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Background: The International Code of Marketing of Breast-Milk Substitutes is a global public health policy aiming to protect breastfeeding from the influence of human-milk substitutes marketing. Brazil is one of the few countries substantially implementing it. Most countries adopted selected provisions, including Portugal., Research Aim: To explore whether Brazilians' perspectives about breastfeeding intention and practice are influenced by human-milk substitutes marketing upon migration to Portugal., Methods: A qualitative, prospective, cross-sectional survey design was conducted in Brazil and Portugal (2018-2019). Qualitative semi-structured interviews were performed with native ( n = 16) and immigrant ( n = 15) Brazilians. Women aged 18 or above, mothers of 0-12 month infants, and without contraindications to breastfeed, were eligible for the study. Heterogeneity sampling was employed based on socioeconomic status and infants' age. Content analysis was conducted using NVivo., Results: Brazilian immigrants were more aware of the potential negative influence of human-milk substitutes marketing than natives. Sociocultural factors contributed to Brazilian immigrants being less permeable to the influence of human-milk substitutes marketing in the host country, where a less protective breastfeeding environment was perceived., Conclusions: Sociocultural factors including breastfeeding promotion strategies and a strong breastfeeding culture in the home country appear to play a protective role on breastfeeding intention and practice among Brazilians migrating to Portugal.

Background: Intravenous administration of zidovudine (ZDV) during labour is a key step for vertical HIV transmission (VT) prevention, but there is no evidence of benefit when maternal HIV-RNA at delivery is <50 copies/mL. The aim of this study is evaluating the appropriateness of intrapartum ZDV use in Italy., Methods: Observational study including mother-infant pairs with perinatal HIV exposure during 2002-2019, enrolled in the Italian Register for HIV Infection in Children. Univariable and multivariable logistic regression were used to evaluate factors associated with VT., Results: A total of 3,861 infants, born from 3,791 pregnancies were included. The frequency of ZDV use was 79.9%, 92.1%, 93.7% and 92.8% when HIV-RNA was not available, ≥400 copies, between 50 and 399 copies, and <50 copies/mL. Thirty-three out of 3861 (0.85%) infants were subsequently diagnosed with HIV, 25/3861 (0.6%) of them born to mothers receiving intrapartum ZDV, and 31 (93.9%) to mothers with HIV-RNA ≥50 copies/mL or not available. In women with HIV-RNA < 50 copies/mL, ART discontinuation during pregnancy was the strongest risk factor for VT (odds ratio, OR, 23.1, 95%CI 2.4-219.3), while a higher gestational age (OR 0.6, 95%CI 0.4-0.8) and PEP administration to the newborn (aOR 0.004, 95%CI <0.0001-0.4) were protective factors. Intrapartum ZDV administration did not influence the final outcome in this group., Conclusions: In ART era, more transmission events may occur in utero, limiting value of intrapartum ZDV, particularly for women with suppressed HIV-RNA load. More attention to the HIV-RNA testing of mothers before delivery may avoid unnecessary ZDV use., Competing Interests: Declaration of Competing Interest None of the authors declare conflicts of interest relevant to the present study., (Copyright © 2022. Published by Elsevier Ltd.)

Summary: The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. Currently there are two commonly used surgical procedures: middle third patellar tendon grafts (bone-patellar tendon-bone: BTB) and semitendinosus autografts or semitendinosus combined with gracilis tendon autografts (ST/G). Purpose. The aim of this study is to compare the rehabilitation results over time of amateur sportsmen who have undergone anterior cruciate ligament (ACL) reconstruction surgery by means of one of the two most commonly used procedures: middle third patellar tendon grafts (bone-patellar tendon-bone: BTB) and semitendinosus and gracilis tendon autografts (ST/G). Method. 30 subjects divided into two groups, (15 BTB and 15 ST / G), were evaluated during rehabilitation and at three follow-up periods (16 weeks, 24 weeks, 2 years). Evaluation involved clinical examination, isokinetic tests, and functional rating scales: Lysholm and IKDC. Results. The clinical evaluation resulted in the following mean values: the value of the Lysholm score was 78 in both group at 16 weeks, 91 in group A and 94 in group B at 24 weeks, 98 in group A and 99 in group B at 2 years; the value of the IKDC score was 14 in group A and 15 in group B at 16 weeks, 12 in group A and 14 in group B at 24 weeks, 14 in group A and 15 in group B at 2 years. No major complications occurred during rehabilatation Conclusions. Subjects in both groups showed good neoligament stability up to the 24-week follow up. At the 2-year follow-up the subjects of group B showed poor neoligament stability that prevented the return to the previous level of sporting activity; all the subjects with high intensity sports activity needed a greater muscle strengthening. No statistically significant differences between the two groups are seen., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by GIMLE.)

(1) Background: Quantitative CT analysis (QCT) has demonstrated promising results in the prognosis prediction of patients affected by COVID-19. We implemented QCT not only at diagnosis but also at short-term follow-up, pairing it with a clinical examination in search of a correlation between residual respiratory symptoms and abnormal QCT results. (2) Methods: In this prospective monocentric trial performed during the "first wave" of the Italian pandemic, i.e., from March to May 2020, we aimed to test the relationship between %deltaCL (variation of %CL-compromised lung volume) and variations of symptoms-dyspnea, cough and chest pain-at follow-up clinical assessment after hospitalization. (3) Results: 282 patients (95 females, 34%) with a median age of 60 years (IQR, 51-69) were included. We reported a correlation between changing lung abnormalities measured by QCT, and residual symptoms at short-term follow up after COVID-19 pneumonia. Independently from age, a low percentage of surviving patients (1-4%) may present residual respiratory symptoms at approximately two months after discharge. QCT was able to quantify the extent of residual lung damage underlying such symptoms, as the reduction of both %PAL (poorly aerated lung) and %CL volumes was correlated to their disappearance. (4) Conclusions QCT may be used as an objective metric for the measurement of COVID-19 sequelae.

This study was designed to determine the utility of procalcitonin (PCT) and C-reactive protein (CRP) as predictors of Gram-negative bloodstream infection (GN-BSI) in hematological febrile outpatients at the time of the emergency unit admission. Overall, 286 febrile episodes, which included 42 GN-BSI (16%), were considered. PCT levels at patient admission were statistically higher in GNB-BSI when compared to Gram-positive bacteria BSI (median 4.06 ng/ml (range 1.10-25.04) vs 0.88 ng/ml (0.42-10), p<0.03) and to all other fever etiologies. For CRP, differences within fever etiologies were less profound but statistically significant, except for GN-BSIs vs GP BSIs (p=0.4). ROC analysis of PCT showed that an AUC of 0.85 (95%CI 0.79-0.95) discriminated GN-BSI from all other fever etiologies, with a best cut-off of 0.5 ng/ml, a negative predictive value (NPV) of 98%, and a negative likelihood ratio (negLR) of 0.1. ROC analysis of CRP showed an AUC of 0.67 (95%CI 0.53-0.81) with a best cut-off of 6.64 mg/dl, a NPV of 94%, and a negLR of 0.33. This study confirms that 0.5 ng/ml represents the PCT best cut-off to differentiate the cause of fever and rule out a GN-BSI in febrile hematologic outpatients at the time of the emergency unit admission. Therefore, introducing PCT testing could be a valid measure in order to tailor a more precise prompt antimicrobial therapy to the febrile outpatient while waiting for blood culture results., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Coronavirus disease (COVID-19) is characterized by different clinical pictures that may require prolonged hospitalization and produce disabilities challenging the recovery of previous independence., Aim: The aim is to evaluate the impact of an early assisted rehabilitation program on the functional status of an acutely hospitalized population affected by COVID-19., Design: Single-institution retrospective longitudinal study., Setting: Inpatient intensive care units (ICU) and medical care units (MCU)., Population: Acute COVID-19 patients., Methods: General information was collected; age-adjusted Charlson Comorbidity Index was used for comorbidities. Duration of hospital stay, the length of stay in ICU and/or MCU, the length of the rehabilitative treatment, and the destination at the discharge were collected. Evaluation was performed when patients were clinically stable (T0), and at hospital discharge (T1); for subjects enrolled in ICU functional status was assessed at the time of transfer to the MCU. Muscle strength of the four limbs was measured with the Medical Research Council (MRC) sum-score. Functional status was assessed using the 3-item Barthel Index (BI-3) and the General Physical Mobility Score (GPMS). Early assisted-tailored rehabilitation protocol was applied in ICU and in MCU: the aims were the maintenance (or recovery) of the range of motion and of the strength and the recovery of sitting/standing position and gait., Results: We evaluated 116 patients (mean age 65, SD 11) (65% male), 68 in ICU (mean age 60, SD 10), 48 in MCU (mean age 73, SD 9). At discharge, BI-3 and GPMS significantly improved in both ICU (P<0.001) and MCU (P<0.001) subgroups of patients. MRC sum-score significantly improved in ICU patients (P<0.001). Patients hospitalized in ICU had a significantly longer hospital stay. At discharge, patients admitted to the ICU reach a functional state that is close to that of patients admitted to the MCU., Conclusions: The results suggest that an early assisted rehabilitation program may be helpful in improving the short-term functional status of an acutely hospitalized population affected by COVID-19, with discharge at home of 48% CLINICAL REHABILITATION IMPACT: this study focuses on a functional assessment method to be used to identify the rehabilitation needs and verify the results of an early rehabilitation protocol applied to the acute COVID-19 patient admitted to ICU and MCU.

