Cavernous haemangioma and mid trimester pregnancy loss leading to severe haemorrhage and hysterectomy: a case report and review of literature.

Background: Cavernous haemangiomas are benign vascular tumours that are known to occasionally involve the female genital tract, including the uterus. They are often underdiagnosed during pregnancy, although they can also lead to severe postpartum or antepartum haemorrhage. Objectives: Describe our case of an uncommon second-trimester pregnancy loss in a woman with a diffuse cavernous haemangioma of the uterus and cervix and review the wider literature. Methods: The review was conducted using MEDLINE, Scopus and PubMed electronic databases from beginning of the database to May 2023, using the following keywords: arteriovenous malformation; cavernous haemangioma/hemangioma; uterine neoplasms; pregnancy complications; abnormal vaginal bleeding. Main outcome measures: Description of the characteristics of cavernous haemangioma during pregnancy as well as diagnostic criteria and treatment options. Results: Twenty publications were included in the review, which included English-language case reports over a period from 1959 to 2022. No pathognomonic symptoms for cavernous haemangioma of the uterus in a pregnant woman were noted. Complications including massive secondary postpartum haemorrhage, haemoperitoneum, and severe thrombocytopenia with anaemia after delivery were reported. Conclusions: Diagnosis and management during pregnancy can be challenging and requires considerable attention, with a multidisciplinary approach including gynaecologists, radiologists, and pathologists to avoid major complications. What is new?: An additional case of diffuse cavernous haemangioma of the uterus and cervix is described, that adds to the little existing literature.

A mathematical model for nutrient-limited uniaxial growth of a compressible tissue.

We consider the uniaxial growth of a tissue or colony of cells, where a nutrient (or some other chemical) required for cell proliferation is supplied at one end, and is consumed by the cells. An example would be the growth of a cylindrical yeast colony in the experiments described by Vulin et al. (2014). We develop a reaction-diffusion model of this scenario which couples nutrient concentration and cell density on a growing domain. A novel element of our model is that the tissue is assumed to be compressible. We define replicative regions, where cells have sufficient nutrient to proliferate, and quiescent regions, where the nutrient level is insufficient for this to occur. We also define pathlines, which allow us to track individual cell paths within the tissue. We begin our investigation of the model by considering an incompressible tissue where cell density is constant before exploring the solution space of the full compressible model. In a large part of the parameter space, the incompressible and compressible models give qualitatively similar results for both the nutrient concentration and cell pathlines, with the key distinction being the variation in density in the compressible case. In particular, the replicative region is located at the base of the tissue, where nutrient is supplied, and nutrient concentration decreases monotonically with distance from the nutrient source. However, for a highly-compressible tissue with small nutrient consumption rate, we observe a counter-intuitive scenario where the nutrient concentration is not necessarily monotonically decreasing, and there can be two replicative regions. For parameter values given in the paper by Vulin et al. (2014), the incompressible model slightly overestimates the colony length compared to experimental observations; this suggests the colony may be somewhat compressible. Both incompressible and compressible models predict that, for these parameter values, cell proliferation is ultimately confined to a small region close to the colony base.

NF-YA isoforms with alternative splicing of exon-5 in Aves.

NF-YA, the regulatory subunit of the trimeric CCAAT-binding transcription factor NF-Y, is present in vertebrates in two major alternative spliced isoforms: NF-YAl and NF-YAs, differing for the presence of exon-3. NF-YAx, a third isoform without exon-3/-5, was reported only in human neuronal cells and tumors. These events affect the Trans-Activation Domain. We provide here evidence for the expression of NF-YAx and for the existence of a new isoform, NF-YAg, skipping only exon-5. These isoforms are abundant in Aves, but not in reptiles, and are the prevalent transcripts in the initial phases of embryo development in chicken. Finally, we analyzed NF-YAg and NF-YAx amino acid sequence using AlphaFold: absence of exon-5 denotes a global reduction of ß-stranded elements, while removal of the disordered exon-3 sequence has limited effects on TAD architecture. These data identify an expanded program of NF-YA isoforms within the TAD in Aves, implying a role during early development.

