-4-seronegative patients with NMOSD-like manifestations also had a clinical follow-up (median duration of 4 years). The deep-learning neural network architecture was based on four 3D convolutional layers. It was trained and validated on MRI scans of aquaporin-4-seropositive NMOSD and MS patients and was then applied to aquaporin-4-seronegative NMOSD and NMOSD-like manifestations. Assignment of unclassified aquaporin-4-seronegative patients was compared with their clinical follow-up. The final algorithm differentiated aquaporin-4-seropositive NMOSD and MS patients with an accuracy of 0.95. All aquaporin-4-seronegative NMOSD and 36/37 aquaporin-4-seronegative patients with NMOSD-like manifestations were classified as NMOSD. Anti-MOG patients had a similar probability of being NMOSD or MS. At clinical follow-up, one unclassified aquaporin-4-seronegative patient evolved to MS, three developed NMOSD, and the others did not change phenotype. Our findings support the inclusion of aquaporin4-seronegative patients into NMOSD and suggest a possible expansion to aquaporin-4-seronegative unclassified patients with NMOSD-like manifestations. Anti-MOG patients are likely to have intermediate brain features between NMOSD and MS.

Objective: Major hepatectomy in cirrhotic patients still represents a great challenge for liver surgeons. Hence, the aim in the present study is to investigate the clinical impact of major hepatectomy and to assess whether the surgical approach influences the outcome of cirrhotic patients. Methods: Multicenter retrospective study including cirrhotic patients undergoing major laparoscopic (mjLLR) and open liver resection (mjOLR) in 14 Western liver centers was performed (2009–2020). Clinical, demographic, and perioperative data were compared using propensity score matching (PSM). Long-term outcome after resection for hepatocellular carcinoma was analyzed. Results: Overall, 352 patients were included; 108 after mjLLR and 244 after mjOLR. After PSM, 88 patients were matched in each group. In the mjLLR group, compared to mjOLR, less blood loss (P=.042), lower overall and severe complication (P&nbsp

Treatment of childhood seizures is a pressing challenge within neuropediatrics because of its severe impact to the children and families affected by these debilitating disorders. It is of upmost importance to make an early diagnosis, to start a promptly treatment, to use therapy and dosage of the drug appropriately, based on the specific epileptic type and epileptic syndrome. Single therapy with appropriate dosage is the main approach to treatment. When the drug is the cause of an idiosyncratic reaction it is advisable to replace the suboptimal seizure response with another antiepileptic drug, combined therapy with two antiepileptic drugs is also a viable option. In childhood, polytherapy using more than two antiepileptic drugs remains controversial because the harm of interaction with deleterious drugs could potentially replace the damage caused by the seizures themselves. The use of three or more antiepileptic drugs should be limited to epileptic seizures that are particularly resistant to drugs and when non-drug antiepileptic therapies have failed. An approach to the difficult topic of epileptic treatment in childhood is reported. Key point: mono vs polytherapy in epileptic children; single and alternative therapy in epileptic children; use or three or more AEDs in children.

Pediatric acute-onset neuropsychiatric syndrome (PANS) is a condition characterized by the abrupt, dramatic onset of obsessive&ndash, compulsive disorder (OCD) or eating restriction accompanied by equally abrupt and severe comorbid neuropsychiatric symptoms. PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection) is a heterogeneous syndrome identified as post-Streptococcus pyogenes infection (&beta, hemolytic Streptococcus group A) complications regarding the central nervous system with specific involvement of neuropsychiatric and behavioral skills. In the first part of our study, we share our experience in the treatment of a group of extreme-grade (according to CY-BOCS severity scale) symptomatic patients with intravenous immunoglobulin (IVIG), following the most recent studies regarding the dosage of the drug. Our contribution is to share our experience made on a sample of 55 patients all in the highest level of a severity grade. In the second part of our study, we also analyze the literature on PANS/PANDAS rehabilitation therapy, since in the literature there is no discussion of union and comparison on this method. Objective: This study aims to evaluate the clinical features of the patients observed from different Italian cohorts, with the attempt at evaluating clinical response to IVIG treatment in children with an extreme severity grade of PANS/PANDAS disease. Furthermore, after having analyzed the literature, we propose rehabilitation therapy as an added value to the pharmacological treatment. Materials and Methods: A total of 55 patients with a diagnosis of PANS/PANDAS, who belonged to an extreme grade of disease, were enrolled. All patients were administered with IVIG treatment at 2 g/kg per day for two consecutive days. Results: From our study, a noticeable improvement (until complete remission) of symptoms was evident for at least one year in 47 out of 55 (85%) observed children, while 11 out of these 43 (25%) showed an evident symptoms remission in a single attempt and the remaining 32 (75%) required a second administration to notice a lasting symptomatic improvement.