Background: SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents who are less susceptible to adverse clinical outcomes and are often asymptomatic., Objectives: We conducted this prospective multicentre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return to play., Methods: Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting ECG, echocardiogram and exercise ECG testing. Further investigations were performed in cases of abnormal findings., Results: A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%) and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation was found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return to play was achieved after complete clinical resolution., Conclusions: The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: In diabetic patients, a blunted left ventricular contractile reserve (LVCR) and/or a reduced coronary flow velocity reserve (CFVR) identify patients at higher risk in spite of stress echocardiography (SE) negative for ischaemia. Cardiac autonomic dysfunction contributes to risk profile independently of inducible ischaemia and can be assessed with heart rate reserve (HRR). We sought to assess the added prognostic value of HRR to LVCR and CFVR in diabetic patients with non-ischaemic SE., Methods and Results: Six-hundred and thirty-six diabetic patients (age 68 ± 9 years, 396 men, ejection fraction 58 ± 10%) with sinus rhythm on resting electrocardiogram underwent dipyridamole SE in a two-centre prospective study with assessment of wall motion, force-based LVCR (stress/rest ratio, normal value > 1.1), CFVR of the left anterior descending coronary artery (stress/rest ratio, normal value >2.0), and HRR (stress/rest ratio, normal value >1.22). All-cause death was the only considered endpoint. During a median follow-up of 39 months, 94 (15%) patients died. Independent predictors of death were abnormal CFVR [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.0-2.52, P = 0.05], reduced LVCR (HR 1.76, 95% CI 1.15-2.69, P = 0.009), and blunted HRR (HR 1.92, 95% CI 1.24-2.96, P = 0.003). Eight-year death rate was 9% for patients with triple negativity (n = 252; 40%), 18% for those with single positivity (n = 216; 34%), 36% with double positivity (n = 124; 19%), and 64% for triple positivity (n = 44; 7%) (P < 0.0001)., Conclusion: Diabetic patients with dipyridamole SE negative for ischaemia still may have a significant risk in presence of an abnormal LVCR and/or CFVR and/or HRR, which assess the underlying myocardial, microvascular, and cardiac autonomic dysfunction., Clinical Trials: Gov Identifier NCT 030.49995., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Early start of highly active antiretroviral therapy (HAART) in perinatally HIV-1 infected children is the optimal strategy to prevent immunological and clinical deterioration. To date, according to EMA, only 35% of antiretroviral drugs are licenced in children < 2 years of age and 60% in those aged 2-12 years, due to the lack of adequate paediatric clinical studies on pharmacokinetics, pharmacodynamics and drug safety in children., Methods: An observational retrospective study investigating the rate and the outcomes of off-label prescription of HAART was conducted on 225 perinatally HIV-1 infected children enrolled in the Italian Register for HIV Infection in Children and followed-up from 2001 to 2018., Results: 22.2% (50/225) of included children were receiving an off-label HAART regimen at last check. Only 26% (13/50) of off-label children had an undetectable viral load (VL) before the commencing of the regimen and the 52.0% (26/50) had a CD4 + T lymphocyte percentage > 25%. At last check, during the off label regimen, the 80% (40/50) of patients had an undetectable VL, and 90% (45/50) of them displayed CD4 + T lymphocyte percentage > 25%. The most widely used off-label drugs were: dolutegravir/abacavir/lamivudine (16%; 8/50), emtricitbine/tenofovir disoproxil (22%; 11/50), lopinavir/ritonavir (20%; 10/50) and elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide (10%; 10/50). At logistic regression analysis, detectable VL before starting the current HAART regimen was a risk factor for receiving an off-label therapy (OR: 2.41; 95% CI 1.13-5.19; p = 0.024). Moreover, children < 2 years of age were at increased risk for receiving off-label HAART with respect to older children (OR: 3.24; 95% CI 1063-7.3; p = 0.001). Even if our safety data regarding off-label regimens where poor, no adverse event was reported., Conclusion: The prescription of an off-label HAART regimen in perinatally HIV-1 infected children was common, in particular in children with detectable VL despite previous HAART and in younger children, especially those receiving their first regimen. Our data suggest similar proportions of virological and immunological successes at last check among children receiving off-label or on-label HAART. Larger studies are needed to better clarify efficacy and safety of off-label HAART regimens in children, in order to allow the enlargement of on-label prescription in children., (© 2022. The Author(s).)

Aims: Systematic pre-participation screening of subjects practicing sports activity has the potential to identify athletes at risk of sudden cardiac death. However, limited evidence are present concerning the yield of echocardiography as a second-line exam in athletes with abnormal pre-participation screening., Methods: Consecutive athletes were screened (2011-2017) in a community-based sports medicine center in Tuscany, with familial history, physical examination and ECG. Patients with abnormal/>1 borderline ECG findings, symptoms/signs of cardiovascular diseases, cardiovascular risk factors or family history of juvenile/genetic cardiac disease underwent echocardiography., Results: A total of 30109 athletes (age 21 [15;31]) were evaluated. Of these, 6234 (21%) were aged 8-11 years, 18309 (61%) 12-18 years, 4442 (15%) 19-35 years, 1124 (4%) >35 years. A total of 2569 (9%) athletes were addressed to echocardiography. Referral rates increased significantly with age (5% in preadolescents to 38% in master athletes, P< 0.01). Subclinical heart diseases were found in 290/30109 (0.8%) and were common >35 years (135/1124, 11%), but rare at 19-35 years (91/4442, 2%), very rare <18 years (64/24 543, 0.2%; P< 0.01). Seventy-four (0.3%) athletes were disqualified because of the structural alterations identified, 29 (0.1%) with cardiac structural diseases at risk for sudden death., Conclusions: Italian community-based pre-participation screening showed an age-dependent yield, with a three-fold increase in referral in athletes >35 years. Subclinical structural abnormalities potentially predisposing to sudden death were rare (0.01%), mostly in post-pubertal and senior athletes. Age-specific pre-participation screening protocols may help optimize resources and improve specificity., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Introduction: Lifelong benefits of breastfeeding are far-reaching. However, optimal breastfeeding practices may be negatively affected by the marketing of different forms of breast milk substitutes. In addition, whether market factors have a different impact on migrants' breastfeeding practices when compared to natives has been poorly investigated. Objectives: Our study's aims are (1) to assess the effect of market factors on breastfeeding discontinuation (any and exclusive), (2) comparing migrant and native women. Methods: A longitudinal study was conducted within baMBINO, a nationwide project on perinatal health among migrant women in Portugal. Our final sample included 1,251 migrants and 1,150 natives recruited between April 2017 and March 2019 in 32 public maternities. Cox regression analysis was performed, adjusting for important confounders, and interactions were tested. Results: Market factors were associated with any and exclusive breastfeeding discontinuation. Participants receiving free formula samples from a health professional were more likely to stop exclusive breastfeeding (adjusted hazard ratios [a HR ] = 1.37, 95% confidence intervals [95% CI] = 1.13-1.66, p  = 0.002). Reporting exposure to formula discounts was associated with discontinuation of exclusive (a HR  = 1.22, 95% CI = 1.09-1.38, p  = 0.001) and any breastfeeding (a HR  = 1.21, 95% CI = 1.00-1.46, p  = 0.046). No interactions were found between being migrant and exposure to market factors. Conclusions: Market factors influence discontinuation of any and exclusive breastfeeding. The impact of marketing does not differ between native and migrant women.

