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Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a pathogen with enteric tropism. We compared the clinical, biochemical and radiological features of children hospitalized for acute SARS-CoV-2 infection, classified in two groups based on the presence of diarrhea. Logistic regression analyses were used to investigate the variables associated with diarrhea. Overall, 407 children were included in the study (226 males, 55.5%, mean age 3.9 ± 5.0 years), of whom 77 (18.9%) presented with diarrhea, which was mild in most cases. Diarrhea prevalence was higher during the Alpha (23.6%) and Delta waves (21.9%), and in children aged 5-11 y (23.8%). Other gastrointestinal symptoms were most commonly reported in children with diarrhea ( p < 0.05). Children with diarrhea showed an increased systemic inflammatory state (higher C-reactive protein, procalcitonin and ferritin levels, p < 0.005), higher local inflammation as judged by mesenteric fat hyperechogenicity (adjusted Odds Ratio 3.31, 95%CI 1.13-9.70) and a lower chance of previous immunosuppressive state (adjusted Odds Ratio 0.19, 95%CI 0.05-0.70). Diarrhea is a frequent feature of pediatric COVID-19 and is associated with increased systemic inflammation, which is related to the local mesenteric fat inflammatory response, confirming the implication of the gut not only in multisystem inflammatory syndrome but also in the acute phase of the infection.

Depression is one of the most serious chronic psychiatric disorders affecting people worldwide. Subthreshold depression (SD) is a form of subclinical depression with increased risk of major depressive disorder (MDD). Patients diagnosed with SD may not be eligible for antidepressant drugs and, particularly in the case of MDD, these antidepressants may have adverse effects which outweigh their therapeutic effects, leading to discontinuation of therapy. Food supplements could provide an alternative strategy. The aim of this study is to demonstrate the efficacy of a food supplement based on a combination of S-adenosyl methionine (SAMe, 200 mg/day) and probiotics (Lactobacillus helveticus Rosell®-52, Bifidobacterium longum Rosell®-175, 3 ×10 9 CFU/day) in reducing depression symptoms in a monocentric, randomised, double-blind, placebo-controlled, cross-over clinical trial. 80 Subjects were recruited and offered the food supplement or placebo daily for three months, according to a cross-over clinical trial design, followed by a six-week follow-up period. The efficacy of the food supplement was measured by means of the "Hamilton Depression Rating Scale" (HAM-D) and "Patient Health Questionnaire-9" (PHQ-9), using a mixed analysis of variance model, with random intercept, for statistical analysis. The food supplement showed a significant decrease of PHQ-9 and HAM-D scores resulting in reduced SD and MDD symptoms as compared to placebo. In conclusion, the daily intake of the food supplement based on SAMe and probiotic strains for a period of three months is effective in improving the quality of life of SD subjects who are not eligible for antidepressant therapies, and patients suffering from mild-to-moderate depression who are not sensitive or cannot tolerate conventional drugs., Competing Interests: Conflict of interest statement All authors declare no conflict of interest., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Personality traits are patterns of thoughts, feelings and actions that are usually assessed by means of psychometric questionnaires. In the present study we described the Phenomenological Personality Factor (PPF), a short questionnaire assessing the personality traits, taking into account the different interpretative models of personality., Methods: A sample of 554 healthy subjects (357 female; 197 males) aged 18-60 years were enrolled. Each participant was required to complete PPF, by indicating the presence/absence of the individual personality trait, and the Italian version of the Affective Neuroscience Personality Scale (ANPS)., Results: The principal component analysis showed that seven factors explained the 35.07% of the total variance. Moreover, the correlation analysis revealed that the PPF components were significantly and positively associated with the ANPS scales., Conclusions: Our findings suggest that the PPF is a useful questionnaire to assess the personality traits, and the adaptive functioning, in healthy individuals.

Background: The study of complex systems, such as the psychotherapeutic encounter, transcends the mechanistic and reductionist methods for describing linear processes and needs suitable approaches to describe probabilistic and scarcely predictable phenomena., Objective: The present study undertakes a scoping review of research on the computational methods in psychotherapy to gather new developments in this field and to better understand the phenomena occurring in psychotherapeutic interactions as well as in human interaction more generally., Design: Online databases were used to identify papers published 2011-2022, from which we selected 18 publications from different resources, selected according to criteria established in advance and described in the text. A flow chart and a summary table of the articles consulted have been created., Results: The majority of publications (44.4%) reported combined computational and experimental approaches, so we grouped the studies according to the types of computational methods used. All but one of the studies collected measured data. All the studies confirmed the usefulness of predictive and learning models in the study of complex variables such as those belonging to psychological, psychopathological and psychotherapeutic processes., Conclusions: Research on computational methods will benefit from a careful selection of reference methods and standards. Therefore, this review represents an attempt to systematise the empirical literature on the applications of computational methods in psychotherapy research in order to offer clinicians an overview of the usefulness of these methods and the possibilities of their use in the various fields of application, highlighting their clinical implications, and ultimately attempting to identify potential opportunities for further research.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes Coronavirus Disease 2019 (COVID-19), which, since 2019 in China, has rapidly become a worldwide pandemic. The aggressiveness and global spread were enhanced by the many SARS-CoV-2 variants that have been isolated up to now. These mutations affect mostly the viral glycoprotein Spike (S), the capsid protein mainly involved in the early stages of viral entry processes, through the recognition of specific receptors on the host cell surface. In particular, the subunit S1 of the Spike glycoprotein contains the Receptor Binding Domain (RBD) and it is responsible for the interaction with the angiotensin-converting enzyme 2 (ACE2). Although ACE2 is the primary Spike host receptor currently studied, it has been demonstrated that SARS-CoV-2 is also able to infect cells expressing low levels of ACE2, indicating that the virus may have alternative receptors on the host cells. The identification of the alternative receptors can better elucidate the pathogenicity and the tropism of SARS-CoV-2. Therefore, we investigated the Spike S1 interactomes, starting from host membrane proteins of non-pulmonary cell lines, such as human kidney (HK-2), normal colon (NCM460D), and colorectal adenocarcinoma (Caco-2). We employed an affinity purification-mass spectrometry (AP-MS) to pull down, from the membrane protein extracts of all cell lines, the protein partners of the recombinant form of the Spike S1 domain. The purified interactors were identified by a shotgun proteomics approach. The lists of S1 potential interacting proteins were then clusterized according to cellular localization, biological processes, and pathways, highlighting new possible S1 intracellular functions, crucial not only for the entrance mechanisms but also for viral replication and propagation processes., Competing Interests: II, VM, LC, FB, FC, MZ, and MM were affiliated with the company CEINGE Advanced Biotechnologies. The remaining 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 © 2022 Iacobucci, Monaco, Canè, Bibbò, Cioffi, Cozzolino, Guarino, Zollo and Monti.)

