The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP).

BACKGROUND AND PURPOSE: Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case-control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. METHODS: We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. RESULTS: Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP's predicting model and the only significant ones per se. CONCLUSIONS: The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

The fifth cranial nerve in headaches.

The fifth cranial nerve is the common denominator for many headaches and facial pain pathologies currently known. Projecting from the trigeminal ganglion, in a bipolar manner, it connects to the brainstem and supplies various parts of the head and face with sensory innervation. In this review, we describe the neuroanatomical structures and pathways implicated in the sensation of the trigeminal system. Furthermore, we present the current understanding of several primary headaches, painful neuropathies and their pharmacological treatments. We hope that this overview can elucidate the complex field of headache pathologies, and their link to the trigeminal nerve, to a broader field of young scientists.

Medicine in the time of Carracci: the cases of Domenico Lanzoni and Giuseppe Rosaccio.

During the 16th century and at the beginning of the 17th century the age-old competition between scholarly doctors and folk healers became more and more serious, creating a division between the two categories entrusted with treating population diseases. On one side there were the representatives who practiced medicine in an official capacity, and on the other, the "others", that is, the charlatans, the acrobats and female healers. Two representatives of these contrasting approaches of practicing medicine within the health profession during that historical period were two Italian doctors, Domenico Lanzoni and Giuseppe Rosaccio. Together, with their ties to the city of Bologna and the bolognese Carracci family of painters, they were able to describe in complete detail these two types of practices as medical sciences of the sixteenth and early seventeenth century.

Sapienza Global Bedside Evaluation of Swallowing after Stroke: the GLOBE-3S study.

BACKGROUND AND PURPOSE: Dysphagia occurs in up to 50% of all patients with acute stroke. There is debate regarding which is the most effective screening tool in identifying aspiration in patients with acute stroke. We assessed the accuracy of the Sapienza Global Bedside Evaluation of Swallowing after Stroke (GLOBE-3S), which combines the Toronto Bedside Swallowing Screening Test (TOR-BSST©) with oxygen desaturation and laryngeal elevation measurement during swallowing. METHODS: We prospectively enrolled consecutive patients with stroke within 72 h of symptom onset. All patients with stroke firstly underwent a standard neurological examination, then the GLOBE-3S evaluation and finally the fiberoptic endoscopic evaluation of swallowing (FEES). Two different assessors, a neurologist and a speech pathologist, blind to both the clinical data and each other's evaluation, administered the GLOBE-3S and FEES examination. We assessed the accuracy of the GLOBE-3S in detecting post-stroke swallow impairment with aspiration using the FEES as the standard. RESULTS: We enrolled 50 patients with acute stroke, 28 of whom (56%) had swallowing impairment with aspiration at FEES evaluation. A total of 33 patients (66%) failed the GLOBE-3S evaluation. The GLOBE-3S reached a sensitivity of 100% and a specificity of 77.3% (negative predictive value, 100%; positive likelihood ratio, 4.34). The median time required for the GLOBE-3S to be performed was 297 s. CONCLUSIONS: GLOBE-3S is quick to perform at the bedside and can accurately identify aspiration in patients with acute stroke. By including the measurement of laryngeal elevation and monitoring of oxygen desaturation, it could represent a highly sensitive instrument to avoid the misdiagnosis of silent aspirators.

On the shoulders of giants: a history of success and a future of excellence - Istituto Ortopedico Rizzoli.

In 1896 the Rizzoli Orthopedic Institute was inaugurated in Bologna, an important hospital whose history is strictly connected with the development of the orthopedic discipline in Italy. The aim of this manuscript was to retrace the history of the institution by analyzing the work of the main personalities who have contributed to making the Italian Orthopedic Institute still famous in the world today.

Cerebral venous hemodynamic abnormalities in episodic and chronic migraine.

Alterations of cerebral venous drainage have been demonstrated in chronic migraine (CM), suggesting that cerebral venous hemodynamic abnormalities (CVHAs) play a role in this condition. The aim of the present study was to look for a correlation between CM and CVHAs. We recruited 33 subjects suffering from CM with or without analgesic overuse, 29 episodic migraine (EM) patients with or without aura, and 21 healthy subjects as controls (HCs). CVHAs were evaluated by transcranial and extracranial echo-color Doppler evaluation of five venous hemodynamic parameters. CVHAs were significantly more frequent in the CM and EM patients than in the HCs. In the migraine patients, CVHAs were not correlated with clinical features. The significantly greater frequency of CVHAs observed in the migraineurs may reflect a possible relationship between migraine and these abnormalities. Prospective longitudinal studies are needed to investigate whether CVHAs have a role in the processes of migraine chronification.