Background: Combined antiretroviral therapy (cART) has been associated with a steep decrease in mortality and morbidity in HIV-1 infected children. New antiretroviral molecules and drug classes have been developed and the management of HIV-infected children has improved, but recent data on survival are limited. Methods: An observational retrospective study investigating changes in mortality and morbidity was conducted on 1,091 perinatally HIV-1 infected children enrolled in the Italian Register for HIV Infection in Children and followed-up from 2001 to 2018. Results: Three hundred and fifty-four (32%) AIDS events and 26 (2%) deaths occurred overtime. Mortality rates decreased from 0.4/100 person-years in 2001-2006 to 0.27/100 person-years in 2007-2012 and 0.07/100 person-years in 2013-2018. Notably, 92% of the dead children were born in Italy, but only 50% were followed-up since birth or within three months of age. Seventy three percent of children had started cART at age ≥6 months; 23% were treated for <30 days before death. B and C clinical events progressively decreased ( P < 0.0001). Opportunistic infections significantly decreased over time, but still were the most common events in all the periods (6.76/100 person-years in 2013-2018). In the last period, severe bacterial infections were the most common ones. Cancer rates were 0.07/100; 0.17/100; 0.07/100 person-years in the three periods, respectively. Conclusions: Progressive reductions both in mortality and in rates of class B and C clinical events and OIs have been observed during the cART era. However, deaths were still registered; more than half of dead children were enrolled after birth and had belatedly started cART., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Chiappini, Larotonda, Lisi, Giacomet, Erba, Bernardi, Zangari, Di Biagio, Taramasso, Giaquinto, Rampon, Gabiano, Garazzino, Tagliabue, Esposito, Bruzzese, Badolato, Zanaboni, Cellini, Dedoni, Mazza, Pession, Giannini, Salvini, Dodi, Carloni, Cazzato, Tovo, de Martino and Galli.)

Background: Hemostatic abnormalities have been described in COVID-19, and pulmonary microthrombosis was consistently found at autopsy with concomitant severe lung damage., Methods: This is a retrospective observational cross-sectional study including consecutive patients with COVID-19 pneumonia who underwent unenhanced chest CT upon admittance at the emergency room (ER) in one large academic hospital. QCT was used for the calculation of compromised lung volume (%CL). Clinical data were retrieved from patients' files. Laboratory data were obtained upon presentation at the ER., Aim: The aim of this study was to evaluate the correlation between hemostatic abnormalities and lung involvement in patients affected by COVID-19 pneumonia as described using computer-aided quantitative evaluation of chest CT (quantitative CT (QCT))., Results: A total of 510 consecutive patients (68% males), aged 67 years in median, diagnosed with COVID-19 pneumonia, who underwent unenhanced CT scan upon admission to the ER, were included. In all, 115 patients had %CL > 23%; compared to those with %CL < 23%, they showed higher levels of D-dimer, fibrinogen, and CRP, greater platelet count, and longer PT ratio. Via multivariate regression analysis, BMI ≥ 30 kg/m 2 , D-dimer levels > 500 ng/mL, CRP > 5.0 ng/mL and PT ratio > 1.2 were found to be independent predictors of a %CL > 23% (adjusted odds ratios (95% confidence intervals): 2.1 (1.1-4.0), 3.1 (1.6-5.8), 2.4 (1.3-4.5), and 3.4 (1.4-8.5), respectively)., Conclusions: Hemostatic abnormalities in patients affected by COVID-19 correlate with the severity of lung injury as measured by %CL. Our results underline the pathogenetic role of hemostasis in COVID-19 pneumonia beyond the presence of clinically evident thromboembolic complications.

Summary: Haemophilia in its most severe clinical form can lead to alterations in the physical and psychosocial state with important repercussions on the quality of life. Purpose. A retrospective study was conducted to highlight the impact of haemophilic arthropathy on quality of life. Materials. We considered 25 patients, with a mean age of 42 years (min 17 - max 71) with haemophilia A, 18 had the severe clinical form (72%). The WFH Physical Examination Score, specific for haemophilia, was used for joint function; the joints examined were: knee, ankle, hip and elbow. To assess the quality of life, two generic self-filling questionnaires were used, SF-36 and the EQ 5D. Results. Significant statistical values have shown that arthropathy affects the SF-36 domain of general health and the subjective well-being EQ-VAS. Conclusions. In the treatment of haemophilic arthropathy, prevention is essential, understood both as a prophylactic medical therapy and as a physiotherapeutic treatment in order to maintain or improve joint function and at the same time play a fundamental role in improving the quality of life of patients., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by GIMLE.)

Background: Early breastfeeding practices are important determinants of later breastfeeding behaviors and can be influenced by multiple factors. Despite the Baby-Friendly Hospital Initiative reported positive influence on breastfeeding initiation, its influence on the association between maternal country of birth and first day in-hospital breastfeeding has not been examined., Research Aims: To determine (1) if association between maternal country of birth and first day in-hospital exclusive breastfeeding exists in Portugal and (2) if any association is affected by giving birth in a Baby-Friendly Hospital., Methods: Data were drawn from baMBINO-a longitudinal, 2017-2019 nationwide study designed to assess the perinatal health and healthcare experiences of migrant and native Portuguese women. Data from participants ( N = 5,340) were collected during their hospital stay from 32 maternity units. Missing data were handled through multiple imputation. After stratifying by Baby-Friendly Hospital Initiative accreditation, a multivariate logistic regression was performed., Results: First day in-hospital exclusive breastfeeding rates were high among both migrant and native participants (89.2% vs. 87.4%). Migrants were more likely to exclusively breastfeed when compared to natives ( OR = 1.19, 95% CI [1.00, 1.41]). In non-Baby-Friendly Hospitals, a positive association was found between participants from Eastern European countries (a OR = 2.46, 95% CI [1.27, 4.78]) and first day in-hospital exclusive breastfeeding. In accredited hospitals, maternal country of birth did not influence exclusive breastfeeding during the first 24 hr., Conclusions: The Baby-Friendly Hospital Initiative attenuates differences between migrant and native participants, promoting optimal breastfeeding practices among natives.

Spondylodiscitis (SD) is the concurrent infection of the intervertebral disc and the adjacent vertebral bodies. Currently, there is a substantial lack of structured reviews about this topic. The aim of this study was to systematically review the available literature in order to determine the main features of pediatric SD. A systematic search of MEDLINE database was performed, according to the PRISMA guideline recommendations. Clinical features, laboratory data, radiological signs, treatments strategies, and outcomes were summarized. Studies' quality assessments were performed using the JBI Critical Appraisal Checklists. A total of 35 retrospective studies were analyzed and 340 children were identified. The most frequently affected age class was 0.5-4 years. The most affected site was the lumbar spine. The most commonly reported symptoms were back pain (37.97%) and refusal to walk/to stand/to sit (49.79%). The most frequently identified pathogen was Staphylococcus aureus (n = 33). The most used antibiotics were third generation cephalosporins. The intravenous therapy duration range was 1-25 weeks, the oral therapy duration range was 5 days-36 months. Surgery was used in 5.88% of children. In 29 cases clinical sequelae were documented. This study provides the main features of pediatric SD; it also emphasizes the significant gaps in the literature regarding this topic.

