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Posterior reversible encephalopathy syndrome (PRES) is a variable etiology clinical syndrome with similar neuroimaging results and clinical symptoms. PRES can develop in both adults and children and is characterized by headaches, disorders of consciousness, seizures and especially focal visual disturbances, often associated with hypertensive state. In most cases, symptoms resolve without neurological consequences. The treatment strategy concerns early diagnosis and general measures to correct the underlying cause of PRES. Here, we report a case of PRES that occurs in a 6-year-old child with nephrotic syndrome.

Infantile acute upper gastrointestinal bleeding involves a decision for therapeutic intervention that most pediatricians first coming into contact with the patient are, not unreasonably, unable to objectively provide. Therefore, some objective tools of individual risk assessment would seem to be crucial. The principal aim of the present study was to investigate the anamnestic and clinical parameters of infants with hematemesis, together with laboratory and instrumental findings, to create a scoring system that may help identify those infants requiring an appropriate and timely application of upper gastrointestinal (GI) endoscopy.Clinical data of infants admitted for hematemesis to the participating centers over the study period were systematically collected. According to the outcome dealing with rebleeding, need for blood transfusion, mortality, finding of GI bleeding lesions, or need for surgical intervention, patients were blindly divided into a group with major clinical severity and a group with minor clinical severity. Univariate and multivariate logistic regressions were conducted to investigate significant prognostic factors for clinical severity.According to our findings, we drafted a practical diagnostic algorithm and a clinical score able to predict the need for timely upper GI endoscopy (BLOVO infant score). Our clinical scoring system was created by incorporating anamnestic factors, clinical parameters, and laboratory findings that emerged as predictors of a worst outcome.We provided the first objective tool of individual risk assessment for infants with hematemesis, which could be very useful for pediatricians first coming into contact with the patient in the emergency department.

Objectives: In this commentary we emphasize the importance of breakfast for children, both from the point of view of proper nutritional education and as a strategy for the prevention of obesity. Methods: We reviewed the international literature, drawing particularly on information regarding the possible negative effects of skipping breakfast. Results: Obese children often do not eat breakfast and may face metabolic problems such as insulin resistance and hypercholesterolemia. The child who does not eat breakfast often becomes an adult who does not eat breakfast. The role of parents is fundamental in the acquisition of correct eating habits. Conclusions: The awareness that habits during childhood become elements of everyday life in adulthood, makes us understand the importance of the long-term consequences of skipping breakfast during childhood and adolescence.

Background Exclusive enteral nutrition (EEN) is the first choice to induce remission and promote mucosal healing in pediatric Crohn’s disease (CD). However, full adherence to EEN treatment may be problematic for children with CD. Methods The goal of the current multicenter retrospective study was to define predictive factors of nonadherence to treatment and nonremission at the end of induction treatment. Those data together were analyzed with the ultimate goal of trying to define an individualized induction treatment for children with CD. Results Three hundred seventy-six children with CD from 14 IBD pediatric referral centers were enrolled in the study. The rate of EEN adherence was 89%. Colonic involvement and fecal calprotectin >600 μg/g at diagnosis were found to be associated with a reduced EEN adherence. Exclusive enteral nutrition administered for 8 weeks was effective for inducing clinical remission in 67% of the total cohort. Factors determining lower remission rates were age >15 years and Pediatric Crohn’s Disease Activity Index >50. Conclusion Although EEN is extremely effective in promoting disease remission, several patients’ related factors may adversely impact EEN adherence and response. Personalized treatments should be proposed that weigh benefits and risks based on the patient’s disease location, phenotype, and disease activity and aim to promote a rapid control of inflammation to reduce long-term bowel damage.

Introduction: The present study aimed at evaluating Italian epidemiological trends of pediatric inflammatory bowel diseases (IBD) over the period 2009–2018. Materials and methods: Data from 1969 patients enrolled in the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition Registry, by 49 pediatric IBD centers throughout the country, were analyzed, comparing three different time intervals (2009–2012, 2013–2015, 2016–2018). Results: The number of new IBD diagnoses ranged from 175 to 219 per year, evenly distributed over the examined period of time. From 2009 to 2018, the minimal incidence ranged from 1.59 to 2.04 /105 inhabitants aged < 18 years, with an overall slight predominance of ulcerative colitis (UC) over Crohn's disease (CD) (ratio: 1.1). Mean diagnostic delay was 6.8 months for CD and 4.1 months for UC, with a significant reduction for CD when comparing the three-time intervals (p =0.008). The most frequent disease locations according to the Paris classification were ileocolonic for CD (41.3%) and pancolitis for UC (54.6%). Conclusions: The minimal incidence rate in Italy seems to have stabilized over the last two decades, even if it has increased when compared to previous reports. UC is still slightly more prevalent than CD in our country. Diagnostic delay significantly decreased for CD, reflecting an improved diagnostic capacity.