A history of meniscal surgery: from ancient times to the twenty-first century.

The science and surgery of the meniscus have evolved significantly over time. Surgeons and scientists always enjoy looking forward to novel therapies. However, as part of the ongoing effort at optimizing interventions and outcomes, it may also be useful to reflect on important milestones from the past. The aim of the present manuscript was to explore the history of meniscal surgery across the ages, from ancient times to the twenty-first century. Herein, some of the investigations of the pioneers in orthopaedics are described, to underline how their work has influenced the management of the injured meniscus in modern times. Level of evidence V.

Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study.

AIMS: The aim of this study was to investigate the predictive ability of screening tools regarding the occurrence of major postoperative complications in onco-geriatric surgical patients and to propose a scoring system. METHODS: 328 patients ≥ 70 years undergoing surgery for solid tumors were prospectively recruited. Preoperatively, twelve screening tools were administered. Primary endpoint was the incidence of major complications within 30 days. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. A scoring system was derived from multivariate logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was applied to evaluate model performance. RESULTS: At a median age of 76 years, 61 patients (18.6%) experienced major complications. In multivariate analysis, Timed Up and Go (TUG), ASA-classification and Nutritional Risk Screening (NRS) were predictors of major complications (TUG>20 OR 3.1, 95% CI 1.1-8.6; ASA ≥ 3 OR 2.8, 95% CI 1.2-6.3; NRS impaired OR 3.3, 95% CI 1.6-6.8). The scoring system, including TUG, ASA, NRS, gender and type of surgery, showed good accuracy (AUC: 0.81, 95% CI 0.75-0.86). The negative predictive value with a cut-off point >8 was 93.8% and the positive predictive value was 40.3%. CONCLUSIONS: A substantial number of patients experience major postoperative complications. TUG, ASA and NRS are screening tools predictive of the occurrence of major postoperative complications and, together with gender and type of surgery, compose a good scoring system.

The first world war drives rehabilitation toward the modern concepts of disability and participation.

The First World War produced a huge number of disabled soldiers. During the war, surgeons realized that it was not enough to merely treat the limbs of the wounded soldiers; it was also necessary to train them to use their remaining abilities to their greatest capacity. Governments at the same time realized that such a high number of veterans created a financial burden, by entitling disabled veterans to full healthcare, raising the issues of social welfare. Both in the US and Europe, programs of rehabilitation were instituted, providing injured soldiers with long-term medical care and vocational training aimed at restituting soldier's independence for a speedy return to work. In Italy at the Istituto Ortopedico Rizzoli, one of the most renowned Hospitals for the treatment of orthopedic deformities, Putti set up a technologically advanced Orthopedic Workshop, and a Rehabilitation House. The so called "reconstruction programs" addressed all aspects of rehabilitation (including physiotherapy, curative workshops and vocational therapy), seeing disability in terms of function. The experience gained in the treatment of war victims markedly enriched rehabilitation techniques, but overall the First World War helped engender the concept of rehabilitative programs to assist disabled veterans reintegrate in the workplace, thus laying the foundations of the modern concept of participation at a social level. In the centenary of Italy's entry into the First World War, it is worth underlining just how much hindsight affords us a new perspective on Physical Medicine and Rehabilitation. It reminds us that rehabilitation is not merely the role of medicine, but forms part of a multifaceted approach involving societal roles and expectations, regardless of the psychological and physical impairments suffered by the individuals concerned.

Gaspare Tagliacozzi, pioneer of plastic surgery and the spread of his technique throughout Europe in "De Curtorum Chirurgia per Insitionem".