Objective: Lombardy (Italy) was the epicentre of the COVID-19 pandemic in March 2020. The healthcare system suffered from a shortage of ICU beds and oxygenation support devices. In our Institution, most patients received chest CT at admission, only interpreted visually. Given the proven value of quantitative CT analysis (QCT) in the setting of ARDS, we tested QCT as an outcome predictor for COVID-19., Methods: We performed a single-centre retrospective study on COVID-19 patients hospitalised from January 25, 2020, to April 28, 2020, who received CT at admission prompted by respiratory symptoms such as dyspnea or desaturation. QCT was performed using a semi-automated method (3D Slicer). Lungs were divided by Hounsfield unit intervals. Compromised lung (%CL) volume was the sum of poorly and non-aerated volumes (- 500, 100 HU). We collected patient's clinical data including oxygenation support throughout hospitalisation., Results: Two hundred twenty-two patients (163 males, median age 66, IQR 54-6) were included; 75% received oxygenation support (20% intubation rate). Compromised lung volume was the most accurate outcome predictor (logistic regression, p < 0.001). %CL values in the 6-23% range increased risk of oxygenation support; values above 23% were at risk for intubation. %CL showed a negative correlation with PaO 2 /FiO 2 ratio (p < 0.001) and was a risk factor for in-hospital mortality (p < 0.001)., Conclusions: QCT provides new metrics of COVID-19. The compromised lung volume is accurate in predicting the need for oxygenation support and intubation and is a significant risk factor for in-hospital death. QCT may serve as a tool for the triaging process of COVID-19., Key Points: • Quantitative computer-aided analysis of chest CT (QCT) provides new metrics of COVID-19. • The compromised lung volume measured in the - 500, 100 HU interval predicts oxygenation support and intubation and is a risk factor for in-hospital death. • Compromised lung values in the 6-23% range prompt oxygenation therapy; values above 23% increase the need for intubation.

Background: Recent evidence suggests that gadolinium ethoxybenzyl diethylenetriamine penta acetic acid-enhanced (Gd-EOB-DTPA) magnetic resonance imaging may be used to evaluate liver function. The aim of this study was to assess whether the signal intensity of Gd-EOB-DTPA magnetic resonance imaging may be used to predict functional liver reserve and posthepatectomy liver failure in patients undergoing hepatectomy for liver tumors., Methods: This is an observational retrospective study on 137 preoperative Gd-EOB-DTPA magnetic resonance imaging of patients undergoing hepatectomy between 2015 and 2018. Mean signal intensity of liver (L 20 ) and spleen (S 20 ) were measured on T1-weighted single-breath-hold 3-dimensional fat-saturated gradient echo sequences acquired 20 minutes after Gd-EOB-DTPA administration. The hepatocellular uptake index of liver volume (V L ) was calculated with the formula V L ([L 20 /S 20 ] - 1) and was tested with several score systems for liver diseases and to the occurrence of post-hepatectomy liver failure., Results: Patients with diseased liver had significantly lower values of hepatic uptake index in comparison with those with normal function. This was found for a Model for End-Stage Liver Disease score ≤9 versus >9 (P = .04), combination of bilirubin and cholinesterases levels score ≤2 versus >2 (P = .02), albumin to bilirubin grades (P = .03), and Humanitas score ≤6 versus >6 (P = .03). Twenty-two patients (16%) developed posthepatectomy liver failure, and 2 (1.4%) died within 90 days. The hepatocellular uptake index was significantly lower in those patients with posthepatectomy liver failure (P < .01). Receiver operating characteristics curve analysis revealed valuable hepatocellular uptake index ability in predicting post-hepatectomy liver failure (area under the curve = 0.84; 95% confidence interval, 0.71-0.92; P < .01), with a cutoff value of 574.33 (98% sensitivity; 83% specificity)., Conclusion: The hepatocellular uptake index hepatocellular uptake index measured on preoperative Gd-EOB-DTPA magnetic resonance imaging identifies patients with diseased liver and predicts posthepatectomy liver failure. This index could be used to discern those patients at higher risk of complications after hepatectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The Ehlers-Danlos Syndrome (EDS) is a rare disorder affecting the connective tissue. EDS patients may suffer of proprioception and balance impairment but all the studies dealing with such symptoms have been addressed to adult subjects. The Study of such impairment in younger patients may lead to a better awareness of own motor abilities and to a focused rehabilitative intervention. Therefore, our work aims to assess the occurrence of these alterations in a pediatric cohort of EDS patients., Methods: The Research was designed as a cross-sectional study with a matching control group and performed on a pediatric cohort of 12 subjects with Ehlers-Danlos Syndrome (Classic and Hypermobility type) and on 12 healthy controls, during a follow-up visit at the Department of Pediatrics and at the Rehabilitation Unit of the Foundation IRCCS Policlinico San Matteo, in Pavia from April 2015 to October 2015. A square forceplatform was used to obtain the CoP (center of pressure) displacement during quiet standing during an open and a closed eyes trials. The comparisons between EDS and control group were performed using a t-test for independent data. P<0.05 was considered statistically significant. All tests were two-sided., Results: All the postural parameters considered raised at closed eyes, no significant modifications without vision were found only for the standard deviation along the antero-posterior (AP) axis for the two groups. Both at open eyes and at closed eyes, Patients with EDS showed the postural parameters significantly greater than controls (P≤0.05) and this observation was most notably for the Sway., Conclusions: According to our results, a planned monitoring of age-related changes in postural parameters of patients with EDS could be really interesting to provide a perspective of the development of postural control in these patients. In fact, considering our results, it could be interesting to apply rehabilitative strategies to enhance motor coordination and postural reflexes so improving their postural control as soon as possible. Further studies about the postural control in EDS children and adolescents are required to confirm our results.

Background: Malnutrition and muscle wasting are common in haemodialysis (HD) patients. Their pathogenesis is complex and involves many molecules including Myostatin (Mstn), which acts as a negative regulator of skeletal muscle. The characterisation of Mstn as a biomarker of malnutrition could be useful in the prevention and management of this condition. Previous studies have reported no conclusive results on the actual relationship between serum Mstn and wasting and malnutrition. So, in this study, we evaluated Mstn profile in a cohort of regular HD patients., Methods: We performed a cross-sectional study, enrolling 37 patients undergoing bicarbonate-HD (BHD) or haemodiafiltration (HDF) at least for six months. 20 sex-matched healthy subjects comprised the control group. Mstn serum levels were evaluated by ELISA before and after HD. We collected clinical and biochemical data, evaluated insulin resistance, body composition, malnutrition [by Malnutrition Inflammation Score (MIS)] and tested muscle function (by hand-grip strength, six-minute walking test and a questionnaire on fatigue)., Results: Mstn levels were not significantly different between HD patients and controls (4.7 ± 2.8 vs 4.5 ± 1.3 ng/ml). In addition, while a decrease in Mstn was observed after HD treatment, there were no differences between BHD and HDF. In whole group of HD patients Mstn was positively correlated with muscle mass (r = 0.82, p < 0.001) and inversely correlated with age (r = - 0.63, p < 0.01) and MIS (r = - 0.39, p = 0.01). No correlations were found between Mstn and insulin resistance, such as between Mstn levels and parameters of muscle strength and fatigue. In multivariate analysis, Mstn resulted inversely correlated with fat body content (β = - 1.055, p = 0.002)., Conclusions: Circulating Mstn is related to muscle mass and nutritional status in HD patients, suggesting that it may have a role in the regulation of skeletal muscle and metabolic processes. However, also considering the lack of difference of serum Mstn between healthy controls and HD patients and the absence of correlations with muscle function tests, our findings do not support the use of circulating Mstn as a biomarker of muscle wasting and malnutrition in HD.