Advances in neuromyelitis optica spectrum disorder pathogenesis have allowed the development of targeted drugs. These treatments act on core elements of the disease, including the pro-inflammatory IL-6 pathway (tocilizumab and satralizumab), B cells (rituximab and inebilizumab), and complement (eculizumab). According to recent phase II–III trials, biologics significantly reduced the risk of relapses in aquaporin-4-seropositive patients, whereas results were less striking in the small cohorts of aquaporin-4-seronegative patients. Most adverse events were mild to moderate, with systemic symptoms (headache, arthralgia) or infections (upper respiratory and urinary tracts) being most commonly reported. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13311-021-01055-0.

Craniosynostosis, the premature closure of cranial sutures, is one of the principal causes of pediatric skull deformities. It can cause aesthetic, neurological, acoustic, ophthalmological complications up to real emergencies. Craniosynostosis are primarily diagnosed with accurate physical examination, skull measurement and observation of the deformity, but the radiological support currently plays an increasingly important role in confirming a more precise diagnosis and better planning for therapeutic interventions. The clinician must know how to diagnose in the earliest and least invasive way for the child. In the past, technological limitations reduced the choices; today, however, there are plenty of choices and it is necessary to use the various types of available imaging correctly. In the future, imaging techniques will probably rewrite the common classifications we use today. We provide an updated review of the role of imaging in this condition, through the ages, to outline the correct choice for the clinician for an early and non-invasive diagnosis.

Background Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available. Methods Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age ≥ 23 weeks. Results The incidence of IUFD was 2.8‰ live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks. Conclusion The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs.

Background In multiple sclerosis (MS), knowledge about how spinal cord abnormalities translate into clinical manifestations is incomplete. Comprehensive, multiparametric MRI studies are useful in this perspective, but studies for the spinal cord are lacking. Purpose To identify MRI features of cervical spinal cord damage that could help predict disability and disease course in MS by using a comprehensive, multiparametric MRI approach. Materials and Methods In this retrospective hypothesis-driven analysis of longitudinally acquired data between June 2017 and April 2019, 120 patients with MS (58 with relapsing-remitting MS [RRMS] and 62 with progressive MS [PMS]) and 30 age- and sex-matched healthy control participants underwent 3.0-T MRI of the brain and cervical spinal cord. Cervical spinal cord MRI was performed with three-dimensional (3D) T1-weighted, T2-weighted, and diffusion-weighted imaging; sagittal two-dimensional (2D) short inversion time inversion-recovery imaging; and axial 2D phase-sensitive inversion-recovery imaging at the C2-C3 level. Brain MRI was performed with 3D T1-weighted, fluid-attenuated inversion-recovery and T2-weighted sequences. Associations between MRI variables and disability were explored with age-, sex- and phenotype-adjusted linear models. Results In patients with MS, multivariable analysis identified phenotype, cervical spinal cord gray matter (GM) cross-sectional area (CSA), lateral funiculi fractional anisotropy (FA), and brain GM volume as independent predictors of Expanded Disability Status Scale (EDSS) score (R2 = 0.86). The independent predictors of EDSS score in RRMS were lateral funiculi FA, normalized brain volume, and cervical spinal cord GM T2 lesion volume (R2 = 0.51). The independent predictors of EDSS score in PMS were cervical spinal cord GM CSA and brain GM volume (R2 = 0.44). Logistic regression analysis identified cervical spinal cord GM CSA and T2 lesion volume as independent predictors of phenotype (area under the receiver operating characteristic curve = 0.95). An optimal cervical spinal cord GM CSA cut-off value of 11.1 mm2 was found to enable accurate differentiation of patients with PMS, having values below the threshold, from those with RRMS (sensitivity = 90% [56 of 62], specificity = 91% [53 of 58]). Conclusion Cervical spinal cord MRI involvement has a central role in explaining disability in multiple sclerosis (MS): Lesion-induced damage in the lateral funiculi and gray matter (GM) in relapsing-remitting MS and GM atrophy in patients with progressive MS are the most relevant variables. Cervical spinal cord GM atrophy is an accurate predictor of progressive phenotype. Cervical spinal cord GM lesions may subsequently cause GM atrophy, which may contribute to evolution to PMS. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Zivadinov and Bergsland in this issue.