Feedback thinking in dairy farm management: system dynamics modelling for herd dynamics.

Systems perspectives and system dynamics have been widely used in decision-making for agricultural problems. However, their use in dairy farm management remains limited. This work demonstrates the use of systems approaches and feedback thinking in modelling for dairy farm management. The application of feedback thinking was illustrated with causal loop and stock-and-flow diagrams to disentangle the complexity of the relationship among farm elements. The study aimed to identify the dynamic processes of an intensive dairy farm by mapping the animal stocks (e.g., heifers, lactating cows, dry cows) with the final objective of anticipating the expected milk deliveries over a long time period. The project was conducted for a reference dairy farm that was intensively managed with a herd size of >2 500 cattle heads, which provided monthly farm records from Jan 2016 to Dec 2019. Model development steps included: (i) problem articulation with farm interviews and data analysis; (ii) the development of a dynamic hypothesis and a causal loop diagram; (iii) the development of a stock-and-flow cattle model describing ageing chains of heifers and cows and subsequent calibration of the model parameters; (iv) the evaluation of the model based on lactating cows and milk deliveries against farm historical records; and (v) the analysis of the model results. The model characterized the farm dynamics using three main feedback loops: one balancing loop of culling and two reinforcing loops of heifers' replacement and cows' pregnancy, pushing milk delivery. The model reproduced the historical oscillation patterns of lactating cows and milk deliveries with high accuracy (root mean square percentage error of 2.8 and 5.2% for the number of lactating cows and milk deliveries, respectively). The model was shown to be valid for its purpose, and applications of this model in dairy farm management can support decision-making practices for herd composition and milk delivery targets.

Effects of ensiling time on corn silage starch ruminal degradability evaluated in situ or in vitro.

Accurate measurements of concentration and ruminal degradability of corn silage starch is necessary for formulation of diets that meet the energy requirements of dairy cows. Five corn silage hybrids ensiled for 0 (unfermented), 30, 60, 120, and 150 d were used to determine the effects of ensiling time on starch degradability of corn silage. In addition, the effects of grind size of silage samples on 7-h in vitro starch degradability and the relationship between in vitro, in situ and near-infrared reflectance spectroscopy (NIRS) starch degradability were studied. In situ disappearance of corn silage starch increased from 0 to 150 d of ensiling, primarily as a result of an increase in the washout or rapidly degraded fraction of starch, particularly during the first 60 d of ensiling. When analyzed in vitro and by NIRS, ensiling time increased corn silage starch degradability either linearly or to a greater extent during the first 2 mo of ensiling. Differences in in situ starch disappearance among corn silage hybrids were apparent during the first 2 mo of ensiling but were attenuated as silages aged. No differences among hybrids were detected using a 7-h in vitro starch digestibility approach. Results from the in vitro subexperiment indicate that 7-h in vitro starch degradability was increased by reducing grind size of corn silage from 4 to 1 mm, regardless of ensiling duration. Fine grinding corn silages samples (i.e., 1-mm sieve) allowed distinguishing low- from medium- and high-starch degradability rated hybrids. Correlations among in situ, in vitro and NIRS measurements for starch degradability were medium to high (r ≥0.57); however, agreement among methods was low (concordance correlation coefficient ≤0.15). In conclusion, ensiling time linearly increased degradation rate of corn silage resulting in greater in situ starch disappearance after 150 d of ensiling. Reductions in grind size from 4 to 1 mm resulted in greater in vitro starch degradability, regardless of ensiling duration. Strong correlation but low agreement between starch degradability methods suggest that absolute estimations of corn silage starch degradability will vary, but all methods can be used to assess the effect of ensiling time on starch degradability.

Use of potassium polyaspartate on white wines: Interaction with proteins and aroma compounds.

