Multidisciplinary model for hospital-territory integrated management of patient with bone fragility: primary and secondary prevention of fractures according to severity and complexity.

The aim of this study was to promote the construction of a real network and a shared diagnostic and therapeutic management model between hospitals and out-of-hospital healthcare services to capture as many patients with bone fragility as possible. Starting from the analysis of the clinical competences present in the province of Pavia, the bone specialists (BSs) organized some educational events involving both general practitioners (GPs) and hospital specialists. The Fracture Liaison Service (FLS) model, the revision of Note 79, the national plan for chronicity and the health reform of the Lombardy Regional Authority supported the structure of our model, in which the roles of clinicians are well defined and based on the complexity and severity of patients. In our method the GP has a central role as clinical manager, facilitating patient management and communication between the specialists and the BS. In January 2019, the Therapeutic Care Diagnostic Path (PDTA) shared between 2 bone specialists (BSs), 9 GPs, as reference treaters, and a multidisciplinary group of 25 specialists of the Province of Pavia was defined. The strategic directions of the two largest public hospitals in Pavia have supported the PDTA, which was validated by the quality departments of the hospitals themselves. Finally, sixty GPs belonging to the network have joined the PDTA. This model is the first example of integrated management between hospitals and out-of-hospital healthcare services for the primary and secondary prevention of fragility fractures (FF), where the GPs play a pivotal role as managers and supervisors to ensure proper care to chronic patients according to their levels of severity.

Laparoscopic posterior cruroplasty: a patient tailored approach.

BACKGROUND: Different surgical variations have been described for laparoscopic crural repair however, the technique is not standardized and left to the surgeons' preference. OBJECTIVE: The purpose of this study is to describe a standardized "patient tailored" approach for laparoscopic posterior cruroplasty in the setting of elective hiatal hernia repair. METHODS: Retrospective single-center study was conducted (November 2015 to November 2019). The technical aspects of a standardized "patient tailored" laparoscopic posterior crural repair are described. Perioperative outcomes and patients' quality of life, measured with the disease specific Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and generic Short Form-36 (SF-36), were analyzed. RESULTS: One hundred and forty-one patients were treated for symptomatic hiatal hernia according to the described "patient tailored" concept. Overall, 102 (72.3%) patients underwent simple suture repair while simple suture repair buttressed with biosynthetic resorbable U shaped mesh [Phasix ST®-Bard] was used in 39 (27.7%) patients. Toupet fundoplication was fashioned in all patients. The median operative time was 131 min (IQR 55-240). No intraoperative complications or conversion to open surgery occurred. The median postoperative stay was 1.8 days (range 1-7). The overall postoperative complication rate was 4.2%. The median follow-up was 21 months (IQR range 1-34) with 102 patients having a minimum follow-up of 6 months. Recurrent hernia was diagnosed in three patients (2.1%), but none required reoperation. No mesh-related complications occurred. Compared to baseline, the median GERD-HRQL (p = 0.003) and all SF-36 items (p < 0.001) were significantly improved. CONCLUSION: The application of a standardized "patient tailored" concept for laparoscopic posterior cruroplasty seems safe and effective in the medium-term follow-up with promising perioperative outcomes and quality of life improvement. This approach may be valuable to assure procedure reproducibility, standardization, and to uniformly interpret the outcomes.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life.

BACKGROUND: Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression. OBJECTIVE: To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms. METHODS: Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used. RESULTS: Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved. CONCLUSIONS: LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience.

BACKGROUND: Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus. OBJECTIVE: The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST®). METHODS: Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST® mesh and Toupet fundoplication. RESULTS: Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001). CONCLUSIONS: Laparoscopic crura augmentation with Phasix-ST® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

The importance of hydrodynamics in UV advanced oxidation reactors.

The flow field of UV reactors was characterised experimentally using particle image velocimetry (PIV) and modelled with computational fluid dynamics (CFD). The reactor flow was integrated with the radiation fluence rate and photolysis kinetics to calculate the overall conversion of photo-reactant components in annular UV reactors with an inlet parallel and perpendicular to the reactor axis. The results indicated that the fluid flow distribution within the reactor volume affects photo-reactor performance.

Zea mays L. protein changes in response to potassium dichromate treatments.

The plant metabolic response to heavy metal stress is largely unknown. The present investigation was undertaken to examine the influence of different concentrations of potassium dichromate on the Zea mays L. plantlets. A clear effect of chromium on maize plantlets growth and seed germination was observed strating from 100-300 ppm up to 1500 ppm. In this concentration range, chromium uptake was dependent on the concentration in the medium. Metallothioneins, involved in heavy metal binding, were measured by capillary electrophoresis (CE), and showed a dose-response induction. Protein profile analyzed by two-dimensional gel electrophoresis showed differential expression of several proteins. Identification of spots of upregulated proteins was performed by MALDI mass spectrometry. Results showed that proteins induced by heavy metal exposure are principally involved in oxidative stress tolerance or in other stress pathways. Induction of proteins implicated in sugar metabolism was also observed. Identification of factors involved in plant response may lead to a better understanding of the mechanisms involved in cell protection and tolerance. This information could be used to improve agricultural production and environmental quality.