Background: The incidence of drug-resistant forms of tuberculosis (DR-TB) and the number of children treated with second-line drugs (SLDs) are increasing. However, limited amount of information is available regarding the use of SLDs in this population., Methods: To describe the treatment of pediatric TB with SLDs and factors associated with use of SLDs in children with and without documented DR-TB, records of pediatric TB patients referred to a center in Italy from 2007 to 2018 were reviewed retrospectively., Results: Of 204 children diagnosed with active TB during the study period, 42 were treated with SLDs because of confirmed or probable drug resistance (42.8%), adverse reactions to first-line drugs (7.1%), central nervous system involvement (11.9%) or unconfirmed possible drug resistance (38.1%). There were no deaths or adverse reactions to SLDs reported. Treatment was successful in 85.2% children treated with first-line drugs and 92.9% children treated with SLDs. After adjusting for calendar period, the only factor associated with DR-TB was <2 years old [odds ratio (OR): 5.24 for <2 years vs. 5-18 years; P = 0.008]. Factors associated with treatment with SLDs were TB at 2 or more sites (OR: 11.30; P < 0.001), extrapulmonary TB (OR: 8.48; P < 0.001) or adverse reactions to first-line drugs (OR: 7.48; P = 0.002). No differences were noted in age or region of origin., Conclusions: A substantial proportion of TB children were treated with SLDs. The main reason for using SLDs was failure of a first-line drug regimen, suggesting possible DR-TB and underestimation of DR-TB in children. The use of SLD regimens was associated with a high success rate and good tolerability profile.

Objectives:: To investigate if focused extracorporeal shock wave therapy (f-ESWT) is an effective treatment in a population affected by greater trochanteric pain syndrome (GTPS)., Design:: Randomized controlled trial, with blind outcome assessors., Setting:: Outpatients, University Hospital., Subjects:: A total of 50 patients affected by GTPS with gluteal tendinopathy., Interventions:: The study group was assigned to receive f-ESWT, the control group received ultrasound therapy (UST)., Main Measures:: We assessed hip pain and lower limb function by means of a numeric rating scale (p-NRS) and the Lower Extremity Functional Scale (LEFS scale), respectively. The first follow-up evaluation (2M-FUP) was performed two months after the first treatment session, the second (6M-FUP) was carried out six months later., Results:: The mean age of the population was 61.24 (9.26) years. A marked prevalence of the female sex was recorded (44 subjects, 86%). The statistical analysis showed a significant pain reduction over time for the study group and the control group, the f-ESWT proving to be significantly more effective than UST ( P < 0.05) at the 2M-FUP (2.08 vs 3.36) and at the 6M-FUP (0.79 vs 2.03). A marked improvement of the LEFS total score was observed in both groups as well, but we found no statistical differences in the comparisons between groups., Conclusion:: Our findings support the hypothesis that f-ESWT is effective in reducing pain, both in the short-term and in the mid-term perspective. We also observed a functional improvement in the affected lower limb, but, in this case, f-ESWT showed not to be superior to UST.

Introduction: Neonatal sepsis represents a major cause of morbidity and mortality in neonates. No diagnostic test has been demonstrated to be sufficiently accurate to confirm or exclude neonatal sepsis. This study aimed to evaluate the diagnostic accuracy of presepsin (P-SEP) for neonatal sepsis. Areas covered: A systematic review of literature was performed on Medline and EMBASE. A meta-analysis was performed to calculate pooled sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic of P-SEP for neonatal sepsis. Eight studies were included, involving 636 neonates. Pooled sensitivity and specificity were 0.90 and 0.90, respectively. The pooled DOR was 120.94, and the Area Under Curve (AUC) was 0.968, indicating a high level of diagnostic accuracy. Using cut-off values <600 ng/L, sensitivity reached 0.93, with a specificity of 0.81 and AUC 0.8195, while using a threshold >600 ng/L, sensitivity was 0.87 and specificity 0.97, with higher diagnostic accuracy (AUC 0.976). Significant heterogeneity was found between studies. Expert commentary: Diagnostic accuracy of P-SEP resulted high in detecting neonatal sepsis. Even though it cannot be recommended as a single diagnostic test, P-SEP could be a helpful and valuable biomarker in neonates with suspected sepsis.

Background: Strategies for prevention of HIV-1 mother-to-child transmission (PMTCT) have been continuously optimized. However, cases of vertical transmission continue to occur in high-income countries., Objectives: To investigate changes in PMTCT strategies adopted by Italian clinicians over time and to evaluate risk factors for transmission., Methods: Data from mother-child pairs prospectively collected by the Italian Register, born in Italy in 1996-2016, were analyzed. Risk factors for MTCT were explored by logistic regression analyses., Results: Six thousand five hundred three children (348 infections) were included. In our cohort, the proportion of children born to foreign mothers increased from 18.3% (563/3078) in 1996%-2003% to 66.2% (559/857) in 2011-2016 (P < 0.0001). Combination neonatal prophylaxis use significantly (P < 0.0001) increased over time, reaching 6.3% (56/857) after 2010, and it was largely (4.2%) adopted in early preterm infants. The proportion of vaginal deliveries in women with undetectable viral load (VL) increased over time and was 9.9% (85/857) in 2011-2016; no infection occurred among them. In children followed up since birth MTCT, rate was 3.5% (96/2783) in 1996-2003; 1.4% (36/2480) in 2004-2010; and 1.1% (9/835) in 2011-2016. At a multivariate analysis, factors associated with MTCT were vaginal delivery with detectable or missing VL or nonelective caesarean delivery, prematurity, breastfeeding, lack of maternal or neonatal antiretroviral therapy, detectable maternal VL, and age at first observation. Previously described increased risk of offspring of immigrant women was not confirmed., Conclusions: Risk of MTCT in Italy is ongoing, even in recent years, underling the need for implementation of the current screening program in pregnancy. Large combination neonatal prophylaxis use in preterm infants was observed, even if data on safety and efficacy in prematures are poor.

Residing in socioeconomically deprived neighborhoods may pose substantial physiological stress, which can then lead to higher allostatic load (AL), a marker of biological wear and tear that precedes disease. The aim of the present study was to map the current evidence about the relationship between neighborhood socioeconomic deprivation and AL. A scoping review approach was chosen to provide an overview of the type, quantity, and extent of research available. The review was conducted using three bibliographic databases (PubMed, SCOPUS, and Web of Science) and a standardized protocol. Fourteen studies were identified. Studies were predominantly from the USA, cross-sectional, focused on adults, and involved different races and ethnic groups. A wide range of measures of AL were identified: the mode of the number of biomarkers per study was eight but with large variability (range: 6⁻24). Most studies ( n = 12) reported a significant association between neighborhood deprivation and AL. Behaviors and environmental stressors seem to mediate this relationship and associations appear more pronounced among Blacks, men, and individuals with poor social support. Such conclusions have important public health implications as they enforce the idea that neighborhood environment should be improved to prevent physiological dysregulation and consequent chronic diseases.

Aim: To report feasibility and safety of endovascular interventions on iliac and common femoral arteries, using the transradial access (TRA)., Methods: 100 consecutive patients (19 women; mean age 71, range 37-90years) with critical limb ischemia (30%) or claudication, and TASC A-D lesions in iliac or common femoral arteries, were prospectively enrolled, from January 2013 to June 2015, to be treated via the TRA. Exclusion criteria included no palpable radial arteries (RA) and the presence of a fistula for hemodialysis. Patients were evaluated for procedural technical success, in-hospital complications, and 30days clinical success (defined as improvement of at least one grade in the Rutherford classification of symptoms)., Results: A total of 131 iliac and common femoral arteries lesions were treated (58 in common iliac arteries, 38 in external iliac arteries and 35 in common femoral arteries). Ninety-two stents were deployed in 58 patients. Procedural technical success was achieved in 91% of the lesions; with 95% technical success rate in common iliac arteries, 87% in external iliac arteries and 89% in common femoral arteries; with 72% technical success rate in occlusions and 98% in stenosis. No in-hospital complications were observed. At 30days, 93 patients (93%) had an improvement of at least one category in the Rutherford classification of symptoms (clinical success rate 93%); 12 patients (12%) had an asymptomatic occlusion of the RA., Conclusions: TRA can be used to treat iliac and common femoral arteries lesions with a high grade of technical success and a low rate of complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Aim of this trial was to compare efficacy of activated platelet-rich plasma against hyaluronic acid as intra-articular injections to people with osteoarthritis of the knee., Design: Phase-2 randomized controlled trial, with blind patients and outcome assessors., Setting: Outpatient rehabilitation service; years 2011-2013., Subjects: Patients with knee osteoarthritis grades 2-3 at magnetic resonance imaging (MRI) were included after consent and randomized. Target sample size was 25 patients per group., Interventions: Patients received three activated platelet-rich plasma (intervention group) or hyaluronic acid (controls) intra-articular injections at 4-week intervals., Main Measures: Main outcome measure was proportion of patients with >1 grade improvement at six months from last injection, as assessed by a radiologist blind to study group. Patients were evaluated over time clinically and with functional scales (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm, Tegner, American Knee Society Score (AKSS), Lequesne, visual analogue scale (VAS) for pain)., Results: Overall, 30 patients were randomized to intervention and 28 to control group. For primary outcome, 28 patients (29 knees) in the intervention and 22 (25 knees) in the control group were available. Patients with at least 1 grade improvement at repeat MRI were 14 (48.3%) in the intervention and 2 (8%) in the control group ( P < 0.003). Improvement in symptoms and functional scales was consistently higher in the intervention group. No side-effects were observed in either group., Conclusion: Activated platelet-rich plasma reduces articular damage as evident at MRI, as soon as six months after treatment; it reduces pain and improves patient's function and overall quality of life.