Urinary tract infections (UTIs) are among the most frequent bacterial diseases in infants and children. Physician adherence to recommendations is notoriously often poor, but no data are available on UTIs management in the emergency setting. In this multicenter national study, we investigated the policies regarding UTIs management in children aged 2 months to 3 years in Italian emergency units. Between April and June 2021, directors of the emergency units were invited to answer an online survey on the following items: diagnostic approach to children with fever without an apparent source, therapeutic approach to UTIs, the use of kidney and urinary tract ultrasound, and the criteria for hospitalization. A total of 121 (89%) out of 139 of invited units participated in the study. Overall, units manage children with a suspected or confirmed UTI according to available recommendations for most of the items. However, in almost 80% (n = 94) of units, a sterile perineal bag is used to collect urine for culture. When urine is collected by cathether, heterogeneity exists on the threshold of bacterial load considered for UTI diagnosis. Conclusions: Available recommendations on UTIs in children are followed by Italian emergency units for most of the items. However, the methods to collect urine specimens for culture, one of the crucial steps of the diagnostic work-up, often do not align with current recommendations and CFU thresholds considered for diagnosis largely vary among centers. Efforts should be addressed to validate and implement new child and family friendly urine collection techniques. What is Known:• Several guidelines are published on the management of children with suspected or confirmed urinary tract infection.• No data are available on the management of pediatric urinary tract infections in the emergency setting. What is New:• Almost 80% of the Italian emergency units employ a sterile perineal bag to collect urine for culture.• Diagnostic CFU thresholds largely vary among centers.

The prevalence of primary hypertension in pediatric patients is increasing, especially as a result of the increased prevalence of obesity in children. New diagnostic guidelines for blood pressure were published by the American Academy of Pediatrics (AAP) in 2017 to better define classes of hypertension in children. The aim of our study is to evaluate the impact of new guidelines on diagnosis of hypertension in pediatrics and their capacity to identify the presence of cardiovascular and metabolic risk. Methods: Retrospective clinical and laboratory data from 489 overweight and obese children and adolescents were reviewed. Children were classified according to the 2004 and 2017 AAP guidelines for systolic and diastolic blood pressure. Lipid profile and glucose metabolism data were recorded, triglyceride/HDL ratio (TG/HDL) was calculated as an index of endothelial dysfunction. Hepatic steatosis was detected using the ultrasonographic steatosis score. Results: Children with elevated blood pressure increased from 12.5% with the 2004 AAP to 23.1% with the 2017 AAP criteria (p &lt, 0.001). There was a statistically significant increase in children with high blood pressure in all age groups according to the new cut-off values. Notably, the diagnosis of hypertension according to 2017 AAP criteria had a greater positive association with Hepatic Steatosis (rho 0.2, p &lt, 0.001) and TG/HDL ratio (rho 0.125, p = 0.025). Conclusions: The 2017 AAP tables offer the opportunity to better identify overweight and obese children at risk for organ damage, allowing an earlier and more impactful prevention strategy to be designed.

Excess intake of energy, sugars, salt and saturated fats is an important causal factor of obesity and related non-communicable diseases. In order to help consumers to make healthy food choices, many European countries have developed proposals for “front-of-pack” food labeling, intended as an integration to the nutritional information provided by the mandatory nutritional declaration. Based on the European strategic program “Farm to Fork”, the intention is to achieve a harmonized front-of-pack label proposal by Q4 2022. Among the different proposals, the one which received most attention by experts and greater feedback by the EU member countries is the Nutri-Score, a tool based on an algorithm whereby a “quality” category ranging from A to E is assigned to each single food on a background colored from dark green to dark orange. As an alternative to Nutri-Score, the NutrInform Battery has been developed by Italy in association with a few other EU member states: this proposal is objectively alternative to the Nutri-Score proposal due to a different underlying philosophy, in particular for its informative and educational intent rather than purchase orientation. The present document, prepared by the Scientific Board and reviewed by the Scientific Council of the Italian Society of Human Nutrition, represents the scientific-based position of the Society in relation to the general theme of front-of-pack labeling and in particular to the dualism created between the Nutri-Score and NutrInform Battery proposals.