Background The spinal cord is commonly involved in patients with neuromyelitis optica spectrum disorders (NMOSDs). However, the relationship between inflammation and atrophy remains unclear. Purpose To characterize the spatial distribution of T1-hypointense lesions in the spinal cord at MRI, its association with cord atrophy, and its correlation with disability in participants with NMOSDs. Materials and Methods This prospective study evaluated three-dimensional T1-weighted spinal cord MRI scans in seropositive participants with NMOSDs and in age-matched healthy control participants acquired between February 2010 and July 2018. Binary masks of T1-hypointense lesions and lesion probability maps were produced. Cross-sectional area of the cervical and upper thoracic cord (down to T3 level) was calculated with the active-surface method. Full factorial models were used to assess cord atrophy in participants with NMOSDs. Correlations between cord atrophy and clinical and brain MRI measures were investigated with multiple regression models. Results A total of 52 participants with NMOSDs (mean age ± standard deviation, 44 years ± 15; 45 women) and 28 age-matched healthy control participants (mean age, 44 years ± 13; 16 women) were evaluated. Thirty-eight of 52 (73%) participants with NMOSDs had T1-hypointense cord lesions. No cord lesions were detected in the healthy control participants. Lesion probability maps showed a predominant involvement of the upper cervical (C2-C4) and upper thoracic (T1-T3 level) cord. The greater involvement of C1-C4 survived Bonferroni correction (P value range, .007-.04), with a higher percentage lesion extent in the gray matter (P < .001). Atrophy colocalized with focal cord lesions and correlated with pyramidal subscore (r ranging from -0.53 to -0.40; P < .001) and sensitive subscore (r ranging from -0.48 to -0.46; P = .001) of the Expanded Disability Status Scale. Participants without cord lesions had no cord atrophy. Conclusion In participants with neuromyelitis optica spectrum disorders, focal areas of spinal cord atrophy at MRI were topographically associated with lesions and correlated to motor and sensory disability. Participants without visible cord lesions had no atrophy. © RSNA, 2020 Online supplemental material is available for this article.

Due to the rarity of the association of esophageal and duodenal atresia, no consensus exists regarding the optimal treatment strategy. However, a staged approach is advised in order to reduce morbidities and improve survival. We report a case of a very preterm infant with combined esophageal and duodenal atresia, treated successfully with a staged approach. Treatment consisted in percutaneous radiologic gastrostomy placement prior to tracheoesophageal fistula ligation and esophageal anastomosis, and in delayed duodenal atresia repair. The use of the radiologic approach for gastrostomy placement proved to be minimally invasive, effective and without complications, even in a very preterm baby.

SARS-CoV-2 (Severe Acute Respiratory Syndrome, Coronavirus, type 2) is the virus responsible for the global pandemic of Coronavirus disease 2019 (COVID-19) that began in China in December 2019. The variability of nasal olfactory symptoms in pediatric patients is interlinked with possible warning signs, including respiratory, gastrointestinal, ocular, or dermatological symptoms. Skin findings in patients with COVID-19 can range from petechiae to papulovesicular rashes to diffuse urticaria and can be confused with rashes of non-COVID-19 conditions. These lesions typically appear early during COVID-19 and are thought to be secondary to viral replication or circulating cytokines. Herein, we discuss two pediatric cases, presenting with skin lesions, which tested positive for SARS-CoV-2, thus, briefly reviewing current literature for similar reports and related management. Although these lesions heal spontaneously in most cases, an adequate "targeted" therapeutic approach can shorten the time and the discomfort of the skin disease.

Background: Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as ‘textbook outcome’ (TBO). Methods: In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012–January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009–April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test. Results: The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005). Conclusion: Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS.

Objectives To validate imaging features able to discriminate neuromyelitis optica spectrum disorders from multiple sclerosis with conventional magnetic resonance imaging (MRI). Methods In this cross-sectional study, brain and spinal cord scans were evaluated from 116 neuromyelitis optica spectrum disorder patients (98 seropositive and 18 seronegative) in chronic disease phase and 65 age-, sex-, and disease duration-matched multiple sclerosis patients. To identify independent predictors of neuromyelitis optica diagnosis, after assessing the prevalence of typical/atypical findings, the original cohort was 2:1 randomized in a training sample (where a multivariate logistic regression analysis was run) and a validation sample (where the performance of the selected variables was tested and validated). Results Typical brain lesions occurred in 50.9% of neuromyelitis optica patients (18.1% brainstem periventricular/periaqueductal, 32.7% periependymal along lateral ventricles, 3.4% large hemispheric, 6.0% diencephalic, 4.3% corticospinal tract), 72.2% had spinal cord lesions (46.3% long transverse myelitis, 36.1% short transverse myelitis), 37.1% satisfied 2010 McDonald criteria, and none had cortical lesions. Fulfillment of at least 2 of 5 of absence of juxtacortical/cortical lesions, absence of periventricular lesions, absence of Dawson fingers, presence of long transverse myelitis, and presence of periependymal lesions along lateral ventricles discriminated neuromyelitis optica patients in both training (sensitivity = 0.92, 95% confidence interval [CI] = 0.84-0.97; specificity = 0.91, 95% CI = 0.78-0.97) and validation samples (sensitivity = 0.82, 95% CI = 0.66-0.92; specificity = 0.91, 95% CI = 0.71-0.99). MRI findings and criteria performance were similar irrespective of serostatus. Interpretation Although up to 50% of neuromyelitis optica patients have no typical lesions and a relatively high percentage of them satisfy multiple sclerosis criteria, several easily applicable imaging features can help to distinguish neuromyelitis optica from multiple sclerosis. ANN NEUROL 2019;85:371-384.