Background and Aims: The pathophysiology of SARS-CoV-2-associated diarrhea is unknown. Using an experimental model validated for rotavirus-induced diarrhea, we investigated the effects of SARS-CoV-2 on transepithelial ion fluxes and epithelial integrity of human intestinal cells. The effect of the antidiarrheal agent diosmectite on secretion was also evaluated following its inclusion in COVID-19 management protocols., Methods: We evaluated electrical parameters (intensity of short-circuit current [ Isc ] and transepithelial electrical resistance [TEER]) in polarized Caco-2 cells and in colonic specimens mounted in Ussing chambers after exposure to heat-inactivated (hi) SARS-CoV-2 and spike protein. Spectrofluorometry was used to measure reactive oxygen species (ROS), a marker of oxidative stress. Experiments were repeated after pretreatment with diosmectite, an antidiarrheal drug used in COVID-19 patients., Results: hiSARS-CoV-2 induced an increase in Isc when added to the mucosal (but not serosal) side of Caco-2 cells. The effect was inhibited in the absence of chloride and calcium and by the mucosal addition of the Ca 2+ -activated Cl - channel inhibitor A01, suggesting calcium-dependent chloride secretion. Spike protein had a lower, but similar, effect on Isc . The findings were consistent when repeated in human colonic mucosa specimens. Neither hiSARS-CoV-2 nor spike protein affected TEER, indicating epithelial integrity; both increased ROS production. Pretreatment with diosmectite inhibited the secretory effect and significantly reduced ROS of both hiSARS-CoV-2 and spike protein., Conclusions: SARS-CoV-2 induces calcium-dependent chloride secretion and oxidative stress without damaging intestinal epithelial structure. The effects are largely induced by the spike protein and are significantly reduced by diosmectite. SARS-CoV-2 should be added to the list of human enteric pathogens., Competing Interests: The authors declare no conflict of interest., (© 2022 Published by Elsevier Ltd.)

Background: Administration of Lacticaseibacillus rhamnosus GG (LGG) to children with gastroenteritis is recommended by universal guidelines. Rotavirus (RV) causes diarrhea through combined cytotoxic and enterotoxic effects. Aim of this study was to evaluate the mechanisms of efficacy of LGG in an in-vitro model of RV diarrhea in its viable form (LGG) and conditioned medium (mLGG)., Methods: Ion secretion corresponding to the NSP4 enterotoxic effect, was evaluated by short circuit current ( Isc ) and the cytotoxic effect by transepithelial electrical resistance (TEER) in Ussing chambers, upon exposure to RV in Caco-2 enterocyte monolayers treated or not with living probiotic or its culture supernatant. Mechanisms of enterotoxic and cytotoxic damage were evaluated including oxidative stress measured by reactive oxygen species, apoptosis evaluated by DAPI and nuclear staining, NFkβ immunofluorescence., Results: RV induced Isc increase and TEER decrease, respectively indicating ion secretion and epithelial damage, the two established pathways of diarrhea. Both probiotic preparations reduced both diarrheal effects, but their potency was different. Live LGG was equally effective on both enterotoxic and cytotoxic effect whereas mLGG was highly effective on ion secretion and showed minimal protective effects on cytoskeleton, apoptosis and NFkβ., Conclusions: LGG counteracts RV-induced diarrhea by inhibiting both cytotoxic and enterotoxic pathogenic mechanisms. Namely, LGG inhibits chloride secretion by specific moieties secreted in the medium with a direct pharmacologic-like action. This is considered a postbiotic effect. Subsequently, live bacteria exert a probiotic effect protecting the enterocyte structure., Competing Interests: The study was in part supported by Dicofarm S.p.A. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results. All authors declare no other competing interests., (Copyright © 2022 Buccigrossi, Poeta, Cioffi, Terranova, Nunziata, Lo Vecchio and Guarino.)

SARS-CoV-2 enters the intestine by the spike protein binding to angiotensin-converting enzyme 2 (ACE2) receptors in enterocyte apical membranes, leading to diarrhea in some patients. Early treatment of COVID-19-associated diarrhea could relieve symptoms and limit viral spread within the gastrointestinal (GI) tract. Diosmectite, an aluminomagnesium silicate adsorbent clay with antidiarrheal effects, is recommended in some COVID-19 management protocols. In rotavirus models, diosmectite prevents pathogenic effects by binding the virus and its enterotoxin. We tested the trapping and anti-inflammatory properties of diosmectite in a SARS-CoV-2 model. Trapping effects were tested in Caco-2 cells using spike protein receptor-binding domain (RBD) and heat-inactivated SARS-CoV-2 preparations. Trapping was assessed by immunofluorescence, alone or in the presence of cells. The effect of diosmectite on nuclear factor kappa B (NF-kappaB) activation and CXCL10 secretion induced by the spike protein RBD and heat-inactivated SARS-CoV-2 were analyzed by Western blot and ELISA, respectively. Diosmectite bound the spike protein RBD and SARS-CoV-2 preparation, and inhibited interaction of the spike protein RBD with ACE2 receptors on the Caco-2 cell surface. Diosmectite exposure also inhibited NF-kappaB activation and CXCL10 secretion. These data provide direct evidence that diosmectite can bind SARS-CoV-2 components and inhibit downstream inflammation, supporting a mechanistic rationale for consideration of diosmectite as a management option for COVID-19-associated diarrhea., (© 2021. The Author(s).)