Bisphenol A (BPA) is an endocrine disruptor (ED) frequently used in food packaging. BPA is used as a monomer in the manufacture of some food packaging. This study aimed to evaluate the urinary BPA concentration in an Italian pediatric cohort, testing the levels of this ED over a period of 6 months, evaluating the effects of a diet regimen with a reduction of Plastic Food Packaging (PFP). One hundred thirty Italian children were enrolled and divided into two groups “School Canteen” and “No School Canteen.” The first group consumed one meal at school using a plastic-free service for 5 days/weeks, while the other group did not modify their normal meal-time habits. The BPA levels were tested in urine samples at three time points: T0, is the time before the application of the plastic-free regimen diet; T3, 3 months later; and T6, 6 months later. A reduction of urine BPA levels was detected in the “School Canteen” group. In particular, the reduction was significant analyzing both the intra (among the three testing times) group and inter (between “School Canteen” and “No School Canteen”) group variability. Our results show the effects of a diet regimen with a reduction of PFP, demonstrating a connection between urinary BPA levels and food packaging.

With the current obesity epidemic and the decline of fitness among school-aged children, the importance of obesity interventions to promote physical activity and healthy habits has become indisputable. The purpose of this study was to assess the efficacy of a school-based multicomponent intervention in increasing physical activity (PA) levels, actual physical abilities, and perceived physical abilities in clinical and nonclinical samples of overweight/obese boys and girls aged 10–12 years. The clinical intervention group (n = 35) participated in a 7-month after-school program in addition to curricular physical education lessons, while the nonclinical control group (n = 29) received usual curricular lessons. Measures included levels of PA and fitness and individual’s perceptions of physical ability. After treatment, the intervention group showed improved PA levels, perceived physical ability, and throwing and jumping task performances compared to the control group. Results indicate that a multicomponent program can improve levels of PA, fitness, and perceived competence of overweight participants. Findings highlight the importance of a comprehensive healthy lifestyle program that includes physical, psychosocial, and behavioral factors and suggest practical implications for educators, trainers, and teachers in identifying best practices targeting childhood obesity.

Because it is involved in calcium homeostasis, vitamin D is a prohormone with many implications for health, especially bone health. Hypovitaminosis D is considered pandemic worldwide, with important health health consequences. The aim of our study was to evaluate vitamin D levels in children living in a southern region of Italy with high exposure to sunlight for at least 5 mo a year along with contributing factors.A total of 1484 children and adolescents (age 0.02-17.74 y) living in the Apulia region (Southern Italy) were studied. Serum 25-hydroxyvitamin D (25[OH]D) concentrations were assessed and vitamin status defined as follows: deficiency with serum 25(OH)D20 ng/mL, insufficiency from 20 to 29.9 ng/mL, and sufficiency with serum 25(OH)D from 30 to 100 ng/mL.The median serum 25(OH)D levels were 20.2 ng/mL (interquartile range, 14.5-26.4 ng/mL): 48.9% of the overall population had 25(OH)D20 ng/mL and only 15% had sufficient 25(OH)D values. There was an inverse association between blood levels of 25(OH)D and age (P0.001, ρ: -0.113). Significant 25(OH)D variations were recorded according to the season in which blood samples were drawn, but even during summer only 32.6% of analyzed children had sufficient 25(OH)D levels.More than 80% of our population had 25(OH)D less than sufficiency cutoff levels. Results highlight a high prevalence of 25(OH)D deficiency in our area, even during summer. It is important to establish screening, supplementation guidelines, and pediatric cutoff levels to optimize vitamin D status in children, taking into account age, nutritional status, and seasonality.

The aims of this study were (1) to investigate whether 6−7-year-old children are accurate in perceiving their actual movement competence, and (2) to examine possible age- and gender-related differences. A total of 603 children (301 girls and 302 boys, aged 6 to 7 years) were assessed on the execution accuracy of six locomotor skills and six object control skills using the Test of Gross Motor Development (TGMD-2). The perceived competence of the same skills, plus six active play activities, was also gauged through the Pictorial Scale of Perceived Movement Skill Competence (PMSC-2). The factorial validity of the TGMD-2 and PMSC-2 scales was preliminarily ascertained using a Bayesian structural equation modeling approach. The relationships between the latent factors of the two instruments were then assessed. Gender and age differences were also examined. The factorial validity of the TGMD-2 and the PMSC-2 was confirmed after some adjustments. A subsequent analysis of the relationship between the latent factors (i.e., locomotor skills and object control) of the two instruments yielded very low estimates. Finally, boys and older children showed better competence in object control skills compared to their counterparts. Weak associations between actual and perceived competence suggest that inaccuracy in children’s perceptions can be likely due to a still limited development of cognitive skills needed for the evaluation of the own competence. From an applied perspective, interventions aimed at improving actual motor competence may also increase children’s self-perceived motor competence and their motivation toward physical activity. peerReviewed