Gaspare Tagliacozzi's innovative surgical technique, which consisted of reconstructing parts of the face by grafting, was masterfully described in the work that made him famous, "De Curtorum Chirurgia per Insitionem." It was published by Gaspare Bindoni the Younger in 1597 in Venice, who was granted the exclusive right to print it by the Senate. However, in the same year in Venice Roberto Meietti published an unauthorized edition; nevertheless, this edition was soon discovered. The great demand for the text even abroad was soon testified by a 3rd edition published in Frankfurt in 1598, similar to the Bindoni edition but in another format and with a different title. This has caused confusion among bibliographers and Authors. Two centuries later, in 1831 in Berlin, a 4th edition was printed, thus suggesting renewed interest in rhinoplasty procedures, which surgeons Van Graefe and Dieffenbach promoted in Germany. However, few people know that the integral text of Tagliacozzi's De Curtorum was also published by Jacques Manget in his "Bibliotheca Chirurgica," printed in Venice in 1721. The name of the illustrator of the three fourteenth-century editions, whose illustrations in the text are compared, is not known. Instead the name of the artist, Tiburzio Passerotti, who painted Tagliacozzi's portrait holding his De Curtorum open at the ninth woodcut shortly before it was printed, is well known. The impact of Tagliacozzi's technique on modern surgery is supported by experience of the last century as well as recent years, mostly in musculoskeletal oncology reconstruction.

Handgrip strength predicts survival and is associated with markers of clinical and functional outcomes in advanced cancer patients.

PURPOSE: Handgrip strength (HGS) has been shown to predict survival and is associated with changes in body composition, nutritional status, inflammation, and functional ability in several chronic disease conditions. Whether similar relationships exist between HGS and clinical outcomes in patients with advanced cancer are currently unknown. We evaluated the association between HGS and survival as well as several key markers of body composition (e.g., sarcopenia), subjective performance measures (e.g., quality of life), and muscle strength (e.g., isokinetic torque of the quadriceps) in patients with advanced forms of non-small cell lung and gastrointestinal cancers. METHODS: A consecutive cohort of 203 patients with advanced cancer was enrolled and categorized into three HGS percentiles (e.g., ≥50th, 25th, and ≤10th) according to published normative values. Multivariate regression analyses were used to test for independent associations between HGS and survival, sarcopenia, quality of life (QoL), and lower extremity muscle strength as well as key biological markers (e.g., hemoglobin, albumin, and C-reactive protein) while controlling for age, gender, cancer diagnosis, treatment (chemotherapy/radiotherapy), medications, and time from diagnosis to assessment. RESULTS: When compared to HGS ≥50th, patients in the HGS ≤10th percentile had lower BMI (B, -2.5 kg/m(2); 95% CI, -4.5 to -0.45), shorter survival (hazard ratio, 3.2; 2.0-5.1), lower hemoglobin (-19.70 g/L; -27.28 to -12.13) and albumin (-4.99 g/L; -7.85 to -2.13), greater occurrence of sarcopenia (odds ratio, 9.53; 1.95-46.55), lower isokinetic torque of the quadriceps at both 60°/s (-30.6 Nm; -57.9 to -3.3) and 120°/s (-25.1 Nm; -46.4 to -3.7), lower QoL (-1.6 on McGill Quality of Life Questionnaire scale; -2.5 to -0.6), higher levels of fatigue (18.8 on Brief Fatigue Inventory scale; 4.7 -32.9), poorer performance status (0.75 on Eastern Cooperative Oncology Group Performance Status scale; 0.34-1.15), lower fat mass (-7.4 kg; -14.4 to -0.5), and lower lean body mass (-6.5 kg; -10.3 to -2.8). CONCLUSIONS: HGS is independently associated with survival and important biological, functional, and quality of life characteristics in advanced cancer patients. Patients presenting with very low percentiles with respect to their handgrip assessment may require timely referral to supportive and/or palliative care services.

Italian consensus statement on paediatric HIV infection.

The objective of this document is to identify and reinforce current recommendations concerning the management of HIV infection in infants and children in the context of good resource availability. All recommendations were graded according to the strength and quality of the evidence and were voted on by the 57 participants attending the first Italian Consensus on Paediatric HIV, held in Siracusa in 2008. Paediatricians and HIV/AIDS care specialists were requested to agree on different statements summarizing key issues in the management of paediatric HIV. The comprehensive approach on preventing mother-to-child transmission (PMTCT) has clearly reduced the number of children acquiring the infection in Italy. Although further reduction of MTCT should be attempted, efforts to personalize intervention to specific cases are now required in order to optimise the treatment and care of HIV-infected children. The prompt initiation of treatment and careful selection of first-line regimen, taking into consideration potency and tolerance, remain central. In addition, opportunistic infection prevention, adherence to treatment, and long-term psychosocial consequences are becoming increasingly relevant in the era of effective antiretroviral combination therapies (ART). The increasing proportion of infected children achieving adulthood highlights the need for multidisciplinary strategies to facilitate transition to adult care and maintain strategies specific to perinatally acquired HIV infection.