The precipitation of tartaric salts represents one of the main visual sensory faults of white wines. It can be prevented by cold stabilization or adding some adjuvants, such as potassium polyaspartate (KPA). KPA is a biopolymer that can limit the precipitation of tartaric salts linking the potassium cation, however, it could interact also with other compounds affecting wine quality. The present work aims to study the effect of potassium polyaspartate on proteins and aroma compounds of two white wines, at different storage temperatures (4 °C and 16 °C). The KPA addition showed positive effects on the quality of wines, with a significant decrease of unstable proteins (up to 92%), also related to better wine protein stability indices. A Logistic function well described the effect of KPA and storage temperature on protein concentration (R2 > 0.93; NRMSD: 1.54-3.82%). Moreover, the KPA addition allowed the preservation of the aroma concentration and no adversely effects were pointed out. Alternatively to common enological adjuvants, KPA could be considered a multifunctional product against tartaric and protein instability of white wines, avoiding adverse effects on their aroma profile.

Acetylsalicylic acid (ASA) desensitization in an allergic pregnant woman post-vascular scaffolds implantation.

Summary: The use of acetylsalicylic acid (ASA) desensitization for patients with coronary artery disease (CAD) is growing, but no data are available on desensitization protocol in patients with ASA sensitivity and CAD during pregnancy. This case report shows that ASA desensitization protocol during pregnancy could be safe and effective in a tertiary centre with a multidisciplinary team.

Perspectives in linear accelerator for FLASH VHEE: Study of a compact C-band system.

PURPOSE: In order to translate the FLASH effect in clinical use and to treat deep tumors, Very High Electron Energy irradiations could represent a valid technique. Here, we address the main issues in the design of a VHEE FLASH machine. We present preliminary results for a compact C-band system aiming to reach a high accelerating gradient and high current necessary to deliver a Ultra High Dose Rate with a beam pulse duration of 3µs. METHODS: The proposed system is composed by low energy high current injector linac followed by a high acceleration gradient structure able to reach 60-160 MeV energy range. To obtain the maximum energy, an energy pulse compressor options is considered. CST code was used to define the specifications RF parameters of the linac. To optimize the accelerated current and therefore the delivered dose, beam dynamics simulations was performed using TSTEP and ASTRA codes. RESULTS: The VHEE parameters Linac suitable to satisfy FLASH criteria were simulated. Preliminary results allow to obtain a maximum energy of 160 MeV, with a peak current of 200 mA, which corresponds to a charge of 600 nC. CONCLUSIONS: A promising preliminary design of VHEE linac for FLASH RT has been performed. Supplementary studies are on going to complete the characterization of the machine and to manufacture and test the RF prototypes.

Near-infrared calibration models for estimating volatile fatty acids and methane production from in vitro rumen fermentation of different total mixed rations.