Background: Extracorporeal shockwave therapy (ESWT) is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Eccentric exercise has been introduced as an effective treatment choice for Achilles tendinopathy, but poor evidence exists about its role in the treatment of rotator cuff tendinopathy., Aim: To investigate if adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome of ESWT., Design: Pre-post intervention pilot study with matched control-group., Setting: Outpatient, University Hospital., Population: Twenty-two subjects affected by painful supraspinatus calcific tendinopathy., Methods: The study-group was assigned to receive focal ESWT (f-ESWT) plus a supervised eccentric training (SET) of the shoulder abductor muscles. The matched control-group received f-ESWT only. The post-treatment assessment at follow-up (T1) was performed nine weeks after the enrollment (T0). We assessed shoulder pain and function by the means of a numeric rating scale (p-NRS) and a DASH scale. As secondary outcome, we measured the isometric strength of the abductor muscles of the affected shoulder using a handheld dynamometer., Results: At T1, we recorded a significant decrease in pain (P<0.001) and an improvement in upper limb function (P<0.001) in both groups. However, we observed no statistical differences in favor of the study-group, in terms of p-NRS and DASH total score. A mild increase (+13% from baseline) of the maximum isometric abduction strength was noticed in the study group at T1., Conclusions: Our findings did not support the hypothesis that adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome (pain and function) of shock wave therapy., Clinical Rehabilitation Impact: Our study confirmed that f-ESWT is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Adding a supervised eccentric training, focused on the abductor muscles, was useful to improve maximum isometric abduction strength, but appeared to give no advantage in the short-term outcome of shock wave therapy.

Introduction: The management of children with fever without apparent sources (FWAS) is difficult. This study aimed to evaluate the diagnostic accuracy of procalcitonin (PCT) in detecting serious or invasive bacterial infection (SBI or IBI) in children with FWAS. Areas covered: A systematic review of literature from 2007 to 2017 was performed on Medline. Twelve studies were included, involving 7,260 children with FWAS and analyzing the diagnostic performance of PCT. Four meta-analyses were performed to calculate pooled sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic curve for PCT in detecting SBI and IBI, at two different thresholds. Considering IBI, PCT sensitivity and specificity at a threshold of 0.5 ng/mL were 0.82 and 0.86, respectively; at a threshold of 2 ng/mL sensitivity and specificity were 0.61 and 0.94, respectively. In detecting SBI, PCT performance was lower, with 55% sensitivity and 85% specificity at a threshold of 0.5 ng/mL, and 30% sensitivity and 95% specificity at a threshold of 2 ng/mL. Expert commentary: Considering IBI, results showed high diagnostic accuracy for PCT. Conversely, PCT performance in diagnosis of SBI was poor. These findings suggest that PCT level determination could be helpful in detecting meningitis, bacteremia and sepsis in children with FWAS.

Objectives: Hand burn is not a common condition in the clinical practice and needs a long and laboured rehabilitative treatment to restore the lost function., Methods: This case report illustrates the achievable improvements in mobility and function by using innovative inertial systems for occupational exercise in a Virtual Reality, in addition to a traditional rehabilitative treatment., Results: Through these instruments, we could promote and concurrently assess the recovery of a functional grasp and the ability in the execution of Activities of Daily Living., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Background and Aim of the Work: Outcomes after TKA surgery are supposed to be related to the intensity and type of post-operative rehabilitation. Aim of this paper is to describe our early rehabilitation protocol following TKA with mini-invasive surgery in the immediate post-operative period and analyze functional recovery and changes in pain scores in these patients., Methods: in this observational study, data were collected on 215 total knee arthroplasty patients referred to Orthopedics and Traumatology inpatient ward from July 2012 to January 2014, treated with the same early start rehabilitation protocol. We recorded times to reach functional goals (sitting, standing and assisted ambulation) and pain after the treatment., Results: length of hospital stay in TKA was 4.6±1.8 days, with a rehabilitation treatment lenght of 3.3±1.3 days. The mean time needed to achieve the sitting position was 2.3±0.7 days, to reach the standing position was 2.6±1.0 days to reach the walking functional goal was 2.9±1.0 days.  Pain NRS scores remained below 4 in the first and second post-operative day and below 3 from the third post-operative day., Conclusion: Our study confirms that rehabilitation started as soon as 24 hours after surgery with mini-invasive approach, enables early verticalization of patients and early recovery of walking with a good control of pain.

Background and Aim of the Work: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain., Methods: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge)., Results: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant., Conclusion: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status.

Objective: To provide information on the clinical presentation of sciatic neuropathy and its management in a real-world setting, and to analyze the effects of a multimodal approach based on the association of physical and pharmacological therapy., Patients and Methods: A multicentric observational prospective study was conducted in 44 Italian tertiary centers specialized in Physical Medicine and Rehabilitation, Orthopedics, Neurology, Neurosurgery, and Rheumatology. To develop a shared management of LPB with sciatica, a dedicated clinical record was proposed to collect data about diagnosis, treatment, and outcomes. Pain, disability, and quality of life were recorded trough validated questionnaires at baseline and after a two-month follow-up., Results: 394 patients (age, mean ± SD 55.7 ± 14.1 years, 57.1% females) with chronic LBP and sciatica were enrolled in the study. The characteristics of the selected group showed a certain variability in the clinical presentation. At baseline, patients received several different therapeutic options among physical, pharmacological and neurotrophic treatments. A subgroup of 312 patients was treated with a combination of neurotrophic agents containing alpha-lipoic acid (ALA). After a two-month follow-up, a general improvement in both perceived pain and functional disabilities was observed. A significant improvement (p < 0.001) in the Pain Numeric Rating Scale (NRS), Roland e Morris Disability Questionnaire (RMDQ) and Brief Pain Inventory (BPI) Italian short version was observed., Conclusions: Sciatic neuropathy is a multifaceted condition managed by means of a wide spectrum of therapeutic options. The results of this study suggest that a multimodal approach based on the association of ALA with physical and pharmacological therapies can be beneficial in the treatment of LBP with sciatica.