Background: Obesity and type 2 diabetes mellitus, which are widespread throughout the world, require therapeutic interventions targeted to solve clinical problems (insulin resistance, hyperglycaemia, dyslipidaemia and steatosis). Several natural compounds are now part of the therapeutic repertoire developed to better manage these pathological conditions. Cladosporols, secondary metabolites from the fungus Cladosporium tenuissimum, have been characterised for their ability to control cell proliferation in human colon cancer cell lines through peroxisome proliferator-activated receptor gamma (PPARγ)-mediated modulation of gene expression. Here, we report data concerning the ability of cladosporols to regulate the differentiation of murine 3T3-L1 preadipocytes., Methods: Cell counting and MTT assay were used for analysing cell proliferation. RT-PCR and Western blotting assays were performed to evaluate differentiation marker expression. Cell migration was analysed by wound-healing assay., Results: We showed that cladosporol A and B inhibited the storage of lipids in 3T3-L1 mature adipocytes, while their administration did not affect the proliferative ability of preadipocytes. Moreover, both cladosporols downregulated mRNA and protein levels of early (C/EBPα and PPARγ) and late (aP2, LPL, FASN, GLUT-4, adiponectin and leptin) differentiation markers of adipogenesis. Finally, we found that proliferation and migration of HT-29 colorectal cancer cells were inhibited by conditioned medium from cladosporol-treated 3T3-L1 cells compared with the preadipocyte conditioned medium., Conclusions: To our knowledge, this is the first report describing that cladosporols inhibit in vitro adipogenesis and through this inhibition may interfere with HT-29 cancer cell growth and migration., General Significance: Cladosporols are promising tools to inhibit concomitantly adipogenesis and control colon cancer initiation and progression., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Providing remote psychotherapy using technology is a growing practice, especially since the outbreak of the COVID-19 pandemic. Even if in numerous studies video conferencing psychotherapy (VCP) was found to be clinically effective, some doubts continue to exist about how the psychotherapeutic alliance works in the online setting, and the characteristics of the empathic process are still poorly understood. This is an exploratory study aimed at analyzing the degree of empathy between the psychotherapist and client pair, and the degree of support perceived by the client who shall be referred to as the patient interchangeably in this study, comparing the sessions in person with those online, during the current pandemic, in order to discriminate the impact of empathy in the digital setting. The sample analyzed was composed of 23 patients with different severity of pathology engaged in online and in-person therapeutic sessions with five psychotherapists of different theoretical leanings. The scores of the support and empathy scale, obtained by both members of the psychotherapeutic couple in the two settings, were analyzed and compared. The test used belongs to an Italian adaptation of the Empathic Understanding (EU) of the Relationship Inventory. What emerged from comparing the scores was interesting: Unlike the psychotherapists, the patients perceived their therapists as significantly more empathic and supportive in the remote setting. These are rather important data, because the literature documents that client empathic perception measures represent a more accurate measure of the empathic relationship and, in general, can predict a good treatment outcome. Although these results need further investigation, they represent an important contribution in filling the scientific gap in the understanding of digital empathy. Also, this study provides new insights for future research on the characteristics and impact empathy has on the practice of remote psychotherapy., 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 Sperandeo, Cioffi, Mosca, Longobardi, Moretto, Alfano, Scandurra, Muzii, Cantone, Guerriera, Architravo and Maldonato.)

Glioblastoma is the most frequent and aggressive brain cancer in adults. While precision medicine in oncology has produced remarkable progress in several malignancies, treatment of glioblastoma has still limited available options and a dismal prognosis. After first-line treatment with surgery followed by radiochemotherapy based on the 2005 STUPP trial, no significant therapeutic advancements have been registered. While waiting that genomic characterization moves from a prognostic/predictive value into therapeutic applications, practical and easy-to-use approaches are eagerly awaited. Medical reports on the role of the ketogenic diet in adult neurological disorders and in glioblastoma suggest that nutritional interventions may condition outcomes and be associated with standard therapies. The acceptable macronutrient distribution of daily calories in a regular diet are 45-65% of daily calories from carbohydrates, 20-35% from fats, and 10-35% from protein. Basically, the ketogenic diet follows an approach based on low carbohydrates/high fat intake. In carbohydrates starvation, body energy derives from fat storage which is used to produce ketones and act as glucose surrogates. The ketogenic diet has several effects: metabolic interference with glucose and insulin and IGF-1 pathways, influence on neurotransmission, reduction of oxidative stress and inflammation, direct effect on gene expression through epigenetic mechanisms. Apart from these central effects working at the synapsis level, recent evidence also suggests a role for microbiome and gut-brain axis induced by a ketogenic diet. This review focuses on rationales supporting the ketogenic diet and clinical studies will be reported, looking at future possible perspectives., 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 Montella, Sarno, Altucci, Cioffi, Sigona, Di Colandrea, De Simone, Marinelli, Facchini, De Vita, Berretta, de Falco and Facchini.)