Volatile fatty acids (VFA) and methane (CH4) are the major products of rumen fermentation. The VFA are considered an energy source for the animal and rumen microbiota, and CH4 (which is released by eructation) is considered an energy loss. Quantification of these fermentation products is fundamental for the evaluation of feeds and diets, and provides important information regarding the use of nutrients by ruminants. Near-infrared (NIR) spectroscopy is increasingly used for the evaluation of animal feeds because it is rapid, nondestructive, noninvasive, and inexpensive; does not require reagents; and the results are reproducible. The aim of this study was to develop NIR calibration models for estimating the production of VFA (acetic, propionic, butyric, valeric, isovaleric, and isobutyric acids), total gas, and CH4 using in vitro gas production tests with buffered rumen inoculum throughout fermentation. Fifty-four total mixed rations (TMRs) were examined, and rumen fluid was manually collected from 2 dry Holstein dairy cows that had ruminal fistulas and were fed at maintenance energy levels. Then, 30 mL of buffered rumen fluid was incubated in bottles with ~220 mg of TMR. The total gas, VFA, and CH4 were measured after 2, 5, 9, 24, 30, 48, and 72 h of rumen incubation for each TMR. The VFA were measured on 32 randomly selected TMR. In particular, 7 bottles were used for each TMR, one for each incubation time. Methane was measured in the headspace and VFA were measured in the buffered rumen fluid. The bottles were considered experimental units for calibration purposes. The production of CH4 was quantified from the bottle headspaces by gas chromatography, and total gas production was measured using a pressure transducer at each incubation time. Two aliquots of the fermented liquids were sampled by opening the bottles at each incubation time, and (1) the concentrations of VFA were determined by gas chromatography or (2) spectra were obtained from Fourier-transform NIR spectroscopy. The data were randomly divided into calibration and validation data sets. The average concentrations of acetic acid (45.30 ± 11.92 and 43.86 ± 11.93 mmol/L), propionic acid (14.97 ± 6.08 and 14.38 ± 6.56 mmol/L), butyric acid (8.47 ± 3.47 and 8.65 ± 3.79 mmol/L), total gas (111.34 ± 81.90 and 116.46 ± 82.44 mL/g of organic matter), and CH4 (9.65 ± 9.45 and 10.35 ± 9.33 mmol/L) were similar in the 2 data sets. The best calibration models were retained based on the coefficient of determination (R2) and the ratio of prediction to deviation (RPD). The R2 values for prediction of VFA ranged from 0.69 (RPD = 3.28) for valeric acid to 0.94 (RPD = 4.20) for acetic acid. The models also provided good predictions of CH4 (R2 = 0.89, RPD = 3.05) and cumulative gas production (R2 = 0.91, RPD = 3.30). The models described here precisely and accurately estimated the production of CH4 and VFA during in vitro rumen fermentation tests. Validations at additional laboratories may provide more robust calibrations.

Milk metabolome reveals pyrimidine and its degradation products as the discriminant markers of different corn silage-based nutritional strategies.

The purpose of this study was to evaluate the effect of 6 different feeding systems (based on corn silage as the main ingredient) on the chemical composition of milk and to highlight the potential of untargeted metabolomics to find discriminant marker compounds of different nutritional strategies. Interestingly, the multivariate statistical analysis discriminated milk samples mainly according to the high-moisture ear corn (HMC) included in the diet formulation. Overall, the most discriminant compounds, identified as a function of the HMC, belonged to AA (10 compounds), peptides (71 compounds), pyrimidines (38 compounds), purines (15 compounds), and pyridines (14 compounds). The discriminant milk metabolites were found to significantly explain the metabolic pathways of pyrimidines and vitamin B6. Interestingly, pathway analyses revealed that the inclusion of HMC in the diet formulation strongly affected the pyrimidine metabolism in milk, determining a significant up-accumulation of pyrimidine degradation products, such as 3-ureidopropionic acid, 3-ureidoisobutyric acid, and 3-aminoisobutyric acid. Also, some pyrimidine intermediates (such as l-aspartic acid, N-carbamoyl-l-aspartic acid, and orotic acid) were found to possess a high discrimination degree. Additionally, our findings suggested that the inclusion of alfalfa silage in the diet formulation was potentially correlated with the vitamin B6 metabolism in milk, being 4-pyridoxic acid (a pyridoxal phosphate degradation product) the most significant and up-accumulated compound. Taken together, the accumulation trends of different marker compounds revealed that both pyrimidine intermediates and degradation products are potential marker compounds of HMC-based diets, likely involving a complex metabolism of microbial nitrogen based on total splanchnic fluxes from the rumen to mammary gland in dairy cows. Also, our findings highlight the potential of untargeted metabolomics in both foodomics and foodomics-based studies involving dairy products.

A double-blind randomised crossover trial of low-dose flumazenil for benzodiazepine withdrawal: A proof of concept.