Background:Different subregional patterns of hippocampal involvement have been observed in diverse multiple sclerosis (MS) phenotypes.Objective:To evaluate the occurrence of regional hippocampal variations in clinically isolated syndrome (CIS) patients, their relationships with focal white matter (WM) lesions, and their prognostic implications.Methods:Brain dual-echo and three-dimensional (3D) T1-weighted scans were acquired from 14 healthy controls and 36 CIS patients within 2 months from clinical onset and after 3, 12, and 24 months. Radial distance distribution was assessed using 3D parametric surface mesh models. A cognitive screening was also performed.Results:Patients showed clusters of reduced radial distance in the Cornu Ammonis 1 from month 3, progressively extending to the subiculum, negatively correlated with ipsilateral T2 and T1 lesion volume. Increased radial distance appeared in the right dentate gyrus after 3 ( p Conclusion:Regional hippocampal changes occur in CIS, are more pronounced in patients converting to MS, and are modulated by focal WM lesions.

Background and aims: Brain white matter hyperintensities (WMHs) have been associated with an increased risk of ischemic stroke and considered as markers of brain ischemia. Progression of WMHs in asymptomatic patients with non-hemodynamically significant carotid plaque could represent a putative marker of plaque vulnerability. We prospectively evaluate progression and determinants of WMHs in this population. Methods: This prospective study included 51 asymptomatic patients with carotid stenosis

The preservation of a graft's aberrant left hepatic artery (LHA) during liver transplantation (LT) ensures optimal vascularization of the left liver but can also be considered a risk factor for hepatic artery thrombosis (HAT). In contrast, ligation of an aberrant LHA may lead to hepatic ischemia with the potential risk of graft dysfunction and biliary complications. The aim of this study was to prospectively analyze the impact on the surgical strategy for LT of 5 tests performed to establish whether an aberrant LHA was an accessory or a replaced artery, thus leading to the design of a decisional algorithm. From August 2005 to December 2016, 395 whole LTs were performed in 376 patients. Five parameters were evaluated to determine whether an aberrant LHA was an accessory or a replaced artery. On the basis of our decision algorithm, an aberrant LHA was ligated during surgery when assessed as accessory and preserved when assessed as replaced. A total of 138 anatomical variants of hepatic arterial vascularization occurred in 120/395 (30.4%) grafts. Overall, the incidence of an aberrant LHA was 63/395 (15.9%). The LHA was ligated in 33 (52.4%) patients and preserved in 30 (47.6%) patients. After a mean follow-up period of 50.9 ± 39.7 months, the incidence of HAT, primary nonfunction, early allograft dysfunction, biliary stricture or leaks, and overall survival was similar in the 2 groups. In conclusion, once shown to be an accessory, an LHA can be safely ligated without clinical consequences on the outcome of LT. Liver Transplantation 24 204-213 2018 AASLD.

Respiratory distress is a common presenting feature among newborns. Thorough clinical assessment and prompt investigation are required to ensure correct treatment and improve outcomes. Pneumothorax (PTX) is the most common of the air-leak disorders in neonates and is more frequently observed in low birth weight infants. Although it is one of the few treatable causes of respiratory distress in neonatal age, it is life-threatening and is associated with an increased risk of mortality and morbidity. Incidence increases in patients with concurrent lung disease or requiring mechanical ventilation. Furthermore, neonatal PTX can develop due to high transpulmonary pressure, generated at the onset of respiration. Chylothorax is rarer, but it represents the most frequent cause of pleural effusion in the neonatal period. Clinical features depend on the amount of chyle collected in the pleural space, ranging from asymptomatic to life-threatening conditions, requiring urgent treatment. Prognosis is much better when chylothorax is diagnosed after birth than when discovered in utero, because during fetal life pleural effusion can act as a space-occupying mass resulting in pulmonary hypoplasia.

The TRACER multicenter retrospective study aimed to collect data on treatment adherence in a real-life setting, in order to identify predictors of adherence at baseline.We recruited 384 relapsing-remitting (RR) multiple sclerosis patients with at least 12 months of use of RebiSmart®. This electronic device records the performed injections and assesses adherence as the percentage of 'not missing doses', through the connection to the iMed database. Subjects with at least 80% of completed doses at the 12 month of therapy were defined 'treatment adherents'.After 12 months, 89.3% of patients were adherent; 93.2% of patients aged 26-40 years at baseline were adherent (vs 79% of the ≤25 and 87.5% of the ≥41 year olds; p = 0.006). Furthermore, 90.5% of patients with a baseline Expanded Disability Status Scale (EDSS) score4 showed ≥80% adherence (vs 71.4% in those with EDSS score ≥4; p = 0.016). Fifty-four percent of the patients who were not adherent after 3 months were also not adherent after 12 months (OR 16.8; CI 95%:7.1-39.8).Patients aged 26-40 years and with an EDSS score4 at baseline were the most adherent. The status of 'treatment adherent' in the first 3 months was predictive of higher adherence in the long term.