The covid-19 lockdown forced psychotherapists to use videoconferencing psychotherapy (VCP). There is little literature on the relationship between VCP and the theoretical orientation of the psychotherapist. The aim of our research work is to explore to what extent the Italian therapists used VCP and how they experienced the change in setting during lockdown. A sample of psychotherapists completed an on-line questionnaire including data about any previous experience of remote work, information on changes in setting during lockdown and their opinions on this experience. In the second phase, a statistical analysis of the data collected was performed with SPSS. The most represented theoretical orientations are psychoanalytic, Gestalt, systemic-relational and psychodynamic. Almost all the respondents had chosen to change the setting, opting for remote work via video calls, with no differences in terms of theoretical orientation and age group. Psychotherapeutic orientation seems to affect the type of difficulties encountered. The scientific literature on remote psychotherapy (VCP) so far does not correlate it with any specific theoretical-clinical model. Our research work offers some preliminary hypotheses about potential correlations between setting variations with the theoretical-clinical models.

A simple and low-cost procedure for gel-like time-durable biological phantoms is presented in this work. Easily accessible materials are adopted, which are able to provide a flexible and controllable method to rapidly realize different kind of tissues. The proposed technique is applied to fabricate various tissue-mimicking phantoms, namely skin, muscle, blood and fat. Their effectiveness is first tested by performing dielectric characterization on a wide frequency range, from 500 MHz up to 5 GHz, and validating the measured dielectric parameters (dielectric constant and conductivity) by comparison with reference models in the literature. Then, a multi-layer phantom simulating the human arm is realized, and a wearable body sensor is adopted to prove the perfect agreement of the biometric response achieved in the presence of the fabricated phantom and that provided by a real human arm.

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.

Oral rehydration solutions (ORSs) is the key treatment of acute diarrhea in children, as it restores the electrolyte balance by stimulating the intestinal sodium/glucose transporter SGLT1 to induce fluid absorption. The World Health Organization (WHO) and The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) proposed ORSs with different chemical compositions. The main agent of childhood acute gastroenteritis is rotavirus (RV). We evaluate the effects of ORS with different concentration of glucose and sodium on RV induced secretion. Ussing chambers technique was used for electophysiology experiments to evaluate ion fluid flux. ESPGHAN ORS (sodium 60 mmol/L and glucose 111 mmol/L) induced a more potent proabsorptive effect in Caco-2 cells than WHO ORS, and this effect depended on the sodium/glucose ratio. Titration experiments showed that RV-induced fluid secretion can be reverted to a proabsorptive direction when sodium and glucose concentration fall in specific ranges, specifically 45-60 mEq/L and 80-110 mM respectively. The results were confirmed by testing commercial ORSs. These findings indicated that ORS proabsorptive potency depends on sodium and glucose concentrations. Optimal ORS composition should be tailored to reduce RV-induced ion secretion by also considering palatability. These in vitro data should be confirmed by clinical trials.

Background: Clinical audit is a process by which physicians or other health care professionals perform a regular and systematic review of their clinical practice and amend it, when necessary. An internal audit allows to review the activities carried out by professionals, in order to assess the appropriateness, effectiveness, efficiency and safety of the services provided. Aim of this study was to apply the process of clinical audit to the obesity/overweight care in toddlers. After the correction of the nutritional errors that were considered potentially responsible for the excess weight gain, the effect of the changes of dietary advice on the frequency of overweight/obesity was assessed in a cohort of children aged 24-36 months., Methods: Three Italian primary care pediatricians set up the audit strategy by recognizing the high prevalence of overweight and obesity in the entire cohort of toddlers born in 2005, 2006 and 2007 (Pre-Audit group, age 24-36 months old) under their care. By reviewing their clinical practice, they changed the protocol of weaning and feeding up to 36 months, mainly reducing protein and sugar excess. The change involved the cohorts of toddlers born in the years 2010, 2011 and 2012 (Post-Audit group)., Results: Change in the approach of pediatricians to children's diet yielded a reduction of the frequency of overweight/obesity in children between 24 and 36 months of life from 26.3% in the Pre-Audit group to 13.9% in the Post-Audit group (p < 0.0001)., Conclusion: Clinical audit revealed high rates of obesity/overweight among toddlers. The practice developed a new strategy for nutritional counseling, which was effective in reducing the frequency of overweight/obesity in young children.

Background: A number of studies have evaluated the association between cognitive function, pain, and physical activity. To our knowledge, however, no previous studies have evaluated these factors at the population level., Aims: To evaluate the association between cognitive function in the elderly with pain, physical activity, and the interaction between these variables. Estimates are generated for the United States population., Methods: We made use of the NHANES database (1999-2002), making adjustments so that our results represent the United States population. Cognitive function was evaluated through the Digit Symbol Substitution Test. Our main predictors were (1) pain, defined as soreness of either the shoulder, neck, lower back and joint, or a severe headache (2) physical activity, measured as the performance while performing tasks at home, physical activity intensity, walking, bicycle riding, and muscle strengthening., Results: Most individual pain sites were not significantly associated with cognitive function, while all physical activity factors were associated with an increase in cognitive function. When evaluating the sample subset of those with cognitive scores lower than the median, a combination of more pain and less physical activity was consistently associated with lower cognitive scores when compared to those performing more physical activity with or without pain. When evaluating individuals with cognitive scores above the median, a similar association pattern was perceived., Conclusions: Among the population of individuals above the age of 60, higher cognitive levels are associated with more physical activity and less with pain, although both factors might impact cognition. Public policy resources should be commensurate with these findings when targeting cognitive function among the aging population., Competing Interests: The authors have declared that no competing interests exist.