Obesity is a multifactorial disease and the most primary risk of this is the development of type 2 diabetes. Numerous studies show that the effects of obesity on glucose metabolism result in the deterioration of glucose tolerance, the development of insulin resistance and the consequent damage of the secretory function of beta-cells. The type 2 diabetes is a worldwide health problem associated with obesity and sedentary lifestyle. As reported the American Diabetes Association, the physical activity is fundamental for type 2 diabetes patients, reducing blood pressure, cardiovascular events, and improve glucose metabolism and insulin sensitivity. In the light of these evidences, the aim of this study is to analyse the effects of healthy lifestyle, characterized by a correct diet and by adequate physical activity program in type 2 diabetes patients. We analysed 25 sedentary type 2 diabetes patients subjected to a correct diet and therapeutic treatment and 20 active type 2 diabetes patients subjected to a correct nutrition and a program of physical activity. We found an amelioration in biochemical and anthropometric parameters such as blood pressure, glycemia, glycated haemoglobin, body mass index (BMI). Given these results we can conclude that the physical activity has always been considered one of the cornerstones of type 2 diabetes therapy together with diet and pharmacotherapy. However, the results obtained show that physical activity deserves the same level of consideration as diet and insulin therapy even in the subject with type 2 diabetes.

Neurodevelopmental disorders (NDDs) include diverse neuropathologies characterized by abnormal brain development leading to impaired cognition, communication and social skills. A common feature of NDDs is defective synaptic plasticity, but the underlying molecular mechanisms are only partially known. Several studies have indicated that people’s lifestyles such as diet pattern and physical exercise have significant influence on synaptic plasticity of the brain. Indeed, it has been reported that a high-fat diet (HFD, with 30–50% fat content), which leads to systemic low-grade inflammation, has also a detrimental effect on synaptic efficiency. Interestingly, metabolic alterations associated with obesity in pregnant woman may represent a risk factor for NDDs in the offspring. In this review, we have discussed the potential molecular mechanisms linking the HFD-induced metabolic dysfunctions to altered synaptic plasticity underlying NDDs, with a special emphasis on the roles played by synaptic protein synthesis and mitochondrial functions.

The obesity epidemic and the decline of fitness among children highlights the need for suitable interventions designed to promote Physical Activity (PA) and healthy habits. The purpose of our pilot study was to assess the feasibility of a school-based program among overweight and obese children, by examining changes in their body composition, PA, physical fitness, and some psychosocial determinants of active behavior. An additional objective was to investigate the reciprocal relationship over time between PA and body image. Self-reported PA and health-related fitness tests were administered to 18 overweight and obese children (11.3 ± 0.4 years), before and after a 6-month intervention including nutritional education, skill-learning, playful physical activities, and exercise training. Participants were assessed on body composition, perceived physical ability, body image, and pleasant and unpleasant psychobiosocial states towards PA. After treatment, children showed decreased body mass index, body fat percentage, arm and waist circumferences, and skinfold thickness. Actual and perceived physical abilities, body image, and PA also improved over six months. Cross-lagged correlations suggest body image to be an antecedent to being physically active. Results showed that the multi-component school program may have sustainable benefits in reducing adiposity indicators and improving exercise adherence, physical fitness, and psychological well-being.

Regular physical activity and sport are able to modify the diffused neuro-immuno-endocrine-endothelial system. This emerges from careful scientific research that finds deep interconnections between the psyche, the nervous system, endocrine organs and the immune response. There is an interconnection between the psychoendocrine-immunological system and respiratory infections in athletes. The appearance of leucocytosis during intense physical activity can explain to us how strenuous exercise is responsible for a temporary depression of the immune system; indeed, the physical activity reduces the proliferative activity and function of T-lymphocytes and Natural Killer cells. This is associated with the influence of multiple factors such as age and gender. The respiratory mechanics during strenuous physical activity favours the dehydration of the mucous membranes, the modification of the mucociliary clearance and therefore the predisposition to infections, until the appearance of more complicated diseases such as neoplasms, as reported by data literature. In conclusion, regular and moderate exercise improves the immune system, reduces environmental and psychological stress, decreases the demand and administration of chemotherapy and immunosuppressants.