Pregnancy, bovine somatotropin, and dietary n-3 fatty acids in lactating dairy cows: I. Ovarian, conceptus, and growth hormone-insulin-like growth factor system responses.

The objective was to examine effects of bovine somatotropin (bST), pregnancy, and dietary fatty acids on reproductive responses in lactating dairy cows. Beginning at approximately 17 d in milk (DIM), a comparison was made of isoenergetic diets comprising supplementary lipids of whole cottonseed vs. calcium salts of fish oil enriched lipid (FO). Ovulation was synchronized in cows with a presynchronization plus Ovsynch protocol, and cows were inseminated artificially by appointment or not inseminated (d 0 = time of synchronized ovulation; 77 +/- 12 DIM). On d 0 and 11, cows received bST (500 mg) or no bST. All cows were slaughtered on d 17. Number of cows in each group was as follows: control diet had 5 bST-treated cyclic (bST-C), 5 non-bST-treated cyclic (no bST-C), 4 bST-treated pregnant (bST-P), and 5 non-bST-treated pregnant (no bST-P) cows; and cyclic cows fed FO diet had 4 bST-treated (bST-FO) and 5 non-bST-treated cyclic (no bST-FO-C) cows. Feeding FO increased milk production, number of class 1 follicles (2 to 5 mm), and decreased insulin during the period before d 0 compared with control-fed cows. The bST increased milk production, pregnancy rate [83% (5/6) vs. 40% (4/10)], conceptus length (45 vs. 34 cm), and interferon-tau in the uterine luminal flushings (9.4 vs. 5.3 microg) with no effect on interferon-tau mRNA concentration in the conceptus. Treatment with bST increased plasma growth hormone (GH) and insulin-like growth factor (IGF)-I. Among control-fed cows (cyclic and pregnant), bST decreased progesterone concentration in plasma. Cows fed FO had less plasma insulin than control-fed cyclic cows, and FO altered the plasma GH (bST-FO > bST-C) and IGF-I (bST-C > bST-FO-C) responses to bST injections. Endometrial IGF-I mRNA was reduced in pregnant cows and tended to decrease in those fed FO. The IGF-II mRNA was increased in the endometrium of pregnant and bST-treated cows fed the control diet. Cows fed FO had increased concentrations of IGF-II mRNA, when bST was not injected. The insulin-like growth factor binding protein-2 (IGFBP-2) mRNA was increased in bST-P cows, whereas bST decreased the IGFBP-2 mRNA in all cyclic cows. In summary, bST and FO seemed to modulate reproductive responses that may be beneficial to the developing conceptus and pregnancy rate.

Resynchronization of ovulation and timed insemination in lactating dairy cows, II: assigning protocols according to stages of the estrous cycle, or presence of ovarian cysts or anestrus.

Pregnancy rates were compared in lactating dairy cows (n = 1083) assigned to protocols for resynchronization of ovulation based on stages of the estrous cycle, or presence of ovarian cysts or anestrus. Cows were detected not pregnant by ultrasonography 30 d after a previous AI (study day 0) and classified as diestrus, metestrus, proestrus, with ovarian cysts or anestrus. Cows in diestrus (January-May) were assigned to either Ovsynch (GnRH day 0, PGF2alpha day 7, GnRH day 9, and timed-AI [TAI] 16 h later; n = 96), or Quicksynch (PGF2alpha day 0, estradiol cypionate [ECP] day 1, AI at detected estrus [AIDE] on day 2, or TAI on day 3; n = 96). Cows in diestrus (June-December) were assigned to either Ovsynch (n = 156) or Modified Quicksynch (PGF2alpha day 0, ECP day 1, AIDE days 2 and 3, and to Ovsynch on day 4 if not detected in estrus; n = 142). Cows in metestrus were assigned either to Ovsynch (n = 68), Heatsynch (GnRH day 0, PGF2alpha day 7, ECP day 8, AIDE day 9, or TAI day 10; n = 62), or GnRH + Ovsynch (GnRH on day 0, followed by Ovsynch on day 8; n = 64). Cows in proestrus, with ovarian cysts, or anestrus were assigned to either Ovsynch (proestrus n = 89, ovarian cysts n = 97, anestrus n = 8) or GnRH + Ovsynch (proestrus n = 87, ovarian cysts n = 109, anestrus n = 9). Pregnancy rate was evaluated 30, 55 and 90 d after resynchronized AI. For cows in diestrus (January-May), pregnancy rates were higher for Ovsynch (35.9, 29.2 and 26.0%) than for Quicksynch (21.7, 16.7 and 15.6%). For cows in diestrus (June-December), pregnancy rates were similar for Ovsynch (34.4, 24.0 and 23.6%) and Modified Quicksynch (27.1, 26.2 and 21.6%). For cows in metestrus, pregnancy rates were higher for GnRH + Ovsynch (33.3, 24.5 and 20.3%) than for Heatsynch (20.3, 12.9 and 9.8%). For cows with ovarian cysts, pregnancy rates were higher for GnRH + Ovsynch (30.3, 26.6 and 22.9%) than for Ovsynch (20.2, 18.5 and 14.7%). Assignment to resynchronization protocols based on the stages of the estrous cycle, or presence of ovarian cysts improved pregnancy rates.