Objective: To describe how Italian medical societies interact with pharmaceutical and medical device industries through an analysis of the information available on their websites., Design: Cross sectional study., Setting: Italy., Participants: 154 medical societies registered with the Italian Federation of Medical-Scientific Societies., Main Outcome Measures: Indicators of industry sponsorship (presence of industry sponsorship in the programme of the last medical societies' annual conference; presence of manufacturers' logos on the homepage; presence of industry sponsorship of satellite symposia during the last annual conference)., Results: 131 Italian medical societies were considered. Of these, 4.6% had an ethical code covering relationships with industry on their websites, while 45.6% had a statute that mentioned the issue of conflict of interest and 6.1% published the annual financial report. With regard to industry sponsorship, 64.9% received private sponsorship for their last conference, 29.0% had manufacturers' logos on their webpage, while 35.9% had industry-sponsored satellite symposia at their last conference. The presence of an ethical code on the societies' websites was associated with both an increased risk of industry sponsorship of the last conference (relative risk (RR) 1.22, 95% CIs 1.01 to 1.48 after adjustment) and of conferences and/or satellite symposia (RR 1.22, 95% CIs 1.02 to 1.48 after adjustment) but not with the presence of manufacturers' logos on the websites (RR 1.79, 95% CIs 0.66 to 4.82 after adjustment). No association was observed with the other indicators of governance and transparency., Conclusions: This survey shows that industry sponsorship of Italian medical societies' conferences is common, while the presence of a structured regulatory system is not. Disclosure of the amount of industry funding to medical societies is scarce. The level of transparency therefore needs to be improved and the whole relationship between medical societies and industry should be further disciplined in order to avoid any potential for conflict of interest., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: After masseteric-facial nerve (V-VII) anastomosis, a new neurological circuit oversees the facial muscles and patients should learn to activate the facial movements using the masseteric function., Aim: To monitor the rehabilitative protocol of facial muscles activation through teeth clenching and to assess the clinical evolution after V-VII anastomosis in terms of facial symmetry and functional recovery., Design: Case series., Setting: Outpatients clinic., Population: Eleven patients undergone V-VII anastomosis for complete unilateral facial palsy., Methods: After surgery, patients underwent a needle electromyography (EMG) and a rehabilitative training with mirror feedback to learn how to reach the symmetry at rest and during facial movements through teeth clenching. The rehabilitative protocol at the first clinical evaluation has been monitored through the Italian version of Sunnybrook Facial Grading System (SFGS) and the Software Facial Assessment by Computer Evaluation (FACE). Functional limitations and quality of life have been evaluated using the Italian version of Facial Disability Index (FDI). The clinical evolution at 18 months was evaluated with EMG, SFGS, biting evaluation and FDI., Results: At the first clinical evaluation after reinnervation, through teeth clenching patients displayed an improvement of symmetry at rest, symmetry of voluntary movement, symmetry of smile and composite score of SFGS. Objective measurement of facial structures with FACE system demonstrated an improvement of symmetry at rest and during smile through teeth clenching. At 18 months patients displayed a good reinnervation with a further improvement of SFGS scores and reduction of functional disability. No biting deficit has been observed., Conclusions: After V-VII anastomosis, at the first rehabilitative visit, patients learn to activate the reinnervated facial muscles through teeth clenching. Eighteen months after the anastomosis, patients display a further improvement of voluntary control on facial symmetry and smile and a reduction of disability., Clinical Rehabilitation Impact: Our study illustrates the rehabilitative protocol after V-VII anastomosis and analyzes the clinical evolution after this intervention in terms of recovery of facial symmetry and reduction of disability. This will be instrumental to standardize the rehabilitative protocol among different centers and to choose the best patient-tailored surgical approach for subjects affected by complete facial palsy.

Purpose: To evaluate and compare clinical, functional and quality of life (QOL) outcomes after two types of surgical approach for single level cervical disc herniation: anterior cervical discectomy andfusion (ACDF) with cage and cervical artificial disc replacement (C-ADR)., Method: 119 patients with cervical disc herniation underwent surgery from January 2007 to December 2010; 55 patients were included in the study (27 ACDF, 28 C-ADR). We performed: a pre and postoperative clinical evaluation of cervicobrachial pain, motor and sensory deficit in the upper limbs; a functional and QOL evaluation with self assessment scales (VAS, NPNQ, SF-36); a postoperative instrumental evaluation of cervical ROM and pain. Mean follow-up period was 24 months., Results: After surgery both groups showed clinical, functional and QOL improvement. No pre and postoperative differences were found between the groups. The postoperative instrumental evaluation showed a globally reduced cervical ROM and a decreased pain threshold in comparison with normal values in both groups., Conclusion: Our results demonstrate the clinical equivalence of the two surgical techniques and the satisfaction of the two groups of patients two years after surgery. Although functional changes persist after surgery they do not affect quality of life.

Purpose: To report the results and complications of a single-center experience of above-the-knee angioplasty via transradial access (TRA)., Methods: In a prospective study, 110 consecutive patients (88 men; mean age 72 years, range 37-90) referred for critical limb ischemia (26, 24%) or claudication were eligible for lower limb angioplasty via TRA (patients with TASC D lesions of the superficial femoral artery and below-the-knee lesions were excluded)., Results: The majority of patients (84, 76%) were treated via a left TRA. A total of 170 lesions were addressed, of which 38 (22%) were occlusions; 113 stents were positioned in 82 patients. The overall technical success rate was 91%, with a 63% success rate in occlusions and a 98% success rate in stenoses; by location, the success rates were 91% in suprainguinal lesions and 90% in infrainguinal lesions. No hemorrhagic or local complications requiring surgery were observed. At 1-month follow-up, 101 patients had a downward shift of at least one category in the Rutherford classification of symptoms (clinical success rate 92%); 18 (16%) patients had occlusion of their access radial artery, but none had symptoms or discomfort., Conclusion: The present study demonstrates that TRA is a safe and effective approach for lower extremity arterial revascularization, at least for interventionists with longstanding experience in TRA and in selected anatomical subsets.

Background: Curve evolution in idiopathic scoliosis frequently occurs in lumbar and thoracic-lumbar spine. The spinal and iliopsoas muscles play a major role in maintaining the static and dynamic stability of the spine., Objective: To monitor by video recording, the degree to which asymmetric isometric contractions of the iliopsoas muscle improve the lumbar curve., Design: 10 subjects (9 female, 1 male), mean age of 14.1 years (11-18), who were undergoing rehabilitation for idiopathic scoliosis. 8 subjects wore a brace, 6 had a single lumbar curve, 4 had a thoracic curve; 9 curves were convex to the left and 1 convex to the right. The mean Cobb angle was 20.1 degrees ±8.2523) with a mean degree of rotation of 1.2 (±0.4216)., Method: The scoliotic curves were monitored on video whilst the patients performed muscle contraction exercises. Adhesive markers were applied to the skin to be used as reference points of the curve on video. Subjects performed the exercises in a sitting position, facing away from the video camera, with their knees bent at an angle of 90 degrees. The complete exercise procedure was as follows: initial lengthening of the spine and postural control, concentric activation of the iliopsoas, isometric activation for about 3 seconds, then final release. Differences in curvature angle detected on the video recording were analysed and processed using the computer software Dartfish Pro Suite 5.0&#95;Dartfish LTD&#95;Switzerland., Results: The mean angle of correction through exercise was 6.9 degrees (±3.6) during concentric activation and 4.9 degrees (±3.5) during isometric activation of the iliopsoas., Conclusions: Data show the corrective effect that iliopsoas muscle contraction produces on the scoliotic curve.