Aim The aim of the study was to investigate the level of cytokines in cultures of cow's milk protein- stimulated peripheral blood mononuclear cells of patients with cow's milk protein allergy. Material and Methods Eleven children with cow's milk protein allergy and 11 non-allergic controls were studied. Their peripheral blood mononuclear cells were cultured alone and in the presence of cow's milk α-lactalbumin; β-lactoglobulin; αS 1, αS 2, β, and κ-casein fraction mixtures; and a cow's protein mixture from whole milk. Production of cytokines, tumor necrosis factor-α, interleukin-10, and interleukin-12 were determined in culture supernatants. Results In cow's milk protein-stimulated peripheral blood mononuclear cell cultures of children with cow's milk protein allergy, tumor necrosis factor-α, interleukin-10, and interleukin-12 production was significantly higher than in non-allergic controls (p

Pediatric metabolic syndrome (MetS) is a well-recognized entity; however, there is no consensus on its exact value in predicting long-term cardiovascular (CV) risk. Hepatic steatosis (HS) is another emerging condition associated with pediatric obesity, and data have been reported suggesting a possible role of HS in CV risk linked to MetS. The aim of the present study was to evaluate the usefulness of HS and MetS cluster in predicting CV risk linked to pediatric obesity.We studied 803 overweight and obese children (395 girls and 408 boys, mean age 9.4 ± 2.5 y, body mass index z-score 2.2 ± 0.53) with complete clinical and biological assessment. MetS was defined using the modified criteria of the American Heart Association. The diagnosis and severity of the HS was based on ultrasound. To assess CV risk, all patients underwent ultrasonography to measure carotid intima-media thickness (cIMT)-a validated marker of subclinical vascular disease.The overall prevalence of MetS was 13.07%; HS was significantly higher in patients with MetS (40.9 versus 18.5%; P 0.001; odds ratio, 3.059; 95% confidence interval, 1.98-4.7). Spearman's correlation between HS grade and the number of MetS criteria met by each patient was significant (r = 0.285; P 0.001). No statistical difference was recorded in cIMT and cIMT z-scores between patients with or without MetS, until inclusion of HS as an additional criterion for the diagnosis of MetS. In this case, there was a significant difference in cIMT z-scores between the two groups. In multiple linear regression analysis, the cIMT z-score value was better predicted with HS grade and the MetS cluster (adjusted RHS could be used as additional criterion in detecting pediatric MetS phenotype at higher risk for long-term CV morbidity.

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological condition characterized by headache, nausea, vomiting, seizures, and visual disturbances with typical radiological features of symmetrical edema mostly involving the white matter in the occipital regions (1–2). PRES can develop in association with a wide array of clinical conditions, including systemic infections, hypertension, organ transplantation, and immunosuppression (especially with calcineurin inhibitors). Children who are on prolonged steroid therapy or on calcineurin inhibitor therapy in nephrotic syndrome (NS) are at risk of developing PRES (3–4). A 6-year-old Moroccan-boy, followed in his country for nephrotic syndrome, was hospitalized in our unit of pediatrics for severe generalized body edema, proteinuria (18600 mg/day), low serum albumin (0.9 g/L), high serum cholesterol (468 mg/dl). His arterial blood pressure value was 122/77 mmHg. We treated him with steroid intravenous, albumin supplementations and we continued cyclosporine. While his general conditions were improving, on the seventh day of hospitalization he developed headache, vomiting, dizziness, temporal blindness. A non-contrast computerized tomography was performed and it showed symmetrical hypodensities in parieto-occipital regions. His blood pressure was 132/71 mmHg. Then he developed two episodes of generalized tonic clonic convulsion, followed by unconsciousness. Magnetic resonance imaging (MRI) showed hyperintense signal in the parieto-occipital regions, and revealed bilateral cortical and subcortical white matter edema in parieto-occipital lobes The child was treated with antihypertensive medications, diuretic, steroids and immunosuppressant (cyclosporine A), thereafter he got no seizure and regained full consciousness and vision. His blood pressure was kept at normal range and urinary protein excretion gradually decreased. MRI performed two weeks later revealed no abnormality of the brain, which is a usual phenomenon in case of PRES The pathophysiology of PRES remains controversial, and two main hypotheses have been suggested; impaired cerebral autoregulation resulting in increased cerebral blood flow, and endothelial dysfunction with cerebral hypoperfusion (5–6). PRES must be managed carefully and its pathogenic factors should be suspected and recognized as soon as possible in order to properly treat the patient. In hypertension-related and drug-induced PRES, in fact, effective management includes prompt withdraw of offending agent, aggressive control of blood pressure, timely anti-convulsant therapy. In our case, hypertension was undoubtedly an important cause, but we were uncertain whether cyclosporine also played a pathogenic role. PRES should be always considered in the differential diagnosis of a child with idiopathic nephrotic syndrome, headache and visual disturbance.