Resynchronization of ovulation and timed insemination in lactating dairy cows III. Administration of GnRH 23 days post AI and ultrasonography for nonpregnancy diagnosis on day 30.

The objective was to compare pregnancy rates to resynchronization and timed AI (TAI) protocols in lactating dairy cows that received GnRH at 23 d and were diagnosed not pregnant at 30 d after the pre-enrollment AI. Nonpregnant cows (624) at ultrasonography on day 30 (study day 0) were classified as diestrus (74.8%), metestrus (5.6%) and without a CL (19.5%). Cows in diestrus were assigned either to the GnRH group (PGF2alpha on day 0, GnRH on day 2 and TAI 16 h later, n = 238) or the estradiol cypionate (ECP) group (PGF2alpha on day 0, ECP on day 1, and TAI 36 h later, n = 229). Cows in metestrus were assigned to the Modified Heatsynch Group (GnRH on day 0, PGF(2alpha) on day 7, ECP on day 8 and TAI on day 9, n = 35). Cows without a CL (n = 122) were classified either as proestrus (10.6%), ovarian cysts (7.5%) or anestrus (1.4%), and assigned to factorial treatments (i.e., use of GnRH versus CIDR) to either the GnRH group (GnRH on day 0, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28), the CIDR group (CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 34), the GnRH + CIDR group (GnRH on day 0, CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16h later, n = 32), and the control group (PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28). For cows without a CL, plasma P4 concentrations were determined on days 0, 7, 10 and 17 and ovarian structures determined on days 0, 7 and 17. Pregnancy rates were evaluated at 30, 55 and 90 d after the resynchronized AI. For cows in diestrus, there were no differences in pregnancy rates on days 30, 55 and 90 for cows in the GnRH (27.5, 26.5 and 24.2%) or ECP (29.1, 25.5 and 24.1%) groups. In addition, there were no differences in pregnancy losses between days 30 and 55 and 55 and 90 between the GnRH (7.0 and 8.6%) and ECP (9.8 and 5.4%) groups. For cows without a CL, GnRH on day 0 increased the proportion of cows with a CL on days 7 and 17 and plasma P4 concentration on day 17 in cows with ovarian cysts but not for cows in proestrus. The CIDR insert increased pregnancy rate in cows with ovarian cysts but reduced pregnancy rate for cows in proestrus.

Affordable, automatic quantitative fall risk assessment based on clinical balance scales and Kinect data.

The problem of a correct fall risk assessment is becoming more and more critical with the ageing of the population. In spite of the available approaches allowing a quantitative analysis of the human movement control system's performance, the clinical assessment and diagnostic approach to fall risk assessment still relies mostly on non-quantitative exams, such as clinical scales. This work documents our current effort to develop a novel method to assess balance control abilities through a system implementing an automatic evaluation of exercises drawn from balance assessment scales. Our aim is to overcome the classical limits characterizing these scales i.e. limited granularity and inter-/intra-examiner reliability, to obtain objective scores and more detailed information allowing to predict fall risk. We used Microsoft Kinect to record subjects' movements while performing challenging exercises drawn from clinical balance scales. We then computed a set of parameters quantifying the execution of the exercises and fed them to a supervised classifier to perform a classification based on the clinical score. We obtained a good accuracy (~82%) and especially a high sensitivity (~83%).

In vitro estrogenic activity of Achillea millefolium L.

Isolation and biological characterization of pure compounds was used to identify and characterize estrogenic activity and estrogen receptors (ER) preference in chemical components of Achillea millefolium. This medicinal plant is used in folk medicine as an emmenagogue. In vitro assay, based on recombinant MCF-7 cells, showed estrogenic activity in a crude extract of the aerial parts of A. millefolium. After fractionation of the crude extract with increasing polar solvents, estrogenic activity was found in the methanol/water fraction. Nine compounds were isolated and characterized by HR-MS spectra and 1D- and 2D-NMR techniques. In particular, dihydrodehydrodiconiferyl alcohol 9-O-beta-D-glucopyranoside - a glycosyl-neolignan - was isolated for the first time from the genus Achillea in addition to six flavone derivatives, apigenin, apigenin-7-O-beta-D-glucopyranoside, luteolin, luteolin-7-O-beta-D-glucopyranoside, luteolin-4'-O-beta-D-glucopyranoside, rutin, and two caffeic acid derivatives, 3,5-dicaffeoylquinic acid and chlorogenic acid. Apigenin and luteolin, the most important estrogenic compounds among those tested, were studied for their ability to activate alpha or beta estrogen receptors (ERalpha, ERbeta) using transiently transfected cells. Our results suggest that isolation and biological characterization of estrogenic compounds in traditionally used medicinal plants could be a first step in better assessing further (e.g. in vivo) tests of nutraceutical and pharmacological strategies based on phytoestrogens.