INTRODUCTION: Benzodiazepines (BZD) are a class of anxiolytics with varying uses, which primarily act on the GABAA receptor resulting in hyperpolarisation. BZDs are often a difficult drug class to cease once neuroadaptation has occurred; recommendations usually involve gradual dose reductions at variable rates. A growing body of evidence has suggested that low-dose flumazenil, a GABAA receptor antagonist, may be a useful agent to allow for rapid detoxification. AIM: To collect pilot data on the safety and efficacy of low-dose subcutaneous flumazenil to reduce BZD use, withdrawal symptoms, and craving in participants taking above and below the therapeutic maximum diazepam equivalent of 30 mg to inform on sample size for future trials. METHOD: In a randomised double-blinded crossover study design, participants received low-dose flumazenil first (4 mg/24 h for approximately eight days) or placebo first. Groups were divided into those taking < 30 mg diazepam equivalent and ≥ 30 mg diazepam equivalent at baseline. Main outcome measures were percentage reduction in daily diazepam use, withdrawal symptoms, and craving scores from baseline, difference in diazepam use across the placebo first group, and flumazenil related adverse events. RESULTS: Twenty-eight participants were recruited and randomised to flumazenil first (n = 14) and placebo first (n = 14). In participants taking ≥ 30 mg diazepam equivalent at baseline (n = 15), flumazenil significantly reduced diazepam use by 30.5% (p = 0.024) compared to placebo. CONCLUSION: Low-dose flumazenil may aid in BZD detoxification in participants taking daily diazepam equivalent doses greater than or equal to the therapeutic maximum (≥30 mg) by reducing the need for diazepam.

Outcomes of patients treated with low-dose flumazenil for benzodiazepine detoxification: A description of 26 participants.

INTRODUCTION: Benzodiazepines are commonly prescribed for a variety of indications and can be employed in the short- and long-term. While they are efficacious, issues arise from long-term use with the emergence of dependence and tolerance to doses within the therapeutic range and beyond. Discontinuation from benzodiazepines can be problematic for patients and may result in a withdrawal syndrome, which can be protracted and last months to years. METHODS: 26 participants received low-dose subcutaneous flumazenil infusions (4 mg/24 h for approximately eight days) as part of a randomised control crossover trial. Return to benzodiazepine use was assessed monthly for three months based on the benzodiazepine use in the previous week. Where data was not available, the treating psychiatrist examined patient files and clinical documents to determine benzodiazepine use. Withdrawal and craving scores were also measured. RESULTS: Abstinence rates from benzodiazepines at one-, two-, and three-month follow ups were 65.4 %, 50.0 %, and 46.2 % respectively. When considering patient files and clinical documents for those lost to follow-up, abstinence rates were higher at 73.1 %, 65.4 % and 61.5 % at the one-, two-, and three-month follow ups respectively. Withdrawal and craving scores were higher in those that had returned to any benzodiazepine use. CONCLUSION: Self-reported rates of abstinence from benzodiazepines at three months was between 46.2 % and 61.5 %. Flumazenil may yield greater success than benzodiazepine tapering from high dose benzodiazepine use (≥30 mg diazepam equivalent). Further research should compare abstinence rates after treatment with flumazenil compared to benzodiazepine tapering in high dose benzodiazepine users.

MRI in acute simple elbow dislocations: correlation of preoperative imaging and intraoperative findings of collateral ligaments and associated soft tissue injuries.

PURPOSE: The aim of our study was the evaluation of correspondence among collateral ligaments and other soft tissue injuries detected by MRI and by intraoperative findings in a consecutive series of patients treated for simple elbow dislocation. METHODS: After clinical and MRI examination, 16 out of 59 consecutive patients with moderate or severe instability after simple elbow dislocation were addressed to surgical treatment. There were 14 men and 2 women. The mean age was 39.6 years (range 16-69 years). RESULTS: MRI showed full-thickness lesion of MCL in 9/16 patients (53.3%) and partial lesion in 6/16 patients (40%), and in 1 case, the MCL was considered intact. On the lateral side, MRI showed complete injury of LCL in 7/16 patients (46.6%) and partial injury in 7/16 patients (40%). No lesions of LCL were observed in 2 patients (13.4%). MCL was surgically explored in all the patients. We observed 10/16 full-thickness lesions (62.5%) and 6/16 partial lesions (37.5%). LCL was surgically explored in 11/16 patients. We observed 6/11 full-thickness lesions (54.6%) and 5/11 partial lesions (45.4%). In 3 cases, associated soft tissue injuries were detected. The rate of concordance between MRI and surgical findings was 87.5% (14/16 cases) on the medial side and 90.9% (10/11 cases) on the lateral side. CONCLUSION: Our study demonstrated that MRI is a reliable and useful tool to investigate collateral ligaments and soft tissue injuries around the elbow and to plan the most adequate surgical treatment.