BACKGROUND Iodine is an essential micronutrient for intellectual development in children. Information on iodine intakes based on 24-h urinary iodine excretion (UIE) is scant, because iodine status is only assessed by the measurement of urinary iodine concentration (UIC) in spot urine samples. OBJECTIVES The aim of our study was to evaluate the iodine intake of school-age children and adolescents, using UIE measurement in 24-h urine collections. METHODS The study population included 1270 healthy subjects (677 boys, 593 girls) aged 6-18 y (mean age ± SD: 10.3 ± 2.9) from 10 Italian regions. Daily iodine intake was estimated as UIE/0.92, based on the notion that $\sim$92% of the dietary iodine intake is absorbed. The adequacy of intakes was assessed according to the Dietary Reference Values for iodine of the European Food Safety Authority (EFSA). Body mass index (BMI) and UIC were also measured for each subject. RESULTS Based on the scientific opinion of EFSA, 600 of 1270 subjects (47.2%) had a lower than adequate iodine intake, with a higher prevalence among girls (54.6%) compared with boys (40.2%) (P

Background Functional gastrointestinal disorders (FGIDs) are characterized by chronic/recurrent gastrointestinal symptoms not related to organic disorders. Due to the limited treatment options and to the perception of subjects with FGIDs suffering from a food intolerance, in recent years there has been an increase in the self-prescription of elimination diets, especially gluten free diet (GFD), for the treatment of these disorders. For this reason, we decided to perform this systematic review with the aim to evaluate the available evidence on the effects of a GFD on gastrointestinal symptoms, in subjects with FGIDs. Methods Cochrane Library and MEDLINE (via PubMed) databases were searched, from inception to March 2018, using the MeSH terms “functional gastrointestinal disorder OR irritable bowel syndrome AND gluten”. We included all the clinical trials published in English and evaluating the effects of a GFD in subjects with FGIDs diagnosed according to the Rome II, III, and IV criteria. Results Eleven trials were eligible (3 prospective trials, 8 single or double-blind placebo-controlled trials), with 10/11 trials including adult subjects with irritable bowel syndrome (IBS) or FGIDs. Most of the prospective studies found an effect of GFD on gastrointestinal symptoms control. Nevertheless, 1 trial failed to find an association between gluten and GI symptoms when FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) content was simultaneously reduced in the diet, and 2 trials reported a worsening of symptoms during placebo administration. The results of the different trials are difficult to compare due to discrepancies in the study protocols regarding the amount and type of gluten administered, the duration of the gluten challenge, the type of placebo used, and the duration of the challenge itself. Conclusions According to our results, gluten may contribute to the occurrence of gastrointestinal symptoms in patients with FGIDs, particularly in those with IBS. Nevertheless, the results of the currently available trials are difficult to compare due to the lack of standardization in the study designs. For this reason, it is still not possible to recommend the use of the GFD in the routine management of FGIDs.

The accumulation of adipose tissue represents one of the characteristics of obesity, increasing the risk of developing correlated obesity diseases such as cardiovascular disease, type 2 diabetes, cancer, and immune diseases. Visceral adipose tissue accumulation leads to chronic low inflammation inducing an imbalanced adipokine secretion. Among these adipokines, Adiponectin is an important metabolic and inflammatory mediator. It is also known that adipose tissue is influenced by Orexin-A levels, a neuropeptide produced in the lateral hypothalamus. Adiponectin and Orexin-A are strongly decreased in obesity and are associated with metabolic and inflammatory pathways. The aim of this review was to investigate the involvement of the autonomic nervous system focusing on Adiponectin and Orexin-A after bariatric surgery. After bariatric surgery, Adiponectin and Orexin-A levels are strongly increased independently of weight loss showing that hormone increases are also attributable to a rearrangement of metabolic and inflammatory mediators. The restriction of food intake and malabsorption are not sufficient to clarify the clinical effects of bariatric surgery suggesting the involvement of neuro-hormonal feedback loops and also of mediators such as Adiponectin and Orexin-A.