[Emergence of Salmonella Typhimurium monophasic serovar: determinants of antimicrobial resistance in porcine and human strains]. / Emergenza di una variante monofasica di Salmonella Typhi- murium: caratteri di antibiotico-resistenza in stipiti isolati dalla filiera suinicola e da casi di infezione nell'uomo.

Salmonella enterica serovar Typhimurium (S. Typhimurium) is a common cause of non-typhoideal salmonellosis in humans and animals; since the end of '90 a monophasic serovar defined by the antigenic formula 4,5:i:- has been emerged. This study shows occurrence of monophasic serovar in Italy (Lombardia Region) and analyses antimicrobial resistance of 147 S. Typhimurium and 45 monophasic strains. Multiple drug resistance (MDR) has been detected in 94,5% and 76,6% of 55 porcine and 137 human isolates, respectively; tetra-resistance pattern AmSSuTe is the most common among in both sources (55 out of 116 strains of MDR S. Typhimurium and 16 out of 41 strains of MDR monophasic variant). Transfer of resistance determinants has been investigated by plasmid conjugation for all the 157MDR strains: only 16 isolates (10,2%) gave positive results, and transfer has almost been partial. Data from our investigation and data reported by other studies show a wide difference in the circulating phenotypes and in polymorphism of S. Typhimurium, confirmed also by the emergence of the monophasic serovar.

European AIDS Clinical Society (EACS) guidelines on the prevention and management of metabolic diseases in HIV.

BACKGROUND: Metabolic diseases are frequently observed in HIV-infected persons and, as the risk of contracting these diseases is age-related, their prevalence will increase in the future as a consequence of the benefits of antiretroviral therapy (ART). SUMMARY OF GUIDELINES: All HIV-infected persons should be screened at regular intervals for a history of metabolic disease, dyslipidaemia, diabetes mellitus, hypertension and alteration of body composition; cardiovascular risk and renal function should also be assessed. Efforts to prevent cardiovascular disease will vary in intensity depending on an individual's absolute risk of ischaemic heart disease and should be comprehensive in nature. Lifestyle interventions should focus on counselling to stop smoking, modify diet and take regular exercise. A healthy diet, exercise and maintaining normal body weight tend to reduce dyslipidaemia; if not effective, a change of ART should be considered, followed by use of lipid-lowering medication in high-risk patients. A pre-emptive switch from thymidine analogues is recommended to reduce the risk of development or progression of lipoatrophy. Intra-abdominal fat accumulation is best managed by exercise and diet. Prevention and management of type 2 diabetes mellitus and hypertension follow guidelines used in the general population. When using medical interventions to prevent and/or treat metabolic disease(s), impairment of the efficacy of ART should be avoided by considering the possibility of pharmacokinetic interactions and compromised adherence. Specialists in HIV and specialists in metabolic diseases should consult each other, in particular in difficult-to-treat cases. CONCLUSION: Multiple and relatively simple approaches exist to prevent metabolic diseases in HIV-infected persons; priority should be given to patients at high risk of contracting these diseases.

Renal safety of tenofovir in HIV-infected children: a prospective, 96-week longitudinal study.

BACKGROUND: The renal safety of tenofovir in HIV-infected children has not been well studied. In paediatrics, prediction of glomerular filtration rate (GFR) is usually obtained by the Schwartz equation; the Cockcroft-Gault equation is considered more appropriate in children aged >12 years, but can be misleading in younger children. The aims of this study were to assess renal safety and GFR changes as estimated by the Schwartz and Cockcroft-Gault equations in HIV-infected children treated with tenofovir for 96 weeks. METHODS: Several parameters of glomerular and tubular function were prospectively assessed (at baseline and at weeks 24, 48, 72 and 96) in 27 HIV-infected children (aged 4.9-18.0 years) receiving a tenofovir-containing antiretroviral regimen. GFR was estimated using Schwartz and Cockcroft-Gault equations in children younger and older than 12 years, respectively. RESULTS: No child experienced a grade 1 (> or =44 micromol/L) or higher increase in serum creatinine or a grade 1 (< or =0.71 mmol/L) or higher hypophosphataemia. Serum bicarbonate values were in the normal range for age at baseline. Mean serum creatinine, serum phosphorus and serum bicarbonate values remained unchanged. No child showed proteinuria, microalbuminuria or glycosuria at baseline or during the study period. The mean urinary protein/creatinine, albumin/creatinine, alpha(1)-microglobulin/creatinine and maximal tubular phosphate reabsorption (TmPO(4)/GFR) ratios remained unchanged. Up to week 96, no patient experienced a significant decrease in GFR, as estimated by the more appropriate formula for age. CONCLUSION: Through 96 weeks, we found no evidence of impaired glomerular or tubular renal function in tenofovir-treated HIV-infected children.