Purpose Thoracic disk herniation is uncommon. It still represents a challenge for spinal surgeons. Multiple surgical strategies are available and, often, they are matter of debate. We describe a preliminary experience about a combined extra-intra dural approach for posterolateral disk herniation in patients affected by spinal cord compression., Methods: We performed a combined extra-intra dural approach in two preliminary cases. We performed bilateral laminectomy of adjacent vertebrae and unilateral partial medial arthrectomy of the involved segment. After a lateral extradural diskectomy, we, subsequently, performed a median longitudinal durotomy. The conflict between disk herniation and spinal cord was identified. We removed disk herniation moving disk fragments in the extradural compartment without ventral spinal dura opening., Results: We solved spinal cord compression in both cases. Postoperative neurological improvement was observed in both cases. No major complications were observed., Conclusion: Our preliminary results are probably insufficient to establish surgical criteria but offer another surgical perspective to especially treat patients with contraindication to anterior approaches.

Background: Foramen magnum meningiomas (FMM) represent a challenge for neurosurgeons. Multiple surgical strategies have been reported to treat these lesions in their variable location. Contemporary technical innovations allow the utilization of common sub-occipital craniotomy to treat ventrally, ventro-laterally and dorsally located FMMs. We present our technique and experience., Methods: From November 2004 to November 2015, we treated 14 patients with FMM at the Department of Neurosurgery of the Santa Maria delle Grazie Hospital in Pozzuoli, Naples, Italy. There were 10 females and 4 males, with a mean age of 64.5 years (range, 55-77 years). All patients had high field magnetic resonance imaging (MRI) with contrast enhancement preoperatively, which led to the radiological diagnosis. A sub-occipital craniotomy was performed in all patients as well as the removal of the posterior arch of C1. Partial removal of C2 was necessary in 2 patients. Neck pain was the most common symptom of presentation. Paraparesis was present in patients in 3 patients. Upper limbs dysesthesia or pain existed in 3 cases., Results: Thirty days after surgery neck pain and dysesthesia decreased in all patients affected. Neurological improvement was observed in 2 patients affected by weakness in lower limbs at 6 months follow up. Paraparesis was unchanged in 1 patient. Two patients presented transient worsening after surgery. Transient dysphagia occurred in one case and postoperative hemorrhage with subsequent surgery in another patient. We had no postoperative mortality., Conclusions: FMM surgery should be tailored to the lesion at hand as in most instances it is possible to avoid the use of extensive skull base approaches., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Rationale and Objectives: To assess the capability of digital tomosynthesis (DTS) as a problem-solving imaging technique to confirm or exclude potential thoracic lesions based on chest x-ray radiography (CXR)., Materials and Methods: Four hundred and-sixty five patients (263 male, 202 female; age, 72.47 ± 11.33 years) with suspected thoracic lesion(s) after the initial onsite analysis of CXR underwent DTS. Two independent readers prospectively analyzed in consensus CXR and DTS images on a picture archiving and communications system-integrated workstation and proposed a diagnosis according to a confidence score for each lesion: 1 or 2 = definite or probable pulmonary or pleural benign lesion or pseudolesion deserving no further diagnostic work-up; 3 = indeterminate; 4 or 5 = probable or definite pulmonary lesion deserving further diagnostic work-up by computed tomography (CT). In patients who did not undergo chest CT, the DTS findings had to be confirmed by 6 to 12 months' imaging follow-up., Results: Finally, 229 pulmonary lesions (193 thoracic and 36 pleural lesions) and 236 pseudolesions were identified. Based on DTS images, readers correctly classified all pseudolesions except for 10/236 (reader 1) or 11/236 (reader 2) pseudolesions and 7 (reader 1) or 6 (reader 2) pulmonary subpleural lesions located in the anterior or posterior lung region close to the thoracic wall. Chest CT was performed in 127/465 (27%) patients, whereas in 338/465 patients (73%) CXR doubtful findings were resolved by DTS., Conclusions: DTS allowed to exclude most pseudolesions initially considered as potential thoracic lesions on the preliminary onsite assessment of CXR and allowed to exclude pulmonary lesions deserving CT assessment in about three fourths of the patients., (Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the impact of digital tomosynthesis (DTS) on the radiological investigation of patients with suspected pulmonary lesions on chest radiography (CXR)., Methods: Three hundred thirty-nine patients (200 male; age, 71.19 ± 11.9 years) with suspected pulmonary lesion(s) on CXR underwent DTS. Two readers prospectively analysed CXR and DTS images, and recorded their diagnostic confidence: 1 or 2 = definite or probable benign lesion or pseudolesion deserving no further diagnostic workup; 3 = indeterminate; 4 or 5 = probable or definite pulmonary lesion deserving further diagnostic workup by computed tomography (CT). Imaging follow-up by CT (n = 76 patients), CXR (n = 256) or histology (n = 7) was the reference standard., Results: DTS resolved doubtful CXR findings in 256/339 (76 %) patients, while 83/339 (24 %) patients proceeded to CT. The mean interpretation time for DTS (mean ± SD, 220 ± 40 s) was higher (P < 0.05; Wilcoxon test) than for CXR (110 ± 30 s), but lower than CT (600 ± 150 s). Mean effective dose was 0.06 mSv (range 0.03-0.1 mSv) for CXR, 0.107 mSv (range 0.094-0.12 mSv) for DTS, and 3 mSv (range 2-4 mSv) for CT., Conclusions: DTS avoided the need for CT in about three-quarters of patients with a slight increase in the interpretation time and effective dose compared to CXR.