Background Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration. Methods A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH). Results A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported. Conclusions This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

The pituitary gland can be involved in a variety of medical conditions, including metastatic tumors. Metastases to the pituitary gland, although absolutely rare, more commonly affect the posterior pituitary lobe and so frequently present with diabetes insipidus. We report on a 48-year-old male heavy smoker patient suffering from sudden onset of polyuria and persistent thirst. Laboratory results revealed central diabetes insipidus. Computed tomography (CT) scan of the brain showed a mass located in the sella turcica and in the suprasellar region. CT scan of the chest showed a mass in the right superior lobe with mediastinal lymphadenopathy, with bronchoscopy and biopsy features of pulmonary adenocarcinoma. The patient received radiotherapy on the pituitary gland and adjuvant chemotherapy, and as intrasellar and suprasellar mass decreased in size, urinary output was accordingly reduced. Therefore, is that in patients with risk factors for cancer and sudden onset of diabetes insipidus pituitary metastasis should be taken into account in differential diagnosis.

Background: At the beginning of every dermatopathy, including alopecia areata, one can frequently encounter the presence of a stressful event or situation. We have analyzed the fa

Liver transplant (LT) is considered the best curative treatment for patients with cirrhosis and hepatocellular carcinoma (HCC) within Milan criteria. The possibility to perform LT in HCC patients is limited by the liver grafts supply; indeed, the shortage of donors often leads to a long time on waiting list and then to dropout because of tumor progression. Bridging therapies are neo-adjuvant treatments given to patients on LT waitlist, with the aim to prevent tumor progression and to reduce dropout rate. Many bridging modalities have been proposed. The choice of each treatment is based on the characteristics of the patient, liver function, comorbidities and on the number, dimensions and localization of HCC. This review article describes several types of bridging therapies, focusing on the indications for different kind of patients.

Three children with tracheomalacia had tracheal reinforcement with free three-quarter circumference ring grafts of autologous cartilage taken from the costal margin. A low cervical manubrium-splitting approach gave excellent access to the anterior mediastinum and the intrathoracic trachea in two children. The first child, a neonate with oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF), had 11 grafts to support the whole of the trachea from the cricoid to the carina and never required a tracheostomy. For the first 5 years she had frequent pneumonic episodes and on one occasion bilateral pneumothoraces. These episodes and radiographic lung hyperinflation, attributed to distal bronchomalacia, have reduced spontaneously in frequency and severity. At 9 years of age she has a well-supported trachea with palpable cartilage rings in the cervical segment. The trachea has grown to approximately 75% of expected normal size for her age. Another child with tracheomalacia related to innominate-artery compression and who presented with 'dying episodes' was completely relieved and resumed a normal life without a tracheostomy following insertion of four grafts to the intrathoracic trachea. He remains well and symptom-free 8 months postoperatively. A third child had cartilage-graft reinforcement of the lower cervical trachea, including the tracheostomy site, to achieve tracheostomy closure at 16 months of age. Five years later he continues to have a well-supported trachea showing acceptable growth. However, he has ongoing evidence of tracheo-bronchomalacia presenting as expiratory wheezing, lung hyperinflation, and pneumonic episodes that are diminishing spontaneously with growth. Our experience, limited to three children, recommends primary tracheal reinforcement with autologous free costal-cartilage grafts for tracheomalacia in the neonate and young infant. This procedure and the anterior mediastinal approach are well-tolerated, providing instant tracheal support, removing the need for a tracheostomy, and allowing the child's rapid return to the family. Long-term follow-up, presently 9 and 5 years in two children originally presenting with OA and TOF, indicates adequate tracheal growth and an aesthetically acceptable appearance. It is relevant to prognosis that relief of the life-threatening tracheal component exposed the full extent of the bronchial cartilaginous weakness, which has significantly detracted from the quality of life for these two children with OA and TOF-related tracheomalacia.

The authors describe a case of hepatobiliary cystadenoma and its pathogenetic, histopathologic, and clinical aspects and point out its association with multiple hemangiomas.

A case of hemangiopericytoma of the neck is reported. Following excision of the mass, the patient is free of disease after 3 years. The authors review the literature and describe the pathologic features of this tumor.

The aim of this study was to evaluate the association between prepregnancy BMI, and adverse maternal and neonatal outcomes. In this retrospective cohort study 916 consecutive singleton gestations were included who gave birth between 1 January 2006 and 31 August 2006 at the Department of Obstetrics and Gynecology, University of Udine, Italy. Statistical analysis was performed using univaried logistic regression and measured by odds ratio. The obese patients had a statistically, significantly increased incidence of Caesarean section (OR = 2.17, p = 0.009). Women with overweight (OR = 2.43, p = 0.002) and obese weight (OR = 4.86, p

A case of intra-abdominal pulmonary sequestration associated with histological features of congenital cystic adenomatoid malformation (CCAM) of the lung is reported. The lesion consisted of a Stocker type II CCAM in which numerous striated muscle cells were present. A review of the literature of this rare combination of congenital pulmonary anomalies is presented.