Metabolic modulation induced by chronic hypoxia in rats using a comparative proteomic analysis of skeletal muscle tissue.

Hypoxia-induced changes of rat skeletal muscle were investigated by two-dimensional difference in-gel electrophoresis (2D-DIGE) and mass spectrometry. The results indicated that proteins involved in the TCA cycle, ATP production, and electron transport are down-regulated, whereas glycolytic enzymes and deaminases involved in ATP and AMP production were up-regulated. Up-regulation of the hypoxia markers hypoxia inducible factor 1 (HIF-1alpha) and pyruvate dehydrogenase kinase 1 (PDK1) was also observed, suggesting that in vivo adaptation to hypoxia requires an active metabolic switch. The kinase protein, mammalian target of rapamycin (mTOR), which has been implicated in the regulation of protein synthesis in hypoxia, appears unchanged, suggesting that its activity, in this system, is not controlled by oxygen partial pressure.

Prevalence of E. coli, thermotolerant coliforms, Salmonella spp. and Vibrio spp. in ready-to-eat foods: Pemba Island, United Republic of Tanzania.

This study is aimed to evaluate the microbiological quality of ready-to-eat foods in Pemba island. A total of 300 food samples have been analysed: 66 household preparations, 115 samples of raw cow milk, and 119 fried sea-foods. The thermotolerant coliforms have been detected in 34% sea-foods, 58% household meals, and 98% milk samples; the coliforms count is 5 x 10(2), 10(3), and 3 x 10(4) cfu/g, respectively. E. coli is the species most frequently isolated: 60 on 100 strains agglutinate one of the tested polyvalent antisera. Salmonella spp. have been found exclusively in cow milk (11%); in 15% sea-foods V. alginolyticus has been isolated. The prevalence of faecal contamination is extremely high in cow milk, a critical vehicle for the transmission of pathogens, probably for a lacking thermal treatment (pasteurization). Salmonella spp., V. cholerae, and V. parahaemolyticus have not been isolated from boiled or fried foodstuffs, but in any case the cooked foods are faecally contaminated: their contamination occurs likely after preparation and before consumption. The identification of risk factors for the faecal contamination could be helpful to plan educational programmes involving food operators and may be an effective preventive measure, especially in settings where financial resources are lacking for the construction of adequate infrastructures.

Analysis of bone mineral content in horizontally HIV-infected children naïve to antiretroviral treatment.

Low bone mass is a frequent finding in HIV-infected individuals. Reduced bone mass has been found in vertically infected children who are receiving antiretroviral treatment. Little is known about bone mass in horizontally infected young patients who are naïve to antiretroviral therapy. We measured the bone mineral content (BMC) at the lumbar spine and in the whole skeleton by using dual-energy X-ray absorptiometry (DXA) in 16 HIV-infected children (age 9.3 +/- 3.9 years) naïve to antiretroviral treatment, and in 119 healthy children (age 9.7 +/- 3.3 years). Thirteen patients were also pair-matched by anthropometric measures, sex, and age with healthy children. Median spine BMC of HIV-infected children was 14.9 g (8.2-39.2 g), and whole body BMC was 1106.1 g (55.5-2344.1 g). Spine BMC of healthy children was 18.6 g (6.8-52.2 g), and whole body BMC was 1213.5 g (541.0-2722.0 g). Multivariate analysis showed a mean difference of spine BMC values of 0.004 g (P = 0.64) between the two groups. Similarly, the whole body BMC difference between the two groups (0.001 g) was not statistically significant (P = 0.55). Mean spine BMC measurements in the case-control evaluation were 21.1 g (9.7 g) (patients), and 22.3 g (6.9 g) (controls). Whole body BMC measurements of patients and controls were 1258.5 g (539.6 g) and 1311.1 g (479.2 g), respectively. In both cases the differences were not significant. The duration of HIV infection did not relate to BMC values. In conclusion, horizontally HIV-infected children naïve to antiretroviral therapy have bone mineral measurements comparable to those of healthy children.