Purpose. To determine whether the presence of cognitive impairment (CI) affects physical recovery of patients with chronic heart failure (CHF) undergoing a cardiac rehabilitation program (CRP). Methods. We enrolled 80 CHF patients (M/F = 53/27). CI was evaluated by means of the Mini-Mental State Examination (MMSE), exercise tolerance was evaluated by six-minute walking test (6 mwt). All patients underwent a 6-week CRP program at 50-70% of maximal V(O2). Patients were divided into two groups according to their MMSE (group 1: 16-23; group 2: 24-30). Results. MMSE resulted directly related to ejection fraction (r = 0.42; P = 0.03), and it was inversely related to creatinine (r = -0.36; P = 0.04). At 6 week group 1 had a lower increase in distance walked at 6 MWT than group 2 (P = 0.008). At multivariate logistic regression MMSE 16-23 predicted a reduced exercise recovery in the overall population (OR = 1.84; 95% CI = 1.50-2.18) and in women (OR = 1.42; 95% CI = 1.22-1.75), while it was not predicted in males. Conclusions. CI is a marker of advanced CHF and is an independent predictor of lower exercise recovery after CRP.

There is no effective alternative to surgery in the treatment of the symptomatic cases of chiari malformation. Nonetheless, in literature there is no unanimous consensus about what is the surgical "gold standard" and which are the candidates for surgery. No doubt that intracranial hypertension and ventricular dilatation have to be investigated and treated before considering decompression. It is also very important to keep in mind that a surgery does not guarantee a complete recovery from every symptoms. We report our experience about who are the candidates for surgery, which is the most appropriate surgical technique and when is the correct time for surgery along the natural history of the disease.

Object: Endoscopic surgery is routinely used to treat intracranial arachnoid cysts. However, the indications and results with respect to the different cyst locations, compared with those of microsurgical fenestration and cyst shunting, deserve to be discussed., Methods: The authors review 18 patients with intracranial arachnoid cysts treated by pure endoscopic technique in their neurosurgical department. There were 10 male and 8 female patients ranging in age from 2 months to 48 years (median age 19.4 years). The cyst location was suprasellar in 5 cases, quadrigeminal in 5, cortical hemispheric in 2, sylvian region in 3, and posterior fossa in 3. The authors also reviewed the literature, comprising 61 reports for an overall number of 645 patients with intracranial arachnoid cysts treated by different surgical techniques. These techniques included microsurgical excision or fenestration by craniotomy, cyst shunting, and endoscopic fenestration. The surgical results of the different techniques according to the different cyst locations underwent statistical analysis., Results: The overall success rate (complete or partial clinical remission) in the authors' endoscopic series was 83.3% (15 of 18 cases), which is rather similar to that of 222 patients treated endoscopically and reported on in the literature (84.2%). In the overall endoscopic group, a higher success rate was found for cysts in the suprasellar (89.7%), quadrigeminal (88.5%), and posterior cranial fossa (83.3%) regions compared with sylvian (70%) and cortical and interhemispheric (75%) regions. The statistical comparison of the results of the endoscopic series with those of craniotomy and shunting revealed no significant differences for suprasellar, quadrigeminal, or posterior cranial fossa cysts, whereas the success rate of endoscopy is lower than that of other techniques for sylvian and cortical cysts., Conclusions: Endoscopy is a safe and effective therapeutic modality for patients with intracranial arachnoid cysts. Cysts of the suprasellar and quadrigeminal regions and posterior fossa are the best indications for neuroendoscopy; on the other hand, cortical cysts are best treated by microsurgical fenestration or shunting. For sylvian cysts, the endoscopic procedure may be advocated in most cases.

Whipple's disease is a rare multisystemic infection caused by the intracellular bacteria Thropheryma whippelii. Central nervous system (CNS) involvement is not rare. The most frequent CNS manifestations are cognitive and behavioural changes, sopranuclear ophtalmoplegia, myoclonus, epilepsy, ataxia, meningitis and focal cerebral palsy. We report one case of cerebral localization of Whipple's disease with a clinical presentation of recurrent endocranic hypertension and hydrocephalus, and uncommon neurological symptoms, successfully treated by endoscopic third ventriculostomy and antibiotic therapy with ceftriaxone and Trimethoprim-Sulfamethoxazole., ((c) 2010 Elsevier B.V. All rights reserved.)

Rationale and Objectives: The aim of this study was to investigate the value of digital tomosynthesis in the diagnosis of suspected pulmonary lesions on chest radiography., Materials and Methods: Two-hundred twenty-eight patients (133 men, 95 women; mean age, 70.8 ± 11.1 years) with suspected pulmonary lesions after initial analysis of chest radiography underwent digital tomosynthesis. Two independent readers (with 3 and 20 years of experience) prospectively analyzed the chest radiographic and digital tomosynthesis images on a picture archiving and communication system workstation and proposed a diagnostic confidence score for each lesion (1 or 2 = definitely or probably extrapulmonary lesion or pseudolesion, 3 = indeterminate, 4 or 5 = probably or definitely pulmonary lesion). Chest computed tomography was the reference standard examination., Results: A total of 251 suspected pulmonary lesions were identified. In 71 patients, digital tomosynthesis and computed tomography did not confirm any lesion. In the remaining 157 patients, 180 lesions were identified, including 112 pulmonary and 68 extrapulmonary lesions. In 110 (reader 1) and 123 (reader 2) lesions, correct diagnoses were provided after analysis of the chest radiographs. All lesions were correctly classified after digital tomosynthesis except for 14 extrapulmonary lesions (both readers) that were misinterpreted as pulmonary and 10 (reader 1) and six (reader 2) pulmonary lesions that were misinterpreted as pleural. Digital radiography versus tomosynthesis differed in accuracy (reader 1, 43% vs 90%; reader 2, 49% vs 92%; P < .05) and confidence by area under the receiver-operating characteristic curve (reader 1, 0.788 vs 0.944; reader 2, 0.840 vs 0.997; P < .05)., Conclusions: Digital tomosynthesis improved diagnostic accuracy and confidence in the diagnosis of suspected pulmonary lesions on chest radiography., (Copyright © 2010 AUR. Published by Elsevier Inc. All rights reserved.)