Background/purpose The natural history of parenchymal lung lesions such as congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration (PS) has been altered by the advent of antenatal ultrasonography. Initial reports were characterized by a high (about 30%) incidence of adverse features (eg, hydrops) and a poor outcome and did not accord with our recent experience. The authors have reviewed the outcome of fetuses that had been diagnosed in a large tertiary referral fetal medicine unit with the aim of delineating current experience. The term cystic lung disease was used throughout to avoid unjustifiable histologic precision. Methods The scans of all fetuses that had been diagnosed with cystic lung disease between January 1995 and July 2001 were reviewed. The outcome of each pregnancy was established, and, where possible, all infants underwent appropriate investigations, including thoracic computed tomography (CT) scans. Results Sixty-seven fetuses had a cystic lung abnormality diagnosed from January 1995 to July 2001. The median (range) age at diagnosis was 21 (19 to 28) weeks. The lesion was right sided in 29 (43%), left in 36 (54%), and bilateral in 2 (3%); it was characterized as dominantly macrocystic in 27 (40%), microcystic in 35 (52%), and mixed in 5 (8%). Mediastinal shift was present in 30 fetuses (45%). Severe signs of fetal distress (eg, hydrops) were present in 5 fetuses (7%). Antenatal intervention was performed in 4 fetuses (thoraco-amniotic shunts [n = 3] and percutaneous intrauterine laser therapy [n = 1]). Sixty-four (96%) of the fetuses were born alive. There was 1 termination of pregnancy and 2 intrauterine deaths (all severe microcystic lesions). Forty-two infants (63%) underwent thoracotomy and appropriate excisional surgery at a median of 7.5 months (range, 1 day to 34 months). Two infants (which included the fetus having intrauterine laser therapy) died early in the postnatal period. Both were large microcystic lesions and had antenatal features of severe fetal distress. Twelve infants were investigated in the postnatal period but did not undergo surgery. Ten infants were not appropriately investigated or were lost to follow-up. Histologic examination showed definitive diagnostic features of CCAM (n = 25) or PS (n = 6). Other lesions with hybrid features of both were also seen (n = 11). There was a degree of correlation between antenatal ultrasound features (size of cyst [ P = .03], in-utero behavior [ P = .06], mediastinal shift [ P = 0.05]) and the need for surgery but not with the final histologic diagnosis. Surgical excision was required in 45% of lesions showing late-gestation "resolution." Conclusions Antenatally diagnosed "cystic lung disease" has an excellent prognosis in the absence of signs of severe fetal distress. The need for surgery should be based on appropriate postnatal investigations (eg, CT scans), rather than on antenatal behavior.

Sonographic and operative findings in both groins of 23 infants presenting with a unilateral inguinal hernia were compared in a prospective study. Ultrasound accurately confirmed the presence of a hernia on the affected side in all infants but provided no useful additional diagnostic information. Ultrasound examination of the unaffected side was less accurate. Surgical exploration revealed the presence of a patent processus vaginalis (PPV) in 18 cases and its absence in five. Ultrasound was found to be accurate in only 15 out of the 23 cases with four false positive and four false negative results. This yielded an accuracy of 65%, a sensitivity of 78% and a specificity of only 20%. It is concluded that ultrasound cannot at present be used alone to plan the management of the contralateral groin, especially as the majority of children who do have a PPV will never develop an inguinal hernia.

We have investigated the structure and the dehydration/rehydration process of Tobermorite-like Calcium Silicates Hydrates (CSH) by using High Resolution Transmission Electronic Microscopy (HRTEM) and a new in-situ temperature and pressure controlled X-Ray Diffraction set up. CSH samples were synthesized with a Calcium/Silicium ratio 0.9 following a procedure which allows to produce model compounds of cement: a calcio-silicate layered structure with an interlamellar spacing of 14 A. Atomic scale resolved TEM data confirm the layered structure of Tobermoritic CSH: in particular we were able to show directly for the first time the silicate chain alignment and measure the so-called dreierketten pattern within the silicate chains. A newly developed X-Ray diffraction cell which allows to control temperature and pressure is used to study the dehydration/rehydration of Tobermorite and Ca-Montmorillonite. In the particular case of Tobermorite, the variations of the interlayer distance, as measured with the new in-situ X-Ray cell at atmospheric pressure and upon increasing temperature, are very close to those obtained with a standard ex-situ X-Ray apparatus coupled to a Controlled Rate Thermal Analysis heating technique (which allows for quasi-equilibrium conditions). This validates the (T,P) in-situ X-Ray cell: in agreement with literature, we have clearly identified two structural transitions upon heating under atmospheric pressure : (14 A -11 A) and (11 A − 9.5 A) at T = 330 K and 510 K respectively. Furthermore, we demonstrate that the first structural transition of Tobermorite upon dehydration is irreversible by contrast to that observed for Ca-Montmorillonite clay.