Assessment of feed and economic efficiency of dairy farms based on multivariate aggregation of partial indicators measured on field.

Many of the metrics used to evaluate farm performance are only partial indicators of farm operations, which are assumed to be best predictors of the whole farm efficiency. The main objective of this work was to identify aggregated multiple indexes of profitability using common partial indicators that are routinely available from individual farms to better support the short-term decision-making processes of the cattle-feeding process. Data were collected from face-to-face interviews with farmers from 90 dairy farms in Italy and used to calculate 16 partial indicators that covered almost all indicators currently used to target feeding and economic efficiency in dairy farms. These partial indicators described feed efficiency, energy utilization, feed costs, milk-to-feed price ratio, income over feed costs, income equal feed cost, money-corrected milk, and bargaining power for feed costs. Calculations of feeding costs were based on lactating cows or the whole herd, and income from milk deliveries was determined with or without considering the milk quality payment. Multivariate factor analysis was then applied to the 16 partial indicators to determine simplified and latent structures. The results indicated that 5 factors explained 70% of the variability. Each of the original partial indicator was associated with all factors in different proportions, as indicated by loading scores from the multivariate factor analysis. Based on the loading scores, we labeled these 5 factors as "economic efficiency," "energy utilization," "break-even point," "milk-to-feed price," and "bargaining power of the farm," in decreasing order of explained communality. The first 3 factors shared 83% of the total communality. Feed efficiency was similarly associated with factor 1 (53% loading) and factor 2 (66% loading). Only factor 4 was significantly affected by farm location. Milk production and herd size had significant effects on factor 1 and factor 2. Our multivariate approach eliminated the problem of multicollinearity of partial indicators, providing simple and effective descriptions of farm feeding economics. The proposed method allowed the evaluation, benchmarking, and ranking of dairy herd performance at the level of single farms and at territorial level with high opportunity to be used or replicated in other areas.

How particle-particle and liquid-particle interactions govern the fate of evaporating liquid marbles.

Liquid marbles refer to droplets that are covered with a layer of non-wetting particles. They are observed in nature and have practical significance. These squishy objects bounce, coalesce, break, inflate, and deflate while the liquid does not touch the substrate underneath. Despite the considerable cross-disciplinary interest and value of the research on liquid marbles, a unified framework for describing the mechanics of deflating liquid marbles-as the liquid evaporates-is unavailable. For instance, analytical approaches for modeling the evaporation of liquid marbles exploit empirical parameters that are not based on liquid-particle and particle-particle interactions. Here, we have combined complementary experiments and theory to fill this gap. To unentangle the contributions of particle size, roughness, friction, and chemical make-up, we investigated the evaporation of liquid marbles formed with particles of sizes varying over 7 nm-300 µm and chemical compositions ranging from hydrophilic to superhydrophobic. We demonstrate that the potential final states of evaporating liquid marbles are characterized by one of the following: (I) constant surface area, (II) particle ejection, or (III) multilayering. Based on these insights, we developed an evaporation model for liquid marbles that takes into account their time-dependent shape evolution. The model fits are in excellent agreement with our experimental results. Furthermore, this model and the general framework can provide mechanistic insights into extant literature on the evaporation of liquid marbles. Altogether, these findings advance our fundamental understanding of liquid marbles and should contribute to the rational development of technologies.

Effectiveness of standard cervical physiotherapy plus diaphragm manual therapy on pain in patients with chronic neck pain: A randomized controlled trial.