Available evidence about the relationship between poor insight and other clinical characteristics in patients with obsessive-compulsive disorder (OCD) is inconclusive and conflicting. There is also a paucity of data on the long-term course and treatment outcome of OCD patients with poor insight. The present study reports the findings of a relatively large sample (n=106) of outpatients fulfilling DSM-IV criteria for OCD, treated with serotonin reuptake inhibitors (SRIs) and prospectively followed up for 3 years. Baseline information was collected on demographic and clinical characteristics, using standardized instruments. Insight was assessed by means of the Brown Assessment of Beliefs Scale (BABS). Eighty-three patients were followed prospectively and evaluated systematically by validated measures of psychopathology. Compared to their good insight counterparts, the OCD patients with poor insight (22%) showed a greater severity of obsessive-compulsive and depressive symptomatology; an earlier age at onset; a higher rate of schizophrenia spectrum disorder in their first-degree relatives; a higher comorbidity with schizotypal personality disorder. During the follow-up period, poor insight OCD patients were less likely to achieve at least a partial remission of obsessive-compulsive symptoms; required a significantly greater number of therapeutic trials; received more frequently augmentation with antipsychotics. The results suggest that the specifier "poor insight" helps to identify a subgroup of patients at the more severe end of OCD spectrum, characterized by a more complex clinical presentation, a diminished response to standard pharmacological interventions, and a poorer prognosis. Further research is needed to identify alternative strategies for the management of these patients., (Copyright 2009 Elsevier Inc. All rights reserved.)

Objective: The objective of our study was to evaluate contrast-enhanced sonography in the diagnosis of malignancy in complex cystic renal masses., Materials and Methods: We analyzed a series of 40 cystic renal masses (diameter, 2-8 cm) with a complex pattern at contrast-enhanced CT in 40 consecutive subjects (18 men, 22 women; mean age +/- SD, 62 +/- 11 years). Each renal mass was scanned using sonography without contrast material and after IV injection of sulfur hexafluoride-filled microbubbles during the arterial (15-40 seconds) and venous (40-120 seconds from injection) phases. Two radiologists in consensus assessed onsite the enhancement patterns in the peripheral wall and intracystic septa and the evidence of solid endocystic components. Three blinded readers with 2, 6, and 10 years of experience in renal imaging performed a retrospective off-site interpretation of unenhanced sonography, contrast-enhanced sonography, and CT images and made a benign or malignant diagnosis according to refer ence diagnostic criteria for contrast-enhanced sonography and to the Bosniak classification for CT., Results: Final diagnoses comprised two multilocular cystic nephromas, two inflammatory and seven hemorrhagic cysts, and eight uncomplicated benign cysts and 21 cystic renal cell carcinomas. The overall diagnostic accuracy of contrast-enhanced sonography was better than unenhanced sonography and CT (contrast-enhanced sonography vs unenhanced sonography vs CT: reader 1, 83% vs 30% vs 75%; reader 2, 83% vs 30% vs 63%; reader 3, 80% vs 30% vs 70%; p < 0.05, McNemar test)., Conclusion: Contrast-enhanced sonography was found to be better than unenhanced sonography and CT in the diagnosis of malignancy in complex cystic renal masses.

Objective: The purpose of this study was to examine the association between body mass index (BMI), venous capacitance, and clinical evidence of varicose veins after adjustment for sex hormones in postmenopausal women., Methods: This study group of the DIANA (DIet and ANdrogens) project (a randomized controlled trial on the effect of some dietary changes on sex hormone pattern in women with elevated androgenic hormone levels in Italy) was comprised of 104 healthy volunteer postmenopausal women, aged 48 to 65 years. The main outcome measures were physical examination to determine the presence and severity of varicose veins and plethysmographic measurement of lower limb venous capacitance and outflow., Results: Women in the upper quartile of BMI (>30 kg/m(2)) showed a positive association with clinical evidence of varicose veins (odds ration, 5.8; 95% CI, 1.2 to 28.2) after adjustment for age, estradiol, testosterone, and sex hormone binding globulin. No association was found between BMI and plethysmographic measurements of venous parameters., Conclusion: Obesity is associated with clinical evidence of varicose veins independently from the influence of sex hormones in postmenopausal women and is not associated with venous capacitance. Increased body weight increases the risk of varicose veins.

Objective: The purpose of this study was to determine if there is an association between elevated sex hormones (ie, serum estradiol, sex hormone binding globulin [SHBG], testosterone) and increased venous distension and clinical evidence of varicose veins in menopausal women., Methods: Participants were 104 healthy volunteer menopausal women, aged 48 to 65 years, who were not undergoing hormonal treatment. Of these 104, 14 were excluded from analyses because their estradiol levels were compatible with a premenopausal condition (4), because they had missing values for insulin concentration (5), and because they did not show up at venous vessel examination (5). Patients underwent a physical examination to determine the presence of varicose veins; a venous strain-gauge plethysmographic examination to compute instrumental measures of venous distensibility; and laboratory analyses of blood so serum testosterone, estradiol, SHBG, glucose, and insulin could be measured. There were also prevalence ratios and odds ratios used to test the presence of an association between biochemical and instrumental variables., Results: Serum levels of estradiol in the upper tertile of the frequency distribution were significantly associated with clinical evidence of varicose veins (prevalence odds ratios 3.6; 95% CI 1.1-11.6) and with increased lower limb venous distensibility (prevalence odds ratios 4.4; 95% CI 1.2-15.5). No association was found for SHBG and testosterone., Conclusions: Our finding that high serum levels of estradiol are associated with clinical evidence of varicose veins and instrumental measurements indicating increased venous distensibility in menopausal women suggests that endogenous estrogens may play a role in the development of this very common venous vessel abnormalities.