The first neonatal case of a hemangioma of the diaphragm in a neonate is reported. After 25 months the patient is well with no signs of recurrence. Diaphragmatic tumors should be considered in the differential diagnosis of neonatal thoracic masses. J Pediatr Surg 36:E21. Copyright © 2001 by W.B. Saunders Company.

In this study we characterized calcitonin (CT) receptors in human neuroblastoma IMR 32 cells. Saturation binding assays indicated that [125I]-human CT bound with high affinity to IMR 32 cell membranes (K(d) = 253.6 pM; Bmax = 3.84 fmol/ mg protein). In competition binding studies, human adrenomedullin displayed high affinity for these sites (IC50 = 30 nM) whereas human alpha calcitonin-gene related peptide (alphaCGRP; IC50 = 145 nM) and human amylin (IC50 = 415 nM) showed lower affinity. These peptides increased cAMP levels in viable cells; the relative potencies were: human CT > human adrenomedullin > human cCGRP > or = human amylin. The expression of mRNA coding for the published sequences of the human calcitonin receptor and of the human calcitonin receptor-like receptorwas evaluated by reverse transcriptase-polymerase chain reaction. Electrophoretic analysis did not confirm the occurrence of mRNA coding for the above mentioned receptors in these cells. This study suggests the presence of a novel, putative CT receptor in IMR 32 cells.

A 1.8 kg chromosomally normal child was suspected antenatally to have a cloacal anomaly and oligohydramnios. Both parents had a chromosome 9 inversion (inv [9] [p11 q13]). Postnatal study showed a high confluence of the urinary, genital and intestinal tracts. Because of prematurity, a right colostomy was performed on a short colon, but the genitourinary tract was not drained. Poor weight gain, urinary tract infection and septicaemia led to a one-stage reconstruction at 5 months of age and a weight of 3.2 kg. Follow-up although short at 15 months, is encouragingly suggestive of urinary and faecal continence. The vagina is patent. This paper considers concepts in cloacal management and submits for evaluation an alternative surgical plan to the presently almost exclusively accepted posterior sagittal approach of Pena and De Vries.

The authors present a case of prenatal diagnosis of cloacal anomaly, characterized by the presence of oligohydramnios and cystic pelvic mass with changing features during observation. Postnatal study confirmed the presence of a recto-cloacal fistula, with a high confluence of the urinary, genital and intestinal systems. Both parents had a chromosome 9 inversion (p11q13), but the child was chromosomally normal.

Gastric carcinoma represents only 0.05% of malignant paediatric gastrointestinal tumours. This condition is associated with a poor prognosis because its rarity and non-specificity of the symptoms usually delay its diagnosis. The authors present a 16-year-old girl with a poorly differentiated gastric carcinoma (signet-ring-cell type) with bilateral ovarian metastases who died of peritoneal carcinomatosis despite extensive surgery and chemotherapy. The epidemiological, clinical, and pathological features of gastric carcinoma in childhood are discussed.

Background Anti-EGFR chemotherapy drugs cause skin toxicity due to high numbers of receptors in keratinocytes of the epidermis, sebaceous glands, epithelial hair follicles. Cetuximab treatment for metastatic colorectal cancer causes rash (1st to 4th degree), xerosis and nail changes. When the symptoms are severe (3rd degree rash extended to 50% of the body surface) treatment must be interrupted and, if symptoms don’t subside, permanently discontinued. High incidence of rash makes it necessary to reduce the severe symptoms to prevent treatment disruptions. Clinical evidence suggests that prophylactic use of vitamin K prevents and reduces cetuximab skin toxicity. Purpose To support the patient in managing cetuximab dermatological toxicities to allow treatment to continue. Materials and methods In the Oncology departments of Azienda Sanitaria Provinciale, Siracusa, Italy, a cream containing urea and vitamin K1 (0.1%) is supplied to the patient after each chemotherapy treatment. The cream is accompanied by specific instructions, prepared by the Pharmacovigilance team, (apply 2 times a day on the face and chest) and preventive indications: use sunscreen, moisturise the skin with emollient creams without alcohol or tocopherol acetate, avoid tight shoes, prevent beard growth, don’t use electric shavers. Results From September 2012 to February 2013, 12 patients treated with cetuximab received the cream and behavioural instructions. There were 4 women, 8 men, mean age 63, no patients used antibiotic creams. All patients had a peak of skin toxicity around the 3rd week of treatment, with a rash of 70% (moderate); use of the cream persuaded the rash to gradually reduce, limiting toxicity to 1st degree. Conclusions The information provided to patients meant that nobody suspended treatment. 80% of patients reported that the cream had reduced the pain and itching. Women demonstrated greater compliance with the instructions provided. The results show that the proper information can prevent predictable adverse drug events, ensuring continuity of care. No conflict of interest.