BACKGROUND: Literature concerning the effect of diaphragm treatment to reduce neck pain symptoms is scarce. Aim of this trial was to investigate the effects of diaphragm manual therapy associated with standard physiotherapy treatment on pain in patients with Chronic Neck Pain (CNP). METHODS: In a private practice clinic, subjects with CNP were randomly assigned to receive three 30-min treatment sessions of standard cervical physiotherapy and Diaphragm Manual Therapy (DMT) or Sham Diaphragm Technique (SDT). Participants and assessors were blinded to the assignment. Primary outcome was pain, secondary outcomes were cervical active range of motion, pain pressure threshold, disability and quality of life measured at baseline, before and after each session, at 3 and 6-months. Adverse events were monitored. A non-parametric multivariate approach (combined permutation test) was applied to assess the effect of the treatment on all the outcomes. An intention to treat analysis was performed. RESULTS: Forty patients were randomly allocated to DMT and SDT groups. Combined permutation test showed a significant higher improvement in DMT group compared to SDT group (p-value = 0.0002). The between-group comparisons on single outcomes showed a statistically significant improvement only for pain pressure threshold on upper trapezius (adjusted p-value = 0.029). No adverse events related to the intervention were registered. CONCLUSIONS: In patients with CNP, addition of diaphragm manual techniques to standard cervical treatment seems to give a better global outcome, but this improvement is of unclear clinical relevance; the primary outcome seems not to have a role. Further studies are needed to confirm and clarify these results. TRIAL REGISTRATION: Release Date: July 18, 2017 Registered in ClinicalTrial.gov database ID: NCT03223285A.

A multicenter survey on access to care in Multiple Sclerosis-related trigeminal neuralgia.

The prevalence of trigeminal neuralgia (TN) in patients with Multiple Sclerosis (MS) is higher than in the general population and its management can be particularly challenging due to a number of reasons including high recurrence rates, lack of MS-specific treatment guidelines and uncertainties about pain pathophysiology. Aim of this cross-sectional, multicentre survey was to gather information on the current treatment modalities and options of MS-related TN across 23 Italian MS centres. Initial medical management (carbamazepine or oxcarbazepine) of MS-related TN was fairly homogeneous throughout Italian centres. The most commonly available surgical procedure was microvascular decompression, but the frequency and types of surgical procedures available locally differed considerably throughout MS centers, and were unavailable in one quarter of them. This survey reveals some of the issues that could hamper an optimal patient management and underlines the need for a consensus on MS-related TN to support health-care professionals in their approach to this challenging condition and to facilitate the development of local guidelines aimed at ensuring equity in access to care and treatment optimization.

Probiotic intake unmasking a gastro-pleural fistula.

OBJECTIVE: Gastropleural fistula represents a rare clinical event often resulting in an iatrogenic complication of gastrointestinal surgery. Clinical presentation is insidious, patients complain of chronic and non-specific respiratory symptoms and may be conservatively treated for lung infections for several months until detailed tests finally reveal the correct diagnosis. PATIENTS AND METHODS: We describe a case of a healthy patient with an unexpected diagnosis of empyema due to a gastropleural fistula. RESULTS: A 51-year-old man with a past history of splenectomy for cyst was admitted because of high fever and cough. A chest radiography and CT-scan revealed a left-side pneumonia complicated with pleural empyema. Broad spectrum empirical antibiotics and pleural drainage did not significantly improve the clinical picture. While the need for a surgical complex thoracic approach becomes a collective awareness, questions about causes of empyema and its unfavorable evolution in our patient did not initially find a common satisfactory answer. It was only by the identification of probiotics bacteria in the pleural fluid that a gastropleural fistula was suspected, and then, it was confirmed by CT-scan and by digestive endoscopy. A combined thoraco-abdominal surgical treatment was therefore scheduled, leading to progressive improvement till total healing. CONCLUSIONS: Although gastropleural fistula is rare, it is necessary to include this pathological condition in the differential diagnosis of a persistent complicated pneumonia, because early diagnosis and, consequently, surgical management, may significantly impact on the prognosis of these patients. In our case, the detection of probiotics bacteria in the pleural fluid helped us to suspect and to look for the fistula.