Purpose: The increasing use of ultrasound (US) for both diagnostic and interventional procedures has not been supported yet by proper and adequate planning of dedicated rooms. Therefore we studied both the organization and the design of such areas., Methods and Discussion: As for organization, we considered: a) the kind of examination performed; b) the main department activity (in-/outpatients, diagnostic or interventional procedures); c) the schedule for each room by examination type and timing (patient preparation, actual examination and read-out times). As for room design, we studied the size and location of the diagnostic unit, dressing rooms, entrances and restrooms, as well as the furniture in general. We also studied the location of waiting rooms and corridors, the location and size of the read-out areas, and the room for post-interventional monitoring, as well as all the details about microclimate and lighting. Then we designed two different modules with the relevant planimetry: one featuring two adjacent diagnostic rooms and the other featuring a single diagnostic room. Some ergonomic solutions are also proposed concerning the location of the US system relative to the stretchers entrance and the location of the post-interventional monitoring room relative to the radiologic room(s). Finally, we evaluated the size of some peculiar pieces of equipment of a radiologic room by their function., Conclusions: The functional arrangement of the diagnostic US unit and its space requirements, permits to optimize the use of the whole structure complying with the ergonomic criteria for operators and enabling the rapid throughout of patients with no waste of time.

Introduction: Virtual endoscopy is a new 3D technique which permits to depict the inner surface of anatomic cavities. We report our experience in the study of the nasal cavity and paranasal sinuses., Material and Methods: CT examinations of the maxillofacial region were obtained using 1.5 or 3.0 mm slices, 1.5 or 3.0 mm table feed, 120 kV, 140 mA, 2 s scan time, standard and high resolution algorithms for bony structures and a field of view of 14-16 cm. The images were transferred on a workstation and processed with the Navigator virtual endoscopy software (General Electric). A threshold value ranging -300 to -550 UH was applied., Results: We report a series of virtual images of the nasal cavity which includes rhinopharynx vault, torius tubarius, choanae, turbinates, tubal orifice and osteomeatal complex. Moreover, images of frontal sinus and tear duct, of polyps and fracture of maxillary sinus are also presented. 3D virtual endoscopy provides a clear visualization of the anatomic structures of the nasal cavity and sinuses. The images are similar to those of conventional endoscopy. Moreover virtual endoscopy visualizes the paranasal sinuses, which are not accessible at conventional endoscopy. The main limitations of this new technique are the arbitrary choice of the threshold value and the homogenization of different tissue densities, which reduces the contrast resolution., Conclusions: Virtual endoscopy can presently be considered a complementary technique of the standard axial and coronal CT examination. It provides an effective demonstration of the anatomy of these structures and shows areas which are difficult to visualize with conventional endoscopy. This technique could be of help in didactical activity; its clinical application has to be verified.

Introduction: We applied the new technique of virtual endoscopy to the middle ear because this anatomical area is characterized by favorable contrast., Materials and Methods: CT examinations of the petrous bone were obtained using 1.5 mm thick 1 coronal axis slices, with 1 mm or 1.5 mm table feed, 120 kV, 140-170 mA and 2 s scan time. The images were reconstructed with the high resolution algorithm for bony structures and a small field of view (9.6 cm), separately for the right and left petrous bone. The images were then transferred on a workstation and processed with the Navigator virtual endoscopic software (General Electric). A threshold value ranging -350 to -600 HU was applied., Results: A series of images is acquired as the virtual endoscope moves from the external auditory canal to the middle ear cavity. Images of the anterior, medial, and posterior surfaces of the middle ear are presented. Different views of the ossicles are also presented. High quality images were always obtained for the middle ear structures, including the ossicles. CT endoscopy of the middle ear provides a new view of the anatomy of this complex area. It has some advantages and disadvantages; the former can be summarized as follows: -demonstration of areas which are difficult to show with endoscopy because of the presence of membrana tympani; -the virtual endoscope can be placed in several positions and therefore it can be inserted in all sites and tortuous places of anatomical cavity; -nice and effective demonstration of the ossicular chain including the stapes. The disadvantages are related to the fact that the endoscopic reconstruction (such as any other three-dimensional reconstruction) is a representation of surfaces where different densities are necessarily homogenized., Conclusions: CT virtual endoscopy of the middle ear can currently be considered a complementary technique to conventional CT because it permits better anatomical detailing of this complex region.

A case of familiar bilateral multicentric RCC in a young woman is an ideal model to evaluate preoperative and intraoperative diagnostic and surgical tools in order to achieve two distinct goals: the oncologic radicalness and the renal function preserved. Radical bilateral nephrectomy, the renal hypothermia by perfusion of both kidneys, the bench high resolution sonography of parenchyma, the choose of one kidney suitable for conservative surgery, the resection of suspect lesions with intraoperative pathology, the reconstructive bench surgery, the autotransplantation, are the steps accurately performed with particular concern to eradication of all the tumoral lesions present in the kidneys. The results confirm that renal function has been preserved with this method. Radicalness should be appointed by a longlasting follow up. However, as it is discussed, conservative surgery, when accurately performed can give results not different from radical demolitive surgery. In this paper tools to improve diagnostic and therapeutic methods are described in order to increase the diagnostic accuracy and the therapeutic efficacy. The possibility that this multiple RCC can be a part of the abnormalities occurring in the Von Hippel-Lindau syndrome does not change the surgical approach, being the RCC the worst prognostic factor of the syndrome.

The anatomic and pathologic involvement of the structures in the neck can be accurately studied with small parts ultrasonography. The thyroid and parathyroid glands and nodal chains are treated in this article; masses of the neck spaces are not considered because of their relative rarity.