This study was aimed at determining the serum concentration of homocysteine (Hcy) and big endothelin-1 (big ET-1, the precursor of endothelin) in dogs with chronic kidney disease (CKD) with and without hypertension, proteinuria and inflammation, in order to explore their role as biomarkers of hypertension associated with CKD. Hcy and big ET-1 were measured using an enzyme-linked immunosorbent assay and an enzymatic cyclic reaction, respectively, in dogs with CKD staged, as proposed by the International Renal Interest Society (IRIS), using serum creatinine, urinary protein to creatinine (UPC) ratio and systolic blood pressure, and classified as affected or not by inflammation based on the serum concentration of C-reactive protein (CRP). Serum Hcy was significantly higher in dogs of IRIS stages II, III and IV compared with controls and in proteinuric compared with non-proteinuric dogs. No differences relating to the degree of hypertension or to the CRP concentration were found. Serum big ET-1 significantly increased in dogs of IRIS stage IV compared with controls, in proteinuric compared with non-proteinuric dogs, in dogs with severe hypertension compared with those without hypertension, and in dogs with increased CRP compared to those with normal CRP concentrations. Hcy only correlated with serum creatinine but big ET-1 significantly correlated with serum creatinine, UPC ratio, systolic blood pressure, and increased CRP. In conclusion, both Hcy and big ET-1 increase in dogs with CKD. Although further research is needed, big ET-1, but not Hcy, may also be considered as a biomarker of hypertension., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Nitrogen is the second most critical factor for crop production after water. In this study, the beneficial rhizobacterium Pseudomonas protegens Pf-5 was genetically modified to fix nitrogen using the genes encoding the nitrogenase of Pseudomonas stutzeri A1501 via the X940 cosmid. Pf-5 X940 was able to grow in L medium without nitrogen, displayed high nitrogenase activity and released significant quantities of ammonium to the medium. Pf-5 X940 also showed constitutive expression and enzymatic activity of nitrogenase in ammonium medium or in nitrogen-free medium, suggesting a constitutive nitrogen fixation. Similar to Pseudomonas protegens Pf-5, Pseudomonas putida, Pseudomonas veronii and Pseudomonas taetrolens but not Pseudomonas balearica and Pseudomonas stutzeri transformed with cosmid X940 showed constitutive nitrogenase activity and high ammonium production, suggesting that this phenotype depends on the genome context and that this technology to obtain nitrogen-fixing bacteria is not restricted to Pf-5. Interestingly, inoculation of Arabidopsis, alfalfa, tall fescue and maize with Pf-5 X940 increased the ammonium concentration in soil and plant productivity under nitrogen-deficient conditions. In conclusion, these results open the way to the production of effective recombinant inoculants for nitrogen fixation on a wide range of crops.

Objectives: To evaluate use of combination neonatal prophylaxis (CNP) in infants at high risk for mother-to-child transmission (MTCT) of HIV in Europe and investigate whether CNP is more effective in preventing MTCT than single drug neonatal prophylaxis (SNP)., Design: Individual patient-data meta-analysis across eight observational studies., Methods: Factors associated with CNP receipt and with MTCT were explored by logistic regression using data from nonbreastfed infants, born between 1996 and 2010 and at high risk for MTCT., Results: In 5285 mother-infant pairs, 1463 (27.7%) had no antenatal or intrapartum antiretroviral prophylaxis, 915 (17.3%) had only intrapartum prophylaxis and 2907 (55.0%) mothers had detectable delivery viral load despite receiving antenatal antiretroviral therapy. Any neonatal prophylaxis was administered to 4623 (87.5%) infants altogether; 1105 (23.9%) received CNP. Factors significantly associated with the receipt of CNP were later calendar birth year, no elective caesarean section, maternal CD4 cell count less than 200 cells/μl, maternal delivery viral load more than 1000 copies/ml, no antenatal antiretroviral therapy, receipt of intrapartum single-dose nevirapine and cohort. After adjustment, absence of neonatal prophylaxis was associated with higher risk of MTCT compared to neonatal prophylaxis [adjusted odds ratio (aOR) 2.29; 95% confidence interval (95% CI) 1.46-2.59; P < 0.0001]. Further, there was no association between CNP and MTCT compared to SNP (aOR 1.41; 95% CI 0.97-2.5; P = 0.07)., Conclusion: In this European population, CNP use is increasing and associated with presence of MTCT risk factors. The finding of no observed difference in MTCT risk between one drug and CNP may reflect residual confounding or the fact that CNP may be effective only in a subgroup of infants rather than the whole population of high-risk infants.

Objective: Over the past several decades, researchers have sought the ideal substances for use in injection laryngoplasty. This search has inspired several basic science studies centering on the viscoelastic properties of popularly used injectables as well as of experimental substances. Unfortunately, these studies have used various techniques and different units for measuring viscosity. For clinical purposes, there has been a need for a concise compilation of these data, converted into consistent units, to permit easy comparison of the reported viscosities of various substances. The literature has been reviewed to address this need., Method: Scholarly review., Results: Comparable data are available for various substances, including vocal fold mucosa, subcutaneous fat, bovine dermal collagen, glutaraldehyde cross-linked collagen, polytetrafluoroethylene, and hyaluronic acid products. The values for difference substances vary widely., Conclusion: There appears to be a growing body of useful knowledge about viscosity of substances used for medial (vibratory margin) injection. However, decisions regarding viscosity of substances for lateral injection medialization appear to have been made without the benefit of evidence-based research. It is possible that the trend toward relatively low viscosity materials for lateral injection is based on ease of surgical use through a small needle, but that the low viscosity may adversely affect the control over the position of the injected substance. Research is needed comparing viscosity with predictability of surgical deposition of injected substances., (Copyright © 2013 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objective: Evaluation of fatigue and pain following surgical activities., Methods: Cross-sectional study. We distributed a self-evaluation questionnaire to 180 surgeons to investigate working postures and fatigue and/or pain following working activities., Results: 100 surgeons replied (74 male), mean age 40.1 (SD 10.85; 26-65). Multivariate analysis suggests that the highest risk factor for developing muscle fatigue whilst performing surgical operations is standing compared to sitting (OR: 4.92; 95% CI: 1.32-18.33),followed by the ability to alternate between the two postures (OR: 3.46: 95% CI: 1.26-9.52). Surgeons who complain of intense fatigue when standing have 16 times the risk of developing musculoskeletal pain than surgeons who complain of light fatigue when standing (OR: 15.77; 95% CI: 1.51-164.37). The ability to adjust the height of the operating table before each operation reduces the risk of developing musculoskeletal pain by 83% (OR: 017; 95% CI: 0.03-0.87); 90.9% of surgeons who rest their forearms for less than half the duration of an operation reported pain., Conclusions: Fatigue and pain associated with performing surgical interventions could be managed more effectively by: controlling the working posture, being able to rest forearms, being able to regulate the height of the operating table, and possibly by applying the ergonomic guidelines.

Background: Information on the use of new antiretroviral drugs in children in the real setting of clinical fields is largely unknown., Methods: Data from 2554 combined antiretroviral therapy (cART) regimens administered to 911 children enrolled in the Italian Register for HIV infection in children, between 1996 and 2009, were analysed. Factors potentially associated with undetectable viral load and immunological response to cART were explored by Cox regression analysis., Results: Proportion of protease inhibitor (PI)-based regimens significantly decreased from 88.0% to 51.2% and 54.9%, while proportion on non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens increased from 4.5% to 38.8% and 40.2% in 1996-1999, 2000-2004 and 2005-2009, respectively (p < 0.0001). Significant change in the use of each antiretroviral drug occurred over the time periods (p < 0.0001). Factors independently associated with virological and immunological success were as follows: later calendar periods, younger age at regimen (only for virological success) and higher CD4(+) T-lymphocyte percentage at baseline. Use of unboosted PI was associated with lower adjusted hazard ratio (aHR) of virological or immunological success with respect to NNRTI- and boosted PI-based regimens, with no difference among these two latter types., Conclusion: Use of new generation antiretroviral drugs in Italian HIV-infected children is increasing. No different viro-immunological outcomes between NNRTI- and boosted PI-based cART were observed., (© 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.)

Polyhydroxybutyrate (PHB), a typical carbon and energy storage compound, is widely found in Bacteria and Archae domains. This polymer is produced in response to conditions of physiological stress. PHB is composed of repeating units of β-hydroxybutyrate (R-3HB). It has been previously shown that R-3HB functions as an osmolyte in extremophile strains. In this study, Pseudomonas sp. CT13, a halotolerant bacterium, and its PHB synthase-minus mutant (phaC) were used to analyze the chaperone role of R-3HB. The production of this compound was found to be essential to salt stress resistance and positively correlated with salt concentration, suggesting that PHB monomer acts as a compatible solute in Pseudomonas sp. CT13. R-3HB accumulation was also associated with the prevention of protein aggregation under combined salt and thermal stresses in Pseudomonas sp. CT13. Physiological concentrations of R-3HB efficiently reduced citrate synthase (CS) aggregation and stabilized the enzymatic activities of CS during thermal stress. Docking analysis of the CS/R-3HB interaction predicted the stability of this complex under physiological concentrations of R-3HB. Thus, in vivo, in vitro and in silico analyses suggest that R-3HB can act as a chemical chaperone.