Background Psoriasis is a chronic disease that significantly affects patients’ quality of life (QoL). Biological drugs interfere in the immunological processes that trigger and support psoriasis and, therefore, prove effective in its treatment. Purpose To analyse the adherence, tolerability and the short- and long-term effectiveness of biological drugs in patients with moderate to severe plaque psoriasis. To evaluate how the increase in QoL perceived by the patient can be related to treatment adherence and remission of the disease. Materials and methods Retrospective study of all the patients with psoriasis treated with biological drugs from March 2012. Clinical efficacy in the treatment was determined by the Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI) scores before and during the treatment. To calculate the adherence we used a record of prescriptions dispensed over a period of six months. We used the formula:% adherence = n. of units dispensed/n. of units theoretically needed ×100. Results 41 treatment-naive patients, 64.2% men. Administered drugs were: ustekinumab (78%) adalimumab (17%) and etanercept (5%). 25 patients achieved least 75% improvement (PASI75) in the disease between weeks 12–18 of treatment; 15 patients had already reached PASI75 within 12 weeks. The median baseline DLQI score was 16.97 and the median DLQI score during the treatment was 1.34. No patients developed significant adverse reactions to the treatment (1% headache, 5% temporary redness at the injection site) and there was only one therapeutic switch (for lack of efficacy). The adherence was very high: 82% of patients had adherence > 95%, 17% adherence between 60% and 80% and only 1% Conclusions The biological drugs demonstrated rapid onset of action and high effectiveness, safety and a great improvement in the quality of life in patients with moderate to severe plaque psoriasis. The therapeutic adherence was related to the increase of QoL. The involvement of the patient is essential for cost-effective management of disease. No conflict of interest.

Background Rheumatic diseases are chronic diseases with a high cost. New drugs are the anti-TNF inhibitors adalimumab (A) and etanercept (E). The Infectious Diseases Unit of Umberto I Hospital, Syracuse, Italy, was identified as a Regional Centre for the prescription of biologicals. Furthermore, D.A. 0264/16.02.2011 authorised a regional Treatment Plan (PT) by which these drugs are to be dispensed, health care costs and appropriateness of prescription monitored. Purpose To evaluate the consequences of the PT and the effects of A and E on PCR values and number of joints involved (NJI). Materials and Methods The PT is annual and consists of two sections containing: 1. Demographic features, diagnosis, prior therapy with any failures, clinical and laboratory data (NJI, PCR), date of first prescription and dose of biological agent. 2. Follow-up at 6 months, with the assessment of therapeutic efficacy (excellent, good, adequate, inadequate), side effects and updated clinical data. Results Overall, 56 PTs were examined: 32.7% of patients (mean±SD age: 50.7 ± 12.1) taking A and 67.3% (mean±SD age: 54.1 ± 13.7) taking E. In subjects treated with A the PCR values were: 0.5 ± 1.0 g/dl (baseline) and 0.1 ± 0.2 g/dl (6 months); NJI were: 11.9 ± 7.2 (baseline) and 10.1 ± 9.2 (6 months). In subjects treated with E, the PCR values were: 2.5 ± 6.2 g/dl (baseline) and 1.2 ± 3.9 g/dl (6 months); NJI were: 15.4 ± 10.8 (baseline) and 8.2 ± 8.2 (6 months). Conclusions The use of A and E has been shown to improve the clinical condition of the patients. Furthermore, the use of the PT has allowed all patients with rheumatic diseases in the province of Syracuse to access a dedicated health facility, reducing their physical/economic inconvenience. A significant economic benefit was recorded for the ASP 8, not having to refund the costs of flow-compensation activation (File F). No conflict of interest.

Background The increased prevalence of chronic diseases, including diabetes, requires a critical review of models of care and the introduction of new strategies of intervention. Health Literacy (HL) is a tool for educating patients in order to increase their understanding of medical information and thus educate them about their treatment. Diabetic patients are educated to manage the disease in accordance with the perceived needs for better compliance with drug treatment and its outcomes. Purpose To adopt a diagnostic-therapeutic protocol shared between the diabetologist and the pharmacist, and to promote the active inclusion of people with diabetes in the course of their treatment. The secondary aim was to activate an information, monitoring and evaluation system through clinical indicators. Materials and Methods Overall, 70 patients (32 women and 38 men) aged between 35 and 87 used the HL tool themselves and were monitored in this study. Ten patients were treated with insulin + oral hypoglycaemic agents (OHA), 53 with OHA alone and 7 with insulin alone. All patients received a sheet containing clear instructions for the proper management of the disease and treatment. The patient underwent monthly clinical monitoring, and were urged to adopt the right behaviours at home: frequent monitoring of blood glucose, a healthy and balanced diet, moderate activity and preventive screening for diabetes complications. Results Values of blood glucose test, HbA1c, body weight and waist circumference were reduced by 42.2%, 15.2%, 6% and 3.3%, respectively. Compliance was improved in 30% of patients (screening tests carried out on time). Overall patient satisfaction was high. Conclusions Our experience confirms that the multidisciplinary HL tool is useful for improving the communication between doctor/pharmacist and the patient. It is important to consider that the patient learning should focus on simple terms and on the knowledge of complications, in order to obtain good management of diabetes. No conflict of interest.